Marianne Klose1, Kirstine Stochholm, Jourgita Janukonyté, Louise Lehman Christensen, Jan Frystyk, Marianne Andersen, Peter Laurberg, Jens Sandahl Christiansen, Ulla Feldt-Rasmussen. 1. Department of Medical Endocrinology (M.K., U.F.-R.), Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark; Department of Internal Medicine and Endocrinology (K.S., J.J., J.F., J.S.C.), Aarhus University Hospital, DK-8000 Aarhus, Denmark; Department of Medical Endocrinology (L.L.C., M.A.), Odense University Hospital, DK-5000 Odense, Denmark; and Department of Medical Endocrinology (P.L.), Aalborg University Hospital, DK-9100 Aalborg, Denmark.
Abstract
CONTEXT: Recent international guidelines suggest pituitary screening in patients with moderate and severe traumatic brain injury (TBI). Predominantly isolated GH deficiency (GHD) was reported in the literature, raising the question of potential methodological bias. OBJECTIVE: Our objective was to assess the prevalence of GHD in patients admitted in 2008 with TBI, with concurrent assessment of methodological bias. DESIGN AND SETTING: We conducted a nationwide population-based cohort study at tertiary referral university hospitals. PARTICIPANTS: Participants were Danish patients with a head trauma diagnosis from the Danish Board of Health diagnostic code registry; 439 patients and 124 healthy controls underwent dynamic assessment of GH secretion 2.5 years (median) after TBI. MAIN OUTCOME: We evaluated the prevalence of GHD given use of 1) local versus guideline cutoffs, 2) insulin tolerance test (ITT), pyridostigmine (PD)-GHRH or GHRH-arginine (arg) test, 3) single versus repeated testing, and 4) GH assessment by assays with different isoform specificities. RESULTS: The prevalence of GHD was lower by local than by guideline cutoffs (12% vs 19% [PD-GHRH/GHRH-arg, P<.001]; 4.5% vs 5% [ITT, P=.9]), and by ITT than by PD-GHRH/GHRH-arg (P=.006 [local cutoffs]; P<.001 [guideline cutoffs]). Only 1% of patients had GHD according to 2 tests. GH assessment by the Immulite or iSYS assay caused no significant diagnostic differences. CONCLUSIONS: The study confirmed a high risk of bias in the management of pituitary testing of patients with TBI and stresses the importance of a proper control group and stringent GH testing including confirmatory testing in cohorts with low a priori likelihood of GHD such as in TBI. Our results question the evidence for newly introduced recommendations for routine pituitary assessment in TBI.
CONTEXT: Recent international guidelines suggest pituitary screening in patients with moderate and severe traumatic brain injury (TBI). Predominantly isolated GH deficiency (GHD) was reported in the literature, raising the question of potential methodological bias. OBJECTIVE: Our objective was to assess the prevalence of GHD in patients admitted in 2008 with TBI, with concurrent assessment of methodological bias. DESIGN AND SETTING: We conducted a nationwide population-based cohort study at tertiary referral university hospitals. PARTICIPANTS: Participants were Danish patients with a head trauma diagnosis from the Danish Board of Health diagnostic code registry; 439 patients and 124 healthy controls underwent dynamic assessment of GH secretion 2.5 years (median) after TBI. MAIN OUTCOME: We evaluated the prevalence of GHD given use of 1) local versus guideline cutoffs, 2) insulin tolerance test (ITT), pyridostigmine (PD)-GHRH or GHRH-arginine (arg) test, 3) single versus repeated testing, and 4) GH assessment by assays with different isoform specificities. RESULTS: The prevalence of GHD was lower by local than by guideline cutoffs (12% vs 19% [PD-GHRH/GHRH-arg, P<.001]; 4.5% vs 5% [ITT, P=.9]), and by ITT than by PD-GHRH/GHRH-arg (P=.006 [local cutoffs]; P<.001 [guideline cutoffs]). Only 1% of patients had GHD according to 2 tests. GH assessment by the Immulite or iSYS assay caused no significant diagnostic differences. CONCLUSIONS: The study confirmed a high risk of bias in the management of pituitary testing of patients with TBI and stresses the importance of a proper control group and stringent GH testing including confirmatory testing in cohorts with low a priori likelihood of GHD such as in TBI. Our results question the evidence for newly introduced recommendations for routine pituitary assessment in TBI.
Authors: Adriana G Ioachimescu; Benjamin M Hampstead; Anna Moore; Elizabeth Burgess; Lawrence S Phillips Journal: Pituitary Date: 2015-08 Impact factor: 4.107