Hypoadrenalism in patients with fatigue and rheumatic disease

<!DOCTYPE html> <html lang="en-US" xml:lang="en-US"> <head> <meta charset="utf-8"> <meta name="viewport" content="width=device-width, initial-scale=1.0"> <title> Hypoadrenalism in patients with fatigue and rheumatic disease | Rheumatology Reports </title> <link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/6.0.0/css/all.min.css"> <link href="https://fonts.googleapis.com/css2?family=Raleway:wght@400;600;800&display=swap" rel="stylesheet"> <link rel="icon" href="https://www.pagepress.org/journals/public/journals/5/favicon_en_US.png"> <meta name="generator" content="Open Journal Systems 3.3.0.13">  <script async src="https://www.googletagmanager.com/gtag/js?id=UA-10606404-17"></script> <script> window.dataLayer = window.dataLayer || []; function gtag(){dataLayer.push(arguments);} gtag('js', new Date()); gtag('config', 'UA-10606404-17'); </script> <link rel="schema.DC" href="http://purl.org/dc/elements/1.1/" /> <meta name="DC.Creator.PersonalName" content="Dimitra Methiniti"/> <meta name="DC.Creator.PersonalName" content="Jennifer Hamilton"/> <meta name="DC.Creator.PersonalName" content="Vadivelu Saravanan"/> <meta name="DC.Creator.PersonalName" content="Carol Heycock"/> <meta name="DC.Creator.PersonalName" content="Clive Anthony Kelly"/> <meta name="DC.Date.created" scheme="ISO8601" content="2010-01-04"/> <meta name="DC.Date.dateSubmitted" scheme="ISO8601" content="2009-02-27"/> <meta name="DC.Date.issued" scheme="ISO8601" content="2009-06-03"/> <meta name="DC.Date.modified" scheme="ISO8601" content="2015-09-10"/> <meta name="DC.Description" xml:lang="en" content="Many patients with rheumatic disease complain of fatigue. Clinicians may interpret this as part of the disease process in the absence of anaemia or hypothyroidism, and sometimes respond with the empiric addition of steroids to therapy. The possibility of true hypoadrenalism is only occasionally considered, and little data exists on the frequency with which it coexists with rheumatic disease. Random serum cortisol may be requested by clinicians to help exclude hypoadrenalism as a factor in fatigue. We undertook a survey to assess how frequently this test was of clinical relevance, what was done in patients with low results, and which patients were most likely to have true adrenal failure. All random cortisol assays requested by the members of a rheumatological team over one year were identified and the notes examined retrospectively. The indication for the request, the result, the ultimate clinical diagnosis and all prior diagnoses were recorded. Where further investigations were undertaken, these too were noted. The results were compared to those in an age and gender matched population of patients with general medical conditions (excluding endocrine disorders) for whom cortisol assays had also been requested. Random cortisol was requested by a team of four consultants in 74 patients with a variety of rheumatic disorders over 12 months, usually because of unexplained fatigue. Among the control group of 75 medical patients, the commonest reasons for requesting cortisol assay were fatigue, low sodium and unexplained anaemia. Mean cortisol levels were significantly higher in medical patients (512 nmol/L) than those with rheumatic disease (351 nmol/L) [P=0.04]. The results were low ("/> <meta name="DC.Format" scheme="IMT" content="application/pdf"/> <meta name="DC.Format" scheme="IMT" content="text/html"/> <meta name="DC.Identifier" content="rr.2009.e13"/> <meta name="DC.Identifier.pageNumber" content="e13"/> <meta name="DC.Identifier.DOI" content="10.4081/rr.2009.e13"/> <meta name="DC.Identifier.URI" content="https://www.pagepress.org/journals/rr/article/view/rr.2009.e13"/> <meta name="DC.Language" scheme="ISO639-1" content="en"/> <meta name="DC.Rights" content="Copyright (c) 2010 Dimitra Methiniti, Jennifer Hamilton, Vadivelu Saravanan, Carol Heycock, Clive Anthony Kelly"/> <meta name="DC.Rights" content=""/> <meta name="DC.Source" content="Rheumatology Reports"/> <meta name="DC.Source.ISSN" content="2036-752X"/> <meta name="DC.Source.Issue" content="1"/> <meta name="DC.Source.Volume" content="1"/> <meta name="DC.Source.URI" content="https://www.pagepress.org/journals/rr"/> <meta name="DC.Title" content="Hypoadrenalism in patients with fatigue and rheumatic disease"/> <meta name="DC.Type" content="Text.Serial.Journal"/> <meta name="DC.Type.articleType" content="Featured Articles"/> <meta name="gs_meta_revision" content="1.1"/> <meta name="citation_journal_title" content="Rheumatology Reports"/> <meta name="citation_journal_abbrev" content="Rheumatol Rep"/> <meta name="citation_issn" content="2036-752X"/> <meta name="citation_author" content="Dimitra Methiniti"/> <meta name="citation_author" content="Jennifer Hamilton"/> <meta name="citation_author" content="Vadivelu Saravanan"/> <meta name="citation_author" content="Carol Heycock"/> <meta name="citation_author" content="Clive Anthony Kelly"/> <meta name="citation_author_institution" content="Consultant Physician"/> <meta name="citation_title" content="Hypoadrenalism in patients with fatigue and rheumatic disease"/> <meta name="citation_language" content="en"/> <meta name="citation_date" content="2009"/> <meta name="citation_volume" content="1"/> <meta name="citation_issue" content="1"/> <meta name="citation_firstpage" content="e13"/> <meta name="citation_lastpage" content="e13"/> <meta name="citation_doi" content="10.4081/rr.2009.e13"/> <meta name="citation_abstract_html_url" content="https://www.pagepress.org/journals/rr/article/view/rr.2009.e13"/> <meta name="citation_pdf_url" content="https://www.pagepress.org/journals/rr/article/download/rr.2009.e13/1709"/> <meta name="citation_fulltext_html_url" content="https://www.pagepress.org/journals/rr/article/view/rr.2009.e13/1730"/> <link rel="alternate" type="application/atom+xml" href="https://www.pagepress.org/journals/rr/gateway/plugin/AnnouncementFeedGatewayPlugin/atom"> <link rel="alternate" type="application/rdf+xml" href="https://www.pagepress.org/journals/rr/gateway/plugin/AnnouncementFeedGatewayPlugin/rss"> <link rel="alternate" type="application/rss+xml" href="https://www.pagepress.org/journals/rr/gateway/plugin/AnnouncementFeedGatewayPlugin/rss2"> <link rel="alternate" type="application/atom+xml" href="https://www.pagepress.org/journals/rr/gateway/plugin/WebFeedGatewayPlugin/atom"> <link rel="alternate" type="application/rdf+xml" href="https://www.pagepress.org/journals/rr/gateway/plugin/WebFeedGatewayPlugin/rss"> <link rel="alternate" type="application/rss+xml" href="https://www.pagepress.org/journals/rr/gateway/plugin/WebFeedGatewayPlugin/rss2"> <link rel="stylesheet" href="https://www.pagepress.org/journals/rr/$$$call$$$/page/page/css?name=stylesheet" type="text/css" /><link rel="stylesheet" href="https://www.pagepress.org/journals/rr/$$$call$$$/page/page/css?name=font" type="text/css" /><link rel="stylesheet" href="https://www.pagepress.org/journals/lib/pkp/styles/fontawesome/fontawesome.css?v=3.3.0.13" type="text/css" /><link rel="stylesheet" href="https://www.pagepress.org/journals/plugins/themes/defaultManuscript/styles/custom_style.css?v=3.3.0.13" type="text/css" /><link rel="stylesheet" href="https://www.pagepress.org/journals/plugins/generic/citations/css/citations.css?v=3.3.0.13" type="text/css" /><link rel="stylesheet" href="https://www.pagepress.org/journals/plugins/generic/orcidProfile/css/orcidProfile.css?v=3.3.0.13" type="text/css" /> </head> <body class="pkp_page_article pkp_op_view has_site_logo" dir="ltr"> <div class="pkp_structure_page">  <header class="pkp_structure_head" id="headerNavigationContainer" role="banner"> <nav class="cmp_skip_to_content" aria-label="Jump to content links"> <a href="#pkp_content_main">Skip to main content</a> <a href="#siteNav">Skip to main navigation menu</a> <a href="#pkp_content_footer">Skip to site footer</a> </nav> <div class="pkp_head_wrapper"> <div id="container_logo_login"> <div class="content_logo_login"> <div class="logo_PP"> <a href="http://www.pagepress.org" target="_blank"> <img src="https://www.pagepress.org/journals/plugins/themes/defaultManuscript/styles/images/pagepress_logo_menu_bianco.png"/> </a> </div>  </div>  </div>  <div class="pkp_site_name_wrapper"> <button class="pkp_site_nav_toggle"> <span>Open Menu</span> </button> <div class="pkp_site_name"> <a href=" https://www.pagepress.org/journals/rr/index " class="is_img"> <img src="https://www.pagepress.org/journals/public/journals/5/pageHeaderLogoImage_en_US.png" width="374" height="134" /> </a>  </div> </div> <nav class="pkp_site_nav_menu" aria-label="Site Navigation"> <a id="siteNav"></a> <div class="pkp_navigation_primary_row"> <div class="pkp_navigation_primary_wrapper"> <ul id="navigationPrimary" class="pkp_navigation_primary pkp_nav_list"> <li class=""> <a href="https://www.pagepress.org/journals/rr/about"> About the Journal </a> </li> <li class=""> <a href="https://www.pagepress.org/journals/rr/ethics"> Publication Ethics </a> </li> <li class=""> <a href="https://www.pagepress.org/journals/index.php/rr/board"> Editorial Board </a> </li> <li class=""> <a href="https://www.pagepress.org/journals/rr/issue/current"> Current Issue </a> </li> <li class=""> <a href="https://www.pagepress.org/journals/rr/issue/archive"> Archives </a> </li> <li class=""> <a href="https://www.pagepress.org/journals/rr/announcement"> Announcements </a> </li> </ul>  </div> </div> <div class="pkp_navigation_user_wrapper" id="navigationUserWrapper"> <ul id="navigationUser" class="pkp_navigation_user pkp_nav_list"> <li class="profile"> <a href="https://www.pagepress.org/journals/rr/search/search"> <i class="fas fa-search"></i> Search </a> </li> <li class="profile"> <a href="https://www.pagepress.org/journals/rr/about/contact"> <i class="far fa-address-book"></i> Contacts </a> </li> <li class="profile"> <a href="https://www.pagepress.org/journals/rr/user/register"> <i class="fas fa-edit"></i> Register </a> </li> <li class="profile"> <a href="https://www.pagepress.org/journals/rr/login"> <i class="fas fa-sign-in-alt"></i> Login </a> </li> </ul> </div> </nav> </div> </header> <div class="pkp_structure_content has_sidebar"> <div class="pkp_structure_main" role="main"> <a id="pkp_content_main"></a> <div class="page page_article"> <nav class="cmp_breadcrumbs" role="navigation" aria-label="You are here:"> <ol> <li> <a href="https://www.pagepress.org/journals/rr/index"> Home </a> <span class="separator">/</span> </li> <li> <a href="https://www.pagepress.org/journals/rr/issue/archive"> Archives </a> <span class="separator">/</span> </li> <li> <a href="https://www.pagepress.org/journals/rr/issue/view/56"> Vol. 1 No. 1 (2009) </a> <span class="separator">/</span> </li> <li class="current" aria-current="page"> <span aria-current="page"> Featured Articles </span> </li> </ol> </nav> <article class="obj_article_details"> <h1 class="page_title"> Hypoadrenalism in patients with fatigue and rheumatic disease </h1> <br /> <div id="content_doi_crossmar"> <div class="doi_content"> <section class="item doi"> <span class="value"> <a href="https://doi.org/10.4081/rr.2009.e13"> <img src="https://www.pagepress.org/journals/plugins/themes/defaultManuscript/styles/images/DOI_logo.png"/> https://doi.org/10.4081/rr.2009.e13 </a> </span> </section> </div> <div class="scite-badge" data-doi="10.4081/rr.2009.e13" data-layout="horizontal" data-tooltip-placement="bottom" data-show-zero="true" data-small="true" data-show-labels="false"></div><script async type="application/javascript" src="https://cdn.scite.ai/badge/scite-badge-latest.min.js"></script> </div> <div class="item cover_image"> <div class="sub_item"> <img src="https://www.pagepress.org/journals/public/journals/5/cover_article_75_en_US.jpg" alt=""> </div> </div> <div class="item galleys"> <div id="container_galleys_flex"> <a class="obj_galley_link pdf" href="https://www.pagepress.org/journals/rr/article/view/rr.2009.e13/1709"> PDF </a> <a class="obj_galley_link file" href="https://www.pagepress.org/journals/rr/article/view/rr.2009.e13/1730"> HTML </a> </div> </div> <div class="item issue"> <section class="issue" title="Issue"> <div class="content"> <a href="https://www.pagepress.org/journals/rr/issue/view/56"><i class="fa-solid fa-book"></i> Vol. 1 No. 1 (2009)</a> </div> </section>  <section class="categories" title="Categories"> <ul class="categories"> </ul> </section> </div> <div class="item published" title="Publication"> <section class="sub_item"> <div class="content"> <div class="value"> <b>Submitted:</b> 27 February 2009<br /> <b>Accepted:</b> 3 December 2009  </div> <b>Published:</b> <span> 4 January 2010</span> </div> </section> </div>    <div class="item published"> <section class="stats" title="Statistics"> <div class="content"> <div id="container_stats"> <div class="content_stats"> <i class="fa-solid fa-eye"></i> Abstract Views: <span>1181</span> </div> <div class="content_stats"> <i class="fa-solid fa-download"></i> PDF: <span>515</span><br /> <i class="fa-solid fa-eye"></i> HTML: <span>6329</span><br /> </div> </div> </div> </section> </div>     <section class="panel panel-default dimension_badge" title="Dimensions"> <div class="content"> <span class="__dimensions_badge_embed__" data-doi="10.4081/rr.2009.e13" data-legend="always" data-style="small_circle"></span><script async src="https://badge.dimensions.ai/badge.js" charset="utf-8"></script> </div> </section>  <section class="panel panel-default" title="PlumX Metrics"> <div class="content"> <a href="https://plu.mx/plum/a/?doi=10.4081/rr.2009.e13" data-orientation="vertical" class="plumx-summary" data-site="plum" data-hide-when-empty="true"></a> <script type="text/javascript" src="//cdn.plu.mx/widget-summary.js"></script> </div> </section> <div class="discl_content_col_dx"> <b><i class="fa-solid fa-circle-info"></i> Publisher's note</b><br /> All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. </div>  <div class="row"> <div class="main_entry"> <section class="item authors"> <h2 class="pkp_screen_reader">Authors</h2> <ul class="authors"> <li> <span class="name"> <a href="https://www.pagepress.org/journals/rr/search?authors=Dimitra Methiniti"><i class="fa fa-fw fa-user"></i> Dimitra Methiniti</a> </span> </li> <li> <span class="name"> <a href="https://www.pagepress.org/journals/rr/search?authors=Jennifer Hamilton"><i class="fa fa-fw fa-user"></i> Jennifer Hamilton</a> </span> </li> <li> <span class="name"> <a href="https://www.pagepress.org/journals/rr/search?authors=Vadivelu Saravanan"><i class="fa fa-fw fa-user"></i> Vadivelu Saravanan</a> </span> </li> <li> <span class="name"> <a href="https://www.pagepress.org/journals/rr/search?authors=Carol Heycock"><i class="fa fa-fw fa-user"></i> Carol Heycock</a> </span> </li> <li> <span class="name"> <a href="https://www.pagepress.org/journals/rr/search?authors=Clive Anthony Kelly"><i class="fa fa-fw fa-user"></i> Clive Anthony Kelly</a> </span> <div class="primary_contact"> <i class="fa fa-fw fa-envelope-o"> </i><a href="mailto:clive.kelly@ghnt.nhs.uk" >clive.kelly@ghnt.nhs.uk</a> </div> <span class="affiliation"> <i class="fa fa-fw fa-university" aria-hidden="true"> </i>Consultant Physician, United Kingdom. </span> </li> </ul> </section>  <div class="tab"> <button class="tablinks" onclick="openCity(event, 'abstract')" id="defaultOpen"><i class="fa-solid fa-folder-open"></i> Abstract</button> <button class="tablinks" onclick="openCity(event, 'subjects')"> <i class="fa-solid fa-check-double"></i> Information </button>  <button class="tablinks" onclick="openCity(event, 'biographies')"> <i class="fa-solid fa-list"></i> Author Biographies </button> <button class="tablinks" onclick="openCity(event, 'howToCite_license')"> <i class="fa-solid fa-link"></i> Citation / <i class="fa-solid fa-copyright"></i> Copyright </button> <button class="tablinks" onclick="openCity(event, 'metrics')"> <i class="fa-solid fa-chart-column"></i> Metrics </button> </div>  <div id="abstract" class="tabcontent"> <section class="item abstract"> Many patients with rheumatic disease complain of fatigue. Clinicians may interpret this as part of the disease process in the absence of anaemia or hypothyroidism, and sometimes respond with the empiric addition of steroids to therapy. The possibility of true hypoadrenalism is only occasionally considered, and little data exists on the frequency with which it coexists with rheumatic disease. Random serum cortisol may be requested by clinicians to help exclude hypoadrenalism as a factor in fatigue. We undertook a survey to assess how frequently this test was of clinical relevance, what was done in patients with low results, and which patients were most likely to have true adrenal failure. All random cortisol assays requested by the members of a rheumatological team over one year were identified and the notes examined retrospectively. The indication for the request, the result, the ultimate clinical diagnosis and all prior diagnoses were recorded. Where further investigations were undertaken, these too were noted. The results were compared to those in an age and gender matched population of patients with general medical conditions (excluding endocrine disorders) for whom cortisol assays had also been requested. Random cortisol was requested by a team of four consultants in 74 patients with a variety of rheumatic disorders over 12 months, usually because of unexplained fatigue. Among the control group of 75 medical patients, the commonest reasons for requesting cortisol assay were fatigue, low sodium and unexplained anaemia. Mean cortisol levels were significantly higher in medical patients (512 nmol/L) than those with rheumatic disease (351 nmol/L) [P=0.04]. The results were low (<200 nmol/L) in 14 rheumatic patients and 7 medical patients. Among these 21 individuals, synacthen tests were performed in 16 and were indicative of hypoadrenalism in 6 cases. Further investigations revealed primary hypoadrenalism in 3 patients, with tertiary adrenal suppression from oral steroids in three others. All six of these patients had underlying rheumatic disorders, usually RA (3) or systemic lupus erythematosus (SLE) (2). None of the medical patients had an abnormal synacthen test. Fatigue in patients with rheumatic disease may be a presenting feature of hypoadrenalism. Although adrenal failure is rare in medical patients with anaemia, hyponatraemia or fatigue, patients with rheumatic disease and unexplained fatigue merit a random cortisol. If this is low, synacthen testing may be appropriate. Steroids should not be commenced empirically in such patients until hypoadrenalism has been excluded, as a significant minority will have genuine primary adrenal failure, usually due to autoimmune disease. </section> <br /> </div> <div id="citations" class="tabcontent"> <section class="item references"> <div class="value"> </div> </section> </div> <div id="biographies" class="tabcontent"> <section class="item author_bios"> <div class="sub_item"> <div class="label"> Dimitra Methiniti </div> <div class="value" style="margin-left:1em;"> Medical Student </div> </div> <div class="sub_item"> <div class="label"> Jennifer Hamilton </div> <div class="value" style="margin-left:1em;"> Consultant </div> </div> <div class="sub_item"> <div class="label"> Vadivelu Saravanan </div> <div class="value" style="margin-left:1em;"> Consultant </div> </div> <div class="sub_item"> <div class="label"> Carol Heycock </div> <div class="value" style="margin-left:1em;"> Consultant </div> </div> <div class="sub_item"> <div class="label"> Clive Anthony Kelly, <span class="affiliation">Consultant Physician</span> </div> <div class="value" style="margin-left:1em;"> Consultant Rheumatologist and Head of Department </div> </div> </section> </div> <div id="subjects" class="tabcontent"> <div class="content"> <h3 class="label">Ethics Approval</h3> </div> <br /> <div class="content"> <h3 class="label">Supporting Agencies</h3> Nil </div> <br /> </div>  <div id="howToCite_license" class="tabcontent"> <div class="citation"> <section class="sub_item citation_display"> <div class="content"> <div id="citationOutput" role="region" aria-live="polite"><div class="csl-bib-body"> <div class="csl-entry">Methiniti, D., Hamilton, J., Saravanan, V., Heycock, C., & Kelly, C. A. (2010). Hypoadrenalism in patients with fatigue and rheumatic disease. <i>Rheumatology Reports</i>, <i>1</i>(1), e13. https://doi.org/10.4081/rr.2009.e13</div> </div></div> <div class="citation_formats"> <button class="cmp_button citation_formats_button" aria-controls="cslCitationFormats" aria-expanded="false" data-csl-dropdown="true"> More Citation Formats </button> <div id="cslCitationFormats" class="citation_formats_list" aria-hidden="true"> <ul class="citation_formats_styles"> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/acm-sig-proceedings?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/acm-sig-proceedings?submissionId=75&publicationId=40&return=json" > ACM </a> </li> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/acs-nano?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/acs-nano?submissionId=75&publicationId=40&return=json" > ACS </a> </li> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/apa?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/apa?submissionId=75&publicationId=40&return=json" > APA </a> </li> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/associacao-brasileira-de-normas-tecnicas?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/associacao-brasileira-de-normas-tecnicas?submissionId=75&publicationId=40&return=json" > ABNT </a> </li> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/chicago-author-date?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/chicago-author-date?submissionId=75&publicationId=40&return=json" > Chicago </a> </li> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/harvard-cite-them-right?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/harvard-cite-them-right?submissionId=75&publicationId=40&return=json" > Harvard </a> </li> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/ieee?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/ieee?submissionId=75&publicationId=40&return=json" > IEEE </a> </li> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/modern-language-association?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/modern-language-association?submissionId=75&publicationId=40&return=json" > MLA </a> </li> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/turabian-fullnote-bibliography?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/turabian-fullnote-bibliography?submissionId=75&publicationId=40&return=json" > Turabian </a> </li> <li> <a aria-controls="citationOutput" href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/vancouver?submissionId=75&publicationId=40" data-load-citation data-json-href="https://www.pagepress.org/journals/rr/citationstylelanguage/get/vancouver?submissionId=75&publicationId=40&return=json" > Vancouver </a> </li> </ul> <div class="label">Download Citation</div> <ul class="citation_formats_styles"> <li> <a href="https://www.pagepress.org/journals/rr/citationstylelanguage/download/ris?submissionId=75&publicationId=40"> <span class="fa fa-download"></span> Endnote/Zotero/Mendeley (RIS) </a> </li> <li> <a href="https://www.pagepress.org/journals/rr/citationstylelanguage/download/bibtex?submissionId=75&publicationId=40"> <span class="fa fa-download"></span> BibTeX </a> </li> </ul> </div> </div> </div> </section> </div> <div class="item copyright"> <div class="content"> <p><strong>PAGEPress</strong> has chosen to apply the <a href="http://creativecommons.org/licenses/by-nc/4.0/" target="_blank" rel="noopener"><strong>Creative Commons Attribution NonCommercial 4.0 International License</strong></a> (CC BY-NC 4.0) to all manuscripts to be published.</p> </div> </div> </div> <div id="metrics" class="tabcontent"> <div id="container_other_info"> <div class="grafico_downloads"> <h3 class="label">Downloads</h3> <div class="item downloads_chart">  <div class="value"> <canvas class="usageStatsGraph" data-object-type="Submission" data-object-id="75"></canvas> <div class="usageStatsUnavailable" data-object-type="Submission" data-object-id="75"> Download data is not yet available. </div> </div> </div> </div>  <div class="cross_scopus_badge"> <h3 class="label">Citations</h3> <div class="item citations-container" data-image-path="https://www.pagepress.org/journals/plugins/generic/citations/images/" data-citations-url="https://www.pagepress.org/journals/rr/citations/get?citationsId=10.4081%2Frr.2009.e13&citationsShowList=1&citationsProvider=all" data-citations-provider="all" data-citations-total="1" data-citations-list="1" data-show-google="1" data-show-pmc="0"> <div id="citations-loader"></div> <div class="citations-count"> <div class="citations-count-crossref"> <img class="img-fluid" src="https://www.pagepress.org/journals/plugins/generic/citations/images/crossref.png" alt="Crossref"/> <div class="badge_total"></div> </div> <div class="citations-count-scopus"> <img src="https://www.pagepress.org/journals/plugins/generic/citations/images/scopus.png" alt="Scopus"/> <br/> <span class="badge_total"></span> </div> <div class="citations-count-google"> <a href="https://scholar.google.com/scholar?q=10.4081/rr.2009.e13" target="_blank" rel="noreferrer"> <img src="https://www.pagepress.org/journals/plugins/generic/citations/images/scholar.png" alt="Google Scholar"/> </a> </div> <div class="citations-count-pmc"> <a href="http://europepmc.org/search?scope=fulltext&query=(REF:10.4081/rr.2009.e13)" target="_blank" rel="noreferrer"> <img src="https://www.pagepress.org/journals/plugins/generic/citations/images/pmc.png" alt="Europe PMC"/> <br/> <span class="badge_total"></span> </a> </div> </div> <div class="citations-list"></div> </div> <link rel="stylesheet" type="text/css" href="https://www.pagepress.org/journals/plugins/generic/shariff/shariff-3.2.1/shariff.complete.css"> <link rel="stylesheet" type="text/css" href=""> <div><div> <div class="shariff item" data-lang="en" data-services="[twitter,facebook,linkedin,whatsapp,telegram,mail]" data-mail-url="mailto:" data-mail-body={url} data-backend-url="https://www.pagepress.org/journals/shariff-backend" data-theme="standard" data-orientation="horizontal" data-url="https://www.pagepress.org/journals/rr/article/view/rr.2009.e13"> </div> </div> </div> <script src="https://www.pagepress.org/journals/plugins/generic/shariff/shariff-3.2.1/shariff.complete.js"></script> </div> </div> </div> <br /> </div> </div> </article> </div> </div> <div class="pkp_structure_sidebar left" role="complementary" aria-label="Sidebar">  <div class="pkp_block block_custom" id="customblock-authors"> <h2 class="title pkp_screen_reader">authors</h2> <div class="content"> <div class="title"><strong>FOR AUTHORS</strong></div> <ul> <li><a href="/journals/index.php/rr/guide">Guide for Authors</a></li> <li><a href="/journals/index.php/rr/benefits">Benefits for Authors</a></li> <li><a href="https://www.pagepress.org/public/How_to_write_a_scientific_paper.pdf" target="_blank" rel="noopener">How to write a Scientific paper</a></li> <li><a href="https://www.pagepress.org/public/How_to_write_a_review_article.pdf" target="_blank" rel="noopener">How to write a Review article</a></li> </ul> </div> </div> <div class="pkp_block block_custom" id="customblock-reviewers"> <h2 class="title pkp_screen_reader">reviewers</h2> <div class="content"> <div class="title"><strong>FOR REVIEWERS</strong></div> <ul> <li><a href="/journals/index.php/rr/benefit_r">Benefits for Reviewers</a></li> <li><a href="https://www.pagepress.org/public/Peer_review_at_its_best.pdf" target="_blank" rel="noopener">How to Review</a></li> <li><a href="/journals/index.php/rr/revs">Thanks to Reviewers</a></li> </ul> </div> </div> <div class="pkp_block block_custom" id="customblock-indexing"> <h2 class="title pkp_screen_reader">INDEXING</h2> <div class="content"> <div class="title"><strong>INDEXING</strong></div> <ul> <li><a href="https://www.scopus.com/sourceid/19700175134" target="_blank" rel="noopener">Scopus</a></li> <li><a href="http://wokinfo.com/products_tools/multidisciplinary/esci/" target="_blank" rel="noopener">ESCI</a></li> </ul> </div> </div> <div class="pkp_block block_developed_by"> <div class="content"> <span class="title">Most read last month</span> <ul class="most_read"> <li class="most_read_article"> <div class="most_read_article_title"><a href="https://www.pagepress.org/journals/rr/article/view/1504">Rotator cuff disease – basics of diagnosis and treatment</a></div> <div class="most_read_article_journal"><span class="fa fa-eye"></span> 28</div> </li> <li class="most_read_article"> <div class="most_read_article_title"><a href="https://www.pagepress.org/journals/rr/article/view/251">A case of relapsing polychondritis mimicking Ludwig’s angina</a></div> <div class="most_read_article_journal"><span class="fa fa-eye"></span> 22</div> </li> <li class="most_read_article"> <div class="most_read_article_title"><a href="https://www.pagepress.org/journals/rr/article/view/591">Vitiligo, morphea and Sjögren’s syndrome: a case study</a></div> <div class="most_read_article_journal"><span class="fa fa-eye"></span> 19</div> </li> <li class="most_read_article"> <div class="most_read_article_title"><a href="https://www.pagepress.org/journals/rr/article/view/75">Hypoadrenalism in patients with fatigue and rheumatic disease</a></div> <div class="most_read_article_journal"><span class="fa fa-eye"></span> 18</div> </li> <li class="most_read_article"> <div class="most_read_article_title"><a href="https://www.pagepress.org/journals/rr/article/view/5127">Tumor necrosis factor-alpha inhibitor combined with methotrexate for ankylosing spondylitis: a systematic review and meta-analysis</a></div> <div class="most_read_article_journal"><span class="fa fa-eye"></span> 16</div> </li> </ul> </div> </div> <div class="pkp_block block_Keywordcloud"> <h2 class="title">Keywords</h2> <div class="content" id='wordcloud'></div> <script> function randomColor() { var cores = ['#1f77b4', '#ff7f0e', '#2ca02c', '#d62728', '#9467bd', '#8c564b', '#e377c2', '#7f7f7f', '#bcbd22', '#17becf']; return cores[Math.floor(Math.random()*cores.length)]; } document.addEventListener("DOMContentLoaded", function() { var keywords = [{"text":"cryopyrin associated periodic syndrome","size":1},{"text":"multiple myeloma","size":1},{"text":"information use","size":1},{"text":"coping","size":1},{"text":"quality of life","size":1},{"text":"information needs","size":1},{"text":"internet","size":1},{"text":"survey","size":1},{"text":"quality of life.","size":1},{"text":"pulmonary aneurysms","size":1},{"text":"reactive arthritis","size":1},{"text":"clostridium difficile colitis","size":1},{"text":"recurrence","size":1},{"text":"cervical spinal cord compression","size":1},{"text":"chronic pain","size":1},{"text":"magnetic resonance imaging","size":1},{"text":"hyaluronic acid","size":1},{"text":"scleroderma","size":1},{"text":"antibodies","size":1},{"text":"antineutrophil cytoplasmic","size":1},{"text":"environment","size":1},{"text":"knee pain","size":1},{"text":"mechanical pain","size":1},{"text":"inflammatory pain","size":1},{"text":"qualitative study","size":1},{"text":"vas","size":1},{"text":"pain grading","size":1},{"text":"women\u2019s health","size":1},{"text":"fibromyalgia","size":1},{"text":"health seeking behaviour","size":1},{"text":"knee osteoarthritis","size":1},{"text":"thrombolytic therapy","size":1},{"text":"left ventricular systolic function","size":1},{"text":"left ventricular diastolic function","size":1},{"text":"tissue doppler echocardiography","size":1},{"text":"henoch-scho\u0308nlein purpura","size":1},{"text":"wegener\u2019s granulomatosis","size":1},{"text":"uric acid","size":1},{"text":"carotid artery","size":1},{"text":"ultrasound","size":1},{"text":"adaptation","size":1},{"text":"disability","size":1},{"text":"pain","size":1},{"text":"rheumatology.","size":1},{"text":"rehabilitation","size":1},{"text":"self-efficacy","size":1},{"text":"self-management","size":1},{"text":"knee","size":1},{"text":"radiography","size":1},{"text":"progression","size":1}]; var totalWeight = 0; var width = 300; var height = 200; var transitionDuration = 200; var length_keywords = keywords.length; var layout = d3.layout.cloud(); layout.size([width, height]) .words(keywords) .fontSize(function(d) { return fontSize(+d.size); }) .on('end', draw); var svg = d3.select("#wordcloud").append("svg") .attr("viewBox", "0 0 " + width + " " + height) .attr("width", '100%'); function update() { var words = layout.words(); fontSize = d3.scaleLinear().range([16, 34]); if (words.length) { fontSize.domain([+words[words.length - 1].size || 1, +words[0].size]); } } keywords.forEach(function(item,index){totalWeight += item.size;}); update(); function draw(words, bounds) { var w = layout.size()[0], h = layout.size()[1]; scaling = bounds ? Math.min( w / Math.abs(bounds[1].x - w / 2), w / Math.abs(bounds[0].x - w / 2), h / Math.abs(bounds[1].y - h / 2), h / Math.abs(bounds[0].y - h / 2), ) / 2 : 1; svg .append("g") .attr( "transform", "translate(" + [w >> 1, h >> 1] + ")scale(" + scaling + ")", ) .selectAll("text") .data(words) .enter().append("text") .style("font-size", function(d) { return d.size + "px"; }) .style("font-family", 'serif') .style("fill", randomColor) .style('cursor', 'pointer') .style('opacity', 0.7) .attr('class', 'keyword') .attr("text-anchor", "middle") .attr("transform", function(d) { return "translate(" + [d.x, d.y] + ")rotate(" + d.rotate + ")"; }) .text(function(d) { return d.text; }) .on("click", function(d, i){ window.location = "https://www.pagepress.org/journals/rr/search?query=QUERY_SLUG".replace(/QUERY_SLUG/, encodeURIComponent(''+d.text+'')); }) .on("mouseover", function(d, i) { d3.select(this).transition() .duration(transitionDuration) .style('font-size',function(d) { return (d.size + 3) + "px"; }) .style('opacity', 1); }) .on("mouseout", function(d, i) { d3.select(this).transition() .duration(transitionDuration) .style('font-size',function(d) { return d.size + "px"; }) .style('opacity', 0.7); }) .on('resize', function() { update() }); } layout.start(); }); </script> </div> </div> </div> <div class="pkp_structure_footer_wrapper" role="contentinfo"> <a id="pkp_content_footer"></a> <footer class="footer"> <div class="container"> <div class="row"> <div class="footer-col">  <div class="pkp_footer_info"><div class="nome_rivista_footer"><strong>Rheumatology Reports</strong></div> <p><em>is an Open Access, peer-reviewed journal published by <a href="http://www.pagepress.org" target="_blank" rel="noopener">PAGEPress</a><sup>®</sup>, Pavia, Italy. All credits and honors to <a href="http://pkp.sfu.ca/">PKP</a> for their <a href="http://pkp.sfu.ca/?q=ojs">OJS</a>.</em></p> pISSN: 2036-7511<br />eISSN: 2036-752X </div> </div> <div class="footer-col"> <h4>About</h4> <ul> <li><a href="https://www.pagepress.org/journals/rr/about">About the Journal</a></li> <li><a href="https://www.pagepress.org/journals/rr/board">Editorial Board</a></li>  </ul> </div> <div class="footer-col"> <h4>Info submission</h4> <ul> <li><a href="https://www.pagepress.org/journals/rr/submissions">Submissions</a></li> <li><a href="https://www.pagepress.org/journals/rr/guide">Guidelines for Authors</a></li> </ul> </div> <div class="footer-col"> <h4>Our app is free for anyone!</h4> <div class="social-links"> <a href="https://wa.me/393928266776" target="_blank"><i class="fab fa-whatsapp"></i></a>  <a href="https://apps.apple.com/sn/app/pagepress/id1606895363" target="_blank"><i class="fa-brands fa-apple"></i></a> <a href="https://appgallery.huawei.com/#/app/C105426991" target="_blank"><img src="https://www.pagepress.org/journals/plugins/themes/defaultManuscript/styles/images/huawei-white.png"/></a>  </div> </div> </div> </div> </footer> </div> </div> <script src="https://www.pagepress.org/journals/lib/pkp/lib/vendor/components/jquery/jquery.min.js?v=3.3.0.13" type="text/javascript"></script><script src="https://www.pagepress.org/journals/lib/pkp/lib/vendor/components/jqueryui/jquery-ui.min.js?v=3.3.0.13" type="text/javascript"></script><script src="https://www.pagepress.org/journals/plugins/themes/default/js/lib/popper/popper.js?v=3.3.0.13" type="text/javascript"></script><script src="https://www.pagepress.org/journals/plugins/themes/default/js/lib/bootstrap/util.js?v=3.3.0.13" type="text/javascript"></script><script src="https://www.pagepress.org/journals/plugins/themes/default/js/lib/bootstrap/dropdown.js?v=3.3.0.13" type="text/javascript"></script><script src="https://www.pagepress.org/journals/plugins/themes/default/js/main.js?v=3.3.0.13" type="text/javascript"></script><script src="https://www.pagepress.org/journals/plugins/themes/defaultManuscript/js/noble.js?v=3.3.0.13" type="text/javascript"></script><script src="https://www.pagepress.org/journals/plugins/generic/citationStyleLanguage/js/articleCitation.js?v=3.3.0.13" type="text/javascript"></script><script src="https://www.pagepress.org/journals/plugins/generic/citations/js/citations.js?v=3.3.0.13" type="text/javascript"></script><script src="https://d3js.org/d3.v4.js?v=3.3.0.13" type="text/javascript"></script><script src="https://cdn.jsdelivr.net/gh/holtzy/D3-graph-gallery@master/LIB/d3.layout.cloud.js?v=3.3.0.13" type="text/javascript"></script><script type="text/javascript">var pkpUsageStats = pkpUsageStats || {};pkpUsageStats.data = pkpUsageStats.data || {};pkpUsageStats.data.Submission = pkpUsageStats.data.Submission || {};pkpUsageStats.data.Submission[75] = {"data":{"2013":{"1":0,"2":0,"3":0,"4":0,"5":0,"6":0,"7":0,"8":0,"9":0,"10":0,"11":0,"12":19},"2014":{"1":66,"2":62,"3":109,"4":106,"5":75,"6":64,"7":85,"8":93,"9":78,"10":91,"11":133,"12":97},"2015":{"1":98,"2":94,"3":102,"4":104,"5":101,"6":100,"7":78,"8":65,"9":96,"10":93,"11":136,"12":125},"2016":{"1":133,"2":301,"3":143,"4":182,"5":271,"6":164,"7":248,"8":284,"9":222,"10":47,"11":66,"12":4},"2017":{"1":147,"2":61,"3":104,"4":60,"5":64,"6":81,"7":36,"8":65,"9":82,"10":60,"11":73,"12":20},"2018":{"1":24,"2":23,"3":29,"4":19,"5":19,"6":36,"7":25,"8":38,"9":35,"10":23,"11":21,"12":21},"2019":{"1":19,"2":8,"3":13,"4":17,"5":17,"6":18,"7":25,"8":28,"9":26,"10":24,"11":29,"12":23},"2020":{"1":24,"2":23,"3":38,"4":33,"5":45,"6":31,"7":22,"8":30,"9":14,"10":20,"11":19,"12":17},"2021":{"1":17,"2":17,"3":14,"4":16,"5":8,"6":12,"7":15,"8":23,"9":29,"10":31,"11":28,"12":17},"2022":{"1":16,"2":7,"3":23,"4":12,"5":18,"6":11,"7":16,"8":8,"9":9,"10":10,"11":8,"12":12},"2023":{"1":15,"2":13,"3":14,"4":19,"5":30,"6":16,"7":20,"8":9,"9":20,"10":23,"11":18,"12":9},"2024":{"1":16,"2":27,"3":21,"4":12,"5":32,"6":10,"7":9,"8":19,"9":15,"10":18,"11":18,"12":0}},"label":"All Downloads","color":"79,181,217","total":6844};</script><script src="https://cdnjs.cloudflare.com/ajax/libs/Chart.js/2.0.1/Chart.js?v=3.3.0.13" type="text/javascript"></script><script type="text/javascript">var pkpUsageStats = pkpUsageStats || {};pkpUsageStats.locale = pkpUsageStats.locale || {};pkpUsageStats.locale.months = ["Jan","Feb","Mar","Apr","May","Jun","Jul","Aug","Sep","Oct","Nov","Dec"];pkpUsageStats.config = pkpUsageStats.config || {};pkpUsageStats.config.chartType = "bar";</script><script src="https://www.pagepress.org/journals/plugins/generic/usageStats/js/UsageStatsFrontendHandler.js?v=3.3.0.13" type="text/javascript"></script><script type="text/javascript"> (function (w, d, s, l, i) { w[l] = w[l] || []; var f = d.getElementsByTagName(s)[0], j = d.createElement(s), dl = l != 'dataLayer' ? '&l=' + l : ''; j.async = true; j.src = 'https://www.googletagmanager.com/gtag/js?id=' + i + dl; f.parentNode.insertBefore(j, f); function gtag(){dataLayer.push(arguments)}; gtag('js', new Date()); gtag('config', i); }) (window, document, 'script', 'dataLayer', 'UA-10606404-17'); </script> <span class="Z3988" title="ctx_ver=Z39.88-2004&rft_id=https%3A%2F%2Fwww.pagepress.org%2Fjournals%2Frr%2Farticle%2Fview%2F75&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.language=en_US&rft.genre=article&rft.title=Rheumatology+Reports&rft.jtitle=Rheumatology+Reports&rft.atitle=Hypoadrenalism+in+patients+with+fatigue+and+rheumatic+disease&rft.artnum=rr.2009.e13&rft.stitle=Rheumatol+Rep&rft.volume=1&rft.issue=1&rft.aulast=Methiniti&rft.aufirst=Dimitra&rft.date=2010-01-04&rft.au=Jennifer+Hamilton&rft.au=Vadivelu+Saravanan&rft.au=Carol+Heycock&rft.au=Clive+Anthony+Kelly&rft_id=info%3Adoi%2F10.4081%2Frr.2009.e13&rft.pages=e13&rft.issn=2036-7511&rft.eissn=2036-752X"></span> <div class="credits_pgp"> <p>&copy PAGEPress 2008-2024 • <a href="http://www.pagepress.org/" target="_blank">PAGEPress</a><sup>®</sup> is a registered trademark property of PAGEPress srl, Italy    •    VAT: IT02125780185    •    <a href="https://www.pagepress.org/index.php/site/privacy" target="_blank">Privacy</a></p> </div>  <script src='https://cdnjs.cloudflare.com/ajax/libs/jquery/3.1.1/jquery.min.js'></script> <script src='https://cdnjs.cloudflare.com/ajax/libs/gsap/1.19.1/TweenMax.min.js'></script> <script src="https://www.pagepress.org/journals/plugins/themes/defaultManuscript/js/slide.js"></script> </body> </html>

CINXE.COM

Hypoadrenalism in patients with fatigue and rheumatic disease | Rheumatology Reports