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  1. The pituitary gland works hard to keep you healthy, doing everything from ensuring proper bone and muscle growth to helping nursing mothers produce milk for their babies. Its functionality is even more remarkable when you consider the gland is the size of a pea. “The pituitary is commonly referred to as the ‘master’ gland because it does so many important jobs in the body,” says Karen Frankwich, MD, a board-certified endocrinologist at Mission Hospital. “Not only does the pituitary make its own hormones, but it also triggers hormone production in other glands. The pituitary is aided in its job by the hypothalamus. This part of the brain is situated above the pituitary, and sends messages to the gland on when to release or stimulate production of necessary hormones.” These hormones include: Growth hormone, for healthy bone and muscle mass Thyroid-stimulating hormone, which signals the thyroid to produce its hormones that govern metabolism and the body’s nervous system, among others Follicle-stimulating and luteinizing hormones for healthy reproductive systems (including ovarian egg development in women and sperm formation in men, as well as estrogen and testosterone production) Prolactin, for breast milk production in nursing mothers Adrenocorticotropin (ACTH), which prompts the adrenal glands to produce the stress hormone cortisol. The proper amount of cortisol helps the body adapt to stressful situations by affecting the immune and nervous systems, blood sugar levels, blood pressure and metabolism. Antidiuretic (ADH), which helps the kidneys control urine levels Oxytocin, which can stimulate labor in pregnant women The work of the pituitary gland can be affected by non-cancerous tumors called adenomas. “These tumors can affect hormone production, so you have too little or too much of a certain hormone,” Dr. Frankwich says. “Larger tumors that are more than 1 centimeter, called macroadenomas, can also put pressure on the area surrounding the gland, which can lead to vision problems and headaches. Because symptoms can vary depending on the hormone that is affected by a tumor, or sometimes there are no symptoms, adenomas can be difficult to pinpoint. General symptoms can include nausea, weight loss or gain, sluggishness or weakness, and changes in menstruation for women and sex drive for men.” If there’s a suspected tumor, a doctor will usually run tests on a patient’s blood and urine, and possibly order a brain-imaging scan. An endocrinologist can help guide a patient on the best course of treatment, which could consist of surgery, medication, radiation therapy or careful monitoring of the tumor if it hasn’t caused major disruption. “The pituitary gland is integral to a healthy, well-functioning body in so many ways,” Dr. Frankwich says. “It may not be a major organ you think about much, but it’s important to know how it works, and how it touches on so many aspects of your health.” Adapted from http://www.stjhs.org/HealthCalling/2016/December/The-Pituitary-Gland-Small-but-Mighty.aspx
  2. – AI false positives pose serious danger to patients; cutoff changes recommended by Scott Harris , Contributing Writer, MedPage Today November 15, 2021 share to facebook share to twitter share to linkedin email article This Reading Room is a collaboration between MedPage Today® and: For adrenal insufficiency (AI), reducing false positives means more than reducing resource utilization. Treatments like glucocorticoid replacement therapy can cause serious harm in people who do not actually have AI. Research published in the Journal of the Endocrine Society makes multiple findings that report authors say could help bring down false positive rates for AI. This retrospective study ultimately analyzed 6,531 medical records from the Imperial College Healthcare NHS Trust in the United Kingdom. Sirazum Choudhury, MBBS, an endocrinologist-researcher with the trust, served as a co-author of the report. He discussed the study with MedPage Today. The exchange has been edited for length and clarity. This study ultimately addressed two related but distinct questions. What was the first? Choudhury: Initially the path we were following had to do with when cortisol levels are tested. Cortisol levels follow a diurnal pattern; levels are highest in the morning and then decline to almost nothing overnight. This means we ought to be measuring the level in the morning. But there are logistical issues to doing so. In many hospitals, we end up taking measurements of cortisol in the afternoon. That creates a dilemma, because if it comes back low, there's an issue as to what we ought to do with the result. Here at Imperial, we call out results of <100 nmol/L among those taken in the afternoon. Patients and doctors then have to deal with these abnormal results, when in fact they may not actually be abnormal. We may be investigating individuals who should really not be investigated. So the first aim of our study was to try and ascertain whether we could bring that down to a lower level and in doing so stop erroneously capturing people who are actually fine. What was the second aim of the study? Choudhury: As we went through tens of thousands of data sets, we realized we could answer more than that one simple question. So the next part of the study became: if an individual is identified as suspicious for AI, what's the best way to prove this diagnosis? We do this with different tests like short Synacthen Tests (SST), all with different cutoff points. Obviously, we want to get the testing right, because if you falsely label a person as having AI, the upshot is that treatments will interfere with their cortisol access and they will not do well. Simply put, we would be shortening their life. So, our second goal was to look at all the SSTs we've done at the center and track them to see whether we could do better with the benchmarks. What did you find? Choudhury: When you look at the data, you see that you can bring those benchmarks down and potentially create a more accurate test. First, we can be quite sure that a patient who is tested in the afternoon and whose cortisol level is >234 does not have AI. If their level is <53.5 then further investigation is needed There were similar findings for SSTs, which in our case were processed using a platform made by Abbott. For this platform, we concluded that the existing cut-offs should be dropped down to 367 at 30 minutes or 419 at about 60 minutes. Did anything surprise you about the study or its findings? Choudhury: If you look at the literature, the number of individuals who fail at 30 minutes but pass at 60 minutes is around 5%. But I was very surprised to see that our number at Imperial was about 20%. This is a key issue because, as I mentioned, if individuals are wrongly labelled adrenally insufficient, you're shortening their life. It's scary to think about the number of people who might have been given steroids and treated for AI when they didn't have the condition. What do you see as the next steps? Choudhury: I see centers unifying their cutoffs for SST results and making sure we're all consistent in the way we treat these results. From a research perspective, on the testing we're obviously talking about one specific platform with Abbott, so research needs to be done on SST analyzers from other manufacturers to work out what their specific cutoffs should be. Read the study here and expert commentary on the clinical implications here. The study authors did not disclose any relevant relationship with industry. Primary Source Journal of the Endocrine Society Source Reference: Ramadoss V, et al "Improving the interpretation of afternoon cortisol levels and SSTs to prevent misdiagnosis of adrenal insufficiency" J Endocrine Soc 2021; 5(11): bvab147. From https://www.medpagetoday.com/reading-room/endocrine-society/adrenal-disorders/95661
  3. I first became aware of Bill on November 6, but now that I know about him, I am pretty sure he officially arrived during the summer of 2012. Since then, I suffered from depression, acne, menstrual problems, 30lb weight gain (while training for a marathon), and high blood pressure. Best of all, Bill has taken up residence on the back of my neck and created a little colony on my belly too. I always been pretty healthy (except for hypothyroidism) but in the last year, I had seen several different doctors for all of the weird things that have been happening to me. A gynecologist and dermatologist both suggested my menstrual and acne problems were likely hormonal and happening because I was probably going through perimenopause (I was 40 at the time). A psychiatrist put me on Effexor for depression and a beta-blocker for anxiety (I jump a foot when the phone would ring or someone would knock on my office door). All of these treatments seemed completely reasonable to me and they helped. It never occurred to me or anyone else they could be related. And all potentially explained why I kept gaining weight, despite not changing my diet and exercise (5-6 days a week) regime. Who knew hitting your 40s was going to be this rough? I started to really slow down on my runs - 2 to 3 minutes per mile slower than before. Maybe it was the weight gain that was making running harder, maybe it was the unusually hot and humid summer. I kept waiting for my running to get back to normal. But it never did. Every day it was a struggle to run. It was something I used to love so much - it was my way of working through stress. Now, it just made me feel bad. When I went to my regular endocrinologist in July for my annual thyroid check-up, he discovered my TSH was "way off" - and a little light went on. That's why I felt so crappy this year! I recounted my symptoms to Endo 1 (whom I had been seeing for 7 years). He thought I must be "very sensitive" to changes in hormones to have such a large reaction to the drop in TSH but hey, you never know. My Synthroid does was adjusted and I kept waiting to feel better. But I just kept getting worse. At my follow-up appointment in October, Endo 1 (who was with a medical student) told me my hormone levels were perfect and my face fell. He said I looked like I wanted a different answer. I explained that I felt worse and was having very troubling symptoms now. I run the week before and two miles in developed an excruciating headache, blurry vision and unsteadiness that stopped me in my tracks. I had to sit down for 30 minutes before the symptoms subsided and I could walk back to my car. I haven't run since. He started standing up, with the medical student in tow, and told me "this is not an endocrine problem - you should talk to your PCP and go see a cardiologist." That was that. I found a great cardiologist that deals with athletes, Dr. B. I was supposed to run the Philly marathon in November and so I tried to get his nurse to squeeze me onto his schedule in early November so I could figure out if there was something wrong with my heart. I had a stress test at his lab which came out completely normal. However, my blood pressure was very high. He told me that my heart was fine but something was very wrong for my blood pressure to be so high. I had mentioned to him that I had high BP readings at the various doctor's offices I had visited over the year - but I was always told "you are young and healthy, your BP is just high because you are in seeing the doctor today" (which for the record is ridiculous - it is hard to stress me out and a visit to the doctor is certainly not enough to do it). After reviewing my records and giving me a physical exam, he came back and told me he suspected I had Cushing's. He started some lab work to try and test for it too - two 24 hour UFC's and a dexamethasone suppression test. I had never heard of Cushing's, but my symptoms fit to a T. And as I read about "buffalo humps" and reached up to feel my neck, I realized I had known about Bill for some time. The cardiologist was so wonderful. He told me. "This is an endocrine issue, not a cardiac issue. But I am going to keep seeing you until you are better and I am going to help you navigate through the system." I felt very happy and relieved when I left his office. There was something wrong and it had a name. Now, I would just have a couple of tests, see my endocrinologist and go back to my normal life. If only life were so easy....
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