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Lazarus K, Hayes A, Narula K, Papadopolou D, Tan TMM, Meeran K, Choudhury S. Redefining ITT cortisol thresholds on Abbott platforms to prevent misdiagnosis of adrenal insufficiency. Clin Endocrinol (Oxf) 2024. [PMID: 38798198 DOI: 10.1111/cen.15074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/11/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Adrenal insufficiency (AI) is a life-threatening condition which requires long term glucocorticoid replacement. The insulin tolerance test (ITT) is the current gold standard test for diagnosis of secondary AI, but the widely accepted cut-off value of a peak cortisol of less than 500 nmol/L assumes that anyone who does not reach this value has AI and thus requires full replacement. The cut-off used to diagnose AI is also founded on outdated assays. Use of this cut-off in an era of more specific immunoassays therefore risks misdiagnosis, subsequent unnecessary glucocorticoid exposure and associated adverse effects with increased mortality risk. DESIGN, PATIENTS AND MEASUREMENTS This retrospective analysis assessed 300 ITT cortisol responses using the Abbott Architect and Alinity analyser platforms in patients with suspected AI over a period of 12 years (August 2010 to January 2022), at a tertiary centre. RESULTS Patients were classified as having AI or not, based on a comprehensive clinical review of electronic patient records from the point of test to the present day by a panel of pituitary and adrenal specialists. Using the current institutional cut-off value of 500 nmol/L, receiver operating characteristic analysis identified a 100.0% sensitivity and 43.6% specificity (area under the curve 0.979). Using a lower cortisol threshold value of 416 nmol/L on the Abbott analyser platform maintained a sensitivity of 100.0% and improved the specificity to 86.7%. CONCLUSION This data supports lowering the Abbott analyser ITT peak cortisol threshold to 416 nmol/L. Use of this improved cut-off avoids unnecessary glucocorticoid replacement therapy in 104 (34.7%) of individuals in this study. All patients remained well with at least 1 year longitudinal follow up of glucocorticoid replacement.
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Affiliation(s)
- Katharine Lazarus
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Annabel Hayes
- Department of Metabolism, Digestion and Reproduction, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Kavita Narula
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Debbie Papadopolou
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Tricia M-M Tan
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
- Department of Clinical Biochemistry, North West London Pathology, London, UK
| | - Karim Meeran
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Sirazum Choudhury
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
- Department of Clinical Biochemistry, North West London Pathology, London, UK
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Fu VX, Lagarde SM, Favoccia CT, Heisterkamp J, van Oers AE, Coene PPLO, Koopman JSHA, van den Berg SAA, Dik WA, Jeekel J, Wijnhoven BPL. Intraoperative Music to Promote Patient Outcome (IMPROMPTU): A Double-Blind Randomized Controlled Trial. J Surg Res 2024; 296:291-301. [PMID: 38306934 DOI: 10.1016/j.jss.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 12/03/2023] [Accepted: 01/02/2024] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Perioperative music can have beneficial effects on postoperative pain, anxiety, opioid requirement, and the physiological stress response to surgery. The aim was to assess the effects of intraoperative music during general anesthesia in patients undergoing surgery for esophagogastric cancer. MATERIALS AND METHODS The IMPROMPTU study was a double-blind, placebo-controlled, randomized multicenter trial. Adult patients undergoing surgery for stage II-III esophagogastric cancer were eligible. Exclusion criteria were a hearing impairment, insufficient Dutch language knowledge, corticosteroids use, or objection to hearing unknown music. Patients wore active noise-cancelling headphones intraoperatively with preselected instrumental classical music (intervention) or no music (control). Computerized randomization with centralized allocation, stratified according to surgical procedure using variable block sizes, was employed. Primary endpoint was postoperative pain on the first postoperative day. Secondary endpoints were postoperative pain during the first postoperative week, postoperative opioid requirement, intraoperative medication requirement, the stress response to surgery, postoperative complication rate, length of stay, and mortality, with follow-up lasting 30 d. RESULTS From November 2018 to September 2020, 145 patients were assessed and 83 randomized. Seventy patients (music n = 31, control n = 39) were analyzed. Median age was 70 [IQR 63-70], and 48 patients (69%) were male. Music did not reduce postoperative pain (numeric rating scale 1.8 (SD0.94) versus 2.0 (1.0), mean difference -0.28 [95% CI -0.76-0.19], P = 0.236). No statistically significant differences were seen in medication requirement, stress response, complication rate, or length of stay. CONCLUSIONS Intraoperative, preselected, classical music during esophagogastric cancer surgery did not significantly improve postoperative outcome and recovery when compared to no music using noise-cancelling headphones.
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Affiliation(s)
- Victor X Fu
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Christian T Favoccia
- Department of Anesthesiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Annemarie E van Oers
- Department of Anesthesiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | | | - Sjoerd A A van den Berg
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Willem A Dik
- Department of Immunology, Laboratory Medical Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Department of Neuroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Zarour S, Weiss Y, Kiselevich Y, Iacubovici L, Karol D, Shaylor R, Davydov T, Matot I, Cohen B. The association between midazolam premedication and postoperative delirium - a retrospective cohort study. J Clin Anesth 2024; 92:111113. [PMID: 37280146 DOI: 10.1016/j.jclinane.2023.111113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/17/2023] [Accepted: 03/17/2023] [Indexed: 06/08/2023]
Abstract
STUDY OBJECTIVE To evaluate the association between midazolam premedication and postoperative delirium in a large retrospective cohort of patients ≥70 years. DESIGN Retrospective cohort study. SETTING A single tertiary academic medical center. PATIENTS Patients ≥70 years having elective non-cardiac surgery under general anesthesia from 2020 to 2021. INTERVENTIONS Midazolam premedication, defined as intravenous midazolam administration prior to induction of general anesthesia. MEASUREMENTS The primary outcome, postoperative delirium, was a collapsed composite outcome including at least one of the following: a positive 4A's test during post-anesthesia care unit stay and/or the initial 2 postoperative days; physician or nursing records reporting new-onset confusion as captured by the CHART-DEL instrument; or a positive 3D-CAM test. The association between midazolam premedication and postoperative delirium was assessed using multivariable logistic regression, adjusting for potential confounding variables. As secondary analysis, we investigated the association between midazolam premedication and a composite of other postoperative complications. Several sensitivity analyses were performed using similar regression models. MAIN RESULTS In total, 1973 patients were analyzed (median age 75 years, 47% women, 50% ASA score ≥ 3, 32% high risk surgery). The overall incidence of postoperative delirium was 15.3% (302/1973). Midazolam premedication was administered to 782 (40%) patients (median [IQR] dose 2 [1,2] mg). After adjustment for potential confounding variables, midazolam premedication was not associated with increased odds of postoperative delirium, with adjusted odds ratio of 1.09 (95% confidence interval 0.82-1.45; P = 0.538). Midazolam premedication was also not associated with the composite of other postoperative complications. Furthermore, no association was found between midazolam premedication and postoperative delirium in any of the sensitivity analyses preformed. CONCLUSIONS Our results suggest that low doses of midazolam can be safely used to pre-medicate elective surgical patients 70 years or older before non-cardiac surgery, without significant effect on the risk of developing postoperative delirium.
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Affiliation(s)
- Shiri Zarour
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yotam Weiss
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yossef Kiselevich
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Liat Iacubovici
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Karol
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Ruth Shaylor
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Tamara Davydov
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Barak Cohen
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel; Outcomes Research Consortium, Cleveland, OH, United States of America.
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Chen Cardenas SM, Santhanam P, Morris-Wiseman L, Salvatori R, Hamrahian AH. Perioperative Evaluation and Management of Patients on Glucocorticoids. J Endocr Soc 2022; 7:bvac185. [PMID: 36545644 PMCID: PMC9760550 DOI: 10.1210/jendso/bvac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Indexed: 12/04/2022] Open
Abstract
Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.
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Affiliation(s)
- Stanley M Chen Cardenas
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Prasanna Santhanam
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lilah Morris-Wiseman
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Amir H Hamrahian
- Correspondence: Amir Hamrahian, MD, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 E Monument St, Ste 333, Baltimore, MD 21287, USA.
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Santander Ballestín S, Lanuza Bardaji A, Marco Continente C, Luesma Bartolomé MJ. Antitumor Anesthetic Strategy in the Perioperatory Period of the Oncological Patient: A Review. Front Med (Lausanne) 2022; 9:799355. [PMID: 35252243 PMCID: PMC8894666 DOI: 10.3389/fmed.2022.799355] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/11/2022] [Indexed: 12/13/2022] Open
Abstract
The stress response triggered by the surgical aggression and the transient immunosuppression produced by anesthetic agents stimulate the inadvertent dispersion of neoplastic cells and, paradoxically, tumor progression during the perioperative period. Anesthetic agents and techniques, in relation to metastatic development, are investigated for their impact on long-term survival. Scientific evidence indicates that inhaled anesthetics and opioids benefit immunosuppression, cell proliferation, and angiogenesis, providing the ideal microenvironment for tumor progression. The likely benefit of reducing their use, or even replacing them as much as possible with anesthetic techniques that protect patients from the metastatic process, is still being investigated. The possibility of using "immunoprotective" or "antitumor" anesthetic techniques would represent a turning point in clinical practice. Through understanding of pharmacological mechanisms of anesthetics and their effects on tumor cells, new perioperative approaches emerge with the aim of halting and controlling metastatic development. Epidural anesthesia and propofol have been shown to maintain immune activity and reduce catecholaminergic and inflammatory responses, considering the protective techniques against tumor spread. The current data generate hypotheses about the influence of anesthesia on metastatic development, although prospective trials that determinate causality are necessary to make changes in clinical practice.
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Affiliation(s)
- Sonia Santander Ballestín
- Department of Pharmacology, Physiology and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
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Amiri-Dashatan N, Koushki M, Parsamanesh N, Chiti H. Serum cortisol concentration and COVID-19 severity: a systematic review and meta-analysis. J Investig Med 2022; 70:766-772. [DOI: 10.1136/jim-2021-001989] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 12/11/2022]
Abstract
The novel COVID-19 outbreak is a major health threat to human beings with multiorgan injuries. However, its endocrine system manifestations are much less studied. In this study, we aimed to reassess the available findings on the association between cortisol level and severity of COVID-19 infection. We conducted a systematic search on Medline/PubMed, Scopus, Web of Science, and Cochrane Library databases. To pool data, a random-effects model was performed depending on the heterogeneity among studies. Sensitivity analysis was also carried out by removing each study systematically. In addition, subgroup and meta-regression analyses were performed depending on the presence of the variables of sex and age. Subsequently, 11 studies (5 observational studies and 6 case reports) were included in the meta-analysis. Pooled analysis on the observational studies showed significantly higher levels of cortisol in patients with severe COVID-19 in comparison with those with mild-to-moderate COVID-19 (standardized mean difference: 1.48 µg/dL; 95% CI (0.51 to 2.46); p=0.003). Assessment of the results of case reports revealed that the patients with severe COVID-19 demonstrated higher cortisol levels than the patients with mild-to-moderate COVID-19. No publication bias was observed using the Begg’s (p=0.08) and Egger’s tests (p=0.09). Meta-regression illustrated a significant correlation between cortisol levels with sex. The serum cortisol level seems to be higher in patients with severe COVID-19 infection. This finding could be helpful to detect patients with poor prognosis at early stages of the disease, although age and sex may modify this level.
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Fu VX, Jeekel J, Van Lieshout EMM, Van der Velde D, Slegers LJP, Haverlag R, Haumann J, Poley MJ, Verhofstad MHJ. Effect of music on clinical outcome after hip fracture operations (MCHOPIN): study protocol of a multicentre randomised controlled trial. BMJ Open 2021; 11:e049706. [PMID: 34949611 PMCID: PMC8705073 DOI: 10.1136/bmjopen-2021-049706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Patients undergoing proximal femur fracture surgery are at high risk of postoperative complications, with postoperative delirium occurring in 25%-40% of patients. Delirium has profound effects on patient outcome and recovery, the patient's family, caregivers and medical costs. Perioperative music has a beneficial effect on eliciting modifiable risk factors of delirium. Therefore, the aim of this trial was to evaluate the effect of perioperative recorded music on postoperative delirium in patients with proximal femur fracture undergoing surgery. METHODS AND ANALYSIS The Music on Clinical Outcome after Hip Fracture Operations study is an investigator-initiated, multicentre, randomised controlled, open-label, clinical trial. Five hundred and eight patients with proximal femur fracture meeting eligibility criteria will be randomised to the music intervention or control group with concealed allocation in a 1:1 ratio, stratified by hospital site. The perioperative music intervention consists of preselected lists totalling 30 hours of music, allowing participants to choose their preferred music from these lists (classical, jazz and blues, pop and Dutch). The primary outcome measure is postoperative delirium rate. Secondary outcome measures include pain, anxiety, medication requirement, postoperative complications, hospital length of stay and 30-day mortality. A 90-day follow-up will be performed in order to assess nursing home length of stay, readmission rate and functional ability to perform daily living activities. Furthermore, the cost and cost-effectiveness of the music intervention will be assessed. Data will be analysed according to an intention-to-treat principle. ETHICS AND DISSEMINATION The study protocol has been approved by the Medical Research Ethics Committee Erasmus MC on 8 October 2018 (MEC-2018-110, NL64721.078.18). The trial will be carried out following the Declaration of Helsinki principles, Good Clinical Practice guidelines and Dutch Medical Research Involving Human Subjects Act. Research data will be reported following Consolidated Standards of Reporting Trials guidelines and study results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NTR7036.
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Affiliation(s)
- Victor X Fu
- Trauma Research Unit, Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Department of Neuroscience, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Leonie J P Slegers
- Department of Anaesthesiology, Sint Antonius Ziekenhuis, Utrecht, The Netherlands
| | - Robert Haverlag
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Johan Haumann
- Department of Anaesthesiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Marten J Poley
- Institute for Medical Technology Assessment, Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
- Department of Pediatric Surgery and Intensive Care, Erasmus MC, Rotterdam, The Netherlands
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Kim MH, Kim NY, Yoo YC, Kong HJ, Lee HS, Jo A, Bai SJ. Influence of Deep Neuromuscular Blockade on Perioperative Stress Response in Patients Undergoing Robot-Assisted Gastrectomy: A Prospective Double-Blinded Randomized-Controlled Trial. J Pers Med 2021; 11:jpm11121308. [PMID: 34945780 PMCID: PMC8703636 DOI: 10.3390/jpm11121308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 12/17/2022] Open
Abstract
Attenuating the intraoperative stress response is crucial; however, the effect of neuromuscular blockade (NMB) on surgical stress is not completely understood. We aimed to investigate the effects of NMB on the perioperative stress response during robot-assisted gastrectomy. Patients were assigned to the deep or moderate NMB group. Serum cortisol, prolactin, and interleukin-6 (IL-6) levels and natural killer (NK) cell percentage were measured before anesthesia induction, 90 min after pneumoperitoneum, operation end (OPEnd), and postoperative day 1. Additionally, C-reactive protein (CRP) and albumin levels were estimated. Additionally, intraoperative heart rate variability was evaluated. The deep NMB group showed significantly lower levels of low-frequency/high-frequency (HF) ratio at OPEnd compared to the moderate NMB group (1.4 ± 0.2 vs. 2.2 ± 0.3, respectively; Bonferroni corrected p = 0.039). Furthermore, HF power in the deep NMB group was significantly higher at OPEnd than that in the moderate NMB group (45.2 ± 3.6 vs. 33.8 ± 4.0, respectively; Bonferroni corrected p = 0.044). However, no significant differences in cortisol, prolactin, IL-6, CRP, and albumin levels and NK cell percentage were found between the two groups. The degree of NMB may have similar effects on stress-related biological markers in patients undergoing robot-assisted gastrectomy.
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Affiliation(s)
- Myoung Hwa Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea; (M.H.K.); (A.J.)
| | - Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (N.Y.K.); (Y.C.Y.); (H.J.K.)
| | - Young Chul Yoo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (N.Y.K.); (Y.C.Y.); (H.J.K.)
| | - Hee Jung Kong
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (N.Y.K.); (Y.C.Y.); (H.J.K.)
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea;
| | - Arim Jo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea; (M.H.K.); (A.J.)
| | - Sun Joon Bai
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (N.Y.K.); (Y.C.Y.); (H.J.K.)
- Correspondence: ; Tel.: +82-2-2228-4435
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Ramadoss V, Lazarus K, Prevost AT, Tan T, Meeran K, Choudhury S. Improving the Interpretation of Afternoon Cortisol Levels and SSTs to Prevent Misdiagnosis of Adrenal Insufficiency. J Endocr Soc 2021; 5:bvab147. [PMID: 34611573 PMCID: PMC8486915 DOI: 10.1210/jendso/bvab147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adrenal Insufficiency (AI), especially iatrogenic-AI, is a treatable cause of mortality. The difficulty in obtaining 9 am cortisol levels means samples are taken at suboptimal times, including a substantial proportion in the afternoon. Low afternoon cortisol levels often provoke short Synacthen tests (SSTs). It is important that this does not lead to patients misdiagnosed with AI, exposing them to the excess mortality and morbidity of inappropriate steroid replacement therapy. METHODS This retrospective study collected 60 178 cortisol results. Medical records, including subsequent SSTs of initial cortisol results measured after midday were reviewed. RESULTS Receiver operating characteristic analysis (area under the curve: 0.89) on 6531 suitable cortisol values showed that a limit of <201.5 nmol/L achieved a sensitivity and specificity of 95.6% and 72.6%, while a limit of <234 nmol/L had a sensitivity of 100% and a specificity of 59.5%. Out of 670 SSTs, 628 patients passed. Of these, 140 would have otherwise failed if only their 30-min cortisol was assessed without the 60-min value. A 30- and 60-min SST cortisol cutoff of 366.5 nmol/L and 418.5 nmol/L, respectively, can achieve a sensitivity of >95% on the Abbott analyser platform. CONCLUSION An afternoon cortisol >234 nmol/L excludes AI on Abbott analyser platforms. In patients who have an afternoon cortisol <234 nmol/L, including both 30- and 60-min SST cortisol values prevents unnecessary glucocorticoid replacement therapy in 22.3% of individuals in this study. The Abbott analyser SST cortisol cutoffs used to define AI should be 366.5 nmol/L and 418.5 nmol/L at 30 and 60 min, respectively. All patients remained well subsequently with at least 1-year longitudinal follow-up.
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Affiliation(s)
- Vijay Ramadoss
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Katharine Lazarus
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Andrew Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King’s College London, London, UK
| | - Tricia Tan
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Clinical Biochemistry, Northwest London Pathology, London, UK
| | - Karim Meeran
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Sirazum Choudhury
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Clinical Biochemistry, Northwest London Pathology, London, UK
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Cheng W, Liu J, Zhi M, Shen D, Shao M, Zhang C, Wang G, Jiang Z. Stress and autonomic nerve dysfunction monitoring in perioperative gastric cancer patients using a smart device. Ann Noninvasive Electrocardiol 2021; 27:e12903. [PMID: 34669995 PMCID: PMC8739623 DOI: 10.1111/anec.12903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/22/2022] Open
Abstract
Background Heart rate variability (HRV), a sensitive marker of stress and autonomic nervous disorders, was significantly decreased in cardiovascular disease, inflammation, and surgical injury. However, the effect of radical gastrectomy on HRV parameters needs to be further investigated. Methods A prospective, observational study including 45 consecutive enrolled patients undergoing radical gastrectomy in our enhanced recovery after surgery (ERAS) programs was conducted. Frequency‐ and time‐domain parameters of HRV from 1 day prior to operation to 4 days postoperatively were continuously measured. Meanwhile, plasma cortisol and inflammatory markers were recorded and correlated to HRV parameters. Results Heart rate variability showed a solidly circadian rhythm. Anesthesia severely disturbed HRV parameters, resulting in a reduction of most of the HRV parameters. Frequency‐domain parameter (including VLF) and time‐domain parameters (including the SDNN, SDANN, and triangular index) of HRV demonstrated a significant reduction compared to preoperative values on the postoperative day 1 (Pod1), and these HRV parameters could return to baseline on Pod2 or Pod3, indicating surgical stress and autonomic nerve dysfunction existed in the early postoperative period. Inflammatory biomarkers were significantly elevated on Pod1 and Pod3. Plasma cortisol decreased significantly on Pod1 and Pod3. Both inflammatory biomarkers and plasma cortisol had no significant correlation with HRV parameters. Conclusions Compared with plasma cortisol and inflammation biomarkers, HRV is more sensitive to detect surgical stress and autonomic nervous dysfunction induced by radical gastrectomy in patients with gastric cancer.
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Affiliation(s)
- Wei Cheng
- Department of General Surgery, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Jiang Liu
- Department of General Surgery, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Mengwei Zhi
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Danli Shen
- Department of General Surgery, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Mingyue Shao
- Department of General Surgery, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Cheng Zhang
- Department of General Surgery, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Gang Wang
- Department of General Surgery, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhiwei Jiang
- Department of General Surgery, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
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11
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Effects of Transcutaneous Electrical Acupoint Stimulation on Stress Response during Intubation and Extubation in Patients Undergoing Video-Assisted Thoracoscopic Surgery: A Prospective, Randomized Controlled Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:1098915. [PMID: 34630601 PMCID: PMC8497099 DOI: 10.1155/2021/1098915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 08/15/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022]
Abstract
Objective The study aimed to evaluate the effect of transcutaneous electrical acupoint stimulation (TEAS) on the stress response during intubation and extubation in patients undergoing video-assisted thoracoscopic surgery (VATS). Methods 122 patients undergoing VATS lobectomy were randomly divided into two groups: the TEAS group (n = 62) and the control group (n = 60). Patients in the TEAS group underwent electroacupuncture stimulation of bilateral Neiguan (PC6), Hegu (L14), Lieque (LU7), and Chize (LU5) acupoints from 30 min before anesthesia to the end of surgery. The patients in the control group did not undergo stimulation. The primary endpoints were the hemodynamic parameters and plasma concentrations of epinephrine, norepinephrine, and cortisol. The secondary endpoints were the consumption of remifentanil and propofol, Ramsay sedation score and arousal time, extubation quality score, and postoperative complications. Results The hemodynamic variables and plasma concentrations of epinephrine, norepinephrine, and cortisol during intubation and extubation were lower in the TEAS group at T1, T3, and T4 compared with the control group. TEAS led to a reduction in the consumption of remifentanil (P < 0.01), as well as a reduction in the incidence of postoperative complications. The extubation quality score was lower (P < 0.01) while the Ramsay sedation score was higher (P < 0.01) in the TEAS group than in the control group. However, the arousal time and consumption of propofol were not significantly different between the two groups. Conclusion TEAS can maintain hemodynamic stability, reduce the stress response during intubation and extubation, improve the quality of anesthesia recovery, and decrease the incidence of postoperative complications in patients undergoing VATS.
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12
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Yau M, Jacob M, Orton S, Howell JD, Lekarev O, Vogiatzi MG, Poppas D, Nimkarn S, Lin-Su K. Perioperative stress dose steroid management of children with classical congenital adrenal hyperplasia: Too much or too little? J Pediatr Urol 2021; 17:654.e1-654.e6. [PMID: 34266748 DOI: 10.1016/j.jpurol.2021.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/21/2021] [Accepted: 06/24/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children with congenital adrenal hyperplasia (CAH) are at risk for adrenal crises in the perioperative period and require higher doses of glucocorticoids. However, there are no specific protocols detailing the appropriate stress dosing required for children with CAH undergoing surgery with anesthesia. OBJECTIVE To evaluate CAH patients using our current hydrocortisone stress dose surgical protocol. We hypothesized that current clinical protocols may overestimate the endogenous response to perioperative stress. STUDY DESIGN 14 children with CAH scheduled to have genital surgery and a control group of 10 unaffected children scheduled to have cardiac or urologic surgery (of a similar duration) were evaluated in a prospective observational study. Urinary free cortisol (UFC) and urinary 17-hydroxycorticosteroids (17-OHCS) per body surface area were measured in the postoperative period. RESULTS UFC levels were significantly higher in CAH patients (115.8 ± 24.6 nmol/m2) than in controls (26.5 ± 12.2 nmol/m2), P < 0.05.17-OHCS levels were also higher in CAH patients than in controls (6.5 ± 0.5 nmol/m2 vs. 3.4 ± 0.5 nmol/m2), P < 0.05). CONCLUSION In the immediate postoperative period, urinary cortisol and its metabolites are significantly higher in pediatric CAH patients receiving stress dose corticosteroids compared to controls. Results suggest that the amount of hydrocortisone given during our stress dose protocol may be higher than physiologic needs. Future dynamic studies are needed to determine appropriate perioperative and postoperative cortisol requirements in pediatric CAH patients in order to develop optimal stress dose regimens.
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Affiliation(s)
- Mabel Yau
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA; Pediatric Endocrinology, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY, 10028, USA.
| | - Marianne Jacob
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
| | - Sarah Orton
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA; Pediatric Endocrinology, Morris Heights Health Center, 85 W. Burnside Ave, Bronx, NY, 10453, USA.
| | - Joy D Howell
- Pediatric Critical Care Medicine, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
| | - Oksana Lekarev
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
| | - Maria G Vogiatzi
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA; Pediatric Endocrinology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Dix Poppas
- Pediatric Urology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
| | - Saroj Nimkarn
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA; Children's Center, Bumrungrad International Hospital, 33 Soi Sukhumvit 3, Khlong Toei Nuea, Watthana, Bangkok, 110110, Thailand.
| | - Karen Lin-Su
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
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13
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Song Y, Liu Y, Yuan Y, Jia X, Zhang W, Wang G, Jia Y, Wang X, Liu L, Li W, Li X, Cai N, Liu C, Li Y, Han Y, Zhou Y, Mi X, Shi C, Wang JQ, Vuylsteke A, Guo X, Li Z. Effects of general versus subarachnoid anaesthesia on circadian melatonin rhythm and postoperative delirium in elderly patients undergoing hip fracture surgery: A prospective cohort clinical trial. EBioMedicine 2021; 70:103490. [PMID: 34280784 PMCID: PMC8318871 DOI: 10.1016/j.ebiom.2021.103490] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/30/2021] [Accepted: 06/30/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Circadian rhythm disturbance is common postoperatively in older patients with hip fractures, which may contribute to the development of postoperative delirium (POD). As a reliable biomarker of endogenous circadian rhythms, melatonin regulates the sleep-wake cycle and environmental adaptation, and its secretory rhythm may be modified by anaesthesia and surgery. This study compared the impact of subarachnoid anaesthesia (SA) and general anaesthesia (GA), on the peak of melatonin secretion (primary outcome), the circadian rhythm of melatonin, cortisol and sleep, and the POD incidence (secondary outcome). METHODS In this prospective cohort observational study, hip fracture surgery patients were enrolled and assigned to receive either SA or GA. Postoperative plasma melatonin and cortisol levels were dynamically measured every six hours on seven time-points, and the circadian rhythm parameters including mesor, amplitude, and acrophase were calculated. Subjective and objective sleep assessments were performed by sleep diaries and sleep trackers, respectively. The Confusion Assessment Method was used twice daily by a specific geriatrician to screen for POD occurrence. FINDINGS In a cohort of 138 patients who underwent hip fracture surgery, the circadian rhythm disruption of the patients in the GA group (n=69) was greater than the SA group (n=69). Compared with SA, GA provided the lower peak concentration, mesor, and amplitude of melatonin secretion on postoperative day 1 (p < 0.05). Patients in the GA group experienced higher awakenings, more sleep deprivation, and poor sleep quality on surgery day (p < 0.05). A proportion of 12 patients in the SA group (17.4%) and 24 patients in the GA group (34.8%) experienced POD (p = 0.020). INTERPRETATION These results suggest that SA may be superior to GA in elderly patients undergoing hip fracture surgery as SA is associated with less impairment of the melatonin rhythm and sleep patterns, and fewer POD occurrences. FUNDING The study was supported by the National Natural Science Foundation of China (81971012, 81873726, 81901095, 81701052, and 81801070), Key Clinical Projects of Peking University Third Hospital (BYSYZD2019027), and Peking University "Clinical Medicine plus X" Youth Project (PKU2020LCXQ016).
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Affiliation(s)
- Yanan Song
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - Yajie Liu
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - Yi Yuan
- Department of Anesthesiology, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China
| | - Xixi Jia
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - Wenchao Zhang
- Department of Anesthesiology, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China
| | - Geng Wang
- Department of Anesthesiology, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China
| | - Yunyang Jia
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China
| | - Xiaoxiao Wang
- Department of Research Center of Clinical Epidemiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - Lei Liu
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Shandong University, Shandong 250012, China
| | - Weitian Li
- College of Veterinary Medicine, China Agricultural University, No.2, Yuanmingyuan West Road, Haidian District, Beijing 100193, China
| | - Xinping Li
- Department of Geriatrics, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China
| | - Nan Cai
- Department of Anesthesiology, Beijing Jishuitan Hospital, 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China
| | - Chang Liu
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - Yue Li
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - Yongzheng Han
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - Yang Zhou
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - Xinning Mi
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - Chengmei Shi
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China
| | - John Q Wang
- Department of Anesthesiology, University of Missouri Kansas City, School of Medicine, Kansas 64110, MO, USA
| | - Alain Vuylsteke
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, CB2 0AY Cambridge, UK
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China.
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, No. 49, North Garden Street, Haidian District, Beijing 100191, China.
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14
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Whyte MB, Vas PRJ, Umpleby AM. Could Exogenous Insulin Ameliorate the Metabolic Dysfunction Induced by Glucocorticoids and COVID-19? Front Endocrinol (Lausanne) 2021; 12:649405. [PMID: 34220705 PMCID: PMC8249851 DOI: 10.3389/fendo.2021.649405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/02/2021] [Indexed: 01/08/2023] Open
Abstract
The finding that high-dose dexamethasone improves survival in those requiring critical care due to COVID-19 will mean much greater usage of glucocorticoids in the subsequent waves of coronavirus infection. Furthermore, the consistent finding of adverse outcomes from COVID-19 in individuals with obesity, hypertension and diabetes has focussed attention on the metabolic dysfunction that may arise with critical illness. The SARS coronavirus itself may promote relative insulin deficiency, ketogenesis and hyperglycaemia in susceptible individuals. In conjunction with prolonged critical care, these components will promote a catabolic state. Insulin infusion is the mainstay of therapy for treatment of hyperglycaemia in acute illness but what is the effect of insulin on the admixture of glucocorticoids and COVID-19? This article reviews the evidence for the effect of insulin on clinical outcomes and intermediary metabolism in critical illness.
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Affiliation(s)
- Martin Brunel Whyte
- Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Anne M. Umpleby
- Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
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15
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Karaca Z, Grossman A, Kelestimur F. Investigation of the Hypothalamo-pituitary-adrenal (HPA) axis: a contemporary synthesis. Rev Endocr Metab Disord 2021; 22:179-204. [PMID: 33770352 DOI: 10.1007/s11154-020-09611-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 01/11/2023]
Abstract
The hypothalamo-pituitary-adrenal (HPA) axis is one of the main components of the stress system. Maintenance of normal physiological events, which include stress responses to internal or external stimuli in the body, depends on appropriate HPA axis function. In the case of severe cortisol deficiency, especially when there is a triggering factor, the patient may develop a life-threatening adrenal crisis which may result in death unless early diagnosis and adequate treatment are carried out. The maintenance of normal physiology and survival depend upon a sufficient level of cortisol in the circulation. Life-long glucocorticoid replacement therapy, in most cases meeting but not exceeding the need of the patient, is essential for normal life expectancy and maintenance of the quality of life. To enable this, the initial step should be the correct diagnosis of adrenal insufficiency (AI) which requires careful evaluation of the HPA axis, a highly dynamic endocrine system. The diagnosis of AI in patients with frank manifestations is not challenging. These patients do not need dynamic tests, and basal cortisol is usually enough to give a correct diagnosis. However, most cases of secondary adrenal insufficiency (SAI) take place in a gray zone when clinical manifestations are mild. In this situation, more complicated methods that can simulate the response of the HPA axis to a major stress are required. Numerous studies in the assessment of HPA axis have been published in the world literature. In this review, the tests used in the diagnosis of secondary AI or in the investigation of suspected HPA axis insufficiency are discussed in detail, and in the light of this, various recommendations are made.
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Affiliation(s)
- Zuleyha Karaca
- Department of Endocrinology, Erciyes University, Medical School, Kayseri, Turkey
| | - Ashley Grossman
- Centre for Endocrinology, Barts and London School of Medicine, London, UK
- OCDEM, University of Oxford, Oxford, UK
| | - Fahrettin Kelestimur
- Department of Endocrinology, Yeditepe University, Medical School, Istanbul, Turkey.
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16
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Khanna R, Slovacek H, Liles J, Haddad S, Poredos P, Bontekoe E, Jezovnik M, Hoppensteadt D, Fareed J, Hopkinson W. Regulation of Cortisol in Patients Undergoing Total Joint Arthoplasty. Clin Appl Thromb Hemost 2021; 27:1076029621987614. [PMID: 34000837 PMCID: PMC8135205 DOI: 10.1177/1076029621987614] [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: 11/17/2022] Open
Abstract
Osteoarthritis is a condition in which joint cartilage and bone degenerate progressively over time. Total joint arthroplasty is a definitive treatment. Cortisol is a hormone that is associated with pain and inflammation. This study aims to investigate the cortisol levels in patients undergoing total joint arthroplasty. Plasma samples were collected from 71 total joint arthroplasty (TJA) patients at baseline (pre-surgery), 24 hours post-operation, and 5 days post-operation. Cortisol levels were measured in each sample using a commercially available ELISA kit. All results were compiled as group means ± SD. The plasma cortisol level at baseline were 218.5 ± 12 ng/mL. The 24-hour post-surgical samples showed a marked increase in cortisol levels 240.7 ± 15 ng/mL. The blood samples drawn at the 5th day after surgery showed a downward trend (74 ± 12 ng/mL). At 5 days post-operation, cortisol levels were significantly lower than at baseline or 24 hours post-operation. These results point to the fact that prior to surgery, the patient’s emotional stress contributes to increased serum cortisol levels. The higher level of cortisol persists at 24 hours post-operation due to inflammation from the procedure. This data also suggests that at 5 days post-operation, the inflammatory response from the surgery and emotional stress subside, resulting in a near normalization of the cortisol levels. Cortisol is a hormone that plays a major role in the body’s response to surgery. The relevance between cortisol and different points in the surgical timeline has the potential to prognosticate and improve recovery measures.
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Affiliation(s)
- Rajan Khanna
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Hannah Slovacek
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Jeffrey Liles
- Department of Orthopedic Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Sandra Haddad
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Pavel Poredos
- Medical Clinic Division of Vascular Medicine, Ljubljana University Medical Center, Ljubljana, Slovenia
| | - Emily Bontekoe
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Mateja Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Debra Hoppensteadt
- Department of Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Jawed Fareed
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - William Hopkinson
- Orthopaedic Surgery and Rehabilitation Department, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
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17
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Schaal NK, Brückner J, Wolf OT, Ruckhäberle E, Fehm T, Hepp P. The effects of a music intervention during port catheter placement on anxiety and stress. Sci Rep 2021; 11:5807. [PMID: 33707520 PMCID: PMC7970967 DOI: 10.1038/s41598-021-85139-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 02/25/2021] [Indexed: 11/09/2022] Open
Abstract
Studies have shown that perioperative music interventions can reduce patients' anxiety levels. However, in small operations like port catheter surgery evidence is sparse. The present single-blinded, randomised controlled two-armed study included 84 female patients undergoing port catheter placement who were randomly assigned to either listening to music during surgery vs. no music intervention. The medical staff was blind to group allocation. On the day of the surgery anxiety and stress levels were evaluated using subjective (STAI questionnaire, visual analogue scales) and objective (vital parameters, salivary cortisol) parameters at different time points (before the surgery, at the end of the surgery and 1 h post-surgery). The music group showed significant reductions of systolic blood pressure (from 136.5 mmHg ± 26.1 to 123.3 mmHg ± 22.0, p = .002) and heart rate (from 75.6 bpm ± 12.3 to 73.1 bpm ± 12.2, p = .035) from beginning of the surgery to skin suture, whereas the control group did not. No significant effects of the music intervention on subjective anxiety measures or salivary cortisol were revealed. In sum, the study demonstrates that a music intervention during port catheter placement positively influences physiological anxiety levels, whereas no effects were revealed for subjective anxiety and salivary cortisol. Thus, music can be considered as a low cost addition in clinical routine in order to reduce patients' heart rate and blood pressure. Future studies are encouraged to further explore the differential effects of intraoperative music interventions on physiological, endocrinological and subjective anxiety levels.
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Affiliation(s)
- Nora K Schaal
- Department of Experimental Psychology, Heinrich-Heine-University, Universitätsstraße 1, 40225, Düsseldorf, Germany.
| | - Johanna Brückner
- Department of Experimental Psychology, Heinrich-Heine-University, Universitätsstraße 1, 40225, Düsseldorf, Germany
| | - Oliver T Wolf
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr-University, Bochum, Germany
| | - Eugen Ruckhäberle
- Clinic for Gynecology and Obstetrics, Heinrich-Heine-University, Düsseldorf, Germany
| | - Tanja Fehm
- Clinic for Gynecology and Obstetrics, Heinrich-Heine-University, Düsseldorf, Germany
| | - Philip Hepp
- Clinic for Gynecology and Obstetrics, University Clinic, Augsburg, Germany.,Clinic for Gynecology and Obstetrics, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany
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18
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Akin S, Kubat GB, Guray U, Akin Y, Demirel HA. Possible value of galectin-3 on follow-up of cardiac remodeling during glucocorticoid treatment. J Biochem Mol Toxicol 2021; 35:e22717. [PMID: 33484019 DOI: 10.1002/jbt.22717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 11/07/2022]
Abstract
Glucocorticoids are among the most prescribed drugs globally due to their potent anti-inflammatory and immunosuppressive properties. Although they have positive effects on the treatment of various disease states; long-term administration is associated with high blood pressure, insulin resistance, and susceptibility to type 2 diabetes. The heart attempts to cope with increased blood pressure and a decrease in glucose utilization by developing pathological cardiac remodeling. However, in this process, cardiac fibrosis formation and deterioration in heart structure and functions occur. Galectin-3, a member of the β-galactoside binding lectins, is consistently associated with inflammation and fibrosis in the pathogenesis of various disease states including insulin resistance and heart failure. Galectin-3 expression is markedly increased in activated macrophages and a subset of activated fibroblasts and vascular cells. Also, failing and remodeling myocardium show increased Gal-3 expression and elevated Gal-3 levels are related to heart failure severity and prognosis. Furthermore, Gal-3-related pathways are recently suggested as therapeutic targets both pharmacologically and genetically to increase insulin sensitivity in vivo. The objective of this review is to provide a summary of our current understanding of the role of glucocorticoid-associated insulin resistance, which is important for some cardiac events, and the potential role of galectin in this pathophysiological process.
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Affiliation(s)
- Senay Akin
- Department of Exercise and Sport Physiology, Faculty of Sport Sciences, Hacettepe University, Ankara, Turkey
| | - Gokhan B Kubat
- Department of Exercise and Sport Physiology, Faculty of Sport Sciences, Hacettepe University, Ankara, Turkey.,Department of Pathology, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Umit Guray
- Department of Cardiology, Ankara City Hospital, Ankara, Turkey
| | - Yesim Akin
- Department of Cardiology, Faculty of Medicine, Karabuk University, Karabuk, Turkey
| | - Haydar A Demirel
- Department of Exercise and Sport Physiology, Faculty of Sport Sciences, Hacettepe University, Ankara, Turkey.,Department of Sports Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Zaman S, Almazrouei R, Sam AH, DiMarco AN, Todd JF, Palazzo FF, Tan T, Dhillo WS, Meeran K, Wernig F. Synacthen Stimulation Test Following Unilateral Adrenalectomy Needs to Be Interpreted With Caution. Front Endocrinol (Lausanne) 2021; 12:654600. [PMID: 34046013 PMCID: PMC8147556 DOI: 10.3389/fendo.2021.654600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/28/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cortisol levels in response to stress are highly variable. Baseline and stimulated cortisol levels are commonly used to determine adrenal function following unilateral adrenalectomy. We report the results of synacthen stimulation testing following unilateral adrenalectomy in a tertiary referral center. METHODS Data were collected retrospectively for 36 patients who underwent synacthen stimulation testing one day post unilateral adrenalectomy. None of the patients had clinical signs of hypercortisolism preoperatively. No patient received pre- or intraoperative steroids. Patients with overt Cushing's syndrome were excluded. RESULTS The median age was 58 (31-79) years. Preoperatively, 16 (44%) patients had a diagnosis of pheochromocytoma, 12 (33%) patients had primary aldosteronism and 8 (22%) patients had non-functioning adenomas with indeterminate/atypical imaging characteristics necessitating surgery. Preoperative overnight dexamethasone suppression test results revealed that 6 of 29 patients failed to suppress cortisol to <50 nmol/L. Twenty (56%) patients achieved a stimulated cortisol ≥450 nmol/L at 30 minutes and 28 (78%) at 60 minutes. None of the patients developed clinical adrenal insufficiency necessitating steroid replacement. CONCLUSIONS Synacthen stimulation testing following unilateral adrenalectomy using standard stimulated cortisol cut-off values would wrongly label many patients adrenally insufficient and may lead to inappropriate prescriptions of steroids to patients who do not need them.
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Affiliation(s)
- Shamaila Zaman
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- *Correspondence: Shamaila Zaman, ; Florian Wernig,
| | - Raya Almazrouei
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Endocrine Division, Tawam Hospital, Al Ain, United Arab Emirates
| | - Amir H. Sam
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom
| | - Aimee N. DiMarco
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jeannie F. Todd
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fausto F. Palazzo
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Tricia Tan
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom
| | - Waljit S. Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom
| | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, United Kingdom
| | - Florian Wernig
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- *Correspondence: Shamaila Zaman, ; Florian Wernig,
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20
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Wu F, Laza-Cagigas R, Pagarkar A, Olaoke A, El Gammal M, Rampal T. The Feasibility of Prehabilitation as Part of the Breast Cancer Treatment Pathway. PM R 2020; 13:1237-1246. [PMID: 33369236 PMCID: PMC8596630 DOI: 10.1002/pmrj.12543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 11/19/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022]
Abstract
Background There is compelling support for implementing prehabilitation to optimize perioperative risk factors and to improve postoperative outcomes. However, there is limited evidence studying the application of multimodal prehabilitation for patients with breast cancer. Objective To determine the feasibility of multimodal prehabilitation as part of the breast cancer treatment pathway. Design This was a prospective, cohort observational study. Breast cancer patients undergoing surgery were recruited. They were assigned to an intervention or control group according to patient preference. Setting UK prehabilitation center. Participants A total of 75 patients were referred during the study period. Forty eight patients (64%) did not participate; 20 of those opted to be in the control group. Twenty four patients engaged with prehabilitation and returned completed questionnaires. In total, 44 patients were included in the analysis. Interventions The program consisted of supervised exercise, nutritional advice, smoking cessation, and psychosocial support. Outcome Measures Feasibility was determined by the center's ability to deliver the program. This was measured by the number of patients who wanted to access the service, compared with those able to. Service uptake, patient satisfaction, and project costs were recorded. Patient‐reported outcomes (PROs) and the use of healthcare resources were also evaluated. Results A total of 61 patients (81%) wanted to participate; 24 (32%) were able to partake and return questionnaires. Reasons for nonparticipation included surgery within weeks, full‐time commitments, and transportation difficulties. A total of 25 (93%) prehabilitation patients recorded high satisfaction with the program. There was a significant reduction in anxiety among prehabilitation patients. There were no significant improvements in the other PROs. There were no changes to hospital length of stay, readmissions, and complications. Conclusions Multimodal prehabilitation is a feasible intervention. Logistical challenges need to be addressed to improve engagement. These results are limited and would require a larger sample to confirm the findings. Work on a thorough cost‐benefit analysis is also required.
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Affiliation(s)
- Fiona Wu
- Surgery Department, Medway Maritime Hospital, Gillingham, UK
| | | | - Aalia Pagarkar
- Surgery Department, Medway Maritime Hospital, Gillingham, UK
| | - Adeola Olaoke
- Surgery Department, Medway Maritime Hospital, Gillingham, UK
| | | | - Tarannum Rampal
- Prehabilitation Unit, Medway Maritime Hospital, Gillingham, UK
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21
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Gall TM, Pencavel TD, Cunningham D, Nicol D, Jiao LR. Transition from open and laparoscopic to robotic pancreaticoduodenectomy in a UK tertiary referral hepatobiliary and pancreatic centre - Early experience of robotic pancreaticoduodenectomy. HPB (Oxford) 2020; 22:1637-1644. [PMID: 32247586 DOI: 10.1016/j.hpb.2020.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 01/30/2020] [Accepted: 03/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy is performed using an open technique (OPD) as the gold standard. An increase in those performed laparoscopically (LPD) and robotically (RPD) are now reported. We compared the short-term outcomes of RPD cases with LPD and OPD. METHODS A retrospective review of a prospectively collected database was undertaken of our first consecutive RPD, our first LPD and consecutive OPD cases. Those requiring venous and/or arterial resection were excluded. RESULTS RPD (n = 25) had longer median operating times (461 (IQR 358-564) mins) than LPD (n = 41) (330 (IQR 262.5-397.5) mins) and OPD (n = 37) (330 (IQR 257-403) mins, p < 0.0001). Estimated blood loss and transfusion requirement was less after RPD and LPD compared to OPD (p = 0.012 and p < 0.0001 respectively). No RPD cases required conversion to open operation compared to 24.4% of LPD. Morbidity was comparable with a Clavien Dindo score ≥3 in 20.00%, 24.39% and 18.92% for RPD, LPD and OPD respectively (p = 0.83). Post-operative pancreatic fistula rates were seen in 16.00%, 29.27% and 21.62% of our RPD, LPD and OPD cohorts respectively (p = 0.81). 90-day mortality was seen in 0.97% of the total cohort. Length of hospital stay (LOS) was shorter for RPD compared to both LPD (p = 0.030) and OPD (p = 0.002). CONCLUSION RPD is safe to perform with comparable outcomes to LPD and OPD. Further evidence is provided that a randomised controlled trial for PD techniques is required.
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Affiliation(s)
- Tamara Mh Gall
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Tim D Pencavel
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - David Cunningham
- Surgery and Oncology, The Royal Marsden Hospital, 203 Fulham Road, London, SW3 6JJ, UK
| | - David Nicol
- Surgery and Oncology, The Royal Marsden Hospital, 203 Fulham Road, London, SW3 6JJ, UK
| | - Long R Jiao
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK; Surgery and Oncology, The Royal Marsden Hospital, 203 Fulham Road, London, SW3 6JJ, UK.
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22
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Tan T, Khoo B, Mills EG, Phylactou M, Patel B, Eng PC, Thurston L, Muzi B, Meeran K, Prevost AT, Comninos AN, Abbara A, Dhillo WS. Cortisol concentrations and mortality from COVID-19 - Authors' reply. Lancet Diabetes Endocrinol 2020; 8:809-810. [PMID: 32946818 PMCID: PMC7492064 DOI: 10.1016/s2213-8587(20)30306-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Tricia Tan
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Bernard Khoo
- Department of Endocrinology, Division of Medicine, Faculty of Medical Sciences, Royal Free Campus, University College London, London, UK
| | - Edouard G Mills
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Maria Phylactou
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Bijal Patel
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Pei C Eng
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Layla Thurston
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Beatrice Muzi
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK
| | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - A Toby Prevost
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Alexander N Comninos
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Ali Abbara
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Waljit S Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK.
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23
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Tan T, Khoo B, Mills EG, Phylactou M, Patel B, Eng PC, Thurston L, Muzi B, Meeran K, Prevost AT, Comninos AN, Abbara A, Dhillo WS. Association between high serum total cortisol concentrations and mortality from COVID-19. Lancet Diabetes Endocrinol 2020; 8:659-660. [PMID: 32563278 PMCID: PMC7302794 DOI: 10.1016/s2213-8587(20)30216-3] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Tricia Tan
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Bernard Khoo
- Department of Endocrinology, Division of Medicine, Faculty of Medical Sciences, Royal Free Campus, University College London, London, UK
| | - Edouard G Mills
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Maria Phylactou
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Bijal Patel
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Pei C Eng
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Layla Thurston
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Beatrice Muzi
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK
| | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - A Toby Prevost
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Alexander N Comninos
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Ali Abbara
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK
| | - Waljit S Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, UK.
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24
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Prete A, Taylor AE, Bancos I, Smith DJ, Foster MA, Kohler S, Fazal-Sanderson V, Komninos J, O’Neil DM, Vassiliadi DA, Mowatt CJ, Mihai R, Fallowfield JL, Annane D, Lord JM, Keevil BG, Wass JAH, Karavitaki N, Arlt W. Prevention of Adrenal Crisis: Cortisol Responses to Major Stress Compared to Stress Dose Hydrocortisone Delivery. J Clin Endocrinol Metab 2020; 105:5805157. [PMID: 32170323 PMCID: PMC7241266 DOI: 10.1210/clinem/dgaa133] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/09/2020] [Indexed: 01/16/2023]
Abstract
CONTEXT Patients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid a life-threatening adrenal crisis. However, current treatment recommendations are not evidence-based. OBJECTIVE To identify the most appropriate mode of hydrocortisone delivery in patients with adrenal insufficiency who are exposed to major stress. DESIGN AND PARTICIPANTS Cross-sectional study: 122 unstressed healthy subjects and 288 subjects exposed to different stressors (major trauma [N = 83], sepsis [N = 100], and combat stress [N = 105]). Longitudinal study: 22 patients with preserved adrenal function undergoing elective surgery. Pharmacokinetic study: 10 patients with primary adrenal insufficiency undergoing administration of 200 mg hydrocortisone over 24 hours in 4 different delivery modes (continuous intravenous infusion; 6-hourly oral, intramuscular or intravenous bolus administration). MAIN OUTCOME MEASURE We measured total serum cortisol and cortisone, free serum cortisol, and urinary glucocorticoid metabolite excretion by mass spectrometry. Linear pharmacokinetic modeling was used to determine the most appropriate mode and dose of hydrocortisone administration in patients with adrenal insufficiency exposed to major stress. RESULTS Serum cortisol was increased in all stress conditions, with the highest values observed in surgery and sepsis. Continuous intravenous hydrocortisone was the only administration mode persistently achieving median cortisol concentrations in the range observed during major stress. Linear pharmacokinetic modeling identified continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, as best suited for maintaining cortisol concentrations in the required range. CONCLUSIONS Continuous intravenous hydrocortisone infusion should be favored over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - David J Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- School of Mathematics, University of Birmingham, Birmingham, UK
| | - Mark A Foster
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Sibylle Kohler
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Violet Fazal-Sanderson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - John Komninos
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Donna M O’Neil
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Christopher J Mowatt
- Department of Anaesthesiology, Royal Shrewsbury Hospital, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford, UK
| | | | - Djillali Annane
- Critical Care Department, Hôpital Raymond-Poincaré, Laboratory of Infection & Inflammation U1173 INSERM/University Paris Saclay-UVSQ, Garches, France
| | - Janet M Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - John A H Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Correspondence and Reprint Requests: Wiebke Arlt, MD, DSc, FRCP, FMedSci, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK. E-mail:
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25
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Perogamvros L, Castelnovo A, Samson D, Dang-Vu TT. Failure of fear extinction in insomnia: An evolutionary perspective. Sleep Med Rev 2020; 51:101277. [DOI: 10.1016/j.smrv.2020.101277] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 12/22/2022]
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26
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Villafañe JH, Pedersini P, Bertozzi L, Drago L, Fernandez-Carnero J, Bishop MD, Berjano P. Exploring the relationship between chronic pain and cortisol levels in subjects with osteoarthritis: results from a systematic review of the literature. Osteoarthritis Cartilage 2020; 28:572-580. [PMID: 32156623 DOI: 10.1016/j.joca.2020.02.836] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 02/04/2020] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Several reports in the literature have identified an association between cortisol levels and the presence of chronic pain in conditions such as rheumatoid arthritis, low back pain or whiplash. In contrast, few have examined the association of cortisol and pain in people with osteoarthritis (OA). The purpose of this systematic review was to verify the association between cortisol and pain in the OA population. DESIGN The databases MEDLINE, CINAHL, EMBASE were searched systematically for human studies written in English up to December 2018. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Articles were included if they measured the cortisol levels in adults with pain in the OA population. Methodological quality was assessed using Methodological Index for non-randomized Studies (MINORS) score. RESULTS Seven studies reporting on 415 patients were included in this review. The MINORS scale yielded mean scores of 8.6 of 16 and 17.5 of 24, for the cohort and case-control studies respectively. In general, the studies were of poor quality. A discrepancy of noteworthy associations between cortisol level comparison and pain was found. CONCLUSIONS This study shows that there is a discrepancy in the relationship between cortisol and pain dependent on how and when cortisol is measured. Evidence from three low-quality studies suggest increased cortisol levels in patients with pain but the conclusions have a high risk of bias. It was not possible to make a quantitative analysis comparing the relationship between cortisol and pain in the OA population.
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Affiliation(s)
| | - P Pedersini
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy.
| | - L Bertozzi
- Alma Mater Studiorum Università di Bologna, Bologna, Italy.
| | - L Drago
- Clinical Microbiology Department of Biomedical Sciences for Health, University of Milan, Italy.
| | | | - M D Bishop
- Department of Physical Therapy, University of Florida, USA.
| | - P Berjano
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
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27
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Jansen P, Stoffels I, Müseler AC, Petri M, Brinker TJ, Schedlowski M, Schadendorf D, Engler H, Klode J. Salivary cortisol levels and anxiety in melanoma patients undergoing sentinel lymph node excision under local anesthesia versus general anesthesia: a prospective study. World J Surg Oncol 2020; 18:53. [PMID: 32156303 PMCID: PMC7065350 DOI: 10.1186/s12957-020-01823-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/18/2020] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Sentinel lymph node excision (SLNE) can be performed in tumescent local anesthesia (TLA) or general anesthesia (GA). Perioperative cortisol level changes and anxiety are common in surgical interventions and might be influenced by the type of anesthesia. In this study, we intended to determine whether the type of anesthesia impacts the patients' perioperative levels of salivary cortisol (primary outcome) and the feeling of anxiety evaluated by psychological questionnaires (secondary outcome). METHODS All melanoma patients of age undergoing SLNE at the University Hospital Essen, Germany, could be included in the study. Exclusion criteria were patients' intake of glucocorticoids or psychotropic medication during the former 6 months, pregnancy, age under 18 years, and BMI ≥ 30 as salivary cortisol levels were reported to be significantly impacted by obesity and might confound results. RESULTS In total, 111 melanoma patients undergoing SLNE were included in our prospective study between May 2011 and April 2017 and could choose between TLA or GA. Salivary cortisol levels were measured three times intraoperatively, twice on the third and second preoperative day and twice on the second postoperative day. To assess anxiety, patients completed questionnaires (Hospital Anxiety and Depression Scale (HADS), State-Trait Anxiety Inventory (STAI)) perioperatively. Patients of both groups exhibited comparable baseline levels of cortisol and perioperative anxiety levels. Independent of the type of anesthesia, all patients showed significantly increasing salivary cortisol level from baseline to 30 min before surgery (T3) (TLA: t = 5.07, p < 0.001; GA: t = 3.09, p = 0.006). Post hoc independent t tests showed that the TLA group exhibited significantly higher cortisol concentrations at the beginning of surgery (T4; t = 3.29, p = 0.002) as well as 20 min after incision (T5; t = 277, p = 0.008) compared to the GA group. CONCLUSIONS The type of anesthesia chosen for SLNE surgery significantly affects intraoperative cortisol levels in melanoma patients. Further studies are mandatory to evaluate the relevance of endogenous perioperative cortisol levels on the postoperative clinical course. TRIAL REGISTRATION German Clinical Trials Register DRKS00003076, registered 1 May 2011.
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Affiliation(s)
- Philipp Jansen
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany.,West German Cancer Center, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium, Heidelberg, Germany
| | - Ingo Stoffels
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany.,West German Cancer Center, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium, Heidelberg, Germany
| | - Anne-Christine Müseler
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany.,West German Cancer Center, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium, Heidelberg, Germany
| | - Maximilian Petri
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany.,West German Cancer Center, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium, Heidelberg, Germany
| | - Titus J Brinker
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany.,National Center for Tumor Diseases, German Cancer Research Center, Heidelberg, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dirk Schadendorf
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany.,West German Cancer Center, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium, Heidelberg, Germany
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Joachim Klode
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Germany. .,West German Cancer Center, University Duisburg-Essen, Essen, Germany. .,German Cancer Consortium, Heidelberg, Germany.
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Betterle C, Presotto F, Furmaniak J. Epidemiology, pathogenesis, and diagnosis of Addison's disease in adults. J Endocrinol Invest 2019; 42:1407-1433. [PMID: 31321757 DOI: 10.1007/s40618-019-01079-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/25/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Addison's disease (AD) is a rare disorder and among adult population in developed countries is most commonly caused by autoimmunity. In contrast, in children genetic causes are responsible for AD in the majority of patients. PURPOSE This review describes epidemiology, pathogenesis, genetics, natural history, clinical manifestations, immunological markers and diagnostic strategies in patients with AD. Standard care treatments including the management of patients during pregnancy and adrenal crises consistent with the recent consensus statement of the European Consortium and the Endocrine Society Clinical Practice Guideline are described. In addition, emerging therapies designed to improve the quality of life and new strategies to modify the natural history of autoimmune AD are discussed. CONCLUSIONS Progress in optimizing replacement therapy for patients with AD has allowed the patients to lead a normal life. However, continuous education of patients and health care professionals of ever-present danger of adrenal crisis is essential to save lives of patients with AD.
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Affiliation(s)
- C Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padova, Via Ospedale Civile 105, 35128, Padua, Italy
| | - F Presotto
- Endocrine Unit, Department of Medicine (DIMED), University of Padova, Via Ospedale Civile 105, 35128, Padua, Italy.
- Unit of Internal Medicine, Ospedale dell'Angelo, via Paccagnella 11, 30174, Mestre-Venice, Italy.
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Taylor HE, Simons K, Willmott C, Smith RER, Bramley DEP. A feasibility study to investigate post-operative oxygen consumption (POpOC) after colorectal surgery requiring bowel resection. Pilot Feasibility Stud 2019; 5:94. [PMID: 31363419 PMCID: PMC6643312 DOI: 10.1186/s40814-019-0477-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/09/2019] [Indexed: 01/03/2023] Open
Abstract
Background Oxygen consumption after surgery is increased in response to the tissue trauma sustained intra-operatively and the subsequent systemic inflammatory response that ensues. The cardio-respiratory system must match the tissue oxygen and metabolic requirements; otherwise, peri-operative complications may occur. Existing data is several decades old. The primary objective of this feasibility study was to determine the ease of recruiting participants and collecting relevant data to assess the extent and duration of increased oxygen consumption and post-operative complications after major abdominal surgery in contemporaneous times. Methods One hundred patients scheduled for elective colorectal surgery requiring a bowel resection were screened to test specific feasibility criteria relating to ease of recruitment, duration of post-operative stay, ease of data collection, and drop-out rates. A calibrated metabolic cart was used to obtain unblinded pre-operative resting oxygen consumption recordings. The metabolic cart was then used to obtain post-operative oxygen consumption readings on days 1 to 5 as long as the participant remained as an inpatient. At the time of the oxygen consumption reading, a Post-Operative Morbidity Survey score (POMS) was calculated. Feasibility outcomes chosen a priori were that at least one participant would be recruited every 2 weeks from the pre-admission colorectal clinic, at least 10% of potential subjects screened would be enrolled, at least 80% of recruited participants would have a minimum post-operative stay of 2 nights, a minimum of 3 consecutive days of oxygen consumption data would be collected for each subject, at least 8 of 9 POMS score domains would be completed per participant per day and the drop-out rate would be no greater than 10%. We deemed that screening 100 patients would be sufficient to test our feasibility outcomes. Results Twelve participants completed the protocol. All pre-specified feasibility criteria were met. No increase in post-operative oxygen consumption was observed in this feasibility cohort. Conclusions The protocol and experiences gained from this feasibility study could be used to plan a larger study to better define changes in post-operative oxygen consumption after major abdominal surgery utilizing current surgical techniques.
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Affiliation(s)
- H E Taylor
- 1Department Anaesthesia, Pain and Perioperative Medicine, Western Health, 160 Gordon Street, Footscray, Melbourne, VIC 3011 Australia
| | - K Simons
- 2Centre for Epidemiology and Biostatistics, Melbourne School of Population Health, University of Melbourne, Melbourne, Australia.,3Western Health Office for Research, Western Health, Melbourne, Australia
| | - C Willmott
- 4Royal Melbourne Hospital, Melbourne, Australia
| | - R E R Smith
- 1Department Anaesthesia, Pain and Perioperative Medicine, Western Health, 160 Gordon Street, Footscray, Melbourne, VIC 3011 Australia
| | - D E P Bramley
- 1Department Anaesthesia, Pain and Perioperative Medicine, Western Health, 160 Gordon Street, Footscray, Melbourne, VIC 3011 Australia
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The Effect of Perioperative Music on the Stress Response to Surgery: A Meta-analysis. J Surg Res 2019; 244:444-455. [PMID: 31326711 DOI: 10.1016/j.jss.2019.06.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 04/15/2019] [Accepted: 06/14/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Current perioperative patient care aims to maintain homeostasis by attenuation of the stress response to surgery, as a more vigorous stress response can have detrimental effects on postoperative recovery. This systematic review and meta-analysis aims to assess the effect of perioperative music on the physiological stress response to surgery. METHODS The Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar databases were searched from inception date until February 5, 2019, using a systematic literature search following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines for randomized controlled trials investigating the effect of music before, during, and/or after surgery in adult surgical patients on the stress response to surgery. Meta-analysis was performed using a random effects model and pooled standardized mean differences were calculated with 95% confidence intervals. This study was registered in the PROSPERO database (CRD42018097060). RESULTS The literature search identified 1076 articles. Eighteen studies (1301 patients) were included in the systematic review, of which eight were included in the meta-analysis. Perioperative music attenuated the neuroendocrine cortisol stress response to surgery (pooled standardized mean difference -0.30, [95% confidence interval -0.53 to -0.07], P = 0.01, I2 = 0). CONCLUSIONS Perioperative music can attenuate the neuroendocrine stress response to surgery.
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Catania VD, Boscarelli A, Lauriti G, Morini F, Zani A. Risk Factors for Surgical Site Infection in Neonates: A Systematic Review of the Literature and Meta-Analysis. Front Pediatr 2019; 7:101. [PMID: 30984722 PMCID: PMC6449628 DOI: 10.3389/fped.2019.00101] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 03/05/2019] [Indexed: 12/17/2022] Open
Abstract
Purpose: Surgical site infections (SSI) contribute to postoperative morbidity and mortality in children. Our aim was to evaluate the prevalence and identify risk factors for SSI in neonates. Methods: Using a defined strategy, three investigators searched articles on neonatal SSI published since 2000. Studies on neonates and/or patients admitted to neonatal intensive care unit following cervical/thoracic/abdominal surgery were included. Risk factors were identified from comparative studies. Meta-analysis was conducted according to PRISMA guidelines using RevMan 5.3. Data are (mean ± SD) prevalence. Results: Systematic review-of 885 abstracts screened, 48 studies (27,760 neonates) were included. The incidence of SSI was 5.6% (1,564 patients). SSI was more frequent in males (61.8%), premature babies (77.4%), and following gastrointestinal surgery (95.4%). Meta-analysis-10 comparative studies (16,442 neonates; 946 SSI 5.7%) showed that predictive factors for SSI development were gestational age, birth weight, age at surgery, length of surgical procedure, number of procedure per patient, length of preoperative hospital stay, and preoperative sepsis. Conversely, preoperative antibiotic use was not significantly associated with development of SSI. Conclusions: Younger neonates and those undergoing abdominal procedures are at higher risk for SSI. Given the lack of evidence-based literature, prospective studies may help determine the risk factors for SSI in neonates.
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Affiliation(s)
- Vincenzo Davide Catania
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Alessandro Boscarelli
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giuseppe Lauriti
- Department of Pediatric Surgery, Spirito Santo Hospital and G. d'Annunzio University of Chieti and Pescara, Chieti, Italy
| | - Francesco Morini
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Mo X, Liang H, Xiao Y, Wen Y, Yuan Y, Jin S. [Effects of propofol sedation on psychological stress in surgical patients under epidural]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:1498-1502. [PMID: 30613020 DOI: 10.12122/j.issn.1673-4254.2018.12.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To explore the effects of propofol sedation on psychological stress in patients undergoing surgery under epidural anesthesia. METHODS Sixty patients scheduled to undergo elective ileostomy closure under epidural anesthesia were randomized into propofol sedation group and control group (n=30). The patients in the sedation group received a loading dose of propofol of 0.6 mg·kg- 1· h- 1 followed by a maintenance dose with continuous infusion of 3 mg·kg- 1· h- 1 given after the Observer's Assessment of Alertness/Sedation (OAA/S) score reached 2-3. An equivalent volume of normal saline was administered in patients in the control group. The patients' preoperative and intraoperative anxiety scores were assessed with the State Anxiety Inventory (SAI) on the day before and on the first day after the surgery, respectively. The mean blood pressure (MBP), heart rate (HR), SpO2, OAA/S, and the indicators of psychological stress of brain functional state of the patients (including the wavelet index [WLi], anxiety index [ANXi], comfortable index [CFi] and pain index [Pi]) were recorded at 5 min after entering the operating room (T0), at the time of lumbar puncture (T1) and change to supine position after the puncture (T2), at 20 s (T3), 40 s (T4), and 60 s (T5) after intravenous administration, and at 2 min (T6), 4 min (T5), 6 min (T8), 8 min (T9), 10 min (T10) and 40 min (T11) after skin incision. The patient's satisfaction with anesthesia was assessed with the Visual Analog Scale (VAS) score on the first day after the operation. Serum cortisol level was measured before anesthesia and at the end of operation to calculate the changes in cortisol level. RESULTS The two groups of patients were comparable for preoperative SAI scores (P>0.05); The patients in the sedation group appeared to have lower intraoprative SAI scores, but this difference was not statistically significant (P=0.05). MBP, HR, and SpO2 at the time points from T6 to T10 and OAA/S, WLi, ANXi, CFi, and Pi at the time points from T6 to T11 were significantly lower in the sedation group (all P < 0.05), and these parameters were not significantly different between the two groups at the other time points (all P>0.05). The patient satisfaction scores were significantly higher in the sedation group (Z=2.07, P < 0.05). Compared with the preoperative levels, serum cortisol level at the end of the operation was increased in the sedation group but lowered in the control group, and the variations of serum cortisol level differed significantly between the two groups (t=4.75, P < 0.01). CONCLUSIONS Intraoperative propofol sedation can alleviate the patients' anxiety, improve the comfort level, and lessen physiological stress during surgeries under epidural anesthesia.
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Affiliation(s)
- Xiaofei Mo
- Department of Anesthesia, Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Huiming Liang
- Department of Anesthesia, Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Yanhong Xiao
- Department of Clinical Laboratory, Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Yi Wen
- Department of Anesthesia, Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Yi Yuan
- Department of Anesthesia, Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Sanqing Jin
- Department of Anesthesia, Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
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Prete A, Yan Q, Al-Tarrah K, Akturk HK, Prokop LJ, Alahdab F, Foster MA, Lord JM, Karavitaki N, Wass JA, Murad MH, Arlt W, Bancos I. The cortisol stress response induced by surgery: A systematic review and meta-analysis. Clin Endocrinol (Oxf) 2018; 89:554-567. [PMID: 30047158 DOI: 10.1111/cen.13820] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/12/2018] [Accepted: 07/17/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Surgery is a stressor that can be categorized by duration and severity and induces a systemic stress response that includes increased adrenal cortisol production. However, the precise impact of surgical stress on the cortisol response remains to be defined. DESIGN We performed a systematic review and meta-analysis to assess the cortisol stress response induced by surgery and to stratify this response according to different parameters. METHODS We conducted a comprehensive search in several databases from 1990 to 2016. Pairs of reviewers independently selected studies, extracted data and evaluated the risk of bias. Cortisol concentrations were standardized, pooled in meta-analysis and plotted over time. RESULTS We included 71 studies reporting peri-operative serum cortisol measurements in 2953 patients. The cortisol response differed substantially between moderately/highly invasive and minimally invasive surgical procedures. Minimally invasive procedures did not show a peri-operative cortisol peak, whereas more invasive surgeries caused a cortisol surge that was more pronounced in older subjects, women and patients undergoing open surgery and general anaesthesia. The duration of the procedure and the use of etomidate for induction of anaesthesia did not affect the cortisol response. CONCLUSIONS The peri-operative cortisol stress response is dynamic and influenced by patient-specific, surgical and anaesthetic features. However, the available evidence is derived from highly heterogeneous studies, with only two of 71 studies measuring cortisol by mass spectrometry, which currently prevents a precise and reproducible definition of this response.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Qi Yan
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Khaled Al-Tarrah
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Halis K Akturk
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | - Fares Alahdab
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Mark A Foster
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital Birmingham & Royal Centre for Defence Medicine, Birmingham, UK
| | - Janet M Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - John A Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Mohammad H Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Kisani AI, Tughgba T, Elsa AT. Effects of various surgical procedures on biochemical parameters of Nigerian dogs and their clinical implications. Vet World 2018; 11:909-914. [PMID: 30147258 PMCID: PMC6097566 DOI: 10.14202/vetworld.2018.909-914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/21/2018] [Indexed: 12/05/2022] Open
Abstract
AIM The importance of physical and psychological stress caused by pain during surgery cannot be overemphasized. The aim of this study was to assess the effects of ovariohysterectomy (OVH), gastrotomy (GST), and intestinal resection and anastomosis (IRA) on biochemical parameters of Nigerian dogs anesthetized with the xylazine-propofol combination. MATERIALS AND METHODS A total of 12 dogs were randomly divided into three groups of four each. The animals were treated with xylazine and propofol anesthetics for OVH, GST, and IRA in Groups 1-3, respectively. Blood samples were collected at 0 h, 2, 24, 48, 72, 96, 120, and 144 h postsurgery for determination of cortisol (CORT), glucose (GLU), total protein (TP), albumin (ALB), globulin (GL), and ALB/GL ratio. RESULTS There were significant increases (p<0.05) in mean CORT concentrations 2 h postsurgery in the three groups and at 24 h in Group 3 and 96 h in Groups 1 and 3, respectively. GLU concentrations increased significantly (p<0.05) in the three groups at 2 h postsurgery. The mean protein concentrations in Groups 2 and 3 decreased significantly (p<0.05) at 2h and 24 h and 72 h, 96 h, 120 h, and 144 h in Group 3, respectively. There was significant decrease (p<0.05) in the mean ALB concentrations at 2 h, 24 h, 72 h, 96 h, 120 h, and 144 h postsurgery. There was a significant difference (p<0.05) in the mean GL concentrations in Group 3 at 24 h, 72 h, 96 h, and 144 h. All other parameters were not significantly different (p>0.05) in comparison with the control. CONCLUSION Xylazine-propofol combination could decrease humoral immune status and increase serum GLU level invariably portending a high risk of diabetes in the vulnerable dogs.
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Affiliation(s)
- Aboh Iku Kisani
- Department of Veterinary Surgery and Theriogenology, College of Veterinary Medicine, Federal University of Agriculture, P.M.B. 2373, Makurdi, Benue State, Nigeria
| | - Terzungwe Tughgba
- Department of Veterinary Surgery and Theriogenology, College of Veterinary Medicine, Federal University of Agriculture, P.M.B. 2373, Makurdi, Benue State, Nigeria
| | - Abdullahi Teleh Elsa
- Department of Veterinary Surgery and Theriogenology, College of Veterinary Medicine, Federal University of Agriculture, P.M.B. 2373, Makurdi, Benue State, Nigeria
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Amabebe E, Anumba DOC. Psychosocial Stress, Cortisol Levels, and Maintenance of Vaginal Health. Front Endocrinol (Lausanne) 2018; 9:568. [PMID: 30319548 PMCID: PMC6165882 DOI: 10.3389/fendo.2018.00568] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/05/2018] [Indexed: 01/01/2023] Open
Abstract
Stress stimuli are ubiquitous and women do not enjoy any exemptions. The physiologic "fight-or-flight" response may be deleterious to the female lower genital tract microbiome if the stress stimuli persist for longer than necessary. Persistent exposure to psychosocial stress and stimulation of the hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal-medullary (SAM) axes, and associated hormones are risk factors for several infections including genitourinary tract infections. Though this could be due to a dysregulated immune response, a cortisol-induced inhibition of vaginal glycogen deposition may be involved especially in the instance of vaginal infection. The estrogen-related increased vaginal glycogen and epithelial maturation are required for the maintenance of a healthy vaginal ecosystem (eubiosis). The ability of cortisol to disrupt this process as indicated in animal models is important in the pathogenesis of vaginal dysbiosis and the subsequent development of infection and inflammation. This phenomenon may be more crucial in pregnancy where a healthy Lactobacillus-dominated vaginal microbiota is sacrosanct, and there is local production of more corticotropin-releasing hormone (CRH) from the decidua, fetal membranes and placenta. To highlight the relationship between the stress hormone cortisol and the vaginal microbiomial architecture and function, the potential role of cortisol in the maintenance of vaginal health is examined.
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