Baseline Serum Cortisol Levels Research Articles

Effect of Music Therapy on Anxiety, Stress and Sedative Requirements in Patients Undergoing Lower Limb Orthopedic Surgery Under Spinal Anesthesia: A Randomized Controlled Study.

Background Music therapy is a safe, non-pharmacological way to help reduce anxiety, especially before surgery. It helps to calm the nervous system, promotes relaxation, and offers comfort by blocking outside noise and distracting from pain. This can be helpful in managing preoperative anxiety and symptoms like hypertension and tachycardia. While the benefits of music therapy for stress and sedation are well known, its specific effects on patients receiving spinal anesthesia haven't been studied yet. Understanding this could improve care for these patients. Overall, music therapy could be a valuable tool in the surgical process. Objectives Primary objective: The study aimed to compare sedative requirements between two patient groups. Secondary objectives: To compare anxiety levels between two patient groupsusing the State-Trait Anxiety Inventory. It also assessed hemodynamic changes and measured stress levels by analyzing serum cortisol and immunoglobulin A levels in both groups. Materials and methods Ninety-two American Society of Anesthesiologists physical status class I and II patients, aged 18-65 years, with a body mass index of 18-25 kg/m2 undergoing lower limb orthopedic surgery under spinal anesthesia were selected for the study. After spinal anesthesia, the group M (n=46)patients received the music of their choice from headphones connected to mobile phones and patients in group NM (n=46)were attached headphones without any music therapy. After the attachment of headphones, propofol was administered in both the groups for sedation in a bolus dose of 1-2mg/kg iv followed by an infusion dose of 5-50 μg/kg/min. The propofol infusion was titrated based on Bispectral Index (BIS) values kept between 70 and 80 for moderate sedation. Preoperatively, blood samples were collected to measure baseline serum cortisol and IgA levels. Intraoperatively, hemodynamic parameters were measured, and anxiety level was assessed using the State-Trait Anxiety Inventory (STAI) Scale 30 minutes prior to the administration of spinal anesthesia. Postoperatively, anxiety was re-evaluated, and additional blood samples for the assessment of cortisol and IgA were taken at 30 minutes and 12 hours after the administration of spinal anesthesia. Results The mean serum cortisol was lower in Group M as compared to Group NM (15.1±1.2 vs. 17.1±1; p = 0.0001). Mean serum IgA was significantly lower in Group M as compared to Group NM (269.3±54.5 vs. 294.2±49.9; p = 0.024) during the intraoperative period. The mean STAI Score was lower in Group Mcompared to Group NM (34.87±4.53 vs. 34.61±5.06; p = 0.008). The mean propofol requirement (mg) was lower in Group M as compared to Group NM (147.8±11.3 vs. 193±16; p = 0.0001). The hemodynamic parameters were comparable between the groups (p>0.05). Conclusion Patients in the music therapy group experienced lower anxiety, stress, and serum cortisol levels during surgery, with reduced serum IgA levels and decreased propofol requirement for sedation. Overall, music therapy was effective in reducing anxiety, stress, and sedative requirements during surgery under regional anesthesia.

Cognitive decline in Cushing's syndrome: A systematic review.

The neurocognitive and psychiatric effects of Cushing's syndrome (CS) are well recognized and negatively impact quality of life. The aim of this systematic review is to compare neurocognitive disease, psychiatric symptoms, and structural brain changes in patients with Cushing's disease (CD)/CS and those with non-functioning pituitary adenoma (NFPA), both before and after surgical treatment, and in comparison to healthy controls. Possible predictors of persistent neurocognitive symptoms and reduced quality of life in patients with CS are highlighted. We reviewed the English literature published in Medline/Pubmed until 2021 to identify eligible studies. This systematic review was registered on Prospero and reported following the PRISMA statement guidelines. The initial literature search yielded 1772 articles, of which 1096 articles remained after removing duplicates. After excluding case reports, animal studies, narrative reviews, comparative reviews, and articles not in English, 86 papers underwent full-text review. Studies eligible for inclusion met the following criteria: (1) described patients with CD/CS, (2) reports of psychiatric symptoms, (3) written in English or with available English translation, and (4) published in a peer-reviewed journal. The full-text review process identified 40 eligible studies. The 40 studies included a total of 2603 participants with CD or CS, with 45.2% of the total participants having CD. The majority of studies were case-control studies and used validated questionnaires such as the Beck's Depression Index, Trail Making Test, Hospital Anxiety and Depression Scale, and Cushing Quality of Life for screening. Compared to NFPA controls, patients with CD who had greater baseline serum cortisol levels had worse cognitive function, even after surgical remission. This suggests a possible association between greater baseline cortisol levels in patients with CS and persistent cognitive impairment. A longer duration of uncontrolled CS was associated with worse cognitive function; however, there was no association found between the length of remission and memory. Overall brain volume was increased in patients in remission from CD compared to active disease. However, temporal and frontal lobe volumes did not recover to normal volumes. Patients with CS experience neurocognitive dysfunction, psychiatric disorders, and diminished quality of life, and symptoms may persist after curative surgery. We found several factors consistently associated with persistent cognitive and neuropsychiatric symptoms in patients with CS including higher pre-operatively baseline cortisol production, longer duration of disease, frontal and temporal lobe atrophy, and the presence of cognitive and neuropsychiatric symptoms at baseline. Larger prospective studies are required to validate these findings.

Adrenal morphology and cortical function in patients with extrapulmonary tuberculosis: response to antituberculosis treatment.

Enlargement of the adrenal glands and variable adrenocortical function have been reported in patients with pulmonary tuberculosis and, in a few studies, in patients with extrapulmonary tuberculosis (EPTB). However, none of the studies have evaluated the course of the adrenal morphology in these patients. Prospective study including 37 patients with EPTB and 37 healthy age- and sex-matched controls. The adrenal function was evaluated by measurement of cortisol levels at baseline and after stimulation with ACTH (Acton Prolongatum) before and 6 months after antituberculosis treatment. The size of both adrenal glands was evaluated using 64-slice computed tomography (CT) scanning before and 6 months after treatment. The findings were compared with those in a group of healthy matched controls. Clinical and biochemical parameters were comparable between groups. The mean baseline serum cortisol level was significantly lower in the EPTB group (397.1 ± 184.9 nmol/L) compared with the control group (696.3 ± 101.8 nmol/L). Compared with controls, patients with EPTB had significantly lower mean cortisol levels at baseline and 1 hour after ACTH, both before (397 ± 184.9 nmol/L and 750.7 ± 176.8 nmol/L, respectively) and after (529.7 ± 100.4 nmol/L and 1017.2 ± 119.7 nmol/L, respectively) antituberculosis treatment. Both the length and thickness of the right and left adrenal glands were greater in patients with EPTB than in controls but became comparable to those in controls after treatment completion. Patients with EPTB have an enlarged adrenal size and low baseline and stimulated serum cortisol levels. After treatment completion, cortisol levels increased significantly, and the adrenal size normalized in these patients.

Neuroendocrine System Adaptation during Consecutive Extrinsic Stimuli: A Pilot Dynamic Study.

This pilot repeated measures study aims to evaluate the dynamics of the autonomic nervous system (ANS), the hypothalamic-pituitary-adrenal (HPA) axis, and/or their interplay with low-level inflammation in healthy schoolchildren during consecutive extrinsic stimuli. Twenty healthy schoolchildren and adolescents aged 11-14 years (12.5 ± 1.5) were consecutively exposed to an oral task (#2) and an arithmetic task (#3) (Trier Social Stress Test for Children (TSST-C)), lasting 5 min each, and a three-minute cellular phone call (#4). Salivary cortisol (SC) was sampled at baseline (#1) and immediately after each exposure (#2, 3, and 4). Baseline serum high-sensitivity C-reactive protein (hsCRP) and cortisol levels were also assessed. ANS dynamics and complexity were measured using Sample Entropy (SampEn) at each experimental time period (#1-4). Baseline serum hCRP and cortisol correlated negatively to each other, while the ANS and HPA axis acute reactions to the three consecutive stimuli differed over time. The ANS adaptation to these stimuli included complexity modulation, which was not dependent on baseline hsCRP or cortisol, and weakened during the third stimulation. However, baseline hsCRP and cortisol had a weakening and an increasing effect on the HPA axis over time, respectively. We conclude that low-level inflammation and baseline morning cortisol level have no effect on ANS dynamics but influence the HPA axis response to consecutive external stimuli.

Metabolic disorders during endogenous Cushing's syndrome: prevalence, associated factors, and outcome after remission.

Objective. The prognosis of Cushing's syndrome (CS) is related to a higher cardiovascular morbidity and mortality. This study aimed to determine the prevalence of metabolic disorders in patients with CS, the associated factors, and the rate of remission of these disorders after the remission from CS. Methods. It is a retrospective study including 75 cases of CS followed up at the university hospital La Rabta of Tunis from 1987 to 2018. Clinical and paraclinical data were collected from medical files. Results. The mean age of the patients was 44.1±18.9 years and the sex ratio was 0.39. At CS diagnosis, the frequencies of obesity, hypertension, diabetes, dyslipidemia, and metabolic syndrome were 52, 75, 43, 83, and 73%, respectively. The age, gender, body mass index, waist circumference, and baseline serum cortisol level were not associated with the presence of diabetes, hypertension or dyslipidemia. Forty-eight patients were operated on. At one year, 38 patients were in remission from CS. The remission rates of hypertension, diabetes, and dyslipidemia were respectively 58% (p<0.001), 76% (p<0.001), and 17% (NS). Conclusion. Metabolic disorders were frequent during CS and their frequencies decreased after the remission from the syndrome.

Effect of Surya Namaskar on Autonomic Status and Serum Cortisol Levels in Male Medical Students: A Longitudinal Study

Introduction: Stress is an unavoidable and ongoing phenomenon in human life that affects physiological processes in the body. Regular practice of Surya Namaskar, a yogic exercise, has been shown to improve autonomic functions by reducing sympathetic activity, thereby decreasing stress levels and improving cortisol levels. Aim: To evaluate the effects of Surya Namaskar on autonomic status and serum cortisol levels among medical students. in the Department of Physiology at the Faculty of Medicine and Health Sciences, SGT University, Gurugram, Haryana, India. The study duration was three months, from November 2021 to January 2022. A total of 30 male medical students, aged between 18 and 21 years, were included in the study. Blood samples for cortisol estimation were collected before the start of the study and after six weeks of regular yogic practice. Parameters such as mean pulse rate, Blood Pressure (BP), and Low Frequency to High Frequency (LF/HF) ratio were also studied during these two time points. Statistical analysis of Heart Rate Variability (HRV) parameters, including Standard deviation of the N-N interval (SDNN), mean Heart Rate (HR), and pNN50, was performed using Analysis of Variance (ANOVA) at baseline and after six weeks. Comparison of serum cortisol levels within the groups was done using paired t-tests. Results: The mean age of the study participants was 20.37 years. Comparison of HRV frequency domain parameters (LF, HF, and LF/HF ratio) at baseline, day one, and after six weeks of yogic practice showed statistically significant variations in LF/ HF ratio after six weeks (p-value=0.001). Baseline serum cortisol levels compared to levels after six weeks of yogic practice were also found to be statistically significant (p&lt;0.001). Conclusion: There is a positive association between cortisol levels and autonomic parameters, as evidenced by the results of the autonomic battery of tests. Incorporating yogic interventions into one’s lifestyle helps reduce sympathetic parameters and shift the balance towards parasympathetic dominance.

Is There Any Correlation between Baseline Serum Cortisol Levels and Disease Severity in PCR-Positive COVID-19 Patients with and without Diabetes Mellitus?

Background: COVID-19 has caused a pandemic and is associated with significant mortality. The pathophysiology of COVID-19, affecting many organs and systems, is still being investigated. The hypothalamus, pituitary gland, and possibly adrenal glands are the targets of SARS-CoV-2 because of its angiotensin-converting enzyme 2 (ACE2) and transmembrane serine protease 2 (TMPRSS2) receptors expression. Hypocortisolemia can be seen in the postinfection period. COVID-19 infection tends to be severe in diabetic patients due to immune dysfunction. In this study, our aim was to investigate the relationship between basal cortisol levels and the course of COVID-19 infection in diabetic and non-diabetic patients. Methods: Our retrospective study included 311 PCR-positive COVID-19 patients over the age of 18 who were hospitalized in Ankara City Hospital Infectious Diseases Department or Intensive Care Unit (ICU) between 15 March 2020 and 15 May 2020. Serum basal cortisol, fasting plasma glucose (FPG), HbA1c values, and diabetes history were recorded within the first 24 h of hospitalization. The presence of pulmonary involvement was noted from the patients’ imaging records. Pregnant and breastfeeding women, patients with chronic liver disease or chronic kidney disease, and patients who were already using steroids or had started COVID-19 infection treatment within the 72 h before blood collection were excluded from the study. Results: Of the 311 patients, 100 had Type 2 Diabetes Mellitus (T2D), while 211 did not. The age, serum basal cortisol, and glucose levels of the patients with T2D (64.51 ± 12.29, 19.5 ± 13.12, and 143.5 (77–345)) were higher than those of the patients without T2D (46.67 ± 16.38, 15.26 ± 8.75, and 96 (65–202)), and the differences were statistically significant (p = 0.004, p = 0.004, and p < 0.001, respectively). The basal cortisol values of the ICU patients (27.89 (13.91–75)) were significantly higher than those of the ward patients (13.68 (1.48–51.93)) and patients who were transferred to the ICU from the ward due to worsening conditions (19.28 (7.74–55.21)) (p < 0.001 and p = 0.007, respectively). The factors affecting ICU admission were determined to be age, T2D history, basal cortisol, and elevation in FPG using univariate logistic regression analysis. In the multiple logistic regression analysis, age, basal cortisol level, and infiltrative involvement in thorax CT were determined to be the risk factors affecting intensive care admission. Conclusion: High basal cortisol levels in patients with T2D may predict the severity of COVID-19 infection or mortality. Although high basal cortisol levels are among the risk factors affecting ICU admission, patients with COVID-19 should also be evaluated in terms of clinical and laboratory findings and relative adrenal insufficiency.

A characterization of cortisol level and adrenal reservation in human cardiopulmonary arrest: systematic review and meta-analysis

BackgroundCardiopulmonary arrest (CPA) is an urgency, which is associated with high mortality. This systematic review evaluated the relationship between baseline cortisol level and the outcome of resuscitated CPA patients.MethodsWe searched the following databases: PubMed, Scopus, ISI Web of Science, and Google Scholar. Relevant observational and controlled trials were explored from inception by April 2020. The quality of the articles was assessed using the Newcastle-Ottawa Scale (NOS).ResultsFinally, five cohort studies (n = 201 participants in total) were eligible for including in the meta-analysis. The results of this meta-analysis showed that although the baseline serum cortisol levels were higher in survivors of cardiac arrest compared with non-survivors, the differences between groups do not reach a significance level (Hedges’ g = 0.371, 95% CI, −0.727, 1.469, P value = 0.508). Between-study heterogeneity was statistically significant (Cochrane Q test: P value < 0.001, I2 = 89.323).ConclusionsThe result of the present meta-analysis was suggestive of a higher baseline serum cortisol levels in survivors of CPA. Future randomized controlled studies with a large sample size will determine the exact relationship between adrenal reservation and the eventual outcome of patients with CPA.Systematic review registrationPROSPERO CRD42018085468

Comparing the utility of 30- and 60-minute cortisol levels after the standard short synacthen test to determine adrenal insufficiency: A retrospective cross-sectional study.

Short Synacthen test (SST) involves measuring the baseline, 30-, and 60-minute serum cortisol levels, after injecting 250 μg of synthetic adrenocorticotropic hormone or Synacthen (ACTH). This study aimed to review the current clinical practice of performing SST to establish a standardized test protocol and to additionally test the hypothesis regarding performing the 60-minute cortisol test alone and the dependence of overall SST result on baseline cortisol level.Patients >14 years who underwent SST from January 2010 to December 2017 were included. Pearson's chi-square cross-tabulation was used to identify individuals with inconsistent 30- and 60-minute serum cortisol test results. Logistic regression analysis was performed to predict normal responses based on the baseline cortisol value.Of the 965 patients identified from pharmacy, medical, and laboratory records, 849 were included. Mean baseline, 30-, and 60-minute cortisol levels after ACTH injection were 394 ± 286.58, 722 ± 327.11, and 827 ± 369.30 nmol/L, respectively. Overall, 715 (84%) and 134 (16%) patients had normal and abnormal responses, respectively. Primary and secondary adrenal insufficiency was diagnosed in 10% and 35%, respectively, while ACTH levels were not measured in 55% of the patients. Overall, 9.49% (n = 72) of the patients had a suboptimal response at 30 minutes, but reached the threshold value of 550 nmol/L at 60 minutes. This particular subgroup's mean change (240 nmol/L) in cortisol level from baseline to 30-minute was higher than that observed in patients with abnormal response at both time-points (mean change, 152 nmol/L). No patient with 30-minute optimal responses had 60-minute suboptimal responses. The baseline serum cortisol threshold of ≥226 nmol/L had 80% sensitivity, 71% specificity, and 93% positive predictive value for detecting a normal SST (P-value < .0001).Relying on a 60-minute cortisol level can identify all normal and abnormal responses, while relying on 30-minute cortisol level alone may produce false-positives. Additionally, a baseline cortisol level of ≥226 nmol/L is a reliable threshold for determining adequate adrenal function, particularly with a low pretest hypoadrenalism probability.

Association of serum cortisol level with severity of depression and improvement in newly diagnosed patients with major depressive disorder in Jimma medical center, Southwest Ethiopia.

BackgroundMajor Depressive Disorder (MDD) is the leading psychiatric disorder in low- and middle-income countries, and is to be the second leading cause of burden of disease by 2020. Cortisol plays a significant role in pathophysiology of MDD. Depression can alter serum cortisol level. However, the change in serum cortisol level and its association with depressive symptom severity and improvement among patients with MDD is not well studied.ObjectiveTo outline change in serum cortisol levels and its association with severity and improvement of depressive symptoms in newly diagnosed patients with MDD.MethodHospital based longitudinal study was conducted among 34 newly diagnosed patients who met DSM-V criteria of MDD. Venous blood sample was performed twice; pre- and post- 8 weeks of treatment. Serum cortisol concentration was measured using an extracted radioimmunoassay. The 17-item Hamilton Depression Scale (HAM-D) was used to rate depression at baseline and after 8 weeks of treatment. Paired t-test was done to look the mean difference of serum cortisol level and HAM-D, before and after treatment. Pearson correlation was done to look the association between serum cortisol levels, HAM-D scores and, sociodemographic and clinical factors. Statistical significance was set at p<0.05.ResultsThere is no significant difference in cortisol concentrations at baseline and end line (t (33) = 2.02, p = 0.052). However, there is significant difference in HAM-D total score (t (33) = 5.67, p<0.001). Baseline and end line serum cortisol levels were significantly correlated (r = .561, p = .001). Monthly family income is correlated with baseline HAM-D total score (r = -0.373, p = .030). There is no significant relationship between baseline serum cortisol level and HAM-D score. There is also no significant relationship between end line serum cortisol level and HAM-D score.ConclusionsThe symptoms of MDD were reduced following treatment but there is no significant difference in serum cortisol levels. Baseline and end line serum cortisol levels were significantly correlated. We recommend further research based on large sample.

Correlation Between Size and Function of Unilateral and Bilateral Adrenocortical Nodules: An Observational Study

OBJECTIVE. Adrenal incidentalomas occur in 5% of adults and can produce autonomous cortisol secretion that increases the risk of metabolic syndrome and cardiovascular disease. The objective of our study was to evaluate the relationship between adrenal nodule size measured on CT and autonomous cortisol secretion. SUBJECTS AND METHODS. In a prospective study of 73 patients 22-87 years old with incidentalomas, unilateral in 52 patients and bilateral in 21 patients, we measured maximum nodule diameter on CT and serum cortisol levels at 8:00 am, 60 minutes after the adrenocorticotropic hormone stimulation test, and after the dexamethasone suppression test. We also studied 34 age-, sex-, and body mass index-matched control subjects. Statistics used were Spearman correlation coefficients, t tests, ANOVA test, and multivariate analysis. RESULTS. The mean maximum diameter of unilateral nodules measured on CT was larger on the right (2.47 ± 0.98 [SD] cm) than on the left (2.04 ± 0.86 cm) (p = 0.01). In the bilateral cases, the mean diameter of the right nodules was 2.69 ± 0.93 cm compared with 2.13 ± 0.89 cm on the left (p = 0.06). Mean baseline serum cortisol level was significantly higher in the patients with incidentalomas (bilateral, 13.1 ± 4.5 mcg/dL [p < 0.001]; unilateral, 9.7 ± 3.2 mcg/dL [p = 0.019]) than in the control subjects (7.5 ± 3.6 mcg/dL). After dexamethasone suppression test, serum cortisol levels were suppressed to less than 1.8 mcg/dL in 100% of control subjects, 33% of patients with bilateral incidentalomas, and 62% of patients with unilateral incidentalomas (p < 0.001). There were significant correlations between maximum nodule diameter on CT and serum cortisol levels after the dexamethasone suppression test (ρ = 0.500; p < 0.001) and at baseline (ρ = 0.373; p = 0.003). CONCLUSION. Increasing size of adrenal nodules is associated with more severe hyper-cortisolism and less dexamethasone suppression; these cases need further evaluation and possibly surgery because of increased risks of metabolic syndrome and cardiovascular mortality.

The prevalence and clinical profile of adrenocortical deficiency among HIV infected persons in Northern Nigeria.

Infection with the human immune deficiency virus (HIV) is still a prevalent problem in Africa. The aim of this study was to determine the prevalence of hypocortisolism among patients with HIV and their clinical profile at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. Three hundred and fifty adult patients with HIV infection were recruited from the HIV clinic of AKTH, Kano. Blood samples for serum electrolytes, and cortisol both before and after the short Synacthen test were taken for estimation. Data were analyzed using the SPSS version 20.0 software. One hundred and eight (30.9%) of participants had low baseline serum cortisol levels, while 57 (16.3%) had a low serum cortisol after short synacthen test. There was no significant relationship between the cortisol levels and clinical features of hypocortisolism, WHO clinical stage of HIV, hypernatremia or HAART regimen. There was a negative correlation between the stimulated serum cortisol and duration of diagnosis of HIV, participants BMI and CD4 counts. The biochemical evidence of hypocortisolism was common among patients infected with HIV, associated with a longer duration of HIV infection. However, none of CD4 counts, clinical features or HAART regimen were associated with hypocortisolism.

SUN-460 Anticipating Hypokalemia in Patients With ACTH-Dependent Cushing Syndrome Treated With Mifepristone: Utilization of Cortisol and ACTH Levels to Identify At-Risk Patients

Background: Hypokalemia (K+ level <3.5 mEq/L) is common in patients with hypercortisolism. Treatment with mifepristone, a glucocorticoid receptor antagonist, can exacerbate hypokalemia due to the mineralocorticoid effects produced by the rapid and significant increase in cortisol levels that result from the loss of negative feedback of the HPA axis. Correction of hypokalemia is required prior to initiating mifepristone and K+ levels must be closely monitored during treatment. However, there is little guidance to help clinicians identify patients who may be at a greater risk for developing hypokalemia during mifepristone therapy and who may benefit from prophylactic treatment (eg, mineralocorticoid antagonists, potassium replacement). Method: Using data from the 24-week, open-label, phase 3 SEISMIC study, this report investigated associations between cortisol and adrenocorticotropic hormone (ACTH) levels and the development of hypokalemia in patients with ACTH-dependent Cushing syndrome treated with mifepristone. Data from 47 patients were retrospectively analyzed using logistic regressions and receiver operating characteristic (ROC) curves. Analyses were performed to identify factors associated with early-onset hypokalemia (occurring within the first 2 weeks of mifepristone treatment during doses of 300 mg/day) and late-onset hypokalemia (occurring after 2 weeks of mifepristone treatment during dose escalation). Results: Nineteen patients (40.4%) developed hypokalemia at least once during mifepristone treatment. Of these 19 patients, 10 (52.6%) developed hypokalemia by day 14. Early-onset hypokalemia was significantly related to baseline serum cortisol levels (P=.0155). Baseline serum cortisol levels >27 µg/dL (>750 nmol/L) were associated with a 6.8-fold increase in the occurrence of early-onset hypokalemia vs patients with cortisol ≤27 µg/dL (≤750 nmol/L) (58.3% vs 8.6%, P<.0011). Late-onset hypokalemia was significantly related to the 2-week ACTH levels (P=.0032). At 2 weeks, ACTH levels >112 pg/mL (>25 pmol/L) were associated with a 5.64-fold higher risk of late-onset hypokalemia vs patients with ACTH ≤112 pg/mL (≤25 pmol/L) (75% vs 13.3%; P<.0001). ACTH levels >112 pg/mL (>25 pmol/L) at 2 weeks were also associated with a greater risk of severe (K+ ≤2.5 mEq/L) or recurrent hypokalemia. Conclusions: Serum cortisol and ACTH levels may be useful in identifying patients at risk for developing hypokalemia while being treated with mifepristone. Patients with serum cortisol levels >27 µg/dL (>750 nmol/L) assessed before mifepristone initiation had a 6.8-fold increase in occurrence of early-onset hypokalemia. Patients with ACTH levels >112 pg/mL (>25 pmol/L) at 2 weeks after initiation of mifepristone (prior to dose escalation) had a 5.64-fold higher risk of late-onset hypokalemia.

Adrenal Insufficiency in Cardiogenic Shock: Incidence and Prognostic Implication

Introduction: Functional integrity of the hypothalamic pituitary axis is disrupted during severe infection or stress. The observed blunted response to corticotropin was interpreted as impaired secretory reserve of the adrenal glands and was termed as relative adrenocortical insufficiency. Aim of the work: To study the incidence of adrenal insufficiency in patients developed cardiogenic shock complicating ST segment elevation myocardial infarction. Materials and methods: Prospective cohort study was done for 90 patients admitted to Algalaa Hospital for whom basal cortisol and ACTH level were measured immediately before a standard-dose (250 μg) ACTH stimulation test (SST) and 60 minutes after SST Δmax is defined as the difference between the maximal value after the test and basal level of serum cortisol. Results: Baseline ACTH and total cortisol showed positive correlation to clinical severity scores (APACHE II and Lactate), LVEF as well as vasoactive inotrope score, all with significant p value (0.000). The higher baseline cortisol level was co-related to increased mortality (Baseline serum cortisol level was significantly lower in survivors (30.6 ± 6.1 vs 45.0 ± 16.3) p value: 0.000) while the better response of the adrenal gland to short stimulation test was co-related more to survival as detected by Δmax TC (difference of cortisol level before and after SST) (13.8 ±3.8 in survivors vs 8.5 ± 4.42 in non survivors) p value 0.000. Conclusion: A high baseline plasma TC was associated with increased mortality in patients with cardiogenic shock post acute myocardial infarction. Patients with lower baseline TC, but with a better adrenal response, appeared to have a survival benefit.

Role of basal stress hormones and amygdala dimensions in stress coping strategies of male rhesus monkeys in response to a hazard-reward conflict.

Objective(s):In the present study the effect of stress on monkeys that had learned to retrieve food from a five-chamber receptacle, as well as the relationship between their behavior and the serum cortisol and epinephrine levels and relative size of the amygdala was evaluated.Materials and Methods:Six male rhesus monkeys were individually given access to the food reward orderly. They could easily retrieve the rewards from all chambers except for the chamber 4, which a brief, mild electric shock (3 V) was delivered to them upon touching the chamber’s interior. The coping behaviors were video-recorded and analyzed offline. Baseline serum cortisol and epinephrine levels were measured before the experiments using monkey enzyme-linked immunosorbent assay kit. One week after the behavioral experiment, the monkeys’ brains were scanned using magnetic resonance imaging under general anesthesia. The cross-sectional area of the left amygdala in sagittal plane relative to the area of the whole brain in the same slice was evaluated by the planimetric method using ImageJ software.Results:Exposure to the distressing condition caused different behavioral responses. Monkeys with higher baseline levels of serum cortisol and epinephrine and larger amygdala behaved more violently in the face of stress, indicating adopting emotion-focused stress-coping strategies. Conversely, those with low plasma epinephrine, moderate cortisol, and smaller amygdala showed perseverative behavior, indicating a problem-focused coping style.Conclusion:In dealing with the same stress, different responses might be observed from nonhuman primates according to their cortisol and epinephrine levels as well as their amygdala dimensions.

Salivary and serum cortisol levels in newborn infants.

Given that serum cortisol level interpretation in newborn infants (NBIs) is hard, the objective of this study was to correlate baseline salivary and serum cortisol levels and to describe salivary cortisol levels in the first month of life. Descriptive, prospective, longitudinal, and correlational study. Term NBIs were selected from the Division of Neonatology of Hospital Nacional Profesor Alejandro Posadas in 2014. Cortisol was measured in saliva specimens while cortisol, cortisol-binding globulin, and albumin were measured in blood specimens. A linear correlation was performed to relate serum and salivary cortisol levels; Friedman test was conducted to compare cortisol levels during the first month of life, and the difference was used to analyze the performance of values equal to or lower than the first quartile. Fifty-five NBIs were studied. Serum cortisol: 7.65 (1.0-18.1 gg/dL); salivary cortisol: 35.88 (5.52-107.64 mmol/L); cortisol-binding globulin: 22.07 (16.5-33.0 gg/mL), expressed as median and range. The correlation coefficient between serum and salivary cortisol was 0.54, P = 0.001. Cortisol performance during the first month of life showed no statistically significant differences, and the difference between the second and the first specimen of values equal to or lower than the first quartile increased in 10 out of 12 patients. The measurement of cortisol in saliva reflects serum cortisol levels in normal NBIs. Some patients had low levels of cortisol at 36 hours of life and showed a trend towards a spontaneous increase during the first month of life.

Serum dehydroepiandrosterone sulfate in assessing the integrity of the hypothalamic-pituitary-adrenal axis

ObjectiveTo evaluate the relationship between age- and gender-adjusted dehydroepiandrosterone sulfate (DHEA-S) levels and low-dose adrenocorticotropic hormone (ACTH) stimulation in assessing the integrity of the hypothalamic-pituitary-adrenal (HPA) axis, in patients who were at risk of HPA insufficiency, including those currently being treated with glucocorticoids. MethodsForty-six participants with a suspicion of secondary adrenal insufficiency were recruited from the Diabetes and Endocrinology Clinic at Ramathibodi Hospital, Mahidol University, Bangkok. Low-dose (1μg) ACTH stimulation was performed in every participants, and serum DHEA-S was measured at baseline before ACTH injection. ResultsIndividuals with normal age- and gender-specific DHEA-S levels had baseline serum cortisol and peak cortisol levels higher than those with reduced DHEA-S. Normal age- and gender-specific DHEA-S levels predicted intact HPA function with a sensitivity of 87.1%, a specificity of 86.7%, a positive predictive value of 93.1%, and a negative predictive value of 76.5%. To account for the age and gender dependency of DHEA-S, the DHEA-S ratio was calculated by measured DHEA-S divided by the lower limit of the respective reference range for all participants. A DHEA-S ratio of more than 1.78 had 100% sensitivity regarding intact HPA function. Area under the receiver operating characteristic [ROC] curve was 0.920. (95% CI, 0.844–0.997). ConclusionNormal age- and gender-specific DHEA-S level or a DHEA-S ratio of more than 1.78 are valuable markers of HPA integrity. Serum DHEA-S may be a candidate for a less costly approach where ACTH stimulation is unavailable.

Pre-injection of hyaluronic acid does not affect the systemic effects of intra-articular depot betamethasone injection at the knee joint.

Intra-articular injection (IAI) of both hyaluronic acid (HA) and depot-steroid preparations had the advantage of quick and prolonged favorable effects on pain relief among patients with symptomatic osteoarthritis of the knee (OAK). The effect of IAI of HA on the systemic effects of the intra-articular steroids had not been investigated. Non-selected patients attending the rheumatology clinic with symptomatic OAK who failed NSAIDS and physical therapy were offered an IAI of HA at the knee joint followed 20min later by an IAI of 1ml of Celestone Chronodose at the same joint (group 1). Morning serum levels of cortisol were obtained just prior to the IAI and 1, 2 and 8days later. Demographic, clinical, and laboratory parameters were obtained also from all the patients. Age- and sex-matched group of patients from the same clinic were recruited as a control group (group 2). Mean baseline serum cortisol levels in group 1 was 381 ± 154mmol/l vs. 376 ± 119 in group 2 (p = 0.954). Morning serum cortisol levels at day 1 and day 2 were 24 ± 6 and 22 ± 6mmol/l, respectively, in group 1 patients vs. 27 ± 5.8 (p = 0.214) and 25 ± 5.6mmol/l (p = 0.200), respectively, in group 2. These levels were significantly lower than baseline levels in each group. Morning serum cortisol levels at day 8 in group 1 and group 2 were 349 ± 128 and 314 ± 99mmol/l, respectively (p = 0.419). Pre-injection of HA at the knee joint did not affect the systemic effect on the hypothalamic-pituitary-adrenal axis of IAI of Celestone Chronodose.

Recovery of Adrenal Function in Patients with Glucocorticoids Induced Secondary Adrenal Insufficiency.

BackgroundThe chronic use of glucocorticoids (GC) suppresses function of the hypothalamic-pituitary-adrenal axis and often results in secondary adrenal insufficiency (AI). The present study aimed to determine the recovery rate of adrenal function in patients with secondary AI within 1 to 2 years and to assess the factors predictive of adrenal function recovery.MethodsThis was a retrospective observational study that enrolled patients diagnosed with GC-induced secondary AI between 2007 and 2013. AI was defined by peak serum cortisol levels <18 µg/dL during a standard-dose short synacthen test (SST). A follow-up SST was performed after 1 to 2 years, and responders were defined as those with adrenocorticotropic hormone (ACTH)-stimulated peak serum cortisol levels ≥18 µg/dL.ResultsOf the total 34 patients diagnosed with GC-induced secondary AI at first, 20 patients (58.8%) recovered normal adrenal function by the time of the follow-up SST (median follow-up period, 16.5 months). Although the baseline serum ACTH and cortisol levels at the first SST did not differ between responders and non-responders, the incremental cortisol response during the first SST was higher in responders than that of non-responders (7.88 vs. 3.56, P<0.01). Additionally, higher cortisol increments during the first SST were an independent predictive factor of the adrenal function recovery (odds ratio, 1.58; 95% confidence interval, 1.02 to 2.46; P<0.05).ConclusionIn the present study, adrenal function recovery was achieved frequently in patients with GC-induced secondary AI within 1 to 2 years. Additionally, an incremental cortisol response at the first SST may be an important predictive factor of adrenal function recovery.

Suppression of Adrenal Axis Function After High-Dose Steroid Therapy for Childhood Acute Lymphoblastic Leukemia in Iran

A 4 weeks course of high-dose glucocorticoids (GCs) may cause prolonged adrenal suppression even after a 9 days tapering phase. In this study, adrenal function and signs and symptoms of adrenal insufficiency were prospectively assessed in children with acute lymphoblastic leukemia (ALL) after induction treatment with high-dose prednisone. In 42 children with newly diagnosed ALL, a baseline serum cortisol level was assessed and after receiving a 28 days of high dose prednisone according to the Berlin-Frankfu¨rt-Mu¨nster 2009 protocol ad a 9 days tapering phase, serum cortisol level was assessed again and those whose serum cortisol level was normal underwent low-dose adrenocorticotropic hormone (LDACTH) stimulation 24 h after the last tapered steroid dose. Signs and symptoms of adrenal insufficiency were recorded during the observation period. All patients except one who was excluded had normal basal cortisol values at diagnosis. Twenty-four hours after last GC dose, morning cortisol was reduced in 15 (36.5%) patients. LDACTH testing showed adrenal suppression in 17 (41.4%) patients. High-dose GC therapy in ALL children may cause adrenal suppression even after a tapering phase. Laboratory monitoring of cortisol levels and steroid coverage during stress episodes may be indicated.