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Original article
Study of abnormal adrenal receptors in subjects with ACTH-independent Cushing's syndrome and nodular adrenal hyperplasia
Estudio de receptor anómalo suprarrenal en sujetos con síndrome de Cushing ACTH-independiente e hiperplasia nodular suprarrenal
Jordi Ferria, Eva Perellóa, Rosario I. Lorentea, Carlos Argenteb, Paolo Rossettic, Teresa Pedrod, Sergio Martinez-Hervasa,e,f,
Corresponding author
sergio.martinez@uv.es

Corresponding author.
, José T. Reala,e,f
a Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain
b Endocrinología y Nutrición, Hospital Marina Baixa, Villajoyosa (Alicante), Spain
c Endocrinología y Nutrición, Hospital de Gandía, Gandía (Valencia), Spain
d Endocrinología y Nutrición, Hospital de Dénia, Dénia (Alicante), Spain
e Departamento de Medicina, Universidad de Valencia, Valencia, Spain
f CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Adrenocorticotropic hormone &#40;ACTH&#41;-independent Cushing&#39;s syndrome &#40;AICS&#41; accounts for 15&#8211;20&#37; of all cases of Cushing&#39;s syndrome&#46; Most cases of AICS are due to unilateral adrenal tumors &#40;&#8805;90&#37;&#41;&#44; while the remainder are due to bilateral adrenal lesions&#46; The causes of AICS secondary to bilateral adrenal lesions include pigmented micronodular adrenal hyperplasia and bilateral macronodular adrenal hyperplasia &#40;BMAH&#41; of unknown cause or secondary to the expression of aberrant receptors&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Pigmented micronodular hyperplasia is a very rare cause of Cushing&#39;s syndrome&#46; The adrenal glands are usually normal or slightly enlarged&#44; and are occupied by pigmented nodules measuring 2&#8211;4<span class="elsevierStyleHsp" style=""></span>mm in size&#44; with an atrophic inter-nodular cortex&#46; Approximately 50&#37; of all cases are sporadic&#44; while the rest are familial cases that may be associated with Carney complex with an autosomal dominant hereditary trait&#46; The symptoms of hypercortisolism always appear before 30 years of age&#44; and under 15 years of age in half of the cases&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Bilateral macronodular adrenal hyperplasia&#44; formerly known as ACTH-independent macronodular adrenal hyperplasia&#44; is the cause of less than 1&#8211;2&#37; of all cases of Cushing&#39;s syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;2</span></a> However&#44; its prevalence may be underestimated because of the few symptoms it causes in many cases&#44; and the difficulties involved in diagnosing the condition&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> Bilateral macronodular adrenal hyperplasia most often occurs in the fifth or sixth decade of life and is characterized by enlarged adrenal glands containing non-pigmented nodules measuring over 10<span class="elsevierStyleHsp" style=""></span>mm in diameter&#44; with hypertrophic inter-nodular tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> The condition is usually associated with moderate urinary cortisol elevation as a result of inefficient steroidogenesis&#44; and manifests as a discrete and long-standing clinical syndrome&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Bilateral macronodular adrenal hyperplasia is a heterogeneous disorder whose diagnosis is usually delayed because of its clinical diversity and slow course&#46; The most common presentation is diagnosis established in the context of the study of a patient with bilateral adrenal gland incidentalomas&#44; where a differential diagnosis with malignancy is sometimes required in view of the radiological findings&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> The physiopathology underlying BMAH is not fully known&#46; Germline mutations of the <span class="elsevierStyleItalic">armadillo repeat containing 5</span> &#40;ARMC5&#41; gene have recently been reported in approximately half of all cases&#44; and steroidogenesis in BMAH is known to be regulated by non-ACTH dependent circulating factors&#44; resulting from the anomalous expression of receptors of various hormones in the adrenocortical cell membrane&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The presence of anomalous receptors in adrenal tissue was first described in 1971 by Schorr and Ney&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> but it was not until 1987 that the function of these receptors could be shown in the studies published by Hamet et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> In these cases&#44; excessive cortisol production may be attributed to the abnormal expression of hormone receptors&#44; particularly in BMAH&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Two types of receptors are distinguished&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Ectopic receptors not normally expressed in the adrenal cortex&#46; These include receptors for&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Gastric inhibitory peptide &#40;GIP&#41;&#58; these receptors are stimulated by oral intake&#44; particularly of carbohydrates and lipids&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Catecholamines&#58; these receptors are stimulated by a variety of factors such as the standing position or hypoglycemia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Vasopressin&#58; there are three different types of receptors for vasopressin&#46; Of these&#44; receptor V1 can be found in healthy cells of the adrenal cortex&#44; but V2 and V3 are ectopic receptors&#46; They can be stimulated by common vasopressin releasing stimuli such as the standing position &#40;orthostatism&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Serotonin &#40;5-HT<span class="elsevierStyleInf">7</span> receptor&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Glucagon&#46;</p></li></ul></p></li></ul><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Eutopic receptors with an abnormal function due to the increased expression of receptors that are common in the adrenal cortex&#44; such as&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Vasopressin&#58; as mentioned above&#44; receptor V1 can be found in cells of the healthy adrenal cortex&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Luteinizing hormone &#40;LH&#41;&#58; the LH receptor is over-stimulated in situations of important LH elevation&#44; as occurs in primary hypogonadism &#40;particularly in men&#41; or in women after menopause&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Human chorionic gonadotropin &#40;hCG&#41; in pregnant women&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Serotonin &#40;5-HT<span class="elsevierStyleInf">4</span> receptor&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Angiotensin II&#46;</p></li></ul></p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">All of these will cause cortisol elevation with a characteristic pattern&#44; depending on the circumstances that increase the expression of the corresponding factor&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Most anomalous receptors are part of the family of G protein-coupled receptors&#44; which through the stimulation of adenylate cyclase activate steroidogenesis in the way the ACTH receptor would do under normal conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Lacroix has developed a diagnostic protocol for the presence of anomalous receptors in adrenal tissue that is used as a reference in studies in this field&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> According to this protocol&#44; screening tests are initially made&#44; followed&#44; if positive&#44; by other tests targeting specific ligands&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The objective of the present study was to explore the presence of anomalous receptors in subjects diagnosed with AICS with adrenal nodular hyperplasia over a 14-year period &#40;from 2002 to 2016&#41;&#44; and to describe our experience in the management and follow-up of these cases&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0110" class="elsevierStylePara elsevierViewall">A descriptive study was made of a series of cases of AICS with adrenal nodular hyperplasia selected through consecutive sampling during the period 2002&#8211;2016 at the Endocrinology and Nutrition Outpatient Clinics of several centers in the Valencian Community &#40;Spain&#41; 1&#58; Hospital Cl&#237;nico Universitario de Valencia&#44; Hospital Francesc de Borja &#40;Gandia&#41;&#44; Hospital de D&#233;nia and Hospital Marina Baixa &#40;Villajoyosa&#41;&#46; A total of 15 cases were diagnosed&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The following criteria were used to diagnose AICS&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">Cushing&#39;s syndrome&#58; two of the following three anomalous tests&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">24-h urinary free cortisol &#62;450<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;24<span class="elsevierStyleHsp" style=""></span>h in at least two measurements&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Salivary cortisol at 23&#58;00<span class="elsevierStyleHsp" style=""></span>h &#62;145<span class="elsevierStyleHsp" style=""></span>ng&#47;dl&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Plasma cortisol after nocturnal suppression with dexamethasone 1<span class="elsevierStyleHsp" style=""></span>mg at 23&#58;00<span class="elsevierStyleHsp" style=""></span>h &#40;or the Nugent test&#41; &#8805;2<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dl&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Plasma cortisol after weak suppression with dexamethasone 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg every 6<span class="elsevierStyleHsp" style=""></span>h for two days &#8805;2<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dl&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">ACTH-independent&#58; ACTH &#60;10<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46; At least three determinations were made to establish independence&#46;</p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">Adrenal nodular hyperplasia was diagnosed using imaging techniques &#40;CAT or MRI&#41;&#44; including those cases in which multiple lesions were seen in the adrenal glands&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Anomalous receptor screening was performed in the 15 patients meeting these criteria&#46; We followed the protocols of studies based on the recommendations of Lacroix et al&#46; to determine these receptors&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;11</span></a> The study was carried out in each patient in the Functional Tests Unit of Hospital Cl&#237;nico Universitario &#40;Valencia&#44; Spain&#41; on three alternate days of the same week&#44; and involved the sequential application of different stimulus tests&#46; The sequence&#44; dose&#44; administration route of the stimulus used&#44; and the timings of each of them were those recommended by Outeirino et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> With regard to the test meal&#44; at 8&#58;00<span class="elsevierStyleHsp" style=""></span>h&#44; and after overnight fasting&#44; the patient consumed&#58; 100<span class="elsevierStyleHsp" style=""></span>g of bread&#44; 250<span class="elsevierStyleHsp" style=""></span>ml of coffee with milk&#44; 20<span class="elsevierStyleHsp" style=""></span>g of butter and 20<span class="elsevierStyleHsp" style=""></span>g of jam&#46; The tests lasted 2<span class="elsevierStyleHsp" style=""></span>h&#44; and 5 cortisol measurements were taken at time 0 and every 30<span class="elsevierStyleHsp" style=""></span>min&#44; until the end of the test&#46; An increase in plasma cortisol &#8805;25&#37; from baseline was considered pathological&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The following tests were performed in our study&#58;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">First diagnostic step&#58; this included some screening tests&#44; the positivity of which could correspond to the presence of different receptors&#46;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">The test meal&#44; assessing GIP or GLP-1&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">The postural test&#44; evaluating receptors for angiotensin II&#44; vasopressin&#44; catecholamines and atrial natriuretic peptide&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">The GnRH test&#44; evaluating receptors for LH&#44; FSH or GnRH&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">The TRH test&#44; evaluating receptors for TRH&#44; TSH or prolactin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">The glucagon test&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">The metoclopramide test&#44; evaluating the 5-HT<span class="elsevierStyleInf">4</span> serotonin receptor&#46;</p></li></ul></p></li></ul><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">In the case of positivity in any of the above tests&#44; confirmatory tests were performed to establish the receptor involved&#58;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">The desmopressin test&#44; which evaluates V2 receptors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">The terlipressin test&#44; which evaluates V1 receptors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">The LH test&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">The FSH test&#46;</p></li></ul></p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">In some cases the tests varied due to the characteristics and limitations of the patient &#40;such as limited mobility for performing the postural test&#41; or because of changes in the Department protocols over time&#44; since these were adapted over the years based on the previous results obtained &#40;those tests not proving positive in any of the cases were eliminated&#41;&#46; Thus&#44; the test meal and metoclopramide test were performed in all 15 patients&#44; the postural test in 13 patients&#44; the GnRH test in 11 patients&#44; the desmopressin test in 7&#44; the TRH test and glucagon test in 5&#44; the terlipressin test in four&#44; the LH test in two&#44; and the FSH test in two patients&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0230" class="elsevierStylePara elsevierViewall">In all the patients enrolled&#44; the study was started after the incidental imaging test finding of bilateral adrenal masses &#40;except in patient 6&#44; who presented a unilateral lesion&#41;&#44; all of them suggesting a benign nature&#44; with incomplete suppression after the administration of dexamethasone 1<span class="elsevierStyleHsp" style=""></span>mg&#46; Of the 15 cases&#44; 13 were women&#44; with a mean age at diagnosis of 56&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;9 years&#46; The mean basal cortisol values at diagnosis were 17&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;3<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dl&#44; while those of ACTH were 3&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;1<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46; The cortisol values after suppression with 1<span class="elsevierStyleHsp" style=""></span>mg of dexamethasone were 9&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;9<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dl&#44; with cortisol after weak suppression 10&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dl and cortisol in 24-h urine 285&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>335&#46;3<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;24<span class="elsevierStyleHsp" style=""></span>h &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">Anomalous receptor testing proved positive in 12 of the 15 cases &#40;80&#37;&#41;&#46; Of these&#44; test meal positivity was observed in cases 3&#44; 7 and 12 &#40;25&#37;&#41;&#44; with posture walking test positivity in cases 2&#44; 3&#44; 4&#44; 5&#44; 7&#44; 12 and 15 &#40;58&#46;3&#37;&#41;&#44; desmopressin positivity in cases 2&#44; 3&#44; 7 and 8 &#40;33&#46;3&#37;&#41;&#44; terlipressin positivity in cases 2&#44; 4 and 5 &#40;25&#37;&#41;&#44; GnRH positivity in cases 1&#44; 7&#44; 12 and 15 &#40;33&#46;3&#37;&#41;&#44; LH positivity in cases 1&#44; 3 and 5 &#40;25&#37;&#41;&#44; and metoclopramide test positivity in cases 3&#44; 10&#44; 11&#44; 12&#44; 14 and 15 &#40;50&#37;&#41;&#46; Thus&#44; the most frequently positive test was the posture walking test&#44; which was found to be positive in 58&#46;3&#37; of the cases in which an anomalous receptor was detected&#44; and reached a maximum percentage change of 166&#46;8&#37; in case number 2 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall">In cases 6&#44; 9 and 13&#44; no positivity was detected for any of the tests&#46; The TRH&#44; FSH and glucagon tests were not positive in any of the cases&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Management of the patients with positive screening comprised bilateral or unilateral adrenalectomy&#44; or observation &#40;monitoring&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Bilateral adrenalectomy was performed in those patients with a clear Cushing phenotype and associated comorbidities such as diabetes or arterial hypertension &#40;cases 1&#44; 2&#44; and 4&#59; 25&#37;&#41;&#46; Those patients with a Cushing phenotype but no other comorbidities underwent unilateral adrenalectomy&#44; with the largest gland being removed &#40;cases 3&#44; 7&#44; 8&#44; 11&#44; and 14&#59; 41&#46;7&#37;&#41;&#46; The remaining patients with positive tests&#44; who only had subclinical Cushing&#39;s disease&#44; continue to undergo periodic monitoring &#40;cases 5&#44; 10&#44; 12 and 15&#59; 33&#46;3&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0250" class="elsevierStylePara elsevierViewall">Four of the cases were initially monitored and started to present clinical symptoms during follow-up&#46; Surgery was therefore performed later&#46; Likewise&#44; in one case with a positive test for GnRH and LH&#44; medical treatment was attempted with leuprolide acetate &#40;an LHRH agonist&#41; for four months&#58; the basal cortisol levels were initially normalized and the urinary cortisol levels decreased&#44; but without reaching normal levels&#46; In addition&#44; we recorded a worsened control of diabetes mellitus and arterial hypertension&#44; as well as of proximal myopathy&#46; Bilateral adrenalectomy was therefore finally performed&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Over subsequent follow-up&#44; those patients with bilateral adrenalectomy met the cure criteria and are currently subjected to follow-up&#44; with the administration of corticosteroid replacement therapy&#46; Those patients with unilateral adrenalectomy remain under follow-up with regular check-ups and are clinically asymptomatic after a mean follow-up period of 41&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>41&#46;6 months&#46; Likewise&#44; those patients in whom no procedure was performed remain for the time being with subclinical Cushing&#39;s syndrome after 45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;9 months of follow-up &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0265" class="elsevierStylePara elsevierViewall">The present study describes 12 patients with AICS due to an anomalous receptor presence&#46; Adrenocorticotropic hormone &#40;ACTH&#41;-independent Cushing&#39;s syndrome is a low prevalence disorder&#59; as a result&#44; the available clinical and biological information is based on studies of case series&#46; The aberrant expression of ectopic and eutopic receptors in adrenal tissue&#44; coupled to G protein&#44; is present in most cases of BMAH&#44; but also in some unilateral adrenal tumors&#44; as in one of our cases&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> Alterations have also been described in the cyclic AMP&#47;protein kinase A signaling pathway mediated by phosphodiesterases that are implicated in patient susceptibility to develop adrenal hyperplasia and tumors&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> and in the regulation of cortisol secretion&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">Our case series shows the existence of at least one of the anomalous receptors studied in 80&#37; of the patients analyzed&#46; In 8 of the 15 cases &#40;53&#46;3&#37;&#41;&#44; positivity for more than one receptor was detected&#46; The results obtained are similar to those of other previous series&#46; The most frequently positive test was the posture walking test&#44; as seen in previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;16&#44;17</span></a> On the other hand&#44; the most common pathological test was the metoclopramide test&#44; which is also described as being frequently positive in other series&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> By contrast&#44; in our series the glucagon test was not positive in any of the cases&#44; which agrees with some previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a> However&#44; other studies have shown that some cases of AICS may express anomalous glucagon receptors&#44; stimulating cortisol secretion under fasting conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;20</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">The posture walking test evaluates the potential modulation of steroidogenesis by angiotensin II&#44; vasopressin&#44; catecholamines and atrial natriuretic peptide&#46; Other studies reported in the literature perform specific <span class="elsevierStyleItalic">a posteriori</span> tests to determine which of these receptors is present in the adrenal tissue of the patients&#46; We have not performed these measurements in our center due to their complexity and their possible side effects&#46; We cannot therefore rule out that hypercortisolism was due to the presence of multiple anomalous receptors in the same adrenal tissue&#44; with a common response to the posture walking test&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">The presence of anomalous receptors in adrenal tissue has been demonstrated in different studies by both the response to stimuli and the use of molecular biology techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> It has been suggested that these receptors may be an effective pharmacological target in some patients&#44; as an alternative to surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> In our series&#44; drug treatment with leuprolide acetate &#40;an LHRH agonist&#41; was attempted in a patient with a positive LH and GnRH test&#44; an intramuscular dose of 3&#46;75<span class="elsevierStyleHsp" style=""></span>mg every four weeks being administered for four months&#44; with a partial response&#46; Definitive treatment in the form of bilateral adrenalectomy was therefore finally decided upon&#46; This treatment has been used by other authors with good results&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Other proposed pharmacological treatments include propranolol in catecholamine-dependent AICS&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> or pasireotide or octreotide in GIP-dependent AICS&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Of the 15 patients included in our series&#44; 14 had BMAH&#46; The only patient with unilateral hyperplasia &#40;case 6&#41; did not show positivity with any of the tests&#46; These findings suggest a possible genetic relationship in the pathogenesis of this disorder&#46; Bilateral macronodular adrenal hyperplasia was initially considered a sporadic disease characterized by somatic mutations in adrenal progenitor cells occurring during embryogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> However&#44; familial cases with an autosomal dominant hereditary pattern indicative of a genetic etiology have been reported&#46; In addition&#44; specific anomalous receptors have been described in the members of the same family with BMAH&#44; including vasopressin and 5-HT<span class="elsevierStyleInf">4</span> receptors&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">25&#44;26</span></a> Furthermore&#44; recent studies have shown a relationship between AICS in the context of BMAH and mutations of the <span class="elsevierStyleItalic">ARMC5</span> gene in approximately one-half of the cases&#44; with a dominant autosomal hereditary pattern&#46; This gene is located in the 16p11&#46;2 genomic region&#44; which had already been associated with BMAH in previous studies&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> The role of <span class="elsevierStyleItalic">ARMC5</span> is not fully understood&#44; but it has been suggested that it possibly acts as a tumor suppressor gene inducing apoptosis in adrenal cortical cell lines&#46; Although the relationship between variations in the <span class="elsevierStyleItalic">ARMC5</span> gene and the presence of anomalous receptors has not been fully established&#44; preliminary studies have found that the carriers of mutations of this gene can present aberrant responses to postural tests and to vasopressin and metoclopramide testing&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;27</span></a> It has also been suggested that the <span class="elsevierStyleItalic">ARMC5</span> gene plays a role in the development of other tumors&#44; since mutations of this gene have been described in patients with meningiomas&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;6</span></a> Some authors therefore recommend screening for mutations of the <span class="elsevierStyleItalic">ARMC5</span> gene in patients with BMAH and AICS&#44; as well as in the relatives of carriers&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">Another gene that has been associated with AICS in the context of BMAH is the <span class="elsevierStyleItalic">GNAS1</span> gene&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">28&#44;29</span></a> No familial clustering or aggregation was seen in our series&#44; and no genetic study was therefore made&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; First&#44; the availability of patient information was not complete&#44; since some individuals were referred from other centers&#44; and some data were not adequately collected&#44; particularly as regards the family history&#46; However&#44; the entire study was conducted at our center&#59; we therefore do have the data referring to the stimulation tests&#46; Another important limitation is the fact that not all screening tests were performed in all patients&#46; In some cases&#44; this was due to the clinical characteristics of the patient &#40;seeking to prevent adverse effects&#41;&#44; while in other cases it was due to changes in the center protocols&#44; since these patients were studied over an extensive 14-year period &#40;2002&#8211;2016&#41;&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">Another controversial issue is the cut-off point from which a stimulus test is considered to be positive&#46; In this regard we followed the criteria of Lacroix et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> who established a 25&#8211;49&#37; change as representing a partial response and a &#8805;50&#37; change as indicating a complete response&#46; These criteria have also been subsequently accepted by other authors&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> though a firm consensus is lacking&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">There are many publications in the medical literature related to this disease condition&#44; though most of them are isolated cases or small case series&#46; The generation of new hypotheses with descriptive studies of this kind is quite limited&#44; though our series largely follows the trends seen in previous studies&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">In conclusion&#44; the results of our series are consistent with anomalous receptor expression in subjects with AICS and BMAH&#44; and in line with the observations of other case series&#46; The regulatory mechanisms involved in cortisol secretion in AICS include genetic and molecular factors that are not fully known&#46; The identification of aberrant regulation offers the perspective of possible diagnostic and pharmacological treatment options targeted to hormone receptors coupled to G protein or its ligands&#44; in an attempt to avoid bilateral adrenalectomy&#44; which is the current standard therapy for BMAH&#46; Protocolized study in reference centers and units&#44; as well as the creation of registries&#44; can help in the compilation of information&#44; allowing us to better characterize the expression of anomalous hormone receptors coupled to G protein and to advance in the management of these patients&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0315" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            1 => "Cushing&#39;s syndrome"
            2 => "Nodular adrenal hyperplasia"
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          "palabras" => array:3 [
            0 => "Receptor an&#243;malo"
            1 => "S&#237;ndrome de Cushing"
            2 => "Hiperplasia suprarrenal nodular"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">ACTH-independent Cushing&#39;s syndrome &#40;AICS&#41; accounts for 15&#8211;20&#37; of cases of Cushing&#39;s syndrome&#44; with &#60;1&#37; due to abnormal receptors&#46; Our aim is to study the presence of abnormal receptors in subjects diagnosed with AICS with nodular adrenal hyperplasia in a 14-year period &#40;2002&#8211;2016&#41;&#44; as well as its clinical&#8211;biological and evolutive characteristics&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A multicentre descriptive study of a 15-case series of AICS with nodular adrenal hyperplasia &#40;study period&#58; 2002&#8211;2016&#41;&#46; In these cases&#44; abnormal receptor screening was performed by means of stimulation tests&#44; with a plasma cortisol increase of &#8805;25&#37; from baseline being considered pathologic&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 15 cases&#44; 13 were female&#44; with a mean age at diagnosis of 56&#46;8 years&#46; In 12 of the 15 cases studied&#44; positivity was detected with stimulation tests&#44; and&#44; of them&#44; 25&#37; were positive for the meal test&#44; 58&#46;3&#37; for posture walking test&#44; 33&#46;3&#37; for desmopressin&#59; 25&#37; for terlipressin&#59; 33&#46;3&#37; for GnRH&#59; 25&#37; for LH and 50&#37; for metoclopramide&#46; Regarding treatment&#44; bilateral adrenalectomy was performed in 16&#46;7&#37; and unilateral adrenalectomy in 41&#46;7&#37;&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The rest continue under observation with periodic follow-up &#40;41&#46;7&#37;&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In most of the cases studied with AICS and nodular adrenal hyperplasia &#40;80&#37;&#41;&#44; an abnormal cortisol response is detected due to the presence of abnormal receptors&#46; The test with the highest percentage of positivity was the postural walking test &#40;58&#46;3&#37;&#41;&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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            "identificador" => "abst0015"
            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de Cushing ACTH-independiente &#40;SCAI&#41; supone el 15&#8211;20&#37; de los casos de s&#237;ndrome de Cushing&#44; de los cuales &#60;1&#37; son debidos a receptor an&#243;malo&#46; Nuestro objetivo es estudiar la presencia de receptor an&#243;malo en los sujetos diagnosticados de SCAI con hiperplasia nodular suprarrenal en un per&#237;odo de 14 a&#241;os &#40;2002-2016&#41;&#44; as&#237; como sus caracter&#237;sticas cl&#237;nico-biol&#243;gicas y evolutivas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo multic&#233;ntrico de una serie de 15 casos de SCAI con hiperplasia nodular suprarrenal &#40;per&#237;odo de estudio&#58; 2002-2016&#41;&#46; En ellos se hizo el despistaje de receptor an&#243;malo&#44; mediante pruebas de estimulaci&#243;n&#44; considerando patol&#243;gico un aumento de cortisol plasm&#225;tico &#8805;del 25&#37; respecto al valor basal&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">De los 15 casos&#44; 13 fueron mujeres&#44; con una edad media al diagn&#243;stico de 56&#44;8 a&#241;os&#46; En 12 de los 15 casos estudiados se detect&#243; positividad de las pruebas de estimulaci&#243;n&#46; De ellos&#44; fueron positivos para comida de prueba el 25&#37;&#44; para test postural de deambulaci&#243;n el 58&#44;3&#37;&#44; para desmopresina el 33&#44;3&#37;&#44; para terlipresina el 25&#37;&#44; para GnRH el 33&#44;3&#37;&#44; para LH el 25&#37; y para metoclopramida el 50&#37;&#46; En cuanto al tratamiento&#44; se llev&#243; a cabo suprarrenalectom&#237;a bilateral en el 16&#44;7&#37; y unilateral en el 41&#44;7&#37;&#46; El resto contin&#250;an en observaci&#243;n con revisiones peri&#243;dicas &#40;41&#44;7&#37;&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En la mayor parte de los casos estudiados con SCAI e hiperplasia nodular suprarrenal &#40;80&#37;&#41; se detecta una respuesta de cortisol anormal debida a la presencia de receptor an&#243;malo&#46; La prueba con mayor porcentaje de positividad fue el test postural de deambulaci&#243;n &#40;58&#44;3&#37;&#41;&#46;</p></span>"
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            "titulo" => "Material y m&#233;todos"
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            "titulo" => "Resultados"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ferri J&#44; Perell&#243; E&#44; Lorente RI&#44; Argente C&#44; Rossetti P&#44; Pedro T&#44; et al&#46; Estudio de receptor an&#243;malo suprarrenal en sujetos con s&#237;ndrome de Cushing ACTH-independiente e hiperplasia nodular suprarrenal&#46; Endocrinol Diabetes Nutr&#46; 2020&#59;67&#58;245&#8211;252&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Age at diagnosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">56&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">12&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Basal cortisol &#40;&#956;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">26&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ACTH &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cortisol after suppression with dexamethasone 1<span class="elsevierStyleHsp" style=""></span>mg &#40;&#956;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cortisol after weak suppression &#40;&#956;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urinary cortisol &#40;&#956;g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">18&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1210&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">285&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">335&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2337084.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Test &#40;&#37; positivity&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Basal cortisol &#40;&#956;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Maximum cortisol &#40;&#956;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Change &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Test meal &#40;25&#37;&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posture walking test &#40;58&#46;3&#37;&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">166&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">111&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desmopressin &#40;33&#46;3&#37;&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">145&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">225&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2337082.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cases with positive test results&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatments used&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pathology report&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">GnRHLHACTH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leuprolide acetateBilateral adrenalectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adrenal cortical adenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cure after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posture walking testVasopressinTerlipressin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilateral adrenalectomy &#40;in 2 steps&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adrenal nodular hyperplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cure after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Test mealPosture walking testLHVasopressinMetoclopramide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unilateral adrenalectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adrenal cortical adenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cure after surgeryAsymptomatic for last 6 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posture walking testTerlipressin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilateral adrenalectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adrenal cortical adenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cure after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posture walking testLHTerlipressin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic since diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic since diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Test mealPosture walking testGnRHVasopressin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unilateral adrenalectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adrenal cortical adenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cure after surgeryAsymptomatic for last 4 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vasopressin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unilateral adrenalectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cortical macronodular hyperplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cure after surgeryAsymptomatic for last 3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic since diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metoclopramide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic since diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metoclopramide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unilateral adrenalectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Test mealPosture walking testGnRHMetoclopramide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic since diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic since diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metoclopramide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unilateral adrenalectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adrenal cortical adenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cure after surgeryAsymptomatic for last 2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posture walking testGnRHMetoclopramide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic since diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Summary of the cases studied&#46;</p>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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