Purpose To assess the reliability and safety of a postsurgical evaluation strategy of adrenal function using CRH stimulation and basal cortisol concentrations after transsphenoidal pituitary... Show morePurpose To assess the reliability and safety of a postsurgical evaluation strategy of adrenal function using CRH stimulation and basal cortisol concentrations after transsphenoidal pituitary surgery.Methods Retrospective cohort study of all patients undergoing endoscopic transsphenoidal surgery from 2010 to 2017, in whom early postoperative basal cortisol and/or CRH-stimulated cortisol secretion were available, including confirmation of adrenal function during follow-up. Patients with Cushing's disease were excluded. Optimal test performances were assessed using ROC analysis.Results A total of 156 patients were included. Sensitivity and specificity of the CRH test were 78% and 90%, respectively, and 86% and 92% for basal cortisol, respectively, using an optimal cutoff of 220 nmol/L. Eight patients had false-negative test results with the CRH test (normal test but adrenal insufficient at follow-up), and six patients with basal cortisol, the majority of which had multiple pituitary hormone deficiencies and fluid imbalances. No clinical adverse events occurred in patients with false-negative test results. The diagnostic performance of a single basal cortisol measurement was superior to the CRH test.Conclusions The early postoperative basal cortisol is a safe and simple measurement to guide (dis)continuation of hydrocortisone replacement. However, disturbing factors, e.g., sodium balance disorders, contraceptives, untreated hypopituitarism, and illness impact the interpretation and in those cases this measure is unreliable. We propose an algorithm in which hydrocortisone replacement at discharge is based on basal cortisol <220 nmol/L on postoperative day 2 or 3 in a stable condition. Show less
Hypercortisolism causes numerous and potentially severe complications, which are often underestimated and not well recognized in clinical practice. There are two main causes for... Show moreHypercortisolism causes numerous and potentially severe complications, which are often underestimated and not well recognized in clinical practice. There are two main causes for hypercortisolism. Firstly, exogenous hypercortisolism through corticosteroid use, which is highly prevalent, since around 1% of the general population uses corticosteroids. Secondly, endogenous Cushing’s syndrome, which is rare, but the disease burden is considerable through increased morbidity and mortality risks. In this thesis, potential complications of exogenous hypercortisolism, and treatment and clinical outcomes of Cushing’s syndrome, are discussed. These studies on various aspects of hypercortisolism emphasize the importance of suppressing cortisol secretion to physiological ranges. Both hypercortisolism and adrenal insufficiency have enormous, and sometimes deleterious, impact on physical and psychological functioning. Treatment of hypercortisolism and adrenal insufficiency attempting to restore normal cortisol concentrations does not eliminate risk of adverse outcomes. Finally, increasing knowledge on the effects of endogenous Cushing’s syndrome and exogenous hypercortisolism is likely to improve patient care beyond the endocrinology department, as these conditions serve as a model for long-term exposure to stress, which is a highly prevalent condition. Insight into the potential consequences of long-term stress exposure, can aid all individuals exposed to long-term stress, including patients with chronic disease or long-term hospital admission. Show less
Patients with pituitary disease in a stable medical condition demonstrate persistent morbidity. This thesis describes their health outcomes by using a biopsychosocial approach covering a... Show morePatients with pituitary disease in a stable medical condition demonstrate persistent morbidity. This thesis describes their health outcomes by using a biopsychosocial approach covering a continuum ranging from biological and physiological measures, to measures of general health perceptions, as described by the Wilson-Cleary model. Show less
