Adrenal venous sampling in the diagnostic workup of primary aldosteronism

British Journal of Radiology ◽

10.1259/bjr.20210311 ◽

2021 ◽

Author(s):

Matthias Johannes Betz ◽

Christoph Johannes Zech

Keyword(s):

Primary Aldosteronism ◽

Adrenal Adenoma ◽

Secondary Hypertension ◽

University Hospital ◽

Bilateral Disease ◽

Bilateral Adrenal Hyperplasia ◽

Diagnostic Work ◽

The University ◽

Work Up ◽

Current Guidelines

Primary aldosteronism (PA) is the primary cause of secondary hypertension. The prevalence of PA has probably been underestimated in the past and recent studies suggest that PA could be present in up to 10% of patients suffering from hypertension. Aldosterone excess in PA can be caused by unilateral adrenal disease, usually adrenal adenoma, or bilateral adrenal hyperplasia. Differentiation between unilateral and bilateral disease is clinically important as the former can effectively be treated by removal of the affected adrenal. CT or MRI cannot reliably distinguish unilateral from bilateral disease. Therefore, adrenal vein sampling (AVS) is an important step of the diagnostic work-up in patients with PA. Current guidelines recommend PA in virtually all patients with biochemically diagnosed PA who would undergo adrenal surgery if unilateral PA was diagnosed. In this narrative review, we give an overview of the current technique used for AVS with a focus on the experience with this technique at the University Hospital Basel, Switzerland.

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ICHD-3 is significantly more specific than ICHD-3 beta for diagnosis of migraine with aura and with typical aura

The Journal of Headache and Pain ◽

10.1186/s10194-019-1072-2 ◽

2020 ◽

Vol 21 (1) ◽

Cited By ~ 1

Author(s):

Carl H. Göbel ◽

Sarah C. Karstedt ◽

Thomas F. Münte ◽

Hartmut Göbel ◽

Sebastian Wolfrum ◽

...

Keyword(s):

Emergency Room ◽

Diagnostic Criteria ◽

Migraine With Aura ◽

University Hospital ◽

Headache Disorders ◽

Ischemic Attack ◽

Diagnostic Work ◽

The University ◽

Work Up

Abstract Background In the emergency room, distinguishing between a migraine with aura and a transient ischemic attack (TIA) is often not straightforward and mistakes can be harmful to both the patient and to society. To account for this difficulty, the third edition of the International Classification of Headache disorders (ICHD-3) changed the diagnostic criteria of migraine with aura. Methods One hundred twenty-eight patients referred to the emergency room at the University Hospital of Lübeck, Germany with a suspected TIA were prospectively interviewed about their symptoms leading to admission shortly after initial presentation. The diagnosis that resulted from applying the ICHD-3 and ICHD-3 beta diagnostic criteria was compared to the diagnosis made independently by the treating physicians performing the usual diagnostic work-up. Results The new ICHD-3 diagnostic criteria for migraine with aura and migraine with typical aura display an excellent specificity (96 and 98% respectively), and are significantly more specific than the previous ICHD-3 beta classification system when it comes to diagnosing a first single attack (probable migraine with aura and probable migraine with typical aura). Conclusions The ICHD-3 is a highly useful tool for the clinical neurologist in order to distinguish between a migraine with aura and a TIA, already at the first point of patient contact, such as in the emergency department or a TIA clinic.

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Primary Aldosteronism: The Next Five Years

Hormone and Metabolic Research ◽

10.1055/s-0043-119802 ◽

2017 ◽

Vol 49 (12) ◽

pp. 977-983 ◽

Cited By ~ 11

Author(s):

John Funder

Keyword(s):

Primary Aldosteronism ◽

Germline Mutations ◽

Adrenal Hyperplasia ◽

Bilateral Disease ◽

The Past ◽

Wide Range ◽

Unilateral Disease ◽

Bilateral Adrenal Hyperplasia ◽

Aldosterone Producing Adenoma ◽

Current Guidelines

AbstractThe management of primary aldosteronism is widely varied within various published guidelines, with very little in the way of data supporting the choice of one variation over others. Current estimates of prevalence are probably accurate for aldosterone producing adenoma, but fall very short of that for bilateral adrenal hyperplasia. Discovery at the level of basic science has proven illuminating over the past 6 years in terms of unilateral disease and both somatic and germline mutations, with much less focus on the much more common bilateral disease; Attempts at harmonization have begun – for example, criteria for complete/partial/absent cure after adrenalectomy for unilateral disease; again focus on bilateral disease is muted. A number of possibilities are suggested as agenda for active consideration and change, across a wide range of areas – referral patterns, screening, confirmation and lateralization, what will be needed is discussion and agreement, to fill the lacunae within the current guidelines. Those involved will want to change to make such an agenda possible.

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Recent Development toward the Next Clinical Practice of Primary Aldosteronism: A Literature Review

Biomedicines ◽

10.3390/biomedicines9030310 ◽

2021 ◽

Vol 9 (3) ◽

pp. 310

Author(s):

Yuta Tezuka ◽

Yuto Yamazaki ◽

Yasuhiro Nakamura ◽

Hironobu Sasano ◽

Fumitoshi Satoh

Keyword(s):

Clinical Practice ◽

Primary Aldosteronism ◽

Diagnostic Procedures ◽

Secondary Hypertension ◽

Refractory Hypertension ◽

Diagnostic Biomarkers ◽

Histopathological Classification ◽

Subtype Differentiation ◽

Work Up

For the last seven decades, primary aldosteronism (PA) has been gradually recognized as a leading cause of secondary hypertension harboring increased risks of cardiovascular incidents compared to essential hypertension. Clinically, PA consists of two major subtypes, surgically curable and uncurable phenotypes, determined as unilateral or bilateral PA by adrenal venous sampling. In order to further optimize the treatment, surgery or medications, diagnostic procedures from screening to subtype differentiation is indispensable, while in the general clinical practice, the work-up rate is extremely low even in the patients with refractory hypertension because of the time-consuming and labor-intensive nature of the procedures. Therefore, a novel tool to simplify the diagnostic flow has been recently in enormous demand. In this review, we focus on recent progress in the following clinically important topics of PA: prevalence of PA and its subtypes, newly revealed histopathological classification of aldosterone-producing lesions, novel diagnostic biomarkers and prediction scores. More effective strategy to diagnose PA based on better understanding of its epidemiology and pathology should lead to early detection of PA and could decrease the cardiovascular and renal complications of the patients.

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Combinations of Symptoms in Emergency Presentations: Prevalence and Outcome

Journal of Clinical Medicine ◽

10.3390/jcm8030345 ◽

2019 ◽

Vol 8 (3) ◽

pp. 345 ◽

Cited By ~ 5

Author(s):

Tobias Kuster ◽

Christian Nickel ◽

Mirjam Jenny ◽

Lana Blaschke ◽

Roland Bingisser

Keyword(s):

Time Course ◽

Predictive Power ◽

Secondary Analysis ◽

Clinical Work ◽

Adverse Outcomes ◽

University Hospital ◽

Chief Complaints ◽

The University ◽

Work Up ◽

Inclusion Period

The predictive power of certain symptoms, such as dyspnoea, is well known. However, research is limited to the investigation of single chief complaints. This is in contrast to patients in the emergency department (ED) presenting usually more than one symptom. We aimed to identify the most common combinations of symptoms and to report their related outcomes: hospitalisation, admission to intensive care units, and mortality. This is a secondary analysis of a consecutive sample of all patients presenting to the ED of the University Hospital Basel over a total time course of 6 weeks. The presence of 35 predefined symptoms was systematically assessed upon presentation. A total of 3960 emergency patients (median age 51, 51.7% male) were included. Over 130 combinations of two, 80 combinations of three, and 10 combinations of four symptoms occurred 42 times or more during a total inclusion period of 42 days. Two combinations of two symptoms were predictive for in-hospital mortality: weakness and fatigue (Odds ratio (OR) = 2.45), and weakness and headache (OR = 3.01). Combinations of symptoms were frequent. Nonspecific complaints (NSCs), such as weakness and fatigue, are among the most frequently reported combinations of symptoms, and are associated with adverse outcomes. Systematically assessing symptoms may add valuable information for prognosis and may therefore influence triage, clinical work-up, and disposition.

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Is steroid profiling using LC-MS/MS useful in the diagnostic work-up of primary aldosteronism?

Endocrine Abstracts ◽

10.1530/endoabs.41.gp9 ◽

2016 ◽

Author(s):

Tracy A. Williams ◽

Jacques W.M. Lenders ◽

Mirko Peitzsch ◽

Tanja Dekkers ◽

Anna S. Dietz ◽

...

Keyword(s):

Primary Aldosteronism ◽

Steroid Profiling ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

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Surgery in autoimmune pancreatitis

Digestive Surgery ◽

10.1159/000521490 ◽

2021 ◽

Author(s):

Sara Nikolic ◽

Poya Ghorbani ◽

Raffaella Pozzi Mucelli ◽

Sam Ghazi ◽

Francisco Baldaque- Silva ◽

...

Keyword(s):

Autoimmune Pancreatitis ◽

University Hospital ◽

Premalignant Lesions ◽

Single Centre ◽

Age At Surgery ◽

Diagnostic Work ◽

Work Up

Introduction: Autoimmune pancreatitis (AIP) is a disease that may mimic malignant pancreatic lesions both in terms of symptomatology and imaging appearance. The aim of the present study is to analyse experiences of surgery in patients with AIP in one of the largest European cohorts. Methods: We performed a single-centre retrospective study of patients diagnosed with AIP at the Department of Abdominal Diseases at Karolinska University Hospital in Stockholm, Sweden, between January 2001 and October 2020. Results: There were 159 patients diagnosed with AIP, and among them 35 (22.0%) patients had surgery: 20 (57.1%) males and 15 (42.9%) females; average age at surgery was 59 years (range 37-81). Follow-up period after surgery was 67 months (range 1-235). AIP type 1 was diagnosed in 28 (80%) patients and AIP type 2 in 7 (20%) patients. Malignant and premalignant lesions were diagnosed in 8 (22.9%) patients for whom AIP was not the primary differential diagnosis but, in all cases, it was described as a simultaneous finding and recorded in retrospective analysis in histological reports of surgical specimens. Conclusions: Diagnosis of AIP is not always straightforward, and, in some cases, it is not easy to differentiate it from the malignancy. Surgery is generally not indicated for AIP but might be considered in patients when suspicion of malignant/premalignant lesions cannot be excluded after complete diagnostic work-up.

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Causes of brain dysfunction in acute coma: a cohort study of 1027 patients in the emergency department

Scandinavian Journal of Trauma Resuscitation and Emergency Medicine ◽

10.1186/s13049-019-0669-4 ◽

2019 ◽

Vol 27 (1) ◽

Cited By ~ 2

Author(s):

Wolf Ulrich Schmidt ◽

Christoph J. Ploner ◽

Maximilian Lutz ◽

Martin Möckel ◽

Tobias Lindner ◽

...

Keyword(s):

Hospital Mortality ◽

Clinical Laboratory ◽

Brain Dysfunction ◽

University Hospital ◽

Unknown Etiology ◽

Efficient Management ◽

Observational Study Design ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

Abstract Background Coma of unknown etiology (CUE) is a major challenge in emergency medicine. CUE is caused by a wide variety of pathologies that require immediate and targeted treatment. However, there is little empirical data guiding rational and efficient management of CUE. We present a detailed investigation on the causes of CUE in patients presenting to the ED of a university hospital. Methods One thousand twenty-seven consecutive ED patients with CUE were enrolled. Applying a retrospective observational study design, we analyzed all clinical, laboratory and imaging findings resulting from a standardized emergency work-up of each patient. Following a predefined protocol, we identified main and accessory coma-explaining pathologies and related these with (i.a.) GCS and in-hospital mortality. Results On admission, 854 of the 1027 patients presented with persistent CUE. Their main diagnoses were classified into acute primary brain lesions (39%), primary brain pathologies without acute lesions (25%) and pathologies that affected the brain secondarily (36%). In-hospital mortality associated with persistent CUE amounted to 25%. 33% of patients with persistent CUE presented with more than one coma-explaining pathology. In 173 of the 1027 patients, CUE had already resolved on admission. However, these patients showed a spectrum of main diagnoses similar to persistent CUE and a significant in-hospital mortality of 5%. Conclusion The data from our cohort show that the spectrum of conditions underlying CUE is broad and may include a surprisingly high number of coincidences of multiple coma-explaining pathologies. This finding has not been reported so far. Thus, significant pathologies may be masked by initial findings and only appear at the end of the diagnostic work-up. Furthermore, even transient CUE showed a significant mortality, thus rendering GCS cutoffs for selection of high- and low-risk patients questionable. Taken together, our data advocate for a standardized diagnostic work-up that should be triggered by the emergency symptom CUE and not by any suspected diagnosis. This standardized routine should always be completed - even when initial coma-explaining diagnoses may seem evident.

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The Possibility of Contralateral Non-Sentinel Groin Node’s Metastasis in Early Primary Vulvar Cancer Women After Unilateral Sentinel Node’s Metastasis: A Single Center Evaluation in University Hospital of Düsseldorf

10.21203/rs.3.rs-50733/v1 ◽

2020 ◽

Author(s):

Andreas Suhartoyo Winarno ◽

Anne Mondal ◽

Franca Christina Martignoni ◽

Tanja Natascha Fehm ◽

Monika Hampl

Keyword(s):

Vulvar Cancer ◽

University Hospital ◽

Morbidity Rate ◽

Current Guideline ◽

Single Center ◽

Standard Management ◽

Increased Risk ◽

Early Primary ◽

The University ◽

Current Guidelines

Abstract Background: Sentinel node biopsy (SLNB) technique in unifocal vulvar cancer (diameter of < 4cm) and unsuspicious groin lymph nodes, the morbidity rate of patients has significantly decreased all over the world. In contrast to SLNB, bilateral inguinofemoral lymphadenectomy (IFL) has been associated with increased risk of common morbidities. Current guidelines (NCCN, ESGO, RCOG, and German) suggest that in cases of metastasis of unilateral SLNB, groin node dissection with IFL, should be performed bilaterally. However, a publication by Woelber et al. 0% (p=0/28) and Nica et al. 5.3% (p=1/19) contradicted the current guideline. Methods: A single-center analysis conducted in the University Hospital of Dusseldorf, evaluating vulvar cancer patients treated with SLNB retrospectively from 2002 to 2018. Result, discussion and conclusion: Current guideline for bilateral IFL should remain as the standard management because 22.2% women (n=4/18) had contralateral IFL groin metastasis after unilateral SLNB metastasis initially. The depth of tumor infiltrating cells was correlated significantly and positively with the incidence rate of groin metastasis (p=0.0038). Therefore, it is an indication for bilateral IFL.

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Adrenal venous sampling for primary aldosteronism: laboratory medicine best practice

Journal of Clinical Pathology ◽

10.1136/jclinpath-2017-204423 ◽

2017 ◽

Vol 70 (11) ◽

pp. 911-916 ◽

Cited By ~ 6

Author(s):

Gregory Kline ◽

Daniel T Holmes

Keyword(s):

Primary Aldosteronism ◽

Best Practice ◽

Laboratory Medicine ◽

Secondary Hypertension ◽

Adrenal Venous Sampling ◽

Venous Sampling ◽

Aldosterone Antagonists ◽

Bilateral Disease ◽

Patient Preparation ◽

Aldosterone Producing Adenoma

Primary aldosteronism (PA) is the most common form of secondary hypertension and is critical to identify because when caused by an aldosterone-producing adenoma (APA) or another unilateral form, it is potentially curable, and even when caused by bilateral disease, antihypertensives more specific to PA treatment can be employed (ie, aldosterone antagonists). Identification of unilateral forms is not generally accomplished with imaging because APAs may be small and elude detection, and coincidental identification of a non-functioning incidentaloma contralateral to an APA may lead to removal of an incorrect gland. For this reason, the method of choice for identifying unilateral forms of PA is selective adrenal venous sampling (AVS) followed by aldosterone and cortisol analysis on collected samples. This procedure is technically difficult from a radiological standpoint and, from the laboratory perspective, is fraught with opportunities for preanalytical, analytical and postanalytical error. We review the process of AVS collection, analysis and reporting. Suggestions are made for patient preparation, specimen labelling practices and nomenclature, analytical dilution protocols, which numerical results to report, and the necessary subsequent calculations. We also identify and explain frequent sources of confusion in the aldosterone and cortisol results and provide an example of tabular reporting to facilitate interpretation and communication between laboratorian, radiologist and clinician.

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