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van’t Westeinde A, Padilla N, Fletcher-Sandersjöö S, Kämpe O, Bensing S, Lajic S. Increased Resting-State Functional Connectivity in Patients With Autoimmune Addison Disease. J Clin Endocrinol Metab 2024; 109:701-710. [PMID: 37820745 PMCID: PMC10876407 DOI: 10.1210/clinem/dgad592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/08/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023]
Abstract
CONTEXT Individuals with autoimmune Addison disease (AAD) take replacement medication for the lack of adrenal-derived glucocorticoid (GC) and mineralocorticoid hormones from diagnosis. The brain is highly sensitive to these hormones, but the consequence of having AAD for brain health has not been widely addressed. OBJECTIVE The present study compared resting-state functional connectivity (rs-fc) of the brain between individuals with AAD and healthy controls. METHODS Fifty-seven patients with AAD (33 female) and 69 healthy controls (39 female), aged 19 to 43 years were scanned with 3-T magnetic resonance imaging (MRI). RESULTS Independent component and subsequent dual regression analyses revealed that individuals with AAD had stronger rs-fc compared to controls in 3 networks: the bilateral orbitofrontal cortex (OFC), the left medial visual and left posterior default mode network. A higher GC replacement dose was associated with stronger rs-fc in a small part of the left OFC in patients. We did not find any clear associations between rs-fc and executive functions or mental fatigue. CONCLUSION Our results suggest that having AAD affects the baseline functional organization of the brain and that current treatment strategies of AAD may be one risk factor.
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Affiliation(s)
- Annelies van’t Westeinde
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Nelly Padilla
- Department of Women's and Children's Health, Karolinska Institutet, Unit for Neonatology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sara Fletcher-Sandersjöö
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Olle Kämpe
- Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Sweden and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Pediatric Endocrinology Unit, Sahlgrenska University Hospital, SE-416 50 Gothenburg, Sweden
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2
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Fraga NR, Minaeian N, Kim MS. Congenital Adrenal Hyperplasia. Pediatr Rev 2024; 45:74-84. [PMID: 38296783 DOI: 10.1542/pir.2022-005617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
We describe congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, which is the most common primary adrenal insufficiency in children and adolescents. In this comprehensive review of CAH, we describe presentations at different life stages depending on disease severity. CAH is characterized by androgen excess secondary to impaired steroidogenesis in the adrenal glands. Diagnosis of CAH is most common during infancy with elevated 17-hydroxyprogesterone levels on the newborn screen in the United States. However, CAH can also present in childhood, with late-onset symptoms such as premature adrenarche, growth acceleration, hirsutism, and irregular menses. The growing child with CAH is treated with hydrocortisone for glucocorticoid replacement, along with increased stress doses for acute illness, trauma, and procedures. Mineralocorticoid and salt replacement may also be necessary. Although 21-hydroxylase deficiency is the most common type of CAH, there are other rare types, such as 11β-hydroxylase and 3β-hydroxysteroid dehydrogenase deficiency. In addition, classic CAH is associated with long-term comorbidities, including cardiometabolic risk factors, impaired cognitive function, adrenal rest tumors, and bone health effects. Overall, early identification and treatment of CAH is important for the pediatric patient.
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Affiliation(s)
- Nicole R Fraga
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
| | - Nare Minaeian
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Mimi S Kim
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine of University of Southern California, Los Angeles, CA
- The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, CA
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3
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Russell G, Kalafatakis K, Durant C, Marchant N, Thakrar J, Thirard R, King J, Bowles J, Upton T, Thai NJ, Brooks JCW, Wilson A, Phillips K, Ferguson S, Grabski M, Rogers CA, Lampros T, Wilson S, Harmer C, Munafo M, Lightman SL. Ultradian hydrocortisone replacement alters neuronal processing, emotional ambiguity, affect and fatigue in adrenal insufficiency: The PULSES trial. J Intern Med 2024; 295:51-67. [PMID: 37857352 PMCID: PMC10952319 DOI: 10.1111/joim.13721] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Primary adrenal insufficiency (PAI) mortality and morbidity remain unacceptably high, possibly arising as glucocorticoid replacement does not replicate natural physiology. A pulsatile subcutaneous pump can closely replicate cortisol's circadian and ultradian rhythm. OBJECTIVES To assess the effect of pump therapy on quality of life, mood, functional neuroimaging, behavioural/cognitive responses, sleep and metabolism. METHODS A 6-week randomised, crossover, double-blinded and placebo-controlled feasibility study of usual dose hydrocortisone in PAI administered as either pulsed subcutaneous or standard care in Bristol, United Kingdom (ISRCTN67193733). Participants were stratified by adrenal insufficiency type. All participants who received study drugs are included in the analysis. The primary outcome, the facial expression recognition task (FERT), occurred at week 6. RESULTS Between December 2014 and 2017, 22 participants were recruited - 20 completed both arms, and 21 were analysed. The pump was well-tolerated. No change was seen in the FERT primary outcome; however, there were subjective improvements in fatigue and mood. Additionally, functional magnetic resonance imaging revealed differential neural processing to emotional cues and visual stimulation. Region of interest analysis identified the left amygdala and insula, key glucocorticoid-sensitive regions involved in emotional ambiguity. FERT post hoc analysis confirmed this response. There were four serious adverse events (AE): three intercurrent illnesses requiring hospitalisation (1/3, 33.3% pump) and a planned procedure (1/1, 100% pump). There was a small number of expected AEs: infusion site bruising/itching (3/5, 60% pump), intercurrent illness requiring extra (3/7, 42% pump) and no extra (4/6, 66% pump) steroid. CONCLUSIONS These findings support the administration of hormone therapy that mimics physiology.
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Affiliation(s)
- Georgina Russell
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
- North Bristol NHS TrustBristolUK
| | - Konstantinos Kalafatakis
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- Department of Informatics and Telecommunications, Human‐Computer Interaction LaboratoryUniversity of IoanninaArtaGreece
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
- Faculty of Medicine and Dentistry (Malta Campus)Queen Mary University of LondonVictoriaMalta
| | - Claire Durant
- Department of Brain SciencesFaculty of MedicineImperial College LondonLondonUK
| | - Nicola Marchant
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Jamini Thakrar
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
| | - Russell Thirard
- Bristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Jade King
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
- North Bristol NHS TrustBristolUK
| | - Jane Bowles
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Thomas Upton
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
| | - Ngoc Jade Thai
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
- Neurosciences and Mental HealthLiverpool Health PartnersLiverpoolUK
| | | | - Aileen Wilson
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
| | - Kirsty Phillips
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Stuart Ferguson
- School of MedicineUniversity of TasmaniaHobartTasmaniaAustralia
| | | | - Chris A. Rogers
- Bristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Theodoros Lampros
- Department of Informatics and Telecommunications, Human‐Computer Interaction LaboratoryUniversity of IoanninaArtaGreece
| | - Sue Wilson
- Department of Brain SciencesFaculty of MedicineImperial College LondonLondonUK
| | - Catherine Harmer
- Department of PsychiatryOxford University and Oxford Health NHS Foundation TrustOxfordUK
| | - Marcus Munafo
- MRC Integrative Epidemiology UnitSchool of Psychological ScienceUniversity of BristolBristolUK
| | - Stafford L. Lightman
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
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4
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De Alcubierre D, Ferrari D, Mauro G, Isidori AM, Tomlinson JW, Pofi R. Glucocorticoids and cognitive function: a walkthrough in endogenous and exogenous alterations. J Endocrinol Invest 2023; 46:1961-1982. [PMID: 37058223 PMCID: PMC10514174 DOI: 10.1007/s40618-023-02091-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/05/2023] [Indexed: 04/15/2023]
Abstract
PURPOSE The hypothalamic-pituitary-adrenal (HPA) axis exerts many actions on the central nervous system (CNS) aside from stress regulation. Glucocorticoids (GCs) play an important role in affecting several cognitive functions through the effects on both glucocorticoid (GR) and mineralocorticoid receptors (MR). In this review, we aim to unravel the spectrum of cognitive dysfunction secondary to derangement of circulating levels of endogenous and exogenous glucocorticoids. METHODS All relevant human prospective and retrospective studies published up to 2022 in PubMed reporting information on HPA disorders, GCs, and cognition were included. RESULTS Cognitive impairment is commonly found in GC-related disorders. The main brain areas affected are the hippocampus and pre-frontal cortex, with memory being the most affected domain. Disease duration, circadian rhythm disruption, circulating GCs levels, and unbalanced MR/GR activation are all risk factors for cognitive decline in these patients, albeit with conflicting data among different conditions. Lack of normalization of cognitive dysfunction after treatment is potentially attributable to GC-dependent structural brain alterations, which can persist even after long-term remission. CONCLUSION The recognition of cognitive deficits in patients with GC-related disorders is challenging, often delayed, or mistaken. Prompt recognition and treatment of underlying disease may be important to avoid a long-lasting impact on GC-sensitive areas of the brain. However, the resolution of hormonal imbalance is not always followed by complete recovery, suggesting irreversible adverse effects on the CNS, for which there are no specific treatments. Further studies are needed to find the mechanisms involved, which may eventually be targeted for treatment strategies.
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Affiliation(s)
- D De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D Ferrari
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G Mauro
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - J W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - R Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK.
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5
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Beltz AM, Demidenko MI, Wilson SJ, Berenbaum SA. Prenatal androgen influences on the brain: A review, critique, and illustration of research on congenital adrenal hyperplasia. J Neurosci Res 2023; 101:563-574. [PMID: 34139025 DOI: 10.1002/jnr.24900] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/27/2021] [Accepted: 05/20/2021] [Indexed: 12/28/2022]
Abstract
Sex hormones, especially androgens, contribute to sex and gender differences in the brain and behavior. Organizational effects are particularly important because they are thought to be permanent, reflecting hormone exposure during sensitive periods of development. In human beings, they are often studied with natural experiments in which sex hormones are dissociated from other biopsychosocial aspects of development, such as genes and experiences. Indeed, the greatest evidence for organizational effects on sex differences in human behavior comes from studies of females with congenital adrenal hyperplasia (CAH), who have heightened prenatal androgen exposure, female-typical rearing, and masculinized toy play, activity and career interests, spatial skills, and some personal characteristics. Interestingly, however, neuroimaging studies of females with CAH have revealed few neural mechanisms underlying these hormone-behavior links, with the exception of emotion processing; studies have instead shown reduced gray matter volumes and reduced white matter integrity most consistent with other disease-related processes. The goals of this narrative review are to: (a) describe methods for studying prenatal androgen influences, while offering a brief overview of behavioral outcomes; (b) provide a critical methodological review of neuroimaging research on females with CAH; (c) present an illustrative analysis that overcomes methodological limitations of previous work, focusing on person-specific neural reward networks (and their associations with sensation seeking) in women with CAH and their unaffected sisters in order to inform future research questions and approaches that are most likely to reveal organizational hormone effects on brain structure and function.
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Affiliation(s)
- Adriene M Beltz
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
| | | | - Stephen J Wilson
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
| | - Sheri A Berenbaum
- Department of Psychology, The Pennsylvania State University, University Park, PA, USA
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6
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Auer MK, Nordenström A, Lajic S, Reisch N. Congenital adrenal hyperplasia. Lancet 2023; 401:227-244. [PMID: 36502822 DOI: 10.1016/s0140-6736(22)01330-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 05/17/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders leading to multiple complex hormonal imbalances caused by various enzyme deficiencies in the adrenal steroidogenic pathway. The most common type of congenital adrenal hyperplasia is due to steroid 21-hydroxylase (21-OHase, henceforth 21OH) deficiency. The rare, classic (severe) form caused by 21OH deficiency is characterised by life-threatening adrenal crises and is the most common cause of atypical genitalia in neonates with 46,XX karyotype. After the introduction of life-saving hormone replacement therapy in the 1950s and neonatal screening programmes in many countries, nowadays neonatal survival rates in patients with congenital adrenal hyperplasia are high. However, disease-related mortality is increased and therapeutic management remains challenging, with multiple long-term complications related to treatment and disease affecting growth and development, metabolic and cardiovascular health, and fertility. Non-classic (mild) forms of congenital adrenal hyperplasia caused by 21OH deficiency are more common than the classic ones; they are detected clinically and primarily identified in female patients with hirsutism or impaired fertility. Novel treatment approaches are emerging with the aim of mimicking physiological circadian cortisol rhythm or to reduce adrenal hyperandrogenism independent of the suppressive effect of glucocorticoids.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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7
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Van't Westeinde A, Padilla N, Siqueiros Sanchez M, Fletcher-Sandersjöö S, Kämpe O, Bensing S, Lajic S. Brain structure in autoimmune Addison's disease. Cereb Cortex 2022; 33:4915-4926. [PMID: 36227196 PMCID: PMC10110435 DOI: 10.1093/cercor/bhac389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/12/2022] Open
Abstract
Long-term disturbances in cortisol levels might affect brain structure in individuals with autoimmune Addison's disease (AAD). This study investigated gray and white matter brain structure in a cohort of young adults with AAD. T1- and diffusion-weighted images were acquired for 52 individuals with AAD and 70 healthy controls, aged 19-43 years, using magnetic resonance imaging. Groups were compared on cortical thickness, surface area, cortical gray matter volume, subcortical volume (FreeSurfer), and white matter microstructure (FSL tract-based spatial statistics). Individuals with AAD had 4.3% smaller total brain volume. Correcting for head size, we did not find any regional structural differences, apart from reduced volume of the right superior parietal cortex in males with AAD. Within the patient group, a higher glucocorticoid (GC) replacement dose was associated with smaller total brain volume and smaller volume of the left lingual gyrus, left rostral anterior cingulate cortex, and right supramarginal gyrus. With the exception of smaller total brain volume and potential sensitivity of the parietal cortex to GC disturbances in men, brain structure seems relatively unaffected in young adults with AAD. However, the association between GC replacement dose and reduced brain volume may be reason for concern and requires follow-up study.
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Affiliation(s)
- Annelies Van't Westeinde
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Karolinskavagen 37A, SE-171 76 Stockholm, Sweden
| | - Nelly Padilla
- Unit for Neonatology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Karolinskavagen 37A, SE-171 76 Stockholm, Sweden
| | - Monica Siqueiros Sanchez
- Brain Imaging, Development and Genetics (BRIDGE) Lab, Division of Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5101, United States
| | - Sara Fletcher-Sandersjöö
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Olle Kämpe
- Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.,Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Karolinskavagen 37A, SE-171 76 Stockholm, Sweden
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8
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Messina V, van’t Westeinde A, Padilla N, Lajic S. First Trimester Dexamethasone Treatment Is Not Associated With Alteration in Resting-state Connectivity at Adolescent or Adult Age. J Clin Endocrinol Metab 2022; 107:2769-2776. [PMID: 35882216 PMCID: PMC9516042 DOI: 10.1210/clinem/dgac426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Indexed: 11/28/2022]
Abstract
CONTEXT Prenatal treatment with dexamethasone (DEX) has been used to prevent virilization in females at risk of congenital adrenal hyperplasia (CAH). Both affected and unaffected girls, as well boys, are treated until the genotype and sex of the fetus is known (gestational weeks 10-12). After that, only affected girls are treated until term. Exposure to a high synthetic glucocorticoid dosage may alter the developmental trajectory of the brain, with alterations in resting-state functional connectivity of the brain at adult age. OBJECTIVE To investigate resting-state functional connectivity in subjects at risk of having CAH, exposed to DEX treatment during the first trimester of fetal life, both in the whole brain and in 3 regions of interest (amygdala, hippocampus, and superior frontal gyrus). DESIGN, SETTING, AND PARTICIPANTS Eighteen participants (8 females) at risk of having CAH, exposed to DEX treatment, and 38 controls (24 females), age range 16 to 26 years, from a single research institute, underwent functional magnetic resonance imaging of the brain during rest. We used 2 different approaches: an exploratory whole-brain analysis and seed-based analysis. For seed-based analysis, we chose 3 different brain regions (amygdala, hippocampus, and superior frontal gyrus) based on our previous findings and literature evidence. RESULTS We did not observe any differences in functional connectivity during rest, either in the whole brain nor in seed-based connectivity analyses at this adolescent and young adult age. CONCLUSIONS Our results are reassuring; however, future studies on larger samples and with more sensitive methodologies are needed to confirm these findings.
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Affiliation(s)
- Valeria Messina
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit (QB83), Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Annelies van’t Westeinde
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit (QB83), Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Nelly Padilla
- Department of Women’s and Children’s Health, Karolinska Institutet, Karolinska vägen 8 (S3:03), Karolinska University Hospital, SE- 171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Correspondence: Svetlana Lajic, MD, Department of Women’s and Children’s Health, Pediatric Endocrinology Unit (QB83), Karolinska vägen 37A, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
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9
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Nordenström A, Lajic S, Falhammar H. Long-Term Outcomes of Congenital Adrenal Hyperplasia. Endocrinol Metab (Seoul) 2022; 37:587-598. [PMID: 35799332 PMCID: PMC9449109 DOI: 10.3803/enm.2022.1528] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/11/2022] Open
Abstract
A plethora of negative long-term outcomes have been associated with congenital adrenal hyperplasia (CAH). The causes are multiple and involve supra-physiological gluco- and mineralocorticoid replacement, excess adrenal androgens both intrauterine and postnatal, elevated steroid precursor and adrenocorticotropic hormone levels, living with a congenital condition as well as the proximity of the cytochrome P450 family 21 subfamily A member 2 (CYP21A2) gene to other genes. This review aims to discuss the different long-term outcomes of CAH.
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Affiliation(s)
- Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Corresponding author: Henrik Falhammar. Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden Tel: +46-851776411, Fax: +46-851773096, E-mail:
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10
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Alex AM, Ruvio T, Xia K, Jha SC, Girault JB, Wang L, Li G, Shen D, Cornea E, Styner MA, Gilmore JH, Knickmeyer RC. Influence of gonadal steroids on cortical surface area in infancy. Cereb Cortex 2022; 32:3206-3223. [PMID: 34952542 PMCID: PMC9340392 DOI: 10.1093/cercor/bhab410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/27/2022] Open
Abstract
Sex differences in the human brain emerge as early as mid-gestation and have been linked to sex hormones, particularly testosterone. Here, we analyzed the influence of markers of early sex hormone exposure (polygenic risk score (PRS) for testosterone, salivary testosterone, number of CAG repeats, digit ratios, and PRS for estradiol) on the growth pattern of cortical surface area in a longitudinal cohort of 722 infants. We found PRS for testosterone and right-hand digit ratio to be significantly associated with surface area, but only in females. PRS for testosterone at the most stringent P value threshold was positively associated with surface area development over time. Higher right-hand digit ratio, which is indicative of low prenatal testosterone levels, was negatively related to surface area in females. The current work suggests that variation in testosterone levels during both the prenatal and postnatal period may contribute to cortical surface area development in female infants.
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Affiliation(s)
- Ann Mary Alex
- Neuroengineering Division, Institute for Quantitative Health Sciences and Engineering, Michigan State University, East Lansing, MI 48824, USA
| | - Tom Ruvio
- Neuroengineering Division, Institute for Quantitative Health Sciences and Engineering, Michigan State University, East Lansing, MI 48824, USA
| | - Kai Xia
- Department of Psychiatry, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, USA
| | - Shaili C Jha
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Jessica B Girault
- Department of Psychiatry, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, USA
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Li Wang
- Department of Radiology and Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Gang Li
- Department of Radiology and Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Dinggang Shen
- School of Biomedical Engineering, ShanghaiTech University, Shanghai 201210, China
- Department of Artificial Intelligence, Korea University, Seoul 02841, Republic of Korea
| | - Emil Cornea
- Department of Psychiatry, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, USA
| | - Martin A Styner
- Department of Psychiatry, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - John H Gilmore
- Department of Psychiatry, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, USA
| | - Rebecca C Knickmeyer
- Address correspondence to Rebecca C. Knickmeyer, Institute for Quantitative Health Science and Engineering, 775 Woodlot Dr, East Lansing, MI 48824, USA.
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11
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Rajagopalan V, Overholtzer LN, Kim WS, Wisnowski JL, Miller DA, Geffner ME, Kim MS. A Case of Prenatally Diagnosed Congenital Adrenal Hyperplasia With Brain Morphometric Differences. J Investig Med High Impact Case Rep 2022; 10:23247096221105245. [PMID: 35723282 PMCID: PMC9344108 DOI: 10.1177/23247096221105245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
We report a case of a fetus with a prenatal diagnosis of classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. Although CAH is typically assessed postnatally, this fetal case had multiple prenatal clinical assessments made feasible by an interdisciplinary CAH center. The approach facilitated the development and delivery of comprehensive and earlier care for the fetus, and the family living with this complex, congenital condition, with perinatology, endocrinology, genetic counseling, psychology, and urology involvement. As well, the addition of fetal MRI to standard ultrasound revealed significant deficits in the biparietal diameter, occipitofrontal diameter, and total intracranial volume of the fetal CAH brain. These early anomalies in the brain suggest that neurological comorbidities observed in older children and adults with CAH should be studied as early as prenatally, with the addition of fetal MRI to ultrasound potentially being useful for identifying and understanding prenatal anomalies in CAH.
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Affiliation(s)
- Vidya Rajagopalan
- Children’s Hospital Los Angeles, CA,
USA,University of Southern California, Los
Angeles, CA, USA
| | - Lloyd Nate Overholtzer
- Children’s Hospital Los Angeles, CA,
USA,University of Southern California, Los
Angeles, CA, USA
| | | | - Jessica L. Wisnowski
- Children’s Hospital Los Angeles, CA,
USA,University of Southern California, Los
Angeles, CA, USA
| | - David A. Miller
- Children’s Hospital Los Angeles, CA,
USA,University of Southern California, Los
Angeles, CA, USA
| | - Mitchell E. Geffner
- Children’s Hospital Los Angeles, CA,
USA,University of Southern California, Los
Angeles, CA, USA
| | - Mimi S. Kim
- Children’s Hospital Los Angeles, CA,
USA,University of Southern California, Los
Angeles, CA, USA,Mimi S. Kim, MD, MSc, Center for
Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, 4650
Sunset Boulevard, Mailstop #61, Los Angeles, CA 90027, USA.
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12
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Wang J, Chen F, Zhu S, Li X, Shi W, Dai Z, Hao L, Wang X. Adverse effects of prenatal dexamethasone exposure on fetal development. J Reprod Immunol 2022; 151:103619. [DOI: 10.1016/j.jri.2022.103619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 02/20/2022] [Accepted: 03/24/2022] [Indexed: 12/15/2022]
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13
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Bakker J. The role of steroid hormones in the sexual differentiation of the human brain. J Neuroendocrinol 2022; 34:e13050. [PMID: 34708466 DOI: 10.1111/jne.13050] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/03/2021] [Accepted: 10/05/2021] [Indexed: 12/31/2022]
Abstract
Widespread sex differences in human brain structure and function have been reported. Research on animal models has demonstrated that sex differences in brain and behavior are induced by steroid hormones during specific, hormone sensitive, developmental periods. It was shown that typical male neural and behavioral characteristics develop under the influence of testosterone, mostly acting during perinatal development. By contrast, typical female neural and behavioral characteristics may actually develop under the influence of estradiol during a specific prepubertal period. This review provides an overview of our current knowledge on the role of steroid hormones in the sexual differentiation of the human brain. Both clinical and neuroimaging data obtained in patients with altered androgen levels/actions (i.e., congenital adrenal hyperplasia or complete androgen insensitivity syndrome [CAIS]), point to an important role of (prenatal) androgens in inducing typical male neural and psychosexual characteristics in humans. In contrast to rodents, there appears to be no obvious role for estrogens in masculinizing the human brain. Furthermore, data from CAIS also suggest a contribution of sex chromosome genes to the development of the human brain. The final part of this review is dedicated to a brief discussion of gender incongruence, also known as gender dysphoria, which has been associated with an altered or less pronounced sexual differentiation of the brain.
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Affiliation(s)
- Julie Bakker
- Neuroendocrinology, GIGA Neurosciences, Liège University, Liege, Belgium
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14
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Nordenström A, Falhammar H, Lajic S. Current and Novel Treatment Strategies in Children with Congenital Adrenal Hyperplasia. Horm Res Paediatr 2022; 96:560-572. [PMID: 35086098 DOI: 10.1159/000522260] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The standard treatment for congenital adrenal hyperplasia (CAH) in children is still hydrocortisone. Improved strategies for timing of the dose during the day and the dose per square meter body surface area used in children of different ages and developmental phases have improved the situation and outcome for the patients. Neonatal screening enables an earlier diagnosis and initiation of treatment, prevents from adrenal crisis, and improves growth and development also for children with the less severe forms of CAH. SUMMARY This review describes the current treatment strategies for children with CAH and discusses some potential treatment options that have been developed with the primary aim to decrease the adrenal androgen production. Novel modified release glucocorticoid therapies are also discussed. KEY MESSAGES The long-term effects of the new adjunct therapies are unknown, and some are not suitable for use in children and adolescents. The effects of the new therapies on bone mineral density, gonadal functions, and long-term cognitive development are yet to be assessed. It is not known what levels of adrenal androgens are optimal for normal growth, puberty, and bone health. The basis of using glucocorticoids and mineralocorticoids in the treatment of CAH remains, and in some individuals, it may be beneficial to add therapies to reduce the androgen load during certain life stages.
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Affiliation(s)
- Anna Nordenström
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Department of Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 132] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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Changes in resting-state functional connectivity in patients with congenital adrenal hyperplasia. NEUROIMAGE: CLINICAL 2022; 35:103081. [PMID: 35700599 PMCID: PMC9194649 DOI: 10.1016/j.nicl.2022.103081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 11/25/2022] Open
Abstract
Patients with CAH showed increased functional connectivity during rest in the precuneus compared with controls. This change may reflect a functional reorganisation in response to the CAH disease. The change in functional connectivity may also depend on the severity of CAH.
Context Patients with congenital adrenal hyperplasia (CAH) are treated with life-long glucocorticoid (GC) replacement therapy. Negative effects on cognition, brain structure and function during working memory tasks have been identified. To date, no studies on functional connectivity during rest have been performed in patients with CAH. Objective To investigate resting-state functional connectivity in patients with CAH compared with healthy untreated controls and the association between functional connectivity in the precuneus and disease severity, dose of GC and working memory (WM). Design, Setting and Participants Thirty-one patients with CAH (18 females) and 38 healthy controls (24 females), aged 16–33 years, from a single research institute, underwent functional magnetic resonance imaging of the brain during rest. Results Patients with CAH showed increased functional connectivity in the precuneus compared with controls. Post-hoc tests within the precuneus showed that only patients with simple virilising CAH had stronger connectivity compared to controls. Further, while both patients with salt-wasting and simple virilising CAH performed worse on a WM task compared to controls, functional connectivity in the precuneus was not associated with executive function performance. Conclusion Patients with CAH demonstrated altered functional connectivity during rest in the precuneus. Such a change may reflect a functional reorganisation in response to the CAH disease. The change in functional connectivity may depend on the severity of CAH.
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Cotter DL, Azad A, Cabeen RP, Kim MS, Geffner ME, Sepehrband F, Herting MM. White Matter Microstructural Differences in Youth With Classical Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:3196-3212. [PMID: 34272858 PMCID: PMC8530716 DOI: 10.1210/clinem/dgab520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Gray matter morphology in the prefrontal cortex and subcortical regions, including the hippocampus and amygdala, are affected in youth with classical congenital adrenal hyperplasia (CAH). It remains unclear if white matter connecting these aforementioned brain regions is compromised in youth with CAH. OBJECTIVE To examine brain white matter microstructure in youth with CAH compared to controls. DESIGN A cross-sectional sample of 23 youths with CAH due to 21-hydroxylase deficiency (12.9 ± 3.5 year; 61% female) and 33 healthy controls (13.1 ± 2.8 year; 61% female) with 3T multishell diffusion-weighted magnetic resonance brain scans. MAIN OUTCOME MEASURES Complementary modeling approaches, including diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI), to examine in vivo white matter microstructure in six white matter tracts that innervate the prefrontal and subcortical regions. RESULTS DTI showed CAH youth had lower fractional anisotropy in both the fornix and stria terminalis and higher mean diffusivity in the fornix compared to controls. NODDI modeling revealed that CAH youth have a significantly higher orientation dispersion index in the stria terminalis compared to controls. White matter microstructural integrity was associated with smaller hippocampal and amygdala volumes in CAH youth. CONCLUSIONS These patterns of microstructure reflect less restricted water diffusion likely due to less coherency in oriented microstructure. These results suggest that white matter microstructural integrity in the fornix and stria terminalis is compromised and may be an additional related brain phenotype alongside affected hippocampus and amygdala neurocircuitry in individuals with CAH.
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Affiliation(s)
- Devyn L Cotter
- Neuroscience Graduate Program, University of Southern California, Los Angeles, CA, USA
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anisa Azad
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ryan P Cabeen
- Laboratory of Neuro Imaging, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mimi S Kim
- Center for Endocrinology, Diabetes, and Metabolism, and The Saban Research Institute at Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mitchell E Geffner
- Center for Endocrinology, Diabetes, and Metabolism, and The Saban Research Institute at Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Farshid Sepehrband
- Laboratory of Neuro Imaging, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Megan M Herting
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Center for Endocrinology, Diabetes, and Metabolism, and The Saban Research Institute at Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Abstract
PURPOSE OF REVIEW The introduction of synthetic glucocorticoids 70 years ago made survival possible in classic 21-hydroxylase deficiency (21OHD). The currently used glucocorticoid therapy may lead to unphysiological dosing with negative consequencies on health in addition to the problems that may arise due to androgen over-exposure. RECENT FINDINGS Fertility in females with 21OHD seemed to be impaired, especially in the salt-wasting (SW) phenotype but when pregnancies did occur there was a higher risk for gestational diabetes and cesearean section. Increased fat mass, body mass index, insulin resistance and frequency of autoimmune disorders as well as impaired echocardiographic parameters and lower bone mineral density were found in 21OHD compared to controls. Negative effects on cognitive functions have been identified. Adrenal tumors, especially myelolipomas, were prevalent. Increased knowledge on steroid metabolism in 21OHD and urine steroid profiling may improve assessment of treatment efficacy. Nevanimibe, abiraterone acetate and anastrozole may have a place in the future management of 21OHD. Long-acting glucocorticoids may be a less favorable, especially dexamethasone. SUMMARY The various clinical outcomes need regular monitoring. Negative consequencies are to large extent the result of the unphysiological glucocorticoid replacement. Modern management with improved follow-up and future addition of new drugs may improve outcomes.
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Affiliation(s)
- Anna Nordenström
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital
- Department of Women's and Children's Health, Karolinska Institutet
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital
- Department of Women's and Children's Health, Karolinska Institutet
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital
- Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Lajic S, Karlsson L, Zetterström RH, Falhammar H, Nordenström A. The Success of a Screening Program Is Largely Dependent on Close Collaboration between the Laboratory and the Clinical Follow-Up of the Patients. Int J Neonatal Screen 2020; 6:68. [PMID: 33117907 PMCID: PMC7569867 DOI: 10.3390/ijns6030068] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/24/2020] [Indexed: 02/05/2023] Open
Abstract
Neonatal screening for congenital adrenal hyperplasia due to 21-hydroxylase deficiency is now performed in an increasing number of countries all over the world. The main goal of the screening is to achieve early diagnosis and treatment in order to prevent neonatal salt-crisis and death. The screening laboratory can also play an important role in increasing the general awareness of the disease and act as the source of information and education for clinicians to facilitate improved initial care, ensure prompt and correct glucocorticoid dosing to optimize the long-term outcome for the patients. A National CAH Registry and CYP21A2 genotyping provide valuable information both for evaluating the screening program and the clinical outcome. The Swedish experience is described.
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Affiliation(s)
- Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176 Stockholm, Sweden; (S.L.); (L.K.)
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-17176 Stockholm, Sweden
| | - Leif Karlsson
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176 Stockholm, Sweden; (S.L.); (L.K.)
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, SE-17176 Stockholm, Sweden;
| | - Rolf H Zetterström
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, SE-17176 Stockholm, Sweden;
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176 Stockholm, Sweden;
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176 Stockholm, Sweden;
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, SE-17176 Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176 Stockholm, Sweden; (S.L.); (L.K.)
- Pediatric Endocrinology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-17176 Stockholm, Sweden
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, SE-17176 Stockholm, Sweden;
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