Volume overload is a major characteristic in primary aldosteronism: a 3-year follow-up study

OBJECTIVES

We examined haemodynamics, focusing on volume balance and forward and backward wave amplitudes, before and after 2.8 years of targeted treatment of primary aldosteronism. Patients with essential hypertension and normotensive individuals were examined for comparison (n = 40 in each group).

METHODS

Recordings were performed using radial artery pulse wave analysis and whole-body impedance cardiography. Unilateral aldosteronism was treated with adrenalectomy (n = 20), bilateral aldosteronism with spironolactone-based medication (n = 20), and essential hypertension with standard antihypertensive agents.

RESULTS

Aortic SBP and DBP, forward and backward wave amplitudes, and systemic vascular resistance were equally elevated in primary aldosteronism and essential hypertension. All these haemodynamic variables were similarly reduced by the treatments. Primary aldosteronism presented with 1 litre (∼10%) extracellular water excess (P < 0.001) versus the other groups, and this excess was normalized by treatment. Initial pulse wave velocity (PWV) was similarly increased in primary aldosteronism and essential hypertension, but final values remained higher in primary aldosteronism (P < 0.001). In regression analyses, significant explanatory factors for treatment-induced forward wave amplitude reduction were decreased systemic vascular resistance (β = 0.380) and reduced extracellular water volume (β = 0.183). Explanatory factors for backward wave amplitude reduction were changes in forward wave amplitude (β = 0.599), heart rate (β = -0.427), and PWV (β = 0.252).

CONCLUSION

Compared with essential hypertension, the principal haemodynamic difference in primary aldosteronism was higher volume load. Volume excess elevated forward wave amplitude, which was subsequently reduced by targeted treatment of primary aldosteronism, along with normalization of volume load. We propose that incorporating extracellular water evaluation alongside routine diagnostics could enhance the identification and diagnosis of primary aldosteronism.

Clinical significance of CYP11B2 immunostaining in unilateral primary aldosteronism

Objective

The associations between adrenal histopathology, lateralization studies, and surgical outcomes in primary aldosteronism remain poorly characterized. We examined the value of immunohistochemical analysis of CYP11B2 for evaluation of adrenalectomy outcomes after anatomical versus functional subtyping.

Design

A retrospective multicenter study of 277 patients operated for primary aldosteronism who had an adrenalectomy sample available in the Finnish biobanks from 1 January 2000 to 31 December 2019. Adrenal slides from biobanks were analyzed centrally after CYP11B2 and CYP11B1 staining. Clinical data were obtained from patient registries. Histopathological diagnosis and cure after surgery were assessed as outcome measures.

Results

Re-evaluation with CYP11B2 staining changed the histopathological diagnosis in 91 patients (33%). The presence of a CYP11B2-positive adenoma and the use of functional subtyping independently predicted clinical cure of primary aldosteronism. CYP11B2-positive <7 mm nodules were more frequent in patients without clinical cure, whereas CYP11B2-positive micronodules were common in all patients and had no impact on adrenalectomy outcomes. Small CYP11B2-positive nodules and micronodules were equally prevalent regardless of the subtyping method applied. Clinical cure rates were lower and CYP11B2-negative adenomas more common after adrenalectomy based on anatomical imaging than functional studies.

Conclusions

Incorporating CYP11B2 staining in histopathological diagnosis enhances the prediction of surgical outcomes in primary aldosteronism. A finding of CYP11B2-positive adenoma is indicative of cure of primary aldosteronism, whereas smaller CYP11B2-positive nodules associate with poorer results at postoperative evaluation. Functional subtyping methods decrease the operations of CYP11B2-negative adenomas and are superior to anatomical imaging in identifying unilateral primary aldosteronism.

Adrenal androgens versus cortisol for primary aldosteronism subtype determination in adrenal venous sampling

OBJECTIVE

We examined if measurement of adrenal androgens adds to subtype diagnostics of primary aldosteronism (PA) under cosyntropin-stimulated adrenal venous sampling (AVS).

DESIGN

A prospective pre-specified secondary endpoint analysis of 49 patients with confirmed PA, of whom 29 underwent unilateral adrenalectomy with long-term follow-up.

METHODS

Concentrations of androstenedione, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulphate (DHEAS) were measured during AVS in addition to aldosterone and cortisol. Subjects with lateralisation index (LI) of ≥4 were treated with unilateral adrenalectomy, and the immunohistochemical subtype was determined with CYP11B2 and CYP11B1 stains. The performance of adrenal androgens was evaluated by receiver operating characteristics (ROC) curve analyses in adrenalectomy and medical therapy groups.

RESULTS

During AVS, the correlations between cortisol and androstenedione, DHEA and DHEAS for LI and selectivity index (SI) were highly significant. The right and left side SIs for androstenedione and DHEA were higher (p < .001) than for cortisol. In ROC analysis, the optimal LI cut-off values for androstenedione, DHEA and DHEAS were 4.2, 4.5 and 4.6, respectively. The performance of these LIs for adrenal androgens did not differ from that of cortisol.

CONCLUSIONS

Under cosyntropin-stimulated AVS, the measurement of androstenedione and DHEA did not improve the cannulation selectivity. The performance of cortisol and adrenal androgens are confirmatory but not superior to cortisol-based results in lateralisation diagnostics of PA.

Lateralization in 11 C-Metomidate PET and outcome of adrenalectomy in primary aldosteronism

INTRODUCTION

Subtype classification method is essential when considering adrenalectomy as a possible treatment for primary aldosteronism. We aimed to retrospectively evaluate surgical outcomes of primary aldosteronism in patients who had undergone ¹¹ C-metomidate positron emission tomography (¹¹ C-MTO-PET) for subtype classification.

METHODS

Postoperative clinical and biochemical cure and histopathological diagnosis from biobank samples were retrospectively evaluated in 44 patients who had all undergone preoperative ¹¹ C-MTO-PET with or without adrenal venous sampling (AVS). We compared those operated based on ¹¹ C-MTO-PET alone and those with concordant or discordant lateralization in ¹¹ C-MTO-PET and AVS studies according to postoperative immunohistochemical findings and biochemical and clinical cure.

RESULTS

Adrenalectomy side was based on ¹¹ C-MTO-PET alone in 14 cases and on AVS in 30 cases of whom 42 achieved complete and two partial biochemical cures. Among those who underwent AVS and were operated according to it, the two lateralization methods were concordant in 22 cases and discordant in 8 cases. Similar immunohistochemical profiles and cure rates were seen after ¹¹ C-MTO-PET alone or AVS-based operations. Respectively, those with concordant or discordant ¹¹ C-MTO-PET and AVS lateralization did not differ in surgical outcome. Together, we found errors of lateralization diagnostics with ¹¹ C-MTO-PET in 18% and with AVS in 3% among those eligible for adrenal surgery.

CONCLUSIONS

Outcomes of adrenalectomy based on clinically significant lateralization in ¹¹ C-MTO-PET alone correspond to those based on ¹¹ C-MTO-PET with concordant AVS lateralization. However, our results suggest that diagnosis of unilateral PA should be performed with caution with ¹¹ C-MTO-PET in case of discordant lateralization studies.

Aldosterone-to-renin ratio is related to arterial stiffness when the screening criteria of primary aldosteronism are not met

Aldosterone-to-renin ratio (ARR) is a screening tool for primary aldosteronism (PA), but the significance of ARR when the PA criteria are not met remains largely unknown. In this cross-sectional study we investigated the association of ARR with haemodynamic variables in 545 normotensive and never-medicated hypertensive subjects (267 men, 278 women, age range 19-72 years) without suspicion of PA. Supine haemodynamic data was recorded using whole-body impedance cardiography and radial tonometric pulse wave analysis. In sex-adjusted quartiles of ARR, determined as serum aldosterone to plasma renin activity ratio, the mean values were 282, 504, 744 and 1467 pmol/µg of angiotensin I/h, respectively. The only difference in haemodynamic variables between the ARR quartiles was higher pulse wave velocity (PWV) in the highest quartile versus other quartiles (p = 0.004), while no differences in blood pressure (BP), heart rate, wave reflections, cardiac output or systemic vascular resistance were observed between the quartiles. In linear regression analysis with stepwise elimination, ARR was an independent explanatory factor for PWV (β = 0.146, p < 0.001, R2 of the model 0.634). In conclusion, ARR was directly and independently associated with large arterial stiffness in individuals without clinical suspicion of PA. Therefore, ARR could serve as a clinical marker of cardiovascular risk.Trial registration: ClinicalTrails.gov: NCT01742702.

Psychosis-like absence status of elderly patients: successful treatment with sodium valproate

Absence status and psychosis-like behaviour and continuous spike-and-wave EEG activity in two elderly women is reported. Once the correct diagnosis was made, the patients were successfully treated with sodium valproate. Differential diagnosis between absence status and psychotic syndromes is emphasised.

Low doses of brotizolam and nitrazepam as hypnotics in the elderly

0.125 mg brotizolam and 2.5 mg nitrazepam proved to be equipotent in promoting and maintaining sleep in 29 elderly patients used to long-term hypnotics. These drugs were superior to placebo and they were excellently tolerated. The drugs were administered in a random order, double-blind, for 7 nights each.

Diazepam, promethazine and propiomazine as hypnotics in elderly inpatients

Diazepam 5 mg, promethazine 25 mg, propiomazine 25 mg, and placebo as sleeping aids were studied in 40 elderly inpatients. The drugs were administered in a random order, double-blind, on 21 nights. All active drugs were found effective in the mentally normal elderly, but in the psychogeriatric group of 20 patients, only propiomazine very significantly reduced the number of nocturnal awakenings and only diazepam almost significantly shortened the initial sleep latency, although duration of sleep was prolonged in both groups. There was neither loss of efficacy of the trial drugs nor rebound on withdrawal. Psychomotor skills and serum prolactin levels remained unaffected.

Tolerance and serum levels of haloperidol during parenteral and oral haloperidol treatment in geriatric patients

Eleven geriatric chronic psychotic hospital patients were treated with monthly intramuscular haloperidol decanoate injections for 5 months. The first and second haloperidol decanoate dose was 20 times and thereafter 15 times the "optimal" oral haloperidol dose. The serum haloperidol concentrations were fairly stable during the whole month following parenteral administration. After the second and third injection the concentration was about twice as high as during oral treatment. No clinically significant changes were established in routine haematological or biochemical laboratory tests studied during the trial. No significant changes in serum prolactin levels were observed after parenteral haloperidol compared to the levels during oral treatment. No local or systemic side effects were observed during the trial. The psychiatric status of the patients was fairly constant during the whole study. Haloperidol decanoate was thus shown to be therapeutically effective and it can be administered safely to geriatric patients.

Pharmacokinetics of diazepam administered rectally in geriatric patients: comparison of suppositories with rectal tubes in a cross-over study

The pharmacokinetics of diazepam administered as suppositories or as a solution in rectal tubes were compared in six geriatric hospital patients. A single dose of 10 mg was administered in a cross-over study with a one week interval. There was no statistically significant difference in the bioavailability, the mean maximum serum concentration or the time of achievement of the maximum with these preparations. However, the peak serum concentration was somewhat higher with suppositories but the absorption was somewhat faster via rectal tubes. The serum N-desmethyldiazepam concentration increased during the whole 24 hour observation period, there was no difference between the preparations. Our results are in good agreement with most studies of the pharmacokinetics of diazepam. The basal substance of the suppository is of the utmost importance to the absorption of diazepam. The rectal tube for administration of diazepam did not have any advantage over the optimally formulated (a mixture of macrogols) suppository in geriatric patients. In fact, the use of rectal tubes is more expensive, the tube may not be completely emptied, and the solution may not be completely retained in the rectum.

Haloperidol, thioridazine and placebo in mentally subnormal patients-serum levels and clinical effects

A randomized cross-over trial was conducted in 30 restless mentally subnormal patients by increasing the dosage of haloperidol from 10 to 60 mg and that of thioridazine from 100 to 600 mg daily. The clinical effects of drug holidays on placebo and serum drug levels were also examined. There were more relative drug-responders than nonresponders or negative responders. Correlation between clinical response and drug serum levels was poor, probably owing to the heterogeneity of disorders treated. Mesoridazine and other metabolites had 5-6 times higher serum levels than the parent compound, and relatively high serum levels are achieved already with moderate doses. The observed differences between haloperidol and thioridazine treatment were surprisingly few. Serum cholesterol was higher (P less than 0.05) at the end of thioridazine than of the haloperidol administration.

Effect of anticonvulsants on plasma haloperidol and thioridazine levels

Patients who had therapeutic plasma levels of phenobarbital and/or diphenylhydantoin had significantly lower plasma levels of haloperidol and mesoridazine, the active metabolite of thioridazine, than patients who did not receive anticonvulsants. Plasma thioridazine levels per se were not affected by concomitant anticonvulsant treatment. Biperiden, an antimuscarinic, antiparkinsonian agent, did not affect the plasma levels of these three neuroleptics.

Efficacy and side effects of lorazepam, oxazepam, and temazepam as sleeping aids in psychogeriatric inpatients

The efficacy and side effects of 2 mg of lorazepam, 30 mg of oxazepam, and 20 mg of temazepam as sleeping aids were investigated in 20 psychogeriatric inpatients. The drugs were administered in a random order, double-blind, for 7 night each. All of these short half-life benzodiazepines proved efficacious in maintaining sleep. None of them reduced initial sleep latency. Oxazepam and to a lesser degree temazepam induced withdrawal insomnia during the first night after the treatments. The withdrawal of lorazepam induced a delayed but prolonged insomnia in 3 patients. Both lorazepam and oxazepam had muscle relaxant side effects after awakening.

Efficacy and side effects of chloral hydrate and tryptophan as sleeping aids in psychogeriatric patients

The effects of placebo, L-tryptophan 3 g, and chloral hydrate 500 mg on sleep were studied in 19 nonpsychotic, mildly demented, geriatric inpatients. Only chloral hydrate was more effective in inducing and maintaining sleep than placebo. Neither chloral hydrate not L-tryptophan had any significant side effects, but withdrawal of chloral hydrate was associated with insomnia.

A controlled double-blind study of haloperidol versus thioridazine in the treatment of restless mentally subnormal patients. Serum levels and clinical effects

A randomized cross-over trial was conducted in 30 restless mentally subnormal patients by increasing the dosage of haloperidol from 10 to 60 mg and of thioridazine from 100 to 600 mg daily. The effects of drug holidays and serum drug levels were also examined. Mesoridazine had 5-6 times higher serum levels than the parent compound and relatively high serum levels are achieved already with moderate doses. The observed differences between haloperidol and thioridazine treatment were surprisingly few. Serum cholesterol was higher (P < 0.05) at the end of the thioridazine administration. Drug holidays may benefit may patients.

Attitudes towards criminal and other patients

Staff attitudes towards mentally abnormal offenders were investigated on a forensic psychiatric assessment ward as reflected in a drug trial. The attitude towards drug trials was negative in 79% of the personnel, in contrast to 71% positive in three Swedish mental hospitals. Of the respondents 75% considered that drug treatment did not benefit the patients. Then the attitudes of 21 general physicians towards assessment and drug treatment of mentally abnormal offenders as well as towards 10 illnesses were measured by self-rating scales employing a 10-cm line technique. Both the assessment and drug treatment of mentally abnormal offenders were the least favoured as compared with somatic illnesses. Other neuropsychiatric disorders ranked with them were also very significantly (P less than 0.001) less favoured than pneumonia. They considered that these attitudes were shared in general by medical and nursing staff

Electroencephalography and phenytoin toxicity in mentally retarded epileptic patients

There were significantly more diffuse and focal electroencephalographic abnormalities in 127 mentally retarded epileptic patients treated with phenytoin than in 68 epileptics without phenytoin. Phenytoin intoxication made the difference still more pronounced. Monitoring drug levels and electroencephalograms appears to be the method of choice for ensuring safe and effective medication in intractable epilepsy.

Efficacy and side effects of flurazepam, fosazepam, and nitrazepam as sleeping aids in psychogeriatric patients

Efficacy and side effects of flurazepam 15 mg, fosazepam 60 mg, and nitrazepam 5 mg were studied in 17 psychogeriatric patients. The drugs were equipotent in maintaining sleep but nitrazepam had more side effects than the other hypnotics, and it induced a rebound insomnia after withdrawal. All hypnotics lost some of their efficacy towards the end of 7 days' administration. Patients with evident cerebrovascular disease were vulnerable to the side effects of the benzodiazepine hypnotics. The side effects did not correlate with the age of a patient. In addition, no correlations were found between the serum levels of fosazepam or its main metabolite and the side effects.

Serum medazepam, diazepam, and N-desmethyldiazepam levels after single and multiple oral doses of medazepam

20 mg of medazepam were taken by mouth by 9 healthy volunteers in an acute absorption study. About a 10-fold variation was found during the first 6 hours after the drug in individual serum medazepam, diazepam, and N-desmethyldiazepam levels. In a subacute study 10 mg of medazepam t.i.d. was given to 10 institutionalized mentally subnormal adults with emotional disorders. After 14 days' treatment serum N-desmethyldiazepam levels were generally above 800 ng/ml, 7 to 8 times higher than the serum medazepam or diazepam levels measured 12 hours after the last dose. No correlation was observed between the serum concentration and efficacy of medazepam.

Cerebellar atrophy in phenytoin-treated mentally retarded epileptics

The relationship among the serum concentration of phenytoin, pneumoencephalographic measurements describing, in particular, cerebellar atrophy, and various other clinical variables was analyzed statistically in a series of 131 phenytoin-treated mentally retarded epileptics. Phenytoin intoxication was diagnosed retrospectively in 73 patients (56%), of whom 18 had persistent loss of locomotion. The mean duration of phenytoin intoxication until locomotion was lost was 22.8 +/- 23.6 months. There was a temporal relationship between the high serum level of phenytoin and the loss of locomotion. The degree of brain atrophy in the posterior fossa was most severe in these 18 patients with severe phenytoin intoxication. The frequency of cerebellar and/or brain stem atrophy in the present series was 28%, the same as in mentally retarded epileptics without phenytoin treatment from the same institution. That phenytoin levels in serum correlated significantly with the heights of the fourth ventricle suggests that an overdosage of phenytoin or an underlying disease, or both, were the probable causes of cerebellar impairment and atrophy. Thus brain-damaged mentally retarded epileptics appear to be unusually susceptible to the side effects of phenytoin. This antiepiliptic drug is therefore not recommended for patients with no locomotor ability or with marked cerebellar signs and symptoms. To prevent phenytoin intoxication in susceptible patients, careful observation of the patients and routine monitoring of phenytoin levels in blood are stressed.

Effect of fusaric acid on tardive dyskinesia and mental state in psychogeriatric patients. A pilot study

The effect of fusaric acid 150-450 mg daily on tardive dyskinesia and mental state was studied in 15 chronic psychogeriatric patients. The patient's previous drug treatment was maintained unchanged during the experiment. Fusaric acid significantly relieved oro-facial dyskinesia, tremor, and rigidity, and it improved the mental state of the patients (BPRS). Akathisia was exacerbated, but this change was not significant. Akinesia and anxiety were not altered.

Effect of sodium valproate on tardive dyskinesia

The effect of sodium valproate, a drug which has been demonstrated to increase gamma-aminobutyric acid levels in the CNS, on tardive dyskinesia and psychiatric symptoms was investigated in a double-blind cross-over study on 32 chronic psychiatric patients. The oro-facial dyskinesias were totally or significantly relieved in 17 cases. During the active treatment period the involuntary movements of the extremities and dystonic spasms were also significantly relieved in 7 out of 9 patients. In two patients, however, the extrapyramidal symptoms became slightly worse. A significant improvement was noted in the psychiatric symptoms of 14 out of 32 patients during sodium valproate administration. The psychiatric state of 4 out of 32 patients deteriorated. Three was no correlation between the serum concentration of sodium valproate and its effect on the dyskinesia or on the psychiatric symptoms. Some of the elderly subjects showed a slight accumulation of the drug.

Efficacy and side effects of nitrazepam and thioridazine as sleeping aids in psychogeriatric in-patients

The efficacy and side effects of 10 mg of nitrazepam and 25 mg of thioridazine as sleeping aids were measured in 20 psychogeriatric in-patients during the 14th night and morning of drug administration. The trial used a double blind, cross-over design. The effect of nitrazepam was slightly faster than that of thioridazine. After thioridazine, but not after nitrazepam, the patients slept significantly longer than after placebo. Nitrazepam, but not thioridazine, significantly impaired patients' abilities to move and to conduct everyday activities. It is concluded that thioridazine is a suitable sleeping aid for psychogeriatric patients, but that nitrazepam should be avoided.