Pituitary dysfunction after traumatic brain injury: are there definitive data in children?

Posted on November 21, 2016 by MaryO

Arch Dis Child doi:10.1136/archdischild-2016-311609

  1. Correspondence toDr Paula Casano-Sancho, Pediatric Endocrinology Unit, Sant Joan de Déu Hospital, Passeig Sant Joan de Déu, Santa Rosa 39-57, Esplugues, Barcelona 08950, Spain; pcasano@hsjdbcn.org
  • Received 14 July 2016
  • Revised 26 October 2016
  • Accepted 27 October 2016
  • Published Online First 21 November 2016

Abstract

In the past decade, several studies in adults and children have described the risk of pituitary dysfunction after traumatic brain injury (TBI). As a result, an international consensus statement recommended follow-up on the survivors. This paper reviews published studies regarding hypopituitarism after TBI in children and compares their results.

The prevalence of hypopituitarism ranges from 5% to 57%. Growth hormone (GH) and ACTH deficiency are the most common, followed by gonadotropins and thyroid-stimulating hormone. Paediatric studies have failed to identify risk factors for developing hypopituitarism, and therefore we have no tools to restrict screening in severe TBI. In addition, the present review highlights the lack of a unified follow-up and the fact that unrecognised pituitary dysfunction is frequent in paediatric population.

The effect of hormonal replacement in patient recovery is important enough to consider baseline screening and reassessment between 6 and 12 months after TBI. Medical community should be aware of the risk of pituitary dysfunction in these patients, given the high prevalence of endocrine dysfunction already reported in the studies. Longer prospective studies are needed to uncover the natural course of pituitary dysfunction, and new studies should be designed to test the benefit of hormonal replacement in metabolic, cognitive and functional outcome in these patients.

From http://adc.bmj.com/content/early/2016/11/21/archdischild-2016-311609.short?rss=1

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Low Oxytocin Levels Linked to Reduced Empathy

Posted on November 12, 2016 by MaryO

People suffering from low levels of oxytocin perform worse on empathy tasks, according to new research presented at the 2016 Society for Endocrinology annual conference.

The research suggests that hormone replacement could improve the psychological well-being of those living with low levels, according to researchers at the University of Cardiff.

Oxytocin is often referred to as the “love hormone” due to its role in human behavior, including sexual arousal, recognition, trust, anxiety, and mother-infant bonding. It is produced by the hypothalamus — an area of the brain that controls mood and appetite — and stored in the pituitary gland.

For the study, researchers investigated empathic behavior in people who they suspected of having reduced oxytocin levels due to one of two medical conditions caused in response to pituitary surgery.

The study assessed 20 people with cranial diabetes insipidus (CDI). In CDI, the body has reduced levels of ADH, a chemical also produced in the hypothalamus and structurally very similar to oxytocin.

The researchers also assessed 15 people with hypopituitarism (HP), a condition in which the pituitary gland does not release enough hormones.

These two patient groups were compared to a group of 20 healthy people.

The researchers gave all participants two tasks designed to test empathy, both relating to the recognition of emotional expression. They also measured each group’s oxytocin levels and found that the 35 CDI and HP participants had slightly lower oxytocin compared to the healthy people. The researchers noted that a larger sample is required to establish statistical significance.

The researchers also discovered that the CDI and HP groups performed significantly worse on empathy tasks, compared to the healthy control group. In particular, CDI participants’ ability to identify expressions was predicted by their oxytocin levels — those with the lowest levels of oxytocin produced the worst performances, according to the study’s findings.

“This is the first study which looks at low oxytocin as a result of medical, as opposed to psychological, disorders,” said Katie Daughters, lead researcher. “If replicated, the results from our patient groups suggest it is also important to consider medical conditions carrying a risk of low oxytocin levels.”

“Patients who have undergone pituitary surgery, and in particular those who have acquired CDI as a consequence, may present with lower oxytocin levels,” she continued. “This could impact on their emotional behavior, and in turn affect their psychological well-being. Perhaps we should be considering the introduction of oxytocin level checks in these cases.”

The researchers said they hope to expand their study to further replicate and confirm their findings. They added that the study presents only preliminary results, and has not been peer reviewed.

Source: Society for Endocrinology

From http://psychcentral.com/news/2016/11/06/low-oxytocin-levels-linked-to-reduced-empathy/112110.html

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Severe Trauma May Damage The Brain as Well as the Psyche

Posted on October 24, 2016 by MaryO

NOTE: This is only a portion of the article.  Read the entire post at http://www.nytimes.com/1995/08/01/science/severe-trauma-may-damage-the-brain-as-well-as-the-psyche.html?pagewanted=all

Cortisol is a major means the body uses, with adrenaline, to arouse itself so quickly; its action, for example, triggers an increase in blood pressure and mobilizes energy from fat tissue and the liver.

“The dark side of this picture is the neurological effects,” said Dr. Sapolsky. “It’s necessary for survival, but it can be disastrous if you secrete cortisol for months or years on end. We’ve known it could lead to stress-exacerbated diseases like hypertension or adult onset diabetes. But now we’re finding the hippocampus is also damaged by these secretions.”

Studies in animals show that when glucocorticoids are secreted at high levels for several hours or days, there is a detectable effect on memory, though no neuronal death. But with sustained release from repeated stress, “it eventually kills neurons in the hippocampus,” said Dr. Sapolsky. “This has been shown solidly in rats, with the cell biology well understood.”

A parallel effect has long been known among patients with Cushing’s disease, a hormonal condition in which tumors in the adrenal or pituitary glands or corticosteroid drugs used for a prolonged time cause the adrenal glands to secrete high levels of a hormone called ACTHm and of cortisol. Such patients are prone to a range of diseases “in any organ with stress sensitivity,” including diabetes, hypertension and suppression of the immune system, said Dr. Sapolsky.

Cushing’s patients also have pronounced memory problems, especially for facts like where a car was parked. “The hippocampus is essential for transferring such facts from short-term to long-term memory,” said Dr. Sapolsky.

In 1993, researchers at the University of Michigan reported that magnetic resonance imaging had shown an atrophy and shrinkage of the hippocampus in patients with Cushing’s disease; the higher their levels of cortisol, the more shrinkage.

In an apparent paradox, low levels of cortisol in post-trauma victims were found in a separate research report, also in the July issue of The American Journal of Psychiatry. Dr. Rachel Yehuda, a psychologist at Mount Sinai Medical School in New York City, found the lower levels of cortisol in Holocaust survivors who had been in concentration camps 50 years ago and who still had post-traumatic symptoms.

“There are mixed findings on cortisol levels in trauma victims, with some researchers finding very high levels and others finding very low levels,” said Dr. Sapolsky. “Biologically speaking, there may be different kinds of post-traumatic stress.”

In a series of studies, Dr. Yehuda has found that those post-trauma patients who have low cortisol levels also seem to have “a hypersensitivity in cell receptors for cortisol,” she said. To protect itself, the body seems to reset its cortisol levels at a lower point.

The low cortisol levels “seem paradoxical, but both too much and too little can be bad,” said Dr. Yehuda. “There are different kinds of cells in various regions of the hippocampus that react to cortisol. Some atrophy or die if there is too little cortisol, some if there is too much.”

Dr. Yehuda added, “In a brain scan, there’s no way to know exactly which cells have died.”

To be sure that the shrinkage found in the hippocampus of trauma victims is indeed because of the events they suffered through, researchers are now turning to prospective studies, where before-and-after brain images can be made of people who have not yet undergone trauma, but are at high risk, or who have undergone it so recently that cell death has not had time to occur.

Dr. Charney, for example, is planning to take M.R.I. scans of the brains of emergency workers like police officers and firefighters and hopes to do the same with young inner-city children, who are at very high risk of being traumatized over the course of childhood and adolescence. Dr. Pitman, with Dr. Yehuda, plans a similar study of trauma victims in Israel as they are being treated in emergency rooms.

Dr. Yehuda held out some hope for people who have suffered through traumatic events. “It’s not necessarily the case that if you’ve been traumatized your hippocampus is smaller,” she said. She cited research with rats by Dr. Bruce McEwen, a neuroscientist at Rockefeller University, showing that atrophied dendritic extensions to other cells in the hippocampus grew back when the rats were given drugs that blocked stress hormones.

Dr. Sapolsky cited similar results in patients with Cushing’s disease whose cortisol levels returned to normal after tumors were removed. “If the loss of hippocampal volume in trauma victims is due to the atrophy of dendrites rather than to cell death, then it is potentially reversible, or may be so one day,” he said.

NOTE: This is only a portion of the article.  Read the entire post at http://www.nytimes.com/1995/08/01/science/severe-trauma-may-damage-the-brain-as-well-as-the-psyche.html?pagewanted=all

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Endocrine Society issues new guidelines on hypopituitarism

Posted on October 15, 2016 by MaryO

The Endocrine Society today issued a Clinical Practice Guideline that recommends treating insufficient hormone levels in individuals with hypopituitarism by replacing hormones at levels as close to the body’s natural patterns as possible.

The guideline, titled “Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline,” was published online and will appear in the November 2016 print issue of The Journal of Clinical Endocrinology & Metabolism (JCEM), a publication of the Endocrine Society.

Hypopituitarism, or pituitary insufficiency, occurs when the pituitary gland does not produce sufficient amounts of hormones–the chemical signals that regulate respiration, reproduction, growth, metabolism, sexual function and other important biological functions. The pituitary gland is often called the master gland because the hormones it produces impact many bodily functions. As a result, hypopituitarism can cause a range of symptoms, according to the Hormone Health Network.

The rare disorder can occur due to abnormal development or later in life as a result of a tumor, traumatic brain injury, hemorrhage or autoimmune condition, according to the Society’s

“Hypopituitarism can manifest as low levels of a variety of hormones, including cortisol, thyroid hormone, estrogen, testosterone and growth hormone,” said Maria Fleseriu, MD, FACE, of Oregon Health & Science University in Portland, OR. Fleseriu chaired the task force that developed the guideline. “The goal of treatment should be to restore hormone levels as close to healthy levels as possible The interactions between these hormones also are very important, and patients might require dose changes of one or more of the replacement hormones after starting or discontinuing another one.”

In recommending treatment options, the guideline task force followed the overriding principle of using hormone replacement therapy dose size and timing to mimic the body’s natural functioning as closely as possible.

Accurate and reliable measurements of hormones play a central role in diagnosing hypopituitarism and monitoring the effectiveness of treatments, Fleseriu said. Healthcare providers need to keep in mind technical considerations to ensure the testing procedure is as accurate as possible.

The guideline addresses special circumstances that may affect the treatment of patients with hypopituitarism, including pregnancy care, post-surgical care following pituitary or other operations, treatment in combination with anti-epilepsy medication, and care following pituitary apoplexy–a serious condition that occurs when there is bleeding into the gland or blood flow to it is blocked.

Recommendations from the guideline include:

  • Measurements of both free thyroxine and thyroid-stimulating hormone are needed to evaluate central hypothyroidism, a condition where the thyroid gland does not produce enough hormones because it isn’t stimulated by the pituitary gland.
  • People who have central hypothyroidism should be treated with levothyroxine in doses sufficient to raise levels of the thyroid hormone free thyroxine to the upper half of the reference range.
  • Growth hormone stimulation testing should be used to diagnose patients with suspected growth hormone deficiency.
  • People who have proven cases of growth hormone deficiency and no contraindications should be offered growth hormone replacement as a treatment option.
  • Premenopausal women who have central hypogonadism, a condition where the sex glands produce minimal amounts or no hormones, can undergo hormone treatment, provided there are no contraindications.
  • People producing abnormally large volumes of dilute urine should be tested for central diabetes insipidus–a rare condition that leads to frequent urination–by analyzing the concentration of their blood and urine.
  • For patients who have low levels of glucocorticoid hormones, hydrocortisone can be given in a daily single or divided dose.
  • All hypopituitarism patients should be instructed to obtain an emergency card, bracelet or necklace warning about the possibility of adrenal insufficiency.
  • Patients who are suspected of having an adrenal crisis due to secondary adrenal insufficiency should receive an immediate injection of 50 to 100 milligrams of hydrocortisone.
  • People who have central adrenal insufficiency should receive the lowest tolerable dose of hydrocortisone replacement on a long-term basis to reduce the risk of metabolic and cardiovascular disease.
Source:

The Endocrine Society

From http://www.news-medical.net/news/20161013/Endocrine-Society-issues-new-guidelines-on-hypopituitarism.aspx

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Cushing’s disease best treated by endocrinologist

Posted on October 4, 2016 by MaryO

Dear Dr. Roach: I was told that I have Cushing’s disease, which has caused diabetes, high blood pressure, hunger, weight gain and muscle loss. I was never sick before this, and I did not have any of those things. I am told I have a tumor on my right adrenal gland. I have been to numerous doctors, but most have not been too helpful. They seem to try to treat the diabetes or blood pressure, but nothing else. They seem not to be familiar with Cushing’s. I tell them which medication works, but they still give me new medication. I have an endocrinologist and am scheduled to meet a urologist.

I have managed to go to physical therapy, exercise every day and lose over 50 pounds. I am not happy with the advice I’m getting. I was told that surgery to remove the tumor will fix everything, but that I would need to take steroids for either a short term or for life. My body is already making too much cortisol. I have 50 more pounds to lose. I work hard to keep the weight down. I feel like a science experiment. Within a week, I have had three different medications. I could not tell which was causing the side effects and making me dehydrated. I am not sure surgery is right for me, because they said it can be done laparoscopically, but if they can’t do it that way, they will have to cut me all the way across, which may take a long time to heal and may get infected.

Do you know what tests will confirm the diagnosis? Would surgery fix all these problems? I had the 24-hour urine test, the saliva test and blood tests. I want to know if it may be something else instead of Cushing’s. I’m not on anything for the high cortisol levels.

– A.L.

A: It sounds very much like you have Cushing’s syndrome, which is caused by excess cortisone, a hormone that has many effects. It is called Cushing’s disease when the underlying cause is a pituitary tumor that causes the adrenal gland to make excess cortisone. (Cortisone and cortisol are different names for the same chemical, also called a glucocorticoid.) Cushing’s syndrome also may be caused by an adenoma (benign tumor) of the adrenal gland, which sounds like the case in you.

The high amounts of cortisone produced by the adrenal tumor cause high blood pressure, glucose intolerance or frank diabetes, increased hunger, obesity (especially of the abdomen – large bellies and skinny limbs are classic), dark-colored striae (stretch marks), easy bruising, a reddish face and often weakness of arm and leg muscles. When full-blown, the syndrome is easy to spot, but many people don’t have all the characteristics, especially early in the course of the disease.

Your endocrinologist is the expert in diagnosis and management, and has done most of the tests. I am somewhat surprised that you haven’t yet seen a surgeon to have the tumor removed. Once it is removed, the body quickly starts to return to normal, although losing the weight can be a problem for many.

I have seen cases in my training where, despite many tests, the diagnosis was still uncertain. The endocrinologist orders a test where the blood is sampled from both adrenal veins (which contain the blood that leaves the adrenal glands on top of the kidneys). If the adrenal vein on the side of the tumor has much more cortisone than the opposite side, the diagnosis is certain.

By DR. KEITH ROACH For the Herald & Review at http://herald-review.com/news/opinion/editorial/columnists/roach/dr-roach-cushing-s-disease-best-treated-by-endocrinologist/article_38e71835-464d-5946-aa9c-4cb1366bcee3.html

Filed under: adrenal, Cushing's, Diagnostic Testing, pituitary, symptoms, Treatments | Tagged: , , , , , , , , , | Leave a comment »

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