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Gkaniatsa E, Zverkova Sandström T, Rosengren A, Trimpou P, Olsson DS, Lind M, Muth A, Johannsson G, Ragnarsson O. Mortality in Patients With Primary Aldosteronism: A Swedish Nationwide Study. Hypertension 2023; 80:2601-2610. [PMID: 37855142 DOI: 10.1161/hypertensionaha.123.21895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Primary aldosteronism (PA) is associated with increased mortality. The extent to which this phenomenon is affected by sex, age, comorbidities at diagnosis, and different treatment modalities is largely unknown. The objective was to determine all-cause and cause-specific mortality in a population-based cohort of patients with PA and the impact of age at diagnosis, sex, comorbidities, and treatment modalities. METHODS We used national registers to identify patients diagnosed with PA between 1997 and 2019 (n=2419) and controls (n=24 187) from the general population, matched for sex, age, and county of residence. We obtained mortality data from the Cause-of-Death Register. We used Cox regression models, adjusted for socioeconomic factors and diabetes, to estimate adjusted hazard ratios (HRs [95% CI]). RESULTS Overall, 346 (14.3%) patients with PA and 2736 (11.3%) controls died during a median follow-up time of 8.1 years. PA was associated with increased risk from all-cause mortality (HR, 1.23 [95% CI, 1.10-1.38]), death from cardiovascular disease (HR, 1.57 [95% CI, 1.30-1.89]), and stroke (HR, 1.85 [95% CI, 1.16-2.93]). Patients with cardiovascular disease at diagnosis (HR, 1.53 [1.26-1.85]), age >56 years (HR, 1.28 [95% CI, 1.13-1.45]), patients treated with a low dose of a mineralocorticoid receptor antagonist (HR, 1.30 [95% CI, 1.02-1.66]), and untreated patients (HR, 2.51 [95% CI, 1.72-3.67]) had excess mortality. CONCLUSIONS Mortality, mainly due to cardiovascular disease, is increased in patients with PA compared with controls from the general population, particularly in patients aged >56 years, patients with preexisting cardiovascular comorbidities, and patients receiving low dose of a mineralocorticoid receptor antagonist.
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Affiliation(s)
- Eleftheria Gkaniatsa
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine (A.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Annika Rosengren
- Department of Medicine, Geriatrics and Emergency Medicine (A.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine (A.R., M.L.), University of Gothenburg, Sweden
| | - Penelope Trimpou
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine (A.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Daniel S Olsson
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine (E.G., P.T., D.S.O., G.J., O.R.), University of Gothenburg, Sweden
- Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (D.S.O.)
| | - Marcus Lind
- Department of Molecular and Clinical Medicine, Institute of Medicine (A.R., M.L.), University of Gothenburg, Sweden
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden (M.L.)
| | - Andreas Muth
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital (A.M.), University of Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine (E.G., P.T., D.S.O., G.J., O.R.), University of Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine (E.G., P.T., D.S.O., G.J., O.R.), University of Gothenburg, Sweden
- Sahlgrenska Academy, Wallenberg Centre for Molecular and Translational Medicine, Institute of Medicine (O.R.), University of Gothenburg, Sweden
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Gkaniatsa E, Ragnarsson O. Adrenal Vein Sampling in the Young - Necessary or Not? Exp Clin Endocrinol Diabetes 2023; 131:435-437. [PMID: 37225137 DOI: 10.1055/a-2099-3525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Current clinical guidelines from the US Endocrine Society state that adrenal venous sampling (AVS) may not be necessary in patients younger than 35 years with marked aldosteronism and a solitary adrenal adenoma on imaging. At the time when the guidelines were published, only one study supported the statement, a study that included 6 patients younger than 35 years, all of whom had unilateral adenoma on imaging and unilateral primary aldosteronism (PA), according to AVS. Since then, to our knowledge, four additional studies have been published that provide data on concordance between conventional imaging and AVS among patients younger than 35 years. In these studies, 7 of 66 patients with unilateral disease on imaging had bilateral disease, according to AVS. We find it, therefore, reasonable to conclude that imaging studies alone inaccurately predict laterality in a significant number of young patients with PA and that available data challenge the current clinical guidelines.
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Affiliation(s)
- Eleftheria Gkaniatsa
- Department of Endocrinology
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine
| | - Oskar Ragnarsson
- Department of Endocrinology
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine
- Wallenberg Center for Molecular and Translational Medicine
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Rocca A, Gkaniatsa E, Brunese MC, Hessman E, Muth A, Nwaru BI, Ragnarsson O, Bobbio E, Esposito D. Therapeutic outcomes with surgical and medical management for primary aldosteronism: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e072585. [PMID: 37518075 PMCID: PMC10387625 DOI: 10.1136/bmjopen-2023-072585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
INTRODUCTION Treatment strategies for primary aldosteronism (PA) include unilateral adrenalectomy and medical treatment with mineralocorticoid receptor (MR) antagonists. Whether these two different treatment strategies are comparable in mitigating the detrimental effect of PA on outcomes is still debated. OBJECTIVES The primary aim of this systematic review is to identify, appraise and synthesise existing literature comparing clinical outcomes after treatment in patients with PA. METHODS AND ANALYSIS A systematic and comprehensive search will be performed using PubMed, Web of Science and EMBASE, for studies published until December 2022. Observational and interventional studies will be eligible for inclusion. The quality of observational studies will be assessed using the Newcastle-Ottawa Scale, while interventional studies will be assessed using the Cochrane Effective Practice Organization of Care tool. The collected evidence will be narratively synthesised. We will perform meta-analysis to pool estimates from studies considered to be homogeneous. Reporting of the systematic review and meta-analysis will be in accordance with the Meta-analysis of Observational Studies in Epidemiology Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. ETHICS AND DISSEMINATION As this study is based solely on the published literature, no ethics approval is required. This review will aim to provide some estimates on outcomes, including survival, rates of clinical and biochemical control, cardiovascular and cerebrovascular events, as well as data on quality of life and renal function, in patients with PA treated surgically or with MR antagonists. The study findings will be presented at scientific meetings and will be published in an international peer-reviewed scientific journal. PROSPERO REGISTRATION NUMBER CRD42022362506.
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Affiliation(s)
- Aldo Rocca
- Department of Medicine and Health Science 'V Tiberio', University of Molise, Campobasso, Italy
| | - Eleftheria Gkaniatsa
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Chiara Brunese
- Department of Medicine and Health Science 'V Tiberio', University of Molise, Campobasso, Italy
| | - Eva Hessman
- Biomedical Library, Gothenburg University Library, University of Gothenburg, Gothenburg, Sweden
| | - Andreas Muth
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bright I Nwaru
- Krefting Research Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniela Esposito
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ragnarsson O, Muth A, Johannsson G, Gkaniatsa E, Ung EJ, Jakobsson S. Illness perspectives in patients with primary aldosteronism. PLoS One 2022; 17:e0277902. [PMID: 36441675 PMCID: PMC9704575 DOI: 10.1371/journal.pone.0277902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 11/05/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The burden of symptoms and treatment in patients with primary aldosteronism (PA), as well as the patients' experience of the health care is sparsely studied. The objectives of this study were to describe symptoms considered to be the most troublesome by patients with PA, and to explore health related worries and expectations following treatment. METHODS This was an explorative qualitative study where 25 patients with PA, diagnosed between 2017 and 2019, were included; 13 patients who had undergone adrenalectomy and 12 who were receiving medical treatment. Data was collected during six group interviews and analyzed using a thematic approach. RESULTS Three main themes were identified: 1) Distress of the past, where the most important issues were struggle to receive a correct diagnosis, impaired well-being and the consumption of a large number of tablets, 2) Satisfaction after receiving a correct diagnosis, both in patients with unilateral and bilateral disease, but also dissatisfaction with lack of information about the disease, and 3) Future concerns, where worries about the long-term effects of PA on health in general dominated. CONCLUSIONS Our findings illustrate several important issues related to PA where improvements in patient care are needed, including actions aiming at shortening the long diagnostic delay, a thorough information to the patients about the disease is of great importance, and that all patients with PA, regardless of treatment, would benefit from a structured long-term follow-up.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
| | - Andreas Muth
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eleftheria Gkaniatsa
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Jakobsson Ung
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Sofie Jakobsson
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
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Gkaniatsa E, Ekerstad E, Gavric M, Muth A, Trimpou P, Olsson DS, Johannsson G, Ragnarsson O. Response to Letter to the Editor From Singhania et al.: "Increasing Incidence of Primary Aldosteronism in Western Sweden During 3 Decades - Yet an Underdiagnosed Disorder". J Clin Endocrinol Metab 2022; 107:e1325-e1326. [PMID: 34734266 PMCID: PMC8851921 DOI: 10.1210/clinem/dgab805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Eleftheria Gkaniatsa
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
- Correspondence: Eleftheria Gkaniatsa, Department of Endocrinology, Blå Stråket 5, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
| | - Eva Ekerstad
- Department of Internal Medicine, Northern Älvsborg County Hospital, SE-461 85 Trollhättan, Sweden
| | - Manuela Gavric
- Department of Clinical Medicine, Kungälv Hospital, SE-442 83 Kungälv, Sweden
| | - Andreas Muth
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Penelope Trimpou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Daniel S Olsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
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Gkaniatsa E, Ekerstad E, Gavric M, Muth A, Trimpou P, Olsson DS, Johannsson G, Ragnarsson O. Increasing Incidence of Primary Aldosteronism in Western Sweden During 3 Decades - Yet An Underdiagnosed Disorder. J Clin Endocrinol Metab 2021; 106:e3603-e3610. [PMID: 33974052 PMCID: PMC8372665 DOI: 10.1210/clinem/dgab327] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary aldosteronism (PA) is the most common cause of secondary hypertension. Yet, the incidence of PA in the general population has not been studied. OBJECTIVE To estimate the incidence of PA in the general population. DESIGN AND METHODS Patients who had received a diagnostic code for PA between 1987 and 2016 were identified in the Swedish National Patient Registry. Assessment of clinical and biochemical data was used to validate the diagnosis. The annual incidence of PA was calculated by using the number of inhabitants in the Västra Götaland County as a reference. RESULTS Of 570 identified patients, 473 (83%) had confirmed PA. Eligible for the incidence analysis were 416 patients, 248 (60%) men and 168 (40%) women, diagnosed with PA between 1987 and 2016. The mean (± standard deviation) age at diagnosis was 56 ± 12 years. The median (interquartile range) annual incidence was 2 (1-2) cases per million between 1987 and 1996, 6 (4-9) cases per million between 1997 and 2006 and 17 (12-24) cases per million between 2007 and 2016. At the end of the study (December 31, 2016), 386 patients with confirmed PA were alive and living in the Västra Götaland County, giving a prevalence of 231 cases per million (0.022%). CONCLUSIONS Despite increasing incidence, the proportion of patients identified with PA is lower than expected. Given the serious consequences of untreated PA, the noticeably low prevalence at the end of the study stresses the need to increase the awareness of PA among health care providers.
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Affiliation(s)
- Eleftheria Gkaniatsa
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Sweden
| | - Eva Ekerstad
- Department of Internal Medicine, Northern Älvsborg County Hospital, SE-461 85, Trollhättan, Sweden
| | - Manuela Gavric
- Department of Clinical Medicine, Kungälv Hospital, SE-442 83, Kungälv, Sweden
| | - Andreas Muth
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Sweden
| | - Penelope Trimpou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Sweden
| | - Daniel S Olsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Sweden
- Correspondence: Oskar Ragnarsson, Department of Endocrinology, Blå Stråket 5, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
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Gkaniatsa E, Sakinis A, Palmér M, Muth A, Trimpou P, Ragnarsson O. Adrenal Venous Sampling in Young Patients with Primary Aldosteronism. Extravagance or Irreplaceable? J Clin Endocrinol Metab 2021; 106:e2087-e2095. [PMID: 33507307 DOI: 10.1210/clinem/dgab047] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Current clinical guidelines suggest that adrenal venous sampling (AVS) may not be mandatory in young patients with primary aldosteronism (PA) and a solitary adrenal adenoma on imaging. OBJECTIVE The aim of this study was to further elucidate whether conventional imaging alone is sufficient to distinguish unilateral from bilateral PA among patients aged 40 years or younger. METHODS This was a retrospective study where data from 45 patients with PA, aged between 26 and 40 years, who underwent successful AVS between 2005 and 2019, were analyzed. Results concerning laterality on imaging studies and AVS were recorded. Outcome in surgically treated patients was assessed according to the Primary Aldosteronism Surgical Outcomes criteria. RESULTS In 4 of 25 patients with unilateral aldosterone production according to AVS, computed tomography inaccurately suggested bilateral disease. Following unilateral adrenalectomy, all 4 patients showed complete clinical success. Five of 20 patients with bilateral aldosterone production according to AVS had a solitary adrenal nodule (8-19 mm) on imaging. Two of these 5 patients were treated with unilateral adrenalectomy, neither having complete biochemical and/or clinical success postoperatively. Two of 16 patients younger than 35 years had discordant results, 1 with unilateral and 1 with bilateral aldosterone production, according to AVS. CONCLUSION Imaging studies inaccurately predicted laterality in a significant number of young patients with PA. In contrast to current clinical guidelines, our results support AVS for subtype evaluation in young adults with PA, including patients 35 years or younger.
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Affiliation(s)
- Eleftheria Gkaniatsa
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Sweden
- The Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Augustinas Sakinis
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Palmér
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Muth
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Penelope Trimpou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Sweden
- The Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Sweden
- The Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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