PPV Adrenal Diseases by Elias Triantaphillou https://padlet.com/30felias/du7hagpenz6n1fyu en-us 2023-05-08 20:04:59 UTC 2023-05-25 14:19:37 UTC hello@padlet.com Location 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583622587 in regard to kidneys, slightly different location.
right = Ontop of kidney lobe
left = Hanging onto medial side of kidney]]> 2023-05-09 10:58:43 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583622587 Blood supply 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583622760
  • Both adrenals have their own blood supply 
  • Right suprarenal vein drains directly into vena cava, left suprarenal vein drains into left renal vein 
    • ]]>     2023-05-09 10:58:54 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583622760     Histology (layers) of the gland 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583623858 Outer fatty capsule
    Cortex
    Zona glomerulosa → mineralocorticoids (aldosterone)
    Zona fasciculata → glucocorticoids (cortisol)
    Zona reticularis → androgens 
    Medulla
    • Chromaffin cells → catecholamines: epinephrine (adrenaline), norepinephrine (noradrenaline) (and dopamine to a very small extent) → sympathetic nervous system response 

    ]]>     2023-05-09 10:59:56 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583623858     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583625122 2023-05-09 11:01:04 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583625122 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583627310 2023-05-09 11:03:02 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583627310 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583628128 2023-05-09 11:03:49 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583628128 Steroids produced are grouped into 3 major classes based on their effects: 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583629785 2023-05-09 11:05:17 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583629785 Glucorticoids 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583630797
  • Cortisol has negative feedback on the hypothalamus, affected by circadian rhythm (increases with severe stress)
  • Corticotrophin releasing hormone in response to stress or circadian rhythm, also stimulates ACTH
  • Corticosteroid receptors type 2 
  • Glucocorticoid action is modified locally by the action of 11β-hydroxysteroid dehydrogenase (11βHSD)
  • Glucorticoids have a diabetes like circulation due to increasing circulating glucose



    • ]]>     2023-05-09 11:06:19 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583630797     Mineralocorticoids 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583632059
  • Corticosteroid receptors type 1 
  • Effects on extracellular balance of sodium and potassium in the distal tubule of the kidney (aldosterone) --> done by juxtaglomerular apparatus
    • Used for retention of sodium and excretion of potassium --> This means water reabsorption --> increase in blood pressure --> Counterbalances low perfusion which is sensed at beginning of RAAS cycle
    • ]]>     2023-05-09 11:07:34 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583632059     Androgens 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583632191
  • Sex hormones are secreted but need to be further metabolized to reach their final form of testosterone or dihydrotestosterone 
  • Fat composition of body can have consequences in the synthesis of these hormones
  • If you have a deficiency of progesterone, mineralocorticoids are not produced. A deficiency of one thing means an excess of another.
    • ]]>     2023-05-09 11:07:43 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583632191     Secretion of cortisol: hypothalamus-pituitary-adrenal (HPA) axis 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583634381
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    • ]]>     2023-05-09 11:09:56 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583634381     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583635217 2023-05-09 11:10:42 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583635217 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583635762 2023-05-09 11:11:14 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583635762 Secretion of mineralocorticoids: RAAS system 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583636690 2023-05-09 11:12:11 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583636690 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583639423
  • Basal levels 
    • ACTH & cortisol 
    • Suppression & stimulation tests are used in suspected excess and deficient cortisol production, respectively:


    • Dexamethasone suppression tests

    • Administration of synthetic glucocorticoid (dexamethasone) 

    ACTH stimulation tests (Synthacthen test)
    • Synthetic ACTH (tetrosactide, which consists of the first 24 amino acid of human ACTH) is given to stimulate cortisol production 

    Testing at 9 am for cortisol levels (circadian rhythm has effect on cortisol levels as here it is the highest)
    If suspect an excess of cortisol, dexamethasone suppression test should be done 

    administer synthetic glucocuortoiud in abnormal physiological circumstances there is a feedback suppression of CRH and ACTH

    If there is not enough production of cortisol administer synthetic ACTH (stimulation test)

    ]]>     2023-05-09 11:14:47 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583639423     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583639851 2023-05-09 11:15:13 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583639851 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583640209 2023-05-09 11:15:37 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583640209 Primary hypoadrenalism (Addison’s disease) = primary adrenal insufficiency 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583641162 Disease characterised by adrenal glands not functioning the correct way because no cortisol made, lack of neg. feedback
    \A ot more CRH and ACTH, because body responds to lack of cortisol

    Addison disease itself is autoimmune (self-destrcution of entire adrenal cortex (90%)) = most common cause in developed countries; in other countries other chief aetiologies


    ]]>     2023-05-09 11:16:30 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583641162     Aetiology 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583641622 2023-05-09 11:16:57 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583641622 Pathophysiology 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583641944

    • Destruction of the entire adrenal cortex → reduction of glucocorticoid, mineralocorticoid and sex steroid production are all reduced 
      • → this differs from hypothalamic-pituitary disease: 
  • Reduced cortisol levels → feedback loop → increased CRH & ACTH production 

    • ]]>     2023-05-09 11:17:17 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583641944     Clinical features 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583642554 2023-05-09 11:17:58 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583642554 Signs and symptoms 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583643358 Symptoms tend to be non-specific

    Addisonian crisis = Combination of low blood sugar level, high potassium, and low blood pressure (life-threatening situation) ]]>     2023-05-09 11:18:48 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583643358     Investigations 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583643756
  • Short ACTH stimulation test (if impaired cortisol response, hypoadrenalism confirmed) --> 80 nanograms 
    • ATH is then measured to take out hypothalamic causes 


    All axes connected to hypothalamus , primary disease refers to gland itself, secondary pituitary, tertiary hypothalamus

    Other:
    • A 9:00 hours plasma ACTH level 
    • Electrolytes & urea 
    • Blood glucose 
    • Adrenal antibodies 
    • Chest & abdominal X-rays 
    • Plasma renin activity 
    • Hypercalcaemia & anaemia 
    ]]>     2023-05-09 11:19:13 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583643756     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583645126 2023-05-09 11:20:28 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583645126 Treatment 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583645598 2023-05-09 11:20:58 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583645598 Acute treatment 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583646452 During Addisonian crisis

    1. Instant IV
    2. Glucose
    3. start with saline to balance salt conc.
    4. Hydrocortisone is important to suppress 

    Get blood pressure up!]]>     2023-05-09 11:21:53 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583646452     Long term-treatment 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583648158 Replacement gluco- and mineralocorticoids instead of hydrocortisone

    Assessed if there are comorbidities such as tuberculsosis,,, amount of dose depends on physiology of patients (based on their well-being)

    Then after assess if levels are back to normal]]>     2023-05-09 11:23:26 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583648158     Patient advice 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583649505
  • Know how to increase steroid replacement dose for intercurrent illness
  • Carry a ‘Steroid Card’
  • Wear a Medic-Alert bracelet 
  • Keep an ampoule of hydrocortisone at home 

    • Is important to tell peers if you have a condition that needs to be treated soon; always useful to have this information. Some people want to keep certain things private but it always better to say!

    ]]>     2023-05-09 11:24:39 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583649505     Nelson syndrome 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583649891 Nelson syndrome is due to adrenectomy 

    Addison is due to when 90% of adrenal cortex is destroyed for other reasons]]>     2023-05-09 11:25:05 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583649891     Secondary hypoadrenalism (Secondary adrenal insufficiency) 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583650760 Etiology
    • Problem in ACTH --> adrenal gland gets too little stimulation --> hypoadrenalism + deficiency of cortisol --> can lead to all other sorts of complications 
    • Rathke's pouch
    • Long-term steroid therapy leading HPA suppression (most common)
    Clinical features
    • .
    Treatment
    ]]>     2023-05-09 11:25:59 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583650760     Congenital adrenal hyperplasia (CAH) 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583652489 Etiology
    • Autosomal recessive disorder
    Pathophysiology
    • CYP21 is not produced, (most cmoon cause of adrenal issues in children) --> If there is a complete block, a sign of that is abnormal genitalia at birth

    There is reduced cortisol secretion, hence feedback increases ACTH and other things in the attempt to increase cortisol again
    --> This may lead to adrenal hyperplasia
    • Virilization 
    • Salt wasting
    Clinical features
    • If severe: present at birth with sexual ambiguity or adrenal failure (collapse, hypotension, hypoglycaemia), sometimes with a salt-losing state (hypotension, hyponatraemia) 
    Investigations
    • Expert advice 
    • For ambiguous genitalia → seek advice urgently before any assignment of gender is made 
    • Profile of adrenocortical hormones is measured before and 1 hour after ACTH administration 
      • 17-hydroxyprogesterone levels
      • Urinary pregnanetriol 
      • Androstenedione levels 
      • Basal ACTH levels 
    Treatment
    • Replace glucocorticoid & mineralocorticoid activity 
    • Genetic counselling & antenatal diagnosis are essential 
    ]]>     2023-05-09 11:27:44 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583652489     Steroid therapy 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583653598
  • Therapy is less than 3 weeks, no significant risk of affecting the adrenal axis
  • Long-term it can suppress the adrenal axis giving mimicking endogenous Cushing's syndrome
    • ]]>     2023-05-09 11:28:53 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583653598     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583653923 2023-05-09 11:29:13 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583653923 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583654238 2023-05-09 11:29:31 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583654238 Incidental adrenal tumours (incidentalomas) 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583655814 2 main concerns
    • Is it functional or non-functional (if functional might need surgical removal)
    • Is it benign or malignant



    • Classified as hyperadrenalism if the lesion is functional

    ]]>     2023-05-09 11:31:03 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583655814     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583656300 2023-05-09 11:31:28 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583656300 Treatment 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583656651
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    • ]]>     2023-05-09 11:31:41 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583656651     Cushing's syndrome 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583657426 State with increased glucocorticoid

    ]]>     2023-05-09 11:32:27 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583657426     Aetiology 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583658197 Disease: Pituitary dependent; ectopic; iatrogenic

    Symtpoms: adrenal glands, iatrogenic with glucocorticoids ; can get a crushing appearance with increased alcohol consumption, pathophysiology not known


    ]]>     2023-05-09 11:33:10 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583658197     Clinical manifestations (those of glucorticoid excess) 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583659175 Depression, almost change personality, lemon/potato on a stick (central obesity and atrophic legs)]]> 2023-05-09 11:34:09 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583659175 Signs and symptoms 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583659987 2023-05-09 11:34:55 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583659987 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583660771 2023-05-09 11:35:40 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583660771 Evaluation of Cushing's syndrome 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583662491
  • Too much cortisol, hence dexamethasone suppression test (increased level of cortisol = cushings)
  • 24h urinary-free cortisol tests
  • The difference between low and high doses is that in the high dose, it is more important to assess the difference with pituitary-dependent disease 
  • The low dose is used in the initial diagnosis of Cushing syndrome, and the high dose for differential. If pit. dependent, suppression of treatment in 90% of the cases.


    • ]]>     2023-05-09 11:37:17 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583662491     Differential diagnosis 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583662886
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    • ]]>     2023-05-09 11:37:39 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583662886     Localization 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583663990

    Important for exam!
    ]]>     2023-05-09 11:38:45 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583663990     Treatment 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583664803
  • CT or MRI to test for carcinoma
  • If hypokalemia can be linked to ACTH secretion

    • Surgery (adrenalectomy)
    • Removal of pituitary tumour
    ]]>     2023-05-09 11:39:34 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583664803     Primary hyperaldosteronism 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583668454
  • = increased mineralocorticoid secretion from the adrenal cortex → account for 5-10% of all HTN 
    • Other causes of HTN should also be considered if there is suspicion 
    • DDX: (table below)

    • ]]>     2023-05-09 11:42:39 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583668454     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583668952 2023-05-09 11:43:06 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583668952 Flowchart of primary hyperaldosteronism 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583670663 When to suspect this:

    Aetiology
    • .
    • Difference with secondary hyperaldosteronism 
      • Arises when there is excess renin (and thus angiotensin II) stimulation of the zona glomerulosa 
    • Pathophysiology 
      • Excess aldosterone production → sodium retention & potassium loss → HTN & hypokalaemia 
    • Clinical features 
      • Hypertension 
      • Hypokalaemia not always present (50%) 
    • Investigations 
      • Plasma aldosterone:renin ratio (ARR) 
      • Elevated plasma aldosterone levels that are not suppressed with 0.9% saline infusion or fludrocortisone administration 
      • Suppressed plasma renin activity 
      • Hypokalaemia & urinary potassium loss
      • Once diagnosis of hyperaldosteronism is established → differentiation of adenoma from hyperplasia with CT or MRI 
      • Bilateral adrenal vein sampling (lecture) 

    ]]>     2023-05-09 11:44:38 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583670663     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583671131

    ]]>     2023-05-09 11:45:03 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583671131     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583672008
  • Adenoma → surgical removal (usually laparoscopically) → BP falls in 70% of patients 
  • Hyperplasia → treat with aldosterone antagonist 
    • ]]>     2023-05-09 11:45:47 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583672008     Glucocorticoid (or dexamethasone) suppressible hyperaldosteronism 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583672499
  • Rare condition caused by gene fusion → produces aldosterone which is under ACTH control 
  • Treatment with glucocorticoid solves the problem 

    • ]]>     2023-05-09 11:46:12 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583672499     Syndrome of apparent mineralocorticoid excess 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583672623
  • This causes clinical picture of primary hyperaldosteronism but with low renin & low aldosterone 
  • Reduced activity of the enzyme 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) 

    • ]]>     2023-05-09 11:46:18 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583672623     Phaeochromocytoma and paraganglioma 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583672752
  • = rare tumours of SNS at adrenal gland that secrete catecholamines, noradrenaline, adrenaline and their metabolites 
    • Phaeochromocytoma (adrenals) (90%) vs. paraganglioma (10%) 


    Non-specific symptoms; extreme heartbeat, sweating, headache, hypertension
    ]]>     2023-05-09 11:46:26 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583672752     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583676835 2023-05-09 11:49:46 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583676835 Clinical features of catecholamine excess 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583677472 2023-05-09 11:50:19 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583677472 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583677874 2023-05-09 11:50:42 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583677874 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583678287 2023-05-09 11:51:05 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583678287 Diagnosis 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583679156
  • Blood smaples, and measuring adrenaline and norepinephrine.
  • Imaging; tumours most often benign but can also spread as malignant
  • Biopsy can generate huge release of norepinephrine --> no biopsy!



    • Measure urinary catecholamines and metabolites 
    • Resting plasma catecholamines 
    • Plasma chromogranin A (= storage vesicle protein) 
    • Clonidine suppression test 
    • CT scans (abdomen) 
    • MRI 
    • Scanning with [131I]meta-iodobenzylguanidine (MIBG) 
    Nuclear imaging: 68Ga-DOTATATE or 18F-FDG PET 
    ]]>     2023-05-09 11:51:52 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583679156     30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583679818 2023-05-09 11:52:25 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583679818 Treatment 30felias https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583679952 Surgical removal if possible 
    Combined alpha- and beta-blockade 
    over 10% recur or develop a further tumour
    ]]>     2023-05-09 11:52:32 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2583679952     https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585060331 If cortisol not measured on time (as soon as waking up), you will not catch the high peak of cortisol.]]> 2023-05-10 07:21:51 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585060331 https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585071439 https://www.niddk.nih.gov/health-information/endocrine-diseases/adrenal-insufficiency-addisons-disease/definition-facts]]> 2023-05-10 07:28:43 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585071439 https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585093735 https://www.nature.com/articles/s41574-022-00655-w.pdf]]> 2023-05-10 07:45:31 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585093735 https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585282627 2023-05-10 10:22:58 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585282627 mmtzclaros1 https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585344449 2023-05-10 11:21:56 UTC https://padlet.com/30felias/du7hagpenz6n1fyu/wish/2585344449