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Corticotropin Stimulation Test

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101. Conn Syndrome (Follow-up)

benefit. [ ] Next: Pharmacologic Therapy Calcium channel blockers By inhibiting the intracellular calcium flux in the adrenocortical cells, the dihydropyridine calcium channel blockers reduce the production of aldosterone in response to a variety of stimulants, including potassium, corticotropin, and angiotensin-II. Nifedipine is the most extensively studied of these medications; however, although nifedipine causes a significant improvement in patients with hypertension (HTN), it does not address (...) following chronic corticotropin suppression by exogenous steroids. However, if significant develops, potassium supplements should be discontinued, and the patient can be started on furosemide at doses of 80-160 mg daily. Previous Next: Diet A low-salt diet, although helpful in achieving blood pressure control in primary aldosteronism, may be associated with false-negative results on biochemical testing. A high-salt diet makes the achievement of blood pressure control more difficult and may cause false

2014 eMedicine.com

102. 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

103. Fibromyalgia (Diagnosis)

-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

104. Carney Complex (Diagnosis)

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

105. Carney Syndrome (Diagnosis)

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

106. Alpha2-Plasmin Inhibitor Deficiency (Diagnosis)

. In addition, other 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 (...) United States 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

2014 eMedicine.com

107. Anxiety Disorders (Diagnosis)

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. Conn Syndrome (Diagnosis)

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

109. Pregnancy Diagnosis (Treatment)

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

110. Osteoporosis in Solid Organ Transplantation (Treatment)

are indicated in the pretransplant evaluation of all patients awaiting solid organs [ , ] : Serum calcium level Phosphorus level Bicarbonate level Alkaline phosphatase level BUN/creatinine levels Intact PTH assay, to assess for hyperparathyroidism (primary or secondary) 25-Hydroxyvitamin D value to assess total body vitamin D stores Thyroid function tests (eg, thyroid-stimulating hormone, free levothyroxine) Testosterone level (males only), to ensure eugonadism Estradiol and FSH levels (in females (...) hormone, thereby decreasing gonadal hormone production; may also directly decrease gonadal hormone production Suppress corticotropin, thereby suppressing the adrenal production of androstenedione, a substrate for both testosterone and estrone production Decrease osteoblast-mediated bone formation Increase bone resorption Glucocorticoids result in a disproportionate loss of cancellous or trabecular bone, possibly because trabecular bone has an inherently greater rate of turnover than cortical bone

2014 eMedicine.com

111. Osteoporosis (Secondary) (Treatment)

and patients" can lead to increased bone mineral density (BMD) testing and greater use of osteoporosis medications. [ ] In addition, a physician reminder in conjunction with a patient risk assessment strategy apparently can result in a reduction in patient fractures and an increase in osteoporosis therapy. The authors concluded that multicomponent tools aimed at doctors and patients may support clinical decision making in the management of osteoporosis. A 2009 study indicated that the use of a case manager (...) modalities such as moist hot packs and transcutaneous electrical nerve stimulation should also be considered. During this period, monitoring the patient carefully for signs of constipation, urinary retention, and respiratory depression, which can occur with the use of narcotic analgesics, is essential. A comfortable mechanical support for the spine and, in some cases, a thoracic orthosis may need to be prescribed. The primary reason for the application of a thoracic orthosis is to limit motion

2014 eMedicine.com

112. Osteoporosis (Primary) (Treatment)

and patients" can lead to increased bone mineral density (BMD) testing and greater use of osteoporosis medications. [ ] In addition, a physician reminder in conjunction with a patient risk assessment strategy apparently can result in a reduction in patient fractures and an increase in osteoporosis therapy. The authors concluded that multicomponent tools aimed at doctors and patients may support clinical decision making in the management of osteoporosis. A 2009 study indicated that the use of a case manager (...) modalities such as moist hot packs and transcutaneous electrical nerve stimulation should also be considered. During this period, monitoring the patient carefully for signs of constipation, urinary retention, and respiratory depression, which can occur with the use of narcotic analgesics, is essential. A comfortable mechanical support for the spine and, in some cases, a thoracic orthosis may need to be prescribed. The primary reason for the application of a thoracic orthosis is to limit motion

2014 eMedicine.com

113. Oral Manifestations of Systemic Diseases (Treatment)

loss and loosening of the teeth, as well as mucosal scarring. [ ] Although lifelong morbidity is a feature of cyclic neutropenia, mortality due to severe infections is relatively uncommon. [ ] Granulocyte colony-stimulating factor (G-CSF) can be used to improve neutrophil counts and reduce morbidity. [ ] Patients should also be diligent about oral hygiene to reduce the risk of intraoral infection. Langerhans cell histiocytosis Langerhans cell histiocytosis (LCH), formerly known as histiocytosis X (...) (or >2-fold the reference range if tested by enzyme-linked immunosorbent assay [ELISA]) Anti-Sm: Presence of antibody to Sm nuclear antigen Antiphospholipid antibody positivity as determined by any of the following: Positive test result for lupus anticoagulant False-positive test result for rapid plasma reagin Medium- or high-titer anticardiolipin antibody level (IgA, IgG, or IgM) Positive test result for anti–β 2 -glycoprotein I (IgA, IgG, or IgM) Low complement Low C3 Low C4 Low CH50 Direct Coombs

2014 eMedicine.com

114. Primary Insomnia (Treatment)

insomnia Idiopathic insomnia Paradoxical insomnia [ , ] Next: Treatment Goals and Considerations The pathophysiology of primary insomnia is not well understood, and essential features assist in diagnosis. The focus of management is on symptoms. [ ] However, findings have strengthened the evidence that primary insomnia may be linked with mood disorders and is associated with hypothalamic-pituitary-adrenal (HPA) axis overactivity and excess secretion of corticotropin-releasing factor (CRF (...) as well. Previous Next: Differentials in Primary Insomnia The exclusion of common causes of insomnia is required to make the diagnosis of primary insomnia. Medical causes of insomnia include the following: Chronic pain, especially neuropathic pain Primary sleep disorders (eg, sleep apnea, periodic limb movements, restless legs syndrome) Dyspnea from any cause Pregnancy Drug use or withdrawal (eg, selective serotonin reuptake inhibitors, stimulants, antihistamines, caffeine, diet pills, herbal

2014 eMedicine.com

115. Oral Malignant Melanoma (Treatment)

cavity. They can be extensive in Peutz-Jeghers syndrome and are perioral or intraoral. In Addisonian pigmentation and pigmentation caused by certain medications, the etiology involves the activity of melanocyte-stimulating hormone (MSH). Bronzing associated with adrenal insufficiency is diffuse and commonly uniform. When the adrenal cortex does not respond to pituitary-released corticotropin, the continued release depletes corticotropin. A precursor protein to corticotropin and MSH is released (pro (...) , and alarming in appearance. Blood and melanin coloration Coloration imparted by blood can result from the pooling of red blood cells (RBCs) in vessels (eg, hyperemia, sludging, presence of a thrombus), increased vascularity, or extravasation after an injury. The red, blue, or purple color due to intravascular blood can be blanched during diascopy, in which pressure is placed on the mucosa by using a glass slide or a test tube. This examination can be used to identify telangiectasias, varicosities

2014 eMedicine.com

116. Osteoporosis (Treatment)

and patients" can lead to increased bone mineral density (BMD) testing and greater use of osteoporosis medications. [ ] In addition, a physician reminder in conjunction with a patient risk assessment strategy apparently can result in a reduction in patient fractures and an increase in osteoporosis therapy. The authors concluded that multicomponent tools aimed at doctors and patients may support clinical decision making in the management of osteoporosis. A 2009 study indicated that the use of a case manager (...) modalities such as moist hot packs and transcutaneous electrical nerve stimulation should also be considered. During this period, monitoring the patient carefully for signs of constipation, urinary retention, and respiratory depression, which can occur with the use of narcotic analgesics, is essential. A comfortable mechanical support for the spine and, in some cases, a thoracic orthosis may need to be prescribed. The primary reason for the application of a thoracic orthosis is to limit motion

2014 eMedicine.com

117. Shock, Distributive (Treatment)

patients receiving hydrocortisone had an earlier reversal of shock. Also in contrast to prior work, this study did not find that a corticotropin stimulation test predicted response to hydrocortisone. Additional studies are required to address these discrepancies. The SSC recommendations acknowledge this controversy and support giving hydrocortisone only to hypotensive patients poorly responsive to fluid resuscitation and vasopressors. Given findings that suggest the adrenocorticotropic hormone (ACTH (...) ) stimulation test does not predict response to steroids, this test is no longer recommended. Hydrocortisone, rather than dexamethasone or fludrocortisone, is the steroid of choice; it is not yet clear if adding fludrocortisone to hydrocortisone provides added benefit. [ ] Previous Next: Glucose Protocol-driven management of glucose (target < 150-180 mg/dL) is recommended, with monitoring every 1-2 hours until glucose levels are stable and then every 4 hours thereafter. This SSC recommendation is based

2014 eMedicine.com

118. Conn Syndrome (Treatment)

benefit. [ ] Next: Pharmacologic Therapy Calcium channel blockers By inhibiting the intracellular calcium flux in the adrenocortical cells, the dihydropyridine calcium channel blockers reduce the production of aldosterone in response to a variety of stimulants, including potassium, corticotropin, and angiotensin-II. Nifedipine is the most extensively studied of these medications; however, although nifedipine causes a significant improvement in patients with hypertension (HTN), it does not address (...) following chronic corticotropin suppression by exogenous steroids. However, if significant develops, potassium supplements should be discontinued, and the patient can be started on furosemide at doses of 80-160 mg daily. Previous Next: Diet A low-salt diet, although helpful in achieving blood pressure control in primary aldosteronism, may be associated with false-negative results on biochemical testing. A high-salt diet makes the achievement of blood pressure control more difficult and may cause false

2014 eMedicine.com

119. Carney Syndrome (Treatment)

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

120. Hyperaldosteronism, Primary (Treatment)

benefit. [ ] Next: Pharmacologic Therapy Calcium channel blockers By inhibiting the intracellular calcium flux in the adrenocortical cells, the dihydropyridine calcium channel blockers reduce the production of aldosterone in response to a variety of stimulants, including potassium, corticotropin, and angiotensin-II. Nifedipine is the most extensively studied of these medications; however, although nifedipine causes a significant improvement in patients with hypertension (HTN), it does not address (...) following chronic corticotropin suppression by exogenous steroids. However, if significant develops, potassium supplements should be discontinued, and the patient can be started on furosemide at doses of 80-160 mg daily. Previous Next: Diet A low-salt diet, although helpful in achieving blood pressure control in primary aldosteronism, may be associated with false-negative results on biochemical testing. A high-salt diet makes the achievement of blood pressure control more difficult and may cause false

2014 eMedicine.com

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