The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
This document discusses various diagnostic procedures and dynamic tests used in chemical pathology, focusing on tests for disorders of growth hormone, cortisol, and aldosterone metabolism. It provides details on insulin hypoglycemic tests, glucose stimulation tests, clonidine stimulation tests, and exercise stimulation tests. These tests measure hormonal responses to stimuli like insulin-induced hypoglycemia, glucagon administration, clonidine administration, or exercise to evaluate the functioning of the hypothalamic-pituitary-end organ axes. The document outlines the procedures, normal responses, and interpretations for each type of dynamic test.
The document discusses several medical topics:
1. New guidelines from the Endocrine Society on the management of primary aldosteronism, including case detection criteria, confirmation testing, subtype classification testing, and treatment recommendations.
2. Pros and cons of the National Bone Health Alliance's diagnostic criteria for osteoporosis, which expands the definition to include factors like fracture risk assessment (FRAX) scores in addition to bone mineral density testing.
3. Updated clinical practice guidelines from the American Association of Clinical Endocrinologists and American College of Endocrinology for developing comprehensive care plans for patients with diabetes mellitus.
This document discusses examinations for endocrine disorders. It describes different types of endocrine disorders based on hormone levels and tests to dynamically suppress or stimulate hormones. Various examination methods are outlined, including laboratory tests to measure hormone levels and functional tests like stimulatory and inhibitory tests. Imaging methods like ultrasonography, CT, MRI, and scintigraphy are described for localizing endocrine tumors or complications. Specific tests are detailed for evaluating pituitary, thyroid, and adrenal function.
The document discusses key principles of hormone testing:
1. Biochemical confirmation of endocrine disease is needed before imaging tests.
2. Simultaneous measurement of trophic and target hormones can help determine the location of abnormalities.
3. Test abnormalities do not always reflect endocrine dysfunction, and some tests may be normal despite real dysfunction. Reliability depends on choice of tests, patient preparation, specimen integrity, and test quality.
Case study on paracetamol poisoning(Acetaminophen toxicity)Neeraj Ojha
1) A 16-year-old female was brought to the emergency department six hours after a suspected acetaminophen and alcohol overdose in an apparent suicide attempt following a breakup.
2) Laboratory tests showed mildly elevated liver enzymes and an acetaminophen level of 308 ug/mL, above the toxic threshold.
3) She received oral activated charcoal and intravenous N-acetylcysteine in the hospital over 72 hours, with transient increases in liver enzymes but ultimately an uneventful recovery.
The document summarizes key aspects of acetaminophen toxicity including its biochemical basis, factors that influence toxicity, clinical manifestations, diagnosis, and treatment. Acetaminophen is mostly metabolized safely but can cause liver damage if it depletes glutathione stores, allowing a toxic metabolite to accumulate and bind hepatocytes. Chronic alcoholics are particularly at risk due to induced cytochrome enzymes. Treatment involves gastric decontamination and N-acetylcysteine administration within 10 hours of overdose to prevent liver injury.
Paracetamol was developed in the late 1880s as a less toxic derivative of acetanilide. It is metabolized in the liver to a toxic intermediate called NAPQI, which is normally detoxified by glutathione. An overdose can deplete glutathione stores, allowing NAPQI to damage liver cells. Paracetamol poisoning has few early symptoms but can cause liver failure and death. Treatment involves N-acetylcysteine to replenish glutathione within 8-24 hours of ingestion. Prognosis depends on factors like time to treatment, dose ingested, and underlying liver health.
This document provides information on the management of acetaminophen (APAP) toxicity. It discusses the history of APAP use, its widespread presence in over-the-counter medications, pharmacological actions, pharmacokinetics, toxicity risks, stages of poisoning, and treatment with N-acetylcysteine (NAC). It emphasizes the importance of timely NAC administration based on the Rumack-Matthew nomogram to prevent hepatic damage from APAP overdose. Two case studies demonstrate the application of these principles in clinical practice.
This document discusses various diagnostic procedures and dynamic tests used in chemical pathology, focusing on tests for disorders of growth hormone, cortisol, and aldosterone metabolism. It provides details on insulin hypoglycemic tests, glucose stimulation tests, clonidine stimulation tests, and exercise stimulation tests. These tests measure hormonal responses to stimuli like insulin-induced hypoglycemia, glucagon administration, clonidine administration, or exercise to evaluate the functioning of the hypothalamic-pituitary-end organ axes. The document outlines the procedures, normal responses, and interpretations for each type of dynamic test.
The document discusses several medical topics:
1. New guidelines from the Endocrine Society on the management of primary aldosteronism, including case detection criteria, confirmation testing, subtype classification testing, and treatment recommendations.
2. Pros and cons of the National Bone Health Alliance's diagnostic criteria for osteoporosis, which expands the definition to include factors like fracture risk assessment (FRAX) scores in addition to bone mineral density testing.
3. Updated clinical practice guidelines from the American Association of Clinical Endocrinologists and American College of Endocrinology for developing comprehensive care plans for patients with diabetes mellitus.
This document discusses examinations for endocrine disorders. It describes different types of endocrine disorders based on hormone levels and tests to dynamically suppress or stimulate hormones. Various examination methods are outlined, including laboratory tests to measure hormone levels and functional tests like stimulatory and inhibitory tests. Imaging methods like ultrasonography, CT, MRI, and scintigraphy are described for localizing endocrine tumors or complications. Specific tests are detailed for evaluating pituitary, thyroid, and adrenal function.
The document discusses key principles of hormone testing:
1. Biochemical confirmation of endocrine disease is needed before imaging tests.
2. Simultaneous measurement of trophic and target hormones can help determine the location of abnormalities.
3. Test abnormalities do not always reflect endocrine dysfunction, and some tests may be normal despite real dysfunction. Reliability depends on choice of tests, patient preparation, specimen integrity, and test quality.
Case study on paracetamol poisoning(Acetaminophen toxicity)Neeraj Ojha
1) A 16-year-old female was brought to the emergency department six hours after a suspected acetaminophen and alcohol overdose in an apparent suicide attempt following a breakup.
2) Laboratory tests showed mildly elevated liver enzymes and an acetaminophen level of 308 ug/mL, above the toxic threshold.
3) She received oral activated charcoal and intravenous N-acetylcysteine in the hospital over 72 hours, with transient increases in liver enzymes but ultimately an uneventful recovery.
The document summarizes key aspects of acetaminophen toxicity including its biochemical basis, factors that influence toxicity, clinical manifestations, diagnosis, and treatment. Acetaminophen is mostly metabolized safely but can cause liver damage if it depletes glutathione stores, allowing a toxic metabolite to accumulate and bind hepatocytes. Chronic alcoholics are particularly at risk due to induced cytochrome enzymes. Treatment involves gastric decontamination and N-acetylcysteine administration within 10 hours of overdose to prevent liver injury.
Paracetamol was developed in the late 1880s as a less toxic derivative of acetanilide. It is metabolized in the liver to a toxic intermediate called NAPQI, which is normally detoxified by glutathione. An overdose can deplete glutathione stores, allowing NAPQI to damage liver cells. Paracetamol poisoning has few early symptoms but can cause liver failure and death. Treatment involves N-acetylcysteine to replenish glutathione within 8-24 hours of ingestion. Prognosis depends on factors like time to treatment, dose ingested, and underlying liver health.
This document provides information on the management of acetaminophen (APAP) toxicity. It discusses the history of APAP use, its widespread presence in over-the-counter medications, pharmacological actions, pharmacokinetics, toxicity risks, stages of poisoning, and treatment with N-acetylcysteine (NAC). It emphasizes the importance of timely NAC administration based on the Rumack-Matthew nomogram to prevent hepatic damage from APAP overdose. Two case studies demonstrate the application of these principles in clinical practice.
1. Relative adrenal insufficiency is common in ICU patients with septic shock, but its clinical importance remains controversial. There is no agreed upon standard for diagnosing it, and uncertainty about treatment response.
2. ICU patients with septic shock whose blood pressure does not respond to fluid boluses and vasopressors should receive stress-dose steroids like hydrocortisone, though guidelines are based on limited evidence given mixed study results.
3. Critically ill ICU patients who recently received long-term steroids equivalent to 25 mg prednisone daily for over 7 days may need stress-dose steroid coverage due to risk of adrenal insufficiency.
1. Paracetamol toxicity results from formation of a reactive metabolite that binds to cellular proteins, causing cell death and hepatic or renal failure. Acetylcysteine replenishes glutathione stores and is highly effective if given within 8 hours of overdose.
2. Salicylate poisoning causes respiratory alkalosis, metabolic acidosis, and organ damage. Treatment involves correcting dehydration and acidosis with sodium bicarbonate. Hemodialysis is effective for removing salicylates from the body.
3. Tricyclic antidepressant overdose can cause arrhythmias, hypotension, and seizures due to sodium channel blockade. Treatment involves sodium bicarbonate to correct
A 35-year-old Indian housewife presented to the hospital 2 hours after intentionally ingesting 20 tablets of paracetamol (acetaminophen) due to family problems and suicidal thoughts. Her physical exam was unremarkable except for tachycardia. Laboratory tests and management for paracetamol overdose were recommended based on the risk of liver toxicity and failure from metabolism of excess amounts into a reactive compound depleted by glutathione stores. Treatment with N-acetylcysteine was indicated based on the timing and amount of ingestion to prevent hepatotoxicity.
This document describes four case scenarios involving patients presenting with various endocrine-related symptoms. The first case involves a 17-year-old boy with gynecomastia and absence of secondary sex characteristics. The second case involves a 16-year-old girl with delayed menarche and short stature. The third case involves a 30-year-old woman with spontaneous milk discharge and infertility. The fourth case involves a 32-year-old man with headaches, vision issues, fatigue, and erectile dysfunction. The document then provides background information on conditions like hyperprolactinemia, prolactinomas, Cushing's syndrome, MEN type 1 and 2 syndromes, and their typical clinical presentations, evaluations
The document discusses acetaminophen poisoning in children. It describes acetaminophen as a drug with analgesic and antipyretic properties that can cause toxicity when too much is ingested. The toxicity results from a reactive metabolite that depletes glutathione stores in the liver. It outlines the stages of acetaminophen toxicity and emphasizes the importance of rapid treatment with N-acetylcysteine to prevent liver damage. Diagnosis involves measuring acetaminophen levels in conjunction with liver enzymes and coagulation factors.
A 34-year-old British woman presented to the emergency department 30 minutes after ingesting approximately 100 acetaminophen tablets with alcohol in a suspected suicide attempt. She was treated with activated charcoal and intravenous N-acetylcysteine. On the first day of admission she developed abdominal pain and vomiting. Her liver function tests remained normal during her 3-day admission before she discharged herself against medical advice to return to the UK. Paracetamol overdose is commonly seen and requires prompt treatment with N-acetylcysteine to prevent liver damage from toxic metabolite accumulation if ingestion exceeds toxic thresholds.
A 34-year-old male presented with body aches, muscle weakness, numbness, and tingling in the limbs for 5 days. He also had polyuria, polydipsia, headaches and palpitations. He was found to have hypokalemia (potassium 2.1) and hypernatremia (sodium 156). He was diagnosed with primary hyperaldosteronism or Conn's syndrome, which causes hypokalemia and hypertension due to excessive aldosterone secretion. Treatment depends on the cause, including surgery for unilateral adenomas or medication with aldosterone antagonists for bilateral adrenal hyperplasia.
This document discusses the assessment and management of drug overdoses. It covers evaluating the patient's history, performing examinations and investigations. Key poisoning agents discussed include paracetamol, aspirin, tricyclic antidepressants, benzodiazepines, opiates, and others. Management involves supportive care, decontamination, specific antidotes, and monitoring for complications depending on the toxin ingested.
Aspirin toxicity remains an important clinical problem due to aspirin's widespread availability and use. Aspirin is rapidly absorbed in the stomach and metabolized in the liver. Toxicity can cause a wide range of symptoms affecting multiple organ systems. Diagnosis is based on history of ingestion and characteristic laboratory abnormalities. Management involves gastric decontamination, fluid replacement, urine alkalinization, and hemodialysis in severe cases.
Paracetamol poisoning admissions to the Poison Treatment Center in New York have increased in recent years. Paracetamol is rapidly absorbed and causes liver damage through a toxic metabolite. Treatment involves assessing ingestion amount and time to determine if acetylcysteine (NAC) is needed. NAC treatment is most effective when started within 8 hours and involves a 3-stage infusion or oral dosing. While reactions can occur, NAC is the antidote for paracetamol overdose and aims to prevent liver injury.
A 14-year-old female presented with lethargy, chest pain, vomiting, and a temperature of 95.5°F after ingesting 40-70 acetaminophen tablets (750 mg/kg) following failing a school exam. Her acetaminophen level was critically high at 4-5 hours. She was treated with N-acetylcysteine and recovered without liver toxicity.
This document provides an overview of salicylate (aspirin) overdose or toxicity. It discusses the therapeutic uses and inherent toxicity of salicylates. It covers the pathophysiology, diagnosis, clinical presentation, and treatment of both acute and chronic salicylate poisoning. Symptoms can involve multiple organ systems. Treatment focuses on decontamination, fluid resuscitation, urinary alkalinization, and hemodialysis in severe cases. Prognosis is generally good for acute overdoses but worse for chronic poisoning.
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
This patient is a 25 year old female admitted to the ICU for respiratory failure and hypotension following a 6 day prodromal illness. She is intubated and receiving vasopressors. The differential diagnosis includes sepsis, severe sepsis, or septic shock from an unknown source. Principles of management include identifying the source, administering appropriate antibiotics, optimizing hemodynamics and organ function, and providing lung protective ventilation for her acute respiratory distress syndrome. Early enteral nutrition is important to support her systemic immune response and prevent further organ dysfunction from a cumulative energy deficit.
This document discusses a case of hypothyroidism in a female patient. Key details include:
- The patient presented with depressed mood, lethargy, lack of initiative, heavy menstrual bleeding, and low hemoglobin.
- Examination found cold skin, mild goiter, slowed pulse, high blood pressure, and signs of hypothyroidism like delayed ankle jerk.
- Laboratory tests found elevated TSH, anemia, and other signs consistent with hypothyroidism.
- The patient was diagnosed with hypothyroidism, likely autoimmune/Hashimoto's thyroiditis based on her symptoms and laboratory results. She was started on levothyroxine treatment.
The document discusses hormonal therapy for prostate cancer. It provides a history of hormonal therapy and discusses key figures like Charles Huggins who demonstrated that castration improved outcomes for advanced prostate cancer. It then discusses the molecular biology of the androgen axis and different therapeutic approaches to hormonal therapy including ablation of androgen sources, anti-androgens, LHRH agonists/antagonists, and inhibition of androgen synthesis. Specific drugs are discussed for each class. Adverse effects of hormonal therapy like osteoporosis and hot flashes are also summarized.
Laboratory tests play an important role in psychiatry by helping with diagnosis, monitoring treatment, and detecting potential side effects or medical comorbidities. Key tests include blood tests to evaluate thyroid, liver, kidney, and metabolic function, as well as tests for infections. Monitoring tests are important when prescribing medications like antipsychotics that can affect metabolic parameters and increase risk of conditions like diabetes. Laboratory evaluations can help optimize treatment safety and effectiveness in psychiatry.
Nick Buckley: Paracetamol: More than Meets the EyeSMACC Conference
1) A 24-year-old woman took 15 grams of paracetamol and had a paracetamol level of 300 nmol/mL (45 mg/L) at 12 hours.
2) According to treatment guidelines, it is unclear if she should be treated with acetylcysteine, as her location and year are unknown.
3) The document discusses the risks of hepatotoxicity and death if she is or is not treated with acetylcysteine, as well as debates around treatment thresholds over time.
Katznelson, L., Laws Jr, E. R., Melmed, S., Molitch, M. E., Murad, M. H., Utz, A., & Wass, J. A. (2014). Acromegaly: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 99(11), 3933-3951.
Diagnostic test for Adrenal disorders in children 2.pptxAzad Haleem
The document provides information on various diagnostic tests for adrenal disorders in children, including the ACTH test, serum cortisol test, urinary free cortisol test, salivary cortisol test, and different dexamethasone suppression tests. The ACTH test can help differentiate primary and secondary adrenal insufficiency and ACTH-dependent and independent causes. The cortisol tests evaluate cortisol levels at different times to screen for adrenal insufficiency or excess. The dexamethasone suppression tests use dexamethasone to inhibit ACTH and cortisol production, with inability to suppress indicating hypercortisolism.
Cushing's syndrome is caused by prolonged exposure to high levels of cortisol. It can be divided into ACTH-dependent and ACTH-independent types. ACTH-dependent causes include Cushing's disease (pituitary adenoma), ectopic ACTH syndrome, and ectopic CRH syndrome. ACTH-independent causes include adrenal adenoma or carcinoma. Diagnostic tests include urine cortisol tests, dexamethasone suppression tests, and ACTH level measurements. Bilateral inferior petrosal sinus sampling is the most accurate way to distinguish Cushing's disease from ectopic ACTH syndrome.
1. Relative adrenal insufficiency is common in ICU patients with septic shock, but its clinical importance remains controversial. There is no agreed upon standard for diagnosing it, and uncertainty about treatment response.
2. ICU patients with septic shock whose blood pressure does not respond to fluid boluses and vasopressors should receive stress-dose steroids like hydrocortisone, though guidelines are based on limited evidence given mixed study results.
3. Critically ill ICU patients who recently received long-term steroids equivalent to 25 mg prednisone daily for over 7 days may need stress-dose steroid coverage due to risk of adrenal insufficiency.
1. Paracetamol toxicity results from formation of a reactive metabolite that binds to cellular proteins, causing cell death and hepatic or renal failure. Acetylcysteine replenishes glutathione stores and is highly effective if given within 8 hours of overdose.
2. Salicylate poisoning causes respiratory alkalosis, metabolic acidosis, and organ damage. Treatment involves correcting dehydration and acidosis with sodium bicarbonate. Hemodialysis is effective for removing salicylates from the body.
3. Tricyclic antidepressant overdose can cause arrhythmias, hypotension, and seizures due to sodium channel blockade. Treatment involves sodium bicarbonate to correct
A 35-year-old Indian housewife presented to the hospital 2 hours after intentionally ingesting 20 tablets of paracetamol (acetaminophen) due to family problems and suicidal thoughts. Her physical exam was unremarkable except for tachycardia. Laboratory tests and management for paracetamol overdose were recommended based on the risk of liver toxicity and failure from metabolism of excess amounts into a reactive compound depleted by glutathione stores. Treatment with N-acetylcysteine was indicated based on the timing and amount of ingestion to prevent hepatotoxicity.
This document describes four case scenarios involving patients presenting with various endocrine-related symptoms. The first case involves a 17-year-old boy with gynecomastia and absence of secondary sex characteristics. The second case involves a 16-year-old girl with delayed menarche and short stature. The third case involves a 30-year-old woman with spontaneous milk discharge and infertility. The fourth case involves a 32-year-old man with headaches, vision issues, fatigue, and erectile dysfunction. The document then provides background information on conditions like hyperprolactinemia, prolactinomas, Cushing's syndrome, MEN type 1 and 2 syndromes, and their typical clinical presentations, evaluations
The document discusses acetaminophen poisoning in children. It describes acetaminophen as a drug with analgesic and antipyretic properties that can cause toxicity when too much is ingested. The toxicity results from a reactive metabolite that depletes glutathione stores in the liver. It outlines the stages of acetaminophen toxicity and emphasizes the importance of rapid treatment with N-acetylcysteine to prevent liver damage. Diagnosis involves measuring acetaminophen levels in conjunction with liver enzymes and coagulation factors.
A 34-year-old British woman presented to the emergency department 30 minutes after ingesting approximately 100 acetaminophen tablets with alcohol in a suspected suicide attempt. She was treated with activated charcoal and intravenous N-acetylcysteine. On the first day of admission she developed abdominal pain and vomiting. Her liver function tests remained normal during her 3-day admission before she discharged herself against medical advice to return to the UK. Paracetamol overdose is commonly seen and requires prompt treatment with N-acetylcysteine to prevent liver damage from toxic metabolite accumulation if ingestion exceeds toxic thresholds.
A 34-year-old male presented with body aches, muscle weakness, numbness, and tingling in the limbs for 5 days. He also had polyuria, polydipsia, headaches and palpitations. He was found to have hypokalemia (potassium 2.1) and hypernatremia (sodium 156). He was diagnosed with primary hyperaldosteronism or Conn's syndrome, which causes hypokalemia and hypertension due to excessive aldosterone secretion. Treatment depends on the cause, including surgery for unilateral adenomas or medication with aldosterone antagonists for bilateral adrenal hyperplasia.
This document discusses the assessment and management of drug overdoses. It covers evaluating the patient's history, performing examinations and investigations. Key poisoning agents discussed include paracetamol, aspirin, tricyclic antidepressants, benzodiazepines, opiates, and others. Management involves supportive care, decontamination, specific antidotes, and monitoring for complications depending on the toxin ingested.
Aspirin toxicity remains an important clinical problem due to aspirin's widespread availability and use. Aspirin is rapidly absorbed in the stomach and metabolized in the liver. Toxicity can cause a wide range of symptoms affecting multiple organ systems. Diagnosis is based on history of ingestion and characteristic laboratory abnormalities. Management involves gastric decontamination, fluid replacement, urine alkalinization, and hemodialysis in severe cases.
Paracetamol poisoning admissions to the Poison Treatment Center in New York have increased in recent years. Paracetamol is rapidly absorbed and causes liver damage through a toxic metabolite. Treatment involves assessing ingestion amount and time to determine if acetylcysteine (NAC) is needed. NAC treatment is most effective when started within 8 hours and involves a 3-stage infusion or oral dosing. While reactions can occur, NAC is the antidote for paracetamol overdose and aims to prevent liver injury.
A 14-year-old female presented with lethargy, chest pain, vomiting, and a temperature of 95.5°F after ingesting 40-70 acetaminophen tablets (750 mg/kg) following failing a school exam. Her acetaminophen level was critically high at 4-5 hours. She was treated with N-acetylcysteine and recovered without liver toxicity.
This document provides an overview of salicylate (aspirin) overdose or toxicity. It discusses the therapeutic uses and inherent toxicity of salicylates. It covers the pathophysiology, diagnosis, clinical presentation, and treatment of both acute and chronic salicylate poisoning. Symptoms can involve multiple organ systems. Treatment focuses on decontamination, fluid resuscitation, urinary alkalinization, and hemodialysis in severe cases. Prognosis is generally good for acute overdoses but worse for chronic poisoning.
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
This patient is a 25 year old female admitted to the ICU for respiratory failure and hypotension following a 6 day prodromal illness. She is intubated and receiving vasopressors. The differential diagnosis includes sepsis, severe sepsis, or septic shock from an unknown source. Principles of management include identifying the source, administering appropriate antibiotics, optimizing hemodynamics and organ function, and providing lung protective ventilation for her acute respiratory distress syndrome. Early enteral nutrition is important to support her systemic immune response and prevent further organ dysfunction from a cumulative energy deficit.
This document discusses a case of hypothyroidism in a female patient. Key details include:
- The patient presented with depressed mood, lethargy, lack of initiative, heavy menstrual bleeding, and low hemoglobin.
- Examination found cold skin, mild goiter, slowed pulse, high blood pressure, and signs of hypothyroidism like delayed ankle jerk.
- Laboratory tests found elevated TSH, anemia, and other signs consistent with hypothyroidism.
- The patient was diagnosed with hypothyroidism, likely autoimmune/Hashimoto's thyroiditis based on her symptoms and laboratory results. She was started on levothyroxine treatment.
The document discusses hormonal therapy for prostate cancer. It provides a history of hormonal therapy and discusses key figures like Charles Huggins who demonstrated that castration improved outcomes for advanced prostate cancer. It then discusses the molecular biology of the androgen axis and different therapeutic approaches to hormonal therapy including ablation of androgen sources, anti-androgens, LHRH agonists/antagonists, and inhibition of androgen synthesis. Specific drugs are discussed for each class. Adverse effects of hormonal therapy like osteoporosis and hot flashes are also summarized.
Laboratory tests play an important role in psychiatry by helping with diagnosis, monitoring treatment, and detecting potential side effects or medical comorbidities. Key tests include blood tests to evaluate thyroid, liver, kidney, and metabolic function, as well as tests for infections. Monitoring tests are important when prescribing medications like antipsychotics that can affect metabolic parameters and increase risk of conditions like diabetes. Laboratory evaluations can help optimize treatment safety and effectiveness in psychiatry.
Nick Buckley: Paracetamol: More than Meets the EyeSMACC Conference
1) A 24-year-old woman took 15 grams of paracetamol and had a paracetamol level of 300 nmol/mL (45 mg/L) at 12 hours.
2) According to treatment guidelines, it is unclear if she should be treated with acetylcysteine, as her location and year are unknown.
3) The document discusses the risks of hepatotoxicity and death if she is or is not treated with acetylcysteine, as well as debates around treatment thresholds over time.
Katznelson, L., Laws Jr, E. R., Melmed, S., Molitch, M. E., Murad, M. H., Utz, A., & Wass, J. A. (2014). Acromegaly: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 99(11), 3933-3951.
Diagnostic test for Adrenal disorders in children 2.pptxAzad Haleem
The document provides information on various diagnostic tests for adrenal disorders in children, including the ACTH test, serum cortisol test, urinary free cortisol test, salivary cortisol test, and different dexamethasone suppression tests. The ACTH test can help differentiate primary and secondary adrenal insufficiency and ACTH-dependent and independent causes. The cortisol tests evaluate cortisol levels at different times to screen for adrenal insufficiency or excess. The dexamethasone suppression tests use dexamethasone to inhibit ACTH and cortisol production, with inability to suppress indicating hypercortisolism.
Cushing's syndrome is caused by prolonged exposure to high levels of cortisol. It can be divided into ACTH-dependent and ACTH-independent types. ACTH-dependent causes include Cushing's disease (pituitary adenoma), ectopic ACTH syndrome, and ectopic CRH syndrome. ACTH-independent causes include adrenal adenoma or carcinoma. Diagnostic tests include urine cortisol tests, dexamethasone suppression tests, and ACTH level measurements. Bilateral inferior petrosal sinus sampling is the most accurate way to distinguish Cushing's disease from ectopic ACTH syndrome.
The document summarizes various adrenal function tests that can be used to diagnose disorders of the adrenal glands and related hormones. It describes tests such as cortisol levels, ACTH levels and stimulation tests, dexamethasone suppression tests, and tests for aldosterone, electrolytes, and sex hormones. These tests help evaluate adrenal function, detect tumors, diagnose conditions like Cushing's syndrome and Addison's disease, and assess the hypothalamic-pituitary-adrenal axis.
This document summarizes various endocrine tests used to assess different endocrine functions and disorders. It describes dynamic tests such as the insulin tolerance test used to evaluate the hypothalamic-pituitary-adrenal axis and growth hormone axis. It also summarizes tests used to evaluate disorders of the adrenal glands such as the ACTH stimulation test, dexamethasone suppression tests, and tests used to diagnose Cushing's syndrome and hyperaldosteronism. Precautions, interpretations and procedures are provided for many of the major endocrine dynamic tests.
The document discusses the hypothalamic-pituitary-adrenal (HPA) axis and adrenal gland function. It describes:
- The zones of the adrenal cortex that produce glucocorticoids, mineralocorticoids, and androgens under control of the HPA axis.
- Diseases like Cushing's syndrome caused by excess cortisol and primary hyperaldosteronism caused by excess aldosterone.
- Investigations used to diagnose HPA axis and adrenal disorders and their treatment options which may include drugs, surgery, or radiotherapy depending on the underlying cause.
Accuracy of Laboratory Parameters in Management of CKD and NCDRavi Kumudesh
New model for Health care delivery is suggesting to replace traditional health care organisational structure in Sri Lanka. This type of innovation is essential for "Non Patient" type healthcare receivers, such as "Healthy healthcare receivers" and "Risk Groups".
This topic is inspired by Secretary, CMLS.SL at the Annual Academic Sessions of DiASL on April 22, 2017.
CMLS.SL - College of Medical Laboratory Science, Sri Lanka
DiASL - Dietetic Association of Sri Lanka
This document provides an overview of adrenal gland anatomy, physiology, and the management of several adrenal gland disorders. It discusses Conn's syndrome (primary hyperaldosteronism), Cushing's syndrome, sex hormone excess from adrenal tumors, and pheochromocytoma. For each condition, it describes the epidemiology, clinical presentation, diagnostic approach including localization tests, and surgical and medical management strategies. It provides case examples and details perioperative care for adrenal surgery. The overall document is a lecture on adrenal gland disorders and their clinical approach and treatment.
ASSESSMENT OF AUTONOMIC FUNCTION TEST.pptxNeurologyKota
The document discusses autonomic function tests which are used to evaluate autonomic nervous system disorders. It describes various cardiovascular, sudomotor and pupillary reflex tests to assess different aspects of autonomic function. Cardiovascular tests include postural challenge tests, Valsalva maneuver, deep breathing test and isometric handgrip test. Sudomotor tests include quantitative sudomotor axon reflex test and thermoregulatory sweat test. The tests help diagnose autonomic dysfunction, evaluate its severity and distribution. Management involves identifying and treating the underlying cause, along with medications and lifestyle changes to alleviate symptoms like orthostatic hypotension.
This document summarizes key concepts regarding the endocrine system and hormone testing. It describes how the hypothalamus regulates the anterior pituitary via releasing hormones, and the feedback loops between the hypothalamus/pituitary and target endocrine glands. It also discusses principles of testing the endocrine axes, categories of hormones, hormone resistance, common hormone assays like TSH, testosterone, hemoglobin A1C, and their clinical significance. Finally, it reviews the islets of Langerhans, insulin synthesis and secretion, and the insulin response in normal vs diabetic subjects.
A 54-year-old man presented with symptoms of Cushing's syndrome including weight gain, muscle weakness, high blood pressure, and red stretch marks. His lab tests showed very high ACTH and cortisol levels, confirming Cushing's disease caused by a pituitary tumor that overproduces ACTH. Cushing's disease is the most common cause of Cushing's syndrome and results from a pituitary tumor that releases excess ACTH, stimulating excess cortisol production. Treatment options include surgery to remove the pituitary tumor, radiation therapy if surgery is not possible, and medication to control cortisol levels before and after treatment.
1) The document discusses the evaluation, imaging, and biochemical workup of adrenal incidentalomas to determine if they are hormonally active, malignant, or require surgical removal. Computed tomography, magnetic resonance imaging, and positron emission tomography scans are used to characterize adrenal masses.
2) Biochemical tests evaluate for hypercortisolism, aldosteronism, and pheochromocytoma. Patients with hormonally active or malignant adrenal tumors may require surgery, while others may only need radiographic follow up.
3) For patients requiring surgery, preoperative optimization is important for controlling blood pressure and cardiovascular effects in patients with pheochromocytoma or hypercortisolism
Hypopituitarism is a clinical syndrome caused by deficiency of pituitary hormones. It can result from disorders of the pituitary gland, hypothalamus or surrounding structures. Common causes include tumors, trauma, radiation injury, infections and autoimmune disorders. Patients present with symptoms related to deficiencies of growth hormone, thyroid stimulating hormone, adrenocorticotropic hormone, gonadotropins and antidiuretic hormone. Diagnosis involves hormonal blood tests and imaging. Treatment consists of lifelong hormone replacement therapy to replace deficient hormones and mimic normal physiology.
The document summarizes key information about the adrenal gland and hormones it produces. It discusses cortisol and aldosterone in depth, including their functions, regulation, and diagnostic tests. It also briefly outlines other hormones produced by the adrenal gland such as androgens and catecholamines, and their normal levels and functions. Various functional tests for evaluating the adrenal gland and its response to ACTH stimulation are summarized, including their medical importance.
This document discusses adrenal insufficiency (AI), including its pathophysiology, classification, epidemiology, etiology, diagnosis, clinical presentation, and treatment. AI arises from disruption of the hypothalamus-pituitary-adrenal axis regulation of steroidogenesis. It can be primary, resulting from dysfunction of the adrenal glands, or secondary, due to dysfunction of the hypothalamus or pituitary gland. Diagnosis involves assessing cortisol levels and response to stimulation tests to determine if cortisol secretion is inadequate and if the cause is a lack of ACTH. Treatment differs between acute adrenal crisis and chronic AI.
Cushing's syndrome is caused by chronic overexposure to cortisol and can be difficult to diagnose. It may be due to an ACTH-secreting pituitary adenoma (Cushing's disease), an ectopic ACTH-secreting tumor, or an adrenal tumor. Diagnostic tests include midnight salivary cortisol levels, dexamethasone suppression tests, and imaging of the pituitary and adrenal glands. Treatment depends on the cause but may involve surgery to remove tumors, radiation therapy, or medication to suppress cortisol levels. Even after successful treatment, patients remain at higher risk for cardiovascular disease.
Cushing's syndrome is caused by chronic overexposure to cortisol and can be difficult to diagnose. It may be pituitary-dependent (Cushing's disease), adrenal-dependent (adenoma or carcinoma), or caused by an ectopic ACTH-secreting tumor. Diagnostic tests include urine and salivary cortisol levels, low and high dose dexamethasone suppression tests, and imaging of the pituitary and adrenal glands. Treatment depends on the cause but may involve surgery to remove tumors, adrenalectomy, or medication to suppress cortisol production while managing comorbidities. The prognosis has improved with effective treatments but risks remain high without treatment.
A 46-year-old man presented with symptoms including fatigue, easy bruising, and weight gain over the past 6 months. A physical examination revealed central obesity, a moon face, and abdominal striae. This presentation is consistent with Cushing's syndrome, which is caused by prolonged elevated glucocorticoid levels. Radiological investigations like adrenal CT/MRI, pituitary MRI, and chest X-ray can help determine the underlying cause. Initial treatment would involve pharmacotherapy to reduce cortisol levels through drugs like metyrapone and ketoconazole. Further treatment depends on the specific etiology but may involve surgery such as trans-sphenoidal tumor removal or bilateral adrenalectomy.
Opportunity for Dentists (BDS/MDS )to relocate to United kingdom -Register as a DENTAL HYGIENIST/ DENTAL THERAPIST without Board exams and after approval you can register in GDC as a DH/DT and start working as a DH/DT Immediately and get paid.
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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This document discusses dental occlusion concepts and philosophies for complete dentures. It introduces key terms like physiologic occlusion and defines different occlusion schemes like balanced articulation and monoplane articulation. The document discusses advantages and disadvantages of using anatomic versus non-anatomic teeth for complete dentures. It also outlines requirements for maintaining denture stability, such as balanced occlusal contacts and control of horizontal forces. The goal of occlusion for complete dentures is to re-establish the homeostasis of the masticatory system disrupted by edentulism.
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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This document discusses dental casting investment materials. It describes the three main types of investments - gypsum bonded, phosphate bonded, and ethyl silicate bonded investments. For gypsum bonded investments specifically, it details their classification, composition including the roles of gypsum, silica, and modifiers, setting time, normal and hygroscopic setting expansion, and thermal expansion. It provides information on how the properties of gypsum bonded investments are affected by their composition. The document serves as a comprehensive overview of dental casting investment materials.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
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LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
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The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
2. 2
TopicsTopics
• Regulation of glucocorticoid secretionRegulation of glucocorticoid secretion
• Spectrum of hormonal effects on the HPA axisSpectrum of hormonal effects on the HPA axis
• Spectrum of clinical manifestations of AISpectrum of clinical manifestations of AI
• Importance of diagnosisImportance of diagnosis
• Diagnostic hormonal testsDiagnostic hormonal tests
• Risk factors for HPA axis suppressionRisk factors for HPA axis suppression
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5. 5
Spectrum of Effects of ExogenousSpectrum of Effects of Exogenous
Glucocorticoids on the HPA AxisGlucocorticoids on the HPA Axis
• Effects on the HPA axis are variable as isEffects on the HPA axis are variable as is
individual susceptibility to suppression:individual susceptibility to suppression:
– No HPA axis suppression
– HPA axis suppression: secondary or central AI:
• suppression of the pituitary and hypothalamic
secretions of ACTH and CRH, respectively
• degree of suppression is variable
www.indiandentalacademy.com
6. 6
Spectrum of Effects of ExogenousSpectrum of Effects of Exogenous
Glucocorticoids on the HPA AxisGlucocorticoids on the HPA Axis
• Partial (mild) ACTH suppressionPartial (mild) ACTH suppression
– basal ACTH & cortisol levels may be normal
– pituitary response to stress is impaired, but adrenal
response may be normal
• Complete ACTH suppressionComplete ACTH suppression
– Adrenal gland atrophy with severe or prolonged
ACTH suppression; basal cortisol decreased; entire
HPA axis suppressed
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7. 7
Clinical SpectrumClinical Spectrum
• Abnormal hormonal response clinically relevantAbnormal hormonal response clinically relevant
• May be subclinicalMay be subclinical
• Symptoms may be nonspecific and insidiousSymptoms may be nonspecific and insidious
• Adrenal crisis (triggered by stress)Adrenal crisis (triggered by stress)
– fever
– severe hypotension
– shock
– coma
– death
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8. 8
HPA Axis SuppressionHPA Axis Suppression
Abnormal Hormonal Test
HPA Axis Suppression
No Symptoms Symptoms Present
At Risk for
ACUTE ADRENAL CRISIS !ACUTE ADRENAL CRISIS !
St ress!St ress!St ress!St ress!
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9. 9
Features of Glucocorticoid-InducedFeatures of Glucocorticoid-Induced
Adrenal InsufficiencyAdrenal Insufficiency
• Prevalence unknown:Prevalence unknown:
– lack of clinical suspicion:lack of clinical suspicion:
• absorption of topical corticosteroids may be
unrecognized
• diagnostic hormonal testing not performed
• signs and symptoms may be subtle and non-
specific
• attribution made to other causes
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10. 10
Features of Glucocorticoid-InducedFeatures of Glucocorticoid-Induced
Adrenal InsufficiencyAdrenal Insufficiency
• Prevalence unknown:Prevalence unknown:
– failure to detect if recovery of suppression isfailure to detect if recovery of suppression is
rapidrapid
– failure to detect if a diagnostic test of lowfailure to detect if a diagnostic test of low
sensitivity (i.e. high false negative rate) issensitivity (i.e. high false negative rate) is
performedperformed
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11. 11
Importance of Diagnosing AdrenalImportance of Diagnosing Adrenal
InsufficiencyInsufficiency
Identifying patients with adrenal insufficiency,Identifying patients with adrenal insufficiency,
even if mild, is important because:even if mild, is important because:
• life-threatening hypotension may occur during
periods of stress (e.g. illness, trauma, surgery)
• the condition is totally preventable if supplemental
glucocorticoids are administered
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12. 12
Diagnosis of Glucocorticoid-Induced:Diagnosis of Glucocorticoid-Induced:
Secondary Adrenal InsufficiencySecondary Adrenal Insufficiency
• Basal hormonal testsBasal hormonal tests
• Dynamic testing:Dynamic testing:
– tests of adrenocortical integrity (adrenal
gland integrity only)
– tests of HPA axis integrity (hypothalamic,
pituitary and adrenal integrity)
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13. 13
Basal Hormonal TestsBasal Hormonal Tests
• Plasma cortisol (single or multiple):Plasma cortisol (single or multiple):
– low sensitivity, thus, often non-diagnostic:
endogenous levels variable due to pulsatile secretion
• 24 hour urinary free cortisol:24 hour urinary free cortisol:
– often non-diagnostic: lack of sensitivity at low levels,
i.e. low cortisol excretion may be normal
– errors in 24 hour urine collections
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14. 14
Basal vs. Dynamic TestsBasal vs. Dynamic Tests
• Since basal plasma and 24h cortisol levels are
often non-diagnostic, it is necessary to perform
dynamic testing to diagnose adrenal
insufficiency.
• Advantage of dynamic testing: provide
information regarding the function, reserve
capacity and, hence, the ability of the adrenal
gland or of the entire HPA axis to respond to
stress.
www.indiandentalacademy.com
15. 15
Dynamic TestsDynamic Tests
• Dynamic tests of adrenocortical integrity (assessesDynamic tests of adrenocortical integrity (assesses
only adrenal gland responsiveness):only adrenal gland responsiveness):
– Cosyntropin (ACTH) stimulation test:
• high-dose ACTH
• low-dose ACTH
• Dynamic tests of HPA axis integrity (assesses theDynamic tests of HPA axis integrity (assesses the
responsiveness of the hypothalamus, pituitary andresponsiveness of the hypothalamus, pituitary and
adrenal glands):adrenal glands):
– ITT
– Corticotropin-releasing hormone test (CRH)
www.indiandentalacademy.com
17. 17
Diagnosis of 2Diagnosis of 200
Adrenal InsufficiencyAdrenal Insufficiency
CosyntropinCosyntropin
↓↓
adrenaladrenal
recent-onsetrecent-onset ↓↓ mildmild
suppressionsuppression ↓↓
Potential false negativePotential false negative
ITT or CRHITT or CRH
↓↓
entire HPA axisentire HPA axis
↓↓
↓↓
ITT: more sensitive thanITT: more sensitive than
cosyntropin;cosyntropin;
CRH: reports of equivalence to ITTCRH: reports of equivalence to ITT
www.indiandentalacademy.com
18. 18
High-Dose Cosyntropin TestHigh-Dose Cosyntropin Test
• Most commonly usedMost commonly used
• Methodology:Methodology:
– administer supraphysiologic dose synthetic ACTH, IV or IM:
• 125 ug if <2 years
• 250 ug if >2 years
– measure cortisol concentrations before and either 30 or 60
minutes after ACTH administration
• Advantages: simple, fast and inexpensive:Advantages: simple, fast and inexpensive:
• perform any time of day, outpatient- 30 or 60 minutes
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19. 19
High-Dose Cosyntropin TestHigh-Dose Cosyntropin Test
• Controversy regarding normal cortisol response:Controversy regarding normal cortisol response:
• criteria in cosyntropin label (30 minute test):
– basal cortisol >5 ug/dl, increment > 7ug/dl, peak >18 ug/dl
– low basal cortisol level does not suffice to make the diagnosis
– since the test can be performed at any time during the day
and only the peak plasma cortisol remains unchanged during
the day, this single criterion should be used for the 30’ test.
• since basal cortisol levels vary throughout the day and the
higher the basal level, the lower the incremental cortisol
rise, consensus regarding a normal response appears to be
a peak cortisol level >18ug/dl at 30 minutes.
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20. 20
High-Dose Cosyntropin TestHigh-Dose Cosyntropin Test
• Disadvantage:Disadvantage:
– sensitive screening test for 10
adrenal insufficiency
but less sensitive for diagnosing 20
adrenal
insufficiency, especially if partial (mild) or of recent
onset. In such cases, a false negative test may occur.
Additional testing may be necessary if the patient is
symptomatic or there is a high index of suspicion of
adrenal insufficiency.
www.indiandentalacademy.com
21. 21
Low-Dose Cosyntropin TestLow-Dose Cosyntropin Test
• Newer testNewer test
• Method not standardized regarding dose or timing ofMethod not standardized regarding dose or timing of
samplessamples:
– administer a physiologic ACTH dose intravenously
– measure cortisol before and serially post-ACTH
• Other issues:Other issues:
– physiologic ACTH dosing may be more sensitive than
supraphysiologic dosing for mild or recent-onset secondary AI
– dose not commercially available (dilutional errors, variability
in dose administered among tests, binding to plastic tubing)
www.indiandentalacademy.com
22. 22
Low-Dose vs. High-Dose TestLow-Dose vs. High-Dose Test
Low-DoseLow-Dose
• dose not available
• physiologic ACTH dose
• frequent, carefully timed
venous sampling
• no consensus on method of
performance
• no consensus regarding
normal response criteria:
lower limit cortisol cut-off
High-DoseHigh-Dose (Standard Dose)(Standard Dose)
• dose commercially available
• supraphysiologic ACTH dose
• single cortisol level post-
ACTH, no precise timing
• method of performance has
been standardized
• peak cortisol >18ug/dl at 30
minutes is generally accepted
as a normal response.
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23. 23
Insulin Tolerance Test (ITT)Insulin Tolerance Test (ITT)
• Hypoglycemia: potent stress stimulus for ACTHHypoglycemia: potent stress stimulus for ACTH
releaserelease
• Methodology:Methodology:
– intravenous insulin 0.05 U/kg after an overnight fast
– plasma cortisol and glucose levels before and at 30, 45, 60
and 90 minutes
• Criteria for normal response:Criteria for normal response:
– with serum glucose <40 mg/dl, plasma cortisol should
rise to >18-20 ug/dl at 60 to 90 minutes post-insulin.
www.indiandentalacademy.com
24. 24
Insulin Tolerance Test (ITT)Insulin Tolerance Test (ITT)
• Advantages:Advantages:
– direct and definitive assessment of HPA axis
• Disadvantages:Disadvantages:
– requires intensive in-patient physician monitoring
– risk of morbidity (seizures, neurological
impairment) and mortality from hypoglycemia.
Therefore, rarely, if ever, used. Safer alternatives
are available.
www.indiandentalacademy.com
25. 25
Corticotropin-Releasing HormoneCorticotropin-Releasing Hormone
(CRH) Test(CRH) Test
• Newer testNewer test
• CRH stimulates release of ACTH and, hence, cortisolCRH stimulates release of ACTH and, hence, cortisol
• 1100
(adrenal) vs. 2(adrenal) vs. 200
(pituitary) vs. 3(pituitary) vs. 300
(hypothalamic):(hypothalamic):
– 10
: basal ACTH is high and ↑ with ACTH but not cortisol;
– 20
: basal ACTH is low and does not respond to ACTH;
– 30
: basal ACTH is low and shows an exaggerated response to
ACTH
• Methodology:Methodology:
– administer CRH 1 ug/kg intravenously
– measure plasma ACTH and cortisol levels periodically for 90
to 180 minutes post-CRH.
www.indiandentalacademy.com
26. 26
Advantages of the CRH TestAdvantages of the CRH Test
• Direct and definitive assessment of HPA axisDirect and definitive assessment of HPA axis
integrity.integrity.
• The CRH test may have equivalent diagnosticThe CRH test may have equivalent diagnostic
value to the ITT.value to the ITT.
• Safe for outpatient useSafe for outpatient use
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27. 27
Disadvantages of CRH TestDisadvantages of CRH Test
• ExpensiveExpensive
• Requires multiple blood samplesRequires multiple blood samples
• Errors in blood collection and storage may occur.Errors in blood collection and storage may occur.
• Normal responses of ACTH and cortisol areNormal responses of ACTH and cortisol are
laboratory-dependent.laboratory-dependent.
• No consensus regarding criteria for a normal response.No consensus regarding criteria for a normal response.
• Not an FDA approved indication as a diagnostic for AI.Not an FDA approved indication as a diagnostic for AI.
• Additional studies are needed to confirm its usefulnessAdditional studies are needed to confirm its usefulness
as a diagnostic test for adrenal insufficiency.as a diagnostic test for adrenal insufficiency.
www.indiandentalacademy.com
28. 28
Risk Factors For HPA AxisRisk Factors For HPA Axis
Suppression with TopicallySuppression with Topically
Administered CorticosteriodsAdministered Corticosteriods
Variable individual susceptibility and time to recovery.Variable individual susceptibility and time to recovery.
Risk Factors:Risk Factors:
• steroid properties:steroid properties:
– potency
– half-life
• vehiclevehicle (e.g. cream, lotion, ointment)
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29. 29
Risk Factors For HPA AxisRisk Factors For HPA Axis
Suppression with TopicallySuppression with Topically
Administered CorticosteriodsAdministered Corticosteriods
• extent of absorption:extent of absorption:
– increased:
• thin stratum corneum
• heat and moisture (enhanced by occlusion)
• abraded or inflamed skin
• dose:dose:
– concentration
– body surface area exposed
– contact time
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30. 30
Risk Factors For HPA AxisRisk Factors For HPA Axis
Suppression with TopicallySuppression with Topically
Administered CorticosteriodsAdministered Corticosteriods
• cumulative dose:cumulative dose:
– dosing interval
– duration of treatment
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31. 31
Summary 1Summary 1
• Topical corticosteroids are systemically absorbed,Topical corticosteroids are systemically absorbed,
thereby secondary adrenal insufficiency may occur.thereby secondary adrenal insufficiency may occur.
• Symptoms of AI may be subtle and non-specific.Symptoms of AI may be subtle and non-specific.
• Diagnosis may not be suspected clinically orDiagnosis may not be suspected clinically or
attribution is made to other causes.attribution is made to other causes.
• Patients with secondary AI are at risk for an acutePatients with secondary AI are at risk for an acute
adrenal crisis, regardless of the degree of suppressionadrenal crisis, regardless of the degree of suppression
or the presence of symptoms.or the presence of symptoms.
• Acute adrenal crisis is preventable if supplementalAcute adrenal crisis is preventable if supplemental
glucocorticoids are administered before or early inglucocorticoids are administered before or early in
the course of stress.the course of stress.
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32. 32
Summary 2Summary 2
• Although risk factors for HPA axis suppression mayAlthough risk factors for HPA axis suppression may
be present, individual susceptibility is variable.be present, individual susceptibility is variable.
• Hormonal testing is required for diagnosis.Hormonal testing is required for diagnosis.
• Basal hormonal tests are often non-diagnostic.Basal hormonal tests are often non-diagnostic.
• Dynamic hormonal testing is generally required.Dynamic hormonal testing is generally required.
• Dynamic tests of HPA axis integrity are moreDynamic tests of HPA axis integrity are more
sensitive for the diagnosis of mild or recent-onsetsensitive for the diagnosis of mild or recent-onset
secondary AI than tests which measure onlysecondary AI than tests which measure only
adrenocortical reserve.adrenocortical reserve.
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33. 33
Summary 3Summary 3
• A negative high-dose cosyntropin test may warrantA negative high-dose cosyntropin test may warrant
additional testing particularly if the patient isadditional testing particularly if the patient is
symptomatic or if there is a high index of clinicalsymptomatic or if there is a high index of clinical
suspicion of secondary adrenal insufficiency.suspicion of secondary adrenal insufficiency.
• When HPA axis suppression is diagnosed, treatmentWhen HPA axis suppression is diagnosed, treatment
should follow standard medical practice.should follow standard medical practice.
• Patients should be followed to document full recoveryPatients should be followed to document full recovery
of the HPA axis.of the HPA axis.
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