Thursday, November 18, 2010

Corticotrophin-releasing factor mediates hypophagia after adrenalectomy, increasing meal-related satiety responses

Ernane Torres Uchoa, Lilian Eslaine Costa Mendes da Silva, Margaret de Castro, Jose Antunes-Rodrigues and Lucila Leico K. Elias

a Department of Physiology, School of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil

b Department of Internal Medicine, School of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil


Adrenalectomy-induced hypophagia is associated with increased satiety-related responses, which involve neuronal activation of the nucleus of the solitary tract (NTS). Besides its effects on the pituitary–adrenal axis, corticotrophin-releasing factor (CRF) has been shown to play an important role in feeding behaviour, as it possesses anorexigenic effects. We evaluated feeding-induced CRF mRNA expression in the paraventricular nucleus (PVN) and the effects of pretreatment with CRF2 receptor antagonist (Antisauvagine-30, AS30) on food intake and activation of NTS neurons in response to feeding in adrenalectomised (ADX) rats.


Compared to the sham group, ADX increased CRF mRNA levels in the PVN of fasted animals, which was further augmented by refeeding. AS30 treatment did not affect food intake in the sham and ADX + corticosterone (B) groups; however, it reversed hypophagia in the ADX group. In vehicle-pretreated animals, refeeding increased the number of Fos and Fos/TH-immunoreactive neurons in the NTS in the sham, ADX and ADX + B groups, with the highest number of neurons in the ADX animals. Similarly to its effect on food intake, pretreatment with AS30 in the ADX group also reversed the increased activation of NTS neurons induced by refeeding while having no effect in the sham and ADX + B animals. The present results show that adrenalectomy induces an increase in CRF mRNA expression in the PVN potentiated by feeding and that CRF2 receptor antagonist abolishes the anorexigenic effect and the increased activation of NTS induced by feeding in the ADX animals. These data indicate that increased activity of PVN CRF neurons modulates brainstem satiety-related responses, contributing to hypophagia after adrenalectomy.

Research Highlights

►Primary adrenal insufficiency increases meal-related satiety responses.

►Adrenalectomy-induced hypophagia is associated with increased CRF mRNA expression in the hypothalamic paraventricular nucleus (PVN) and increased NTS neuron activation in the brainstem. ►The increased activity of PVN CRF neurons modulates brainstem satiety-related responses. ►CRF type 2 receptor mediates CRF suppressing effect on food intake after adrenalectomy.

Keywords: Glucocorticoids; Food intake; Corticotrophin-releasing factor; Paraventricular nucleus of the hypothalamus; Nucleus of the solitary tract

Article Outline
Experimental procedures
Intracerebroventricular (icv) surgery
Perfusion, tissue preparation and immunohistochemistry
Microdissection, total RNA isolation and quantitative real-time PCR
Experimental protocols
Experiment 1: effects of ADX and B replacement on CRF mRNA expression in the PVN in the fasting–refeeding regimen
Experiment 2: effects of pretreatment with CRF2 receptor antagonist on food intake in sham, ADX and ADX + B animals
Experiment 3: effects of pretreatment with CRF2 receptor antagonist on NTS neuron activation in sham, ADX and ADX + B animals in the fasting–refeeding regimen
Statistical analysis
Experiment 1: effects of ADX and B replacement on CRF mRNA expression in the PVN in the fasting–refeeding regimen
Experiment 2: effects of pretreatment with CRF2 receptor antagonist on food intake in sham, ADX and ADX + B animals
Experiment 3: effects of pretreatment with CRF2 receptor antagonist on NTS neuron activation in sham, ADX and ADX + B animals in the fasting–refeeding regimen

Thumbnail image

Fig. 1.

Relative CRF mRNA expression in the PVN of fasted and refed sham, ADX and ADX + B animals (n = 5–8 rats/group). Data are shown as mean ± SEM. *P < 0.05.

View Within Article

Thumbnail image

Fig. 2.

Food intake (g/100 g) after 4 h of refeeding (n = 5–7 rats/group) for sham, ADX and ADX + B animals pretreated with vehicle or d-Phe11,His12-Sauvagine 11–40 (Antisauvagine-30, AS30; 5 μg/5 μL icv). Data are shown as mean ± SEM. *P < 0.05.

View Within Article

Thumbnail image

Fig. 3.

Number of Fos-immunoreactive (A) and Fos/TH-immunoreactive (B) neurons in the NTS (n = 4–8 rats/group) of fasted and refed sham, ADX and ADX + B animals pretreated with vehicle or d-Phe11,His12-Sauvagine 11–40 (Antisauvagine-30, AS30; 5 μg/5 μL icv). Data are shown as mean ± SEM. ND: not detectable. *P < 0.05 vs. respective fasted group. #P < 0.05 vs. refed sham/vehicle, refed ADX + B/vehicle and refed ADX/AS30 groups.

View Within Article

Thumbnail image

Fig. 4.

Representative photomicrographs (40× magnification) of coronal sections showing Fos/TH immunoreactivity in the NTS of refed sham, ADX and ADX + B animals pretreated with vehicle or d-Phe11,His12-Sauvagine 11–40 (Antisauvagine-30, AS30; 5 μg/5 μL icv). Each inset depicts at 20× magnification the area where the photomicrograph was taken. Scale bar, 100 μm.

View Within Article

Table 1. Number (means ± SEM) of TH-immunoreactive neurons and percentage of Fos/TH double labelled neurons in the NTS of fasted and refed sham, ADX, and ADX + B animals, pretreated with vehicle or AS30. View table in article

Data are expressed as means ± SEM (n = 4–8 rats/group). NTS, nucleus of the solitary tract; TH, tyrosine hydroxylase.

a P < 0.05 vs. respective fasted group.
b P < 0.05 vs. refed sham/vehicle, refed ADX + B/vehicle and refed ADX/AS30 groups.

View Within Article

Corresponding Author Contact InformationCorresponding author. Avenida Bandeirantes, 3900, 14049-900 Ribeirao Preto, Sao Paulo, Brazil. Fax: +55 16 3633 0017.

Hormones and Behavior
Volume 58, Issue 5, November 2010, Pages 714-719


Tuesday, November 16, 2010

Unilateral adrenalectomy improves urinary protein excretion but does not abolish its relationship to sodium excretion in patients with aldosterone-producing adenoma

E Pimenta, R D Gordon, A H Ahmed, D Cowley, D Robson, C Kogovsek and M Stowasser



Experimental and human data suggest that adverse cardiovascular (CV) and renal effects of aldosterone excess are dependent on concomitant dietary salt intake.

Increased urinary protein (Uprot) is an early sign of nephropathy independently associated with CV risk. We have previously reported a positive association between Uprot and urinary sodium (UNa) in patients with hyperaldosteronism, but not in patients with normal aldosterone levels.


We aimed to determine whether Uprot is related to UNa in patients with aldosterone-producing adenoma (APA) and whether the degree of Uprot and strength of this relationship is reduced following correction of hyperaldosteronism. Subjects with APA (n=24) underwent measurement of 24 h Uprot and UNa before and after unilateral adrenalectomy (follow-up 15.0±11.9 months).


Following surgery, mean clinic systolic blood pressure fell (150.4±18.2 vs 134.5±14.5 mm Hg, P=0.0008), despite a reduction in number of antihypertensive medications, and Uprot (211.2±101.6 vs 106.0±41.8 mg per day, P<0.0001) decreased. There was a positive correlation between Uprot and UNa both before (r=0.5477, P=0.0056) and after (r=0.5097, P=0.0109) adrenalectomy. Changes in UNa independently predicted Uprot reduction (P=0.0189).


These findings suggest that both aldosterone levels and dietary salt contribute to renal damage, and that once glomerular damage occurs it is not completely resolved following correction of hyperaldosteronism. Our study suggests that treatment strategies based on reduction of aldosterone effects, by adrenalectomy or mineralocorticoid receptor blockade, in conjunction with low-salt diet would provide additional target-organ protection in patients with primary aldosteronism.



Saturday, November 13, 2010

Adrenal Crisis Tips

From Ellen, on the Cushing's Help Message Boards

I have a very good friend who has had more adrenal crises than anyone care to count (more than 20). She has tried hard to teach me some important things for the day I should ever have a crisis. Among them is the reality that (as before surgery) success of your care depends on YOU getting everything prepared for the worst as best you can. We can no more depend on the ER staff than any other doc out there who isn't a specialist in pituitary medicine. You all have already done much of preparing by having your medic alert bracelets on, your injectable Cortef (bring it with you in case they don't have it there) and your letter from Dr. F. But that isn't enough much of the time as you have painfully discovered.

1) Prevention is the key. You, Mary, are SO overdoing it, I don't know what to say. You shouldn't even be leaving your house right now, let alone taking on the care of small children. You need a good talking to, missy. Perhaps you can choose to do ONE easy task a day but overall-you should be bored out of your gourd sitting on your tuckus. The more you do, the more you risk events like this. The hardest part is understanding that recovery is not a linear improvement every day. You are going to have weeks or maybe months where you can do no more than you did the first week after surgery. This recovery takes a long time when surgery works. Each tiny task you accomplish depletes you in an additive way. It might not have seemed much at the time to unload the dishwasher but you better believe it counts when you add in each additional task you want to accomplish.

2) Everything is additive. It isn't just what you did today but also what you did the last three, four or five days. You may have felt good the first day but each successive day my guess is you could feel your body pushing a bit. I find I say things like, "If I could just get this ONE more job done, then I will rest" before I am off to the next job. Before I know it, it is too late. Think hard about the twinges you feel the days before this happened this time around, when you were tired. How do you feel in the evenings after a day of activity? Those are the signs to look for and treat early the next time. You are having to listen to your body in a whole new way. Learn your earliest signs.

3) Take more Cortef when you first get those twinges above--the days before a crisis might strike.

4) Everyone in your household needs to be trained to give you Cortef. Teach them that confusion on your part indicates a crisis coming on-if you aren't making sense they need to understand that YOU are not able to help yourself. In most cases the oral cortef will keep you out of the ER if someone else makes sure you take it. Don't hesitate, don't let yourself talk them out of helping you-just take it-it is better to err high than low with your history of crises right now.

5) Knowing that in spite of all of this you need ER care potentially, consider calling the liason in person and talking real-time about your needs for future visits-explaining how quickly things become life threatening. They need to have something about your history in the computer already-a copy of that letter from Dr. F plus their own notes that it is on the up and up along with the note to please page your doctor. Give them a recipe to follow that they have pre-approved and it will help greatly. Most ER doctors will never see an adrenal crisis patient in their ER. Doctors have limits on their abilities just as everyone else does. I can read English really well but if you handed me a book written by someone in 1610, I would likely take longer to get through it because I am not as familiar with the format...the 'wherefore art thous' are English but they sure slow you down. That is what happens in the ER to Addisonians...doctors eventually get there but it takes longer because it is unfamiliar. Help them out by giving them the Cliff-Notes before you ever get there.

5A) Also insist that for now they order and keep Solu-Cortef on the shelves for you. Many (most?) hospitals do NOT have it stocked, as my friend discovered over and over again when she went to the ER. It took hours for them to track some down and give it to her. In the meantime, she was getting sicker and sicker. She finally asked the liason to help be certain they had it for her, ready to go. Now, they have it ready for her, they know her and they know what to do. She is often out of there in about 3 hours.

6) If you are vomiting/collapsed clearly in serious trouble, by the time you head off to the ER, call 911/ambulance so you get taken in and cared for without waiting. Your life is at risk by that stage and you need immediate care. It is justified and potentially life-saving.

7) Always have a trained advocate with you, have several back ups in your life. My friend has her husband but she also has me ready to go-have the hospital list several people to call ahead of time in case you arrive on your own and they can't reach your primary person. Your advocates need to know what to do independently of you. They need to know what to say and how to push the ER staff to get things done on your behalf. We, as patients struggling with Cushing's, are used to having to push but most people are very intimidated by medical personnel and often hang back, figuring they must know what to do. Make sure they understand this just isn't the case sometimes and that your life may depend on what they say or get the staff to do. It is critical they contact your endocrinologist-have your advocate INSIST they do this. If they won't, have your advocate page the doctor for you. Be sure you go over a plan with your advocate periodically or answer their questions about what may happen. I went over much of my plan with my husband prior to my surgery but discovered that within days of surgery, he had forgotten most of what I said. He really wanted to help but just hadn't taken in the medical stuff because it was overwhelming and scary. Keep going over it until they are comfortable.

I really hope these are the last ER visits for you all. I have agonized each time my friend goes into another crisis. I know that in spite of everything you do (or don't do) to prevent a crisis, they still happen. Hopefully the next time around, everything will be in place for you all to have a smooth experience.

So, sit down, turn on that television and get comfy girls. TAKE IT EASY!!

Monday, November 08, 2010

A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials of DHEA Treatment Effects on Quality of Life in Women with Adrenal Insufficiency

Aziz A. Alkatib, Mihaela Cosma, Mohamed B. Elamin, Dana Erickson, Brian A. Swiglo, Patricia J. Erwin, and Victor M. Montori*

Department of Medicine (A.A.A.), Knowledge and Encounter Research Unit (A.A.A., M.C., M.B.E., D.E., B.A.S., P.J.E., V.M.M.), Mayo Clinic Libraries (P.J.E.), and Division of Endocrinology, Diabetes, Metabolism, and Nutrition (M.C., D.E., B.A.S., V.M.M.), Mayo Clinic, Rochester, Minnesota 55905

* To whom correspondence should be addressed. E-mail:


Context: Women with primary or secondary adrenal insufficiency report a decreased health-related quality of life (HRQOL) despite traditional adrenal replacement therapy. Dehydroepiandrosterone (DHEA) has been studied as an agent to improve HRQOL in these patients.


Objective: We sought to conduct a systematic review and meta-analysis of randomized controlled trials of DHEA effects on HRQOL in women with adrenal insufficiency.

Data Sources: We searched electronic databases (MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, CINAHL, and PsycInfo) and reference lists of eligible studies through July 2008.


Study Selection: Eligible trials randomly assigned women with primary or secondary adrenal insufficiency to either DHEA or control and measured the effect of treatment on HRQOL.


Data Extraction: Reviewers working independently and in duplicate assessed the methodological quality of trials and collected data on patient characteristics, interventions, and outcomes.


Data Synthesis: We found 10 eligible trials that measured HRQOL and depression, anxiety, and sexual function. Random-effects meta-analysis showed a small improvement in HRQOL in women treated with DHEA compared with placebo [effect size of 0.21; 95% confidence interval, 0.08 to 0.33; inconsistency (I2) = 32%]. There was a small beneficial effect of DHEA on depression; effects on anxiety and sexual well-being were also small and not statistically significant.


Conclusions: DHEA may improve, in a small and perhaps trivial manner, HRQOL and depression in women with adrenal insufficiency. There was no significant effect of DHEA on anxiety and sexual well-being. The evidence appears insufficient to support the routine use of DHEA in women with adrenal insufficiency.



Saturday, November 06, 2010

Adrenal Crisis

A Bhattacharyya, J Macdonald, AA LAkhdar.

The adrenal cortex normally produces three principal steroid hormones: the glucocorticoid cortisol, the mineralocorticoid adosterone, and a small quantity of sex steroids. In primary adrenocortical insufficiency, there is a deficiency of both cortisol and aldosterone with characteristic clinical and laboratory findings.


In contrast, with a pituitary disorder there is isolated hypocortisolism, because its production is dependant on pituitary adrenocortrophic hormone (ACTH), whereas aldosterone production is controlled by extracellular fluid volume, rennin and serum potassium. Acute adrenocortical crisis is an absolute medical emergency and its presentation is not always typical.


We describe three recent cases of acute adrenocortical crisis in our hospital who presented in three different ways in three different wards.


International Journal of clinical Practice 2001;55:141-4.



Tuesday, November 02, 2010

Are Guidelines for Glucocorticoid Coverage in Adrenal Insufficiency Currently Followed?

Coralie Leblicq, MD, Diane Rottembourg, MD, Johnny Deladoëy, MD, PhD, Guy Van Vliet, MD, Cheri Deal, PhD, MD Corresponding Author

Received 11 January 2010; received in revised form 14 July 2010; accepted 17 August 2010. published online 01 November 2010.



To search for evidence of acute adrenal failure linked to inappropriate use of stress management protocols.

Study design

Patients followed up for primary adrenal insufficiency (n = 102) or secondary adrenal insufficiency (n = 34) between 1973 and 2007 were included. All hospitalizations, both urgent (n = 157) and elective (n = 90), were examined. We recorded clinical evidence of acute adrenal failure, parental management before admission, and details of glucocorticoid prescription and administration in the hospital setting.


For urgent hospitalizations, subgroup and time period did not influence the percentage of patients hospitalized (primary adrenal insufficiency 45%; secondary adrenal insufficiency 38%; P = .55). The use of stress glucocorticoid doses by parents increased significantly after 1997 (P < .05), although still only 47% increased glucocorticoids before hospitalization. Stress doses were more frequently administered on arrival in our emergency department after 1990 (P < .05); patients with signs or symptoms of acute adrenal failure decreased to 27% after 1997 (P < .01). Twenty-four percent of all hospitalizations were marked by suboptimal adherence to glucocorticoid stress protocols, with rare but significant clinical consequences.


In spite of an increased use of glucocorticoid stress dose protocols by parents and physicians, patients remain at risk of morbidity and death from acute adrenal failure. This risk may be minimized with conscientious application of stress protocols, but other patient-specific risk factors may also be implicated.



21OH, 21-hydroxylase, 3?HSD, 3-?-hydroxysteroid dehydrogenase, ACTH, Adrenocorticotropic hormone, AI, Adrenal insufficiency, CAH, Congenital adrenal hyperplasia, ED, Emergency department, EH, Elective hospitalization, HPA, Hypothalamic-pituitary-adrenal, PAI, Primary adrenal insufficiency, UH, Urgent hospitalization


Endocrinology Service and Research Center, CHU Sainte-Justine and Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada

Corresponding Author InformationReprint requests: Cheri Deal, PhD, MD, FRCPC, Endocrinology Service, CHU Sainte-Justine Hospital, Research Center, 3175 Côte Sainte-Catherine, Montréal (Québec), Canada, H3T 1C5.

Supported by scholarships from the Belgian Study Group of Pediatric Endocrinology (C.L.), the Fonds de Recherche en Santé du Québec (C.D.), and a donation from Group Cossette Communications (C.D.). The authors declare no conflicts of interest.

PII: S0022-3476(10)00690-6