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1
Singh, Santosh. "Aromatase Inhibitors in Erectile Dysfunction." Journal of the Endocrine Society 5, Supplement_1 (May 1, 2021): A755. http://dx.doi.org/10.1210/jendso/bvab048.1535.
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Abstract Hyperestrogenism may cause erectile dysfunction(ED) by impeding normal penile development,increasing venous vascular permeability and leakage(via VEGF) and by inhibiting testosterone(T)production. Estrogen excess can impair spermatogenesis and may increase the risk of estrogen-sensitive cancers(viz.breast cancer)[1,2]Weekly and biweekly letrozole(2.5 mg),an aromatase inhibitor,has been reported to normalize serum T in males with obesity related hypogonadism and poor sperm quality,respectively.[3,4]A 40-year old insulin requiring,normotensive,obese(BMI-26.9),diabetic(12 years duration) was evaluated for ED.T was 187 ng/dl and estradiol(E2) was 69 pg/ml(normal-11-44 pg/ml) with normal LH and prolactin levels. There was normalization of T(increased to 487 ng/dl) with 2.5 mg letrozole every 3 weeks. Another patient,55 year old male, insulin requiring,hypertensive,obese(BMI-28.8),diabetic(21 years duration) had normalization of T(401 ng/dl) with baseline low T(224.4 ng/dl) and normal E2(33 pg/ml) with T-E2 ratio of less than 10,with weekly 2.5 mg letrozole. There was one kg weight gain and 0.2 ng/ml increase in PSA in two years. These cases highlight the significance of estimating both T and E2 in the evaluation of ED. Moreover,it also highlights the efficacy and safety of weekly and even every 3-week 2.5 mg letrozole therapy. References: 1. .Schulster M,Bernie AM,Ramasamy R:The role of estradiol in male reproductive function.Asian Journal of Andrology,2016,18(3),435-440. 2. Goldfrank LR and Flomenbaum N:Goldfrank’s Toxicologic Emergencies,McGraw- Hill Professional,2006,p443. 3.Loves S,Ruinemans-Koerts,de Boer H:Letrozole once a week normalizes serum testosterone in obesity-related male hypogonadism. Eur J Endocrinol,2008,158,741-747.4. Singh SK:Aromatase inhibitors in male sex. Indian J Endocrinol Metab,2013,17,S259-261.
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Saraheni, Saraheni, I. Dewa Putu Pramantara, and Herni Astuti. "Asupan zink dan magnesium makanan dengan disfungsi ereksi pada penderita sindrom metabolik." Jurnal Gizi Klinik Indonesia 10, no. 3 (January 30, 2014): 127. http://dx.doi.org/10.22146/ijcn.18861.
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Background: Metabolic syndrome (MetS) is a disease of disorder of lipid and nonlipid metabolism. The West of Scotland Coronary Prevention Study found that men with MetS had probability 3.7 dysfunctions of erection (ED) by using International Index of Erectile Function (IIEF). Patient with heart disease had the risk 2 times to get ED, hypertension was 1.5-2 times, DM was 3-4 times, depression was 2-3.5 times, testosterone deficiency syndrome (TDS) was 1.5-2 times, and high cholesterol was 4 times. The nutrient deficiency of zinc (Zn) and magnesium (Mg) was suspected being the main component which had a role in resisting a sexuality growth and maturation process.Objective: Knowing the correlation of Zn and Mg feeding with erection dysfunction in MetS person.Method: This study was observational analytic study, with case-control design in the patient aged 30-60 years old. The respondent in this study was people with MetS according to WHO criterion. There was 82 patient divided into two groups, consist of 41 cases of MetS and ED, 41 cases with the normal patient. The data collected by interview, laboratory assessment and anthropometric measurement. The data analysis using univariate, bivariate and multivariate analysis using multiple logistic regression.Results: There was significant correlation between Zn feeding and ED (OR=7.15; 95% Cl=1.47-34.71; p=0.007) and there was significant correlation between Mg feeding with ED (OR=3.34; 95% Cl=1.07-10.4; p=0.033). The end result of the multivariate analysis showed the risk variable to the ED event, that was Zn feeding with OR=15.41. If the intake of Zn accompanied with risk factors associated as a cause of ED, multivariate analysis showed HbA1c’s degree with OR=12.57; triglyceride (OR=10.47); blood pressure (OR=5.82); and abdominal obesity (OR=6.94). The result shows that these risk factors can aggravate or anticipate the onset of dysfunction erection beside low Zn intake.Conclusion: There was statistically significant correlation between Zn and Mg feeding with erection dysfunction in MetS patient.
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Kirby, Michael, Geoffrey Hackett, and Sudarshan Ramachandran. "Testosterone and the Heart." European Cardiology Review 14, no. 2 (July 11, 2019): 103–10. http://dx.doi.org/10.15420/ecr.2019.13.1.
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The development of a subnormal level of testosterone (T) is not universal in ageing men, with 75% of men retaining normal levels. However, a substantial number of men do develop T deficiency (TD), with many of them carrying a portfolio of cardiovascular (CV) risk factors, including type 2 diabetes (T2D) and the metabolic syndrome. TD increases the risk of CV disease (CVD) and the risk of developing T2D and the metabolic syndrome. The key symptoms suggesting low T are sexual in nature, including erectile dysfunction (ED), loss of night-time erections and reduced libido. Many men with heart disease, if asked, admit to ED being present; a problem that is often compounded by drugs used to treat CVD. A large number of studies and meta-analyses have provided evidence of the link between TD and an increase in CVD and total mortality. Patients with chronic heart failure (CHF) who have TD have a poor prognosis and this is associated with more frequent admissions and increased mortality compared with those who do not have TD. Conversely, in men with symptoms and documented TD, T therapy has been shown to have beneficial effects, namely improvement in exercise capacity in patients with CHF, improvement of myocardial ischaemia and coronary artery disease. Reductions in BMI and waist circumference, and improvements in glycaemic control and lipid profiles, are observed in T-deficient men receiving T therapy. These effects might be expected to translate into benefits and there are more than 100 studies showing CV benefit or improved CV risk factors with T therapy. There are flawed retrospective and prescribing data studies that have suggested increased mortality in treated men, which has led to regulatory warnings, and one placebo-controlled study demonstrating an increase in coronary artery non-calcified and total plaque volumes in men treated with T, which is open for debate. Men with ED and TD who fail to respond to phosphodiesterase type 5 (PDE5) inhibitors can be salvaged by treating the TD. There are data to suggest that T and PDE5 inhibitors may act synergistically to reduce CV risk.
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Otunctemur, Alper, Emin Ozbek, Suleyman Sami Cakir, Murat Dursun, Emre Can Polat, Levent Ozcan, and Huseyin Besiroglu. "Urolithiasis is associated with low serum testosterone levels in men." Archivio Italiano di Urologia e Andrologia 87, no. 1 (March 31, 2015): 83. http://dx.doi.org/10.4081/aiua.2015.1.83.
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Objective: To evaluate the relationship among urolithiasis, metabolic syndrome (MetS) and serum testosterone (T) level in men. Material and Methods: 513 men older than 18 years were enrolled in this study: 313 of the subjects had a history of stones (group 1) and 200 had no history of stones (controls, group 2). Early morning T levels were recorded and anthropometric measurements were invastigated to evaluate MetS. Analyses were completed using chi-square tests. Result: Serum T level was lower in stone forming patients than coltrol subjects and 161 (%51.4) men in group 1 and 92 (%46) men in group 2 were diagnosed with metabolic syndrome. T level was found lower limit (< 285 ng/dl) in the MetS and urolithiasis group (p 0.002, OR 2.71). Conclusions: We found low testosterone levels in the patients with stone disease and prevalance of the MetS in men with urolithiasis was higher than in men without stone disease. Our findings show that levels of testosterone had no effect on stone formation, but the factors that cause stone formation can have an effect on the level of testosterone.
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Nicholson, H. D., R. T. S. Worley, H. M. Charlton, and B. T. Pickering. "LH and testosterone cause the development of seminiferous tubule contractile activity and the appearance of testicular oxytocin in hypogonadal mice." Journal of Endocrinology 110, no. 1 (July 1986): 159–67. http://dx.doi.org/10.1677/joe.0.1100159.
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ABSTRACT Immunoreactive oxytocin is present in the testis and it has been shown that this hormone increases the contractility of seminiferous tubules. We have investigated the relationship between testicular oxytocin, tubular movements and the effects of LH and testosterone using, as a model, the hypogonadal (hpg/hpg) mouse, which is deficient in hypothalamic LH-releasing hormone (LHRH). Whilst both testicular oxytocin and seminiferous tubule movements, resembling those seen in the rat, can be found in normal adult mice, neither can be found in hypogonadal mice. After 2 weeks of treatment with LH (200 ng to 100 μg daily) low levels of testicular oxytocin and tubular movements were observed. Treatment with large doses of testosterone for 2–12 weeks led to higher concentrations of testicular oxytocin and tubular movements resembling those seen in the normal adult mouse. The results support the evidence that testicular oxytocin modulates seminiferous tubule movements. We suggest that testosterone may play a part in the accumulation of oxytocin in the testis. J. Endocr. (1986) 110, 159–167
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Munshi, Lubna Bashir, Yumiko Tsushima, Kwan Cheng, and Maria Brito. "Megestrol Acetate-Induced Symptomatic Hypogonadism in a Male Patient." Case Reports in Endocrinology 2018 (July 18, 2018): 1–3. http://dx.doi.org/10.1155/2018/7048610.
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The hypothalamic-pituitary-adrenal (HPA) axis and the hypothalamic-pituitary-gonadal (HPG) axis are very sensitive and can be affected by external factors like stress, starvation, and medication. Medication-induced suppression of these axes can cause adrenal insufficiency (AI) and hypogonadism. Exogenous glucocorticoid use is the most common cause of iatrogenic AI. Our aim is to bring attention to another broadly prescribed medication, megestrol acetate (MA), as the cause of suppression of both these axes. We report a case of symptomatic hypogonadism and asymptomatic AI in a male patient secondary to MA. The patient presented with decrease in testicular size and erectile dysfunction. His total testosterone and morning cortisol levels were low, but FH, LH, and TSH were normal. His pituitary MRI was unremarkable. Upon discontinuation of MA, the patient’s testosterone and cortisol levels normalized and his symptoms resolved. Hypogonadism and AI are known adverse effects of MA, but symptomatic hypogonadism as the primary manifestation has only been reported once in previous literature. Prolonged hypogonadism can lead to sarcopenia, depression, and osteoporosis, while asymptomatic AI carries the risk of becoming overt AI. Thus, heightened awareness of the impact of MA on both these axes is necessary.
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Crook, David. "Androgen therapy for ageing men: the implications for arterial disease." British Menopause Society Journal 8, no. 2 (June 1, 2002): 69–71. http://dx.doi.org/10.1258/136218002100321686.
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Steroid hormones such as oestradiol and testosterone have long been viewed as a key to long-term health. Although men do not undergo the precipitous fall in endogenous steroid hormone levels characteristic of the menopause, there is substantial interest in the therapeutic potential of low dose androgen therapies to maintain mental, skeletal and other aspects of health. Testosterone and other androgens seem to conform to the "clutch pedal" theory of hormone action. In terms of atherosclerosis, if plasma androgen levels are too low they may cause disease, but, if they are too high, atherosclerosis may also become a problem. Thus, the rationale for the use of low doses of androgens in ageing males is becoming compelling. Studies of arterial disease surrogates, such as plasma protein levels, may help optimise these therapies but the final answer on disease can only come from formal placebo-controlled trials of clinical endpoints.
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Zarei, Ali, Saeed Changizi Ashtiyani, and Gholam Hassan Vaezi. "A study on the effects of the hydroalcholic extract of the aerial parts of Alhagi camelorum on prolactin and pituitary-gonadal activity in rats with hypercholesterolemia." Archivio Italiano di Urologia e Andrologia 86, no. 3 (September 30, 2014): 188. http://dx.doi.org/10.4081/aiua.2014.3.188.
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Background: Although endocrine disorders are not a common cause of infertility, in some cases, testing thyroid function, and hypothalamus - pituitary - gonadal axis can determine the cause of infertility. We aimed to investigate the effect of the aerial parts of Alhagi camelorum extract on prolactin, cortisol and pituitary - gonadal axis activities in rats with hypercholesterolemia. Materials and methods: In this study, 35 male wistar rats in 5 groups (n = 7) were assigned as: control group with normal diet, the sham group with fat diet and three experimental groups of hypercholesterolaemic animals which received Alhagi camelorum extract at a minimum dose of 100 mg/kg, average dose of 200 ml/kg and maximum dose of 300 mg/kg over a period of 21 days. At the end of the period, blood samples were collected from all groups and blood factors were then measured and analyzed. Results: In the sham group compared to the control, cholesterol levels increased and FSH levels decreased, whereas cholesterol levels reduced in the experimental groups. Alhagi camelorum extract also reduced testosterone level and increased prolactin and gonadotropins. Conclusion: Alhagi camelorum extract at low and average doses reduced cortisol, testosterone and cholesterol and increased gonadotropins. So it can cause reproductive disorders in male rats. The extract at maximum dose can increase cortisol and prolactin. As these two hormones work together to produce milk, this plant can help to boost breastfeeding.
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Mittal, Ashima, Sanat Mishra, Karamvir Yadav, and Rajesh Rajput. "Uncontrolled diabetes as a rare presenting cause of pituitary apoplexy." BMJ Case Reports 12, no. 2 (February 2019): bcr—2018–228161. http://dx.doi.org/10.1136/bcr-2018-228161.
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Pituitary apoplexy is a rare endocrine emergency. The extent to which hyperglycaemia is a contributory risk factor in the precipitation of pituitary apoplexy is not known. A 38-year-old man with poorly controlled diabetes presented to the emergency department with sudden onset of nausea and headache with drooping of his right eyelid for about 4 days. On physical examination, he had orthostatic hypotension, ptosis of the right eye, lateral and downward positioning of the eye and absent pupillary reflex. Visual field testing of the left eye revealed superolateral quadrantanopia. MRI of the brain showed pituitary macroadenoma with necrosis. Investigations showed hyperglycaemia, decreased T3, T4 with normal Thyroid stimulating hormone (TSH), low serum Leutinizing hormone (LH), Follicle stimulating hormone (FSH), testosterone and low normal serum prolactin levels. About 21% of non-functioning pituitary adenomas present with apoplexy as was seen in our patient. It is likely that his uncontrolled diabetes precipitated this episode of apoplexy as hyperosmolarity and dehydration, caused by hyperglycaemia can lead to changed pituitary microvascular environment increasing the risk of pituitary infarction.
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Nandu, Nitish Singh, Wafa Dawahir, Swetha Paduri, Janice L. Gilden, and Dennis L. Citrin. "Can Long-Standing GnRH Therapy Cause a Pituitary Prolactinoma?" Journal of the Endocrine Society 5, Supplement_1 (May 1, 2021): A574—A575. http://dx.doi.org/10.1210/jendso/bvab048.1172.
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Abstract Background: Pituitary adenoma (PA) is the most common cause of sellar masses and accounts for about 10% of all intracranial tumors. Several physiological, pathological, drugs, and rare causes like hypothyroidism can cause PA. We describe a case of long-standing treatment with GnRH analogues possibly contributing to development of PA. Clinical Case: An 86-year-old man with a history of prostate cancer (PC) treated with medical therapy, presented to the hospital with progressively worsening loss of vision in his right eye associated with low-grade headaches over the past few years. Fifteen years prior to presentation, the patient was diagnosed with Gleason 6 (3 + 3) localized PC. He had refused surgical intervention and hence was treated with flutamide, then leuprolide. Labs were significant for an elevated prolactin 34.2 ng/mL [n= 2.5 -17.4], low LH 0.7 mIU/mL [n=1.2-10.6], with normal FSH, TSH, ACTH, IGF, Cortisol, and PTH. CT head and MRI brain identified a 2.7cm x 2.6.3 cm X 1.7 cm mass in the suprasellar region involving the left cavernous sinus and right optic chiasm. These findings were consistent with a diagnosis of Prolactinoma. Patient refused surgery and hence was started on bromocriptine. The findings were suspected to be secondary to long-standing GnRH agonist therapy, and leuprolide was discontinued. DEXA scan confirmed osteoporosis with a T score of --2.5, which was treated with denosumab. Subsequently his vision improved. The patient continues to follow with endocrinology for the management of osteoporosis and prolactinoma. Conclusion: Primary hypothyroidism predisposes to PA due to loss of thyroxine feedback inhibition to hypothalamus with overproduction of TRH with hyperplasia of lactotrophs. We speculate that constant stimulation of the pituitary by GnRH analogues can also lead to enlargement of the anterior pituitary in a similar fashion, and can lead to the development of prolactinoma. LHRH agonists such as Leuprolide, as palliative treatment for advanced prostate cancer, causes desensitization of the anterior pituitary and decreases the production of LH and FSH, which ultimately leads to decreased testosterone in males. Although not standard of care for treatment of locally advance tumors, medical therapy was chosen in this patient’s case due to refusal of surgical intervention. He then developed a clinically significant pituitary adenoma years after the therapy. We suggest that constant stimulation of the pituitary by GnRH analogues can lead to enlargement of the anterior pituitary in a similar fashion, resulting in the development of the prolactinoma. Reference(1) Du J, Ji H, Jin J, Gao S, Yan X, Hu S. Pituitary adenoma secondary to primary hypothyroidism: Two case reports. Medicine (Baltimore). 2020;99(8). https://journals.lww.com/md-journal/Fulltext/2020/02210/Pituitary_adenoma_secondary_to_primary.47.aspx
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Florian, Jana, Huy Duong, and Jennifer Roh. "An Anomalous Cause of Deep Venous Thrombosis: A Case Report." Clinical Practice and Cases in Emergency Medicine 5, no. 3 (June 1, 2021): 299–302. http://dx.doi.org/10.5811/cpcem.2021.4.51517.
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Introduction: Lower extremity deep venous thrombosis (DVT) is a common diagnosis in the emergency department (ED). Deep venous thromboses can be the result of anatomical variation in the vasculature that predisposes the patient to thrombosis. May-Thurner syndrome (MTS) is one such anatomic variant defined by extrinsic compression of the left common iliac vein between the right common iliac artery and lumbar vertebrae. Case Report: We report such a case of a 39-year-old woman with no risk factors for thromboembolic disease who presented to the ED with extensive unilateral leg swelling and was ultimately diagnosed with MTS. Conclusion: This diagnosis is an important consideration particularly in patients who are young, female, have scoliosis or spinal abnormalities, or are at low risk for DVT yet who present with extensive lower extremity swelling and are found to have proximal thrombus burden. Often further imaging, anticoagulation, angioplasty, or thrombectomy are indicated to prevent morbidity and post-thrombotic syndrome in these patients.
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Hieronymi, M., and A. Macke. "On the influence of wind and waves on underwater irradiance fluctuations." Ocean Science 8, no. 4 (July 10, 2012): 455–71. http://dx.doi.org/10.5194/os-8-455-2012.
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Abstract. The influence of various wind and wave conditions on the variability of downwelling irradiance Ed (490 nm) in water is subject of this study. The work is based on a two-dimensional Monte Carlo radiative transfer model with high spatial resolution. The model assumes conditions that are ideal for wave focusing, thus simulation results reveal the upper limit for light fluctuations. Local wind primarily determines the steepness of capillary-gravity waves which in turn dominate the irradiance variability near the surface. Down to 3 m depth, maximum irradiance peaks that exceed the mean irradiance Ed by a factor of more than 7 can be observed at low wind speeds up to 5 m s−1. The strength of irradiance fluctuations can be even amplified under the influence of higher ultra-gravity waves; thereby peaks can exceed 11 Ed. Sea states influence the light field much deeper; gravity waves can cause considerable irradiance variability even at 100 m depth. The simulation results show that under realistic conditions 50% radiative enhancements compared to the mean can still occur at 30 m depth. At greater depths, the underwater light variability depends on the wave steepness of the characteristic wave of a sea state; steeper waves cause stronger light fluctuations.
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Facondo, Paolo, Andrea Delbarba, Filippo Maffezzoni, Carlo Cappelli, and Alberto Ferlin. "INSL3: A Marker of Leydig Cell Function and Testis-Bone-Skeletal Muscle Network." Protein & Peptide Letters 27, no. 12 (December 2, 2020): 1246–52. http://dx.doi.org/10.2174/0929866527666200925105739.
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This article reviews the role of INSL3 as biomarker of Leydig cell function and its systemic action in testis-bone-skeletal muscle crosstalk in adult men. Insulin-like factor 3 (INSL3) is a peptide hormone secreted constitutively in a differentiation-dependent mode by testicular Leydig cells. Besides the role for the testicular descent, this hormone has endocrine anabolic functions on the bone-skeletal muscle unit. INSL3 levels are low in many conditions of undifferentiated or altered Leydig cell status, however the potential clinical utility of INSL3 measurement is not yet well defined. INSL3 levels are modulated by the long-term cytotropic effect of the hypothalamicpituitary- gonadal axis, unlike testosterone that is acutely sensitive to the stimulus by luteinizing hormone (LH). INSL3 directly depends on the number and differentiation state of Leydig cells and therefore it represents the ideal marker of Leydig cell function. This hormone is more sensitive than testosterone to Leydig cell impairment, and the reduction of INSL3 in adult men can precociously detect an endocrine testicular dysfunction. Low INSL3 levels could cause or contribute to some symptoms and signs of male hypogonadism, above all sarcopenia and osteoporosis. The measurement provided suggested that the measurement of INSL3 levels should be considered in the clinical management of male hypogonadism and in the evaluation of testicular endocrine function. The monitoring of INSL3 levels could allow an early detection of Leydig cell damage, even when testosterone levels are still in the normal range.
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Doggrell, Sheila Anne. "Zoledronic Acid Once-yearly: What Role in the Prevention of Non-vertebral Osteoporotic Fractures?" Clinical Medicine Insights: Therapeutics 2 (January 2010): CMT.S4947. http://dx.doi.org/10.4137/cmt.s4947.
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Osteoporosis is the most common bone disease. Low levels of oestrogens or testosterone are risk factors for primary osteoporosis. The most common cause of secondary osteoporosis is glucocorticoid treatment, but there are many other secondary causes of osteoporosis. Osteoporosis can be secondary to anti-oestrogen treatment for hormone-sensitive breast cancer and to androgen-deprivation therapy for prostate cancer. Zoledronic acid is the most potent bisphosphonate at inhibiting bone resorption. In osteoporosis, zoledronic acid increases bone mineral density for at least a year after a single intravenous administration. The efficacy and safety of extended release (once-yearly) zoledronic acid in the treatment of osteoporosis is reviewed.
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Smits, Thomas A., Femke MJ Gresnigt, Milly E. Attema-de Jonge, and Eric JF Franssen. "Can emergency department clinicians diagnose gamma-hydroxybutyrate (GHB) intoxication based on clinical observations alone?" Emergency Medicine Journal 38, no. 7 (March 5, 2021): 520–23. http://dx.doi.org/10.1136/emermed-2020-209577.
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ObjectivesGamma-hydroxybutyrate (GHB) is a drug of abuse with central depressing effects, which may cause coma with a GCS score as low as 3. A rapid diagnosis ‘GHB intoxication’ may prevent unnecessary diagnostic work-up and may lead to guided, less invasive, treatment. The aim of this study was to evaluate if ED physicians’ clinical evaluation were sufficient for diagnosis in patients with suspected GHB-intoxication.MethodsPatients presenting at the ED with a GCS<15 and a potential intoxication with drugs of abuse for whom urine toxicology screen was performed were included consecutively. After a first assessment, the ED physician registered the most likely initial diagnosis in the hospital information system. Urine of these patients was tested with a validated gas chromatography analytical method for GHB (confirmation test). The initial diagnoses were compared for agreement with the results of the confirmation test.ResultsA total of 506 patients were included, 100 patients tested positive for GHB and 406 patients tested negative for GHB. Sensitivity and specificity of the ED physicians compared with the confirmation test to diagnose GHB intoxications were 63% (95% CI 52 to 73) and 93% (95% CI 90 to 95), respectively. The positive predictive value was 67% (95% CI 60 to 77) and the negative predictive value was 92% (95% CI 88 to 94).ConclusionPhysicians underestimate the presence of GHB intoxication and can fail to diagnose GHB intoxication based on clinical observations alone. In the future, a rapid reliable initial analytical GHB test in addition to clinical judgement could be valuable to reduce false negative diagnosis.
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Batra, Neelu, Anhao Sam, Tibebe Woldemariam, George Talbott, Ralph W. de Vere White, Paramita M. Ghosh, Nilesh W. Gaikwad, Simeon O. Kotchoni, and Ruth L. Vinall. "Genistein Combined Polysaccharide (GCP) Can Inhibit Intracrine Androgen Synthesis in Prostate Cancer Cells." Biomedicines 8, no. 8 (August 11, 2020): 282. http://dx.doi.org/10.3390/biomedicines8080282.
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Our group and others have previously shown that genistein combined polysaccharide (GCP), an aglycone isoflavone-rich extract with high bioavailability and low toxicity, can inhibit prostate cancer (CaP) cell growth and survival as well as androgen receptor (AR) activity. We now elucidate the mechanism by which this may occur using LNCaP and PC-346C CaP cell lines; GCP can inhibit intracrine androgen synthesis in CaP cells. UPLC-MS/MS and qPCR analyses demonstrated that GCP can mediate a ~3-fold decrease in testosterone levels (p < 0.001) and cause decreased expression of intracrine androgen synthesis pathway enzymes (~2.5-fold decrease of 3βHSD (p < 0.001), 17βHSD (p < 0.001), CYP17A (p < 0.01), SRB1 (p < 0.0001), and StAR (p < 0.01)), respectively. Reverse-phase HPLC fractionation and bioassay identified three active GCP fractions. Subsequent NMR and LC-MS analysis of the fraction with the highest level of activity, fraction 40, identified genistein as the primary active component of GCP responsible for its anti-proliferative, pro-apoptotic, and anti-AR activity. GCP, fraction 40, and genistein all mediated at least a ~2-fold change in these biological activities relative to vehicle control (p < 0.001). Genistein caused similar decreases in the expression of 17βHSD and CYP17A (2.5-fold (p < 0.001) and 1.5-fold decrease (p < 0.01), respectively) compared to GCP, however it did not cause altered expression of the other intracrine androgen synthesis pathway enzymes; 3βHSD, SRB1, and StAR. Our combined data indicate that GCP and/or genistein may have clinical utility and that further pre-clinical studies are warranted.
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Khan, Muhammad Ilyas, Stuart Ruthven, Peter Smith, Monika Oktaba, Sumer A, and Sravan Thondam. "Elevated Testosterone Levels With Unclear Etiology- the Need for Longer Follow up and Role of Dexamethasone Suppression Test as a Useful Tool to Distinguish Tumorous vs Non Tumorous Etiology." Journal of the Endocrine Society 5, Supplement_1 (May 1, 2021): A757—A758. http://dx.doi.org/10.1210/jendso/bvab048.1540.
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Abstract Background: Severe hirsutism in women in conjunction with elevated testosterone level raises concern for androgen secreting tumors. When initial investigations and radiological imaging do not identify a tumorous pathology, clinicians are faced with a dilemma on whether to investigate further or to consider a benign cause such as PCOS or ovarian hyperthecosis. There is inadequate evidence on how long these patients need to be followed up before considering a benign cause for their symptoms. Clinical Case: 57 years-old female, with pertinent history including primary hypothyroidism and eczema, was referred to endocrine clinic in September-2011 for work-up of severe hirsutism and elevated testosterone levels of 4.1 nmol /L (n: 0 - 2.5). All other tests including androstenedione, DHEAS, baseline pituitary profile and 24-hours urinary free cortisol levels were unremarkable. MRI of adrenal glands and ovaries was also unremarkable. Patient was presumptively diagnosed with ovarian hyperthecosis and commenced on spironolactone. There was improvement in hirsutism and patient was discharged from clinic in Feb 2012. Patient was re-referred to endocrine clinic 7 years later in September-2019 for worsening of hirsutism, male pattern baldness. At this stage, patient had testosterone levels of 17– 23 nmol/L (n: 0 - 2.5). Free androgen index 76.6% (n:0–7), SHBG (35 nmol/L, n: 18 – 114). Androstenedione (4 nmol, n: 1 – 8.5) DHEAS (2.3 umol/L, n: 0.3 – 12), 24-hours urine free cortisol level (< 13 nmol, n: < 165 nmol), 17-hydroxyprogesterone, serum ACTH, TSH, LH and FSH and estradiol levels were all normal. On examination patient had signs of virilization which had developed over previous six months. Patient had a low dose dexamethasone suppression test (0.5 mg of dexamethasone 6 hourly for 48 hours). The androgen profile obtained pre and post test showed no suppression in testosterone but well suppressed cortisol. Patient had repeat MRI of the adrenals and ovaries which revealed focal enhancing mass in right ovary (3.3 x 2.5 x 2.6 cm). Patient had an urgent bilateral oophorectomy and histology confirmed a rare steroid cell tumour of the right ovary. Following surgery there has been a significant improvement in her symptoms. Conclusion: Patients with elevated testosterone level and unclear etiology need longer follow up and review of investigations when symptoms worsen as yet undiscovered sinister etiology could be the likely reason. Dexamethasone suppression can be considered as a useful tool to distinguish tumorous vs non tumorous etiology in early stage of investigations as poor suppression of androgens with dexamethasone increases the likelihood of tumorous etiology1References: 1. Kaltsas GA, Isidori AM, Kola BP, et al. The Value of the Low-Dose Dexamethasone Suppression Test in the Differential Diagnosis of Hyperandrogenism in Women. The Journal of Clinical Endocrinology & Metabolism 2003; 88(6): 2634-43.
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Vujovic, Svetlana, Miomira Ivovic, Milina Tancic-Gajic, Ljiljana Marina, Marija Barac, Zorana Arizanovic, Ana Nenezic, et al. "Premature ovarian failure." Srpski arhiv za celokupno lekarstvo 140, no. 11-12 (2012): 806–11. http://dx.doi.org/10.2298/sarh1212806v.
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Premature ovarian failure (POF) is the occurrence of hypergonadotropic hypoestrogenic amenorrhea in women under the age of forty years. It is idiopathic in 74-90% patients. Known cases can be divided into primary and secondary POF. In primary POF genetic aberrations can involve the X chromosome (monosomy, trisomy, translocations, deletions) or autosomes. Genetic mechanisms include reduced gene dosage and non-specific chromosome effects impairing meiosis, decreasing the pool of primordial follicles and increasing atresia due to apoptosis or failure of follicle maturation. Autoimmune ovarian damage is caused by alteration of T-cell subsets and T-cell mediated injury, increase of autoantibody producing B-cells, a low number of effector/cytotoxic lymphocyte, which decreases the number and activity of natural killer cells. Bilateral oophorectomy, chemotherapy, radiotherapy and infections cause the secondary POF. Symptoms of POF include irritability, nervousness, loss of libido, depression, lack of concentration, hot flushes, weight gaining, dry skin, vaginal dryness, frequent infections etc. The diagnosis is confirmed by the level of FSH of over 40 IU/L and estradiol below 50 pmol/L in women aged below 40 years. Biochemical and other hormonal analysis (free thyroxin, TSH, prolactin, testosterone), karyotype (<30 years of age), ultrasound of the breasts and pelvis are advisable. Optimal therapy is combined estrogen progestagen therapy given in a sequential rhythm, after excluding absolute contraindications. Testosterone can be added to adnexectomized women and those with a low libido. Sequential estrogen progestagen replacement therapy is the first line therapy for ovulation induction in those looking for pregnancy and after that oocyte donation will be advised. Appropriate estro-progestagen therapy improves the quality of life and prevents complications such as cardiovascular diseases, osteoporosis, stroke etc.
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Sun, Junliang. "Structure determination of submicron-sized porous materials by EM and XRD." Acta Crystallographica Section A Foundations and Advances 70, a1 (August 5, 2014): C930. http://dx.doi.org/10.1107/s205327331409069x.
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Structure determination of submicron-sized porous materials is always a great challenge for widening their industrial application. There are a few reasons for this challenge, such as 1) their big unit cell dimensions cause serious peak overlapping in powder X-ray diffraction (PXRD); 2) typical disordered guest molecules in the big portion of pores lower the resolution; 3) their relatively low stability prevents an easy application of high resolution transmission electron microscope image (HRTEM) and STEM techniques. PXRD and electron diffraction (ED) techniques are complimentary for the structure determination of such materials. The PXRD technique gives very accurate intensities and the major difficulty for the structure determination from PXRD is the peak overlapping while there is almost no peak overlapping in ED since the single-crystal-like ED patterns can be obtained from nano-sized crystals. For the ED techniques, the intensities suffer severely from dynamical effects which make it less reliable for the structure determination in many cases. The combination of them can overcome both shortcomings and solve most difficulties in the structure determination of submicron-sized porous materials. Here we will use a few examples to demonstrate how this combination facilitates the structure determination, such as ITQ-37, PKU-16, PKU-3, ITQ51.
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Ferrer, A., D. López, M. Vidal, M. Tobeña, S. Serrano, I. Pajares, E. Millastre, M. Ruiz-Echarri, J. Lambea, and A. Tres. "Evaluation of neurological symptoms in oncologic patients at the emergency department." Journal of Clinical Oncology 27, no. 15_suppl (May 20, 2009): e20728-e20728. http://dx.doi.org/10.1200/jco.2009.27.15_suppl.e20728.
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e20728 Background: Neurological symptoms in cancer patients are common and some of them represent a potentially serious situation. They are a frequent cause of complaint at the Emergency Department (ED). The aim of the study is to describe the profile of cancer patient who consult at ED for neurological symptoms, their diagnosis and management. Methods: From October 2007 to October 2008, all cancer patients treated at the ED of our hospital were prospectively collected. The reasons for consultation, diagnosis and clinical management are described. Results: A total of 560 cancer patients were enrolled. Of them, 61 patients (11%) consulted for a neurologic symptom: 50 of these patients (82%) were stage IV disease and 30 (49,2%) were receiving chemotherapy treatment. Of the total of patients, 14 (23%) had lung cancer; 10 patients (16%) had colorectal cancer; and 8 patients (13%) had primary central nervous system tumor. Most frequent causes of complaint were: low level of consciousness, 13 patients (21%); mobility deficit, 12 patients (19%); syncope, 9 patients (15%) and comitial crisis, 6 patients (10%). Of the patients who consulted for a neurological symptom, 52% of cases (32 patients) the cause was a structural lesion of central nervous system. Tumor progression was the diagnosis made in 27 patients (44,3%), in 14 patients (23%) the diagnosis was a metabolic alteration. A 69% of patients (42 patients) required hospitalization, 26% was discharged (16 patients) and 5% (3 patients) needed to be under observation during at least 24 hours. Conclusions: Neurological symptom is a frequent cause of complaint at ED for cancer patients. especially in patients in advanced stages. The most frequent diagnosis made because of these symptoms is tumor progression. Metabolic alterations are also an important diagnosis because of their frequency and because they can be solved by medical treatment. Most patients who consult for neurological symptoms need hospitalization. No significant financial relationships to disclose.
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Daoust, Raoul, Jean Paquet, Alexis Cournoyer, Éric Piette, Judy Morris, Justine Lessard, Gilles Lavigne, and Jean-Marc Chauny. "Relationship between acute pain trajectories after an emergency department visit and chronic pain: a Canadian prospective cohort study." BMJ Open 10, no. 12 (December 2020): e040390. http://dx.doi.org/10.1136/bmjopen-2020-040390.
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ObjectivesInadequate acute pain management can reduce the quality of life, cause unnecessary suffering and can often lead to the development of chronic pain. Using group-based trajectory modelling, we previously identified six distinct pain intensity trajectories for the first 14-day postemergency department (ED) discharge; two linear ones with moderate or severe pain during follow-up (~40% of the patients) and four cubic polynomial order trajectories with mild or no pain at the end of the 14 days (low final pain trajectories). We assessed if previously described acute pain intensity trajectories over 14 days after ED discharge are predictive of chronic pain 3 months later.DesignProspective cohort study.SettingTertiary care trauma centre academic hospital.ParticipantsThis study included 18 years and older ED patients who consulted for acute (≤2 weeks) pain conditions that were discharged with an opioid prescription. Patients completed a 14-day diary in which they listed their daily pain intensity (0–10 numeric rating scale).OutcomesThree months after ED visit, participants were questioned by phone about their current pain intensity (0–10 numeric rating scale). Chronic pain was defined as patients with current pain intensity ≥4 at 3 months.ResultsA total of 305 participants remained in the study at 3 months, 49% were women and a mean age of 55±15 years. Twelve per cent (11.9; 95% CI 8.2 to 15.4) of patients had chronic pain at the 3-month follow-up. Controlling for age, sex and pain condition, patients with moderate or severe pain trajectories and those with only a severe pain trajectory were respectively 5.1 (95% CI 2.2 to 11.8) and 8.2 (95% CI 3.4 to 20.0) times more likely to develop chronic pain 3 months later compared with patients in the low final pain trajectories.ConclusionSpecific acute pain trajectories following an ED visit are closely related to the development of chronic pain 3 months later.Trial registration numberNCT02799004; Results.
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Symczyk, Oksana, Jennifer Sarah Turner, Nadia Barghouthi, and Jessica Antoinette Perini. "Virilization Secondary to an Ovarian Leydig Cell Tumor." Journal of the Endocrine Society 5, Supplement_1 (May 1, 2021): A785—A786. http://dx.doi.org/10.1210/jendso/bvab048.1598.
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Abstract A 60-year-old female presented with a three-year history of virilizing symptoms including facial hirsutism and deepening of voice. Her medical history was significant for renal transplantation with immunosuppressive therapy consisting of mycophenolate, cyclosporine, and low-dose prednisone. She was noted to have temporal balding and darkly pigmented terminal hair on the upper lip, cheeks, chin, shoulders, and sternum. Pelvic examination revealed clitoromegaly. Menarche occurred at age 12 with regular menstrual cycles until menopause which occurred at age 50. She had two pregnancies: a miscarriage followed by a successful pregnancy. Labs revealed an elevated total testosterone of 530 ng/dL (< 60 ng/dL), free testosterone 14.8 ng/dL (<0.87 ng/dL), androstenedione 2140 ng/dL (<200 ng/dL), and 17-hydroxyprogesterone 704 ng/dL (<285 ng/dL). LH, FSH, and estradiol were inappropriately normal in this post-menopausal female. Prolactin, TSH, DHEA-S, IGF-1 were within normal limits. Transvaginal ultrasound found a 2 cm hypoechoic right ovarian mass which was confirmed on MRI. MRI also revealed a 5 mm right adrenal nodule. Tumor markers including CA-125, Inhibin A, Inhibin B, HCG, and AFP were within normal limits. Dexamethasone suppression testing did not lower the testosterone level. 17-hydroxyprogesterone level after cosyntropin stimulation testing was 704 ng/dL (<1000 ng/dL). The patient underwent laparoscopic bilateral oophorectomy and salpingectomy, pelvic washout and omental biopsy. Pathology was consistent with a benign Leydig cell tumor. Following oophorectomy there was complete normalization of the total testosterone level (15 ng/dL, n< 60 ng/dL). A thorough history and physical exam is vital in determining the cause of hirsutism. Medications, including over-the-counter and herbal formulations should be carefully reviewed. Although cyclosporine has been associated with hirsutism, patients typically present with vellus hair formation in the affected areas rather than darkly pigmented terminal hair. In this case, hirsutism progressively worsened following menopause and physical examination was significant for virilization. Hirsutism in a combination with virilization is typically neoplastic in nature. Endogenous androgen production can originate from either the adrenal glands or ovaries. In our patient, with workup showing both ovarian and adrenal as potential sources of endogenous androgen production, an adrenal cause was excluded due to a normal DHEA-S level at baseline and a lack of suppression of testosterone after dexamethasone suppression testing. As a result, the source was localized to the ovary. While excessive androgen production resulting in virilization is seen with ovarian tumors, Leydig stromal cell tumors are extremely rare and account for less than 0.1% of all ovarian tumors.
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Messier, F., J. Deshaies, and G. Breault. "P057: Impact of a clinical pathway for the treatment of acute asthma in the emergency department." CJEM 22, S1 (May 2020): S84—S85. http://dx.doi.org/10.1017/cem.2020.263.
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Introduction: In Canada, acute asthma is a common cause of emergency department (ED) attendance and its treatment is affected by ED overcrowding and increasing wait times. Literature suggests that a clinical pathway (CP) for the treatment of acute asthma can increase the use of medical therapy, reduce hospital admission rates and decrease associated costs. However, only few have looked at the effect on ED length of stay (ED LOS) when such a CP is initiated by triage nurse/respiratory therapist among adults. In this optic, an asthma CP was launched on Feb. 2016 at Centre Hospitalier Universitaire de Sherbrooke (QC) and included medical directives allowing triage nurse and respiratory therapist initiation of treatment. Methods: The objectives are to determine the effect of an ED nurse/respiratory therapist-initiated asthma CP on (1) ED LOS, (2) time-to-treatment (beta-agonist, corticosteroids), time-to-MD and other secondary outcomes. This was a retrospective before-after study. Adults presenting to the ED before and after CP implementation with a final diagnosis of asthma or asthma exacerbation were eligible. The groups A (before implementation) and B (after implementation) were compared for ED LOS. Three subgroups of 50 patients were generated and compared for outcomes: A1 (before implementation), B1 (after implementation without CP) and B2 (after implementation with CP). All five groups were controlled for triage level and sex. Results: In total, 1086 patients were included; 543 before implementation (Mar. 2011 – Feb. 2016) and 543 after (Feb. 2016 – Jun. 2019), of whom 14% (N = 77) were treated by CP. The average ED LOS was similar (10.36h vs 10.65h; (p = 0,31)) in group A and in group B. In groups A1, B1 and B2, the median ED LOS were respectively 6.00, 6.84, 4.80; these differences were not statistically significant. The average time-to-treatment for beta-agonist in A1, B1 and B2 was respectively 148, 180 and 50 mins; the differences between B2 and A1 and between B2 and B1 were both statistically significant (p < 0,05). Conclusion: Although this study indicates a low compliance to the CP, it shows that time-to-treatment can be reduced. It didn't demonstrate any statistically significant decrease in ED LOS, most likely due to low number of patients and non-normal distribution, but the 1.2h shorter could be a major advantage if it proves true. Further studies are essential to understand facilitators and alleviate the barriers in anticipation of a multi-centric implementation.
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Chary, Priyanka Kesavan, Aziz Ur Rehman, and Tamis Marie Bright. "Adrenoleukodystrophy as a Cause of Spastic Paraparesis and Hyperpigmentation." Journal of the Endocrine Society 5, Supplement_1 (May 1, 2021): A113. http://dx.doi.org/10.1210/jendso/bvab048.227.
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Abstract Background: X-linked Adrenoleukodystrophy (X-ALD) is caused by an abnormal gene mutation on the X chromosome which codes for an abnormal ABC transporter, preventing transport of very long chain fatty acids (VLCFAs) into peroxisomes for beta oxidation. These VLCFAs, unable to be broken down, thus accumulate in the CNS, adrenal cortex, and Leydig cells of the testes. The clinical presentation depends upon the anatomical involvement, which most often includes the CNS and adrenal glands, and can be a cause of adrenomyeloneuropathy (AMN) or adrenal insufficiency. Case Report: We report a 44 year old male who presented with 9 years of progressive spastic paraparesis. Physical exam was significant for lower extremity spasticity, 3/5 bilateral lower extremity weakness, and hyperpigmentation. His initial work-up for autoimmune disease, MRI brain, and lumbar puncture were unremarkable, and genetic testing for Hereditary Spastic Paraparesis was negative. However, due to advancing symptoms over the years with progression of spasticity, polyneuropathy, development of erectile dysfunction and significant hyperpigmentation, re-evaluation with MRI brain and EMG revealed diffuse symmetrical cerebral and cerebellar volume loss and axonal motor peripheral neuropathy, respectively. Due to hyperpigmentation, further work-up for VLCFAs was positive and presence of the ABCD1 mutation confirmed the diagnosis of X-ALD. Evaluation of adrenal glands yielded high ACTH of >2000 pg/mL (normal: 7.2–63.3) and low AM cortisol of 2.5 ug/dL (normal: 6.2–19.4). Insignificant increase of cortisol from 2.5 ug/dL to 2.7 ug/dL with cosyntropin confirmed primary adrenal insufficiency as the cause of hyperpigmentation with elevated ACTH. Surprisingly, his testosterone level was normal at 542 (normal: 250–1100 ng/dL) and suggestive of Leydig cell-sparing and neuropathy-induced erectile dysfunction. The patient was started on hydrocortisone for adrenal insufficiency with improvement in his fatigue and feelings of well-being. He received physical therapy and is being monitored closely for progression of AMN by Neurology. Conclusion: Our case suggests that ALD should be considered in the differential diagnosis of unexplained paraparesis with associated hyperpigmentation in males. Moreover, timely diagnosis and medical intervention can prevent life-threatening adrenal crisis in such patients.
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Anderson, Helen, Naomi Fogel, Stefan K. Grebe, Ravinder J. Singh, Robert L. Taylor, and Andrea Dunaif. "Infants of Women with Polycystic Ovary Syndrome Have Lower Cord Blood Androstenedione and Estradiol Levels." Journal of Clinical Endocrinology & Metabolism 95, no. 5 (May 1, 2010): 2180–86. http://dx.doi.org/10.1210/jc.2009-2651.
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Abstract Context: Prenatal androgen excess can cause a phenocopy of polycystic ovary syndrome (PCOS) in mammals. Retrospective studies have suggested that girls at risk for PCOS have low birth weight, and prospective studies have suggested an increased prevalence of small-for-gestational-age offspring in women with PCOS. Objective: The objective of the study was to determine whether infants of women with PCOS have reduced birth weight or increased intrauterine androgen levels. Design: This was a prospective case-control study. Participants: Thirty-nine PCOS and 31 control women and their infants participated in the study. Main Outcome Measures: Birth weight and mixed cord blood testosterone, androstenedione (A), dehydroepiandrosterone, 17-hydroxyprogesterone, estradiol (E2), and dihydrotestosterone levels were measured. Results: Mean birth weight did not differ, but there was a significant increase in the prevalence of large-for-gestational-age infants in the PCOS group. Cord blood E2 and A levels were lower (P < 0.05), but testosterone to E2 ratios did not differ in female PCOS compared with control offspring. There was no difference in E2 and A levels in the male PCOS and control offspring. There was no difference in 17-hydroxyprogesterone or other androgen levels in either male or female PCOS offspring compared with their respective control group. Conclusion: Infants of women with PCOS were more likely to be large for gestational age. Female offspring of affected women have lower cord blood A levels; other cord blood androgen levels do not differ compared with female control offspring. Cord blood E2 levels are also significantly decreased in PCOS, without any difference in the testosterone to E2 ratio, suggesting decreased fetal or placental production of steroids.
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Turton, James P. G., Charles R. Buchanan, Iain C. A. F. Robinson, Simon J. B. Aylwin, and Mehul T. Dattani. "Evolution of gonadotropin deficiency in a patient with type II autosomal dominant GH deficiency." European Journal of Endocrinology 155, no. 6 (December 2006): 793–99. http://dx.doi.org/10.1530/eje.1.02293.
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Background: Type II isolated GH deficiency (IGHD type II) is caused by dominant negative splicing or point mutations of the GH-1 gene. Studies have suggested that dominant mutant GH forms prevent the secretion of wild-type GH, resulting in eventual cell death; surprisingly, some patients with these GH mutations develop other hormonal deficiencies (ACTH, TSH). Subjects: The proband presented at the age of 2.3 years with IGHD. His father, also known to have been treated for IGHD as a child, had subsequently been lost to follow-up, having remained without treatment during this time. At re-evaluation at the age of 38 years, he complained of lack of stamina and poor libido. Clinical and biochemical assessment confirmed severe GHD, borderline ACTH insufficiency, suboptimal basal and stimulated gonadotropins, and a poor prolactin response to provocation. The basal testosterone concentration was low, and he complained of secondary infertility. Magnetic resonance imaging revealed anterior pituitary hypoplasia in both patients. Genetic testing revealed a heterozygous splicing mutation in GH-1 (intervening sequence-3 + 1G>A) in both patients, known to cause IGHD type II. Interventions: The proband showed an excellent growth response to recombinant human GH (rhGH). His father, also treated with rhGH, showed improved quality of life on rhGH, but testosterone concentrations continued to decline, necessitating treatment with testosterone with symptomatic benefit but no improvement in semen quality. Conclusions: This case supports recent experimental and clinical observations suggesting that the cytotoxicity associated with accumulation of dominant negative mutant 17.5 kDa GH causes a form of GHD that can evolve into multiple hormone deficiencies. Hence, patients diagnosed initially with IGHD type II require continued long-term clinical follow-up.
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Sandri, Andrea, Dario Regis, and Nicola Bizzotto. "Delayed Bleeding and Pelvic Haematoma after Low-Energy Osteoporotic Pubic Rami Fracture in a Warfarin Patient: An Unusual Cause of Abdominal Pain." Case Reports in Emergency Medicine 2014 (2014): 1–4. http://dx.doi.org/10.1155/2014/783268.
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Introduction. Acute abdominal pain may be the presenting symptom in a wide range of diseases in the elderly. Acute abdominal pain related to a delayed bleeding and pelvic haematoma after a low-energy pubic rami fracture is rare and can have important consequences; to the best of our knowledge, only one case has been previously described.Case Report. We present an unusual case of an 83-year-old woman taking warfarin for atrial fibrillation, admitted to the Emergency Department (ED) with acute abdominal pain and progressive anemia related to a delayed bleeding and pelvic haematoma 72 hours after a low-energy osteoporotic pubic rami fracture. Warfarin was withheld, anticoagulation was reversed by using fresh frozen plasma and vitamin K, and concentrated red blood cells were given. Haemoglobin level gradually returned to normal with a progressive resorption of the haematoma.Conclusion. Delayed bleeding and pelvic haematoma after osteoporotic pubic rami fracture should be considered in the differential diagnosis of acute abdominal pain in the elderly. This case indicates the need for hospital admission, careful haemodynamic monitoring, and early identification of bleeding in patients with “benign” osteoporotic pubic rami fracture, especially those receiving anticoagulants, to provide an adequate management and prevent severe complications.
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Thiruganasambandamoorthy, V., M. Taljaard, N. Hudek, J. Brehaut, B. Ghaedi, P. Nguyen, M. Sivilotti, et al. "LO06: Development of practice recommendations for ED management of syncope by mixed methods." CJEM 22, S1 (May 2020): S8—S9. http://dx.doi.org/10.1017/cem.2020.62.
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Introduction: Emergency department (ED) syncope management is extremely variable. We developed practice recommendations based on the validated Canadian Syncope Risk Score (CSRS) and outpatient cardiac monitoring strategy with physician input. Methods: We used a 2-step approach. Step-1: We pooled data from the derivation and validation prospective cohort studies (with adequate sample size) conducted at 11 Canadian sites (Sep 2010 to Apr 2018). Adults with syncope were enrolled excluding those with serious outcome identified during index ED evaluation. 30-day adjudicated serious outcomes were arrhythmic (arrhythmias, unknown cause of death) and non-arrhythmic (MI, structural heart disease, pulmonary embolism, hemorrhage)]. We compared the serious outcome proportion among risk categories using Cochran-Armitage test. Step-2: We conducted semi-structured interviews using observed risk to develop and refine the recommendations. We used purposive sampling of physicians involved in syncope care at 8 sites from Jun-Dec 2019 until theme saturation was reached. Two independent raters coded interviews using an inductive approach to identify themes; discrepancies were resolved by consensus. Results: Of the 8176 patients (mean age 54, 55% female), 293 (3.6%; 95%CI 3.2-4.0%) experienced 30-day serious outcomes; 0.4% deaths, 2.5% arrhythmic, 1.1% non-arrhythmic outcomes. The serious outcome proportion significantly increased from low to high-risk categories (p < 0.001; overall 0.6% to 27.7%; arrhythmic 0.2% to 17.3%; non-arrhythmic 0.4% to 5.9% respectively). C-statistic was 0.88 (95%CI0.86–0.90). Non-arrhythmia risk per day for the first 2 days was 0.5% for medium-risk, 2% for high-risk and very low thereafter. We recruited 31 physicians (14 ED, 7 cardiologists, 10 hospitalists/internists). 80% of physicians agreed that low risk patients can be discharged without specific follow-up with inconsistencies around length of ED observation. For cardiac monitoring of medium and high-risk, 64% indicated that they don't have access; 56% currently admit high-risk patients and an additional 20% agreed to this recommendation. A deeper exploration led to following refinement: discharge without specific follow-up for low-risk, a shared decision approach for medium-risk and short course of hospitalization for high-risk patients. Conclusion: The recommendations were developed (with online calculator) based on in-depth feedback from key stakeholders to improve uptake during implementation.
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Kavsak, Peter A., Joshua O. Cerasuolo, Shawn E. Mondoux, Jonathan Sherbino, Jinhui Ma, Brock K. Hoard, Richard Perez, Hsien Seow, Dennis T. Ko, and Andrew Worster. "Risk Stratification for Patients with Chest Pain Discharged Home from the Emergency Department." Journal of Clinical Medicine 9, no. 9 (September 12, 2020): 2948. http://dx.doi.org/10.3390/jcm9092948.
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For patients with chest pain who are deemed clinically to be low risk and discharged home from the emergency department (ED), it is unclear whether further laboratory tests can improve risk stratification. Here, we investigated the utility of a clinical chemistry score (CCS), which comprises plasma glucose, the estimated glomerular filtration rate, and high-sensitivity cardiac troponin (I or T) to generate a common score for risk stratification. In a cohort of 14,676 chest pain patients in the province of Ontario, Canada and who were discharged home from the ED (November 2012–February 2013 and April 2013–September 2015) we evaluated the CCS as a risk stratification tool for all-cause mortality, plus hospitalization for myocardial infarction or unstable angina (primary outcome) at 30, 90, and 365 days post-discharge using Cox proportional hazard models. At 30 days the primary outcome occurred in 0.3% of patients with a CCS < 2 (n = 6404), 0.9% of patients with a CCS = 2 (n = 4336), and 2.3% of patients with a CCS > 2 (n = 3936) (p < 0.001). At 90 days, patients with CCS < 2 (median age = 52y (IQR = 46–60), 59.4% female) had an adjusted HR = 0.51 (95% confidence interval (CI) = 0.32–0.82) for the composite outcome and patients with a CCS > 2 (median age = 74y (IQR = 64–82), 48.0% female) had an adjusted HR = 2.80 (95%CI = 1.98–3.97). At 365 days, 1.3%, 3.4%, and 11.1% of patients with a CCS < 2, 2, or >2 respectively, had the composite outcome (p < 0.001). In conclusion, the CCS can risk stratify chest pain patients discharged home from the ED and identifies both low- and high-risk patients who may warrant different medical care.
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Fitzpatrick, David, Douglas Maxwell, and Alan Craigie. "PP14 The feasibility and acceptability of a novel low tech intervention to improve pre-hospital data recording for pre-alert and handover to the emergency department." Emergency Medicine Journal 36, no. 1 (January 2019): e6.1-e6. http://dx.doi.org/10.1136/emermed-2019-999.14.
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BackgroundPoor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Data used in handover is not always easily recorded using ambulance based tablets, particularly in time-critical cases. Paramedics have therefore developed pragmatic workarounds (writing on gloves or scrap paper) to record these data. However, such practices can conflict with policy, data recorded can be variable, easily lost and negatively impact on handover quality.AimsTo measure the feasibility and acceptability of a novel, low-tech intervention introduced to support clinical information recording and delivery during pre-alert and handover. The intervention consisted of a reusable card with pre-alert/handover mnemonic and corresponding text boxes for data entry via pen.MethodsA pre and post-test design was used. Paramedics (n=69) based at one city ambulance Station received the intervention. Pre-and post-test measures (12 weeks post-introduction) focussed on paramedic acceptability and utility of intervention, ED staff (n=99) perceptions of handover quality, and proportions of clinical variables documented by ED staff during pre-alert.ResultsTwenty-five (36%) paramedics responded to an intervention acceptability questionnaire. Most felt both the pre-alert (n=23 [92%]) and handover (n=18 [72%]) components of the card were ‘useful’ or ‘very useful’. Nineteen (76%) used the card to record clinical information, almost all (n=23 [92%]) felt it ‘useful’ to ‘very useful’ in supporting pre-alert. Similarly, 65% (n=16) stated they ‘often’ or ‘always’ used the card during handover. For pre-alert information there were improvements in the provision of 8/11 (72.7%) clinical variables measured. Results from the post-test survey evaluating ED staff (n=37 [37%]) perceptions of handover demonstrated perceived improvements in 3/5 domains measured (p<0.05).ConclusionThis novel low-tech intervention was highly acceptable to paramedic participants, improving their data recording and information exchange processes. Further, well conducted studies are required to test the impact of this intervention on information exchange processes.
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James, Elena M., LaShon C. Sturgis, Abdullah Kutlar, Robert Gibson, and Matthew L. Lyon. "Creatinine, Lactate Dehydrogenase, and C-Reactive Protein As Indicators of Acute Vaso-Occlusive Crisis and Sickle Cell Disease Severity in the Emergency Department." Blood 124, no. 21 (December 6, 2014): 4940. http://dx.doi.org/10.1182/blood.v124.21.4940.4940.
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Abstract Sickle cell disease (SCD) patients often seek care in the Emergency Department (ED) due to vaso-occlusive crisis (VOC), the most common complication of SCD. Currently, no diagnostic test can determine if a SCD patient is having an acute VOC. This study analyzed the utility of creatinine (Cr), C-reactive protein (CRP), and lactate dehydrogenase (LDH) as indicators of acute VOC and increased disease severity. We hypothesized that increased levels of these markers correlated with acute VOC and increased SCD severity because they are suggestive of renal injury, accelerated hemolysis, and inflammation with VOC onset. Data was collected from a cohort of 171 patients followed at an adult sickle cell clinic from 2005 to 2012. Eligibility criteria included a minimum age of 18 with SCD genotypes Hb S/S, Hb S/C, Hb S/B+, or Hb S/B0. Marker values were collected prospectively, with baseline values obtained during non-crisis visits to the sickle cell clinic, and crisis values obtained during treatment for VOC in the ED. Patients were categorized as high or low ED users to approximate disease severity using two methods. Aggregate (AG) analysis assigned patients to the high user group, 65 patients (38%), if they had >3 VOC ED visits in any year. The low user group, 106 patients (62%), had 3 or less VOC ED visits in any year. Since disease severity fluctuates in individual patients over time, a second analysis divided the groups using an individual (IN) analysis where high user-years were defined as >3 VOC ED visits/year. IN analysis resulted in 226 (47%) high user-years and 259 (53%) low user-years. Statistical analysis using R Version 3.1.0 compared overall average baseline and crisis values to determine if biomarker levels increased in acute VOC. High and low user values were compared with respect to baseline and crisis averages to determine if biomarker levels correlated with SCD severity. Analysis of baseline and crisis values over the study period evaluated changes with age. Statistical significance was set to p<0.05. Table 1 summarizes the significant results of the statistical analysis. Changes in Cr and LDH between high and low users with respect to baseline, crisis, and difference between baseline and crisis were not statistically significant in both analyses. However, crisis CRP values between high and low user-years differed significantly. In both analyses, overall baseline and crisis Cr and LDH differed significantly. Crisis Cr and baseline LDH increased significantly over the 7-year time span. Table 1 Marker Variable Mean SD P-value Cr (mg/dL) AG overall baseline 0.80 0.687 0.0053 AG overall crisis 1.08 1.55 IN overall baseline 0.817 0.931 0.0178 IN overall crisis 1.00 1.48 Overall crisis start 1.02 1.59 0.0087 Overall crisis end 1.10 1.76 LDH (U/L) AG overall baseline 387 196 7.90E-5 AG overall crisis 463 227 IN overall baseline 395 228 0.0194 IN overall crisis 445 269 Overall baseline start 373 181 0.0015 Overall baseline end 417 234 CRP (mg/dL) IN high user crisis 2.61 4.31 0.0247 IN low user crisis 1.05 1.02 Creatinine, a urinary muscle metabolite, is a marker of kidney function. Dehydration, a potential cause of VOC, may explain the rise in Cr during crisis. LDH increase in crisis reflects increased intravascular hemolysis during VOC. The results support the utility of Cr and LDH as indicators of acute VOC in the ED. However, both AG and IN analyses reveal no distinction between high and low users of the ED. LDH and Cr increase with age, suggesting potential for monitoring SCD disease progression. Increased Cr crisis levels with age may reflect kidney dysfunction due to medullary ischemia from multiple VOCs. Increased non-crisis LDH levels with age suggest increased disease severity, progressive organ damage, and steady state pro-inflammatory conditions. CRP, an acute phase reactant indicative of systemic inflammation, was higher during crisis in high user-years than in low user-years. The correlation of increased crisis CRP to increased ED usage may represent a higher inflammatory state in these patients. Further studies are needed to determine the cause and effect relationship of this correlation. The data supports the utility of Cr and LDH as markers for acute VOC. LDH and Cr also demonstrate potential as indicators of SCD disease severity in a long-term context, while CRP demonstrates potential to monitor for short-term inflammatory states leading to increased severity in frequency and possibly intensity of VOC. Disclosures No relevant conflicts of interest to declare.
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Heath, Julie A., and Peter C. Frederick. "Relationships Among Mercury Concentrations, Hormones, and Nesting Effort of White Ibises (Eudocimus Albus) in the Florida Everglades." Auk 122, no. 1 (January 1, 2005): 255–67. http://dx.doi.org/10.1093/auk/122.1.255.
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Abstract Mercury, a common wetland pollutant, can affect wildlife populations through acute toxicity or through physiological effects that modify behavior and negatively influence reproductive success. We compared body-feather mercury concentrations of free-living male and female adult White Ibises (Eudocimus albus) during three breeding seasons in the Florida Everglades and examined the relationships among mercury, hormone concentrations, and body-condition scores. Female White Ibises consistently had lower mercury concentrations than males. Prebreeding females' estradiol concentrations were negatively correlated with mercury concentrations. However, we found no relationship between mercury and female testosterone, progesterone, and corticosterone concentrations. Incubating male White Ibises showed a significant positive relationship between testosterone and mercury concentrations, but no other significant hormonal correlations with mercury concentrations. We used a seven-year standardized data set of Great Egret (Ardea alba) chick-feather mercury concentrations as a measure of temporal changes in mercury bioavailability in the Everglades and related that measure to annual numbers of White Ibis nests. White Ibis nesting was negatively correlated with the mercury exposure index. Low numbers of nesting White Ibises may have been the result of fewer birds nesting or high abandonment rates. Our results suggest that mercury exposure may cause fewer birds to nest or more birds to abandon nests because of subacute effects on hormone systems. However, the results are correlative; they call for further investigation in free-living populations and in the laboratory. Relaciones entre las Concentraciones de Mercurio, Hormonas y el Esfuerzo de Nidificación de Eudocimus albus en los Everglades, Florida
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Cook, Olivia G., Muhammad A. Mukarram, Soo-Min Kim, Kirtana Arcot, Marie-Joe Nemnom, Monica Taljaard, Marco L. A. Sivilotti, Brian H. Rowe, and Venkatesh Thiruganasambandamoorthy. "Application of outpatient cardiac testing among emergency department patients with syncope." Emergency Medicine Journal 35, no. 8 (April 24, 2018): 486–91. http://dx.doi.org/10.1136/emermed-2017-207081.
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Objectives2.6% of ED syncope patients will suffer cardiac serious adverse events (SAEs) within 30 days of disposition, and outpatient cardiac testing can improve patient safety. The objective is to determine whether outpatient cardiac testing for ED syncope patients is being appropriately ordered after discharge. To this end, we describe the proportion of high-risk and non-high (low and medium)-risk ED syncope patients as per the Canadian Syncope Risk Score (CSRS) who have a SAE after ED discharge, and the proportion referred for outpatient cardiac testing.MethodsOur multicentre prospective cohort study enrolled adult syncope patients between 2010 and 2014 in five academic EDs. We collected patient characteristics, disposition, CSRS predictors, outpatient referrals and testing results (Holter, echocardiography), and 30-day adjudicated SAE (death due to unknown/cardiac cause, myocardial infarction, arrhythmia and structural heart disease). We used descriptive statistics (mean, SD) to report our results.ResultsOf 3584 enrolled patients (mean age 50.9 years, 57.7% women), 800 patients (22.3%) received an outpatient referral. Of these 800 patients, 40.3% of the non-high-risk patients (305/756) and 54.5% of the high-risk patients (24/44) received outpatient cardiac testing. Of all patients who received cardiac testing, five (1.5%; 95% CI 0.6% to 3.5%) suffered outpatient SAE (60.0% arrhythmias). Of all patients who did not receive cardiac testing, four patients (0.9%; 95% CI 0.3% to 2.2%) suffered SAE (all arrhythmias). Of the 20 (45.5%) high-risk patients who did not receive testing, two patients (10.0%; 95% CI 2.8% to 30.1%) suffered arrhythmias outside the hospital, while among the 451 (59.7%) non-high-risk patients, only two (0.4%; 95% CI 0.1% to 1.6%) suffered outpatient arrhythmias.ConclusionOutpatient cardiac testing is largely underused, especially among high-risk ED syncope patients. Better guidelines for outpatient cardiac testing are needed, as the practice is highly variable and mismatched with patient risk.
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Ramaekers, R., C. Leafloor, J. J. Perry, and V. Thiruganasambandamoorthy. "P121: Derivation of a clinical decision tool for predicting adverse outcomes among emergency department patients with lower gastrointestinal bleeding." CJEM 20, S1 (May 2018): S99—S100. http://dx.doi.org/10.1017/cem.2018.319.
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Introduction: Lower gastrointestinal bleeding (LGIB) can result in serious adverse events, including recurrent bleeding, need for intervention and death. Endoscopy is important in the management of LGIB, however gastroenterologists have limited resources to safe endoscopy. Risk stratification of LGIB patients can aid physicians in disposition decisions. Objective: to develop a clinical decision tool to accurately identify LGIB patients presenting to the emergency department (ED) who are at risk for 30-day serious adverse events. Methods: We conducted a health records review and included 372 adult ED patients who presented with an acute LGIB. The outcome was a 30-day composite outcome consisting of all-cause death, recurrent LGIB, need for intervention to control the bleed and ICU admission. A second researcher confirmed data-collection of 10% of the data and we calculated a -value for inter-rater reliability. We analyzed the data using stepwise backwards selection and SELECTION=SCORE option and calculated the diagnostic accuracy of the final model. Results: Age 75 years, hemoglobin 100 g/L, INR 2.0, a bloody stool in the ED and a past medical history of colorectal polyps were significant predictors in the multivariable regression analysis. The AUC was 0.83 (95% CI 0.77-0.89), sensitivity 0.96 (0.90-1.00), specificity 0.53 (0.48-0.59), and negative likelihood ratio 0.08 (0.02-0.30) for a cut-off score of 1. Conclusion: This model showed good ability to identify LGIB patients at low risk for adverse events as evidenced by the high AUC, sensitivity and negative likelihood ratio. Future, large prospective studies should be done to confirm the data, after which it should be validated and implemented.
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Yi, Lingna, Juan Dai, Yong Chen, Yeqing Tong, You Li, Guoqing Fu, Zengguang Teng, et al. "Reproductive toxicity of cadmium in pubertal male rats induced by cell apoptosis." Toxicology and Industrial Health 37, no. 8 (June 15, 2021): 469–80. http://dx.doi.org/10.1177/07482337211022615.
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Cadmium (Cd) is a heavy metal that is widely present in modern industrial production. It is a known, highly toxic environmental endocrine disruptor. Long-term exposure to Cd can cause varying degrees of damage to the liver, kidney, and reproductive system of organisms, especially the male reproductive system. This study aimed to explore the mechanism of Cd toxicity in the male reproductive system during puberty. Eighteen healthy 6-week-old male Sprague–Dawley rats were randomly divided into three groups (control group, low-dose group, and high-dose group) according to their body weight, with six in each group. Cd (0, 1, and 3 mg/kg/day) was given by gavage for 28 consecutive days. The results showed that Cd exposure to each dose group caused a decrease in the testicular organ coefficient and sperm count, compared with the control group. Cd exposure resulted in significant changes in testicular morphology in the 3 mg/kg/day Cd group. In the 1 and 3 mg/kg/day Cd groups, serum testosterone decreased and apoptosis of testicular cells increased significantly ( p < 0.05). In addition, compared with the control group, the activity of glutathione peroxidase and superoxide dismutase in each Cd exposure dose group decreased, but the content of malondialdehyde in the high-dose, 3 mg/kg/day Cd treatment group significantly increased ( p < 0.05). Although Cd exposure caused an increase in the messenger RNA (mRNA) levels of Bcl-2, Caspase-3 and Caspase-9 in the testicular tissues ( p < 0.05), Bcl-2 expression was unchanged ( p > 0.05). The expression level of Akt mRNA in testicular tissue of rats in the high-dose 3 mg/kg/day Cd group was increased ( p < 0.05). Our data suggest that Cd affected testosterone levels, and apoptosis was observed in spermatids.
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Florin, Todd Adam, Daniel Joseph Tancredi, Lilliam Ambroggio, Franz E. Babl, Stuart R. Dalziel, Michelle Eckerle, Santiago Mintegi, Mark Neuman, Amy C. Plint, and Nathan Kuppermann. "Predicting severe pneumonia in the emergency department: a global study of the Pediatric Emergency Research Networks (PERN)—study protocol." BMJ Open 10, no. 12 (December 2020): e041093. http://dx.doi.org/10.1136/bmjopen-2020-041093.
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IntroductionPneumonia is a frequent and costly cause of emergency department (ED) visits and hospitalisations in children. There are no evidence-based, validated tools to assist physicians in management and disposition decisions for children presenting to the ED with community-acquired pneumonia (CAP). The objective of this study is to develop a clinical prediction model to accurately stratify children with CAP who are at risk for low, moderate and severe disease across a global network of EDs.Methods and analysisThis study is a prospective cohort study enrolling up to 4700 children with CAP at EDs at ~80 member sites of the Pediatric Emergency Research Networks (PERN; https://pern-global.com/). We will include children aged 3 months to <14 years with a clinical diagnosis of CAP. We will exclude children with hospital admissions within 7 days prior to the study visit, hospital-acquired pneumonias or chronic complex conditions. Clinical, laboratory and imaging data from the ED visit and hospitalisations within 7 days will be collected. A follow-up telephone or text survey will be completed 7–14 days after the visit. The primary outcome is a three-tier composite of disease severity. Ordinal logistic regression, assuming a partial proportional odds specification, and recursive partitioning will be used to develop the risk stratification models.Ethics and disseminationThis study will result in a clinical prediction model to accurately identify risk of severe disease on presentation to the ED. Ethics approval was obtained for all sites included in the study. Cincinnati Children’s Hospital Institutional Review Board (IRB) serves as the central IRB for most US sites. Informed consent will be obtained from all participants. Results will be disseminated through international conferences and peer-reviewed publications. This study overcomes limitations of prior pneumonia severity scores by allowing for broad generalisability of findings, which can be actively implemented after model development and validation.
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De La Mora, Hector, Juan Hinojosa, Hugo Eduardo Velazquez, Ricardo Alonso Castillejos-Molina, Victor Monjaras, and Maria Teresa Bourlon. "Sexual health and quality of life in testicular cancer survivors (TCS) in a third level hospital of a middle-income country." Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017): e21589-e21589. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.e21589.
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e21589 Background: TCS have long life expectancy, but struggle with numerous potential long-term sequelae, including sexual dysfunction (SD). They can suffer organic SD as a treatment side effect, and non-organic SD as a result of psychosexual changes related to the disease. The aim of this study is to determine the prevalence of SD in a cohort of TCS in a middle-income country, and to examine possible influences on health-related quality of life (HRQoL). Methods: An observational, cross-sectional, descriptive and analytic study was conducted. TCS in our cohort underwent IIEF-5 questionnaire, and sexual hormones measurement. HRQoL was examined using SF-36 questionnaire. Beck Depression Scale was used to assess psychological symptoms. Logistic regression analysis was used to evaluate the association among SD and disease characteristics and HRQoL. A Pearson correlation test was performed between SD and disease free survival interval. Results:The study population comprised 35 men whose and mean age was 32±8.3 years (21-54) and the median follow-up time since the end of treatment was 24 months, . Twelve TCS (34%) reported any level of impairment of erectile function (ED), 21 (60%) had loss of sexual desire, and 15 (42%) reported orgasmic dysfunction (OD). The presence of ED, loss of desire, or OD were not associated with worse scores in all SF36 domains, including both composite scores and the total SF-36 score. Treatment with adjuvant chemotherapy (CT) or CT plus retroperitoneal lymph node dissection were not associated with ED (p = 0.8). Fatigue (SF-36 vitality) was statistically significant higher among our cohort of TCS compared to an age-adjusted normative Mexican male population, independently of SD or depression level (0.001). Fatigue was independently associated with higher levels of gonadotropins and lower of testosterone (p = 0.05). Conclusions: The incidence of SD in Mexican TCS is similar (34%) to the rate reported in other populations. HRQoL is decreased particularly in the vitality section, when compared to age-adjusted normative controls. Nevertheless, we did not demonstrate a correlation between SD and worse HRQoL or depression level. Fatigue was associated with low level of tesosterone.
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Möckel, Martin, Miriam Songa Stegemann, Volker Burst, Philipp Kümpers, Joachim Risse, Felix Carlo Koehler, Domagoj Schunk, Jennifer Hitzek, Tamara Elene Dietrich, and Anna Slagman. "Which parameters support disposition decision in suspected COVID-19 cases in the emergency department (ED): a German clinical cohort study." BMJ Open 11, no. 3 (March 2021): e044853. http://dx.doi.org/10.1136/bmjopen-2020-044853.
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ObjectivesOne major goal of the emergency department (ED) is to decide, whether patients need to be hospitalised or can be sent home safely. We aim at providing criteria for these decisions without knowing the SARS-CoV-2 test result in suspected cases.SettingTertiary emergency medicine.ParticipantsAll patients were treated at the ED of the Charité during the pandemic peak and underwent SARS-CoV-2 testing. Patients with positive test results were characterised in detail and underwent a 14-day-follow-up.Primary and secondary outcome measuresLogistic regression and classification and regression tree (CART) analyses were performed to identify predictors (primary endpoint), which confirm safe discharge. The clinical endpoint was all-cause mortality or need for mechanical ventilation during index stay or after readmission.ResultsThe primary test population of suspected COVID-19 consisted of n=1255 cases, 45.2% were women (n=567). Of these, n=110 tested positive for SARS-CoV-2 (8.8%). The median age of SARS-CoV-2-positive cases was 45 years (IQR: 33–66 years), whereas the median age of the group tested negative for SARS-CoV-2 was 42 years (IQR: 30–60 years) (p=0.096). 43.6% were directly admitted to hospital care.CART analysis identified the variables oxygen saturation (<95%), dyspnoea and history of cardiovascular (CV) disease to distinguish between high and low-risk groups. If all three variables were negative, most patients were discharged from ED, and the incidence of the clinical endpoint was 0%. The validation cohort confirmed the safety of discharge using these variables and revealed an incidence of the clinical endpoint from 14.3% in patients with CV disease, 9.4% in patients with dyspnoea and 18.2% in patients with O2 satuaration below 95%.ConclusionsBased on easily available variables like dyspnoea, oxygen saturation, history of CV disease, approximately 25% of patients subsequently confirmed with COVID-19 can be identified for safe discharge.Trial registration numberDRKS00023117.
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Buffomante, Ashley, Philip Goldstein, Cory Hussain, Carlos Malvestutto, Jose A. Bazan, Mohammad Mahdee Sobhanie, Brandon Pollak, et al. "416. Improvement in Syphilis and HIV Screening Rates at a Community-Based Emergency Department in Columbus, Ohio: Six Month Post-Intervention Analysis." Open Forum Infectious Diseases 6, Supplement_2 (October 2019): S210—S211. http://dx.doi.org/10.1093/ofid/ofz360.489.
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Abstract Background Sexually transmitted infections (STIs) disproportionally affect individuals living in underserved areas and Emergency Departments (ED) can play a major role in STI screening. Given the overlapping risk factors for STIs, patients screened for gonorrhea and chlamydia should also be screened for syphilis and HIV. Rates of syphilis/HIV screening in the ED are very low and barriers include lack of knowledge about the risk/prevalence, difficulty with results interpretation, and concerns about follow-up. Methods The main study objective was to improve rates of syphilis/HIV screening in a community-based ED in Columbus, OH. A team of clinical providers, case managers, and social workers was formed to address barriers to screening. Using root cause analysis and data feedback, a multistep intervention that included provider education along with expert review of syphilis/HIV results was implemented to ensure proper screening, treatment and rapid linkage to care. Syphilis/HIV screening rates in the ED were compared between two periods: 2012–2017 (pre-intervention) and November 2018–April 2019 (post-intervention). Results Between 2012 and 2017, there were 24,427 ED encounters where any STI test was ordered. There were 23,652 (97%) tests for chlamydia, 23,637 (97%) for gonorrhea, 254 (1%) for syphilis, and 466 (2%) for HIV. Twenty-four (0.1%) encounters had screening that included all four tests. Six months after starting the intervention, there were 1,590 encounters where any STI test was ordered. There were 1,444 (91%) tests for chlamydia, 1,446 (91%) for gonorrhea, 493 (31%) for syphilis and 591 (37%) for HIV. Four hundred thirty-eight (28%) of encounters had screening that included all four tests. Conclusion Collaborative and practical interventions aimed at improving syphilis/HIV testing have resulted in dramatic increases in syphilis, HIV, and comprehensive STI screening (31-, 19-, 280-fold, respectively) over a relatively short post-intervention period. Additional steps are planned with the goal to further increase screening rates and improve linkage to prevention and treatment programs. Disclosures All authors: No reported disclosures.
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Kayode, Omowumi T., Damilare E. Rotimi, Abolanle A. A. Kayode, Tomilola D. Olaolu, and Oluyomi S. Adeyemi. "Monosodium Glutamate (MSG)-Induced Male Reproductive Dysfunction: A Mini Review." Toxics 8, no. 1 (January 22, 2020): 7. http://dx.doi.org/10.3390/toxics8010007.
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Reproductive dysfunction is often characterized by malfunction of the reproductive tissues, which may lead to disruption of the synergistic rhythm that should bring about a progression of sexual events and the conception of new life. This may therefore result in the sexual dysfunction and infertility that can be seen in couples having prolonged biological difficulty in reproducing their offspring after having unrestricted sexual intercourse for at least twelve months. Several factors have been implicated in the cause and progression of reproductive dysfunction, including poor nutrition, drug side effects, disease states, and toxicant ingestion. A well-known food additive that has been found to be potent at initiating reproductive anomalies in males is monosodium glutamate (MSG). This regular flavor enhancer is widely used as a taste enhancer in several diets. The different mechanisms by which it may induce reproductive dysfunctions include spermatogenic alteration resulting in a low sperm count, high sperm abnormality, reduced live sperm and decreased sperm pH, oxidative damage (increased lipid peroxidation and reduced antioxidant enzyme activities), histological alteration (blood hemorrhage, distorted germ and Sertoli cells), as well as gonadotropin imbalance (reduced testosterone, luteinizing hormone, and follicle-stimulating hormone concentrations). Therefore, this review discusses various established mechanisms through which MSG may induce reproductive dysfunction and the treatment strategies to ameliorate its toxic effects.
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Loutroukis, Triantafillos, Ekaterini Loutrouki, Jolanta Klukowska-Rötzler, Sabine Koba, Fabian Schlittler, Benoit Schaller, Aristomenis K. Exadaktylos, et al. "Violence as the Most Frequent Cause of Oral and Maxillofacial Injuries among the Patients from Low- and Middle-Income Countries—A Retrospective Study at a Level I Trauma University Emergency Department in Switzerland." International Journal of Environmental Research and Public Health 17, no. 13 (July 7, 2020): 4906. http://dx.doi.org/10.3390/ijerph17134906.
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Preventive strategies can be developed by gathering more information about oral and maxillofacial injuries and oral pathologies in immigrants from low- to middle-income countries (LMIC). Additional information on the quality of care can also improve the allocation of clinical resources for the management of these patients. We studied immigrants from LMIC who presented in the emergency department (ED) at Berne University Hospital with dental problems or oral or maxillofacial injuries. The patient data included age, gender, nationality, the etiology and type of trauma and infection in the oral-maxillofacial area, and overall costs. The greatest incidence of maxillofacial injuries was observed in the age group of 16–35 years (n = 128, 63.6%, p = 0.009), with males outnumbering females in all age groups. Trauma cases were most frequent in the late evening and were mostly associated with violence (n = 82, 55.4%, p = 0.001). The most common fracture was fracture of the nose (n = 31). The mean costs were approximately the same for men (mean = 2466.02 Swiss francs) and women (mean = 2117.95 Swiss francs) with maxillofacial injuries but were greater than for isolated dental problems. In conclusion, the etiology of dental and maxillofacial injuries in immigrants in Switzerland requires better support in the prevention of violence and continued promotion of oral health education.
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Tannock, I., M. Gospodarowicz, W. Meakin, T. Panzarella, L. Stewart, and W. Rider. "Treatment of metastatic prostatic cancer with low-dose prednisone: evaluation of pain and quality of life as pragmatic indices of response." Journal of Clinical Oncology 7, no. 5 (May 1989): 590–97. http://dx.doi.org/10.1200/jco.1989.7.5.590.
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Thirty-seven men with symptomatic bone metastases from prostate cancer that had progressed following earlier treatment with estrogens and/or orchidectomy were treated with low-dose prednisone (7.5 to 10 mg daily). The rationale for this treatment was that some patients might still have hormone-sensitive disease that was stimulated by weak androgens of adrenal origin, and that these androgens could be suppressed by prednisone through its negative feedback on secretion of adrenocorticotrophic hormone (ACTH). Response to treatment was assessed by requirement for analgesics, by the McGill-Melzack pain questionnaire, and by a series of 17 linear analog self-assessment (LASA) scales relating to pain and to various aspects of quality of life. Fourteen patients (38%) had improvement in indices used to assess pain at 1 month after starting prednisone, and seven patients (19%) maintained this improvement for 3 to 30 months (median, 4 months). Reduction in pain was associated with improvement in other dimensions of quality of life, and in the scale for overall well-being. Prednisone treatment led to a decrease in the concentration of serum testosterone in seven of nine patients where it was not initially suppressed below 2 nmol/L, and caused a decrease in serum levels of androstenedione and dehydroepiandrosterone sulfate in more than 50% of patients. Symptomatic response was associated with a decrease in serum concentration of adrenal androgens. We conclude that (1) low-dose prednisone may cause useful relief of pain in some patients with advanced prostatic cancer; (2) relief of pain was associated with suppression of adrenal androgens; and (3) measures of pain and quality of life can be used to assess possible benefits of systemic therapy in patients with metastatic prostate cancer.
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Thompson, Michael A., Auris Huen, Gregory D. Ayers, Bela B. Toth, Rena V. Sellin, Ana O. Hoff, William A. Murphy, and F. B. Hagemeister. "Baseline Osteopenia and Osteoporosis in Untreated Non-Hodgkin’s Lymphoma Patients." Blood 108, no. 11 (November 16, 2006): 4607. http://dx.doi.org/10.1182/blood.v108.11.4607.4607.
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Abstract BACKGROUND: Lymphoma treatment with alkylating agents and steroids can cause premature osteoporosis, increasing the risk of vertebral and hip fracture. Mechanisms of bone loss may include local microenvironment lymphoma-related cytokine activity, steroid-mediated bone loss, and hypogonadism from chemotherapy. The bisphosphonate pamidronate every three months has been found to reduce bone loss and the risk of new vertebral fractures in lymphoma patients receiving chemotherapy; however, the more potent bisphosphonate, zoledronic acid, has not been evaluated in this patient population. We are conducting a randomized study of zoledronic acid in untreated non-Hodgkin’s lymphoma (NHL) patients to study chemotherapy induced bone loss and improve NHL survivorship. While this trial is still accruing patients, we report the abnormal baseline bone mineral density (BMD) and endocrine characteristics found in patients screened for this study. METHODS: We report the preliminary baseline endocrine characteristics for this ongoing bone health research study. Untreated NHL patients were screened for BMD and endocrine studies including vitamin D levels, testosterone, and bone turnover markers. Patients on the study were stratified as male, female (pre-menopausal), and female (post-menopausal). Exclusion criteria included bone fractures, BMD T-scores worse than −2.0, creatinine clearance less than 60 mL/min, dental problems, and prior steroid or bisphosphonate use. Patients accrued to the study are randomized to receive either: 1) oral calcium and vitamin D (Ca+D) or 2) Ca+D and 4 mg zoledronic acid IV at baseline and at 6 months. RESULTS: Patient characteristics included: 49 male, 35 female (10 pre-menopausal), median age 61 (range: 18–87). Of 84 patients screened for BMD to date, patients had the following abnormalities: 12/84 (14%) had osteoporosis and 47/84 (56%) had osteopenia or osteoporosis. Of 20 patients who consented to the trial and who were evaluated with additional studies, 10 were excluded due to the following: 3/20 hypovitaminosis D, 1/20 with prior steroid use, 1/20 low testosterone, 1/20 prior HRT, 1/20 with bone disease, 2/20 required dental extractions, and 1/20 treatment changed to chemotherapy without steroids. Patients with osteoporosis or T score worse than −2.0 were evaluated by their primary oncologist for treatment with bisphosphonates. Patients with other abnormal studies were further evaluated and treated by specialists in endocrinology and dentistry. CONCLUSIONS: Baseline testing of BMD and endocrine studies revealed osteopenia or osteoporosis in 56% of untreated NHL patients. Hypovitaminosis D or low testosterone was found in a smaller number of tested patients. While these patients were excluded from the remainder of the study and referred for further evaluation, patients should benefit from having these underlying problems addressed. Our ongoing clinical trial will address the potential role of zoledronic acid in preserving bone density for survivors of NHL. This trial was funded by Novartis. ClinicalTrials.gov Identifier: NCT00352846.
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Havdal, Lise Beier, Britt Nakstad, Hans Olav Fjærli, Christian Ness, and Christopher Inchley. "Viral lower respiratory tract infections—strict admission guidelines for young children can safely reduce admissions." European Journal of Pediatrics 180, no. 8 (April 8, 2021): 2473–83. http://dx.doi.org/10.1007/s00431-021-04057-4.
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AbstractViral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children < 24 months assessed at the emergency department for VLRTI for a 10-year period. To identify adverse events related to admission guidelines implementation, we reviewed patient records for all those discharged on primary contact followed by readmission within 14 days. During the study period, 3227 children younger than 24 months old were assessed in the ED for VLRTI. The proportion of severe adverse events among children who were discharged on their initial emergency department contact was low both before (0.3%) and after the intervention (0.5%) (p=1.0). Admission rates before vs. after the intervention were for previously healthy children > 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5).Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI. What is Known:• Viral lower respiratory tract infection, including bronchiolitis, is the most common cause of hospitalization for young children in the developed world. Treatment is mainly supportive, and hospitalization should be limited to the cases in need of therapeutic intervention.• Many countries have guidelines for the management of the disease, but the decision on whom to admit for inpatient treatment is often subjective and may vary even between physicians in the same hospital. What is New:• Implementation of admission criteria for viral lower respiratory tract infection may reduce the rate of hospital admissions without increasing adverse events.
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Cook, O., M. A. Mukarram, S. Kim, K. Arcot, M. Taljaard, M. Sivilotti, B. H. Rowe, and V. Thiruganasambandamoorthy. "LO03: Application and usefulness of outpatient cardiac testing among emergency department patients with syncope." CJEM 19, S1 (May 2017): S28. http://dx.doi.org/10.1017/cem.2017.65.
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Introduction: 2.6% of emergency department (ED) syncope patients will have underlying cardiac serious conditions (e.g. arrhythmia, serious structural heart disease) identified within 30-days of disposition. If those at risk are discharged home, outpatient cardiac testing can detect underlying arrhythmias and structural heart disease, and thereby improve patient safety. We describe the frequency of outpatient referrals for cardiac testing and the proportion of cardiac serious adverse events (SAE) among high risk and non-high (low and medium) risk ED syncope patients, as defined by the Canadian Syncope Risk Score (CSRS). Methods: We conducted a multicenter prospective cohort study to enroll adult syncope patients across five large tertiary care EDs. We collected demographics, medical history, disposition, CSRS value, outpatient referrals and testing results (holter, echocardiography), and cardiac SAE. Adjudicated 30-day SAE included death due to unknown cause, myocardial infarction, arrhythmia, and structural heart disease. We used descriptive analysis. Results: Of 4,064 enrolled patients, a total of 955 patients (23%) received an outpatient referral (mean age 57.7 years, 52.1% female). Of the 299 patients (7%) hospitalized, 154 received outpatient cardiac testing after discharge. Among the 3,765 patients discharged home from the ED, 40% of the non-high risk patients (305/756) and 56% of the high risk patients (25/45) received outpatient cardiac testing. Of all patients who received outpatient cardiac testing, 4 patients (0.8%) had serious cardiac conditions identified and all were arrhythmias. Among those with no cardiac testing, 5 patients (0.9%) suffered cardiac SAE (80% arrhythmias) outside the hospital. Of the 20 (44%) high risk patients who did not receive outpatient cardiac testing, 2 (10%) patients suffered arrhythmias outside the hospital. While among the 451 non-high risk patients, only 0.8% suffered arrhythmia outside the hospital. Conclusion: Outpatient cardiac testing among ED syncope patients is largely underutilized, especially among high risk patients. Better guidelines for outpatient cardiac testing are needed, as current practice is highly variable and mismatched with patient risk.
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Frankenfeld, Stephan Pinheiro, Leonardo Pires de Oliveira, Daniele Leão Ignacio, Raquel Guimarães Coelho, Mariana Nigro Mattos, Andrea Claudia Freitas Ferreira, Denise Pires Carvalho, and Rodrigo Soares Fortunato. "Nandrolone decanoate inhibits gluconeogenesis and decreases fasting glucose in Wistar male rats." Journal of Endocrinology 220, no. 2 (February 2014): 143–53. http://dx.doi.org/10.1530/joe-13-0259.
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The use of anabolic–androgenic steroids to improve physical performance or appearance has increased notably. The doses used are 10- to 100- fold higher than the therapeutic dose (TD), and this abuse can cause several side effects. Glucose metabolism is significantly affected by anabolic–androgenic steroid abuse, but studies about glycemic regulation during fasting are scarce. There are some evidences showing that testosterone can antagonize glucocorticoids action, which are crucial to glucose production during fasting. Thus, the aim of this study was to determine the impact of supraphysiological doses (SDs) of nandrolone decanoate (DECA) on rat glucose metabolism during fasting. Male Wistar rats were treated with i.m. injections of vehicle, a low TD (0.016 mg/100 g b.w.-TD group) or a high SD (1 mg/100 g b.w.-SD group) of DECA, once a week for 8 weeks. After 12 h fasting, we evaluated glucose and pyruvate tolerance tests, liver glycogen content, serum levels of gluconeogenic substrates, insulin and corticosterone, glucose uptake and hexokinase (HK) activity in skeletal muscle, and the adrenal catecholamine content. SD group had increased serum insulin levels and a blunted response to insulin regarding glucose uptake in skeletal muscle. Fasting serum glucose decreased significantly in SD group, as well as the pyruvate tolerance test and liver glycogen content. Moreover, serum levels of glycerol were increased in SD group. Our data indicate that SDs of DECA exert effects on different regulatory points of glucose metabolism, resulting in defective gluconeogenesis and decreased skeletal muscle glucose uptake in response to insulin.
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Baby, Merilyn, Deepa Badrinath Murthy, Melissa Kaori Litao, Gail Shust, and Bina Cherryl Shah. "Exogenous Cushing’s Syndrome, Hypogonadism and Diabetes Secondary to Megestrol Acetate." Journal of the Endocrine Society 5, Supplement_1 (May 1, 2021): A700. http://dx.doi.org/10.1210/jendso/bvab048.1425.
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Abstract Introduction: Megestrol acetate (MA) is a synthetic progestin that is often prescribed for anorexic patients with HIV due to its effects on weight gain and appetite stimulation. It can cause several endocrine/metabolic abnormalities. Chronic use of MA can cause exogenous Cushing’s Syndrome (ECS) and iatrogenic adrenal insufficiency (AI) due to its stronger affinity for the glucocorticoid receptor (GR). It can also cause gonadotropin suppression, diabetes and hyperprolactinemia. We present a case of a young woman with perinatal HIV/AIDS that developed ECS secondary to MA treatment in the setting of fatigue, rapid weight gain and irregular menses. Case: A 19 year old female with perinatal HIV/AIDS (CD4<200) was treated with MA (200mg/day for 5 months) for anorexia and weight loss. On exam she was pre-hypertensive (BP 138/62), obese (BMI 43.07, SDS +2.25; weight 114kg, SDS +2.34) with increased fat deposition over upper back and abdominal striae, excessive weight gain (21.5 kg in 5 months) suggestive of ECS. She had menarche at 13 years of age and had regular menses until starting MA, upon which she developed oligomenorrhea. A random serum cortisol level was <0.5ug/dl at 1pm with a low ACTH <1.5pg/ml and DHEAS of 13.4ug/dl. Her FSH was 3.4 mIU/L and LH 0.82 mIU/L, estradiol was <2pg/dl and total testosterone <2.5ng/dl consistent with secondary hypogonadism. Liver/kidney function, prolactin and lipid profile were normal. HbA1c increased from 5.3 to 6.4% in 8 months so she was started on metformin. ECS with AI, central hypogonadism and diabetes were all attributed to MA therapy. MA was discontinued gradually over two weeks. Stress dosing of glucocorticoids were advised as needed. Results: Gradual recovery of HPA axis was noted after discontinuation of MA. Two months after taper, serum ACTH level rose to 2.5pg/ml but AM cortisol level remained low at <0.5ug.dl. Her HPA axis showed partial recovery by 5 months with ACTH level of 53.2pg/ml and AM cortisol level of 5.5ug/dl. By 8 months after discontinuing MA therapy, AM cortisol was 9.3ug/dl, suggesting complete HPA axis recovery. Her HPG axis also normalized by 8 months with FSH 6.6 mIU/L and LH of 14.6 mIU/L, estradiol 32pg/dl with regular menses. Metformin was discontinued at 4 months due to hypoglycemia and HbA1C of 5.7%. Subsequently, euglycemia was achieved (HbA1C of 5.4%) within 9 months. BMI was stable (BMI 43.07, SDS +2.25; weight 114kg, SDS +2.34). Conclusion: Multiple endocrine abnormalities may occur due to MA therapy due to its affinity to bind with glucocorticoid and progesterone/androgen receptors. ECS and AI are known to occur with various forms of glucocorticoid use, but rarely can be seen with MA therapy. HPA axis, HPG axis and metabolic parameters should be evaluated and monitored carefully during MA therapy.
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Jahan, Sharmin, Muhammad Abul Hasanat, Fakhrul Alam, Mohammad Fariduddin, and Tania Tofail. "LEYDIG CELL HYPOPLASIA: A UNIQUE PARADOX IN THE DIAGNOSIS OF 46,XY DISORDERS OF SEX DEVELOPMENT." AACE Clinical Case Reports 6, no. 3 (May 2020): e117-e122. http://dx.doi.org/10.4158/accr-2019-0152.
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Objective: Disorders of sex development (DSD) are defined as conditions in which chromosomal sex is inconsistent with phenotypic sex, or in which the phenotype is not classifiable as either male or female. Mutations in genes present in X, Y or autosomal chromosomes can cause abnormalities of testis determination or 46,XY DSD. Leydig cell hypoplasia (LCH), also known as Leydig cell agenesis, is a rare autosomal recessive endocrine syndrome of 46,XY DSD. Our objective here is to present the case of a 27-year-old, phenotypic female who presented with primary amenorrhea and later found to have LCH. Methods: We used formatted history and clinical examination followed by necessary hormonal investigations. The diagnosis was confirmed by histopathology of resected testes and genetic mutation analysis. Results: The patient's physical examination was unremarkable except 2 ovoid lumps present in the inguinovulvar region. There were no müllerian structures on sonography. Estrogen and both basal and stimulated testosterone levels were low whereas luteinizing hormone and follicle-stimulating hormone were high. Her chromosomal sex was found to be 46,XY. The histopathology of the resected inguinal lumps showed atrophic testicular change lacking Leydig cells with relative preservation of Sertoli cells. Genetic mutation analysis failed to reveal any significant aberration in the LHCGR gene. At present she is on estrogen replacement therapy having undergone bilateral orchidectomy and vaginoplasty. Conclusion: LCH represents a unique example of diagnostic dilemma in gender identification. It requires a multidisciplinary approach for optimum outcome.
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Basri, Lenjani, Baftiu Nehat, Rashiti Premtim, Shabani Gani, Krasniqi Blerim, Demiri Arber, Pelaj Besarta, Spahiu Fllanza, Demi Arban, and Lenjani Dardan. "Emergency care sick palliative and problems oncology in emergency department during the COVID-19 pandemic." Archives of Pathology and Clinical Research 4, no. 1 (September 30, 2020): 024–27. http://dx.doi.org/10.29328/journal.apcr.1001019.
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Emergency medical care in palliative patients during the COVID-19 pandemic, it is important to provide a consistent treatment for stable patients that should be consistent with the goals and benefits, the perspective of these patients, but avoiding palliative patients with a poor prognosis that is unlikely to survive. Cancer is the second leading cause of death in the world around 8.8 million deaths a year. Worldwide, about 7-10 million patients are diagnosed with cancer each year, recently there has been a significant increase in the number of cases diagnosed with cancer. About 70% of cancer deaths are in low- and middle-income countries. The goals of emergency medical care based on the criteria of BLS and ACLS, that is should be done “Do not do resuscitation, do not intubate but continue medical treatment excluding endotracheal intubation without prospects for the patient, but offering BLS only treatment concentrated symptomatic. ED is often the only place that can provide the necessary medical interventions (e.g., intravenous fluids or pain management medications. Medications as well as immediate access to advanced diagnostic tests when needed such as CT, RM and other diagnostic and treatment procedures.
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Anderson, Helen, Naomi Fogel, Stefan K. Grebe, Ravinder J. Singh, Robert L. Taylor, and Andrea Dunaif. "Infants of Women with Polycystic Ovary Syndrome have Lower Cord Blood Androstenedione and Estradiol Levels." Endocrine Reviews 31, no. 2 (April 1, 2010): 255–56. http://dx.doi.org/10.1210/edrv.31.2.9981.
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ABSTRACT Context Prenatal androgen excess can cause a phenocopy of polycystic ovary syndrome (PCOS) in mammals. Retrospective studies have suggested that girls at risk for PCOS have low birth weight and prospective studies have suggested an increased prevalence of small for gestational age offspring in women with PCOS. Objective To determine whether infants of women with PCOS have reduced birth weight or increased intrauterine androgen levels. Design Prospective case-control study. Participants Thirty-nine PCOS and 31 control women and their infants. Main outcome measures Birth weight and mixed cord blood testosterone, androstenedione (A), dehydroepiandrosterone, 17-hydroxyprogesterone, estradiol (E2), and dihydrotestosterone levels. Results Mean birth weight did not differ but there was a significant increase in the prevalence of large for gestational age infants in the PCOS group. Cord blood E2 and A levels were lower (p < 0.05) but testosterone:E2 ratios did not differ in female PCOS compared to control offspring. There was no difference in E2 and A levels in the male PCOS and control offspring. There was no difference in 17-hydroxyprogesterone or in other androgen levels in either male or female PCOS offspring compared to their respective control group. Conclusion Infants of women with PCOS were more likely to be large for gestational age. Female offspring of affected women have lower cord blood A levels; other cord blood androgen levels do not differ compared to female control offspring. Cord blood E2 levels are also significantly decreased in PCOS, without any difference in the testosterone:E2 ratio, suggesting decreased fetal or placental production of steroids.