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  <head>
    <title>023-02 Endocrine pattern recognition, assay interference, and pituitary emergencies</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Endocrine patterns, assay interference, pituitary emergencies">
      <outline text="Concentration as an integrated signal">
        <outline text="Secretion, binding, conversion, clearance"/>
        <outline text="Effect depends on receptors and sensitivity">
          <outline text="Normal level can coexist with resistance"/>
        </outline>
        <outline text="Binding protein raises total concentration">
          <outline text="Pregnancy and oestrogen raise totals"/>
          <outline text="Protein loss and liver disease lower totals"/>
        </outline>
        <outline text="Local conversion">
          <outline text="Deiodinases activate or inactivate thyroid hormone"/>
          <outline text="11-beta dehydrogenase gates mineralocorticoid receptors"/>
          <outline text="Aromatase converts androgens to oestrogens"/>
        </outline>
      </outline>
      <outline text="Paired tests localise the axis">
        <outline text="Low target, high trophic: primary failure"/>
        <outline text="Low target, low or normal trophic: central">
          <outline text="Normal-range trophic can be pathological"/>
        </outline>
        <outline text="High target, suppressed trophic: primary excess"/>
        <outline text="High target, non-suppressed trophic">
          <outline text="Interference, resistance, or central autonomy"/>
          <outline text="Confirm before imaging"/>
        </outline>
        <outline text="Severe acute illness distorts feedback">
          <outline text="Repeat after recovery unless urgent"/>
        </outline>
      </outline>
      <outline text="Pulses, cycles, and sample timing">
        <outline text="Growth hormone undetectable between pulses">
          <outline text="Random value cannot diagnose deficiency"/>
        </outline>
        <outline text="Cortisol follows a circadian rhythm">
          <outline text="Shift work, illness, steroids alter results"/>
        </outline>
        <outline text="Gonadotropins vary with cycle and life stage"/>
        <outline text="Prolactin rises with sleep, stress, medicines"/>
        <outline text="Repeat mild abnormalities under control"/>
      </outline>
      <outline text="Assay interference">
        <outline text="Heterophile antibodies, autoantibodies, biotin"/>
        <outline text="Suspect when results conflict with physiology"/>
        <outline text="Biotin: false highs or false lows by assay">
          <outline text="Mimics thyrotoxicosis, hides trophic rise"/>
        </outline>
        <outline text="Hook effect saturates assay antibodies">
          <outline text="Large mass with mild prolactin: dilute"/>
        </outline>
        <outline text="Macroprolactin: elevation without phenotype"/>
        <outline text="Confirm: other platform, dilution, mass spectrometry"/>
      </outline>
      <outline text="Dynamic tests ask a directional question">
        <outline text="Stimulation assesses reserve">
          <outline text="Synthetic adrenocorticotropic hormone tests cortex"/>
          <outline text="Early central deficiency may still respond"/>
          <outline text="Insulin hypoglycaemia carries real risk"/>
        </outline>
        <outline text="Suppression assesses autonomy">
          <outline text="Dexamethasone: autonomous cortisol escapes"/>
          <outline text="Glucose fails to suppress in acromegaly"/>
        </outline>
        <outline text="Water deprivation separates intake from deficit">
          <outline text="Copeptin as a stable surrogate"/>
        </outline>
      </outline>
      <outline text="Pituitary mass effects">
        <outline text="Beneath chiasm, beside cavernous sinus"/>
        <outline text="Crossing nasal fibres: temporal field loss"/>
        <outline text="Lateral extension: eye movement, facial sensation"/>
        <outline text="Stalk compression raises prolactin modestly"/>
        <outline text="Diabetes insipidus suggests another lesion"/>
        <outline text="Formal visual fields beat confrontation"/>
      </outline>
      <outline text="Apoplexy and hormone-order safety">
        <outline text="Haemorrhage or infarction, often in a tumour">
          <outline text="Mimics subarachnoid haemorrhage or meningitis"/>
        </outline>
        <outline text="Acute adrenocorticotropic loss is immediately dangerous">
          <outline text="Empirical glucocorticoid without delay"/>
        </outline>
        <outline text="Thyroid raises demand and cortisol clearance">
          <outline text="Thyroid before cortisol precipitates crisis"/>
        </outline>
      </outline>
      <outline text="Growth, prolactin, and gonadal consequences">
        <outline text="Growth excess remodels tissues and heart">
          <outline text="Normal growth factor does not reverse structure"/>
        </outline>
        <outline text="Prolactin suppresses pulsatile releasing hormone">
          <outline text="Infertility, sexual dysfunction, bone loss"/>
          <outline text="Coordinate psychiatric medicine changes"/>
        </outline>
        <outline text="Separate central from functional suppression"/>
        <outline text="Sex steroids do not restore gamete production"/>
      </outline>
      <outline text="Water balance and masked diabetes insipidus">
        <outline text="Cortisol deficiency raises vasopressin">
          <outline text="Cortisol treatment unmasks diabetes insipidus"/>
        </outline>
        <outline text="Desmopressin excess causes hyponatraemia"/>
        <outline text="Nephrogenic: remove cause, reduce solute"/>
        <outline text="Review intake, urine, sodium, thirst together"/>
      </outline>
      <outline text="Incidentalomas and long-term care">
        <outline text="Manage from function outward"/>
        <outline text="Stable diameter does not mean stable function"/>
        <outline text="Final report: axis, level, timing, interference"/>
        <outline text="Replacement needs change over time">
          <outline text="Adrenal: stress dosing, emergency injection"/>
          <outline text="Patient knows deficiency and excess signs"/>
        </outline>
      </outline>
    </outline>
  </body>
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