Background: Trauma is a major cause of death and disability. Adverse events, such as prolonged prehospital time, hypoxia, hypotension and/or hyperventilation have been reported to correlate to poor outcome. Adequate cortisol levels are essential for survival after major trauma. In hypotensive critically ill patients, lack of sufficient amount of cortisol can be suspected, and a concept of critical illness related corticosteroid insufficiency has been proposed. Corticosteroid therapy has many adverse effects in critically ill patients and should only be given if life-saving. Correct measurement of serum cortisol levels is important but difficult in critically ill patients with capillary leakage. Estimation of the free and biologically active cortisol is preferable. In serum less than 10% of cortisol is free and biologically active and not possible to measure with routine laboratory methods. Salivary cortisol can be used as a surrogate for free cortisol, but salivary production is reduced in critically ill patients. Liver resection could reduce cortisol levels due to substrate deficiency. Aims: 1. Evaluate the occurrence of early adverse events in patients with traumatic brain injury and relate them to outcome. 2. Assess cortisol levels over time after trauma and correlate to severity of trauma, sedative/analgesic drugs and cardiovascular function. 3. Evaluate if saliva stimulation could be performed without interfering with salivary cortisol levels. 4. Assess cortisol levels over time after liver resection in comparison to other major surgery. Results: There was no significant correlation between prehospital time ³60 minutes, hypoxia (saturation <95%), hypotension (systolic blood pressure <90 mmHg), or hyperventilation (ETCO2 <4.5 kPa) and a poor outcome (Glasgow Outcome Scale 1-3) in patients with traumatic brain injury. Cortisol levels decreased significantly over time after trauma, but there was no correlation between low (<200 nmol/L) serum cortisol levels and severity of trauma. Infusion of sedative/analgesic drugs was the strongest predictor for a low (<200 nmol/L) serum cortisol. The odds ratio for low serum cortisol levels (<200 nmol/L) was 8.0 for patients receiving continuous infusion of sedative/analgesic drugs. There was no significant difference between unstimulated and stimulated salivary cortisol levels (p=0.06) in healthy volunteers. Liver resection was not associated with significantly lower cortisol levels compared to other major surgery. Conclusion: There was no significant correlation between early adverse events and outcome in patients with traumatic brain injury. Cortisol levels decreased significantly over time in trauma patients. Low cortisol levels (<200 nmol/L) were significantly correlated to continuous infusion of sedative/analgesic drugs. Saliva stimulation could be performed without interfering with salivary cortisol levels. Liver resection was not associated with low cortisol levels compared to other major surgery.

Sepsis claims over 215,000 lives in the US annually. Inducible glucocorticoids (iGC) is produced during sepsis. However, the precise effects of iGC in sepsis remain unclear due to a lack of appropriate animal models. Glucocorticoid (GC) insufficiency is associated with a marked increase in mortality and occurs in 60% of severe septic patients. Yet the conclusion of GC therapy on septic patients is still controversial. Scavenger receptor class B type I (SR-BI) in the adrenal mediates the selective uptake of cholesteryl ester from lipoproteins for GC synthesis. SR-BI-/- mice completely lack iGC during sepsis and are highly susceptible to septic death, which presents SR-BI-/- mice as a GC insufficient model. However, SR-BI-/- mice display multiple defects contributing to septic death, making it difficult to study iGC by using these mice. Therefore, we utilized adrenal-specific SR-BI-/- mice (ADR-T SR-BI-/-) generated by adrenal transplantation. As expected, the ADR-T SR-BI-/- mice failed to generate iGC under cecal ligation and puncture (CLP)-induced sepsis and showed a significantly higher mortality than the control mice, demonstrating that iGC is essential for preventing septic death. High blood urea nitrogen (BUN) was observed in the ADR-T SR-BI-/- mice but not in the control mice in CLP, indicating that iGC protects kidney injury in sepsis. Plasma IL-6 was remarkably higher in the ADR-T SR-BI-/- mice than the control mice, demonstrating an anti-inflammatory effect of iGC in sepsis. The ADR-T SR-BI-/- mice also displayed significantly lower phagocytic activity of monocytes and neutrophils in the blood and lower activation of T cells in the spleen compared to the control mice in CLP, suggesting that iGC is immunomodulatory in sepsis. Low-dose GC supplementation significantly improved the survival of SR-BI-/- mice in CLP, but did not increase the survival rate of SR-BI+/+ mice in CLP, indicating that GC supplementation improves the survival specifically in mice with adrenal insufficiency. Overall, we revealed that iGC is essential for sepsis survival. iGC prevents kidney damage, modulates inflammatory responses and exerts immunomodulatory functions in sepsis. GC supplementation specifically improves survival of individuals with adrenal insufficiency in sepsis.

Autosomal recessive triple A syndrome is caused by mutations in the AAAS gene encoding the protein ALADIN. The disorder manifests with the triad of adrenocorticotropin-resistant adrenal insufficiency, achalasia of the stomach cardia and impaired tear production (alacrima) in combination with progressive neurological impairment of the central, peripheral and autonomic nervous systems. ALADIN is part of the nuclear pore complex acting as a scaffold nucleoporin. In this work the role of ALADIN in the human adrenocortical tumour cell line NCI-H295R1 was investigated. These cells were engineered to either over-express or down-regulate AAAS by inducible stable transfection. Alterations in steroidogenic gene expression and functional consequences were determined. In addition, the role of ALADIN on cell viability and oxidative stress response was analysed. Using both the human adrenal NCI-H295R1-TR AAAS knock-down and over-expression models the potential impairment of the nuclear import of aprataxin, DNA ligase 1 and ferritin heavy chain 1 was investigated. For this YFP-specific vectors transiently transfected into the cell lines were employed. The findings indicate that AAAS knock-down induces a down-regulation of genes coding for type II microsomal cytochrome P450 hydroxylases CYP17A1 and CYP21A2 and their electron donor enzyme cytochrome P450 oxidoreductase, thereby decreasing biosynthesis of precursor metabolites required for glucocorticoid and androgen production. Furthermore I demonstrate that ALADIN deficiency leads to increased susceptibility to oxidative stress and alteration in redox homeostasis after paraquat treatment. Finally, I show significantly impaired nuclear import of DNA ligase 1, aprataxin and ferritin heavy chain 1 in ALADIN knock-down cells. I conclude that down-regulating ALADIN results in decreased oxidative stress response leading to alteration in steroidogenesis, highlighting the knock-down cell model as an important in vitro tool for studying the adrenal phenotype in triple A syndrome. In an approach to identify new interaction partners of ALADIN, co-immunoprecipitation followed by proteome analyses using mass spectrometry was conducted in a GFP-ALADIN over-expression model using the human adrenocortical tumor cell line NCI-H295R. These results were verified in co-immunoprecipitation assays of endogenous ALADIN using NCI-H295R wild-type cells. The results suggest a possible interaction between ALADIN and microsomal flavoprotein cytochrome P450 oxidoreductase and progesterone receptor membrane compartment 2. Co-localisation analyses of these findings were done using immunofluorescence. The data are suggestive for an involvement of ALADIN in the export of nuclear-encoded mitochondrial proteins. Regulation of adrenocortical steroidogenesis is complex and there is increasing evidence that oxidative stress due to ROS accumulation and mitochondria are significantly involved. Furthermore, there may be an important cross-talk between functional organelles comprising nucleus, ER and mitochondria which presumably involves lipid metabolism. The goal of this work was to elucidate the function of ALADIN for the cellular oxidative stress response and its possible consequences for adrenocortical steroidogenesis in triple A syndrome patients. / Mutationen im AAAS Gen verursachen die autosomal rezessive Krankheit Triple-A-Syndrom. AAAS kodiert das Nukleoporin ALADIN, welches Bestandteil des nukleären Porenkomplexes ist. Phänotypische Charakteristika des Triple-A-Syndroms sind Nebennierenrinden-Insuffizienz, Achalasie des unteren Speiseröhrenschließmuskels und eine fehlende Tränenproduktion (Alakrimie). Diese Symptome sind kombiniert mit progredienten neurologischen Störungen des zentralen, peripheren und autonomen Nervensystems. In dieser Arbeit wurde die Rolle von ALADIN in der humanen Karzinom-Zelllinie NCI-H295R1 untersucht. Diese Nebennierenrinden-Zellen wurden stabil transfiziert und mit einem induzierbaren Expressionssystem modifiziert, so dass sie AAAS entweder überexprimierten oder herunterregulierten. In NCI-H295R1-Zellen wurden Veränderungen der Genexpression von Enzymen der Steroidogenese und funktionelle Konsequenzen der Überexpression oder Herunterregulation von ALADIN gemessen. Des Weiteren wurde die Rolle von ALADIN auf die Zellviabilität und die Redox-Homöostase analysiert. ALADIN überexprimierende und herunterregulierte Zellen wurden verwendet, um die potentielle Behinderung des nukleären Imports von Proteinen zu untersuchen, welche den Zellkern gegen oxidativen Stress schützen (z.B. Aprataxin, DNA-Ligase 1 und Ferritin Heavy Chain 1). Dazu wurden YFP-spezifische Vektoren transient in diese Zellen gebracht. Mit den Ergebnissen dieser Arbeit wurde gezeigt, dass die Herunterregulation von AAAS eine Verminderung der Genexpression von CYP17A1 und CYP21A2 und deren Elektronendonor Cytochrom P450 Oxidoreduktase bewirken. Die Biosynthese der Vorläufermetabolite von Kortisol und Aldosteron ist in diesen Zellen ebenfalls vermindert. Des Weiteren zeigen die ALADIN-defizienten NCIH295R1-Zellen eine erhöhte Sensitivität gegenüber oxidativem Stress und eine veränderte Redox-Homöostase nach der Behandlung mit Paraquat. Darüber hinaus konnte in dieser Studie auch gezeigt werden, dass herunterregulierte ALADIN NCI-H295R1-Zellen einen verminderten Zellkernimport von Aprataxin, DNA-Ligase 1 und Ferritin heavy chain 1 besitzen. Aus diesen Ergebnissen kann geschlussfolgert werden, dass ALADIN-defiziente Nebennierenzellen eine verminderte Stressantwort auf oxidativen Stress besitzen; dies führt schlussendlich zu einer veränderten Steroidogenese. Das beschriebene ALADIN knock-down Modell in NCI-H295R1-Zellen ist ein wichtiges in vitro Werkzeug, um die Pathogenese der Nebennierenveränderungen im Triple-A-Syndrom zu erforschen. Neue Interaktionspartner von ALADIN wurden mit Hilfe von Co-Immunpräzipitation gefolgt von Proteom-Analysen durch Massenspektrometrie in einem GFP-ALADIN Überexpressionsmodell in NCI-H295R charakterisiert. Die Ergebnisse wurden durch Experimente auf endogenem Niveau in NCI-H295R-Wildtypzellen verifiziert. Mit diesen Daten wird in dieser Arbeit erstmals eine Interaktion zwischen ALADIN und dem Flavoprotein Cytochrom P450 Oxidoreduktase und Progesterone Receptor Membrane Compartment 2 nachgewiesen. Diese Ergebnisse wurden mit Co-Lokalisierungsanalysen durch Immunfluoreszenzfärbung von ALADIN und Cytochrome P450 Oxidoreduktase ergänzt. Außerdem gibt die Arbeit Hinweise darauf, dass ALADIN als Nukleoporin an dem nuklearen Export mitochondrialer Vorläuferproteine beteiligt ist. Die Regulation der Steroidogenese in der Nebennierenrinde ist komplex und es existieren zahlreiche Hinweise darauf, dass oxidativer Stress aufgrund der Ansammlung reaktiver Sauerstoffradikale und. dass die Mitochondrien involviert sind. Außerdem ist ein funktionelles Zusammenspiel verschiedener Organellen, darunter Nukleus, ER und Mitochondrien, von großer Bedeutung. Das Ziel dieser Arbeit war die Identifizierung der Funktion von ALADIN in der zellulären oxidativen Stressantwort und die möglichen Konsequenzen für die Steroidogenese in der Nebennierenrinden in Triple-A-Syndrom-Patienten.

Autosomal recessive triple A syndrome is caused by mutations in the AAAS gene encoding the protein ALADIN. The disorder manifests with the triad of adrenocorticotropin-resistant adrenal insufficiency, achalasia of the stomach cardia and impaired tear production (alacrima) in combination with progressive neurological impairment of the central, peripheral and autonomic nervous systems. ALADIN is part of the nuclear pore complex acting as a scaffold nucleoporin. In this work the role of ALADIN in the human adrenocortical tumour cell line NCI-H295R1 was investigated. These cells were engineered to either over-express or down-regulate AAAS by inducible stable transfection. Alterations in steroidogenic gene expression and functional consequences were determined. In addition, the role of ALADIN on cell viability and oxidative stress response was analysed. Using both the human adrenal NCI-H295R1-TR AAAS knock-down and over-expression models the potential impairment of the nuclear import of aprataxin, DNA ligase 1 and ferritin heavy chain 1 was investigated. For this YFP-specific vectors transiently transfected into the cell lines were employed. The findings indicate that AAAS knock-down induces a down-regulation of genes coding for type II microsomal cytochrome P450 hydroxylases CYP17A1 and CYP21A2 and their electron donor enzyme cytochrome P450 oxidoreductase, thereby decreasing biosynthesis of precursor metabolites required for glucocorticoid and androgen production. Furthermore I demonstrate that ALADIN deficiency leads to increased susceptibility to oxidative stress and alteration in redox homeostasis after paraquat treatment. Finally, I show significantly impaired nuclear import of DNA ligase 1, aprataxin and ferritin heavy chain 1 in ALADIN knock-down cells. I conclude that down-regulating ALADIN results in decreased oxidative stress response leading to alteration in steroidogenesis, highlighting the knock-down cell model as an important in vitro tool for studying the adrenal phenotype in triple A syndrome. In an approach to identify new interaction partners of ALADIN, co-immunoprecipitation followed by proteome analyses using mass spectrometry was conducted in a GFP-ALADIN over-expression model using the human adrenocortical tumor cell line NCI-H295R. These results were verified in co-immunoprecipitation assays of endogenous ALADIN using NCI-H295R wild-type cells. The results suggest a possible interaction between ALADIN and microsomal flavoprotein cytochrome P450 oxidoreductase and progesterone receptor membrane compartment 2. Co-localisation analyses of these findings were done using immunofluorescence. The data are suggestive for an involvement of ALADIN in the export of nuclear-encoded mitochondrial proteins. Regulation of adrenocortical steroidogenesis is complex and there is increasing evidence that oxidative stress due to ROS accumulation and mitochondria are significantly involved. Furthermore, there may be an important cross-talk between functional organelles comprising nucleus, ER and mitochondria which presumably involves lipid metabolism. The goal of this work was to elucidate the function of ALADIN for the cellular oxidative stress response and its possible consequences for adrenocortical steroidogenesis in triple A syndrome patients. / Mutationen im AAAS Gen verursachen die autosomal rezessive Krankheit Triple-A-Syndrom. AAAS kodiert das Nukleoporin ALADIN, welches Bestandteil des nukleären Porenkomplexes ist. Phänotypische Charakteristika des Triple-A-Syndroms sind Nebennierenrinden-Insuffizienz, Achalasie des unteren Speiseröhrenschließmuskels und eine fehlende Tränenproduktion (Alakrimie). Diese Symptome sind kombiniert mit progredienten neurologischen Störungen des zentralen, peripheren und autonomen Nervensystems. In dieser Arbeit wurde die Rolle von ALADIN in der humanen Karzinom-Zelllinie NCI-H295R1 untersucht. Diese Nebennierenrinden-Zellen wurden stabil transfiziert und mit einem induzierbaren Expressionssystem modifiziert, so dass sie AAAS entweder überexprimierten oder herunterregulierten. In NCI-H295R1-Zellen wurden Veränderungen der Genexpression von Enzymen der Steroidogenese und funktionelle Konsequenzen der Überexpression oder Herunterregulation von ALADIN gemessen. Des Weiteren wurde die Rolle von ALADIN auf die Zellviabilität und die Redox-Homöostase analysiert. ALADIN überexprimierende und herunterregulierte Zellen wurden verwendet, um die potentielle Behinderung des nukleären Imports von Proteinen zu untersuchen, welche den Zellkern gegen oxidativen Stress schützen (z.B. Aprataxin, DNA-Ligase 1 und Ferritin Heavy Chain 1). Dazu wurden YFP-spezifische Vektoren transient in diese Zellen gebracht. Mit den Ergebnissen dieser Arbeit wurde gezeigt, dass die Herunterregulation von AAAS eine Verminderung der Genexpression von CYP17A1 und CYP21A2 und deren Elektronendonor Cytochrom P450 Oxidoreduktase bewirken. Die Biosynthese der Vorläufermetabolite von Kortisol und Aldosteron ist in diesen Zellen ebenfalls vermindert. Des Weiteren zeigen die ALADIN-defizienten NCIH295R1-Zellen eine erhöhte Sensitivität gegenüber oxidativem Stress und eine veränderte Redox-Homöostase nach der Behandlung mit Paraquat. Darüber hinaus konnte in dieser Studie auch gezeigt werden, dass herunterregulierte ALADIN NCI-H295R1-Zellen einen verminderten Zellkernimport von Aprataxin, DNA-Ligase 1 und Ferritin heavy chain 1 besitzen. Aus diesen Ergebnissen kann geschlussfolgert werden, dass ALADIN-defiziente Nebennierenzellen eine verminderte Stressantwort auf oxidativen Stress besitzen; dies führt schlussendlich zu einer veränderten Steroidogenese. Das beschriebene ALADIN knock-down Modell in NCI-H295R1-Zellen ist ein wichtiges in vitro Werkzeug, um die Pathogenese der Nebennierenveränderungen im Triple-A-Syndrom zu erforschen. Neue Interaktionspartner von ALADIN wurden mit Hilfe von Co-Immunpräzipitation gefolgt von Proteom-Analysen durch Massenspektrometrie in einem GFP-ALADIN Überexpressionsmodell in NCI-H295R charakterisiert. Die Ergebnisse wurden durch Experimente auf endogenem Niveau in NCI-H295R-Wildtypzellen verifiziert. Mit diesen Daten wird in dieser Arbeit erstmals eine Interaktion zwischen ALADIN und dem Flavoprotein Cytochrom P450 Oxidoreduktase und Progesterone Receptor Membrane Compartment 2 nachgewiesen. Diese Ergebnisse wurden mit Co-Lokalisierungsanalysen durch Immunfluoreszenzfärbung von ALADIN und Cytochrome P450 Oxidoreduktase ergänzt. Außerdem gibt die Arbeit Hinweise darauf, dass ALADIN als Nukleoporin an dem nuklearen Export mitochondrialer Vorläuferproteine beteiligt ist. Die Regulation der Steroidogenese in der Nebennierenrinde ist komplex und es existieren zahlreiche Hinweise darauf, dass oxidativer Stress aufgrund der Ansammlung reaktiver Sauerstoffradikale und. dass die Mitochondrien involviert sind. Außerdem ist ein funktionelles Zusammenspiel verschiedener Organellen, darunter Nukleus, ER und Mitochondrien, von großer Bedeutung. Das Ziel dieser Arbeit war die Identifizierung der Funktion von ALADIN in der zellulären oxidativen Stressantwort und die möglichen Konsequenzen für die Steroidogenese in der Nebennierenrinden in Triple-A-Syndrom-Patienten.

Der septische Schock geht bis heute mit einer hohen Mortalität einher und stellt für die Intensivmedizin ein schwer beherrschbares Krankheitsbild dar. Er ist die häufigste Todesursache auf nicht kardiologischen Intensivstationen und es wird davon ausgegangen, dass der Anteil septischer Patienten relativ wie absolut zunehmen wird. Das Ziel der vorliegenden Arbeit war, den Einfluss von Hydrokortison auf die Schockdauer und die Wirkung von Hydrokortison in Abhängigkeit der Nebennierenrindenfunktion sowie den Einfluss auf die Morbidität, gemessen am SOFA-Score zu untersuchen. Es wurden 41 Patienten mit frühem septischem Schock in eine doppelblinde, placebokontrollierte, randomisierte Studie eingeschlossen. Zur Beurteilung der Nebennierenfunktion wurde vor Beginn der Studie ein ACTH-Test durchgeführt und je nach Anstieg wurden die Patienten in „Non-Responder“ und „Responder“ unterteilt. Es zeigte sich, dass Hydrokortison zu einer signifikanten Verkürzung der Schockdauer führte. Die Frage nach dem unterschiedlichen Effekt von Hydrokortison bei „Respondern“ und „Non-Respondern“ konnte nicht abschließend geklärt werden; es zeigte sich bei den „Respondern“ und „Non-Respondern“, die Hydrokortison erhalten hatten, ein Trend zu einer kürzeren Schockdauer, der aber keine statistische Signifikanz erreichte, vermutlich weil die Gruppengröße durch die Aufteilung zu klein wurde. Die vorliegenden Ergebnisse sind insofern mit anderen Studien kongruent, bedürfen aber noch der weiteren Abklärung in Studien mit größeren Patientenkollektiven. Der SOFA-Score war unter Hydrokortison in den ersten 48 Stunden signifikant reduziert. In anderen Studien war dies mit einer geringeren Mortalität assoziiert. Die Behandlung mit Hydrokortison reduziert also die Schockdauer und stellt eine wichtige Therapierationale zur Vorbeugung des sepsis-induzierten Organversagens dar. / Up to the present day septic shock is often accompanied with high mortality. For the medical intensive care field it is a hardly controllable disease pattern. Septic shock is the most frequent cause of death at non-cardiological intensive care units. It is believed that the number of septic patients will increase relatively as well as absolutely. The aim of this paper was to examine the influence of hydrocortisone on shock duration, the effect of hydrocortisone dependent on the adrenal function and the influence on morbidity, measured with SOFA score. 41 patients with early septic shock participated in a double-blind, placebo-controlled, randomised study. In the beginning of the study an ACTH-test was conducted in order to assess the adrenal function. Dependent on the increase of ACTH, the patients were classified into "non-responder" and "responder". It became apparent that hydrocortisone leads to a significant reduction of shock duration. The question about the different effect of hydrocortisone on “responder“ and “non-responder“ could not cleared up conclusively. “Responder“ and „non-responder“ who received hydrocortisone showed a trend towards shorter shock duration. There was, however, no statistic significance, probably because the groups became too small because of the division. The present results are insofar congruent with other studies, but they need further clarification through studies with bigger patient groups. For those using hydrocortisone the SOFA score was significantly reduced during the first 48 hours. In other studies this fact was associated with less mortality. The treatment with hydrocortisone therefore reduces the shock duration and is an important therapy rationale for the prevention of septic induced multi-organ failure.

Adrenal insufficiency is common in pediatric patients with septic shock, but remains underdiagnosed in the early stages of sepsis. The early recognition of the factors representing risk for septic shock is crucial, since no control of them can increase the risk of death. This study aimed to verify the occurrence of adrenal insufficiency and describe the clinical and initial laboratory findings in children hospitalized for sepsis. This was a descriptive study, which included children admitted to the Pediatric Intensive Care Unit of the University Hospital of Santa Maria, in the period from March to October, 2013. We studied five patients with sepsis. For adrenal insufficiency diagnoses we performed the ACTH stimulation test. A positive test was considered when an increment on the cortisol level equal or less 9 μg/dL occurred. Five children were analyzed, 80 % were male with a mean age of 7.3 years (±4.2). The initial laboratorial findings confirmed the presence of sepsis. Adrenal insufficiency was diagnosed in 2 of 5 patients studied, representing 40 %. Only one patient (20%) required mechanical ventilation. There was no progression to septic shock in any of the patients studied. All patients were discharges from hospital. We concluded that adrenal insufficiency may be present in pediatric patients with sepsis, in its earliest stages. / A insuficiência adrenal é comum em pacientes pediátricos com choque séptico, porém permanece subdiagnosticada nas fases mais precoces da sepse. Reconhecer precocemente os fatores de progressão para o choque séptico é de fundamental importância, uma vez que, o não controle dos mesmos favorece a lesão de órgãos nobres, aumentando, dessa forma, o risco de morte. Este estudo teve por objetivo verificar a ocorrência de insuficiência adrenal e descrever a evolução clínica e os achados laboratoriais iniciais em crianças internadas por sepse. Estudo descritivo, tipo série de casos, que incluiu crianças admitidas na Unidade de Terapia Intensiva Pediátrica do Hospital Universitário de Santa Maria, no período de março/2013 a outubro/2013. Foram estudados pacientes com diagnóstico de sepse. A insuficiência adrenal foi diagnosticada através da realização do teste de estimulação com ACTH (teste da cortrosina). O nível de cortisol foi dosado imediatamente antes (basal) e uma hora após a administração venosa de 250 μg do análogo sintético do ACTH. Um incremento menor ou igual a 9 μ/dL no cortisol sérico definiu insuficiência adrenal. Foram estudadas 5 crianças, sendo 80% do sexo masculino, com idade média de 7,3 anos (±4,2). Os achados laboratoriais iniciais confirmavam presença de sepse. Insuficiência adrenal foi diagnosticada em 2 dos 5 pacientes, representando 40%. Apenas um paciente (20%) necessitou de suporte ventilatório. Não houve evolução para choque séptico em nenhum dos pacientes estudados. Todos os pacientes receberam alta hospitalar. Concluiu-se a insuficiência adrenal pode estar presente, em pacientes pediátricos com diagnóstico de sepse, nas suas fases mais precoces.

L'insuffisance surrénale primaire (ISP) se caractérise par un déficit en hormones stéroïdiennes lié à un trouble du cortex surrénal qui expose au risque d'insuffisance aiguë et de menace vitale. Actuellement, 80% des formes pédiatriques d'ISP sont d'origine génétique et 5% restent sans étiologie génétique identifiée. Les récentes découvertes de mutations de gènes du stress oxydant ouvrent le champ des recherches d'anomalies génétiques non spécifiques de la glande surrénale. Le séquençage parallèle massif (MPS) autorise aujourd'hui la réalisation de millions de séquences et l'étude simultanée de plusieurs gènes de plusieurs patients ce qui permet d'accélérer le diagnostic. C'est aussi la technique de choix pour la recherche de nouveaux gènes. Cependant, parmi les défis de cette nouvelle technologie, il est possible de citer la gestion de la très grande quantité de données qu'elle génère et le besoin d'une validation rigoureuse préalable à son utilisation à des fins diagnostiques.Le premier objectif du présent travail était d'établir un diagnostic génétique dans une cohorte de patients atteints d'ISP et de rechercher de nouveaux gènes. L'étude des génotypes et des phénotypes permet de comprendre les mécanismes physiopathologiques pour les engager dans le traitement et le conseil génétique.Le second objectif était le développement de méthodes bio-informatiques et d'inférence statistique pour faciliter le transfert du séquençage classique (Sanger) vers la technique MPS. Ce développement comprend l'analyse graphique de la qualité du séquençage, l'ajustement de modèles log-linéaires pour comparer les propriétés de différents « pipelines », et l'ajustement de modèles additifs généralisés pour estimer les contributions des sources d'erreurs de séquençage. Les analyses statistiques ont considéré chaque paire de bases comme unité statistique et chaque patient comme étude indépendante, ce qui confère à l'analyse simultanée de tous les patients le caractère d'une méta-analyse / Primary adrenal insufficiency (PAI) is characterized by an impaired production of steroid hormones due to an adrenal cortex defect. This condition exposes to the risk of acute insufficiency which may be life-threatening. Today, 80% of pediatric forms of PAI have a genetic origin but 5% have no clear genetic support. Recently discovered mutations in genes relative to the oxidative stress have opened the way to research works on genes unrelated to the adrenal gland. Massive Parallel Sequencing (MPS) is now able to perform millions of sequences and study simultaneously several genes in several patients, which accelerates the diagnosis. Above all, MPS is the preferred technique for new gene discoveries. However, among the challenges of this new technology one may cite the management of the huge amount of data MPS generates and the need for a strict validation process before the use of MPS for diagnosis purposes.The first objective of the present work was to establish a genetic diagnosis in a cohort of patients with PAI and search for new genes. Study the genotypes and phenotypes allows a better understanding of the physiopathological mechanisms of PAI and offering appropriate care for the patients and counseling for families. The second objective was the development of bioinformatic and statistical inference methods to help shifting from the classical Sanger sequencing to MPS. This shift involves a graphical analysis of the quality of sequencing, an adjustment of log-linear models to allow comparing the properties of different pipelines, an adjustment of the generalized additive models to allow estimating the contributions of various sources of sequencing errors. The statistical methods have considered each DNA base-pair as a statistical unit and each patient as a separate study which confers the simultaneous study of all patients the status of a meta-analysis

Triple A syndrome, formerly known as Allgrove syndrome, is an autosomal recessive disorder characterized clinically by adrenal insufficiency, alacrima, achalasia, and neurological abnormalities. We report a 17-year-old boy presented to the endocrine clinic with delayed puberty and a 4-year’s history of fatigue and muscle weakness. He had achalasia, alacrima, and skin and mucosal hyperpigmentation. Hormonal assessment revealed isolated glucocorticoid deficiency. Clinical diagnosis of triple A syndrome was confirmed by sequencing the entire coding region including exon-intron boundaries of the AAAS gene. Analysis revealed a homozygous novel indel mutation encompassing intron 7 to intron 10 of the gene (g.16166_17813delinsTGAGGCCTGCTG; NG_016775). This is the first report of triple A syndrome in Jordan with a novel indel mutation and presenting with delayed puberty.

Introduction: Triple A syndrome (AAAS) is a rare autosomal recessive disorder characterized by alacrima, achalasia, ACTH-resistant adrenal insufficiency, autonomic dysfunction, and progressive neurodegeneration. Increased oxidative stress, demonstrated in patients’ fibroblasts in vitro, may be a central disease mechanism. N-acetylcysteine protects renal function in patients with kidney injuries associated with increased oxidative stress and improves viability of AAAS-knockdown adrenal cells in vitro. Patient and Results: A boy diagnosed with AAAS presented with short stature and increased oxidative stress in vivo assessed by increased thiobarbituric acid reactive substances (TBARS), which are markers of lipid peroxidation, and by the susceptibility of LDL to oxidation and the capacity of HDL to prevent it. A homozygous missense germline mutation (c.523G>T, p.Val175Phe) in AAAS was identified. N-acetylcysteine (600 mg orally, twice daily) decreased oxidative stress but did not change the patient’s growth pattern. Conclusions: An increase in oxidative stress is reported for the first time in vivo in an AAAS patient. N-acetylcysteine was capable of decreasing TBARS levels, reducing the susceptibility of LDL to oxidation and improving the antioxidant role of HDL. The longterm effect of antioxidant treatment should be evaluated to determine the real benefit for the prevention of the degenerative process in AAAS.

Introdução: A lavagem nasal com budesonida em solução salina de alto volume (BAV) tem sido utilizada no tratamento de rinossinusite crônica (RSC). Atualmente, não existem evidências de superioridade da BAV sobre o placebo (PLA). Objetivo: O estudo avalia a eficácia da lavagem nasal com BAV na RSC com polipose nasossinusal de difícil controle e asma brônquica. Métodos: Os indivíduos foram prospectivamente recrutados e randomizados em dois grupos: budesonida (1mg/dia) ou placebo, diluídos em 250mL de Soro Fisiológico a 0,9%, e orientados para aplicar 125mL dessa solução em cada narina de 12 em 12 horas, por 12 semanas. Os pacientes foram avaliados quanto a: qualidade de vida doença-específica (SNOT-20, NOSE), endoscopia nasossinusal (Lund-Kennedy) e olfato (UPSIT). Efeitos adversos foram avaliados por meio do cortisol sérico e urinário, feita a avaliação da opacidade do cristalino e teste de sobrecarga hídrica para aferição da pressão ocular. Resultados: Trinta e oito pacientes foram randomizados: 20 no grupo budesonida e 18 no grupo placebo; 3 pacientes do grupo placebo não concluíram o tratamento. O grupo BAV apresentou melhora estatisticamente significativa evidenciada nos questionários NOSE e Lund-Kennedy, enquanto no SNOT observou-se melhora em ambos os grupos. Não houve diferença estatisticamente significativa na comparação entre os grupos em nenhum parâmetro. Entretanto, o grupo BAV mostrou uma redução maior da obstrução nasal (NOSE), comparado ao grupo PLA, cuja análise dos dados apresentou uma tendência para significância estatística (p=0,0593) que poderia ter sido evidenciada caso houvesse um tamanho amostral maior. Pacientes com doença respiratória exacerbada por aspirina no grupo BAV apresentaram melhora mais importante da obstrução nasal (NOSE) quando comparada ao placebo (p=0,0030). Não ocorreu aumento significativo dos eventos adversos após os tratamentos. Conclusão: A lavagem nasal com budesonida em alto volume de solução salina na rinossinusite crônica com polipose nasossinusal de difícil controle e asma brônquica não mostrou ser eficaz na melhora da qualidade de vida doença-específica para rinossinusite (SNOT-20) quando comparada ao placebo, mas uma tendência para melhora significativa da obstrução nasal (NOSE) foi observada / Introduction: Nasal irrigation with high-volume budesonide (HVB) in saline solution has been utilized in the treatment of chronic rhinosinusitis (CRS). Currently, there is no evidence of the superiority of HVB over placebo (PLA). The efficacy and safety of this treatment in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) and asthma still needs to be better established. Objective: This study evaluated the efficacy of nasal irrigation with HVB in patients with difficult-to-control CRS with nasal polyposis and bronchial asthma. Methods: Subjects were prospectively recruited and randomized into two groups: budesonide (1 mg/day) or placebo, diluted in 250 mL of 0.9% saline solution. Patients were instructed to irrigate each nostril with 125 mL of this solution every 12 hours for 12 weeks. Patients were evaluated for disease-specific quality of life (SNOT-20, NOSE) and underwent sinonasal endoscopy (Lund-Kennedy score) and an olfactory test (UPSIT). Adverse effects were evaluated by measurement of serum and urinary cortisol levels, assessment of lens opacity, and a water-drinking test for measurement of intraocular pressure. Results: Thirty-eight patients were randomized: 20 to the budesonide and 18 to the placebo group. Three patients in the placebo group did not complete treatment. The HVB group exhibited statistically significant improvement in NOSE and Lund-Kennedy scores, while improvement in NOSE scores was observed in both groups. There were no statistically significant differences in any parameter on between-group comparison. However, the HVB group exhibited a greater reduction in nasal obstruction scores (NOSE) as compared to the PLA group, with data analysis showing a trend toward statistical significance (p=0.0593) if the sample size had been larger. Patients with aspirin-exacerbated respiratory disease in the HVB group exhibited greater improvement in nasal obstruction (NOSE) than those in the placebo group (p=0.0030). There was no increase in adverse effects after treatment. Conclusion: In patients with difficult-to-control chronic rhinosinusitis with nasal polyposis and bronchial asthma, nasal irrigation with high-volume saline solution plus budesonide was not effective in improving disease-specific quality of life (SNOT-20) as compared with placebo, but was associated with a trend toward significant improvement in nasal obstruction (NOSE)