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

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

Hypopituitarism – Deficiency in Pituitary Hormone Production

By Yolanda Smith, BPharm

Hypopituitarism is a health condition in which there is a reduction in the production of hormones by the pituitary gland.

The pituitary gland is located at the base of the brain and is responsible for the production of several hormones, including:

  • Adrenocorticotropic hormone (ACTH), which controls the production of the vital stress hormones cortisol and dehydroepiandrosterone (DHEA) in the adrenal gland
  • Thyroid stimulating hormone (TSH), which controls the production of hormones by the thyroid gland
  • Luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which control the secretion of the primary sex hormones and affect fertility
  • Growth hormone (GH), which regulates the growth processes in childhood and other metabolic processes throughout life
  • Prolactin (PRL), which facilitates the production of breast milk
  • Oxytocin, which is crucial during labor, childbirth and lactation
  • Antidiuretic hormone (ADH), also known as vasopressin, which regulates the retention of water and the blood pressure

An individual with hypopituitarism shows a deficiency in one or more of these hormones. This inevitably leads to abnormal body function, as an effect of the low levels of the hormone in the body, and may result in symptoms.

Causes

Hypopituitarism is most commonly due to the destruction, compression or inflammation of pituitary tissue by a brain tumor in that region. Other causes include:

  • Head injury
  • Infections such as tuberculosis
  • Ischemic or infarct injury
  • Radiation injury
  • Congenital and genetic causes
  • Infiltrative diseases such as sarcoidosis

Symptoms

General symptoms that are associated with pituitary hormone deficiency include:

  • Weakness and fatigue
  • Decreased appetite
  • Weight loss
  • Sensitivity to cold
  • Swollen facial features or body

There are also likely to be more specific symptoms according to the type of pituitary hormone deficiency, such as:

  • ACTH deficiency:
    • abdominal pain
    • low blood pressure
    • low serum sodium levels
    • skin pallor
  • TSH deficiency:
    • generalized body puffiness
    • sensitivity to cold
    • constipation
    • impaired memory and concentration
    • dry skin
    • anemia
  • LH and FSH deficiency:
    • reduction in libido
    • erectile dysfunction in men
    • abnormal menstrual periods
    • vaginal dryness in women
    • difficulty in conceiving
    • infertility.
  • GH deficiency:
    • slow growth
    • short height
    • an increase in body fat

Treatment

The first step in the treatment of hypopituitarism is to identify the cause of the condition.

Secondly, the hormones that are deficient must be identified. From this point, the appropriate treatment decisions can be made to promote optimal patient outcomes.

Hormone replacement therapy is the most common type of treatment for a patient with hypopituitarism.

This may involve supplementation of one or more hormones that are deficient, to reduce or correct the impact of the deficiency.

Follow Up

As hormone replacement therapy is expected to continue on a lifelong basis, it is important that patients have a good understanding of the therapy.

It is especially important to educate patients on what to do in case of particular circumstances that may change their hormone requirements.

For example, during periods of high stress, the demand for many hormones is increased, and the dose of hormone replacement may need to be adjusted accordingly.

It is recommended that patients have regular blood tests to monitor their hormone levels and ensure that they are in the normal range.

Patients should also carry medical identification, such as a medical bracelet or necklace, to show that they are affected by hypopituitarism and inform others about their hormone replacement needs and current treatment. This can help to meet their medical needs in case of any emergency.

Epidemiology

Hypopituitarism is a rare disorder that affects less than 200,000 individuals in the United States, with an incidence of 4.2 cases per 100,000 people per year.

The incidence is expected to be higher in certain subsets of the population, such as those that have suffered from a brain injury. Statistics in reference to these population groups have not yet been determined.

Reviewed by Dr Liji Thomas, MD.

References

From http://www.news-medical.net/health/Hypopituitarism-Deficiency-in-Pituitary-Hormone-Production.aspx

Day 20, Cushing’s Awareness Challenge 2016

And today, we talk about pink jeeps and ziplines…

How in the world did we get here in a Cushing’s Challenge?  I’m sliding these in because earlier I linked (possibly!) my growth hormone use as a cause of my cancer – and I took the GH due to Cushing’s issues.  Clear?  LOL

I had found out that I had my kidney cancer on Friday, April 28, 2006 and my surgery on May 9, 2006.  I was supposed to go on a Cushie Cruise to Bermuda on May 14, 2006.  My surgeon said that there was no way I could go on that cruise and I could not postpone my surgery until after that cruise.

I got out of the hospital on the day that the other Cushies left for the cruise and realized that I wouldn’t have been much (ANY!) fun and I wouldn’t have had any.

An especially amusing thread from that cruise is The Adventures of Penelopee Cruise (on the Cushing’s Help message boards).  Someone had brought a UFC jug and  decorated her and had her pose around the ship.

The beginning text reads:

Penelopee had a lovely time on Explorer of the Seas which was a five day cruise to Bermuda. She needed something to cheer her up since her brother, Tom, went off the deep end, but that’s another story!

Penelopee wanted to take in all of the sights and sounds of this lovely vessel. Every day she needed to do at least one special thing. Being a Cushie, she didn’t have enough spoons to do too much every day.

On the first day, she went sunning on the Libido deck……she didn’t last too long, only about 10 minutes. Goodness, look at her color! Do you think maybe her ACTH is too high?

Although I missed this trip, I was feeling well enough to go to Sedona, Arizona in August, 2006.  I convinced everyone that I was well enough to go off-road in a pink jeep,  DH wanted to report me to my surgeon but I survived without to much pain and posed for the header image.

In 2009, I figured I have “extra years” since I survived the cancer and I wanted to do something kinda scary, yet fun. So, somehow, I decided on ziplining. Tom wouldn’t go with me but Michael would so I set this up almost as soon as we booked a Caribbean cruise to replace the Cushie Cruise to Bermuda.

Each person had a harness around their legs with attached pulleys and carabiners. Women had them on their chests as well. In addition, we had leather construction gloves and hard hats.

We climbed to the top of the first platform and were given brief instructions and off we went. Because of the heavy gloves, I couldn’t get any pictures. I had thought that they would take some of us on the hardest line to sell to us later but they didn’t. They also didn’t have cave pictures or T-Shirts. What a missed opportunity!

This was so cool, so much fun. I thought I might be afraid at first but I wasn’t. I just followed instructions and went.

Sometimes they told us to break. We did that with the right hand, which was always on the upper cable.

After the second line, I must have braked too soon because I stopped before I got to the platform. Michael was headed toward me. The guide on the end of the platform wanted me to do some hand over hand maneuver but I couldn’t figure out what he was saying so he came and got me by wrapping his legs around me and pulling me to the platform.

After that, no more problems with braking!

The next platform was very high – over 70 feet in the air – and the climb up was difficult. It was very hot and the rocks were very uneven. I don’t know that I would have gotten to the next platform if Michael hadn’t cheered me on all the way.

We zipped down the next six lines up to 250-feet between platforms and 85-feet high in the trees, at canopy level. It seemed like it was all over too soon.

But, I did it! No fear, just fun.

Enough of adventures – fun ones like these, and scary ones like transsphenoidal surgery and radical nephrectomy!

 

Day Twenty, Cushing’s Awareness Challenge 2015

And today, we talk about pink jeeps and ziplines…

How in the world did we get here in a Cushing’s Challenge?  I’m sliding these in because earlier I linked (possibly!) my growth hormone use as a cause of my cancer – and I took the GH due to Cushing’s issues.  Clear?  LOL

 

I had found out that I had my kidney cancer on Friday, April 28, 2006 and my surgery on May 9, 2006.  I was supposed to go on a Cushie Cruise to Bermuda on May 14, 2006.  My surgeon said that there was no way I could go on that cruise and I could not postpone my surgery until after that cruise.

 

I got out of the hospital on the day that they left for the cruise and realized that I wouldn’t have been much (ANY!) fun and I wouldn’t have had any.

An especially amusing thread from that cruise is The Adventures of Penelopee Cruise.  Someone had brought a UFC jug and  decorated her and had her pose around the ship.  The beginning text reads:

Penelopee had a lovely time on Explorer of the Seas which was a five day cruise to Bermuda. She needed something to cheer her up since her brother, Tom, went off the deep end, but that’s another story!

Penelopee wanted to take in all of the sights and sounds of this lovely vessel. Every day she needed to do at least one special thing. Being a Cushie, she didn’t have enough spoons to do too much every day.

On the first day, she went sunning on the Libido deck……she didn’t last too long, only about 10 minutes. Goodness, look at her color! Do you think maybe her ACTH is too high?

Although I missed this trip, I was feeling well enough to go to Sedona, Arizona in August, 2006.  I convinced everyone that I was well enough to go off-road in a pink jeep,  DH wanted to report me to my surgeon but I survived without to much pain and posed for the header image.

In 2009, I figured I have “extra years” since I survived the cancer and I wanted to do something kinda scary, yet fun. So, somehow, I decided on ziplining. Tom wouldn’t go with me but Michael would so I set this up almost as soon as we booked a Caribbean cruise to replace the Cushie Cruise to Bermuda.

Each person had a harness around their legs with attached pulleys and carabiners. Women had them on their chests as well. In addition, we had leather construction gloves and hard hats.

We climbed to the top of the first platform and were given brief instructions and off we went. Because of the heavy gloves, I couldn’t get any pictures. I had thought that they would take some of us on the hardest line to sell to us later but they didn’t. They also didn’t have cave pictures or T-Shirts. What a missed opportunity!

This was so cool, so much fun. I thought I might be afraid at first but I wasn’t. I just followed instructions and went.

Sometimes they told us to break. We did that with the right hand, which was always on the upper cable.

After the second line, I must have braked too soon because I stopped before I got to the platform. Michael was headed toward me. The guide on the end of the platform wanted me to do some hand over hand maneuver but I couldn’t figure out what he was saying so he came and got me by wrapping his legs around me and pulling me to the platform.

After that, no more problems with breaking!

The next platform was very high – over 70 feet in the air – and the climb up was difficult. It was very hot and the rocks were very uneven. I don’t know that I would have gotten to the next platform if Michael hadn’t cheered me on all the way.

We zipped down the next six lines up to 250-feet between platforms and 85-feet high in the trees, at canopy level. It seemed like it was all over too soon.

But, I did it! No fear, just fun.

Enough of adventures – fun ones like these, and scary ones like transsphenoidal surgery and radical nephrectomy!

 

Reduced mortality in patients with GH replacement therapy – a Swedish study based on more than 4,000 patient-years

ENDO_2015

 

March 06, 2015

OR20-Pituitary Tumors-New Clinical Considerations

Reduced mortality in patients with GH replacement therapy – a Swedish study based on more than 4,000 patient-years

DS Olsson, AG Nilsson, P Trimpou, B-A Bengtsson, E Andersson, G Johannsson

Summary: In this study, researchers assessed mortality in patients with hypopituitarism with and without long-term growth hormone (GH) replacement therapy (GHRT). Theirs is the first study to report a reduced mortality in non-functioning pituitary adenoma (NFPA) patients with long-term GHRT compared with both the general population and NFPA patients who have not received GHRT, despite a more severe hypopituitarism. Further, researchers found that mortality due to circulatory diseases was not increased in NFPA patients regardless of GHRT. Finally, they found that death due to malignant tumors was decreased in the GHRT-group.

Methods:

  • To eliminate the influence of the etiology of hypopituitarism on mortality, researchers included only  patients with NFPA were studied.
  • Using the Swedish National Patient Registry, researchers identified NFPA patients within the Sahlgrenska University Hospital’s catchment-area (1.5 million inhabitants), and retrospectively reviewed records of all identified NFPA patients from 1987 to 2011.
  • Standardized mortality ratios (SMRs) with 95% confidence intervals (reference: Swedish population) were calculated and cox-regression analyses were used to identify predictors for mortality.

Results:

  • Researchers identified 437 patients with NFPA, of whom 435 (99%) had complete records and were included in the study.
  • They observed that GHRT had been used for at least 1 year by 188 patients (132 men, 56 women), while 247 patients had not been treated with GHRT (148 men, 99 women).
  • Mean (±SD) age at diagnosis was lower (P<0.001) in the GHRT-group (54.2±11.7) compared to the non-GHRT-group (63.8±15.6).
  • Mean duration of GHRT was 10.9 (6.7) years, and mean follow-up time in the non-GHRT-group was 7.0 (5.4) years.
  • In the GHRT-group, ACTH deficiency, gonadotropic deficiency and thyrotrophic deficiency were more frequent (71%, 74% and 93%, respectively) compared with the non-GHRT-group (38%, 34% and 50%).
  • The total number of events/deaths in the study was 83.
  • In the GHRT group, SMR was 0.49 (0.27-0.80, P=0.002) compared with 0.98 (0.76-1.24;P=0.94) in the non-GHRT-group; SMR was lower in the GHRT-group compared to the non-GHRT-group (P=0.02).
  • Researchers found that Cox-regression analyses identified GHRT (P=0.01) and younger age at diagnosis (P<0.0001) as predictors of decreased mortality.
  • They also found that cause-specific mortality due to circulatory diseases was not increased (GHRT-group, SMR 0.62; 0.25-1.28; Non-GHRT-group, SMR 0.96; 0.65-1.36).
  • SMR for malignant tumors was reduced in the GHRT-group (SMR 0.19; 0.02-0.68; P=0.003), and as expected in the non-GHRT-group (SMR 0.74; 0.37-1.31; P=0.37).

From http://www.mdlinx.com/endocrinology/conference-abstract.cfm/ZZ5BA369FDE9DE4CED82CB6A7CD5BFD1BE/42341/?utm_source=confcoveragenl&utm_medium=newsletter&utm_content=abstract-list&utm_campaign=abstract-ENDO2015&nonus=0

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