Primary adrenal insufficiency due to bilateral infiltrative disease.

PURPOSE: Evidence on clinical presentation, evaluation, and management of patients with primary adrenal insufficiency (PAI) due to bilateral adrenal infiltrative disease is scarce. Our objective was to review the clinical presentation, biochemical work-up, imaging findings, and management of patients with PAI due to infiltrative adrenal disease in order to determine the best diagnostic and management approach. METHODS: Retrospective study of patients with PAI due to bilateral infiltrative adrenal disease referred for adrenal biopsy during 2000-2014 at Mayo Clinic, Rochester, Minnesota. Two additional patients evaluated after 2014 were included. RESULTS: Seven patients (six males and one female) were diagnosed with PAI caused by bilateral adrenal infiltrative disease at a median age of 54 (range 36-80) years. Duration of symptoms prior to the diagnosis of PAI and initiating treatment was 6 months (range 3 months-4 years). All patients demonstrated bilateral adrenal masses on adrenal imaging. The underlying diagnosis was confirmed by histopathology and included: bilateral adrenal metastases (lung and breast adenocarcinoma), diffuse large B-cell lymphoma, tuberculosis, cryptococcus, histoplasmosis, and, Erdheim-Chester disease. CONCLUSION: In patients with newly diagnosed PAI, the differential diagnosis should include bilateral infiltrative adrenal disease, especially when testing for autoimmune adrenalitis is negative, or if there is clinical history suggesting another etiology. Patients who present with known bilateral adrenal infiltrative disease should be counseled and tested for PAI periodically, particularly if presenting with suggestive signs or symptoms.

Trends and racial/ethnic disparities in gluten-sensitive problems in the United States: findings from the National Health and Nutrition Examination Surveys from 1988 to 2012.

OBJECTIVES: Racial disparities in the prevalence of celiac disease (CD) and the number of people without CD avoiding gluten (PWAG) in the United States are unknown. We aimed to describe racial differences in the prevalence of CD and PWAG, and evaluate the trends of CD in the noninstitutionalized civilian adult population of the US between 1988 and 2012. METHODS: A population-based cross-sectional study was conducted using data from the National Health and Nutrition Examination Surveys (NHANES) from 1988 to 1994, 1999 to 2004, and 2009 to 2012. Serum samples from the NHANES participants were tested for CD serology, which included IgA tissue transglutaminase (tTG IgA) and, if findings were abnormal, for IgA endomysial antibodies. Information about adherence to a gluten-free diet was obtained by means of an interviewer-administered questionnaire. RESULTS: In NHANES 2009-2012, the adjusted prevalence of CD was significantly higher (P<0.0001) among non-Hispanic whites (1.0%) than among non-Hispanic blacks (0.2%) and Hispanics (0.3%), whereas the adjusted prevalence of PWAG was significantly higher (P=0.01) in blacks (1.2%) as compared with Hispanics (0.5%) and whites (0.7%). The seroprevalence of CD in adults aged 50 years and older increased from 0.17% (95% confidence interval (CI) 0.03-0.33) in 1988-1994 to 0.44% (95% CI 0.24-0.81) in 2009-2012 (P<0.05). CONCLUSIONS: The overall prevalence of CD increased between 1988 and 2012 and is significantly more common in whites. In addition, a higher proportion of individuals maintaining a gluten-free diet in the absence of a diagnosis of CD are blacks.

Support-person promotion of a smoking quitline: a randomized controlled trial.

BACKGROUND: Quitlines and other evidence-based cessation treatments are greatly underutilized by smokers, limiting their public health impact. Social support is correlated with successful cessation. Thus, efforts targeting the social network of smokers could be a potential avenue to promote quitline utilization. PURPOSE: This study examined the efficacy of an intervention for nonsmokers interested in helping a smoker (i.e., support people) to promote smoker utilization of the Minnesota QUITPLAN(®) Helpline. Data were collected from 2007 to 2010, and analyses were conducted from 2010 to 2011. DESIGN: Two-group randomized design evaluating the support-person intervention (n=267) compared with a control condition (written materials, n=267). SETTING/PARTICIPANTS: Enrolled were 534 support people (91% female, 93% Caucasian) residing in Minnesota. INTERVENTION: Written materials plus three weekly telephone sessions lasting 10-30 minutes each. Based on Cohen's theory of social support, the intervention provided participants with information and skills needed to encourage their smoker to call the QUITPLAN Helpline. MAIN OUTCOME MEASURES: Participants completed the Support Provided Measure (SPM) by mail at baseline and Week 4 (end-of-treatment). Helpline intake staff documented smoker calls to the Helpline through 6 months of follow-up. RESULTS: The proportion of calls to the Helpline was significantly (p=0.012) greater for smokers linked to support people in the intervention group (16.1%, 43/267) than in the control group (8.6%, 23/267). The treatment effect remained significant after adjusting for support person residing with the smoker (OR=2.04, 95% CI=1.19, 3.49, p=0.010). Among support people randomly assigned to the intervention group, greater number of sessions completed was associated with increased smokers' calls to the Helpline (p=0.004). After adjusting for the baseline score, the M±SD SPM score at Week 4 was significantly higher for support people in the intervention group (16.4±3.3) than for those in the control group (15.3±3.6), p=0.002. CONCLUSIONS: A support-person intervention is effective in increasing smoker utilization of the QUITPLAN Helpline. There is potential for increasing the reach of quitlines by targeting the social network of smokers. TRIAL REGISTRATION #: NCT01311830.

Randomised trial of intranasal nicotine and postoperative pain, nausea and vomiting in non-smoking women.

BACKGROUND: The primary aim of this study is to test the hypothesis that intranasal nicotine reduces postoperative opioid use among non-smoking women. The second aim is to determine the effects of intranasal nicotine on the incidence of postoperative nausea and vomiting (PONV). METHODS: In this double-blind, randomised placebo-controlled trial, non-smoking women undergoing gynaecological procedures received either 3 mg intranasal nicotine (N=90) or placebo spray (N=89) at the conclusion of surgery. Postoperative opioid use (intravenous morphine equivalents) and PONV rates were recorded during the recovery room (postanaesthesia care unit, PACU) stay and first 24 postoperative hours. RESULTS: From an overall analysis, opioid dose administered within the first 24 h was lower in patients receiving nicotine [median (25th, 75th) 38 (17, 62) mg for placebo vs. 25 (13, 46) mg for nicotine; P=0.012]. Inpatients who received intranasal nicotine used less opioid. From an overall analysis, patients in the nicotine group were more likely to experience nausea (71.1 vs. 56.2% P=0.044), receive rescue antiemetics (57.8 vs. 38.2% P=0.011), and report higher Nausea Verbal Descriptive Scores [2 (0, 2; vs. 1 (0, 2), P=0.006] in PACU. Inpatients who received nicotine were more likely to receive antiemetics (P=0.009) and report higher Nausea Verbal Descriptive Scores (P=0.025) in the PACU. CONCLUSION: Intraoperative use of intranasal nicotine has a sustained opioid-sparing effect in non-smoking women undergoing gynaecological procedures and is associated with a higher frequency of PONV.