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Lower adrenocortical and adrenomedullary responses to hypoglycemia in premenopausal women with systemic sclerosis. To evaluate function of the hypothalamic-pituitary-adrenal (HPA) axis, adrenomedullary hormonal system (AMHS), and sympathetic noradrenergic system (SNS) in premenopausal women with systemic sclerosis (SSc).Insulin-induced hypoglycemia (0.1 IU/kg) was performed in 17 longterm, glucocorticoid-naive SSc patients with low disease activity and in 18 healthy women matched for age (...) and body mass index (BMI). Concentrations of glucose, adrenocorticotrophic hormone (ACTH), cortisol, androstenedione (ASD), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), 17a-hydroxyprogesterone (17OHP), epinephrine (EPI), norepinephrine (NE), interleukin 1ss (IL-1ss), IL-6, and tumor necrosis factor-a (TNF-a) were analyzed in plasma.Basal plasma levels of cortisol, ASD, 17OHP, DHEAS, IL-1ss, IL-6, and TNF-a were not significantly different in SSc compared to controls. Patients
, IGFBP-3 values and DHEA:cortisol ratios were associated with weight- and body mass index-for-age z scores ([WAZ] P = 0.019, <.001 respectively, and [BMZ] P = 0.029, 0.038). DHEA concentration was associated with height-for-age z score (P = 0.049).In these HIV-infected children compared with their uninfected counterparts, IGFBP-3 concentration was different between groups. Infected children had multiple endocrine associations with growth and body composition not found in their uninfected peers. We (...) hypothesize that in HIV-infected children, growth hormone resistance and shunting of precursors from adrenal androgen to cortisol production contributes to altered body composition and stunting.
months of age.The prevalence of endocrinopathies was 71.7%: 64.1% of subjects had growth hormone (GH) axis abnormalities, 48.5% hyperprolactinemia, 34.9% hypothyroidism, 17.1% adrenal insufficiency, and 4.3% diabetes insipidus (DI). Endocrinopathies were not associated with ONH laterality, absence of the septum pellucidum, or pituitary abnormalities on neuroimaging. End height standard deviation score (SDS) was similar to start length SDS independent of GH surrogate status. A significant increase (...) in end weight SDS was found for the cohort (p < .001). A body mass index (BMI) >85th percentile was noted in 44.4% of the cohort and in 52.1% of subjects with GH axis abnormalities. Initial hyperprolactinemia was positively associated with increased end BMI SDS (p = .004).These prospective findings confirm the high prevalence of pituitary endocrinopathies in children with ONH reported in previous retrospective studies. Our data reveal that some of these children maintain normal height velocity
three, the neonatal mass screening showed moderately increased 17-OHP, and no skeletal lesion other than rigid second metacarpophalangeal joints was identified in early infancy. Thus, she was initially suspected as having 21-OHD and/or aromatase deficiency. Subsequently, endocrine studies including urine steroid hormone analysis were performed for the assessment of glucocorticoid treatment in case one and for the virilized genitalia in cases two and three, showing adrenal and/or gonadal dysfunction (...) Cytochrome P450 oxidoreductase deficiency in three patients initially regarded as having 21-hydroxylase deficiency and/or aromatase deficiency: diagnostic value of urine steroid hormone analysis. In this study, we report on three Japanese patients with cytochrome P450 oxidoreductase (POR) deficiency (PORD). Case one was a 46,XY patient who was found to have mildly increased 17alpha-hydroxyprogesterone (17-OHP) by the neonatal mass screening. There was no maternal virilization during pregnancy
1.69 (1.23-2.33), androstenedione 1.94 (1.40-2.69), testosterone 1.85 (1.33-2.57) and free testosterone 2.50 (1.76-3.55). For the oestrogens, relative risk estimates were: oestrone 2.07 (1.42-3.02), oestradiol 2.28 (1.61-3.23) and free oestradiol (odds ratios 2.13 (1.52-2.98)). Adjustments for body mass index or other potential confounding factors did not substantially alter any of these relative risk estimates. Our results have shown that, among postmenopausal women, not only elevated serum (...) oestrogens but also serum androgens are associated with increased breast cancer risk. Since DHEAS and androstenedione are largely of adrenal origin in postmenopausal women, our results indicated that elevated adrenal androgen synthesis is a risk factor for breast cancer. The results from this study caution against the use of DHEA(S), or other androgens, for postmenopausal androgen replacement therapy.
The effects of treatment with recombinant human growth hormone on body composition and metabolism in adults with growth hormone deficiency. In a double-blind, placebo-controlled trial, we studied the effects of six months of growth hormone replacement in 24 adults with growth hormone deficiency. Most of the patients had acquired growth hormone deficiency during adulthood as a consequence of treatment for pituitary tumors, and all were receiving appropriate thyroid, adrenal, and gonadal hormone (...) replacement. The daily dose of recombinant human growth hormone (rhGH) was 0.07 U per kilogram of body weight, given subcutaneously at bedtime. The mean (+/- SE) plasma concentration of insulin-like growth factor I increased from 0.41 +/- 0.05 to 1.53 +/- 0.16 U per liter during rhGH treatment. Treatment with rhGH had no effect on body weight. The mean lean body mass, however, increased by 5.5 +/- 1.1 kg (P less than 0.0001), and the fat mass decreased by 5.7 +/- 0.9 kg (P less than 0.0001) in the group
Effects of inhaled glucocorticoids on bone density in premenopausal women. Inhaled glucocorticoids are the most commonly used medications for the long-term treatment of patients with asthma. Whether long-term therapy with inhaled glucocorticoids reduces bone mass, as oral glucocorticoid therapy does, is controversial. In a three-year prospective study, we examined the relation between the dose of inhaled glucocorticoids and the rate of bone loss in premenopausal women with asthma.We studied 109 (...) the decline in bone density and the number of puffs per year of use. Serum and urinary markers of bone turnover or adrenal function did not predict the degree of bone loss.Inhaled glucocorticoids lead to a dose-related loss of bone at the hip in premenopausal women.
long-term renal dialysis, tuberous sclerosis, renal transplant recipients and acquired renal cystic disease. Presentation [ ] The use of ultrasound and CT scans has increased the detection of asymptomatic RCC. More than 50% of adult renal tumours are detected when using ultrasound to investigate nonspecific features. The classic triad of haematuria, loin pain and loin mass is not often seen now. Other presentations include fatigue, weight loss, macroscopic haematuria, palpable mass, varicocele (...) , bilateral ankle oedema, pyrexia of unknown origin and hypertension. There is often no abnormality on examination. 25-30% of patients present with symptoms of metastatic disease - eg, haemoptysis, bone pain or pathological fracture. Paraneoplastic symptoms (eg, neuromyopathy, anaemia, polycythaemia, amyloidosis, elevated ESR, hypercalcaemia and abnormal LFTs) are found in approximately 30% of patients. [ ] Spread Spread is into adjacent structures of the adrenal glands, liver, spleen, colon or pancreas
mass, varicocele, bilateral ankle oedema, pyrexia of unknown origin and hypertension. There is often no abnormality on examination. 25-30% of patients present with symptoms of metastatic disease - eg, haemoptysis, bone pain or pathological fracture. Paraneoplastic symptoms (eg, neuromyopathy, anaemia, polycythaemia, amyloidosis, elevated ESR, hypercalcaemia and abnormal LFTs) are found in approximately 30% of patients. [ ] Spread Spread is into adjacent structures of the adrenal glands, liver (...) risk factors include long-term renal dialysis, tuberous sclerosis, renal transplant recipients and acquired renal cystic disease. Presentation [ ] The use of ultrasound and CT scans has increased the detection of asymptomatic RCC. More than 50% of adult renal tumours are detected when using ultrasound to investigate nonspecific features. The classic triad of haematuria, loin pain and loin mass is not often seen now. Other presentations include fatigue, weight loss, macroscopic haematuria, palpable
unilateral, is the first obvious sign of puberty. Breast buds may initially be unilateral. Gradually the breast diameter increases and the areola darkens and becomes more prominent. In the UK, breast buds will have appeared in 50% of girls by the age of 11.3, with near-full development in 50% of girls by the age of 13.3. [ ] Pubic and axillary hair growth in girls is a sign of adrenal androgen secretion. It starts at about the time of apocrine gland sweat production and the common complaint of axillary (...) . Spermatozoa become present in early morning urine samples from a mean age of 13.4 (spermarche). Progressive signs of androgen excess without an increase in testicular volume should raise concern about precocious pseudopuberty (androgenic effect from another source such as congenital adrenal hyperplasia or testicular tumour). Penile and scrotal enlargement occur typically about a year after testicular enlargement is noticed. Signs of change in penis (growth), scrotum (reddening and thinning) and pubic hair
-esteem. [ ] Sleep apnoea. Clinical signs These include: The presence of hirsutism, (often on the upper lip, chin, around the nipples and in a line beneath the umbilicus). This occurs in 60% of women with PCOS. [ ] Male-pattern balding, alopecia. Obesity - this is common (usually central distribution). Acanthosis nigricans - may be present and is thought to be a sign of insulin resistance. Occasionally, clitoromegaly, increased muscle mass, deep voice (more usually, these are signs of more severe (...) gain or oligomenorrhoea as side-effects, for example). Late-onset . Androgen-secreting ovarian or adrenal tumours. Ovarian hyperthecosis. If there are signs of virilisation, rapidly progressing hirsutism or high total testosterone level then suspect one of the latter three. 17-hydroxyprogesterone, measured in the follicular phase, will be raised in CAH. Consider checking levels even where testosterone is not significantly raised in those with higher risk, such as Ashkenazi Jews or people
absorption of calcium. Adrenal gland and pancreas Cortisol levels increase in pregnancy, which favours lipogenesis and fat storage. Insulin response also increases so blood sugar should remain normal or low. Peripheral insulin resistance increases after early stages of pregnancy due to increased production of hormones such as cortisol, prolactin, progesterone and human placental lactogen. The combination of insulin resistance and relatively low glucose promotes the use of fat for energy, preserving (...) erythropoietin levels increase the total red cell mass by the end of the second trimester but haemoglobin concentrations never reach pre-pregnancy levels. Usually mean corpuscular volume (MCV) and mean corpuscular haemoglobin concentration (MCHC) are unaffected. A modest leukocytosis is observed. A normal pregnancy creates a demand for about 1000 mg of additional iron. This equates to 60 mg elemental iron or 300 mg ferrous sulfate per day. Serum iron falls during pregnancy whilst transferrin and total iron
in an adrenal gland. This may represent phaeochromocytoma, glucocorticoid excess or primary aldosteronism. The mass may even be irrelevant and misleading. Such findings are called 'incidentalomas'. If the clinical history or physical examination of a patient with unilateral incidentaloma suggests glucocorticoid, mineralocorticoid, adrenal sex hormone or catecholamine excess, which is confirmed biochemically, the treatment of choice is often adrenalectomy [ ] . In one study of 201 patients (...) may find one of our more useful. In this article In This Article Phaeochromocytoma In this article A phaeochromocytoma is a rare tumour that secretes catecholamines. It is derived from chromaffin cells, usually in the adrenal medulla; however, occasionally extra-adrenal phaeochromocytomas or paragangliomas occur [ ] . Many - but not all - authors define phaeochromocytoma as coming from the adrenal medulla and if the tumour is similar but located elsewhere, it is called a paraganglioma
testicular volume: Increase as with normal puberty in CPP and sometimes with testicular disorders. Volume remains prepubertal in many causes of peripheral precocious puberty, such as adrenal disorders. CNS examination - fundoscopy, cranial nerves. Testicular and pelvic examination for masses. Examination for specific causes - signs of hypothyroidism, skin lesions (MAS, neurofibromatosis). Investigations [ ] Investigations are used selectively after a thorough clinical assessment. Tests available (...) GnRH stimulation and levels of testosterone and estradiol are elevated whilst LH and FSH are suppressed. There is a flat GnRH response and no response to treatment with GnRH analogues. Causes include: . Tumours: HCG-secreting tumours in the liver (hepatomas, hepatoblastomas), choriocarcinomas (of gonads, pineal gland, mediastinum, etc) and adrenal tumours (rare). Ovarian tumours may cause either masculinisation or feminisation. Testicular Leydig-cell tumours may cause early virilisation in males
neuroimaging techniques have improved, pituitary tumours are more often diagnosed incidentally. About 16.7% of the general population show changes in the pituitary gland. [ ] Presentation Depends on the hormone secreted by the tumour as well as the pattern of growth of the tumour within the sella turcica. Local effects resulting from an expanding pituitary mass: An expanding mass within the pituitary fossa may give rise to headache, neuro-ophthalmological defects or facial pain according to the size (...) deterioration of vision is an immediate indication for surgery. Postoperative pituitary dysfunction may include adrenal insufficiency, diabetes insipidus, syndrome of inappropriate antidiuretic hormone, and cerebral salt wasting syndrome. Neurosurgical complications may include visual disturbance, cerebrospinal fluid leak, subdural haematoma, and epistaxis. [ ] Radiotherapy Radiotherapy is reserved for patients whose tumour has been incompletely resected or who remain hypersecretory after surgery
on CXR): Secondary malignancy. Arteriovenous malformation. Pulmonary hamartoma: Rare, benign tumour. CT scan shows lobulated mass with flecks of calcification. Often excised to exclude malignancy. Bronchial adenoma: Rare, slow-growing tumour. 90% are carcinoid tumours; 10% are cylindromas. Treatment is surgery. Abscesses. Granuloma - eg, tuberculosis. Encysted effusion (fluid, blood, pus). Cyst. Foreign body. Skin tumour (eg, seborrhoeic wart). Referral [ ] Refer urgently (to be seen within two weeks (...) [ ] : Cough Fatigue Shortness of breath Chest pain Weight loss Appetite loss Urgent CXR (to be performed within two weeks) should also be considered for patients aged over 40 years with any of the following: Persistent or recurrent chest infection. Finger clubbing. Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy. Chest signs consistent with lung cancer. Thrombocytosis. Contrast-enhanced chest CT scan: To stage the tumour. The scan should also include the liver and adrenal glands
is gradual in onset and there may be painless haematuria and possibly a mass. The most common forms are clear cell carcinoma in adults and Wilms' tumour in children. Pelvi-ureteric junction (PUJ) obstruction : It usually follows drinking large amounts of fluid, as the diuresis causes distension of the renal pelvis and colic. Renal infarction : This is frequently misdiagnosed, initially as acute renal colic, pyelonephritis, or acute abdomen. [ ] Acute renal infarction affects both kidneys and both sexes (...) . Berger's disease. Acute nephritis. Polycystic kidney disease. Cholecystitis. Adrenal tumours (and haemorrhage). Colon cancer. Splenic infarction. Beware that patients can present with a fictitious story suggestive of renal colic as a ruse to obtain an injection of pethidine. The patient will usually be insistent that only pethidine works and will be very dissatisfied if given intramuscular diclofenac instead. Investigations Urine examination Microscopy may show haematuria with stones, pyuria
by alternative practitioners if for no other reason than to protect their patients. It must also be acknowledged that within the spectrum of non-mainstream medical tenets, a kernel of truth can sometimes be found, which eventually becomes subsumed into mainstream medicine. Acupuncture is a case in point. The following is a list of common therapies and theories which patients seeking an alternative approach may encounter. Adrenal fatigue [ ] Adrenal fatigue is a term used by alternative practitioners (...) to describe a condition in which long-term mental, emotional or physical stress over-stimulates the adrenal gland, resulting in an eventual reduction in activity. Symptoms include tiredness, trouble falling asleep at night or waking up in the morning, salt and sugar craving and needing stimulants like caffeine to get through the day. The condition needs to be differentiated from which is a recognised medical disease associated with a number of demonstrable laboratory abnormalities. It is important
. Alveolus. Hard palate. Anterior two thirds of the tongue. Floor of the mouth. Mucosal surface of the lip. Oral mucosal melanomas may occur, particularly affecting the palate, alveolar gingivae and lips. Virtually any malignancy can metastasise to the oral cavity but carcinomas of the breast, lung, kidney and adrenal gland are the most common. Early detection and treatment are critical, as they increase survival chances considerably, allow for simpler treatment and result in a better quality of life (...) differentiated. Because of the difficulties with direct visualisation, they may extend into the oral tongue or have clinical lymph metastases before the diagnosis is established. Tonsillar cancer More than 70% of tonsillar cancers are SCC. Most of the others are lymphomas. Metastases to the palatine tonsils are rare but there have been reports of secondaries from breast, lung, renal, pancreatic and colorectal malignancies. Patients with tonsillar carcinomas may present with a neck mass, usually
improved with earlier diagnosis and better management. Cushing's disease is the name given to a pituitary adenoma that secretes ACTH, also called a corticotrophinoma. Such patients have high levels of cortisol which suppress the production of corticotrophin-releasing hormone (CRH) from the paraventricular nucleus of the hypothalamus. The normal cortisol feedback mechanism of the hypothalamo-pituitary-adrenal (HPA) axis is thus disturbed, with loss of circadian rhythm, and excess cortisol production (...) of erectile dysfunction. Testicular pain. During embryogenesis, adrenal cortical cells may migrate along the line of gonadal descent and may even be sequestered in the hilum of the testes, producing adrenal rest tissue. In Nelson's syndrome, this adrenal rest tissue may become stimulated and, if in the testes, it can cause testicular pain and oligospermia. Rarely, the adrenal rest tissue can produce enough cortisol to produce normal levels or even cause recurrence of Cushing's syndrome. The tumour may