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Corticotropin Stimulation Test

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141. Osteoporosis (Primary) (Overview)

difficulties may be evident, especially in patients with an altered center of gravity from severe kyphosis. [ ] Patients may have difficulty performing tandem gait and performing single limb stance. See for more detail. Diagnosis Baseline laboratory studies include the following: Complete blood count: May reveal anemia Serum chemistry levels: Usually normal in persons with primary osteoporosis Liver function tests Thyroid-stimulating hormone level: Thyroid dysfunction has been associated with osteoporosis (...) rotation) hip joint test Decreased weight-bearing on the fractured side or an antalgic gait pattern Patients with Colles fractures may have the following: Pain on movement of the wrist Dinner fork (bayonet) deformity Patients with pubic and sacral fractures may have the following: Marked pain with ambulation Tenderness to palpation, percussion, or both With sacral fractures, pain with physical examination techniques used to assess the sacroiliac joint (eg, FABER, Gaenslen, or squish test) Balance

2014 eMedicine.com

142. Osteoporosis (Secondary) (Overview)

difficulties may be evident, especially in patients with an altered center of gravity from severe kyphosis. [ ] Patients may have difficulty performing tandem gait and performing single limb stance. See for more detail. Diagnosis Baseline laboratory studies include the following: Complete blood count: May reveal anemia Serum chemistry levels: Usually normal in persons with primary osteoporosis Liver function tests Thyroid-stimulating hormone level: Thyroid dysfunction has been associated with osteoporosis (...) rotation) hip joint test Decreased weight-bearing on the fractured side or an antalgic gait pattern Patients with Colles fractures may have the following: Pain on movement of the wrist Dinner fork (bayonet) deformity Patients with pubic and sacral fractures may have the following: Marked pain with ambulation Tenderness to palpation, percussion, or both With sacral fractures, pain with physical examination techniques used to assess the sacroiliac joint (eg, FABER, Gaenslen, or squish test) Balance

2014 eMedicine.com

143. Oral Manifestations of Systemic Diseases (Overview)

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

144. Oral Malignant Melanoma (Overview)

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

145. Pituitary Microadenomas (Overview)

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

146. Pituitary Tumors (Overview)

; 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

147. Epileptic and Epileptiform Encephalopathies (Treatment)

epilepticus or worsen cognitive function. Additionally, adrenocorticotropic hormone (ACTH) or corticosteroids may be used, usually after standard AEDs have failed. A ketogenic diet and intravenous immunoglobulin (IVIG) may also be helpful. Vagus nerve stimulation and epilepsy surgery may be appropriate in select cases. The degree of correlation between EEG abnormalities and neuropsychological deficits requires better description in most of these syndromes. However, often a goal of treatment is to improve (...) , ACTH and vigabatrin are usually used in practice. There is no consensus on ACTH dosing for infants. In infantile spasms, a prospective single-blind study showed no difference in the effectiveness of high-dose, long-duration corticotropin (150 U/m 2 /d for 3 wk then taper over 9 wk) versus low-dose, short-duration corticotropin (20-30 U/d for 2-6 wk then taper over 1 wk) with respect to spasm cessation and improvement in patient's EEG; hypertension was more common with larger doses. Corticosteroids

2014 eMedicine.com

148. Pregnancy Diagnosis (Follow-up)

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

149. Pituitary Disease and Pregnancy (Follow-up)

. 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

150. 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

151. Primary Insomnia (Follow-up)

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

152. Oral Manifestations of Systemic Diseases (Follow-up)

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

153. Oral Malignant Melanoma (Follow-up)

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

154. Osteoporosis (Follow-up)

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

155. Osteoporosis (Primary) (Follow-up)

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

156. Osteoporosis in Solid Organ Transplantation (Follow-up)

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

157. Osteoporosis (Secondary) (Follow-up)

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

158. Pseudo-Cushing Syndrome (Follow-up)

cortisol with an automated immunoassay system. Clinical Chemistry & Laboratory Medicine . 2006. 44(12):1441-5. . Alwani RA, Schmit Jongbloed LW, de Jong FH, van der Lely AJ, de Herder WW, Feelders RA. Differentiating between Cushing's disease and pseudo-Cushing's syndrome: comparison of four tests. Eur J Endocrinol . March/2014. 170(4):477-86. . Yanovski JA, Cutler GB Jr, Chrousos GP, Nieman LK. Corticotropin-releasing hormone stimulation following low-dose dexamethasone administration. A new test (...) cortisol concentrations. [ ] PCS can occur at any age; it can develop in infants exposed to alcohol in breast milk. [ ] Next: Causes and Complications Etiology The mechanism behind PCS is unclear. Most evidence suggests central stimulation of a corticotropin-releasing hormone (CRH), either at the hypothalamic or suprahypothalamic level. [ , ] Rats given 15% alcohol for 3 months showed a greater number of corticotropin-producing cells with increased secretory activity. [ ] A two-hit hypothesis has been

2014 eMedicine.com

159. Epileptic and Epileptiform Encephalopathies (Follow-up)

epilepticus or worsen cognitive function. Additionally, adrenocorticotropic hormone (ACTH) or corticosteroids may be used, usually after standard AEDs have failed. A ketogenic diet and intravenous immunoglobulin (IVIG) may also be helpful. Vagus nerve stimulation and epilepsy surgery may be appropriate in select cases. The degree of correlation between EEG abnormalities and neuropsychological deficits requires better description in most of these syndromes. However, often a goal of treatment is to improve (...) , ACTH and vigabatrin are usually used in practice. There is no consensus on ACTH dosing for infants. In infantile spasms, a prospective single-blind study showed no difference in the effectiveness of high-dose, long-duration corticotropin (150 U/m 2 /d for 3 wk then taper over 9 wk) versus low-dose, short-duration corticotropin (20-30 U/d for 2-6 wk then taper over 1 wk) with respect to spasm cessation and improvement in patient's EEG; hypertension was more common with larger doses. Corticosteroids

2014 eMedicine.com

160. Tourette Syndrome and Other Tic Disorders (Follow-up)

dyskinesia. Dopamine agonist therapy Paradoxically, several mixed dopamine agonists have also been proven effective in reducing tic frequency. [ , , ] To date, they have been tested exclusively in relatively low doses, partly because of a theory that, at these doses, they must antagonize dopamine function by selective action at presynaptic receptors. Accumulating evidence suggests that this rationale is faulty, however, and trials with higher doses may be expected. Habit reversal therapy Five RCTs have (...) demonstrated the efficacy of a specific form of behavior therapy for tics. [ , , , , , ] The originally tested treatment consisted of a package of interventions called habit reversal therapy, [ ] which comprises monitoring, relaxation, and other nonspecific elements of behavior therapy. The most important element is application of a competing response whenever the patient notices either a tic or the urge to tic. Initially, heavy effort on the part of the patient may be needed. However, in all 4 reported

2014 eMedicine.com

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