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Cushing Response

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181. Testosterone Testing - Protocol

for the investigation and diagnosis of female hyperandrogenism is beyond the scope of this document. Indications for urgent or non-urgent referral are outlined in Table 2 below. Monitoring Response to Treatment in Women Women receiving treatment for hyperandrogenism: Response to treatment of hyperandrogenism in women is clinical. Therefore, testing serum total testosterone and cBAT in patients treated for hyperandrogenism is not recommended unless a concrete cause has been identified, such as non-classical (...) . Men Women , Confirmed or suspected: Hypothalamic/pituitary tumour* Hyperprolactinemia* Hemochromatosis Idiopathic hypogonadotropic hypogonadism Cryptorchidism, anorchia Genetic conditions including Klinefelter syndrome, Kallmann syndrome, myotonic dystrophy Male factor infertility Confirmed or suspected: Rapid virilisation/rapid hair loss* Symptoms consistent androgen-secreting tumour of adrenal or ovarian origin* Cushing syndrome* Acromegaly* Congenital adrenal hyperplasia (CAH) Polycystic ovary

2019 Clinical Practice Guidelines and Protocols in British Columbia

182. Adrenal suppression

endogenous glucocorticoid excess (e.g., Cushing's syndrome after treatment). Even locally administered glucocorticoids may result in adrenal suppression. The adrenocorticotropic hormone stimulation test is generally the most useful test to detect adrenal suppression. Treatment consists of augmented corticosteroid therapy plus supportive care for any intercurrent stress or overt signs of adrenal insufficiency. Preventive measures include minimising corticosteroid dose and duration when possible (...) responses to exogenous corticotropin-releasing hormone. N Engl J Med. 1992 Jan 23;326(4):226-30. http://www.nejm.org/doi/full/10.1056/NEJM199201233260403#t=article http://www.ncbi.nlm.nih.gov/pubmed/1309389?tool=bestpractice.com History and exam presence of risk factors sudden cessation or rapid tapering of glucocorticoids hx of weight gain and increased appetite hx of depression, agitation, or sleep disorders hx of easy bruising fatigue, anorexia, or weight loss nausea or vomiting dizziness

2018 BMJ Best Practice

183. Assessment of hirsutism

=bestpractice.com Hair response to androgens varies from person to person and includes increase in follicle size, fibre diameter, and the amount of time spent in anagen (the growth-cycle phase). Rosenfield RL. Clinical practice. Hirsutism. N Engl J Med. 2005 Dec 15;353(24):2578-88. http://www.ncbi.nlm.nih.gov/pubmed/16354894?tool=bestpractice.com Messenger AG. The control of hair growth: an overview. J Invest Dermatol. 1993 Jul;101(suppl 1):4S-9S. http://www.ncbi.nlm.nih.gov/pubmed/8326154?tool=bestpractice.com (...) , Bartolucci AA, et al. Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. J Clin Endocrinol Metab. 2006 Apr;91(4):1345-50. http://jcem.endojournals.org/cgi/content/full/91/4/1345 http://www.ncbi.nlm.nih.gov/pubmed/16449347?tool=bestpractice.com Differentials Polycystic ovary syndrome Idiopathic hirsutism Hyperprolactinaemia Non-classic congenital adrenal hyperplasia Cushing's syndrome (benign) Androgenic medications Androgen

2018 BMJ Best Practice

184. Overview of brain tumours

, is the most common cause of Cushing's syndrome and is responsible for the majority of cases. Diagnosis is by demonstration of unsuppressed ACTH and subsequent cranial MRI. First-line therapy is generally transsphenoidal surgical resection. Benign prolactin-expressing and secreting pituitary adenoma. It is more frequent in women, mainly during the childbearing years. Gillam MP, Molitch ME, Lombardi G, et al. Advances in the treatment of prolactinomas. Endocr Rev. 2006;27:485-534. http (...) . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697616/?tool=pubmed http://www.ncbi.nlm.nih.gov/pubmed/18226732?tool=bestpractice.com Espinosa de los Monteros AL, Carrasco CA, Albarrán AA, et al. The role of primary pharmacological therapy in acromegaly. Pituitary. 2014;17(suppl 1):4-10. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3906545/ http://www.ncbi.nlm.nih.gov/pubmed/24166706?tool=bestpractice.com Cushing's disease, which is hypercortisolism caused by an ACTH-secreting pituitary adenoma

2018 BMJ Best Practice

185. Overview of brain tumours

, is the most common cause of Cushing's syndrome and is responsible for the majority of cases. Diagnosis is by demonstration of unsuppressed ACTH and subsequent cranial MRI. First-line therapy is generally transsphenoidal surgical resection. Benign prolactin-expressing and secreting pituitary adenoma. It is more frequent in women, mainly during the childbearing years. Gillam MP, Molitch ME, Lombardi G, et al. Advances in the treatment of prolactinomas. Endocr Rev. 2006;27:485-534. http (...) . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697616/?tool=pubmed http://www.ncbi.nlm.nih.gov/pubmed/18226732?tool=bestpractice.com Espinosa de los Monteros AL, Carrasco CA, Albarrán AA, et al. The role of primary pharmacological therapy in acromegaly. Pituitary. 2014;17(suppl 1):4-10. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3906545/ http://www.ncbi.nlm.nih.gov/pubmed/24166706?tool=bestpractice.com Cushing's disease, which is hypercortisolism caused by an ACTH-secreting pituitary adenoma

2018 BMJ Best Practice

186. Assessment of hirsutism

=bestpractice.com Hair response to androgens varies from person to person and includes increase in follicle size, fibre diameter, and the amount of time spent in anagen (the growth-cycle phase). Rosenfield RL. Clinical practice. Hirsutism. N Engl J Med. 2005 Dec 15;353(24):2578-88. http://www.ncbi.nlm.nih.gov/pubmed/16354894?tool=bestpractice.com Messenger AG. The control of hair growth: an overview. J Invest Dermatol. 1993 Jul;101(suppl 1):4S-9S. http://www.ncbi.nlm.nih.gov/pubmed/8326154?tool=bestpractice.com (...) , Bartolucci AA, et al. Degree of facial and body terminal hair growth in unselected black and white women: toward a populational definition of hirsutism. J Clin Endocrinol Metab. 2006 Apr;91(4):1345-50. http://jcem.endojournals.org/cgi/content/full/91/4/1345 http://www.ncbi.nlm.nih.gov/pubmed/16449347?tool=bestpractice.com Differentials Polycystic ovary syndrome Idiopathic hirsutism Hyperprolactinaemia Non-classic congenital adrenal hyperplasia Cushing's syndrome (benign) Androgenic medications Androgen

2018 BMJ Best Practice

187. Assessment of hypokalaemia

. Differentials Vomiting Severe diarrhoea Laxative and bowel cleansing agent use Bulimia nervosa Anorexia nervosa Drug-induced Alcoholism Diabetic ketoacidosis Non-ketotic hyperglycaemia Renal tubular acidosis (RTA) Exercising in a hot climate Stress response in critical illness Villous adenoma VIPoma Ileal loop/conduit with ureteric implants Dialysis or plasmapheresis Primary aldosteronism Apparent mineralocorticoid excess Cushing's syndrome Hypomagnesaemia Hypokalaemic periodic paralysis Central diabetes

2018 BMJ Best Practice

188. Assessment of hypernatraemia

of osmotic equilibrium, intracellular fluid (ICF) becomes volume contracted. The appropriate responses are increased water intake stimulated by thirst, and the excretion of the minimal amount of maximally concentrated urine. Infants and adults with cognitive impairment are most commonly affected because of their inability to express thirst and limited access to water. Hypernatraemia is often the result of several disease processes, and the underlying cause needs to be elicited to correct the sodium (...) is diagnosed in males and females in equal numbers. Differentials Central diabetes insipidus Hyperosmolar hyperglycaemic state (HHS) Nephrogenic diabetes insipidus Severe diarrhoea Vomiting Limited access to water Primary hypodipsia Cushing's syndrome Primary aldosteronism Post-obstructive diuresis Laxative and bowel cleansing agent use Enteric fistulae Diuretics Heat exposure Exercise Fever Severe burns Inadequate breastfeeding of infants Salt ingestion High-protein diet Use of intravenous sodium chloride

2018 BMJ Best Practice

189. Assessment of metabolic alkalosis

alkalosis. This is usually compensated by the kidneys with normal function by renal excretion of bicarbonate. Severe circulating volume contraction. This leads to loss of extracellular fluid and relative increase in bicarbonate concentration. Metabolic alkalosis generally requires an initiation factor that starts the process and a maintenance factor that continues the imbalance by preventing renal excretion of excess HCO3. Sometimes, the same factor may be responsible for both initiation and maintenance (...) administration Milk-alkali syndrome Primary hyperaldosteronism Secondary hyperaldosteronism Renal artery stenosis Cushing's syndrome Liquorice ingestion Tobacco chewing Apparent mineralocorticoid excess Liddle's syndrome Bartter's syndrome Gitelman's syndrome Profound potassium depletion Hypercalcaemia of non-hyperparathyroid aetiology Post-starvation refeeding syndrome Transfusion of blood products (sodium citrate) Villous adenoma Chloride diarrhoea Cystic fibrosis Contributors Authors Professor of Medicine

2018 BMJ Best Practice

190. Translation and implementation of the Australian-led PCOS guideline: clinical summary and translation resources from the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome

, with further evaluation in patients with amenorrhea and more severe clinical features including consideration of hypogonadotropic hypogonadism, Cushing disease or androgen-producing tumours. The guideline recognises that PCOS is an insulin-resistant and metabolic disorder; tests for insulin resistance, however, lack accuracy and should not be incorporated into the diagnostic criteria for PCOS at this time. Anti-Müllerian hormone is likewise not recommended for diagnosis at this time. Complication screening (...) . Ngaanyatjarra Health Service, Dec 2006. (viewed Aug 2018). Kildea S, Bowden FJ. Reproductive health, infertility and sexually transmitted infections in Indigenous women in a remote community in the Northern Territory. Aust N Z J Public Health 2000; 24: 382-386. Publication of your online response is subject to the Medical Journal of Australia 's editorial discretion. You will be notified by email within five working days should your response be accepted. Author Salutation First Name Middle Name Last Name

2018 MJA Clinical Guidelines

191. Guidance on the clinical management of anxiety disorders, specifically focusing on diagnosis and treatment strategies

to get better instantly. Their most acute need is appropriate reas- surance that their disorder has been recognised and that help will be forthcoming. Initial treatment should be selected in collaboration with the patient, based on the severity of the disorder, previous response to treatment, availability and the person’s preference. It will usually take 4–6 weeks to see improvement, whether cognitive–behavioural therapy (CBT) or an antide- pressant is used, and most people can tolerate this. Only (...) . Overview of the management of anxiety disorders. CBT: cognitive–behavioural therapy. CBT can be delivered face-to-face by an experienced clinician or as guided digital CBT. dCBT: guided digital CBT (CBT accessed by computer, tablet or smartphone application). §Watchful waiting includes monitoring response to psychoeducation and lifestyle measures. *For the purpose of initial treatment choice, mild, moderate and severe are defined pragmatically, according to effect on function, as inability to perform

2018 Royal Australian and New Zealand College of Psychiatrists

192. International evidence-based guideline for the assessment and management of polycystic ovary syndrome (PCOS)

pharmacological agents 97 4.7 Inositol 99 Chapter Five Assessment and treatment of infertility 100 5.1a Assessment of factors that may affect fertility, treatment response or pregnancy outcomes 101 5.1b Tubal patency testing 103 5.2 Ovulation induction principles 104 5.3 Letrozole 105 5.4 Clomiphene citrate and/or metformin 107 5.5 Gonadotrophins 110 5.6 Anti-obesity agents 112 5.7 Laparoscopic ovarian surgery 113 5.8 Bariatric surgery 115 5.9a In-vitro fertilisation 117 5.9b Gonadotropin releasing hormone (...) with amenorrhea and more severe clinical features including consideration of hypogonadotropic hypogonadism, Cushing’s disease, or androgen producing tumours. We acknowledge the challenges in defining specific diagnostic features, including around menarche and menopause, where diagnostic features naturally evolve. The guideline aims to facilitate timely and appropriate diagnosis for women with PCOS, whilst avoiding over diagnosis, especially in adolescents. Specific recommendations of relevance here include

2018 European Society of Human Reproduction and Embryology

193. ESC/ESH Management of Arterial Hypertension

Vascular endothelial growth factor WUCH White-coat uncontrolled hypertension 1 Preamble Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health (...) and coordinates the preparation of new Guidelines. The Committee is also responsible for the endorsement process of these Guidelines. The ESC Guidelines undergo extensive review by the CPG and external experts, and in this case by ESH -appointed experts. After appropriate revisions the Guidelines are approved by all the experts involved in the Task Force. The finalized document is approved by the CPG and ESH for publication in the European Heart Journal and in the Journal of Hypertension as well as Blood

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2018 European Society of Cardiology

194. Budesonide (Jorveza) - to treat adults with eosinophilic oesophagitis

38 2.4.5. Conclusions on clinical pharmacology 40 2.5. Clinical efficacy 40 2.5.1. Dose response study 40 2.5.2. Main study(ies) 42 2.5.3. Discussion on clinical efficacy 59 2.5.4. Conclusions on the clinical efficacy 63 2.6. Clinical safety 64 2.6.1. Discussion on clinical safety 70 2.6.2. Conclusions on the clinical safety 72 2.7. Risk Management Plan 73 2.8. Pharmacovigilance 75 Assessment report EMA/774645/2017 Page 4/83 2.9. Product information 75 2.9.1. User consultation 75 3. Benefit-Risk (...) -double blind PPI Proton pump inhibitor PPI-REE Proton pump inhibitor-responsive oesophageal eosinophilia PRA Patient’s Response Assessment PRO Patient reported outcome PT Preferred term QoL Quality of life R Reference dose RCI Repeated confidence interval RH Relative Humidity SAE Serious adverse event SAF Safety set Scr 2 Screening visit 2 SD Standard deviation SmPC Summary of Product Characteristics SOC System Organ Class TAMC Total Aerobic Microbial Count TEAE Treatment-emergent adverse event TLC

2018 European Medicines Agency - EPARs

195. CRACKCast E198 – Brain Resuscitation

] What are Lundberg A waves? On ICP monitoring devices, Lundberg A waves represent periods of refractory ICP elevation. These appear as increases in ICP from baseline, plateauing ICP for several minutes, and then spontaneous return of ICP to near-baseline levels. These are generally the result of increasing ICP that leads to increased cerebral vasodilation that further increased ICP and diminished CPP. The return to baseline is the result of the Cushing Response. [2] What is the relationship between

2019 CandiEM

196. Emergency management of adrenal insufficiency in children: advocating for treatment options in outpatient and field settings

, it is difficult to identify a threshold dose for all ICS that will cause HPA axis suppression. 18 Therefore, it is important to recog- nize chronic ICS therapy as a risk factor for AI. A study of infants with hemangiomas treated with high-dose glucocor- ticoid therapy for 12–26 weeks demonstrated the return of normal circadian response in salivary cortisol levels within 6 weeks and normal response to administration of low-dose ACTH stimulation by 12 weeks after stopping treatment. 14 During the process (...) of recovery from HPA suppression, physiological circadian secretion of cortisol may recover before return of the ability of the hypothalamus to respond to stress. 19 Therefore, a patient may have a normal 8:00 AM cortisol, but still be unable to show an appropriate serum cortisol response to stress. 20 21 The wide variability in box 1 Acquired causes of adrenal insufficiency PrimaryPrimary ? Autoimmune adrenalitis (Addison disease) – Isolated. – Autoimmune polyendocrinopathy type 1. – Autoimmune

2019 Pediatric Endocrine Society

197. Overweight, Obesity and Contraception

who were at risk for diabetes due to being overweight. There were few data available for progestogen-only injectables, and one study showed a higher mean fasting glucose, glucose 2-hour response, and fasting insulin level amongst DMPA users compared to those using NET-EN. Overall the review suggested that there was little evidence on which to base conclusions about the impact of hormonal contraceptives in women with diabetes. Among women without diabetes, there did not appear to be any major (...) to COC users, 167,168 other studies have reported a significant two-fold greater VTE risk among patch and ring users compared to COC users. 61,169 Evidence level 2+ A recent systematic review 170 investigated whether CHC use modifies the risk of VTE in obese women, and also evaluated evidence for a dose–response relationship between BMI and VTE. No studies regarding the contraceptive patch or vaginal ring met the inclusion criteria in this review. Data from one pooled analysis, 171 one cohort study

2019 Faculty of Sexual & Reproductive Healthcare

198. An International Consortium Update: Pathophysiology, Diagnosis, and Treatment of PCOS in Adolescence

increase in androgen production are hypothesized to contribute to IR and hyperinsulinemia. The association between IR and androgen excess in women has long been recognized because of the association of hyperandrogenic features with the rare syndromes of extreme IR due to mutations of the insulin receptor or autoantibodies targeting the insulin receptor [ - ]. Insulin may also potentiate the steroidogenic response to gonadotropins indirectly, by acting at the pituitary to increase gonadotrope (...) levels, and greater IR among women with PCOS [ - ]. Endothelial dysfunction has been described and may promote chronic inflammation [ ]. Although the mechanisms responsible for obesity-related IR are not completely clear, ectopic accumulation of fatty acids in organs and tissue that are not meant to store large amounts of fat appears to play a role [ ]. Ectopic fat accumulation can also occur in the absence of obesity, i.e., when there has been reduced prenatal growth and thus a reduction

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2019 Pediatric Endocrine Society

199. Management of Atopic Eczema

. Adherence to these guidelines may not necessarily guarantee the best outcome in every case. Every healthcare provider is responsible for the management of his/her unique patient based on the clinical picture presented by the patient and the management options available locally. Management of Atopic Eczema UPDATING THE CPG These guidelines were issued in 2018 and will be reviewed in a minimum period of four years (2022) or sooner if new evidence becomes available. When it is due for updating (...) . MANAGEMENT OF ATOPIC ECZEMA IN PRIMARY CARE Investigator’s Global Assessment IGA : Investigators’ Global Assessment QoL : Quality of life DLQI : Dermatology Life Quality Index CDLQI: Children’s Dermatology Life Quality Index SEVERITY ASSESSMENT CLEAR TO MILD IGA score: 0 to 2 ATOPIC ECZEMA PATIENT PRESENTING TO PRIMARY CARE MODERATE IGA score: 3 SEVERE TO VERY SEVERE IGA score: 4 to 5 REFER DERMATOLOGY SERVICE DLQI/CDLQI >10 DLQI/CDLQI =10 NO YES TREATMENT Refer Algorithm 2 RESPONSE QoL CONTINUE

2019 Ministry of Health, Malaysia

200. Clinical Practice Guideline for the Management of Infantile Hemangiomas

proliferative growth and involution phases within the expected time frame. , Noninvasive imaging may be used to monitor response to treatment but typically is not required. Occasionally, differentiating an IH from a highly vascularized malignant tumor may be difficult. Clinical history, response to therapy, and imaging characteristics considered together are extremely important in this differentiation. In rare cases, a tissue biopsy may be needed to confirm the diagnosis. Clinicians should use imaging (...) vascular characteristics and no arteriovenous shunting (an exception to the latter is that hepatic IHs may exhibit arteriovenous shunting). This may change as the IH involutes and has a more fatty appearance with decreased vascularity. , Doppler ultrasonography is also the modality of choice when screening for hepatic IHs and can be used to monitor progression of disease and response to treatment. Key Action Statement 2C ( ) View this table: TABLE 10 Key Action Statement 2C: Clinicians should perform

2019 American Academy of Pediatrics

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