1
|
Bowden SA. Current Screening Strategies for the Diagnosis of Adrenal Insufficiency in Children. Pediatric Health Med Ther 2023; 14:117-130. [PMID: 37051221 PMCID: PMC10084833 DOI: 10.2147/phmt.s334576] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
Adrenal insufficiency can arise from a primary adrenal disorder, secondary to adrenocorticotropic hormone deficiency, or by suppression of hypothalamic-pituitary-adrenal axis due to exogenous glucocorticoids. Diagnosis of adrenal insufficiency is usually delayed because the initial presentation is often subtle and nonspecific. Clinician awareness and recognition is crucial for timely diagnosis to avoid adrenal crisis. Current screening strategies for the diagnosis of adrenal insufficiency in children in various clinical situations are discussed in this review.
Collapse
Affiliation(s)
- Sasigarn A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children’s Hospital/The Ohio State University College of Medicine, Columbus, OH, USA
- Correspondence: Sasigarn A Bowden, Nationwide Children’s Hospital, Division of Endocrinology, 700 Children’s Drive, Columbus, OH, 43205, USA, Tel +1 614-722-4118, Fax +1 614-722-4440, Email
| |
Collapse
|
2
|
Yeoh P, Dwyer AA, Anghel E, Bouloux PM, Khoo B, Chew S, Wernig F, Carroll P, Aylwin SJB, Baldeweg SE, Drake W, Todd J, Mangena L, Grossman A. A Comparison of the Blood Glucose, Growth Hormone, and Cortisol Responses to Two Doses of Insulin (0.15 U/kg vs. 0.10 U/kg) in the Insulin Tolerance Test: A Single-Centre Audit of 174 Cases. Int J Endocrinol 2022; 2022:7360282. [PMID: 35465075 PMCID: PMC9019435 DOI: 10.1155/2022/7360282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The insulin tolerance test (ITT) is the gold standard endocrine test used to assess the integrity of the growth hormone (GH) and cortisol axes. The ITT has potential risks, and severe hypoglycaemia may necessitate intravenous glucose rescue. There is no clear consensus as to the optimal insulin dose for the ITT. Therefore, we sought to compare the standard dose (0.15 U/kg) and a low-dose ITT (0.1 U/kg). DESIGN Single-centre audit of ITT data (2012-2021). Patients and Measurements. Patients who underwent an ITT to assess possible GH deficiency/adrenal insufficiency were included. Glucose, GH, and cortisol were measured at baseline and 30, 45, 60, 90, and 120 minutes following I.V. insulin bolus (0.15 U/kg or 0.10 U/kg). RESULTS Of the ITTs performed, only 3/177 (1.7%) did not achieve adequate hypoglycaemia (≤2.2 mmol/L) with a single insulin dose. In total, 174 patients (43.5 ± 12.1 yrs, mean ± standard deviation) were included for analysis (0.15 U/kg: n = 113, 0.10 U/kg: n = 61). All 174 subjects had adequate hypoglycaemia regardless of baseline fasting blood glucose level or insulin dose. Neither nadir glucose nor glucose delta (i.e., baseline minus nadir) differed between insulin doses. Trends in both cortisol and GH responses over time were similar between groups, and a greater proportion of patients receiving the standard dose had an adequate cortisol response (77/106 (72.6%) vs. 32/60 (53.3%), p=0.01). The rates of glucose rescue did not differ in a subset of 79 patients, with on-demand glucose rescue in 4/35 (11%) for the standard dose and 2/44 (5%) for the low dose (p=0.25). CONCLUSIONS Our results suggest that the low-dose ITT produces comparable glucose, cortisol, and GH responses to the higher dose. Given the risks associated with hypoglycaemia, the low dose appears to be preferable to the standard dose ITT in most circumstances.
Collapse
Affiliation(s)
- Phillip Yeoh
- The London Clinic Centre for Endocrinology, London, UK
- Florence Nightingale School of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Andrew A. Dwyer
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, USA
- Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, USA
| | - Ella Anghel
- Boston College, Department of Measurement, Evaluation, Statistics and Assessment, Chestnut Hill, MA, USA
| | - Pierre M. Bouloux
- The London Clinic Centre for Endocrinology, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Bernard Khoo
- The London Clinic Centre for Endocrinology, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- Division of Medicine, University College London, London, UK
| | - Shern Chew
- The London Clinic Centre for Endocrinology, London, UK
- OneWelbeck Endocrine Partners, London, UK
| | - Florian Wernig
- The London Clinic Centre for Endocrinology, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Paul Carroll
- The London Clinic Centre for Endocrinology, London, UK
- Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Simon J. B. Aylwin
- The London Clinic Centre for Endocrinology, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Stephanie E. Baldeweg
- The London Clinic Centre for Endocrinology, London, UK
- Division of Medicine, University College London, London, UK
- Department of Diabetes & Endocrinology, University College London NHS Foundation Trust, London, UK
| | - William Drake
- The London Clinic Centre for Endocrinology, London, UK
- Barts Health NHS Trust, Saint Bartholomew's Hospital, London, UK
| | - Jeannie Todd
- The London Clinic Centre for Endocrinology, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | | | - Ashley Grossman
- The London Clinic Centre for Endocrinology, London, UK
- Centre for Endocrinology, Barts and the London School of Medicine, Queen Mary University of London, UK
| |
Collapse
|
3
|
Cattoni A, Molinari S, Medici F, De Lorenzo P, Valsecchi MG, Masera N, Adavastro M, Biondi A. Dexamethasone Stimulation Test in the Diagnostic Work-Up of Growth Hormone Deficiency in Childhood: Clinical Value and Comparison With Insulin-Induced Hypoglycemia. Front Endocrinol (Lausanne) 2020; 11:599302. [PMID: 33362716 PMCID: PMC7757782 DOI: 10.3389/fendo.2020.599302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/02/2020] [Indexed: 11/13/2022] Open
Abstract
CONTEXT dexamethasone has been demonstrated to elicit GH secretion in adults, but few data are available about its effectiveness as a provocative stimulus in the diagnostic work-up of GH deficiency (GHD) in childhood. OBJECTIVE to assess the clinical value of dexamethasone stimulation test (DST) as a diagnostic tool for pediatric GHD. DESIGN AND SETTING retrospective single-center analysis. The study population included 166 patients with a pathological response to arginine stimulation test (AST, first-line test) and subsequently tested with either insulin tolerance test (ITT) or DST as a second-line investigation between 2008 and 2019. MAIN OUTCOME MEASURES comparison between GH peaks and secretory curves induced by ITT and DST; degree of agreement between DST and AST versus ITT and AST. RESULTS the pathological response to AST (GH peak < 8 ng/mL) was confirmed by an ITT in 80.2% (89/111) of patients and by a DST in 76.4% (42/55), with no statistical difference between the two groups (p value 0.69). Mean GH peaks achieved after ITT and DST were entirely comparable (6.59 ± 3.59 versus 6.50 ± 4.09 ng/ml, respectively, p 0.97) and statistically higher than those elicited by arginine (p < 0.01 for both), irrespectively of the average GH peaks recorded for each patient (Bland-Altman method). Dexamethasone elicited a longer lasting and later secretory response than AST and ITT. No side effects were recorded after DST. CONCLUSIONS DST and ITT confirmed GHD in a superimposable percentage of patients with a pathological first-line test. DST and ITT share a similar secretagogue potency, overall greater than AST.
Collapse
Affiliation(s)
- Alessandro Cattoni
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Silvia Molinari
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
- *Correspondence: Silvia Molinari,
| | - Francesco Medici
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Paola De Lorenzo
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, Università degli studi di Milano-Bicocca, Monza, Italy
- Tettamanti Research Center, Pediatric Clinic, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Maria Grazia Valsecchi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, Università degli studi di Milano-Bicocca, Monza, Italy
| | - Nicoletta Masera
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Marta Adavastro
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Andrea Biondi
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| |
Collapse
|
4
|
Bowden SA, Henry R. Pediatric Adrenal Insufficiency: Diagnosis, Management, and New Therapies. Int J Pediatr 2018; 2018:1739831. [PMID: 30515225 PMCID: PMC6236909 DOI: 10.1155/2018/1739831] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/27/2018] [Indexed: 12/05/2022] Open
Abstract
Adrenal insufficiency may result from a wide variety of congenital or acquired disorders of hypothalamus, pituitary, or adrenal cortex. Destruction or dysfunction of the adrenal cortex is the cause of primary adrenal insufficiency, while secondary adrenal insufficiency is a result of pituitary or hypothalamic disease. Timely diagnosis and clinical management of adrenal insufficiency are critical to prevent morbidity and mortality. This review summarizes the etiologies, presentation, and diagnosis of adrenal insufficiency utilizing different dynamic hormone testing and describes current treatment recommendations and new therapies.
Collapse
Affiliation(s)
- Sasigarn A. Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Rohan Henry
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| |
Collapse
|
5
|
Moritani K, Tauchi H, Ochi F, Yonezawa S, Takemoto K, Eguchi-Ishimae M, Eguchi M, Ishii E, Nagai K. Prolonged adrenal insufficiency after high-dose glucocorticoid in infants with leukemia. Pediatr Hematol Oncol 2018; 35:355-361. [PMID: 30457427 DOI: 10.1080/08880018.2018.1539148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Although outcomes for infant leukemia have improved recently, transient adrenal insufficiency is commonly observed during treatment, especially after glucocorticoid administration. We identified three infants with acute leukemia who suffered from prolonged adrenal insufficiency requiring long-term (from 15 to 66 months) hydrocortisone replacement. All infants showed life-threatening symptoms associated with adrenal crisis after viral infections or other stress. Severe and prolonged damage of hypothalamo-pituitary-adrenal (HPA) axis is likely to occur in early infants with leukemia, therefore routine tolerance testing to evaluate HPA axis and hydrocortisone replacement therapy are recommended for infants with leukemia to avoid life-threatening complications caused by adrenal crisis.
Collapse
Affiliation(s)
- Kyoko Moritani
- a Department of Pediatrics , Ehime University Graduate School of Medicine , Ehime , Japan
| | - Hisamichi Tauchi
- a Department of Pediatrics , Ehime University Graduate School of Medicine , Ehime , Japan
| | - Fumihiro Ochi
- a Department of Pediatrics , Ehime University Graduate School of Medicine , Ehime , Japan
| | - Sachiko Yonezawa
- a Department of Pediatrics , Ehime University Graduate School of Medicine , Ehime , Japan
| | - Koji Takemoto
- a Department of Pediatrics , Ehime University Graduate School of Medicine , Ehime , Japan
| | | | - Mariko Eguchi
- a Department of Pediatrics , Ehime University Graduate School of Medicine , Ehime , Japan
| | - Eiichi Ishii
- a Department of Pediatrics , Ehime University Graduate School of Medicine , Ehime , Japan
| | - Kozo Nagai
- a Department of Pediatrics , Ehime University Graduate School of Medicine , Ehime , Japan
| |
Collapse
|
6
|
Mytinger JR, Bowden SA. Adrenal Function Testing Following Hormone Therapy for Infantile Spasms: Case Series and Review of Literature. Front Neurol 2015; 6:259. [PMID: 26696958 PMCID: PMC4672028 DOI: 10.3389/fneur.2015.00259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/24/2015] [Indexed: 11/17/2022] Open
Abstract
Prednisolone and adrenocorticotropic hormone (ACTH) are “hormone” therapies for infantile spasms. There is limited data on the occurrence of decreased adrenal reserve or signs of clinical adrenal insufficiency after hormone therapy. This is a retrospective medical record review of patients referred to our Infantile Spasms Program. Our standardized infantile spasms management guideline began in September 2012 and initially included a post-hormone laboratory assessment of adrenal function. Medical records were assessed for hormone treatments, adrenal function testing, and signs of adrenal insufficiency. Forty-two patients who received one or both hormone therapies met inclusion criteria. A post-hormone laboratory assessment of adrenal function was done in 14 patients. Of these 14 patients, 2 had an abnormal laboratory assessment of adrenal function, both by adrenal stimulation testing – one after ACTH and one after prednisolone. One patient received hydrocortisone replacement and the other received stress dose hydrocortisone as needed; neither patient developed signs of adrenal insufficiency. Another patient treated with both types of hormone therapy in tandem, who did not have a post-hormone laboratory assessment, developed signs of mild adrenal insufficiency and required replacement hydrocortisone. Our study suggests that adrenal suppression can occur after modern hormone therapy regimens. We found two patients with abnormal adrenal function testing after hormone therapy and another patient with signs adrenal insufficiency. Given the seriousness of adrenal crisis, caregiver education on the signs of adrenal insufficiency is critical. Greater vigilance may be indicated in patients receiving both types of hormone therapy in tandem. Although a routine post-hormone laboratory assessment of adrenal function may not be feasible in all patients, replacement or stress dose hydrocortisone is necessary for all patients with suspected adrenal insufficiency.
Collapse
Affiliation(s)
- John R Mytinger
- Department of Pediatrics, Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University , Columbus, OH , USA
| | - Sasigarn A Bowden
- Department of Pediatrics, Division of Pediatric Endocrinology, Nationwide Children's Hospital, The Ohio State University , Columbus, OH , USA
| |
Collapse
|
7
|
Scranton RA, Baskin DS. Impaired Pituitary Axes Following Traumatic Brain Injury. J Clin Med 2015; 4:1463-79. [PMID: 26239686 PMCID: PMC4519800 DOI: 10.3390/jcm4071463] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 06/29/2015] [Accepted: 07/06/2015] [Indexed: 12/24/2022] Open
Abstract
Pituitary dysfunction following traumatic brain injury (TBI) is significant and rarely considered by clinicians. This topic has received much more attention in the last decade. The incidence of post TBI anterior pituitary dysfunction is around 30% acutely, and declines to around 20% by one year. Growth hormone and gonadotrophic hormones are the most common deficiencies seen after traumatic brain injury, but also the most likely to spontaneously recover. The majority of deficiencies present within the first year, but extreme delayed presentation has been reported. Information on posterior pituitary dysfunction is less reliable ranging from 3%-40% incidence but prospective data suggests a rate around 5%. The mechanism, risk factors, natural history, and long-term effect of treatment are poorly defined in the literature and limited by a lack of standardization. Post TBI pituitary dysfunction is an entity to recognize with significant clinical relevance. Secondary hypoadrenalism, hypothyroidism and central diabetes insipidus should be treated acutely while deficiencies in growth and gonadotrophic hormones should be initially observed.
Collapse
Affiliation(s)
- Robert A Scranton
- Department of Neurosurgery and the Kenneth R. Peak Brain and Pituitary Tumor Treatment Center, Houston Methodist Neurological Institute, 6560 Fannin St. Suite 944, Houston, TX 77030, USA.
| | - David S Baskin
- Department of Neurosurgery and the Kenneth R. Peak Brain and Pituitary Tumor Treatment Center, Houston Methodist Neurological Institute, 6560 Fannin St. Suite 944, Houston, TX 77030, USA.
| |
Collapse
|
8
|
Tenenbaum A, Phillip M, de Vries L. The intramuscular glucagon stimulation test does not provide good discrimination between normal and inadequate ACTH reserve when used in the investigation of short healthy children. Horm Res Paediatr 2015; 82:194-200. [PMID: 25139316 DOI: 10.1159/000365190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/10/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Few studies have addressed the role of the glucagon stimulation test (GST) in evaluating the hypothalamic-pituitary-adrenal axis in children. We investigated the diagnostic value of the GST in evaluating the adrenocortical response in short healthy children. METHODS The GST was performed in 190 children investigated for short stature. A peak cortisol >500 nmol/l was considered a normal response. In the 45 (23.7%) with subnormal response, a 250-μg ACTH test was done. RESULTS The rate of subnormal adrenal response to GST was higher among boys (33.9 vs. 8.9%, p < 0.001) and among children ≥6 years than among younger children (32.7 vs. 18.4%, p < 0.02). Both mean basal and peak cortisol levels were higher in girls than in boys: 381 ± 165 vs. 319 ± 151 nmol/l (p = 0.003) and 741 ± 102 vs. 595 ± 208 nmol/l (p < 0.001), respectively. Peak cortisol on GST was associated with basal cortisol (r = 0.45, p < 0.001) but not with glucose nadir (r = -0.31, p = 0.67), peak GH (r = 0.069, p = 0.33) or BMI-SDS (r = -0.08, p = 0.28). Peak cortisol was >500 nmol/l in all the patients undergoing an ACTH stimulation test. CONCLUSIONS Since adrenal response to GST is age- and gender-related and the false-positive rate is high, its routine performance in healthy children warrants reconsideration.
Collapse
Affiliation(s)
- Ariel Tenenbaum
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | | | | |
Collapse
|
9
|
Palatinus JA, Lieber SB, Joyce KE, Richards JB. Extracorporeal Membrane Oxygenation Support for Hypokalemia-induced Cardiac Arrest: A Case Report and Review of the Literature. J Emerg Med 2015; 49:159-64. [PMID: 26004853 DOI: 10.1016/j.jemermed.2015.02.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 02/24/2015] [Accepted: 02/27/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypokalemia is a reversible cause of cardiac arrest in patients presenting to the emergency department (ED). Extracorporeal membrane oxygenation (ECMO) is an established technology for cardiopulmonary support with emerging roles in resuscitation. Here, we review the literature of hypokalemic-induced cardiac arrests and discuss one such case successfully managed with ECMO. CASE REPORT A 23-year-old Central American man who presented to a community ED under federal custody with several days of nausea and vomiting was found to have a serum potassium level of 1.5 mEq/L. Repeat serum potassium level was 1.1 mEq/L upon arrival to our facility. Within 2 h of arrival, despite electrolyte repletion, he suffered cardiac arrest. Advanced cardiac life support was performed for 45 min. ECMO was initiated while active chest compressions were performed. After aggressive potassium repletion, return of spontaneous circulation was achieved and ECMO was eventually discontinued. Further investigation ultimately confirmed the presence of a potassium-wasting nephropathy, for which the patient had been treated with chronic potassium supplementation prior to entering federal custody. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ECMO is a well-established modality for cardiopulmonary support, with an emerging role for patients in undifferentiated cardiac arrest presenting to the ED. There is a growing interest in the utility of ECMO in these circumstances. This report highlights hypokalemia as an important cause of cardiac arrest, reviews the treatment and causes of hypokalemia, and demonstrates a potential role for ECMO as a critical temporizing measure to provide time for potassium repletion.
Collapse
Affiliation(s)
- Joseph A Palatinus
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sarah B Lieber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Katherine E Joyce
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jeremy B Richards
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
10
|
Prasad K, Dhar I. Oxidative stress as a mechanism of added sugar-induced cardiovascular disease. Int J Angiol 2014; 23:217-26. [PMID: 25484552 PMCID: PMC4244242 DOI: 10.1055/s-0034-1387169] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Added sugars comprising of table sugar, brown sugar, corn syrup, maple syrup, honey, molasses, and other sweeteners in the prepared processed foods and beverages have been implicated in the pathophysiology of cardiovascular diseases. This article deals with the reactive oxygen species (ROS) as a mechanism of sugar-induced cardiovascular diseases. There is an association between the consumption of high levels of serum glucose with cardiovascular diseases. Various sources of sugar-induced generation of ROS, including mitochondria, nicotinamide adenine dinucleotide phosphate-oxidase, advanced glycation end products, insulin, and uric acid have been discussed. The mechanism by which ROS induce the development of atherosclerosis, hypertension, peripheral vascular disease, coronary artery disease, cardiomyopathy, heart failure, and cardiac arrhythmias have been discussed in detail. In conclusion, the data suggest that added sugars induce atherosclerosis, hypertension, peripheral vascular disease, coronary artery disease, cardiomyopathy, heart failure, and cardiac arrhythmias and that these effects of added sugars are mediated through ROS.
Collapse
Affiliation(s)
- Kailash Prasad
- Department of Physiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Indu Dhar
- Department of Pharmacology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| |
Collapse
|
11
|
Wildi-Runge S, Deladoëy J, Bélanger C, Deal CL, Van Vliet G, Alos N, Huot C. A search for variables predicting cortisol response to low-dose corticotropin stimulation following supraphysiological doses of glucocorticoids. J Pediatr 2013; 163:484-8. [PMID: 23414662 DOI: 10.1016/j.jpeds.2013.01.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 11/30/2012] [Accepted: 01/04/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To determine which biological or clinical variables may predict cortisol response to low-dose adrenocorticotropic hormone (ACTH) stimulation following supraphysiological doses of glucocorticoids in children. STUDY DESIGN This retrospective study included all patients who underwent ACTH testing (1 μg) between October 2008 and June 2010 at the Sainte-Justine University Hospital Center, Montreal, after supraphysiological doses of glucocorticoids. RESULTS Data from 103 patients (median age, 8.0 years; range, 0.6-18.5 years; 57 girls) were analyzed, revealing growth deceleration in 37% and excessive weight gain in 33%. Reasons for glucocorticoid treatment included asthma (n = 30) and hematologic (n = 22), dermatologic (n = 19), rheumatologic (n = 16), and miscellaneous (n = 16) disorders. The following information was recorded: duration of glucocorticoid treatment (median, 374 days; range, 5-4226 days); duration of physiological hydrocortisone replacement (median, 118 days; range, 0-1089 days); maximum daily (median, 200 mg/m(2)/day; range, 12-3750 mg/m(2)/day) and cumulative (median, 16 728 mg/m(2); range, 82-178 209 mg/m(2)) doses, in hydrocortisone equivalents; and interval since the last dose (median, 43 days; range, 1-1584 days). Sixty-two patients (58%) exhibited a normal response (ie, peak cortisol >500 nmol/L) to ACTH stimulation. Peak cortisol level was not related to sex, prior morning cortisol level, duration of treatment, or cumulative glucocorticoid dose; 28% of the patients with normal baseline cortisol levels nevertheless demonstrated a subnormal response to ACTH. CONCLUSION Given the absence of clinical or biological predictors of the cortisol response to ACTH after suppressive doses of glucocorticoids, physicians have only 2 options: (1) empirically advocate glucocorticoid stress coverage during 18 months after cessation of high-dose glucocorticoid treatment; or (2) perform serial ACTH testing in all such patients until a normal peak cortisol level is attained.
Collapse
Affiliation(s)
- Stefanie Wildi-Runge
- Endocrinology Service and Research Center, Sainte-Justine University Hospital Center and Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | | | | | | | | | | | | |
Collapse
|
12
|
Abstract
The availability of synthetic recombinant human growth hormone (GH) in potentially unlimited quantities since the 1980s has improved understanding of the many nonstatural effects of GH on metabolism, body composition, physical and psychological function, as well as the consequences of GH deficiency in adult life. Adult GH deficiency is now recognized as a distinct if nonspecific syndrome with considerable adverse health consequences. GH replacement therapy in lower doses than those used in children can reverse many of these abnormalities and restore functional capacities toward or even to normal; if dosed appropriately, GH therapy has few adverse effects. Although some doubts remain about possible long-term risks of childhood GH therapy, most registries of adult GH replacement therapy, albeit limited in study size and duration, have not shown an increased incidence of cancers or of cardiovascular morbidity or mortality.
Collapse
Affiliation(s)
- Atil Y Kargi
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, 1400 North West 10th Avenue, Suite 807, Miami, FL 33136, USA
| | | |
Collapse
|
13
|
O'Grady MJ, Hensey C, Fallon M, Hoey H, Murphy N, Costigan C, Cody D. Lack of sensitivity of the 1-μg low-dose ACTH stimulation test in a paediatric population with suboptimal cortisol responses to insulin-induced hypoglycaemia. Clin Endocrinol (Oxf) 2013; 78:73-8. [PMID: 22712566 DOI: 10.1111/j.1365-2265.2012.04474.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 05/09/2012] [Accepted: 06/12/2012] [Indexed: 01/05/2023]
Abstract
CONTEXT The insulin-tolerance test (ITT) is the gold standard for evaluation of the hypothalamic-pituitary-adrenal (HPA) axis. The low-dose ACTH stimulation test is increasingly used for evaluation of secondary adrenal insufficiency as several studies performed in adults have demonstrated high sensitivity and specificity when compared to the ITT. Whether the ACTH stimulation test demonstrates similar sensitivity in a paediatric and adolescent population compared with the gold standard is unclear. OBJECTIVE To compare the sensitivity of the low-dose (1-μg) Synacthen(™) test (LDSST) and the gold-standard ITT in a paediatric and adolescent population. DESIGN AND PATIENTS A retrospective review of 42 consecutive LDSSTs in children and adolescents with suboptimal cortisol responses (peak <500 nm) on ITT. RESULTS Thirty-one patients (74%) had an adequate cortisol response to low-dose Synacthen(™) (sensitivity 26%). Patients had a higher cortisol increment with the LDSST than ITT (median Δ cortisol 294 vs 168 nm, P < 0.0001) and correspondingly a higher cortisol peak (median peak cortisol 572 vs 396 nm, P < 0.0001). Patients who had a suboptimal peak cortisol both on ITT and on LDSST had a lower baseline cortisol on ITT (median 178 vs 227 nm, P = 0.04). Peak cortisol on ITT was significantly higher in patients who had a subsequent normal LDSST than those that did not (median 417 vs 300 nm, P = 0.0005). CONCLUSIONS The 1-μg LDSST lacks sensitivity in detection of secondary adrenal insufficiency in children when compared to the gold-standard ITT.
Collapse
Affiliation(s)
- Michael J O'Grady
- Department of Endocrinology and Diabetes, Our Ladys' Childrens Hospital, Crumlin, Dublin, Ireland.
| | | | | | | | | | | | | |
Collapse
|
14
|
Kargi AY, Merriam GR. Testing for growth hormone deficiency in adults: doing without growth hormone-releasing hormone. Curr Opin Endocrinol Diabetes Obes 2012; 19:300-5. [PMID: 22596248 DOI: 10.1097/med.0b013e32835430da] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article summarizes recent advances in testing for growth hormone deficiency (GHD) in adults, focusing on critical appraisal of existing growth hormone (GH) provocative tests as well as newer tests in development. RECENT FINDINGS The diagnosis of GHD can be challenging and often requires the use of GH provocative testing. The most widely validated of these is insulin-induced hypoglycemia (ITT), which requires close supervision and has significant contraindications and side-effects. The arginine-growth hormone-releasing hormone (GHRH) test had become widely used as a safe and accurate alternative to the ITT, but GHRH is currently unavailable for clinical use in the USA. On the basis of review of recent literature we recommend that in the absence of GHRH, glucagon stimulation testing should be the preferred alternative to ITT. Several synthetic GH secretagogues that mimic the gastric peptide ghrelin are currently in development and may become available for use in the diagnosis of GHD in the near future. Other GH provocative tests suitable for use in children lack adequate specificity for the diagnosis of GHD in adults. SUMMARY Due to the current unavailability of the arginine-GHRH test in the USA, when ITT is contraindicated or impractical we recommend the glucagon stimulation testing as the GH provocative test of choice. There remains a need for a simple, safe and accurate test for the diagnosis of GHD.
Collapse
Affiliation(s)
- Atil Y Kargi
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | |
Collapse
|
15
|
Kamrath C, Boehles H. The low-dose ACTH test does not identify mild insufficiency of the hypothalamnic-pituitary-adrenal axis in children with inadequate stress response. J Pediatr Endocrinol Metab 2010; 23:1097-104. [PMID: 21284322 DOI: 10.1515/jpem.2010.174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate retrospectively the sensitivity of published cortisol cut-off points of the low-dose ACTH test (LDAT) in children with proven mild hypothalamic-pituitary-adrenal (HPA) axis insufficiency. PATIENTS AND METHODS The HPA axis of 11 pediatric patients (age range: 5.5-14.5 yr) with established mild HPA axis insufficiency was reinvestigated with the LDAT. The sensitivity of the LDAT was calculated on the basis of published stimulated cortisol cut-off points. RESULTS The LDAT showed both a significantly higher cortisol peak and a greater cortisol rise compared with the ITT (both P < 0.01). The LDAT yielded a low sensitivity of 9-55% using published cortisol cut-off points as references. CONCLUSION Using published cortisol cut-off points, the LDAT showed a poor sensitivity to detect mild HPA axis insufficiency. We cannot recommend the use of the LDAT as a screening test of HPA axis impairment in such children.
Collapse
Affiliation(s)
- Clemens Kamrath
- Department of Pediatrics, Division of Pediatric Endocrinology, Johann Wolfgang Goethe-University, Frankfurt, Germany.
| | | |
Collapse
|
16
|
Tseng LL, Lue HC, Huang CH, Niu DM. Severe hyponatremia due to ACTH insufficiency in a 14 year-old girl with growth hormone deficiency. J Pediatr Endocrinol Metab 2010; 23:197-201. [PMID: 20432824 DOI: 10.1515/jpem.2010.23.1-2.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
SIADH-like hyponatremia as the presenting manifestation of ACTH deficiency is rare in childhood. Here we report a 14 year-old girl who, after 8 years of GH replacement and subsequent treatment for subclinical secondary hypothyroidism, presented with confusion and disorientation due to severe hyponatremia. When her pituitary axis was re-assessed, she was diagnosed as having ACTH deficiency associated with multiple pituitary hormone deficiencies (MPHD) (including GH, FSH, LH, and subclinical TSH deficiencies). She responded poorly to treatment with only hypertonic fluid, but improved after addition of hydrocortisone replacement. The purpose of this paper is to emphasize the importance of suspecting ACTH insufficiency in children with GH deficiency if hyponatremia develops.
Collapse
Affiliation(s)
- Lo-Lin Tseng
- Department of Pediatrics, Lo-Tung St. Mary's Hospital, Taipei, Taiwan
| | | | | | | |
Collapse
|
17
|
|
18
|
van Vught AJAH, Nieuwenhuizen AG, Gerver WJ, Veldhorst MAB, Brummer RJM, Westerterp-Plantenga MS. Pharmacological and physiological growth hormone stimulation tests to predict successful GH therapy in children. J Pediatr Endocrinol Metab 2009; 22:679-94. [PMID: 19845119 DOI: 10.1515/jpem.2009.22.8.679] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although the current use of growth hormone (GH) stimulation tests (GHSTs) is still subject to debate, the tests are widely used to diagnose GH deficiency. This literature review evaluates primarily the sensitivity, specificity and reliability of GHSTs and secondarily their convenience. Single pharmacological tests typically address only a single pathway in the complex physiological regulation of GH secretion and are therefore characterized by lower sensitivity, specificity and reliability than combined pharmacological tests or physiological tests. In spite of the high levels of sensitivity, specificity and reliability, physiological tests require considerably more effort to perform, from the physician as well as from the child. Therefore, a need for an alternative, convenient, physiological GHST still remains. Oral ingestion of dietary protein is convenient in practice and may induce more physiological stimulation of GH secretion, hence may be a promising valuable addition to the existing GHSTs in GH deficiency.
Collapse
|
19
|
Abstract
Adrenal insufficiency is relatively rare in childhood and adolescence. Signs and symptoms may be nonspecific; therefore, the diagnosis may not be suspected early in the course. If unrecognized, adrenal insufficiency may present with life-threatening cardiovascular collapse. Adrenal crisis continues to occur in children with known primary or secondary adrenal insufficiency during intercurrent illness because of failure to increase glucocorticoid dosage. In this article, current knowledge of the incidence, diagnosis, and treatment of adrenal insufficiency in children and factors precipitating adrenal crisis are summarized. Suggestions for prevention of adrenal crisis in patients at risk are provided for health care professionals and families.
Collapse
Affiliation(s)
- Dorothy I Shulman
- Department of Pediatrics, All Children's Hospital, University of South Florida College of Medicine, Tampa, Florida 33701, USA.
| | | | | |
Collapse
|
20
|
Francis J, Sankar V, Nair VK, Priori SG. Catecholaminergic polymorphic ventricular tachycardia. Heart Rhythm 2005; 2:550-4. [PMID: 15840485 DOI: 10.1016/j.hrthm.2005.01.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2004] [Accepted: 01/18/2005] [Indexed: 12/22/2022]
Abstract
Catecholaminergic polymorphic ventricular tachycardia (VT) is a rare arrhythmogenic disease characterized by exercise- or stress-induced ventricular tachyarrhythmias, syncope, or sudden death, usually in the pediatric age group. Familial occurrence has been noted in about 30% of cases. Inheritance can be autosomal dominant or recessive, usually with high penetrance. The causative genes have been mapped to chromosome 1. Mutations of the cardiac ryanodine receptor gene (RyR2) have been identified in autosomal dominant pedigrees, while calsequestrin gene (CASQ2) mutations are seen in recessive cases. Ankyrin-B mutations may also be implicated in catecholaminergic polymorphic VT: mutations in this gene were previously linked to the long-QT 4 phenotype. Ventricular ectopy, bidirectional VT, and polymorphic VT occur in a predictable and progressive manner with increasing heart rate during exercise or isoproterenol infusion. Estimated mortality of untreated cases ranges from 30% to 50% before the age of 20-30 years according to family studies. Although beta-blocker therapy was considered to be effective in preventing clinical recurrence in the initial series, recent data show low efficacy. As there is a chance for sudden cardiac death if even a single dose of beta-blocker is missed, there is a trend toward implantation of defibrillators in more and more patients.
Collapse
Affiliation(s)
- Johnson Francis
- Department of Cardiology, Medical College Calicut, Kerala, India.
| | | | | | | |
Collapse
|