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Abstract
OBJECTIVE To evaluate long-term hearing-related quality of life (HRQoL) and device use in bone conduction (BCD) users. Furthermore, to assess differences between indications and changes in HRQoL over time. STUDY DESIGN Prospective questionnaire survey. SETTING Tertiary referral center. PATIENTS Seventy-five patients with a percutaneous BCD. MAIN OUTCOME MEASURES Glasgow Benefit Inventory (GBI) at 3 and 12 months postoperatively, Glasgow Health Status Inventory (GHSI) preoperatively, and 6 and 36 months postoperatively, device use at 6, 12, and 36 months. Changes over time were assessed and outcomes were compared between indications. RESULTS After implantation, 97% of all patients reported a positive benefit on the GBI total. The GHSI total had improved with median 15 points (Interquartile range [IQR] 12). At 36 months, median device use was 15 hours/day (IQR 10) and one nonuser was reported. Patients with bilateral hearing loss (BHL) showed greater improvement on the GHSI total (median 18 vs 14, p < 0.0001) and used their devices more frequently (median 16 vs 8 h/day, p < 0.0001) than patients with unilateral HL (UHL). Postoperative GHSI and GBI scores were consistent over time, in the entire patient population and for every indication. Between 6 and 36 months, device use was stable over time, except for patients with single-sided deafness (SSD; median -6.4 h/day, p = 0.009). CONCLUSION The BCD improves HRQoL in patients with BHL, in patients with unilateral conductive/mixed hearing loss and in patients with SSD. Patients with BHL experienced a greater improvement in hearing status compared to patients with UHL. Although use decreased over time in SSD patients, device use was high for every indication.
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Affiliation(s)
| | - Rik Chrétien Nelissen
- Department of Otorhinolaryngology, Donders Center for Neurosciences, Radboud University Medical Center, Nijmegen
- Department of Otorhinolaryngology, St. Antonius Hospital, Nieuwegein
| | | | - Myrthe Karianne Sophie Hol
- Department of Otorhinolaryngology, Donders Center for Neurosciences, Radboud University Medical Center, Nijmegen
- Department of Otorhinolaryngology/Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen
- Research School of Behavioral and Cognitive Neurosciences, Graduate School of Medical Sciences, University of Groningen, Groningen, The Netherlands
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Velema MS, Canu L, Dekkers T, Hermus ARMM, Timmers HJLM, Schultze Kool LJ, Groenewoud HJMM, Jacobs C, Deinum J. Volumetric evaluation of CT images of adrenal glands in primary aldosteronism. J Endocrinol Invest 2021; 44:2359-2366. [PMID: 33666874 DOI: 10.1007/s40618-021-01540-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/20/2020] [Accepted: 02/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate whether adrenal volumetry provides better agreement with adrenal vein sampling (AVS) than conventional CT for subtyping PA. Furthermore, we evaluated whether the size of this contralateral adrenal was a prognostic factor for clinical outcome after unilateral adrenalectomy. METHODS We retrospectively analyzed volumes of both adrenal glands of the 180 CT-scans (88/180 with unilateral and 92/180 with bilateral disease) of the patients with PA included in the SPARTACUS trial of which 85 also had undergone an AVS. In addition, we examined CT-scans of 20 healthy individuals to compare adrenal volumes with published normal values. RESULTS Adrenal volume was higher for the left than the right adrenal (mean and SD: 6.49 ± 2.77 ml versus 5.25 ± 1.87 ml for the right adrenal; p < 0.001). Concordance between volumetry and AVS in subtyping was 58.8%, versus 51.8% between conventional CT results and AVS (p = NS). The volumes of the contralateral adrenals in the patients with unilateral disease (right 4.78 ± 1.37 ml; left 6.00 ± 2.73 ml) were higher than those of healthy controls reported in the literature (right 3.62 ± 1.23 ml p < 0.001; left 4.84 ± 1.67 ml p = 0.02). In a multivariable analysis the contralateral volume was not associated with biochemical or clinical success, nor with the defined daily doses of antihypertensive agents at 1 year follow-up. CONCLUSIONS Volumetry of the adrenal glands is not superior to current assessment of adrenal size by CT for subtyping patients with PA. Furthermore, in patients with unilateral disease the size of the contralateral adrenal is enlarged but its size is not associated with outcome.
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Affiliation(s)
- M S Velema
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - L Canu
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - T Dekkers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A R M M Hermus
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L J Schultze Kool
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H J M M Groenewoud
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C Jacobs
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Velema MS, Linssen EJM, Hermus ARMM, Groenewoud HJMM, van der Wilt GJ, van Herwaarden AE, Lenders JWM, Timmers HJLM, Deinum J. A prediction model for primary aldosteronism when the salt loading test is inconclusive. Endocr Connect 2018; 7:1308-1314. [PMID: 30352409 PMCID: PMC6240140 DOI: 10.1530/ec-18-0358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/04/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To develop a prediction model to confirm or exclude primary aldosteronism (PA) in patients with an inconclusive salt loading test (SLT). CONTEXT Diagnosis in patients with a suspicion of PA can be confirmed using an SLT. In case of inconclusive test results the decision about how to manage the patient is usually based on contextual clinical data. DESIGN We included a retrospective cohort of 276 patients in the final analysis. METHODS All patients underwent an SLT between 2005 and 2016 in our university medical center. The SLT was inconclusive (post-infusion aldosterone levels 140-280 pmol/L) in 115 patients. An expert panel then used contextual clinical data to diagnose PA in 45 of them. Together with 101 patients with a positive SLT this resulted in a total of 146 patients with PA. A total of 11 variables were used in a multivariable logistic regression analysis. We assessed internal validity by bootstrapping techniques. RESULTS The following variables were independently associated with PA: more intense potassium supplementation, lower plasma potassium concentration, lower plasma renin concentration before SLT and higher plasma aldosterone concentration after SLT. The resulting prediction model had a sensitivity of 84.4% and a specificity of 94.3% in patients with an inconclusive SLT. The positive and negative predictive values were 90.5 and 90.4%, respectively. CONCLUSIONS We developed a prediction model for the diagnosis of PA in patients with an inconclusive SLT that results in a diagnosis that was in high agreement with that of an expert panel.
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Affiliation(s)
- Marieke S Velema
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Correspondence should be addressed to M S Velema:
| | - Evie J M Linssen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ad R M M Hermus
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hans J M M Groenewoud
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert-Jan van der Wilt
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
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Wiegers EC, Rooijackers HM, Tack CJ, Groenewoud HJMM, Heerschap A, de Galan BE, van der Graaf M. Effect of Exercise-Induced Lactate Elevation on Brain Lactate Levels During Hypoglycemia in Patients With Type 1 Diabetes and Impaired Awareness of Hypoglycemia. Diabetes 2017; 66:3105-3110. [PMID: 28935628 DOI: 10.2337/db17-0794] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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] [Received: 07/06/2017] [Accepted: 09/15/2017] [Indexed: 11/13/2022]
Abstract
Since altered brain lactate handling has been implicated in the development of impaired awareness of hypoglycemia (IAH) in type 1 diabetes, the capacity to transport lactate into the brain during hypoglycemia may be relevant in its pathogenesis. High-intensity interval training (HIIT) increases plasma lactate levels. We compared the effect of HIIT-induced hyperlacticacidemia on brain lactate during hypoglycemia between 1) patients with type 1 diabetes and IAH, 2) patients with type 1 diabetes and normal awareness of hypoglycemia, and 3) healthy participants without diabetes (n = 6 per group). All participants underwent a hypoglycemic (2.8 mmol/L) clamp after performing a bout of HIIT on a cycle ergometer. Before HIIT (baseline) and during hypoglycemia, brain lactate levels were determined continuously with J-difference-editing 1H-MRS, and time curves were analyzed using nonlinear mixed-effects modeling. At the beginning of hypoglycemia (after HIIT), brain lactate levels were elevated in all groups but most pronounced in patients with IAH. During hypoglycemia, brain lactate decreased ∼30% below baseline in patients with IAH but returned to baseline levels and remained there in the other two groups. Our results support the concept of enhanced lactate transport as well as increased lactate oxidation in patients with type 1 diabetes and IAH.
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Affiliation(s)
- Evita C Wiegers
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hanne M Rooijackers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cees J Tack
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hans J M M Groenewoud
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Arend Heerschap
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bastiaan E de Galan
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marinette van der Graaf
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Pediatrics, Radboud University Medical Center, Nijmegen, the Netherlands
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Dekkers T, Prejbisz A, Kool LJS, Groenewoud HJMM, Velema M, Spiering W, Kołodziejczyk-Kruk S, Arntz M, Kądziela J, Langenhuijsen JF, Kerstens MN, van den Meiracker AH, van den Born BJ, Sweep FCGJ, Hermus ARMM, Januszewicz A, Ligthart-Naber AF, Makai P, van der Wilt GJ, Lenders JWM, Deinum J. Adrenal vein sampling versus CT scan to determine treatment in primary aldosteronism: an outcome-based randomised diagnostic trial. Lancet Diabetes Endocrinol 2016; 4:739-746. [PMID: 27325147 DOI: 10.1016/s2213-8587(16)30100-0] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [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] [Received: 04/18/2016] [Revised: 05/12/2016] [Accepted: 05/16/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND The distinction between unilateral aldosterone-producing adenoma or bilateral adrenal hyperplasia as causes of primary aldosteronism is usually made by adrenal CT or by adrenal vein sampling (AVS). Whether CT or AVS represents the best test for diagnosis remains unknown. We aimed to compare the outcome of CT-based management with AVS-based management for patients with primary aldosteronism. METHODS In a randomised controlled trial, we randomly assigned patients with aldosteronism to undergo either adrenal CT or AVS to determine the presence of aldosterone-producing adenoma (with subsequent treatment consisting of adrenalectomy) or bilateral adrenal hyperplasia (subsequent treatment with mineralocorticoid receptor antagonists). The primary endpoint was the intensity of drug treatment for obtaining target blood pressure after 1 year of follow-up, in the intention-to-diagnose population. Intensity of drug treatment was expressed as daily defined doses. Key secondary endpoints included biochemical outcome in patients who received adrenalectomy, health-related quality of life, cost-effectiveness, and adverse events. This trial is registered with ClinicalTrials.gov, number NCT01096654. FINDINGS We recruited 200 patients between July 6, 2010, and May 30, 2013. Of the 184 patients that completed follow-up, 92 received CT-based treatment (46 adrenalectomy and 46 mineralocorticoid receptor antagonist) and 92 received AVS-based treatment (46 adrenalectomy and 46 mineralocorticoid receptor antagonist). We found no differences in the intensity of antihypertensive medication required to control blood pressure between patients with CT-based treatment and those with AVS-based treatment (median daily defined doses 3·0 [IQR 1·0-5·0] vs 3·0 [1·1-5·9], p=0·52; median number of drugs 2 [IQR 1-3] vs 2 [1-3], p=0·87). Target blood pressure was reached in 39 (42%) patients and 41 (45%) patients, respectively (p=0·82). On secondary endpoints we found no differences in health-related quality of life (median RAND-36 physical scores 52·7 [IQR 43·9-56·8] vs 53·2 [44·0-56·8], p=0·83; RAND-36 mental scores 49·8 [43·1-54·6] vs 52·7 [44·9-55·5], p=0·17) for CT-based and AVS-based treatment. Biochemically, 37 (80%) of patients with CT-based adrenalectomy and 41 (89%) of those with AVS-based adrenalectomy had resolved hyperaldosteronism (p=0·25). A non-significant mean difference of 0·05 (95% CI -0·04 to 0·13) in quality-adjusted life-years (QALYs) was found to the advantage of the AVS group, associated with a significant increase in mean health-care costs of €2285 per patient (95% CI 1323-3248). At a willingness-to-pay value of €30 000 per QALY, the probability that AVS compared with CT constitutes an efficient use of health-care resources in the diagnostic work-up of patients with primary aldosteronism is less than 0·2. There was no difference in adverse events between groups (159 events of which nine were serious vs 187 events of which 12 were serious) for CT-based and AVS-based treatment. INTERPRETATION Treatment of primary aldosteronism based on CT or AVS did not show significant differences in intensity of antihypertensive medication or clinical benefits for patients after 1 year of follow-up. This finding challenges the current recommendation to perform AVS in all patients with primary aldosteronism. FUNDING Netherlands Organisation for Health Research and Development-Medical Sciences, Institute of Cardiology, Warsaw.
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Affiliation(s)
- Tanja Dekkers
- Department of Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Leo J Schultze Kool
- Department of Radiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hans J M M Groenewoud
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marieke Velema
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Mark Arntz
- Department of Radiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jacek Kądziela
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | | | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Anton H van den Meiracker
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Bert-Jan van den Born
- Department of Internal and Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ad R M M Hermus
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Alike F Ligthart-Naber
- Department of Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter Makai
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gert-Jan van der Wilt
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jacques W M Lenders
- Department of Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, Netherlands; Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Jaap Deinum
- Department of Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, Netherlands.
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