Spontaneous aneurysmal subarachnoid haemorrhage (SAH) is a cause of stroke, which constitutes a severe trauma to the brain and may lead to serious long-term medical, psychosocial and endocrinological sequelae. Adrenocorticotrophic hormone deficiency, which is considered to occur in up to 20% of all survivors, is a possible consequence of bleeding. Moreover, preliminary data suggest that a poor psychosocial outcome in SAH survivors is linked to alterations in cortisol secretion. Despite these findings, investigation of diurnal cortisol profiles and the cortisol awakening response (CAR) in chronic SAH patients has not been done so far. In this study, basal serum cortisol and salivary cortisol concentration profiles were investigated in 31 SAH patients more than 1 year after the acute event and in 25 healthy controls. Additionally, low-dose dexamethasone (DEX) suppression tests were conducted, and sensitivity to stress was measured with a psychometric questionnaire (NeuropatternTM). Although significantly higher salivary cortisol concentrations were observed on waking in SAH patients (p = 0.013, ANOVA), without a CAR change, total serum cortisol concentrations were blunted, but only in patients with high levels of perceived stress (SAH high stress: 337 nmol/l, SAH low stress: 442 nmol/l, controls: 467 nmol/l; Controls vs. SAH high stress p = 0.018). DEX suppression of cortisol secretion was not significantly different between patients and controls. The results indicate that total (serum) and free (salivary) cortisol concentrations give different information about cortisol availability in patients after aneurysmal SAH. Enhanced free cortisol concentrations may reflect a meaningful biological coping mechanism in SAH patients.

Apoplexy of pituitary adenomas with subsequent hypopituitarism is a rare but well recognized complication following cardiac surgery. The nature of cardiac on-pump surgery provides a risk of damage to the pituitary because the vascular supply of the pituitary is not included in the cerebral autoregulation. Thus, pituitary tissue may exhibit an increased susceptibility to hypoperfusion, ischemia or intraoperative embolism. After on-pump procedures, patients often present with physical and psychosocial impairments which resemble symptoms of hypopituitarism. Therefore, we analyzed whether on-pump cardiac surgery may cause pituitary dysfunction also in the absence of pre-existing pituitary disease. Twenty-five patients were examined 3-12 months after on-pump cardiac surgery. Basal hormone levels for all four anterior pituitary hormone axes were measured and a short synacthen test and a growth hormone releasing hormone plus arginine (GHRH-ARG)-test were performed. Quality of life (QoL), depression, subjective distress for a specific life event, sleep quality and fatigue were assessed by means of self-rating questionnaires. Hormonal alterations were only slight and no signs of anterior hypopituitarism were found except for an insufficient growth hormone rise in two overweight patients in the GHRH-ARG-test. Psychosocial impairment was pronounced, including symptoms of moderate to severe depression in 9, reduced mental QoL in 8, dysfunctional coping in 6 and pronounced sleep disturbances in 16 patients. Hormone levels did not correlate with psychosocial impairment. On-pump cardiac surgery did not cause relevant hypopituitarism in our sample of patients and does not serve to explain the psychosocial symptoms of these patients.

Previous work has examined potential links between the etiology of GH deficiency (GHD) and the baseline characteristics of the patients including biochemical and psychometric parameters. Using an update of the KIMS pharmaco-epidemiological database (Pfizer International Metabolic Database), we addressed the question how well such results can be generalized and whether regional differences may play a role. From 30 different countries, 13 167 GH-deficient patients were included in KIMS at the data close in December 2008. In order to explore country-specific differences of baseline characteristics documented in KIMS, separate analyses of baseline characteristics of adult-onset GHD patients (n=7708) were performed for the six largest contributing European countries and the United States. This analysis revealed striking regional variations in the pathogenesis of the disease, clinical characteristics such as body mass index, and in the classical features of the metabolic syndrome such as blood pressure or lipid status between countries. Moreover, the approach to endocrine function testing was widely different between countries, as well as the distribution of etiologies of GHD. These data suggest that a complex relation between biochemical and clinical signs of GHD exists, and that the spectrum of adult GHD syndrome is influenced by regional diagnostic and clinical particularities.

Viele Patienten mit einer demenziellen Erkrankung (z. B. Morbus Alzheimer) werden von Angehörigen zuhause gepflegt. Zahlreiche Studien zeigen, dass die Pflege mit erheblichen körperlichen und psychischen Belastungen, aber auch mit positiven Erfahrungen verbunden sein kann. In diesem Beitrag geben wir einen kurzen Überblick über die mit der Pflege von Demenzkranken verbunden psychosozialen Belastungen und weisen auf die spezifischen Bedürfnisse der Pflegenden hin. Anschließend beschreiben wir therapeutische Interventionen zur Reduktion der Pflegebelastung und gehen auf deren Effektivität ein. Empfehlungen zur Angehörigenberatung beenden den Beitrag.

The purpose of this study was to assess cortisol dynamics in the acute phase after aneurysmal subarachnoid hemorrhage (SAH) and to set the parameters of cortisol release in relation to the severity of illness and outcome. In 22 consecutive patients with aneurysmal SAH, cortisol, corticosteroid binding globulin, interleukin-6, and adrenocorticotrophic hormone were measured immediately after hospital admission (t(0)), 7 days (t(1)) later, and at least 14 days later (t(2)). Additionally, diurnal profiles of cortisol secretion were assessed at t(1) and t(2), and area under the curve (AUC) was computed for calculated free serum cortisol (CFSC). In this study, normal diurnal CFSC profiles were associated with a significantly shorter ICU-stay, less complications, and a more favorable outcome than abnormal diurnal profiles. AUC and 8 a.m. cortisol were not related to clinical course or outcome. It is concluded that cortisol secretion patterns are associated with the severity and outcome of SAH. For an appraisal of the hypothalamo-pituitary-adrenal axis in SAH patients, single cortisol measurements are insufficient.

Recent studies indicate that neuroendocrine dysfunction is a more frequent sequel of aneurysmal subarachnoid hemorrhage (SAH), than has so far been recognized. However, from the available data it remains unclear whether certain subgroups of SAH patients carry a higher risk to sustain endocrine sequelae due to the hemorrhage than others and should be specifically followed-up in terms of hormone assessment. To investigate whether a basal hormone screening is a practical method in clinical routine to single out patients in whom endocrine function testing is warranted, we established a screening protocol, based on the findings from a cohort of 40 SAH patients (study group) who had all been investigated by basal hormone parameters as well as standardized endocrinological function testing, within the framework of a previously published clinical study. We then applied this protocol to 45 newly investigated SAH-patients (screening group). According to the thus established protocol, 20 of the 45 screened patients (44.4%) were recommended further investigations, 12 of whom agreed to undergo dynamic endocrine function testing. Altogether, the percentage of test-confirmed neuroendocrine dysfunction was only 13.3% (6/45) in the screening group as compared to 55% in the study group. Low IGF-I (2 SD below normal) did not serve to predict growth hormone deficiency, whereas low 9 am serum cortisol was of limited value to single out ACTH-deficiency in SAH-patients. In summary we conclude that basal hormone screening is not sufficient to identify SAH patients with impaired hypothalamo-pituitary function, at least not in the context of clinical routine practice.

Objective: In recent years, traumatic brain in jury (TBI) has been identified as a significant cause of growth hormone deficiency (GHD). The aim of the present study was to characterize adult TBI patients with GHD to elucidate the effect of human growth hormone (hGH) replacement in TBI patients as documented in the German Pfizer International Metabolic (KIMS) database.Design: As of October 2006, 84 TBI patients had been included in the German KIMS database (n = 28 childhood-onset and 54 adult-onset GHD). All 84 TBI patients were matched with 84 patients with GHD due to non-functioning pituitary adenoma (NFPA) also included in this database. Analysis of clinical and outcome variables was performed, with comparisons of childhood vs. adult TBI. and TBI vs. NFPA patients, at baseline and one-year follow-up.Results: TBI patients with GHD were significantly younger at the onset Of pituitary disease and exhibited a significantly longer time span between GHD diagnosis and KIMS entry than NFPA patients. Those KIMS patients who had Sustained their TBI in childhood were of significantly shorter stature than adult-onset. TBI patients. At 1-year follow-up, insulin-like growth factor I (IGF-1) standard deviation score levels had returned to the normal range and quality of life (QoL), as measured by QoL- Assessment of Growth Hormone Deficiency in Adults (AGHDA) questionnaire, improved significantly in TBI as in NFPA patients.Conclusion: This analysis provides preliminary data that TBI patients with GHD benefit from hGH replacement in terms of improved QoL in a similar Fashion as do NFPA patients. Moreover. it suggests that belated diagnosis and treatment in childhood-onset GHD due to TBI might be related to a shorter final height in these children. (C) 2008 Elsevier Ltd. All rights reserved.

Objective Patients who have sustained aneurysmal subarachnoid haemorrhage (SAH) often suffer persistent impairments in their quality of life (QoL) and psychological disturbances despite a good neurological outcome. In the light of the high prevalence of partial hypopituitarism in SAH survivors demonstrated in recent investigations, we aimed to determine whether neuroendocrine dysfunction has an impact on QoL and neurobehavioural symptoms in these patients.Design/patients QoL, depression and psychological distress were assessed in 40 SAH survivors who had undergone endocrine function testing at least 1 year after the haemorrhage.Measurements QoL was assessed using the Nottingham Health Profile (NHP), the Quality of Life Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA) and the Short Form-36 questionnaire (SF-36). The Beck Depression Inventory (BDI) and the Impact of Event Scale (IES) were used to evaluate depression and symptoms of current subjective distress in response to the SAH as a stressful life event, respectively.Results In a stepwise multiple regression analysis, basal cortisol level was included as the first and often only predictor for several QoL domains assessing psychological aspects of well-being and depression whereas physical aspects of QoL were predicted primarily by neurological recovery from the SAH. Severe GH deficiency (GHD) was the first predictor for the criterion NHP subscale 'Energy' and highest stimulated ACTH level in the insulin tolerance test (ITT) was the first predictor for disturbed sleep as assessed with the NHP subscale 'Sleep'.Conclusion Our results provide preliminary data that neuroendocrine disturbances contribute to disturbed QoL, depression and sleeping disturbances in SAH patients.