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Corticotropin Stimulation Test

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101. ACTHar in the Treatment of Lupus Nephritis

melanocortin receptors (MCRs). Specifically, ACTH binding to melanocortin 2 receptor subtype (MC2R) on the adrenal cortex stimulates the production of cortisol that reduces inflammation in the kidney. In addition to binding to melanocortin 1-5 receptor subtype (MC1-5R) and acting directly on kidney tissues, ACTH may bind to MCRs on various cell types, such as immune cells, and activate processes to protect the kidney. This study will evaluate the most effective dose of ACTHar gel in proliferative LN (Class (...) , oral, from Week 0-24 CellCept 2 grams daily, oral, from Week 25-144 Other Name: Mycophenolate Mofetil Drug: ACTHar gel Arm 1: 80 U biw, subcutaneous, for 3 months. Optionally additional 3 months of 80 U biw if a patient has partial response. Other Names: ACTHar H.P. ACTHar Gel Repository corticotropin Active Comparator: CellCept daily & ACTHar gel qod Patients will be treated with CellCept 3 grams daily for 3 months, and ACTHar gel 80 U qod for the first month and ACTHar gel 80 U biw

2014 Clinical Trials

102. Inhaled Corticosteroids and Secondary Adrenal Insufficiency (Full text)

between ICS and AI particularly in children and patients using high doses. However, there have also been reports of AI in adults as well as in patients using low to moderate doses of ICS. To conclude, we recommend screening for AI in select patient groups with an initial early morning serum cortisol. If results are abnormal, more definitive testing such as the low dose corticotropin stimulation test may be done to confirm the diagnosis.

2014 The open respiratory medicine journal PubMed abstract

103. Adrenal Disease and Pregnancy (Overview)

replacement. Patients with previously undiagnosed adrenocortical deficiency may present with an acute addisonian crisis during labor or postpartum. Fetal growth restriction Maternal cortisol deficiency has been suggested as a possible cause of fetal intrauterine growth restriction. Clinical suspicion should arise if fetal growth restriction is associated with abnormally low maternal blood pressure and an unusual increase in skin pigmentation due to maternal corticotropin and melanocyte-stimulating hormone (...) , and interpretation of suppression of 24-hour urine cortisol and plasma cortisol levels seems to yield reliable results. Corticotropin levels Once hypercortisolemia is established, corticotropin levels should be measured. For all forms of Cushing syndrome in pregnancy, corticotropin levels are normal or they are high secondary to placental corticotropin production or owing to placental corticotropin-releasing hormone–stimulated pituitary corticotropin production. Therefore, corticotropin levels are not useful

2014 eMedicine.com

104. Fibromyalgia (Overview)

-stimulating hormone level 25-hydroxy vitamin D level Vitamin B12 level Iron studies, including iron level, total iron binding capacity, percent saturation, and serum ferritin level Magnesium level Erythrocyte sedimentation rate Antipolymer antibody assay: May provide conclusive evidence for a subgroup of people with fibromyalgia; about 50% of fibromyalgia patients have antipolymer antibodies Patient self-report forms, clinical psychometric testing Self-report forms, for assessing patients’ pain, fatigue (...) be explained if platelet ATP levels are also low. ATP is necessary to move and then hold serotonin in platelets. More investigation into ATP and the link to serotonin is needed. Dysfunction of the hypothalamic-pituitary-adrenal axis Studies of the neuroendocrine aspects of fibromyalgia have found dysfunction of the HPA axis. [ ] The HPA axis is a critical component of the stress-adaptation response. The sequence of HPA action is that corticotropin-releasing hormone (CRH) from the hypothalamus stimulates

2014 eMedicine.com

105. Alpha2-Plasmin Inhibitor Deficiency (Overview)

noncoagulation proteins, such as complement, growth hormone, corticotropin, and glucagon, are substrates for plasmin. Therefore, the reasons for the bleeding disorder that develops due to the actions of excess unfettered and unneutralized plasmin are easily comprehended. Alpha 2-plasmin inhibitor (alpha 2-PI, a2-PI) belongs to the serpin family of inhibitors, is synthesized by the liver, and is present in plasma as a single-chain protein in approximately half the concentration of plasminogen. Two forms (...) Very few cases of inherited alpha 2-plasmin inhibitor deficiency (alpha 2-PI deficiency, a2-PI deficiency) have been reported; therefore, data do not exist to determine the true frequency. In the next several years, as widespread high-throughput genomic testing becomes commonplace, the frequency of genetic defects will be known, and the frequency of these rare disorders can then be determined. The frequency of acquired alpha 2-plasmin inhibitor deficiency (alpha 2-PI deficiency, a2-PI deficiency

2014 eMedicine.com

106. Hyperaldosteronism, Primary (Overview)

was described by Lifton’s group in 2011. [ ] Workup Screening (first-tier) tests for primary aldosteronism include the following: Serum potassium and bicarbonate levels Sodium and magnesium levels Plasma aldosterone/plasma renin activity ratio Confirmatory (second-tier) tests include the following: Serum aldosterone level 24-hour urinary aldosterone excretion test Salt-loading test Tests for determining the primary aldosteronism subtype (third-tier tests) include the following: Postural stimulation test (...) Furosemide (Lasix) stimulation test Diurnal rhythm of aldosterone The initial radiologic investigation in the workup of primary aldosteronism is high-resolution, thin-sliced (2-2.5 mm) adrenal computed tomography (CT) scanning with contrast. Other tests include the following: NP-59 iodo-methyl-norcholesterol scintigraphy: Although fairly difficult to set up and not routinely available, this test can be useful in select cases for distinguishing between adenomas and hyperplasia Adrenal venous sampling

2014 eMedicine.com

107. Anxiety Disorders (Overview)

response to psychologic or pharmacologic interventions. Previous Next: Pathophysiology In the central nervous system (CNS), the major mediators of the symptoms of anxiety disorders appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Other neurotransmitters and peptides, such as corticotropin-releasing factor, may be involved. Peripherally, the autonomic nervous system, especially the sympathetic nervous system, mediates many of the symptoms. [ ] Positron emission (...) , 22q, 4q31-q34, and probably 9q31 may be associated with the heritability of panic disorder phenotype. [ ] The cognitive theory regarding panic is that patients with panic disorder have a heightened sensitivity to internal autonomic cues (eg, tachycardia). Triggers of panic can include the following: Injury (eg, accidents, surgery) Illness Interpersonal conflict or loss Use of cannabis (can be associated with panic attacks, perhaps because of breath-holding) [ ] Use of stimulants, such as caffeine

2014 eMedicine.com

108. Carney Syndrome (Overview)

See for more detail. Diagnosis Laboratory studies used in the diagnosis of Carney complex include the following: Complete blood count (CBC) Glucose/electrolytes Erythrocyte sedimentation rate Thyroxine/thyroid-stimulating hormone Adrenocorticotropic hormone Growth hormone Twenty-four–hour urinary cortisol excretion test and dexamethasone stimulation test: To evaluate for primary pigmented nodular adrenocortical disease (PPNAD) as part of Carney complex [ ] Echocardiography is the investigation (...) . (See Pathophysiology and Etiology.) Endocrine overactivity is one of the characteristics of this syndrome. [ ] In fact, corticotropin hormone–independent due to primary pigmented nodular adrenocortical disease is an important characteristic of Carney complex. (See Workup and Treatment.) Patient education The family should be aware that this is an autosomal dominant disorder with a 50% chance that the offspring of an affected individual will have the disorder. Previous Next: Pathophysiology Carney

2014 eMedicine.com

109. Carney Complex (Overview)

See for more detail. Diagnosis Laboratory studies used in the diagnosis of Carney complex include the following: Complete blood count (CBC) Glucose/electrolytes Erythrocyte sedimentation rate Thyroxine/thyroid-stimulating hormone Adrenocorticotropic hormone Growth hormone Twenty-four–hour urinary cortisol excretion test and dexamethasone stimulation test: To evaluate for primary pigmented nodular adrenocortical disease (PPNAD) as part of Carney complex [ ] Echocardiography is the investigation (...) . (See Pathophysiology and Etiology.) Endocrine overactivity is one of the characteristics of this syndrome. [ ] In fact, corticotropin hormone–independent due to primary pigmented nodular adrenocortical disease is an important characteristic of Carney complex. (See Workup and Treatment.) Patient education The family should be aware that this is an autosomal dominant disorder with a 50% chance that the offspring of an affected individual will have the disorder. Previous Next: Pathophysiology Carney

2014 eMedicine.com

110. Tourette Syndrome and Other Tic Disorders (Overview)

The onset is before age 18 years The disturbance is not due to the direct physiologic effects of a substance (eg, stimulants) or a general medical condition (eg, Huntington disease or postviral encephalitis) Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder See for more detail. Management Treatments for tics that have demonstrated efficacy in replicated controlled trials include the following: Dopamine D2 receptor antagonist therapy Dopamine agonist (...) -depleting agents also improve tics, and in some patients, tics may be worsened by neuroleptic withdrawal or, possibly, stimulant use. However, other data do not support a simple hypothesis that dopamine function is hyperactive in individuals with TS. Tics are not abated with the subsequent development of Parkinson disease. [ ] However, in Parkinson disease, dopamine loss is most evident in posterior putamen, [ ] whereas caudate and ventral striatum are more implicated in TS. Furthermore, dopamine

2014 eMedicine.com

111. Conn Syndrome (Overview)

group in 2011. [ ] Workup Screening (first-tier) tests for primary aldosteronism include the following: Serum potassium and bicarbonate levels Sodium and magnesium levels Plasma aldosterone/plasma renin activity ratio Confirmatory (second-tier) tests include the following: Serum aldosterone level 24-hour urinary aldosterone excretion test Salt-loading test Tests for determining the primary aldosteronism subtype (third-tier tests) include the following: Postural stimulation test Furosemide (Lasix (...) ) stimulation test Diurnal rhythm of aldosterone The initial radiologic investigation in the workup of primary aldosteronism is high-resolution, thin-sliced (2-2.5 mm) adrenal computed tomography (CT) scanning with contrast. Other tests include the following: NP-59 iodo-methyl-norcholesterol scintigraphy: Although fairly difficult to set up and not routinely available, this test can be useful in select cases for distinguishing between adenomas and hyperplasia Adrenal venous sampling: Adrenal venous sampling

2014 eMedicine.com

112. Infertility, Male (Overview)

), pituitary gland, and testicles to secrete gonadotropin-releasing hormone (GnRH) in a pulsatile pattern approximately every 70-90 minutes. The half-life of GnRH is 2-5 minutes. Release of GnRH is stimulated by melatonin from the pineal gland and inhibited by testosterone, inhibin, corticotropin-releasing hormone, opiates, illness, and stress. GnRH travels down the portal system to the anterior pituitary, located on a stalk in the sella turcica, to stimulate the release of the gonadotropins, luteinizing (...) (normal, >40% of sperm having normal movement) Sperm morphology (sample lower limit for percentage of normal sperm is 4%) Signs of infection – An increased number of white blood cells (WBCs) in the semen may be observed in patients with infectious or inflammatory processes Other variables (eg, levels of zinc, citric acid, acid phosphatase, or alpha-glucosidase) Other laboratory tests that may be helpful include the following: Antisperm antibody test Hormonal analysis (FSH, LH, TSH, testosterone

2014 eMedicine.com

113. Hypopituitarism (Panhypopituitarism) (Overview)

of the pituitary gland can be modulated at many stages. The pituitary hormones, or target organ hormones, can influence the hypothalamus and the pituitary to decrease or increase pituitary hormone secretion through long and short feedback loops. Hormones secreted by the anterior pituitary include the following: Thyrotropin, or thyroid-stimulating hormone (TSH) Gonadotropins, or follicle-stimulating hormone (FSH) and luteinizing hormone (LH) Somatotropin or growth hormone (GH) Corticotropin (...) hormones are often involved, resulting in isolated or partial . [ ] (See Pathophysiology and Etiology.) Pituitary gland physiology The pituitary gland has 2 parts: the anterior pituitary (adenohypophysis) and the posterior pituitary (neurohypophysis). The anterior pituitary receives signals from the hypothalamus that either stimulate or inhibit secretion of pituitary hormones. These hormones are secreted directly into the systemic circulation, where they act on specific organs. The actions

2014 eMedicine.com

114. Luteinizing Hormone Deficiency (Overview)

Hormone Deficiency Updated: Nov 04, 2016 Author: Jennifer L Eaton, MD, MSCI, FACOG; Chief Editor: Richard Scott Lucidi, MD, FACOG Share Email Print Feedback Close Sections Sections Luteinizing Hormone Deficiency Overview Background An isolated luteinizing hormone (LH) deficiency is an uncommon condition. LH deficiency almost always occurs in conjunction with follicle-stimulating hormone (FSH) deficiency because LH and FSH are secreted by the same pituitary gonadotrope cells. LH deficiency can manifest (...) treatment. Structure and genetics LH is a glycoprotein dimer composed of 2 glycosylated noncovalently-linked subunits designated alpha and beta. The alpha subunit is composed of 92 amino acids and is encoded on the long arm of chromosome 6. The beta subunit is 121 amino acids and is encoded on the long arm of chromosome 19. The alpha subunit of LH is biologically identical to 3 other hormones: FSH, thyroid-stimulating hormone (TSH), and human chorionic gonadotropin (hCG). The beta subunit is unique

2014 eMedicine.com

115. Carney Syndrome (Follow-up)

See for more detail. Diagnosis Laboratory studies used in the diagnosis of Carney complex include the following: Complete blood count (CBC) Glucose/electrolytes Erythrocyte sedimentation rate Thyroxine/thyroid-stimulating hormone Adrenocorticotropic hormone Growth hormone Twenty-four–hour urinary cortisol excretion test and dexamethasone stimulation test: To evaluate for primary pigmented nodular adrenocortical disease (PPNAD) as part of Carney complex [ ] Echocardiography is the investigation (...) . (See Pathophysiology and Etiology.) Endocrine overactivity is one of the characteristics of this syndrome. [ ] In fact, corticotropin hormone–independent due to primary pigmented nodular adrenocortical disease is an important characteristic of Carney complex. (See Workup and Treatment.) Patient education The family should be aware that this is an autosomal dominant disorder with a 50% chance that the offspring of an affected individual will have the disorder. Previous Next: Pathophysiology Carney

2014 eMedicine.com

116. Pregnancy Diagnosis (Diagnosis)

feasible tests that use these hormones have been made available to aid in the diagnosis of pregnancy. Beta-human chorionic gonadotropin hCG is a glycoprotein similar in structure to follicle-stimulating hormone (FSH), luteinizing hormone (LH), and thyrotropin. hCG is composed of alpha and beta subunits. The alpha subunit of hCG is similar to the alpha subunit of FSH, LH, and thyrotropin. The free beta subunit of hCG differs from the others in that it has a 30–amino acid tailpiece at the COOH terminus (...) dilutions to look for linearity, and testing using a different method. The five potential sources of positive hCG results outside of pregnancy are described below: [ , ] Phantom hCG Caused by heterophilic antibodies that bind the capture and labeled antibodies together without hCG being present Antibody production results from exposure to animals used to produce antibodies used in assay Rule out with sensitive urine assay, as these antibodies do not cross into urine Pituitary hCG Stimulated

2014 eMedicine.com

117. Pituitary Microadenomas (Diagnosis)

in all cases, especially if early in the course, a serum insulinlike growth factor-1 (IGF-1) level is recommended in all cases. Magnetic resonance imaging (MRI) studies have shown sensitivity and specificity of about 90% for secretory tumors. Enhancement with gadolinium diethylenetriaminepentaacetic acid (DTPA) improves the detection rate. Sensitivity for detection of corticotropin-secreting adenomas is much less (60-75%); diagnosis may require specialized tests such as petrosal sinus sampling (...) , although a variety of other cystic, vascular, neoplastic, hyperplastic, or inflammatory processes may present in a similar manner. Workup and management In the absence of symptoms or signs suggesting excess of specific hormones, the most cost-effective strategy is simply measurement of the prolactin level. [ ] If clinical suspicion of Cushing syndrome, acromegaly, or other hormone excess exists, order appropriate tests. Because excess growth hormone secretion may not produce the clinical phenotype

2014 eMedicine.com

118. Pituitary Tumors (Diagnosis)

; this gene is known to regulate the cellular mitosis process and forced expression of this gene induces tumor formation in nude mice. PTTG-1 is overexpressed in pituitary tumors. [ ] Recent work suggests that pituitary tumorigenesis is more heterogenous than formerly thought. [ ] Nonfunctioning adenomas are associated with hypermethylation of p16 prolactinomas, and corticotropin-secreting tumors express galectin-3 (Gal-3), a gene involved in cell growth and apoptosis. Inhibition of Gal-3 may serve (...) and distant endocrine manifestations that can affect a variety of organ systems. These effects are due to lack or excess of a given stimulating hormone on the target organ. Pituitary adenomas, with a few exceptions, are not under the control of hypothalamic releasing factors. An explanation for the development of bitemporal visual-field defects in association with pituitary tumors has been a subject of renewed interest. In a recent study, comparative pressure gradients were measured between nasal crossing

2014 eMedicine.com

119. Pituitary Disease and Pregnancy (Diagnosis)

. The ACTH stimulation test cannot be used for at least 3 months, because the adrenal cortex needs time to atrophy and lose responsiveness to low-dose ACTH. In the 3-month postpartum period, -induced hypoglycemia or other stimulation tests, such as glucagon, would be needed for definitive diagnosis of ACTH (and GH) deficiency. Even if a clear temporal association exists with parturition, imaging with MRI (preferably) or CT scanning is indicated to exclude mass lesions. In long-standing Sheehan syndrome (...) are started on therapy for hyperprolactinemia, mechanical contraception can be advised for the first 2-3 cycles so that an intermenstrual period can be established. By doing this, the woman will know when she has missed a period when unprotected intercourse is resumed. As soon as this occurs, a pregnancy test can be obtained and dopamine agonist stopped. This approach limits dopamine agonist exposure to a maximum of 3-4 weeks. In practice, this delay is usually not done. appears to be safe in pregnancy

2014 eMedicine.com

120. Luteinizing Hormone Deficiency (Diagnosis)

Hormone Deficiency Updated: Nov 04, 2016 Author: Jennifer L Eaton, MD, MSCI, FACOG; Chief Editor: Richard Scott Lucidi, MD, FACOG Share Email Print Feedback Close Sections Sections Luteinizing Hormone Deficiency Overview Background An isolated luteinizing hormone (LH) deficiency is an uncommon condition. LH deficiency almost always occurs in conjunction with follicle-stimulating hormone (FSH) deficiency because LH and FSH are secreted by the same pituitary gonadotrope cells. LH deficiency can manifest (...) treatment. Structure and genetics LH is a glycoprotein dimer composed of 2 glycosylated noncovalently-linked subunits designated alpha and beta. The alpha subunit is composed of 92 amino acids and is encoded on the long arm of chromosome 6. The beta subunit is 121 amino acids and is encoded on the long arm of chromosome 19. The alpha subunit of LH is biologically identical to 3 other hormones: FSH, thyroid-stimulating hormone (TSH), and human chorionic gonadotropin (hCG). The beta subunit is unique

2014 eMedicine.com

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