Screening For Insufficiency Research Articles

Evaluation of pituitary function in the fatigued patient: a review of 59 cases

The aim of this study was to review the results of dynamic pituitary testing in patients presenting with fatigue. We reviewed clinical histories and insulin tolerance test (ITT) results of 59 patients who presented with fatigue and other symptoms of glucocorticoid insufficiency over a 4-year period. All patients referred for ITT had an early-morning cortisol level of <400 nM and a low or normal ACTH level. Peak cortisol and GH responses following insulin-induced hypoglycaemia were normal in only seven patients (12%). Median age of the remaining 52 patients was 47 years (range, 17-67 years); all but five were female. Common presenting symptoms were neuroglycopaenia (n = 47), depression (n = 37), arthralgia and myalgia (n = 28), weight gain (n = 25), weight loss (n = 9), postural dizziness (n = 15) and headaches (n = 13). Other medical history included autoimmune disease (n = 20; particularly Hashimoto's thyroiditis, Graves' disease and coeliac disease), postpartum (n = 8) and gastrointestinal (n = 2) haemorrhage and hyperprolactinaemia (n = 13). 31 subjects had peak cortisol levels of <500 nM (suggestive of ACTH deficiency; 18 of whom had levels < 400 nM) and a further six had indeterminate results (500-550 nM). The remaining 15 subjects had normal cortisol responses (median 654 nM; range, 553-1062 nM) but had low GH levels following hypoglycaemic stimulation (5.9 mU/l; 3-11.6 mU/l). Our results suggest that patients presenting with fatigue and symptoms suggestive of hypocortisolism should be considered for screening for secondary adrenal insufficiency, particularly in the presence of autoimmune disease or a history of postpartum or gastrointestinal haemorrhage. Whether physiological glucocorticoid replacement improves symptoms in this patient group is yet to be established.

Screening for Vertebrobasilar Insufficiency in Patients With Neck Pain: Manual Therapy Decision-Making in the Presence of Uncertainty

Growing evidence supports the effectiveness of manual therapy interventions in patients with neck pain; however, considerable attention has also been afforded to the potential risks such as vertebrobasilar insufficiency (VBI). Despite the existence of guidelines advocating specific screening procedures, research does not support the ability to accurately identify patients at risk. The logical question becomes, "How does one proceed in the absence of certainty?" Given the lack of clear direction for decision making in the peer-reviewed literature, this commentary discusses the uncertainties that exist regarding the ability to identify patients at risk for VBI. The authors hope that this commentary adds additional perspective on manual therapy decision-making strategies in the presence of uncertainty.

Screening for Vertebrobasilar Insufficiency in Patients With Neck Pain: Manual Therapy Decision Making in the Presence of Uncertainty

Screening for Vertebrobasilar Insufficiency in Patients With Neck Pain: Manual Therapy Decision Making in the Presence of Uncertainty

Les nouveaux marqueurs disponibles en coprologie fonctionnelle et perspectives

Fecal occult blood testing is the most widely prescribed screening test for colorectal cancer. Recent development of immunological tests has increased specificity. Fecal DNA analysis opens up a new field for early detection of this widespread neoplasia. Inflammatory bowel disease is another important area where the development of fecal markers provides an interesting alternative to the gold standard but costly and invasive endoscopic investigations with histological analysis of biopsy specimens. Fecal TNFalpha and calprotectin can now be proposed to distinguish organic from non-organic intestinal disease, so select candidates for further investigations, and to assess disease activity. Measurement of fecal elastase provides real progress in screening for exocrine pancreatic insufficiency in patients with malabsorption syndrome. The development of non-invasive fecal markers is thus of increasing interest, providing data about the entire gastrointestinal tract useful for screening and individual patient management.

Screening for pancreatic exocrine insufficiency in patients with diabetes mellitus

Objectives Fecal elastase 1 (E1) is a relatively sensitive and specific indirect test of pancreatic exocrine function. Despite the high functional reserve of the pancreas, it is recognized that a significant proportion of diabetic patients may also have a deficit of the exocrine function. The aim of this study was to screen patients with diabetes mellitus (DM) for pancreatic exocrine insufficiency. Methods A total of 80 patients were enrolled in this prospective study, including 42 patients with DM and 38 nondiabetic controls. Exclusion criteria were as follows: age >75 yr; alcohol intake >40 g/day; intake of orlistat or acarbose; and history of diarrhea, pancreatitis, GI surgery, immunodeficiency, or cancer. All patients underwent the same study protocol, which included clinical evaluation, determination of fecal E1, plain x-rays of the abdomen, and abdominal ultrasound. An immunoenzymatic method (ScheBoTech, Wettenburg, Germany) was used for E1 determination. Diagnosis of pancreatic insufficiency was established for a fecal E1 <200 μg/g. Results The DM and control groups were comparable regarding age (62 ± 10 yr vs 56 ± 10 yr), sex (18 men and 24 women vs 15 men and 23 women), and proportion of patients with excess weight (50% vs 42%). Patients had DM diagnosed for 11.5 ± 8 yr, with structural changes of the pancreas detected on ultrasound in three cases and calcifications in one case. There was no relationship between E1 determination <200 μg/g and the duration or the type of therapy for DM. Fifteen patients (36%) in the DM group had a fecal E1 <200 μg/g, compared with two patients (5%) in the control group ( p < 0.05). In the DM group (n = 42), 11 patients with excess weight presented a fecal E1 <200 μg/g, whereas four patients with a BMI <25 presented this result ( p < 0.05). Conclusions Pancreatic exocrine insufficiency occurs more frequently in diabetic patients than in controls. Diabetic individuals with excess weight (BMI >25) may be at increased risk for underlying exocrine pancreatic insufficiency.

Screening for pancreatic exocrine insufficiency in patients with diabetes mellitus.

Fecal elastase 1 (E1) is a relatively sensitive and specific indirect test of pancreatic exocrine function. Despite the high functional reserve of the pancreas, it is recognized that a significant proportion of diabetic patients may also have a deficit of the exocrine function. The aim of this study was to screen patients with diabetes mellitus (DM) for pancreatic exocrine insufficiency. A total of 80 patients were enrolled in this prospective study, including 42 patients with DM and 38 nondiabetic controls. Exclusion criteria were as follows: age >75 yr; alcohol intake >40 g/day; intake of orlistat or acarbose; and history of diarrhea, pancreatitis, GI surgery, immunodeficiency, or cancer. All patients underwent the same study protocol, which included clinical evaluation, determination of fecal E1, plain x-rays of the abdomen, and abdominal ultrasound. An immunoenzymatic method (ScheBoTech, Wettenburg, Germany) was used for E1 determination. Diagnosis of pancreatic insufficiency was established for a fecal E1 <200 microg/g. The DM and control groups were comparable regarding age (62 +/- 10 yr vs 56 +/- 10 yr), sex (18 men and 24 women vs 15 men and 23 women), and proportion of patients with excess weight (50% vs 42%). Patients had DM diagnosed for 11.5 +/- 8 yr, with structural changes of the pancreas detected on ultrasound in three cases and calcifications in one case. There was no relationship between E1 determination <200 microg/g and the duration or the type of therapy for DM. Fifteen patients (36%) in the DM group had a fecal E1 <200 microg/g, compared with two patients (5%) in the control group (p < 0.05). In the DM group (n = 42), 11 patients with excess weight presented a fecal E1 <200 microg/g, whereas four patients with a BMI <25 presented this result (p < 0.05). Pancreatic exocrine insufficiency occurs more frequently in diabetic patients than in controls. Diabetic individuals with excess weight (BMI >25) may be at increased risk for underlying exocrine pancreatic insufficiency.

Screening for chronic placental insufficiency by Doppler flow velocimetry of the umbilical artery in patients with symphysis–fundus height determined gestational age

Umbilical artery Doppler flow velocimetry is essential in the clinical management of pregnancies where intrauterine growth restriction (IUGR) is suspected w1,2x. In developing countries 40% or more women are uncertain of the date of their last menstrual period (LMP) w3x. In addition, 28% or more women often visit the antenatal clinic for the first time at a gestational age (GA) beyond 24 weeks when ultrasound determination of GA is inaccurate. Symphysis–fundus (SF) measurement is often used to measure fundal height and GA is determined by plotting this value on the 50th centile of a growth curve w4x. For these reasons it is important to determine how the SF determination of the GA will change the interpretation of the resistance index (RI). The study population was comprised of patients with suspected IUGR whose GAs had been confirmed by ultrasound prior to 24 weeks. A single observer determined the SF height and the RI of the umbilical artery with a Vasoflow Duplex continuous wave Doppler machine.

Iatrogenic adrenal insufficiency as a side-effect of combined treatment of itraconazole and budesonide

A recent case of iatrogenic Cushing's syndrome and complete suppression of the pituitary-adrenal-axis in a patient with cystic fibrosis (CF) and allergic bronchopulmonary aspergillosis treated with itraconazole as an antifungal agent, and budesonide as an anti-inflammatory agent led to a systematic assessment of this axis and gonadal function in all patients treated with itraconazole in the authors' CF centre. Itraconazole can inhibit CYP3A, thus interfering with synthesis of gluco- and mineralocorticoids, androgens and oestradiol as well as the metabolism of budesonide. The aim of this study was to evaluate adrenal and gonadal function in patients treated with itraconazole with or without budesonide. An adrenocorticotrophic hormone (ACTH) test (250 microg tetracosactid) was performed in 25 CF patients treated with both itraconazole and budesonide, and in 12 patients treated with itraconazole alone (six patients with CF and six with chronic granulomateous disease). Mineralocorticoid and gonadal steroid function were evaluated by measurements of plasma-renin, follicle stimulating hormone, luteinising hormone, progesterone, oestradiol, testosterone, serum-inhibin A and B. ACTH tests performed as part of a pretransplantation programme in an additional 30 CF patients were used as controls. Eleven of the 25 patients treated with both itraconazole and budesonide had adrenal insufficiency. None of the patients on itraconazole therapy alone nor the control CF patients had a pathological ACTH test. Mineralocorticoid and gonadal insufficiency was not observed in any of the patients. Only one patient with an initial pathological ACTH-test subsequently normalised, the other 10 patients improved but had not achieved normalised adrenal function 2-10 months after itraconazole treatment had been discontinued. Suppression of the adrenal glucocorticoid synthesis was observed in 11 of 25 cystic fibrosis patients treated with both itraconazole and budesonide. The pathogenesis is most likely an itraconazole caused increase in systemic budesonide concentration through a reduced/inhibited metabolism leading to inhibition of adrenocorticotrophic hormone secretion along with a direct inhibition of steroidogenesis. In patients treated with this combination, screening for adrenal insufficiency at regular intervals is suggested.

Screening for mesenteric vascular insufficiency and follow-up of mesenteric artery bypass procedures.

Duplex ultrasonography is the preferred noninvasive screening test for superior mesenteric artery (SMA) and celiac artery (CA) stenosis. Although postprandial increases in SMA peak systolic velocity (PSV) are known to occur, the principal duplex criteria for hemodynamically significant SMA and CA stenosis are based on fasting flow velocities. In the SMA, a PSV > or =275 cm/s predicts a > or =70% angiographic stenosis with a sensitivity of 92% and a specificity of 96%, whereas a CA PSV of > or =200 cm/sec predicts a > or =70% stenosis with a sensitivity of 87% and a specificity of 80%. Patients with appropriate symptoms of chronic visceral ischemia and a duplex scan showing high-grade stenosis of the SMA, especially when combined with CA stenosis, should have a confirmatory mesenteric angiogram. This approach will facilitate prompt intervention in these patients. If the duplex examination indicates widely patent mesenteric arteries, alternative diagnoses should be investigated. Other applications of mesenteric duplex scanning include evaluation of median arcuate ligament syndrome and postoperative surveillance of mesenteric artery revascularizations.

Ultrasound Estimates of Venous Valve Function in Screening For Insufficiency and Following Patients With Chronic Venous Disease

Ultrasound Estimates of Venous Valve Function in Screening For Insufficiency and Following Patients With Chronic Venous Disease

Ultrasound estimates of venous valve function in screening for insufficiency and following patients with chronic venous disease

Ultrasound estimates of venous valve function in screening for insufficiency and following patients with chronic venous disease

Community nephrology: audit of screening for renal insufficiency in a high risk population.

The rate of acceptance onto dialysis programmes has doubled in the past 10 years and is steadily increasing. Early detection and treatment of renal failure slows the rate of progression. Is it feasible to screen for patients who are at increased risk of developing renal failure? We have audited primary care records of patients aged 50-75 years who have either hypertension or diabetes, and are therefore considered to be at high risk of developing renal insufficiency. Our aim was to see whether patients had had their blood pressure measured and urine tested for protein within 12 months, and plasma creatinine measured within 24 months. This was a retrospective study of case notes and computer records in 12 general practices from inner and greater London. A total of 16,855 patients were aged 50-75 years. From this age group, 2693 (15.5%) patients were identified as being either hypertensive or diabetic, or both. Of the 2561 records audited, 1359 (53.1%) contained a plasma creatinine measured within 24 months, and 11% of these (150) had a value > 125 micromol/l. This equates to a prevalence of renal insufficiency of > 110,000 patients per million in this group. Forty two patients (28%) had been referred to a nephrologist. Of records audited, 73% contained a blood pressure measurement and 29% contained a test for proteinuria within 12 months. There is a high prevalence of chronic renal insufficiency in hypertensive and diabetic patients. It is feasible to detect renal insufficiency at a primary care level, but an effective system will require computerized databases that code for age, ethnicity, measurement of blood pressure and renal function, as well as diagnoses.

Scope for the ?eye ? hand? psychophysiological test in screening for cerebrovascular insufficiency

1. During performance of the “eye ” hand” PPT the reaction time to input signals at the same time contains information on the trend and level of noise and pulsation of the afferent and efferent pathways of the CNS in man. 2. The “eye — hand” PPT is best performed for detecting subjects with possible CVI, and also to determine the precise degree of its severity. 3. Introduction of the “eye — hand” PPT during mass prophylactic examinations is of economic importance because it enables the early discovery of abnormalities of the workers' health and optimal implementation of the tests in industry characterized by two or three shifts.

Spectrum of Serum Cortisol Response to ACTH in ICU Patients: Correlation with Degree of Illness and Mortality

Recent reports suggest adrenal insufficiency in critically ill patients is common. We found only one case of de novo adrenal insufficiency using admission ACTH injection in 70 selected intensive care unit (ICU) patients. Random serum cortisol levels correlated positively with illness severity in ICU patients using proven methods for assessing illness severity. Those with the highest random serum cortisol levels (greater than 60 micrograms/dl) had the greatest mortality, while those with lower random cortisol levels which stimulated to more than 18 micrograms/dl after ACTH injection had improved outcomes. Based on our results, routine screening for adrenal insufficiency in ICU patients is not warranted. If it is suspected, the cosyntropin test should be performed since low random cortisol levels (even to 5 micrograms/dl) are not diagnostic of adrenal insufficiency.

New parameters for evaluation of blood flow in patients with leg ulcers

Three new parameters have been introduced to provide data for quantitative evaluation of peripheral cutaneous blood flow in patients with leg ulcers. Reactive hyperemia was induced by occlusion of the blood flow for four minutes at the thigh-level. Blood flow was subsequently measured by laser-Doppler velocimetry in an unselected group of 14 patients with leg ulcers and a matched control group. The parameters used for evaluation was: 1) "peak flow" f(p), 2) divided by time to "peak flow" t(p), rendering a rate constant k (k = f(p)/t(p)) expressing the ability to increase blood flow abruptly in case of need. These parameters were all significantly reduced in the patients with leg ulcers, indicating that this simple and atraumatic technique was useful for discriminating blood flow values that may be relevant for healing time and with a sensitivity comparable to the measurements of distal systolic blood pressure. Distal systolic blood pressure measurements can still be considered to be of value when screening for arterial insufficiency in patients with leg ulcers. The values obtained were significantly lower in 36 patients with leg ulcers compared with 9 age-matched control persons.

Oral pigmentation, Addison's disease and the results of screening for adrenocortical insufficiency.

Oral pigmentation, Addison's disease and the results of screening for adrenocortical insufficiency

Serum immuno reactive trypsin and pancreatic isoamylase in older patients with cystic fibrosis.

We measured serum trypsin by radio-immunoassay and differential serum amylases using an inhibitor technique, in 24 patients with cystic fibrosis (C.F.), 20 of whom had symptomatic steatorrhea, and 24 normal controls. Both mean serum trypsin and pancreatic isoamylase were significontly lower in the 20 C.F. patients with symptomatic steatorrhea than in the controls (p<0.001), indicating pancreatic insufficiency. Both techniques showed good, though not complete, separation of these 2 groups. The remaining 4 C.F. patients who did not have symptomatic steatorrhea had mean serum trypsin and pancreatic isoamylase values which were significantly higher than those of the controls (p<0.05 and p<0.01, respectively). In these 4 patients this may indicate that the chronic pancreatitis of C.F. may be preceded by a state of active degeneration. Significant correlation between serum trypsin and pancreatic isoamylase levels was found in both the controls and the C.F. patients, particularly in the subgroup with symptomatic steatorrhea (r=+0.92, p<0.001). Measurement of serum immunoreactive trypsin, being simple and non-invasive, may prove useful in screening for pancreatic insufficiency and in helping to diagnose those C.F. patients with repeatedly equivocal sweat tests.

Single-Dose Metyrapone Test

Subnormal plasma 11-deoxycortisol (compound S) responses to metyrapone were found in patients with adrenal insufficiency or with Cushing syndrome caused by adrenal tumors and in those receiving long-term glucocorticoid or diphenylhydantoin sodium therapy. High normal or exaggerated responses were seen in women receiving oral contraceptives, patients with Cushing syndrome caused by adrenal hyperplasia, and those with untreated hypothyroidism. Diabetes mellitus, hypoglycemia, congestive failure, and obesity also were associated with exaggerated responses. Subnormal plasma S responses were observed in 15 patients who responded normally to a repeat test or to the standard metyrapone test. The abnormal response resulted from insufficient metyrapone, administration at the wrong time, or delay in obtaining the blood sample. The single-dose metyrapone test may be the procedure of choice in screening for adrenal insufficiency.

Screening for adrenocortical insufficiency with cosyntropin (synthetic ACTH)

Screening for adrenocortical insufficiency with cosyntropin (synthetic ACTH)

Screening for Adrenocortical Insufficiency With Cosyntropin (Synthetic ACTH)

A screening procedure for adrenocortical insufficiency, utilizing (synthetic a 1-24 adrenocorticotropic hormone [ACTH] and a cortisol-binding globulin technique for serum cortisol, has been evaluated in normal subjects and in patients with primary and secondary adrenal insufficiency. Cosyntropin is injected by vein, and a serum cortisol concentration 60 minutes later is compared with a sample removed just prior to the cosyntropin administration. A clear separation of normal subjects from those with adrenal insufficiency is achieved.