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Incidence of Neuroendocrine Dysfunction in a Postacute , Brain Injury Rehabilitation Setting Lisa A. Kreber , Ph.D.

Incidence of Neuroendocrine Dysfunction in a Postacute , Brain Injury Rehabilitation Setting Lisa A. Kreber , Ph.D., CBIS lkreber@neuroskills.com. Background. Anterior pituitary hormone deficiencies have been found in 33-50% of patients with TBI.

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Incidence of Neuroendocrine Dysfunction in a Postacute , Brain Injury Rehabilitation Setting Lisa A. Kreber , Ph.D.

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  1. Incidence of Neuroendocrine Dysfunction in a Postacute, Brain Injury Rehabilitation SettingLisa A. Kreber, Ph.D., CBISlkreber@neuroskills.com

  2. Background • Anterior pituitary hormone deficiencies have been found in 33-50% of patients with TBI. • Growth hormone deficiencies have been found in 21% of patients with TBI. • Untreated growth hormone deficiency can negatively influence recovery from brain injury, even if the patient is undergoing intensive brain injury rehabilitation (Bondanelli et al, 2007).

  3. Symptoms • Fatigue • Memory Impairment • Inability to concentrate • Anxiety • Depression • Impaired processing speed • Decreased lean body mass • Reduced exercise capacity • Increased abdominal fat **Considerable overlap with several chronic conditions, including TBI**

  4. Methods • Patients: • N=199 adults admitted to an inpatient postacute, residential brain injury facility (Centre for Neuro Skills in Bakersfield, CA) • Patients were admitted over a two year period, from 2008-2010. • Only patients with brain injury of a traumatic nature were included.

  5. Methods • Admission Endocrine Labs: • Thyroid panel (TSH, T3, T4) • Cortisol (AM and PM) • Follicle Stimulating Hormone (FSH) • Luteinizing Hormone (LH) • Prolactin • Estradiol (females only) • Testosterone (males only) • Insulin-like Growth Factor-1 (IGF-1)

  6. Why IGF-1? • IGF-1 is the best marker of growth hormone (GH) available (Frieda et al, 1998). • Low levels of IGF-1 increase the likelihood that GH levels are also deficient (since GH stimulates the release of IGF-1). • However, 50% of adults with GH deficiency have IGF-1 levels in the normal reference range (Lissett et al, 2003).

  7. Provocative Testing • Growth hormone (GH) is released in a pulsatile fashion, making direct measurement difficult. • Provocative testing can be done to stimulate the release of GH within a specific timeframe to allow for direct measurement. • The Glucagon Stimulation Test (GST) was used as the provocative test in this study.

  8. Glucagon Stimulation Test • Patients whose IGF-1 level were less than 200 ng/mL were given a GST to determine GH levels. Patients with levels of IGF-1 less than 100 ng/mL were referred to an endocrinologist. • The GST provokes GH to reach its peak level within a four-hour window, allowing for direct measurement of GH.

  9. Glucagon Stimulation Test • A SubQ injection of glucagon (1 mg) is given in the upper arm. • Blood samples and glucose levels are drawn at: T0, T90, T120, T150, and T180. • Samples are put on dry ice and sent to lab for analysis. • Peak GH levels of: • <3 ug/L=deficient • 4-5ug/L=insufficient

  10. Results: Patient Demogrpahics • Of the 199 patients admitted to Centre for Neuro Skills (Bakersfield, CA facility) that met inclusion criteria, 102 had low levels of IGF-1 that warranted further testing. • That’s 51%!! • Patients were: • Male: 82 Female: 20 • Average age at time of testing: 42 years • Average latency from TBI to testing: 350 days

  11. Results

  12. Results: GST

  13. Treatment • Unfortunately, only 2 individuals in this study were authorized by their insurance company to receive GH replacement therapy. • Consensus guidelines on the treatment of GH deficiency following TBI exist, were provided and explained to the funding sources, but to no avail. • Ghigo et al, 2005 • Ho et al, 2007

  14. Conclusions • There is a high incidence of untreated neuroendocrine deficiencies in the postacute phase recovery phase following TBI. • Hormone replacement therapy has the potential to improve outcome following brain injury. • Patients who have received GH replacement demonstrate decreased abdominal adiposity, increased alertness, increased cognitive processing and greater quality of life.

  15. Future Directions • Standards of care for TBI need to include routine screenings for post-traumatic hormone deficiencies. • Multidisciplinary collaboration between case managers, endocrinologists and rehabilitation professionals is essential in order to maximize the potential for recovery following brain injury.

  16. Acknowledgements • Clinical Research and Education Foundation (CREF) • Dr. Mark Ashley • Dr. Jessica Ashley • Sarah Johnson, M.A. • Dr. Brent Masel (Transitional Learning Center) • Dr. Randy Urban (UTMB)

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