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Corsello A, Paragliola RM, Salvatori R. Diagnosing and treating the elderly individual with hypopituitarism. Rev Endocr Metab Disord 2024; 25:575-597. [PMID: 38150092 DOI: 10.1007/s11154-023-09870-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Abstract
Hypopituitarism in the elderly is an underestimated condition mainly due to the non-specific presentation that can be attributed to the effects of aging and the presence of comorbidities. Diagnosis and treatment of hypopituitarism often represent a challenging task and this is even more significant in the elderly. Diagnosis can be insidious due to the physiological changes occurring with aging that complicate the interpretation of hormonal investigations, and the need to avoid some provocative tests that carry higher risks of side effects in this population. Treatment of hypopituitarism has generally the goal to replace the hormonal deficiencies to restore a physiological balance as close as possible to that of healthy individuals but in the elderly this must be balanced with the risks of over-replacement and worsening of comorbidities. Moreover, the benefit of some hormonal replacement therapies in the elderly, including sex hormones and growth hormone, remains controversial.
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Affiliation(s)
- Andrea Corsello
- Unità di Chirurgia Endocrina, Ospedale Isola Tiberina - Gemelli Isola, 00186, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Rosa Maria Paragliola
- Unicamillus-Saint Camillus International University of Health Sciences, 00131, Rome, Italy
| | - Roberto Salvatori
- Division of Endocrinology, Department of Medicine, and Pituitary Center, Johns Hopkins University, Baltimore, MD, 2187, USA.
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Daloglu OO, Unal MC, Kemaloglu CA, Bolatturk OF, Ozyazgan I, Tanriverdi F, Coruh A, Kelestimur F. Evaluation of pituitary function and metabolic parameters in patients with traumatic maxillofacial fractures. J Endocrinol Invest 2024:10.1007/s40618-024-02349-8. [PMID: 38503991 DOI: 10.1007/s40618-024-02349-8] [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: 09/08/2023] [Accepted: 02/21/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE This study was designed to assess the pituitary functions of patients with traumatic maxillofacial fractures and compare the results with healthy controls. METHODS Thirty patients (mean age, 38.14 ± 14.15 years; twenty-six male, four female) with a traumatic maxillofacial fracture at least 12 months ago (mean 27.5 ± 6.5 months) and thirty healthy controls (mean age, 42.77 ± 11.36 years; twenty-five male, five female) were included. None of the patients were unconscious following head trauma, and none required hospitalization in intensive care. Basal pituitary hormone levels of the patients were evaluated. All patients and controls had a glucagon stimulation test and an ACTH stimulation test to evaluate the hypothalamic-pituitary-adrenal axis and the GH-IGF-1 axis. RESULTS Five of thirty patients (16.6%) had isolated growth hormone (GH) deficiency based on a glucagon stimulation test (GST). The mean peak GH level after GST in patients with hypopituitarism (0.54 ng/ml) was significantly lower than those without hypopituitarism (7.01 ng/ml) and healthy controls (11.70 ng/ml) (P < 0.001). No anterior pituitary hormone deficiency was found in the patients, except for GH. CONCLUSION Our study is the first to evaluate the presence of hypopituitarism in patients with traumatic maxillofacial fractures. Preliminary findings suggest that hypopituitarism and GH deficiency pose significant risks to these patients, particularly during the chronic phase of their trauma. However, these findings need to be validated in larger scale prospective studies with more patients.
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Affiliation(s)
- O O Daloglu
- Department of Endocrinology and Metabolism, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey.
| | - M C Unal
- Department of Endocrinology and Metabolism, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - C A Kemaloglu
- Department of Plastic Surgery and Reconstruction, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - O F Bolatturk
- Department of Neurology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - I Ozyazgan
- Department of Plastic Surgery and Reconstruction, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - F Tanriverdi
- Endocrinology Clinic, Memorial Kayseri Hospital, Kayseri, Turkey
| | - A Coruh
- Department of Plastic Surgery and Reconstruction, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - F Kelestimur
- Department of Endocrinology, Faculty of Medicine, Yeditepe University, Istanbul, Turkey
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3
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Zhang Z, Wu X, Kong Y, Zou P, Wang Y, Zhang H, Cui G, Zhu W, Chen H. Dynamic Changes and Effects of H 2S, IGF-1, and GH in the Traumatic Brain Injury. Biochem Genet 2024:10.1007/s10528-023-10557-9. [PMID: 38233694 DOI: 10.1007/s10528-023-10557-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/21/2023] [Indexed: 01/19/2024]
Abstract
The aim of this study was to examine the expression changes of H2S, IGF-1, and GH in traumatic brain injury (TBI) patients and to detect their neuroprotective functions after TBI. In this study, we first collected cerebrospinal fluid (CSF) and plasma from TBI patients at different times after injury and evaluated the concentrations of H2S, IGF-1, and GH. In vitro studies were using the scratch-induced injury model and cell-cell interaction model (HT22 hippocampal neurons co-cultured with LPS-induced BV2 microglia cells). In vivo studies were using the controlled cortical impact (CCI) model in mice. Cell viability was assessed by CCK-8 assay. Pro-inflammatory cytokines expression was determined by qRT-PCR, ELISA, and nitric oxide production. Western blot was performed to assess the expression of CBS, CSE, IGF-1, and GHRH. Moreover, the recovery of TBI mice was evaluated for behavioral function by applying the modified Neurological Severity Score (mNSS), the Rotarod test, and the Morris water maze. We discovered that serum H2S, CSF H2S, and serum IGF-1 concentrations were all adversely associated with the severity of the TBI, while the concentrations of IGF-1 and GH in CSF and GH in the serum were all positively related to TBI severity. Experiments in vitro and in vivo indicated that treatment with NaHS (H2S donor), IGF-1, and MR-409 (GHRH agonist) showed protective effects after TBI. This study gives novel information on the functions of H2S, IGF-1, and GH in TBI.
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Affiliation(s)
- Zhen Zhang
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yuhuangding East Road, Zhifu District, 264000, Yantai, Shandong, China
| | - Xin Wu
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yuhuangding East Road, Zhifu District, 264000, Yantai, Shandong, China
| | - Yang Kong
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yuhuangding East Road, Zhifu District, 264000, Yantai, Shandong, China
| | - Peng Zou
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yuhuangding East Road, Zhifu District, 264000, Yantai, Shandong, China
| | - Yanbin Wang
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yuhuangding East Road, Zhifu District, 264000, Yantai, Shandong, China
| | - Hongtao Zhang
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yuhuangding East Road, Zhifu District, 264000, Yantai, Shandong, China
| | - Guangqiang Cui
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yuhuangding East Road, Zhifu District, 264000, Yantai, Shandong, China
| | - Wei Zhu
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yuhuangding East Road, Zhifu District, 264000, Yantai, Shandong, China.
| | - Hongguang Chen
- Department of Neurosurgery, Yantai Yuhuangding Hospital, Yuhuangding East Road, Zhifu District, 264000, Yantai, Shandong, China.
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Cárdenas J, Kelepouris N, Adiga R, Yuen KCJ. Coverage of education and training of traumatic brain injury-induced growth hormone deficiency in US residency and fellowship programs: a cross-sectional study. BMC MEDICAL EDUCATION 2024; 24:53. [PMID: 38200500 PMCID: PMC10782717 DOI: 10.1186/s12909-024-05027-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND Hypopituitarism, including growth hormone deficiency (GHD), is a common sequela of traumatic brain injury (TBI). This study explored the coverage of education and training of TBI-induced hypopituitarism in general and GHD in particular, in postgraduate program curricula to identify knowledge gaps and opportunities. METHODS An online survey and qualitative interviews (focus groups) were conducted among endocrinology, neurology, and physiatry postgraduate program directors in the United States (US). The study received an IRB exemption. RESULTS A total of 419 fellowship and residency programs were invited to participate; 60 program directors completed the survey and 11 of these participated in the focus groups. About half of the respondents considered TBI-induced hypopituitarism important or fairly important to include in the curriculum, and nearly two-thirds considered it an appropriate training component. Neurology program directors considered education regarding hypopituitarism following TBI less important and relevant for their curricula compared with endocrinology and physiatry program directors. About half (53%) of the programs responded that they included TBI-induced pituitary disorders in their curricula. About two-thirds (68%) of endocrinology programs, compared with only one-quarter (25%) of neurology programs, covered TBI-induced pituitary disorders. Respondents identified multiple barriers to expanding hypopituitarism following TBI in the curriculum, including the rarity of condition and lack of time/room in the curriculum. Respondents reported that consensus clinical guidelines and the availability of more data on TBI-induced hypopituitarism, including GHD, would greatly impact the development of educational curricula on this topic. CONCLUSIONS To improve the management of TBI-induced hypopituitarism, education and training should be expanded in US fellowship and residency programs to prepare trainees to effectively screen, diagnose, and treat TBI-induced hypopituitarism, including GHD.
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Affiliation(s)
- Javier Cárdenas
- Rockefeller Neuroscience Institute, West Virginia University, 33 Medical Center Dr, Morgantown, WV, 26506, USA
| | - Nicky Kelepouris
- Novo Nordisk Inc, 800 Scudders Mill Rd, Plainsboro, NJ, 08536, USA
| | - Radhika Adiga
- Novo Nordisk Inc, 800 Scudders Mill Rd, Plainsboro, NJ, 08536, USA
| | - Kevin C J Yuen
- Barrow Neurological Institute, 240 W Thomas Rd, Suite 404, Phoenix, AZ, 85013, USA.
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Herodes M, Legaspi A, Garcia JM. Mild traumatic brain injury as a cause of adult growth hormone deficiency: Diagnosis and treatment. Best Pract Res Clin Endocrinol Metab 2023; 37:101818. [PMID: 37666680 DOI: 10.1016/j.beem.2023.101818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
In recent years, mild traumatic brain injury (mTBI) has been recognized as a cause of acquired growth hormone deficiency (AGHD) and is likely much more prevalent than previous estimates. There is great overlap between persistent symptoms following mTBI and those of AGHD and it is possible that these persistent symptoms of mTBI are, at least in part, due to or aggravated by AGHD. This article reviews the current literature of AGHD following mTBI, and proposes practice recommendations for the screening, diagnosis, and management of patients with AGHD following mTBI.
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Affiliation(s)
- Megan Herodes
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Aviel Legaspi
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
| | - Jose M Garcia
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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Abstract
PURPOSE OF REVIEW This article reviews hypopituitarism after TBI, the importance of pituitary hormones, and related controversies, concluding with a suggested patient approach. RECENT FINDINGS While earlier studies focused on increased pituitary deficiencies after moderate-severe TBI, recent studies have focused on deficiencies after mild TBI. There has been increasing focus on the role of growth hormone after injury; growth hormone is the most frequent reported deficiency at 1 year post-TBI, and an area with unresolved questions. While more research is needed to quantify the risk of deficiencies in special populations, and establish the natural history, increasing data indicate an increase in hypopituitarism after other acquired brain injuries; the potential role of pituitary hormone deficiencies after stroke and after COVID-19 infection is an area of active inquiry. Given the negative health effects of untreated hypopituitarism and the opportunity to intervene via hormone replacement, it is important to recognize the role of pituitary hormone deficiencies after TBI.
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Affiliation(s)
- Tamara L Wexler
- Department of Rehabilitation Medicine, NYU Grossman School of Medicine, 240 E 38th St 15th Floor, New York, NY, 10016, USA.
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Mohd Salleh N, Theophilus SC, Rahman NAA, Ghani ARI, Abdullah JM, Idris Z, Tan ZH, Kamil NM. Chronic Anterior Pituitary Dysfunction Following Traumatic Head Injury: Prospective Study in Hospital Sultanah Aminah Johor Bahru, Malaysia. Malays J Med Sci 2023; 30:107-115. [PMID: 36875199 PMCID: PMC9984114 DOI: 10.21315/mjms2023.30.1.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/30/2022] [Indexed: 03/05/2023] Open
Abstract
Background Hypopituitarism following traumatic brain injury (TBI) is not rare however most patients were left undiagnosed and untreated. Association of post TBI hypopituitarism causing neurobehavioural and quality of life impairment. The aim of the study is to determine the incidence of the chronic anterior pituitary deficiency in patients with traumatic brain injury. Subsequently determine the risk factor and the outcome of the patient with chronic anterior pituitary dysfunction. Methods This is single centre cross-sectional study involved 105 traumatic head injury patients under the Neurosurgical Department Hospital Sultanah Aminah, Johor Bahru, Malaysia. The primary investigator will do an interview and the patients will be asked question to complete a questioner from SF-36 (36 questions). Subsequently, consent for participation will be taken and blood sampling will be done. Results Thirty-three patients were noted to have anterior pituitary dysfunction. The mean age was 36.97 ± 12.96 years old. Twenty-seven patients (32.5%) were male and six patients were female (27.3%). Chronic anterior pituitary dysfunction in patients with a severe traumatic head injury around 47.1% (23 patients), as compared to a moderate head injury (8 patients, 38.1%) and 2 sustained mild head injury (5.6%). The mean duration after the onset of trauma was 10.3 ± 1.79 months. All patient with anterior pituitary dysfunction had positive CT brain findings with 22 had subarachnoid haemorrhage (SAH) at the basal cistern and 27 patients had a base of skull fracture, where 52.1% of the patient underwent surgical intervention, 84.8% involved one axis and another 5 patients had two axes involved. Severity of the head injury (P < 0.001), prolonged duration of hospital stay (P = 0.014), radiological findings of a base of skull fracture (P < 0.001) and presence of SAH at basal cistern (P < 0.001) was significantly associated with pituitary dysfunction. The patient with anterior pituitary dysfunction has the lower 36-item Short Form Survey (SF-36) marks 56.3 ± 10.3. Conclusion The prevalence of hypopituitarism was 31%. Indicators are increased TBI severity, prolonged hospitalisation and positive finding in radiological assessment. Post-traumatic chronic anterior pituitary dysfunction also related with poor quality of life as showed by low SF-36 marks.
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Affiliation(s)
| | | | | | - Abdul Rahman Izaini Ghani
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Jafri Malin Abdullah
- Brain and Behaviour Cluster, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Zi Han Tan
- Department of Neurosurgery, Hospital Sultanah Aminah, Johor, Malaysia
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Claessen LÓE, Kristjánsdóttir H, Jónsdóttir MK, Lund SH, Kristensen ISU, Sigurjónsdóttir HÁ. Screening for possible hypopituitarism following mild traumatic brain injury: The first all-female study. Who do we need to evaluate further? NeuroRehabilitation 2023; 52:259-271. [PMID: 36641687 DOI: 10.3233/nre-220194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Studies on hypopituitarism (HP) following mild traumatic brain injury (mTBI) have focused on male populations although women may be more susceptible to the sequelae of mTBI. This is, to the best of our knowledge, the first all-female study screening for HP following mTBI. OBJECTIVE Screening for possible HP in female athletes reporting a history of one or more mTBI. METHODS Pituitary hormone screening blood tests (SBT) were performed in 133 of the 151 female athletes included. Repeated results outside the reference value (O-RV) were considered abnormal necessitating further endocrinological evaluation. RESULTS Repeated SBT were O-RV in 88 women (66.2%). Decreased levels of serum insulin growth factor 1 (S-IGF1) were found in 55.6% of participants and elevated levels of serum prolactin (S-prolactin) in 22.6%. Serum cortisol levels were below the RV in 6.0% and thyroid hormonal levels in 11.3%. Lower age and increased number of mTBI symptoms correlated significantly with the risk of hormonal results O-RV. CONCLUSION The majority of the study population had SBT O-RV, warranting further workup of possible HP. Decreased levels of S-IGF1 were most commonly observed followed by elevated S-prolactin possibly indicating hypothalamic-pituitary impairment. Lower age and increased number of symptoms of mTBI may indicate the need to screen for HP.
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Affiliation(s)
- Lára Ósk Eggertsdóttir Claessen
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland.,Department of Emergency Medicine, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Hafrún Kristjánsdóttir
- Physical Activity, Physical Education, Sport and Health (PAPESH) Research Centre, Sports Science Department, School of Social Sciences, Reykjavik University, Reykjavik, Iceland
| | - María K Jónsdóttir
- Mental Health Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Psychology Department, School of Social Sciences, Reykjavik University, Reykjavik, Iceland
| | | | - Ingunn S U Kristensen
- Psychology Department, School of Social Sciences, Reykjavik University, Reykjavik, Iceland
| | - Helga Ágústa Sigurjónsdóttir
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland.,Department of Medicine, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
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Yuen KCJ, Masel B, Jaffee MS, O'Shanick G, Wexler TL, Reifschneider K, Urban RJ, Hoang S, Kelepouris N, Hoffman AR. A consensus on optimization of care in patients with growth hormone deficiency and mild traumatic brain injury. Growth Horm IGF Res 2022; 66:101495. [PMID: 35933894 DOI: 10.1016/j.ghir.2022.101495] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/01/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE/DESIGN Approximately 2.9 million children and adults in the US experience traumatic brain injuries (TBIs) annually, most of which are considered mild. TBI can induce varying consequences on pituitary function, with growth hormone deficiency (GHD) among the more commonly reported conditions. Panels of pediatric and adult endocrinologists, neurologists, physical medicine and rehabilitation specialists, and neuropsychologists convened in February and October 2020 to discuss ongoing challenges and provide strategies for detection and optimal management of patients with mild TBI and GHD. RESULTS Difficulties include a low rate of seeking medical attention in the population, suboptimal screening tools, cost and complexity of GHD testing, and a lack of consensus regarding when to test or retest for GHD. Additionally, referrals to endocrinologists from other specialists are uncommon. Recommendations from the panels for managing such patients included multidisciplinary guidelines on the diagnosis and management of post-TBI GHD and additional education on long-term metabolic and probable cognitive benefits of GH replacement therapy. CONCLUSION As patients of all ages with mild TBI may develop GHD and/or other pituitary deficiencies, a multidisciplinary approach to provide education to endocrinologists, neurologists, neurosurgeons, traumatologists, and other providers and guidelines for the early identification and management of persistent mild TBI-related GHD are urgently needed.
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Affiliation(s)
- Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ, USA
| | - Brent Masel
- Department of Neurology, University of Texas Medical Branch, Galveston, TX, USA
| | - Michael S Jaffee
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | | | - Tamara L Wexler
- Rusk Rehabilitation, NYU Langone Health, New York, NY, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kent Reifschneider
- Division of Endocrinology, Children's Hospital of The King's Daughters, Norfolk, VA, USA
| | - Randall J Urban
- Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX, USA
| | | | | | - Andrew R Hoffman
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Carmichael J, Hicks AJ, Spitz G, Gould KR, Ponsford J. Moderators of gene-outcome associations following traumatic brain injury. Neurosci Biobehav Rev 2021; 130:107-124. [PMID: 34411558 DOI: 10.1016/j.neubiorev.2021.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/04/2021] [Accepted: 08/13/2021] [Indexed: 12/14/2022]
Abstract
The field of genomics is the principal avenue in the ongoing development of precision/personalised medicine for a variety of health conditions. However, relating genes to outcomes is notoriously complex, especially when considering that other variables can change, or moderate, gene-outcome associations. Here, we comprehensively discuss moderation of gene-outcome associations in the context of traumatic brain injury (TBI), a common, chronically debilitating, and costly neurological condition that is under complex polygenic influence. We focus our narrative review on single nucleotide polymorphisms (SNPs) of three of the most studied genes (apolipoprotein E, brain-derived neurotrophic factor, and catechol-O-methyltransferase) and on three demographic variables believed to moderate associations between these SNPs and TBI outcomes (age, biological sex, and ethnicity). We speculate on the mechanisms which may underlie these moderating effects, drawing widely from biomolecular and behavioural research (n = 175 scientific reports) within the TBI population (n = 72) and other neurological, healthy, ageing, and psychiatric populations (n = 103). We conclude with methodological recommendations for improved exploration of moderators in future genetics research in TBI and other populations.
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Affiliation(s)
- Jai Carmichael
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia.
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Gershon Spitz
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Kate Rachel Gould
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
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11
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Hypophyse und Kontaktsportarten. GYNAKOLOGISCHE ENDOKRINOLOGIE 2021. [DOI: 10.1007/s10304-021-00397-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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Abstract
Thyroid hormone is essential for brain development and brain function in the adult. During development, thyroid hormone acts in a spatial and temporal-specific manner to regulate the expression of genes essential for normal neural cell differentiation, migration, and myelination. In the adult brain, thyroid hormone is important for maintaining normal brain function. Thyroid hormone excess, hyperthyroidism, and thyroid hormone deficiency, hypothyroidism, are associated with disordered brain function, including depression, memory loss, impaired cognitive function, irritability, and anxiety. Adequate thyroid hormone levels are required for normal brain function. Thyroid hormone acts through a cascade of signaling components: activation and inactivation by deiodinase enzymes, thyroid hormone membrane transporters, and nuclear thyroid hormone receptors. Additionally, the hypothalamic-pituitary-thyroid axis, with negative feedback of thyroid hormone on thyrotropin-releasing hormone (TRH) and thyroid-stimulating hormone (TSH) secretion, regulates serum thyroid hormone levels in a narrow range. Animal and human studies have shown both systemic and local reduction in thyroid hormone availability in neurologic disease and after brain trauma. Treatment with thyroid hormone and selective thyroid hormone analogs has resulted in a reduction in injury and improved recovery. This article will describe the thyroid hormone signal transduction pathway in the brain and the role of thyroid hormone in the aging brain, neurologic diseases, and the protective role when administered after traumatic brain injury. © 2021 American Physiological Society. Compr Physiol 11:1-21, 2021.
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Affiliation(s)
- Yan-Yun Liu
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Departments of Medicine and Physiology, Endocrinology, Diabetes and Metabolism Division, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Gregory A Brent
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Departments of Medicine and Physiology, Endocrinology, Diabetes and Metabolism Division, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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13
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Szarka N, Szellar D, Kiss S, Farkas N, Szakacs Z, Czigler A, Ungvari Z, Hegyi P, Buki A, Toth P. Effect of Growth Hormone on Neuropsychological Outcomes and Quality of Life of Patients with Traumatic Brain Injury: A Systematic Review. J Neurotrauma 2021; 38:1467-1483. [PMID: 33677992 PMCID: PMC8672110 DOI: 10.1089/neu.2020.7265] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
One of the most devastating chronic consequences of traumatic brain injury (TBI) is cognitive impairment. One of the possible underlying causes is growth hormone deficiency (GHD) caused by TBI-induced hypopituitarism. Currently, TBI patients are not routinely screened for pituitary function, and there are no standard therapies when GHD is diagnosed. Further, the possible positive effects of GH replacement on cognitive function and quality of life after TBI are not well established. We aimed to assess the current knowledge regarding the effect of GH therapy on cognitive function and quality of life after TBI. We performed a literature search in PubMed, Embase, and Central® databases from inception to October 2019. We extracted data on each term of severity (mild-moderate-severe) of TBI with and without GHD, time since injury, parameters of growth hormone treatment (dosing, length), and cognitive outcomes in terms of verbal and non-verbal memory, and executive, emotional, and motor functions, and performed a meta-analysis on the results of a digit span test assessing working memory. We identified 12 studies (containing two randomized controlled trials) with 264 mild-to-moderate-to-severe TBI patients (Glasgow Coma Score [GCS] varied between 6 and 15) with (n = 255) or without (n = 9) GHD who received GH therapy. GH was administered subcutaneously in gradually increasing doses, monitoring serum insulin-like growth factor-I (IGF-I) level. After TBI, regardless of GCS, 6-12 months of GH therapy, started in the chronic phase post-TBI, induced a moderate improvement in processing speed and memory capacities, decreased the severity of depression, and led to a marked improvement in quality of life. Limitations include the relatively low number of patients involved and the divergent neuropsychological tests used. These results indicate the need for further multi-centric controlled studies to substantiate the use of GH replacement therapy as a potential tool to alleviate TBI-related cognitive impairment and improve quality of life.
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Affiliation(s)
- Nikolett Szarka
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | - Dora Szellar
- Department of Pediatrics, University of Pecs Medical School, Pecs, Hungary
| | - Szabolcs Kiss
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | - Zsolt Szakacs
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | - Andras Czigler
- Department of Neurosurgery and Szentagothai Research Center, University of Pecs Medical School, Pecs, Hungary
| | - Zoltan Ungvari
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging/Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Peter Hegyi
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | - Andras Buki
- Department of Neurosurgery and Szentagothai Research Center, University of Pecs Medical School, Pecs, Hungary
| | - Peter Toth
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
- Department of Neurosurgery and Szentagothai Research Center, University of Pecs Medical School, Pecs, Hungary
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- MTA-PTE Clinical Neuroscience MR Research Group, Pecs, Hungary
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14
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Mercier LJ, Kruger N, Le QB, Fung TS, Kline GA, Debert CT. Growth hormone deficiency testing and treatment following mild traumatic brain injury. Sci Rep 2021; 11:8534. [PMID: 33879807 PMCID: PMC8058058 DOI: 10.1038/s41598-021-87385-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/19/2021] [Indexed: 12/19/2022] Open
Abstract
Pituitary dysfunction, specifically growth hormone (GH) deficiency, can occur following traumatic brain injury. Our objective was to characterize the prevalence of GH deficiency (GHD) testing and response to recombinant human GH (rhGH) treatment in adults with persistent symptoms following mild traumatic brain injury (mTBI) referred for assessment of pituitary dysfunction. A retrospective chart review was conducted of patients seen at an outpatient brain injury clinic with a diagnosis of mTBI and persistent post-concussive symptoms who were referred to endocrinology. Clinical assessments of symptoms were collected. Investigations and results of GHD were collected, including initiation of rhGH treatment and treatment response. Of the 253 patients seen in both brain injury and endocrinology clinics, 97 with mTBI were referred for investigation of pituitary dysfunction and 73 (75%) had dynamic testing for assessment of GHD. Of the 26 individuals diagnosed with GHD, 23 (88%) started rhGH. GH therapy was inconsistently offered based on interpretation of GH dynamic testing results. Of those who started rhGH, 18 (78%) had a useful treatment response. This study suggests that clinical management of these patients is varied, highlighting a need for clear guidelines for the diagnosis and management of GHD following mTBI.
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Affiliation(s)
- Leah J Mercier
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.
| | - Natalia Kruger
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Quynk B Le
- Endocrinology and Metabolism Program, Alberta Health Services, Calgary, AB, Canada
| | - Tak S Fung
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Gregory A Kline
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chantel T Debert
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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15
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Neuroinflammation and Hypothalamo-Pituitary Dysfunction: Focus of Traumatic Brain Injury. Int J Mol Sci 2021; 22:ijms22052686. [PMID: 33799967 PMCID: PMC7961958 DOI: 10.3390/ijms22052686] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022] Open
Abstract
The incidence of traumatic brain injury (TBI) has increased over the last years with an important impact on public health. Many preclinical and clinical studies identified multiple and heterogeneous TBI-related pathophysiological mechanisms that are responsible for functional, cognitive, and behavioral alterations. Recent evidence has suggested that post-TBI neuroinflammation is responsible for several long-term clinical consequences, including hypopituitarism. This review aims to summarize current evidence on TBI-induced neuroinflammation and its potential role in determining hypothalamic-pituitary dysfunctions.
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16
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Prodam F, Caputo M, Mele C, Marzullo P, Aimaretti G. Insights into non-classic and emerging causes of hypopituitarism. Nat Rev Endocrinol 2021; 17:114-129. [PMID: 33247226 DOI: 10.1038/s41574-020-00437-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 12/11/2022]
Abstract
Hypopituitarism is defined as one or more partial or complete pituitary hormone deficiencies, which are related to the anterior and/or posterior gland and can have an onset in childhood or adulthood. The most common aetiology is a sellar or suprasellar lesion, often an adenoma, which causes hypopituitarism due to tumour mass effects, or the effects of surgery and/or radiation therapy. However, other clinical conditions, such as traumatic brain injury, and autoimmune and inflammatory diseases, can result in hypopituitarism, and there are also genetic causes of hypopituitarism. Furthermore, the use of immune checkpoint inhibitors to treat cancer is increasing the risk of hypopituitarism, with a pattern of hormone defects that is different from the classic patterns and depends on mechanisms that are specific for each drug. Moreover, autoantibody production against the pituitary and hypothalamus has been demonstrated in studies investigating the development or worsening of some cases of hypopituitarism. Finally, evidence suggests that posterior pituitary damage can affect oxytocin secretion. The aim of this Review is to summarize current knowledge on non-classic and emerging causes of hypopituitarism, so as to help clinicians improve early identification, avoid life-threatening events and improve the clinical care and quality of life of patients at risk of hypopituitarism.
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Affiliation(s)
- Flavia Prodam
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Marina Caputo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Chiara Mele
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Paolo Marzullo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Division of General Medicine, I.R.C.C.S. Istituto Auxologico Italiano, Ospedale San Giuseppe, Verbania, Italy
| | - Gianluca Aimaretti
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
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Gasco V, Cambria V, Bioletto F, Ghigo E, Grottoli S. Traumatic Brain Injury as Frequent Cause of Hypopituitarism and Growth Hormone Deficiency: Epidemiology, Diagnosis, and Treatment. Front Endocrinol (Lausanne) 2021; 12:634415. [PMID: 33790864 PMCID: PMC8005917 DOI: 10.3389/fendo.2021.634415] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/16/2021] [Indexed: 12/12/2022] Open
Abstract
Traumatic brain injury (TBI)-related hypopituitarism has been recognized as a clinical entity for more than a century, with the first case being reported in 1918. However, during the 20th century hypopituitarism was considered only a rare sequela of TBI. Since 2000 several studies strongly suggest that TBI-mediated pituitary hormones deficiency may be more frequent than previously thought. Growth hormone deficiency (GHD) is the most common abnormality, followed by hypogonadism, hypothyroidism, hypocortisolism, and diabetes insipidus. The pathophysiological mechanisms underlying pituitary damage in TBI patients include a primary injury that may lead to the direct trauma of the hypothalamus or pituitary gland; on the other hand, secondary injuries are mainly related to an interplay of a complex and ongoing cascade of specific molecular/biochemical events. The available data describe the importance of GHD after TBI and its influence in promoting neurocognitive and behavioral deficits. The poor outcomes that are seen with long standing GHD in post TBI patients could be improved by GH treatment, but to date literature data on the possible beneficial effects of GH replacement therapy in post-TBI GHD patients are currently scarce and fragmented. More studies are needed to further characterize this clinical syndrome with the purpose of establishing appropriate standards of care. The purpose of this review is to summarize the current state of knowledge about post-traumatic GH deficiency.
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18
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Bensalah M, Donaldson M, Labassen M, Cherfi L, Nebbal M, Haffaf EM, Abdennebi B, Guenane K, Kemali Z, Ould Kablia S. Prevalence of hypopituitarism and quality of life in survivors of post-traumatic brain injury. Endocrinol Diabetes Metab 2020; 3:e00146. [PMID: 32704567 PMCID: PMC7375098 DOI: 10.1002/edm2.146] [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: 07/24/2019] [Revised: 04/08/2020] [Accepted: 04/19/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hypopituitarism is a recognized sequela of traumatic brain injury (TBI) and may worsen the quality of life (QoL) in survivors. AIMS To assess the prevalence of post-traumatic hypopituitarism (PTHP) and growth hormone deficiency (GHD), and determine their correlation with QoL. METHODS Survivors of moderate to severe TBI were recruited from two Algerian centres. At 3 and 12 months, pituitary function was evaluated using insulin tolerance test (ITT), QoL by growth hormone deficiency in adults' questionnaire (QoL-AGHDA), and 36-item short-form (SF-36) health survey. RESULTS Of 133 (M: 128; F: 5) patients aged 18-65 years, PTHP and GHD were present at 3 and 12 months in 59 (44.4%) and 23 (17.29%), 41/116 (35.3%) and 18 (15.5%). Thirteen patients with GHD at 3 months tested normally at 12 months, while 9 had become GHD at 12 months. At 3 and 12 months, peak cortisol was < 500 nmol/L) in 39 (29.3%) and 29 (25%) patients, but <300 nmol/L in only five and seven. Prevalence for gonadotrophin deficiency was 6.8/8.6%, hypo- and hyperprolactinaemia 6.8/3.8% and 5.2/8.6%, and thyrotrophin deficiency 1.5/0.9%. Mean scores for QoL-AGHDA were higher in patients with PTHP at 3 and 12 months: 7.07 vs 3.62 (P = .001) and in patients with GHD at 12 months: 8.72 vs 4.09 (P = .015). Mean SF-36 scores were significantly lower for PTHP at 3 months. CONCLUSION Prevalence of PTHP and GHD changes with time. AGHDA measures QoL in GHD more specifically than SF-36. Full pituitary evaluation and QoL-AGHDA 12 months after TBI are recommended.
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Affiliation(s)
| | | | - Malek Labassen
- Endocrinology UnitCentral Hospital of ArmyAlgiersAlgeria
| | - Lyes Cherfi
- Critical Care UnitCentral Hospital of ArmyAlgiersAlgeria
| | | | | | | | - Kamel Guenane
- Critical care UnitSalim Zemirli HospitalAlgiersAlgeria
| | - Zahra Kemali
- Endocrinology UnitCentral Hospital of ArmyAlgiersAlgeria
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19
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Ashley MJ. Testosterone, sex steroids, and aging in neurodegenerative disease after acquired brain injury: a commentary. Brain Inj 2020; 34:983-987. [PMID: 32497444 DOI: 10.1080/02699052.2020.1763461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PRIMARY OBJECTIVE Traumatic brain injury (TBI) is associated with higher incidence of neurodegenerative disease and the effects of aging appear more pronounced after TBI. This paper examines the potential interaction of aging, TBI, and change in male testosterone production. METHODS AND PROCEDURES An abbreviated review of literature documenting hypogonadism after TBI is provided. Potential mechanisms of endocrine dysgrasia associated with aging are reviewed as they relate and interact with endocrine change after TBI in males. These factors align to suggest the need for development of surveillance guidelines for male individuals living with TBI. OUTCOMES AND RESULTS The neuroprotectant, neuroactivation, growth, and cell therapy characteristics of testosterone in the central nervous system are considerable. Age-related decrements in testosterone production may be accelerated after TBI. CONCLUSIONS Testosterone deficiency in male individuals after TBI can be present after TBI or can develop during aging. Age-related decreases in testosterone production after TBI may act to amplify endocrine dysfunction after TBI. Ongoing clinical surveillance for testosterone deficiency associated with both TBI and aging may be reasonable.
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Affiliation(s)
- Mark J Ashley
- Centre for Neuro Skills , Bakersfield, CA, USA.,School of Health Sciences, Southern Illinois University , Carbondale, IL, USA.,Department of Physical Therapy, Virginia Commonwealth University , Richmond, USA
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20
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Incidence and Effect of Diabetes Insipidus in the Acute Care of Patients with Severe Traumatic Brain Injury. Neurocrit Care 2020; 33:718-724. [PMID: 32207035 DOI: 10.1007/s12028-020-00955-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Literature on diabetes insipidus (DI) after severe traumatic brain injury (TBI) is scarce. Some studies have reported varying frequencies of DI and have showed its association with increased mortality, suggesting it as a marker of poor outcome. This knowledge gap in the acute care consequences of DI in severe TBI patients led us to conceive this study, aimed at identifying risk factors and quantifying the effect of DI on short-term functional outcomes and mortality. METHODS We assembled a historic cohort of adult patients with severe TBI (Glasgow Coma Scale ≤ 8) admitted to the intensive care unit (ICU) of a tertiary-care university hospital over a 6-year period. Basic demographic characteristics, clinical information, imaging findings, and laboratory results were collected. We used logistic regression models to assess potential risk factors for the development of DI, and the association of this condition with death and unfavorable functional outcomes [modified Rankin scale (mRS)] at hospital discharge. RESULTS A total of 317 patients were included in the study. The frequency of DI was 14.82%, and it presented at a median of 2 days (IQR 1-3) after ICU admission. Severity according to the Abbreviated Injury Scale (AIS) score of the head, intracerebral hemorrhage, subdural hematoma, and skull base fracture was suggested as risk factors for DI. Diagnosis of DI was independently associated death (OR 4.34, CI 95% 1.92-10.11, p = 0.0005) and unfavorable outcome (modified Rankin Scale = 4-6) at discharge (OR 7.38; CI 95% 2.15-37.21, p = 0.0047). CONCLUSIONS Diabetes insipidus is a frequent and early complication in patients with severe TBI in the ICU and is strongly associated with increased mortality and poor short-term outcomes. We provide clinically useful risk factors that will help detect DI early to improve prognosis and therapy of patients with severe TBI.
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21
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Hacioglu A, Kelestimur F, Tanriverdi F. Long-term neuroendocrine consequences of traumatic brain injury and strategies for management. Expert Rev Endocrinol Metab 2020; 15:123-139. [PMID: 32133881 DOI: 10.1080/17446651.2020.1733411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 02/19/2020] [Indexed: 12/15/2022]
Abstract
Introduction: Traumatic brain injuries (TBI) are reported to cause neuroendocrine impairment with a prevalence of 15% with confirmatory testing. Pituitary dysfunction (PD) may have detrimental effects on vital parameters as well as on body composition, cardiovascular functions, cognition, and quality of life. Therefore, much effort has been made to identify predictive factors for post-TBI PD and various screening strategies have been offered.Areas covered: We searched PubMed and reviewed the recent data on clinical perspectives and long-term outcomes as well as predictive factors and screening modalities of post-TBI PD. Inconsistencies in the literature are overviewed and new areas of research are discussed.Expert opinion: Studies investigating biomarkers that will accurately predict TBI patients with a high risk of PD are generally pilot studies with a small number of participants. Anti-pituitary and anti-hypothalamic antibodies, neural proteins, micro-RNAs are promising in this field. As severity of TBI has been the most commonly associated risk factor for post-TBI PD, we suggest prospective screening based on severity of head trauma until new evidence emerges. There is also a need for more studies investigating the clinical effects of hormone replacement in TBI patients with PD.
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Affiliation(s)
- Aysa Hacioglu
- Department of Endocrinology and Metabolism, Erciyes University Medical School, Kayseri, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology and Metabolism, Yeditepe University Medical Faculty, Istanbul, Turkey
| | - Fatih Tanriverdi
- Department of Endocrinology and Metabolism, Memorial Kayseri Hospital, Kayseri, Turkey
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22
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Kesavan C, Bajwa NM, Watt H, Mohan S. Growth Hormone Effects on Bone Loss-Induced by Mild Traumatic Brain Injury and/or Hind Limb Unloading. Sci Rep 2019; 9:18995. [PMID: 31831786 PMCID: PMC6908685 DOI: 10.1038/s41598-019-55258-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/12/2019] [Indexed: 01/06/2023] Open
Abstract
Growth hormone (GH) deficiency and loss of physical activity are common features in traumatic brain injury (TBI) patients that may contribute to bone loss. Therefore, we tested the hypothesis that GH treatment will rescue the hind limb unloading (UL)-induced skeletal deficit in TBI mice. Mild TBI was induced once per day for four consecutive days. UL (right hind limb) and treatment (3 mg/day GH or vehicle) began two weeks after the first TBI episode and lasted for four weeks. GH treatment increased femur BMD and lean body mass but decreased the % fat measured by DXA in the Control group. Micro-CT analysis revealed that the TBI, UL and TBI-UL groups showed reduced tibia trabecular (Tb) bone mass by 15%, 70%, and 75%, respectively compared to Control mice and that GH treatment significantly increased Tb. bone mass in all four groups. Vertebra also showed reduced Tb. bone mass in TBI, UL and TBI-UL groups. GH treatment increased vertebral Tb. bone mass in Control and UL groups but not in the TBI or TBI-UL group. GH treatment increased serum IGF-I levels similarly in TBI, UL and TBI-UL groups at day 14, suggesting the GH effect on liver IGF-I production was unaffected by skeletal UL. In contrast, GH effect on expression of ALP, IGFBP5 and axin2 in bone were compromised by UL. In conclusion, skeletal UL caused a greater Tb. bone deficit than mild TBI alone and that GH anabolic effects in the TBI and UL groups vary depending on the skeletal site.
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Affiliation(s)
- Chandrasekhar Kesavan
- Musculoskeletal Disease Center, VA Loma Linda Healthcare System, Loma Linda, CA, 92357, USA.,Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Nikita M Bajwa
- Musculoskeletal Disease Center, VA Loma Linda Healthcare System, Loma Linda, CA, 92357, USA
| | - Heather Watt
- Musculoskeletal Disease Center, VA Loma Linda Healthcare System, Loma Linda, CA, 92357, USA
| | - Subburaman Mohan
- Musculoskeletal Disease Center, VA Loma Linda Healthcare System, Loma Linda, CA, 92357, USA. .,Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA. .,Division of Biochemistry, Department of Basic Sciences, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA. .,Department of Orthopedics, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA.
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Emelifeonwu JA, Flower H, Loan JJ, McGivern K, Andrews PJD. Prevalence of Anterior Pituitary Dysfunction Twelve Months or More following Traumatic Brain Injury in Adults: A Systematic Review and Meta-Analysis. J Neurotrauma 2019; 37:217-226. [PMID: 31111791 DOI: 10.1089/neu.2018.6349] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The objective of this study is to systematically review clinical studies that have reported on the prevalence of chronic post-traumatic brain injury anterior pituitary dysfunction (PTPD) 12 months or more following traumatic brain injury (TBI). We searched Medline, Embase, and PubMed up to April 2017 and consulted bibliographies of narrative reviews. We included cohort, case-control, and cross-sectional studies enrolling at least five adults with primary TBI in whom at least one anterior pituitary axis was assessed at least 12 months following TBI. We excluded studies in which other brain injuries were indistinguishable from TBI. Study quality was assessed using the Newcastle-Ottawa Scale (NOS) score. We also considered studies that determined growth hormone deficiency and adrenocorticotrophic hormone reserve using provocation test to be at low risk of bias. Data were extracted by four independent reviewers and assessed for risk of bias using a data extraction form. We performed meta-analyses using random effect models and assessed heterogeneity using the I2 index. We identified 58 publications, of which 29 (2756 participants) were selected for meta-analysis. Twelve of these were deemed to be at low risk of bias and therefore "high-quality," as they had NOS scores greater than 8 and had used provocation tests. The overall prevalence of at least one anterior pituitary hormone dysfunction for all 29 studies was 32% (95% confidence interval [CI] 25-38%). The overall prevalence in the 12 high-quality studies was 34% (95% CI 27-42%). We observed significant heterogeneity that was not solely explained by the risk of bias. Studies with a higher proportion of participants with mild TBI had a lower prevalence of PTPD. Our results show that approximately one-third of TBI sufferers have persistent anterior pituitary dysfunction 12 months or more following trauma. Future research on PTPD should differentiate between mild and moderate/severe TBI.
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Affiliation(s)
- John A Emelifeonwu
- Department of Neurosurgery, University of Edinburgh and NHS Lothian Western General Hospital, Edinburgh, United Kingdom.,Center for Clinical Brain Sciences, University of Edinburgh and NHS Lothian Western General Hospital, Edinburgh, United Kingdom
| | - Hannah Flower
- School of Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Jamie J Loan
- Department of Neurosurgery, NHS Lothian Western General Hospital, Edinburgh, United Kingdom
| | - Kieran McGivern
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Peter J D Andrews
- Center for Clinical Brain Sciences, University of Edinburgh and NHS Lothian Western General Hospital, Edinburgh, United Kingdom
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24
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Risk Factors for Anterior Hypopituitarism in Patients With Traumatic Brain Injury. J Craniofac Surg 2019; 30:2119-2123. [DOI: 10.1097/scs.0000000000005405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Gupte R, Brooks W, Vukas R, Pierce J, Harris J. Sex Differences in Traumatic Brain Injury: What We Know and What We Should Know. J Neurotrauma 2019; 36:3063-3091. [PMID: 30794028 PMCID: PMC6818488 DOI: 10.1089/neu.2018.6171] [Citation(s) in RCA: 233] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
There is growing recognition of the problem of male bias in neuroscience research, including in the field of traumatic brain injury (TBI) where fewer women than men are recruited to clinical trials and male rodents have predominantly been used as an experimental injury model. Despite TBI being a leading cause of mortality and disability worldwide, sex differences in pathophysiology and recovery are poorly understood, limiting clinical care and successful drug development. Given growing interest in sex as a biological variable affecting injury outcomes and treatment efficacy, there is a clear need to summarize sex differences in TBI. This scoping review presents an overview of current knowledge of sex differences in TBI and a comparison of human and animal studies. We found that overall, human studies report worse outcomes in women than men, whereas animal studies report better outcomes in females than males. However, closer examination shows that multiple factors including injury severity, sample size, and experimental injury model may differentially interact with sex to affect TBI outcomes. Additionally, we explore how sex differences in mitochondrial structure and function might contribute to possible sex differences in TBI outcomes. We propose recommendations for future investigations of sex differences in TBI, which we hope will lead to improved patient management, prognosis, and translation of therapies from bench to bedside.
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Affiliation(s)
- Raeesa Gupte
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas
| | - William Brooks
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
- Hoglund Brain Center, University of Kansas Medical Center, Kansas City, Kansas
- The University of Kansas Clinical and Translational Sciences Institute, University of Kansas Medical Center, Kansas City, Kansas
| | - Rachel Vukas
- School of Medicine, Dykes Library of Health Sciences, University of Kansas Medical Center, Kansas City, Kansas
| | - Janet Pierce
- Department of Molecular and Integrative Physiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Janna Harris
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas
- Hoglund Brain Center, University of Kansas Medical Center, Kansas City, Kansas
- Address correspondence to: Janna Harris, PhD, Hoglund Brain Imaging Center, MS 1052, 3901 Rainbow Boulevard, Kansas City, KS 66160
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Growth Hormone Deficiency Following Traumatic Brain Injury. Int J Mol Sci 2019; 20:ijms20133323. [PMID: 31284550 PMCID: PMC6651180 DOI: 10.3390/ijms20133323] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 06/28/2019] [Accepted: 07/04/2019] [Indexed: 02/06/2023] Open
Abstract
Traumatic brain injury (TBI) is fairly common and annually affects millions of people worldwide. Post traumatic hypopituitarism (PTHP) has been increasingly recognized as an important and prevalent clinical entity. Growth hormone deficiency (GHD) is the most common pituitary hormone deficit in long-term survivors of TBI. The pathophysiology of GHD post TBI is thought to be multifactorial including primary and secondary mechanisms. An interplay of ischemia, cytotoxicity, and inflammation post TBI have been suggested, resulting in pituitary hormone deficits. Signs and symptoms of GHD can overlap with those of TBI and may delay rehabilitation/recovery if not recognized and treated. Screening for GHD is recommended in the chronic phase, at least six months to a year after TBI as GH may recover in those with GHD in the acute phase; conversely, it may manifest in those with a previously intact GH axis. Dynamic testing is the standard method to diagnose GHD in this population. GHD is associated with long-term poor medical outcomes. Treatment with recombinant human growth hormone (rhGH) seems to ameliorate some of these features. This review will discuss the frequency and pathophysiology of GHD post TBI, its clinical consequences, and the outcomes of treatment with GH replacement.
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Abstract
PURPOSE Clinical research studies over the last 15 years have reported a significant burden of hypopituitarism in survivors of traumatic brain injury (TBI). However, debate still exists about the true prevalence of hypopituitarism after head injury. METHODS We have reviewed the literature describing the frequency of post-traumatic hypopituitarism and discuss the factors which may explain the variable frequency of the reported deficits in clinical studies including research methodology and the natural history of the disease. RESULTS Pituitary hormone perturbations in the acute phase following injury are frequent but are difficult to attribute to traumatic pituitary damage due to physiological hormonal changes in acute illness, the confounding effect of medications, other co-morbidities and lack of appropriate control subjects. Nevertheless, a small number of studies have emphasised the clinical importance of acute, dynamic disturbance of the hypothalamic-pituitary-adrenal axis. There is a much larger evidence base examining the frequency of hypopituitarism in the chronic, recovery phase following head injury. These studies report a very broad prevalence of long-term pituitary hormone dysfunction in survivors of TBI. However, systematic review suggests the prevalence to be between 27 and 31%. CONCLUSION Survivors of head injury are at risk of pituitary hormone dysfunction and we suggest an approach to the diagnosis of post-traumatic hypopituitarism in routine clinical practice.
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Affiliation(s)
- Nigel Glynn
- Department of Endocrinology, Saint Bartholomew's Hospital, London, UK
| | - Amar Agha
- Academic Department of Endocrinology, Beaumont Hospital and the RCSI Medical School, Beaumont Road, Dublin 9, Ireland.
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Abstract
PURPOSE After traumatic brain injury was accepted as an important etiologic factor of pituitary dysfunction (PD), awareness of risk of developing PD following sports-related traumatic brain injury (SR-TBI) has also increased. However there are not many studies investigating PD following SR-TBIs yet. We aimed to summarize the data reported so far and to discuss screening algorithms and treatment strategies. METHODS Recent data on pituitary dysfunction after SR-TBIs is reviewed on basis of diagnosis, clinical perspectives, therapy, screening and possible prevention strategies. RESULTS Pituitary dysfunction is reported to occur in a range of 15-46.6% following SR-TBIs depending on the study design. Growth hormone is the most commonly reported pituitary hormone deficiency in athletes. Pituitary hormone deficiencies may occur during acute phase after head trauma, may improve with time or new deficiencies may develop during follow-up. Central adrenal insufficiency is the only and most critical impairment that requires urgent detection and replacement during acute phase. Decision on replacement of growth hormone and gonadal deficiencies should be individualized. Moreover these two hormones are abused by many athletes and a therapeutic use exemption from the league's drug policy may be required. CONCLUSIONS Even mild and forgotten SR-TBIs may cause PD that may have distressing consequences in some cases if remain undiagnosed. More studies are needed to elucidate epidemiology and pathophysiology of PD after SR-TBIs. Also studies to establish screening algorithms for PD as well as strategies for prevention of SR-TBIs are urgently required.
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Affiliation(s)
- Aysa Hacioglu
- Department of Endocrinology and Metabolism, Erciyes University Medical School, Kayseri, Turkey.
| | | | - Fatih Tanriverdi
- Memorial Kayseri Hospital, Endocrinology Clinic, Kayseri, Turkey
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Abstract
Traumatic brain injury (TBI) is an important public health problem with an increasing incidence in the last years. Relatively few cases are fatal; most individuals will survive and, in the long-term, the sequalae of TBI will include neuroendocrine dysfunctions with a much higher frequency than previously suspected. Patients who develop hypopituitarism after TBI present manifestations due to the number of deficient hormones, severity of hormonal deficiency, and the duration of hypopituitarism without diagnosis and treatment. The clinical spectrum of hypopituitarism is very large and many signs and symptoms of TBI survivors such as fatigue, concentration difficulties, depressive symptoms are nonspecific and overlap with symptoms of post-traumatic stress disorder and variably severe hypopituitarism related to brain damage remaining undiagnosed. This can explain why the diagnosis of hypopituitarism is often missed or delayed after this condition with potentially serious and hazardous consequences for the affected patients. Moreover, clinical experience cumulatively suggests that TBI-associated hypopituitarism is associated with poor recovery and worse outcome, since post-traumatic hypopituitarism is independently associated with cognitive impairment, poor quality of life, abnormal body composition, and adverse metabolic profile. In the present review, the current data related to clinical consequences of pituitary dysfunction after TBI in adult patients and therapeutic approaches are reported.
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Affiliation(s)
- Marina Caputo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy.
| | - C Mele
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - F Prodam
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
- Interdisciplinary Research Center of Autoimmune Diseases, Università del Piemonte Orientale, Novara, Italy
- Department of Health Science, Università del Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
| | - P Marzullo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
- Division of General Medicine, I.R.C.C.S. Istituto Auxologico Italiano, Ospedale San Giuseppe Verbania, Verbania, Italy
| | - G Aimaretti
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy
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De Bellis A, Bellastella G, Maiorino MI, Costantino A, Cirillo P, Longo M, Pernice V, Bellastella A, Esposito K. The role of autoimmunity in pituitary dysfunction due to traumatic brain injury. Pituitary 2019; 22:236-248. [PMID: 30847776 DOI: 10.1007/s11102-019-00953-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) is one of the most common causes of mortality and long-term disability and it is associated with an increased prevalence of neuroendocrine dysfunctions. Post-traumatic hypopituitarism (PTHP) results in major physical, psychological and social consequences leading to impaired quality of life. PTHP can occur at any time after traumatic event, evolving through various ways and degrees of deficit, requiring appropriate screening for early detection and treatment. Although the PTHP pathophysiology remains to be elucitated, on the basis of proposed hypotheses it seems to be the result of combined pathological processes, with a possible role played by hypothalamic-pituitary autoimmunity (HPA). This review is aimed at focusing on this possible role in the development of PTHP and its potential clinical consequences, on the basis of the data so far appeared in the literature and of some results of personal studies on this issue. METHODS Scrutinizing the data so far appeared in literature on this topic, we have found only few studies evaluating the autoimmune pattern in affected patients, searching in particular for antipituitary and antihypothalamus autoantibodies (APA and AHA, respectively) by simple indirect immunofluorescence. RESULTS The presence of APA and/or AHA at high titers was associated with an increased risk of onset/persistence of PTHP. CONCLUSIONS HPA seems to contribute to TBI-induced pituitary damage and related PTHP. However, further prospective studies in a larger cohort of patients are needed to define etiopathogenic and diagnostic role of APA/AHA in development of post-traumatic hypothalamic/pituitary dysfunctions after a TBI.
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Affiliation(s)
- Annamaria De Bellis
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Giuseppe Bellastella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Ida Maiorino
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Angela Costantino
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paolo Cirillo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Miriam Longo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Vlenia Pernice
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Bellastella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Katherine Esposito
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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Kgosidialwa O, Agha A. Hypopituitarism post traumatic brain injury (TBI): review. Ir J Med Sci 2019; 188:1201-1206. [PMID: 30931510 DOI: 10.1007/s11845-019-02007-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/11/2019] [Indexed: 01/27/2023]
Abstract
Post-traumatic hypopituitarism (PTHP) is an important and relatively common complication of TBI (traumatic brain injury). A number of studies have shown that this clinical phenomenon can occur soon after TBI (acute) or later in the chronic phase. Patients with moderate to severe TBI are at a particular risk of developing PTHP. In the acute setting, it is important to monitor patients for hypoadrenalism as this confers a high risk for morbidity and even mortality. The gonadotrophin, growth hormone and TSH deficiencies are better defined in the chronic phase. Untreated PTHP can lead to delayed recovery, impaired rehabilitation and persistent neuropsychiatric symptoms. This review will discuss the frequency and natural history of PTHP and its clinical implications and propose a pathway for investigation and management of this still under-recognised entity.
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Affiliation(s)
- Oratile Kgosidialwa
- Academic Department of Endocrinology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
| | - Amar Agha
- Academic Department of Endocrinology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland.
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Gray S, Bilski T, Dieudonne B, Saeed S. Hypopituitarism After Traumatic Brain Injury. Cureus 2019; 11:e4163. [PMID: 31065469 PMCID: PMC6497183 DOI: 10.7759/cureus.4163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/01/2019] [Indexed: 02/02/2023] Open
Abstract
Acquired hypopituitarism is associated with traumatic brain injury. This neuroendocrine dysfunction can cause both short-term and long-term morbidity resulting in a cognitive, physiological, and behavioral decline, which increases the burden of the disease and the cost of care. Data in the trauma literature is derisory on this subject. The aim of this review is to edify clinicians on this condition, outline the screening criteria and methods for hypopituitarism after traumatic brain injury, and bring awareness to the chronic effects.
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Affiliation(s)
- Sanjiv Gray
- Surgery, University of Central Florida, Orlando, USA
| | - Tracy Bilski
- Surgery, University of South Florida Morsani College of Medicine, Kissimmee, USA
| | | | - Saqib Saeed
- Surgery, Harlem Hospital Center, New York, USA
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Yaseen NT, Al-Khaqani FA, Mansour AA. Patterns of pituitary dysfunction three months or more after traumatic brain injury. Avicenna J Med 2018; 8:125-132. [PMID: 30319953 PMCID: PMC6178569 DOI: 10.4103/ajm.ajm_2_18] [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: 11/19/2022] Open
Abstract
PURPOSE Chronic posttraumatic brain injury (TBI) pituitary dysfunction is not a newly discovered subject, it has been reported more frequently, probably due to increasing chances of exposure to its causes, mainly the road traffic accidents, sport-related injuries, falls, and injuries during wars. This study aims to estimate the frequency of pituitary dysfunction 3 months or more after head trauma and the patterns of hormonal deficiencies. METHODS A cross-sectional study was conducted between January 2016 and August 2017. Participants were patients having a history of moderate-to-severe TBI at least 3 months before enrolment. Pituitary function test was done for all patients to determine the frequency of pituitary dysfunction, the number of axes deficiencies, and which hormone is mostly affected. Statistical Package for the Social Sciences (SPSS) version 23.0 was used for univariate analysis, P < 0.05 was considered statistically significant. RESULTS Out of the 28 patients involved in this study, 17 (61%) had pituitary dysfunction, while 11 (39%) had not. Single hormonal defect was the most prevalent abnormality in 12 (43%), and the most affected hormone was the growth hormone (GH) in 14 patients (50%), followed by gonadal axis, thyroid stimulating hormone, and finally adrenocorticotropic hormone (ACTH), 6 (21%), 3 (11%), and 1 (4%), respectively. CONCLUSION TBI pituitary dysfunction is more prevalent than was predicted in the population studied, single hormonal defect was found to be the most prevalent abnormality, being the GH is the most affected axis, and the ACTH seems to be the least.
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Affiliation(s)
- Nassar Taha Yaseen
- Department of Medicine, Basrah College of Medicine, Faiha Specialized Diabetes, Endocrine and Metabolism Center, Basrah, Iraq
| | - Fateh A. Al-Khaqani
- Department of Medicine, Basrah College of Medicine, Faiha Specialized Diabetes, Endocrine and Metabolism Center, Basrah, Iraq
| | - Abbas Ali Mansour
- Department of Medicine, Basrah College of Medicine, Faiha Specialized Diabetes, Endocrine and Metabolism Center, Basrah, Iraq
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Wagner AK, Kumar RG. TBI Rehabilomics Research: Conceptualizing a humoral triad for designing effective rehabilitation interventions. Neuropharmacology 2018; 145:133-144. [PMID: 30222984 DOI: 10.1016/j.neuropharm.2018.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/14/2018] [Accepted: 09/10/2018] [Indexed: 12/11/2022]
Abstract
Most areas of medicine use biomarkers in some capacity to aid in understanding how personal biology informs clinical care. This article draws upon the Rehabilomics research model as a translational framework for programs of precision rehabilitation and intervention research focused on linking personal biology to treatment response using biopsychosocial constructs that broadly represent function and that can be applied to many clinical populations with disability. The summary applies the Rehabilomics research framework to the population with traumatic brain injury (TBI) and emphasizes a broad vision for biomarker inclusion, beyond typical brain-derived biomarkers, to capture and/or reflect important neurological and non-neurological pathology associated with TBI as a chronic condition. Humoral signaling molecules are explored as important signaling and regulatory drivers of these chronic conditions and their impact on function. Importantly, secondary injury cascades involved in the humoral triad are influenced by the systemic response to TBI and the development of non-neurological organ dysfunction (NNOD). Biomarkers have been successfully leveraged in other medical fields to inform pre-randomization patient selection for clinical trials, however, this practice largely has not been utilized in TBI research. As such, the applicability of the Rehabilomics research model to contemporary clinical trials and comparative effectiveness research designs for neurological and rehabilitation populations is emphasized. Potential points of intervention to modify inflammation, hormonal, or neurotrophic support through rehabilitation interventions are discussed. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".
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Affiliation(s)
- A K Wagner
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, USA; Safar Center for Resuscitation Research, University of Pittsburgh, USA; Department of Neuroscience, University of Pittsburgh, USA; Center for Neuroscience, University of Pittsburgh, USA.
| | - R G Kumar
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, USA; Safar Center for Resuscitation Research, University of Pittsburgh, USA; Department of Epidemiology, University of Pittsburgh, USA
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Li M, Sirko S. Traumatic Brain Injury: At the Crossroads of Neuropathology and Common Metabolic Endocrinopathies. J Clin Med 2018. [PMID: 29538298 PMCID: PMC5867585 DOI: 10.3390/jcm7030059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Building on the seminal work by Geoffrey Harris in the 1970s, the neuroendocrinology field, having undergone spectacular growth, has endeavored to understand the mechanisms of hormonal connectivity between the brain and the rest of the body. Given the fundamental role of the brain in the orchestration of endocrine processes through interactions among neurohormones, it is thus not surprising that the structural and/or functional alterations following traumatic brain injury (TBI) can lead to endocrine changes affecting the whole organism. Taking into account that systemic hormones also act on the brain, modifying its structure and biochemistry, and can acutely and chronically affect several neurophysiological endpoints, the question is to what extent preexisting endocrine dysfunction may set the stage for an adverse outcome after TBI. In this review, we provide an overview of some aspects of three common metabolic endocrinopathies, e.g., diabetes mellitus, obesity, and thyroid dysfunction, and how these could be triggered by TBI. In addition, we discuss how the complex endocrine networks are woven into the responses to sudden changes after TBI, as well as some of the potential mechanisms that, separately or synergistically, can influence outcomes after TBI.
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Affiliation(s)
- Melanie Li
- Physiological Genomics, Biomedical Center (BMC), Institute of Physiology, Medical Faculty of the Ludwig-Maximilian University Munich, 82152 Planegg-Martinsried, Germany.
| | - Swetlana Sirko
- Physiological Genomics, Biomedical Center (BMC), Institute of Physiology, Medical Faculty of the Ludwig-Maximilian University Munich, 82152 Planegg-Martinsried, Germany.
- Institute of Stem Cell Research, Helmholtz Center Munich, Research Center for Environmental Health GmbH, 85764 Neuherberg, Germany.
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Bajwa NM, Kesavan C, Mohan S. Long-term Consequences of Traumatic Brain Injury in Bone Metabolism. Front Neurol 2018; 9:115. [PMID: 29556212 PMCID: PMC5845384 DOI: 10.3389/fneur.2018.00115] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 02/15/2018] [Indexed: 12/14/2022] Open
Abstract
Traumatic brain injury (TBI) leads to long-term cognitive, behavioral, affective deficits, and increase neurodegenerative diseases. It is only in recent years that there is growing awareness that TBI even in its milder form poses long-term health consequences to not only the brain but to other organ systems. Also, the concept that hormonal signals and neural circuits that originate in the hypothalamus play key roles in regulating skeletal system is gaining recognition based on recent mouse genetic studies. Accordingly, many TBI patients have also presented with hormonal dysfunction, increased skeletal fragility, and increased risk of skeletal diseases. Research from animal models suggests that TBI may exacerbate the activation and inactivation of molecular pathways leading to changes in both osteogenesis and bone destruction. TBI has also been found to induce the formation of heterotopic ossification and increased callus formation at sites of muscle or fracture injury through increased vascularization and activation of systemic factors. Recent studies also suggest that the disruption of endocrine factors and neuropeptides caused by TBI may induce adverse skeletal effects. This review will discuss the long-term consequences of TBI on the skeletal system and TBI-induced signaling pathways that contribute to the formation of ectopic bone, altered fracture healing, and reduced bone mass.
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Affiliation(s)
- Nikita M Bajwa
- Musculoskeletal Disease Center, VA Loma Linda Healthcare System, Loma Linda, CA, United States
| | - Chandrasekhar Kesavan
- Musculoskeletal Disease Center, VA Loma Linda Healthcare System, Loma Linda, CA, United States.,Department of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Subburaman Mohan
- Musculoskeletal Disease Center, VA Loma Linda Healthcare System, Loma Linda, CA, United States.,Department of Medicine, Loma Linda University, Loma Linda, CA, United States.,Department of Orthopedic Surgery, Loma Linda University, Loma Linda, CA, United States
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Undurti A, Colasurdo EA, Sikkema CL, Schultz JS, Peskind ER, Pagulayan KF, Wilkinson CW. Chronic Hypopituitarism Associated with Increased Postconcussive Symptoms Is Prevalent after Blast-Induced Mild Traumatic Brain Injury. Front Neurol 2018. [PMID: 29515515 PMCID: PMC5825904 DOI: 10.3389/fneur.2018.00072] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The most frequent injury sustained by US service members deployed to Iraq or Afghanistan is mild traumatic brain injuries (mTBI), or concussion, by far most often caused by blast waves from improvised explosive devices or other explosive ordnance. TBI from all causes gives rise to chronic neuroendocrine disorders with an estimated prevalence of 25-50%. The current study expands upon our earlier finding that chronic pituitary gland dysfunction occurs with a similarly high frequency after blast-related concussions. We measured circulating hormone levels and accessed demographic and testing data from two groups of male veterans with hazardous duty experience in Iraq or Afghanistan. Veterans in the mTBI group had experienced one or more blast-related concussion. Members of the deployment control (DC) group encountered similar deployment conditions but had no history of blast-related mTBI. 12 of 39 (31%) of the mTBI participants and 3 of 20 (15%) veterans in the DC group screened positive for one or more neuroendocrine disorders. Positive screens for growth hormone deficiency occurred most often. Analysis of responses on self-report questionnaires revealed main effects of both mTBI and hypopituitarism on postconcussive and posttraumatic stress disorder (PTSD) symptoms. Symptoms associated with pituitary dysfunction overlap considerably with those of PTSD. They include cognitive deficiencies, mood and anxiety disorders, sleep problems, diminished quality of life, deleterious changes in metabolism and body composition, and increased cardiovascular mortality. When such symptoms are due to hypopituitarism, they may be alleviated by hormone replacement. These findings suggest consideration of routine post-deployment neuroendocrine screening of service members and veterans who have experienced blast-related mTBI and are reporting postconcussive symptoms.
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Affiliation(s)
- Arundhati Undurti
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Elizabeth A Colasurdo
- Geriatric Research, Education and Clinical Center (GRECC), VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, WA, United States
| | - Carl L Sikkema
- Geriatric Research, Education and Clinical Center (GRECC), VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, WA, United States
| | - Jaclyn S Schultz
- Geriatric Research, Education and Clinical Center (GRECC), VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, WA, United States
| | - Elaine R Peskind
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States.,VISN 20 Northwest Network Mental Illness Research, Education, and Clinical Center (MIRECC), VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, WA, United States
| | - Kathleen F Pagulayan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States.,VISN 20 Northwest Network Mental Illness Research, Education, and Clinical Center (MIRECC), VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, WA, United States
| | - Charles W Wilkinson
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States.,Geriatric Research, Education and Clinical Center (GRECC), VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, WA, United States
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Klose M, Feldt-Rasmussen U. Chronic endocrine consequences of traumatic brain injury - what is the evidence? Nat Rev Endocrinol 2018; 14:57-62. [PMID: 28885623 DOI: 10.1038/nrendo.2017.103] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Traumatic brain injury (TBI) is a major public health problem with potentially debilitating consequences for the individual. Hypopituitarism after TBI has received increasing attention over the past decade; development of the condition as a consequence of TBI was previously hardly mentioned in textbooks on the subject. Hypopituitarism has been reported in more than 25% of patients with TBI and is now thought to be one of the most important causes of treatable morbidity in TBI survivors. However, most clinicians dealing with neuroendocrine diseases and TBI generally do not see such a high incidence of hypopituitarism. This disproportion is not clearly explained, but recent data indicate that diagnostic testing, which is designed for high-risk populations and not for a cohort of patients with, for example, de novo isolated growth hormone deficiency (the predominant finding in TBI), might have overestimated the true risk and disease burden of hypopituitarism. In this Opinion article, we discuss current recommendations for post-traumatic hypopituitarism in light of recent evidence.
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Affiliation(s)
- Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Blegdamsvej 9, Copenhagen DK-2100, Denmark
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Quinn M, Agha A. Post-Traumatic Hypopituitarism-Who Should Be Screened, When, and How? Front Endocrinol (Lausanne) 2018; 9:8. [PMID: 29456522 PMCID: PMC5801312 DOI: 10.3389/fendo.2018.00008] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/08/2018] [Indexed: 12/16/2022] Open
Abstract
Traumatic brain injury (TBI) remains a major, global public health concern. Over the last 15 years, a significant body of evidence has emerged demonstrating that post-traumatic hypopituitarism (PTHP) is a common and clinically significant consequence of TBI. Non-specific symptomology and the lack of an agreed approach to screening for PTHP has led to significant under-diagnosis of this debilitating disease. In this review, we will discuss the frequency and clinical significance of acute and chronic PTHP as described in the current literature highlighting the evidence base for screening and hormone replacement in these patients. We will also offer a pragmatic approach to identifying relevant anterior pituitary dysfunction after TBI and a follow-up strategy for those patients. Specific controversies and remaining unanswered questions will be addressed.
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Affiliation(s)
- Mark Quinn
- Department of Endocrinology, Beaumont Hospital and School of Medicine, Royal College Surgeons in Ireland, Dublin, Ireland
- *Correspondence: Mark Quinn,
| | - Amar Agha
- Department of Endocrinology, Beaumont Hospital and School of Medicine, Royal College Surgeons in Ireland, Dublin, Ireland
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Jonasdottir AD, Sigurjonsson P, Olafsson IH, Karason S, Sigthorsson G, Sigurjonsdottir HA. Hypopituitarism 3 and 12 months after traumatic brain injury and subarachnoid haemorrhage. Brain Inj 2017; 32:310-317. [PMID: 29283287 DOI: 10.1080/02699052.2017.1418906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE High prevalence of hypopituitarism (HP) has been reported after traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH). The aim of the study was to prospectively evaluate the prevalence and progression of HP in patients after TBI and SAH in Icelandic population. DESIGN A 12 month prospective single-centre study. METHODS AND PROCEDURES A total of 27 patients were included, 15 patients with TBI and 12 patients with SAH. Pituitary function was evaluated with baseline hormone measurements and diagnostic tests. An insulin tolerance test was used unless contraindicated, then the GHRH-arginine test and Synachten test were used. RESULTS At three months, 16.7% (2/12) of the patients had HP after TBI and 33.3% (4/12) after SAH. At 12 months, 21.4% (3/14) of patients had HP after TBI and 9.1% (1/11) after SAH. Gonadotropin deficiency was the most common deficiency at 3 months and GH and gonadotropin deficiency at 12 months. CONCLUSIONS There is a considerable risk of HP after TBI and reason to study pituitary function further in patients with SAH. We believe that neuroendocrine evaluation is important in these patients. Since recovery commonly occurs 12 months after the event, evaluation should be performed after that time if not clinically indicated earlier.
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Affiliation(s)
- Asta Dogg Jonasdottir
- a Department of Endocrinology , Landspitali University Hospital , Reykjavik , Iceland
| | - Petur Sigurjonsson
- b Department of Intensive Care , Landspitali University Hospital , Reykjavik , Iceland
| | - Ingvar Hakon Olafsson
- c Department of Neurosurgery , Landspitali University Hospital , Reykjavik , Iceland
| | - Sigurbergur Karason
- b Department of Intensive Care , Landspitali University Hospital , Reykjavik , Iceland.,d University of Iceland , Reykjavik , Iceland
| | - Gudmundur Sigthorsson
- e Department of Clinical Chemistry , Landspitali University Hospital , Reykjavik , Iceland
| | - Helga Agusta Sigurjonsdottir
- a Department of Endocrinology , Landspitali University Hospital , Reykjavik , Iceland.,d University of Iceland , Reykjavik , Iceland
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Experimental repetitive mild traumatic brain injury induces deficits in trabecular bone microarchitecture and strength in mice. Bone Res 2017; 5:17042. [PMID: 29263937 PMCID: PMC5735530 DOI: 10.1038/boneres.2017.42] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/30/2017] [Accepted: 07/04/2017] [Indexed: 01/21/2023] Open
Abstract
To evaluate the long-term consequence of repetitive mild traumatic brain injury (mTBI) on bone, mTBI was induced in 10-week-old female C57BL/6J mice using a weight drop model, once per day for 4 consecutive days at different drop heights (0.5, 1 and 1.5 m) and the skeletal phenotype was evaluated at different time points after the impact. In vivo micro-CT (μ-CT) analysis of the tibial metaphysis at 2, 8 and 12 weeks after the impact revealed a 5%-32% reduction in trabecular bone mass. Histomorphometric analyses showed a reduced bone formation rate in the secondary spongiosa of 1.5 m impacted mice at 12 weeks post impact. Apparent modulus (bone strength), was reduced by 30% (P<0.05) at the proximal tibial metaphysis in the 1.5 m drop height group at 2 and 8 weeks post impact. Ex vivo μ-CT analysis of the fifth lumbar vertebra revealed a significant reduction in trabecular bone mass at 12 weeks of age in all three drop height groups. Serum levels of osteocalcin were decreased by 22%, 15%, and 19% in the 0.5, 1.0 and 1.5 m drop height groups, respectively, at 2 weeks post impact. Serum IGF-I levels were reduced by 18%-32% in mTBI mice compared to contro1 mice at 2 weeks post impact. Serum osteocalcin and IGF-I levels correlated with trabecular BV/TV (r2 =0.14 and 0.16, P<0.05). In conclusion, repetitive mTBI exerts significant negative effects on the trabecular bone microarchitecture and bone mechanical properties by influencing osteoblast function via reduced endocrine IGF-I actions.
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Frendl I, Katko M, Galgoczi E, Boda J, Zsiros N, Nemeti Z, Bereczky Z, Hudak R, Kappelmayer J, Erdei A, Turchanyi B, Nagy EV. Plasminogen Activator Inhibitor Type 1: A Possible Novel Biomarker of Late Pituitary Dysfunction after Mild Traumatic Brain Injury. J Neurotrauma 2017; 34:3238-3244. [DOI: 10.1089/neu.2017.5198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Istvan Frendl
- Department of Trauma and Hand Surgery, Faculty of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Monika Katko
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Erika Galgoczi
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Boda
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Noemi Zsiros
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltan Nemeti
- Department of Trauma and Hand Surgery, Faculty of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsanna Bereczky
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Renata Hudak
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Janos Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Annamaria Erdei
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Bela Turchanyi
- Department of Trauma and Hand Surgery, Faculty of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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43
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Bianchi VE, Locatelli V, Rizzi L. Neurotrophic and Neuroregenerative Effects of GH/IGF1. Int J Mol Sci 2017; 18:ijms18112441. [PMID: 29149058 PMCID: PMC5713408 DOI: 10.3390/ijms18112441] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/06/2017] [Accepted: 11/09/2017] [Indexed: 12/12/2022] Open
Abstract
Introduction. Human neurodegenerative diseases increase progressively with age and present a high social and economic burden. Growth hormone (GH) and insulin-like growth factor-1 (IGF-1) are both growth factors exerting trophic effects on neuronal regeneration in the central nervous system (CNS) and peripheral nervous system (PNS). GH and IGF-1 stimulate protein synthesis in neurons, glia, oligodendrocytes, and Schwann cells, and favor neuronal survival, inhibiting apoptosis. This study aims to evaluate the effect of GH and IGF-1 on neurons, and their possible therapeutic clinical applications on neuron regeneration in human subjects. Methods. In the literature, we searched the clinical trials and followed up studies in humans, which have evaluated the effect of GH/IGF-1 on CNS and PNS. The following keywords have been used: “GH/IGF-1” associated with “neuroregeneration”, “amyotrophic lateral sclerosis”, “Alzheimer disease”, “Parkinson’s disease”, “brain”, and “neuron”. Results. Of the retrieved articles, we found nine articles about the effect of GH in healthy patients who suffered from traumatic brain injury (TBI), and six studies (four using IGF-1 and two GH therapy) in patients with amyotrophic lateral sclerosis (ALS). The administration of GH in patients after TBI showed a significantly positive recovery of brain and mental function. Treatment with GH and IGF-1 therapy in ALS produced contradictory results. Conclusions. Although strong findings have shown the positive effects of GH/IGF-1 administration on neuroregeneration in animal models, a very limited number of clinical studies have been conducted in humans. GH/IGF-1 therapy had different effects in patients with TBI, evidencing a high recovery of neurons and clinical outcome, while in ALS patients, the results are contradictory. More complex clinical protocols are necessary to evaluate the effect of GH/IGF-1 efficacy in neurodegenerative diseases. It seems evident that GH and IGF-1 therapy favors the optimal recovery of neurons when a consistent residual activity is still present. Furthermore, the effect of GH/IGF-1 could be mediated by, or be overlapped with that of other hormones, such as estradiol and testosterone.
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Affiliation(s)
- Vittorio Emanuele Bianchi
- Endocrinology and Metabolism, Clinical Center Stella Maris, Strada Rovereta, 42-47891 Falciano, San Marino.
| | - Vittorio Locatelli
- School of Medicine and Surgery, University of Milano-Bicocca via Cadore, 48-20900 Monza Brianza, Italy.
| | - Laura Rizzi
- Molecular Biology, School of Medicine and Surgery, University of Milano-Bicocca, via Cadore, 48-20900 Monza Brianza, Italy.
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Tan CL, Alavi SA, Baldeweg SE, Belli A, Carson A, Feeney C, Goldstone AP, Greenwood R, Menon DK, Simpson HL, Toogood AA, Gurnell M, Hutchinson PJ. The screening and management of pituitary dysfunction following traumatic brain injury in adults: British Neurotrauma Group guidance. J Neurol Neurosurg Psychiatry 2017; 88:971-981. [PMID: 28860331 PMCID: PMC5740545 DOI: 10.1136/jnnp-2016-315500] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/22/2017] [Accepted: 04/02/2017] [Indexed: 12/19/2022]
Abstract
Pituitary dysfunction is a recognised, but potentially underdiagnosed complication of traumatic brain injury (TBI). Post-traumatic hypopituitarism (PTHP) can have major consequences for patients physically, psychologically, emotionally and socially, leading to reduced quality of life, depression and poor rehabilitation outcome. However, studies on the incidence of PTHP have yielded highly variable findings. The risk factors and pathophysiology of this condition are also not yet fully understood. There is currently no national consensus for the screening and detection of PTHP in patients with TBI, with practice likely varying significantly between centres. In view of this, a guidance development group consisting of expert clinicians involved in the care of patients with TBI, including neurosurgeons, neurologists, neurointensivists and endocrinologists, was convened to formulate national guidance with the aim of facilitating consistency and uniformity in the care of patients with TBI, and ensuring timely detection or exclusion of PTHP where appropriate. This article summarises the current literature on PTHP, and sets out guidance for the screening and management of pituitary dysfunction in adult patients with TBI. It is hoped that future research will lead to more definitive recommendations in the form of guidelines.
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Affiliation(s)
- Chin Lik Tan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | | | | | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Claire Feeney
- Centre for Neuropsychopharmacology and Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, UK.,Imperial Centre for Endocrinology, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Anthony P Goldstone
- Centre for Neuropsychopharmacology and Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, UK.,Imperial Centre for Endocrinology, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | | | - David K Menon
- Department of Medicine, Division of Anaesthesia, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Helen L Simpson
- Department of Endocrinology, University College London Hospitals, London, UK
| | - Andrew A Toogood
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, Edgbaston, UK
| | - Mark Gurnell
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
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45
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Giuliano S, Talarico S, Bruno L, Nicoletti FB, Ceccotti C, Belfiore A. Growth hormone deficiency and hypopituitarism in adults after complicated mild traumatic brain injury. Endocrine 2017; 58:115-123. [PMID: 27878771 DOI: 10.1007/s12020-016-1183-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/14/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE Traumatic brain injury is considered the main cause of hypopituitarism in adults, and GH deficiency appears to be the most frequent pituitary deficit. Most of the available studies have included all degrees of severity of trauma. We aimed to assess pituitary function and GH deficiency in adult patients at different time lengths after complicated mild TBI according to Glasgow Coma Scale. We also aimed to evaluate whether mild TBI patients with GH deficiency had developed alterations in the glycolipid profile. METHODS Forty-eight patients (34 men and 14 women) with complicated mild TBI were included in the study. Twenty-three patients were evaluated at 1 year (Group A) and 25 patients at 5 years or longer after the injury (Group B). All patients underwent basal hormonal evaluation for pituitary function. GH deficiency was investigated by the combined test (GH releasing hormone + arginine). The glycolipid profile was also evaluated. RESULTS GH deficiency occurred in 8/23 patients (34.7 %) of Group A and in 12/25 patients (48 %) of Group B. In addition, two patients, one in each group, showed evidence of central hypothyroidism. Patients with GH deficiency, especially in Group A, presented a higher frequency of visceral adiposity and adverse metabolic profile as compared to no-GH deficiency patients. CONCLUSIONS Patients examined at 1 year or several years from complicated mild TBI had a similarly high occurrence of isolated GH deficiency, which was associated with visceral adiposity and metabolic alterations. Our findings suggest that patients undergone complicated mild TBI should be evaluated for GH deficiency even after several years from trauma.
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Affiliation(s)
- Stefania Giuliano
- Department of Health Sciences, Endocrinology, University Magna Graecia of Catanzaro, Campus Universitario, Viale Europa, Località Germaneto, 88100, Catanzaro, Italy
| | - Serafina Talarico
- Department of Health Sciences, Endocrinology, University Magna Graecia of Catanzaro, Campus Universitario, Viale Europa, Località Germaneto, 88100, Catanzaro, Italy
| | - Lucia Bruno
- Department of Health Sciences, Endocrinology, University Magna Graecia of Catanzaro, Campus Universitario, Viale Europa, Località Germaneto, 88100, Catanzaro, Italy
| | - Francesco Beniamino Nicoletti
- Department of Health Sciences, Endocrinology, University Magna Graecia of Catanzaro, Campus Universitario, Viale Europa, Località Germaneto, 88100, Catanzaro, Italy
- Neurosurgery Unit, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - Claudio Ceccotti
- Department of Health Sciences, Endocrinology, University Magna Graecia of Catanzaro, Campus Universitario, Viale Europa, Località Germaneto, 88100, Catanzaro, Italy
- Neurosurgery Unit, Pugliese-Ciaccio Hospital, Catanzaro, Italy
| | - Antonino Belfiore
- Department of Health Sciences, Endocrinology, University Magna Graecia of Catanzaro, Campus Universitario, Viale Europa, Località Germaneto, 88100, Catanzaro, Italy.
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46
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Suzuki S, Suzuki K. Isolated Adrenocorticotropic Hormone Deficiency Following Chronic Subdural Hematoma in an Elderly Man: Is There a Connection? Intern Med 2017; 56:1981-1985. [PMID: 28768968 PMCID: PMC5577074 DOI: 10.2169/internalmedicine.56.6792] [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: 11/04/2015] [Accepted: 10/16/2016] [Indexed: 11/30/2022] Open
Abstract
The delayed diagnosis of adrenal insufficiency is relatively common because its symptoms are non-specific. One of the causes of adrenal insufficiency is isolated adrenocorticotropic hormone deficiency (IAD), which is sometimes caused by traumatic brain injury. Indeed, severe head trauma is considered to contribute to the incidence of this disease. However, the relationship between milder head trauma-such as chronic subdural hematoma - and the occurrence of hormonal deficiency is uncertain. We herein report the case of a 79-year-old man with IAD who presented with leg edema and pain in his extremities following a recent history of chronic subdural hematoma.
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Affiliation(s)
- Satoshi Suzuki
- Department of General Internal Medicine, Asahikawa City Hospital, Japan
| | - Keiko Suzuki
- Department of General Internal Medicine, Asahikawa City Hospital, Japan
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47
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Tölli A, Borg J, Bellander BM, Johansson F, Höybye C. Pituitary function within the first year after traumatic brain injury or subarachnoid haemorrhage. J Endocrinol Invest 2017; 40:193-205. [PMID: 27671168 PMCID: PMC5269462 DOI: 10.1007/s40618-016-0546-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/01/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE Reports on long-term variations in pituitary function after traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH) diverge. The aim of the current study was to evaluate the prevalence and changes in pituitary function during the first year after moderate and severe TBI and SAH and to explore the relation between pituitary function and injury variables. METHODS Adults with moderate and severe TBI or SAH were evaluated at 10 days, 3, 6 and 12 months post-injury/illness. Demographic, clinical, radiological, laboratory, including hormonal data were collected. RESULTS A total of 91 adults, 56 (15 women/41 men) with TBI and 35 (27 women/8 men) with SAH were included. Perturbations in pituitary function were frequent early after the event but declined during the first year of follow-up. The most frequent deficiency was hypogonadotrope hypogonadism which was seen in approximately 25 % of the patients. Most of the variations were transient and without clinical significance. At 12 months, two patients were on replacement with hydrocortisone, four men on testosterone and one man on replacement with growth hormone. No relations were seen between hormonal levels and injury variables. CONCLUSIONS Perturbations in pituitary function continue to occur during the first year after TBI and SAH, but only a few patients need replacement therapy. Our study could not identify a marker of increased risk of pituitary dysfunction that could guide routine screening. However, data demonstrate the need for systematic follow-up of pituitary function after moderate or severe TBI or SAH.
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Affiliation(s)
- A Tölli
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 182 88, Stockholm, Sweden.
| | - J Borg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 182 88, Stockholm, Sweden
| | - B-M Bellander
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Stockholm, Sweden
| | - F Johansson
- Medical Library, Danderyd University Hospital, Stockholm, Sweden
| | - C Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetology, Karolinska University Hospital, Stockholm, Sweden
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48
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Nemes O, Kovacs N, Szujo S, Bodis B, Bajnok L, Buki A, Doczi T, Czeiter E, Mezosi E. Can early clinical parameters predict post-traumatic pituitary dysfunction in severe traumatic brain injury? Acta Neurochir (Wien) 2016; 158:2347-2353. [PMID: 27778105 DOI: 10.1007/s00701-016-2995-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/11/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Post-traumatic hypopituitarism is a major complication after severe head trauma. The aim of our study was to evaluate the possible role of early clinical parameters in the development of endocrine deficits. METHODS Data on endocrine function, on-admission clinical-, laboratory-, and ICU-monitored parameters were available in 63 patients of the surviving 86 severe head injury patients (post-resuscitation GCS under 8) treated at one neurosurgical center during a 10-year period. RESULTS Hypopituitarism was diagnosed in 68.3 % of the patients. The most frequently affected pituitary axis was the growth hormone (GH): GH deficiency or insufficiency was present in 50.8 %. Central hypogonadism affected 23.8 % of male patients; hypothyroidism and secondary adrenal failure were found in 22.2 and 9.5 % of the investigated population, respectively. Early onset (within 1 year of brain injury) hypopituitarism was found in 24 patients. No connection was found between the development of hypopituitarism and any of the clinical parameters assessed on-admission or at ICU. Significant correlations were found between early endocrine dysfunctions and surgical intervention (OR: 4.64) and the diagnosis of subdural hematoma (OR: 12). In our population, after road traffic accidents, the development of late-onset hypopituitarism was less prevalent (OR: 0.22). CONCLUSIONS Since our results do not indicate any reliable predictive parameter for the development of endocrine dysfunction in a cohort of patients with severe traumatic brain injury, regular endocrine screening of this specific patient population seems obligatory.
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49
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Baek CO, Kim YJ, Kim JH, Park JH. Isolated Adrenocorticotropic Hormone or Thyrotropin Deficiency Following Mild Traumatic Brain Injury: Three Cases with Long-Term Follow-Up. Korean J Neurotrauma 2016; 11:139-43. [PMID: 27169080 PMCID: PMC4847509 DOI: 10.13004/kjnt.2015.11.2.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 07/09/2015] [Accepted: 08/13/2015] [Indexed: 12/03/2022] Open
Abstract
Few studies have examined the clinical features and long-term outcomes of isolated pituitary hormone deficiencies after traumatic brain injury (TBI). Such deficiencies typically present at time intervals after TBI, especially after mild injuries such as concussions, which makes their diagnosis difficult without careful history taking. It is necessary to improve diagnosis and prevent life threatening or morbid conditions such as those that may occur in deficiencies of adrenocorticotropic hormone (ACTH) or thyroid-stimulating hormone (as known as thyrotropin, TSH), the two most important pituitary hormones in hypopituitarism treatment. Here, we report two cases of isolated ACTH deficiency and one case of isolated TSH deficiency. These patients presented at different time points after concussion and underwent long-term follow-ups.
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Affiliation(s)
- Cho-Ok Baek
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Yu Ji Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonbuk National University Medical School, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Ji Hye Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Ji Hyun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonbuk National University Medical School, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
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50
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Krewer C, Schneider M, Schneider HJ, Kreitschmann-Andermahr I, Buchfelder M, Faust M, Berg C, Wallaschofski H, Renner C, Uhl E, Koenig E, Jordan M, Stalla GK, Kopczak A. Neuroendocrine Disturbances One to Five or More Years after Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage: Data from the German Database on Hypopituitarism. J Neurotrauma 2016; 33:1544-53. [PMID: 26914840 DOI: 10.1089/neu.2015.4109] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Neuroendocrine disturbances are common after traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH), but only a few data exist on long-term anterior pituitary deficiencies after brain injury. We present data from the Structured Data Assessment of Hypopituitarism after TBI and SAH, a multi-center study including 1242 patients. We studied a subgroup of 351 patients, who had sustained a TBI (245) or SAH (106) at least 1 year before endocrine assessment (range 1-55 years) in a separate analysis. The highest prevalence of neuroendocrine disorders was observed 1-2 years post-injury, and it decreased over time only to show another maximum in the long-term phase in patients with brain injury occurring ≥5 years prior to assessment. Gonadotropic and somatotropic insufficiencies were most common. In the subgroup from 1 to 2 years after brain injury (n = 126), gonadotropic insufficiency was the most common hormonal disturbance (19%, 12/63 men) followed by somatotropic insufficiency (11.5%, 7/61), corticotropic insufficiency (9.2%, 11/119), and thyrotropic insufficiency (3.3%, 4/122). In patients observed ≥ 5 years after brain injury, the prevalence of somatotropic insufficiency increased over time to 24.1%, whereas corticotropic and thyrotrophic insufficiency became less frequent (2.5% and 0%, respectively). The prevalence differed regarding the diagnostic criteria (laboratory values vs. physician`s diagnosis vs. stimulation tests). Our data showed that neuroendocrine disturbances are frequent even years after TBI or SAH, in a cohort of patients who are still on medical treatment.
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Affiliation(s)
| | | | | | | | - Michael Buchfelder
- 4 Department of Neurosurgery, University of Erlangen-Nürnberg , Erlangen, Germany
| | - Michael Faust
- 5 Center of Endocrinology, Diabetes, and Preventive Medicine, University Hospital Cologne , Cologne, Germany
| | - Christian Berg
- 6 Department of Internal Medicine, Evangelical Hospital Mettmann , Mettmann, Germany
| | - Henri Wallaschofski
- 7 Specialized Medical Practice for Diabetes and Hormonal Disorders , Erfurt, Germany
| | - Caroline Renner
- 8 NRZ Neurological Rehabilitation Center, University of Leipzig , Leipzig, Germany
| | - Eberhard Uhl
- 9 Department of Neurosurgery, University Hospital Giessen , Giessen, Germany
| | | | | | - Günter Karl Stalla
- 11 Clinical Neuroendocrinology Group, Max Planck Institute of Psychiatry , Munich, Germany
| | - Anna Kopczak
- 11 Clinical Neuroendocrinology Group, Max Planck Institute of Psychiatry , Munich, Germany
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