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Adrenal Nodule information/FINAL Adrenal Nodual Workflow Flyer copy.pdf_semantic.json

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+    "text": "Evaluating adrenal nodules *See next page for hormonal workup reference Incidental adrenal nodule > 1 cm Found on non-contrast (non-con) CT? DO NOT BIOPSY adrenal mass without hormone workup and consulation Assess imaging characteristics Obtain adrenal protocol CT Suspicious appearance Hormonal workup* Abnormal DST or metanephrines or aldosterone : renin Normal hormonal workup Refer to Endocrine Surgery Adrenal Nodules Clinic Benign appearance Hormonal workup* • Size ≥4 cm in diameter • >10 Hounsfield units (HU) on non-con CT • CT contrast washout <40–60% • On MRI, hyperintense on T2 imaging or no signal loss on chemical-shift analysis • On 18F-FDG PET-CT, SUVmax ≥5 or adrenal-to- spleen or adrenal-to liver signal-intensity ratio ≥1 • Catecholamine Excess – Plasma fractionated metanephrines – Abnormal:",
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+    "text": ">2x Upper Limit of Normal (ULN) • Adrenal hypercortisolism – 1mg Dexamethasone suppression test (DST) – Abnormal: >1.8 mcg/dl • Adrenal hyperaldosteronism – If patient has a history of HTN – Plasma aldosterone and renin – Abnormal:",
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+    "text": "aldosterone >10 and renin <1.0 • Size 1-4 cm in diameter • ≤10 Hounsfield units (HU) on non-con CT • CT contrast washout ≥40–60% • Signal loss on MRI chemical-shift analysis • On 18F-FDG PET-CT, SUVmax <5 or adrenal-to- spleen or adrenal-to liver signal-intensity ratio <1 • Adrenal hypercortisolism – 1mg Dexamethasone suppression test (DST) – Abnormal:",
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+    "text": ">1.8 mcg/dl • Adrenal hyperaldosteronism – If patient has a history of HTN – Plasma aldosterone and renin – Abnormal: aldosterone >10 and renin <1.0 Size > 4cm AND ≤10 HU on non-con CT • Repeat adrenal protocol CT in 1 year to confirm stability • Consider follow-up imaging at 6 months in patients younger than 40 years of age • Autonomous cortisol secretion = most common hormonal excess to develop during surveillance and may be reevaluated at a 2- to 5-year interval Size 1–4cm AND >10 HU on non-con CT Size 1–4 cm AND ≤10 HU on non-con CT • Follow up with primary care provider • No further follow-up imaging needed unless symptoms or signs indicating hormone excess develop Ye s No",
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+    "text": "GS-2727550-26 Hormonal workup reference 1. Cortisol evaluation Dexamethasone Suppression Test (DST) • Prescribe 1 mg of oral dexamethasone to be taken at 11 pm • The next morning at 8 am, a cortisol and dexamethasone level are drawn • If the 8 am cortisol is < 1.8 mcg/dL, cortisol excess is ruled out • If the am cortisol after dexamethasone is >1.8mcg/dL, then screening is POSITIVE or ABNORMAL • Cortisol between 1.8–5.0 mcg/dL may represent mild cortisol excess, therefore you need to proceed with confirmatory testing:",
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+    "text": "– Morning serum corticotropin and cortisol levels – 24-hr urinary cortisol – 3 midnight/late-night salivary cortisol – Midnight serum cortisol – DHEAS (<40 mcg/dL) • Failure to suppress below 5.0 mcg/dL raises concern for cortisol excess 2.",
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+    "text": "Screen for aldosteronoma Aldosterone level : Plasma Renin Activity (PRA) • Perform if patient has a history of hypertension or hypokalemia • Obtain mid-morning plasma aldosterone concentration and plasma renin activity – These must be drawn at the same time and should not be done with the DST • Divide the aldosterone level by the PRA to calculate the aldosterone :",
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+  {
+    "text": "renin (ARR) • If the ARR is > 20, screen is POSITIVE or ABNORMAL for hyperaldosteronism • If aldosterone > 10 ng/dL AND renin < 1.0 ng/dL then screen is POSITIVE or ABNORMAL for hyperaldosteronism – Proceed to confirmatory testing with oral sodium load test, aldosterone suppression test or seated saline infusion test • If aldosterone < 10 ng/dL OR renin > 1.0 ng/dL, then screen is NEGATIVE or NORMAL for hyperaldosteronism • If aldosterone > 10 ng/dL AND renin > 1.0 ng/dL and is on a potentially interfering medication, then hold/replace medications for 4 weeks and repeat 3.",
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+  },
+  {
+    "text": "Screen for pheochromocytoma Plasma-free metanephrines • POSITIVE or ABNORMAL if elevated > 2x ULN • Elevations < 2x ULN may be false positives and should be considered equivocal • Elevations < 2x ULN and no classic signs of pheochromocytoma – Confirm with 24-hour urine metanephrines = less likely to be falsely positive • If mildly elevated or concern for false positive, stop medications:",
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+  {
+    "text": "– Tricyclic antidepressants – Phenoxybenzamine – Levodopa – Beta blockers – Labetalol – Amphetamines – Buspirone – Methyldopa – Chlorpromazine • Confirmatory testing = 24-hour urine metanephrines • Consider genetic testing in confirmed pheochromocytoma",
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Adrenal Nodule information/JAMA Guidelines for Adrenalectomy.pdf_semantic.json

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+    "text": "3% in patients without a history of malignancy and up to 8% in patients with a history of extra-adrenal malignancy. 8 Other features in addition to size should be considered when assess- ing risk of either a primary or secondary malignancy in an ad- renal incidentaloma (eTable 2 in the Supplement ).",
+    "tokenCount": 70,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "611c0d9d5affa2a2fdac4a6ab955a48cba1c1c5805ea796b509054175be7e459"
+  },
+  {
+    "text": "Recommendation 1.2. We recommend that all patients with an adrenal incidentaloma 1 cm or larger undergo biochemical testing for autonomous cortisol secretion. Patients with hy- pertension or hypokalemia also require biochemical evalua- tion for primary aldosteronism.",
+    "tokenCount": 55,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "7a0343ca2f338fc48c275a7fedd589b31f4f9c0f56bf036e1fb2acf86ec2f63e"
+  },
+  {
+    "text": "Patients with adrenal imaging findings that have noncontrast CT with HU greater than 10 should undergo evaluation for pheochromocytoma. (Strong recommendation, low-quality evidence.) Recommendation 1.3.",
+    "tokenCount": 46,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "fff848405c1f3428f584ca1f5b68d5f8554aa6ef346a2d6ef79d40d1b0cbb040"
+  },
+  {
+    "text": "We recommend that a primary ad- renal malignancy be considered in patients with an adrenal in- cidentaloma larger 4 cm and/or HU greater than 20 on non- contrast CT and in any patient younger than 18 years.",
+    "tokenCount": 49,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "45b02e37a79371b58f246904248192a4a1a188d11299696ec18f021a1ae74940"
+  },
+  {
+    "text": "We recommend that patients with a history of extra-adrenal ma- lignancy be recognized to be at increased risk for adrenal me- tastases. (Strong recommendation, low-quality evidence.) Most nonfunctional adrenal nodules with benign imaging characteristics remain stable in size 5,7,12 while up to 10% of ad- renal incidentalomas will grow 1 cm or more over 2 to 5 years of surveillance.",
+    "tokenCount": 87,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "f4a214f8dc6a8c0a9363f58a723b982b854e38709e6c6306294f58f9fd0e50d8"
+  },
+  {
+    "text": "13-15 Surgical resection may be considered for nodules that are larger than 2 cm at initial presentation and grow more than 1 cm by 12 months, while smaller nodules or those with less growth may undergo repeated short-interval imaging at 6 to 12 months.",
+    "tokenCount": 55,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "99ab1086f56ec07327787a29ea9f4ff9219c8f167d261550b6e03d84c0962138"
+  },
+  {
+    "text": "However, there are insufficient data to recommend specific criteria for nodule growth during sur- veillance that should prompt adrenalectomy. Topics and Questions in the Population, Intervention/Exposure, Comparison, and Outcome (PICO) Framework 1.",
+    "tokenCount": 50,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "38b03945d065e8cebc1cd8c38cfd81a6c457ecff868cde5800457fc6f6646e96"
+  },
+  {
+    "text": "Incidentalomas, myelolipomas, and cysts 1. In patients with an adrenal incidentaloma, does adrenal protocol computed tomography improve diagnostic accuracy for malignancy or pheochromocytoma compared with other imaging modalities?",
+    "tokenCount": 53,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "1911d8373369e835215bab63b4e602335b71f60b3d5ef9ac8cd1d8e4e51775e9"
+  },
+  {
+    "text": "In patients with an adrenal incidentaloma, should clinical and imaging characteristics influence the hormonal workup? In patients with an adrenal incidentaloma, what clinical and imaging characteristics increase the risk that malignancy is present? In patients with a nonfunctional adrenal incidentaloma, what are the outcomes during surveillance?",
+    "tokenCount": 62,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "b7c719ec4d2089357e661bdd4498e26135df0691ef979f2e978ec3829da3551d"
+  },
+  {
+    "text": "Does resection of a myelolipoma or an adrenal cyst improve quality of life compared with observation alone? Primary aldosteronism 1. In patients with primary aldosteronism (PA), does adrenalec- tomy compared with mineralocorticoid antagonist therapy alone improve related comorbidities and mortality?",
+    "tokenCount": 71,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "57a39dc11abfdf2f244978b4129fe40dd27696e167f99e939cfb86749604c31c"
+  },
+  {
+    "text": "In patients with PA and cross-sectional imaging consistent with a unilateral adenoma, does preoperative adrenal venous sampling increase the likelihood of a clinical or biochemical cure? In patients with PA due to unilateral disease, does laparo- scopic adrenalectomy improve health-related quality of life and/or reduce health care–related costs compared with medical management?",
+    "tokenCount": 74,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "c92a58644395e17716be128d95f67e367429758f0277460654938a8524b00afe"
+  },
+  {
+    "text": "Hypercortisolism 1. Do patients with mild autonomous cortisol secretion (MACS) who undergo laparoscopic adrenalectomy compared with conservative medical management have improvement in cardiometabolic comorbidities without major surgical (30-day) adverse events?",
+    "tokenCount": 53,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "6bc4a2877d4c77a25312e59151ba9ca513d8164eade85a82d3643bf3d162eb3d"
+  },
+  {
+    "text": "Do patients with Cushing syndrome and bilateral macronodu- lar hyperplasia who undergo unilateral laparoscopic adrenal- ectomy achieve biochemical remission of hypercortisolism when compared with patients treated with bilateral adrenalectomy? In patients with adrenocorticotropic hormone–dependent hypercortisolism, does bilateral laparoscopic adrenalectomy improve disease-free survival or mortality compared with pharmacologic management?",
+    "tokenCount": 86,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "822b22aee09e487b0020c4b0594627330fdb0fe27e89e4dd3780b793e42c99bc"
+  },
+  {
+    "text": "Is the incidence of postoperative adrenal insufficiency after unilateral adrenalectomy different between patients with overt Cushing syndrome vs those with MACS? Adrenocortical carcinoma 1. In patients with adrenocortical carcinoma (ACC), does treat- ment at a high-volume multidisciplinary center improve survival outcomes?",
+    "tokenCount": 67,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "3888c1a331fe91f2eb0a71750f3c35bc878447ea650e42a6a45107f5732c48ac"
+  },
+  {
+    "text": "In patients with ACC without evidence of distant metastatic disease at diagnosis, does operative technique affect survival? In patients with ACC and systemic disease at diagnosis, does resection of the primary tumor improve survival?",
+    "tokenCount": 40,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "03dd3d3b1369bec3035483f2082ac065d7a354bec42e47c6cf4101d22d874c42"
+  },
+  {
+    "text": "In patients with advanced ACC, what is the role of neoadju- vant therapy followed by resection vs surgery with or without adjuvant therapy? Metastasis to the adrenal gland 1.",
+    "tokenCount": 42,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "a03a845c858b408f7c7ef3ed5ad8a11197a18bf29882465514048404b7292e94"
+  },
+  {
+    "text": "In patients with an adrenal mass, does history of an extra- adrenal malignancy influence the hormonal evaluation? In a patient with a history of an extra-adrenal malignancy and an adrenal mass, when is image-guided needle biopsy recommended?",
+    "tokenCount": 56,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "ded2487af766d1274a0925439f83f9e14fe19545eb7c0193be9ae0863aa916b4"
+  },
+  {
+    "text": "In patients with an adrenal metastasis, does resection improve survival compared with systemic therapy alone? Pheochromocytoma and paraganglioma 1. In patients with pheochromocytoma and paraganglioma, how does selective α blockade affect perioperative hemodynamic stability when compared with nonselective blockade with phenoxybenzamine?",
+    "tokenCount": 78,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "6d9d21375d7f5a1a7ee4c61fb123709e63bc3070929b9e7df793267d3df68a89"
+  },
+  {
+    "text": "In patients with genetic mutations driving long-term develop- ment of bilateral pheochromocytomas, what is the impact of cortical-sparing adrenalectomy compared with bilateral total adrenalectomy on steroid dependence and disease recurrence?",
+    "tokenCount": 49,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "ac90ad95a96e7eeef47952c6f64d2aba85a9d3a0ba9264bee41adceb04b6e2ec"
+  },
+  {
+    "text": "In patients with metastatic pheochromocytoma and paragan- glioma, does surgical resection of primary disease improve survival compared with nonsurgical treatment? Technical aspects 1. In patients undergoing adrenalectomy, what is the benefit of minimally invasive surgery compared with open surgery on perioperative outcomes?",
+    "tokenCount": 65,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "27a572f31dd7190adc3e83e21df9571cf32758be09858a28680a9c451a94005e"
+  },
+  {
+    "text": "In patients who are appropriate candidates for minimally invasive adrenalectomy, does a retroperitoneal compared with a transperitoneal approach change perioperative outcomes? For surgeons performing adrenal surgery, does surgeon volume influence morbidity and mortality?",
+    "tokenCount": 50,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "8e7992d452339be8f34c6d960531d967e2b17e7c081e7bfe90ba649880059800"
+  },
+  {
+    "text": "In patients with adrenal tumors, what is the efficacy of radio- frequency ablation and stereotactic radiation compared with adrenalectomy? Research Original Investigation American Association of Endocrine Surgeons Guidelines for Adrenalectomy 872 JAMA Surgery October 2022 Volume 157, Number 10 (Reprinted) jamasurgery.com © 2022 American Medical Association.",
+    "tokenCount": 72,
+    "pageStart": 3,
+    "pageEnd": 3,
+    "hash": "4aabd3a82f267a3c08fccc2137dcdac48718f18e96c58d05737461bb9f4e7d1c"
+  },
+  {
+    "text": "Downloaded from jamanetwork.com by University of Wisconsin -Madison user on 02/20/2026 Recommendation 1.4. We do not recommend routine scheduled follow-up of a nonfunctional adrenal nodule (size <4 cm) with benign imaging characteristics and noncontrast HU less than 10 because the risk of developing malignancy is very low.",
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+    "hash": "663dccfeb8b3c54d0672820f76653a42e1753c12058e781f9d7cca8bcd862c08"
+  },
+  {
+    "text": "Nodules from 1 to 4 cm with indeterminate imaging characteristics (such as noncontrast CT with HU >10) have a slightly increased risk of malignancy and should undergo at least 1 repeated image at 6 to 12 months to confirm stability.",
+    "tokenCount": 53,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "efe852b1e11887078d899f112eff22464322197b7c0c8f0381ea657455fef873"
+  },
+  {
+    "text": "Autonomous cortisol secretion is the most common hor- monal excess to develop during surveillance and thus may be reevaluated at a 2- to 5-year interval. (Strong recommenda- tion, low-quality evidence.) Adrenalmyelolipomasandcystshavecharacteristicimaging features.",
+    "tokenCount": 64,
+    "pageStart": 4,
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+    "hash": "d52062b642b1e338f45098e8c248ab2b122321d743473a48c793ba42bed71d0f"
+  },
+  {
+    "text": "4 Resection may be considered for indeterminate imaging, symptomatic tumors due to mass effect, substantive growth on surveillance, or those that have hemorrhaged. Recommendation 1.5. We do not suggest resecting a my- elolipoma or adrenal cyst with pathognomonic imaging features to improve the patient’s quality of life unless there are symptoms of mass effect.",
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+    "hash": "492310ccdb495da58ec1250b978fff23fa67584e5431546d122e21c8b482b997"
+  },
+  {
+    "text": "(Weak recommendation, low- quality evidence.) 2. Primary Aldosteronism Primary aldosteronism (PA) has been reported in 3% to 10% of hypertensive patients. 16 Once PA is diagnosed, mineralo- corticoid antagonists can be used to effectively manage PA-related hypertension and hypokalemia.",
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+    "pageStart": 4,
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+    "hash": "fc6694df2947b057bac40fbf6ad4578f69ab08e16f2c3d968ce0659554b0fd16"
+  },
+  {
+    "text": "Primary aldoste- ronism may be caused by an aldosterone-secreting adenoma, unilateral adrenal hyperplasia, or bilateral adrenal hyperpla- sia, and adrenal venous sampling (AVS) may be necessary for lateralization (eTable 3 in the Supplement ).",
+    "tokenCount": 67,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "2fce7e4c79d8bd5b1f2e3c2c704ea7c9c164545cfa911326361962969bf06208"
+  },
+  {
+    "text": "After adrenalec- tomy, the majority of patients with PA have either complete or partial clinical success, with less than 20% requiring the same or higher doses of medication postoperatively. Studies to date have assessed cost and quality-of-life outcomes after adrenalectomy via laparoscopy, and whether similar conclu- sions can be made using other minimally invasive surgical ap- proaches is not yet known.",
+    "tokenCount": 89,
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+    "hash": "ea2d2c52b00016c5866e853a0f802cb24ca47cdf4a016d56795cad4339911e8f"
+  },
+  {
+    "text": "Recommendation 2.1. We recommend that patients un- dergo laparoscopic adrenalectomy for unilateral PA because they are more likely to use fewer medications with lower de- fined daily doses to achieve normalization of blood pressure and potassium levels and have lower risks of new-onset atrial fibrillation, chronic kidney disease, stroke, and all-cause mor- tality.",
+    "tokenCount": 79,
+    "pageStart": 4,
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+    "hash": "6d132c11f0231514db8738d2eb709909c1214213fa84f315c7db9027a578e5c8"
+  },
+  {
+    "text": "(Strong recommendation, low-quality evidence.) Recommendation 2.2. We suggest that in patients 35 years and younger with cross-sectional imaging demonstrat- ing a unilateral adenoma and a normal contralateral gland, AVS may be deferred because adrenalectomy directed by CT imaging alone has a cure rate similar to adrenalectomy guided by AVS.",
+    "tokenCount": 74,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "d98f68f1e2534203d206b16499510b7c30df1273d7ef89b9ab7ff52fa8fa4265"
+  },
+  {
+    "text": "However, AVS should still be considered for all patients older than 35 years. (Weak recommendation, low-quality evidence.) Recommendation 2.3. We recommend laparoscopic adre- nalectomy for primary aldosteronism due to unilateral dis- ease because it improves quality of life and reduces health care–related costs.",
+    "tokenCount": 69,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "0c40a02c8ee0b25f35b318f225e0e3bbab5f896a4df063948c2086c25b63be46"
+  },
+  {
+    "text": "(Strong recommendation, low-quality evidence.) 3. Hypercortisolism Previously known as subclinical Cushing syndrome (CS), MACS has been reported in 0.2% to 2% of the general adult popula- tion and in 5% to 30% of patients with an adrenal inciden- taloma (eTable 3 in the Supplement ).",
+    "tokenCount": 74,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "43f70c7def365062b698db9cb7d9d798075d1b5bb90322d6a3dc5f5a3c9c97c5"
+  },
+  {
+    "text": "17 Although patients with MACS may lack the classical stigmata of hypercortisolism, they have a high prevalence of associated comorbidities such as obesity, arterial hypertension, type 2 diabetes, vertebral frac- tures, and cardiovascular morbidity and mortality.",
+    "tokenCount": 58,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "a2fc1728a650b805a885886575befbb0d21f07d0417d75c17dae0eef123a9c53"
+  },
+  {
+    "text": "18,19 Recommendation 3.1. We recommend that patients with MACS secondary to a unilateral adenoma undergo laparo- scopic adrenalectomy because of anticipated significant improvements in cardiometabolic comorbidities.",
+    "tokenCount": 47,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "831627949389b08650ba2163d87e71ead6eaca1ceaeffe6b75cfcad3b374c9c4"
+  },
+  {
+    "text": "(Strong rec- ommendation, moderate-quality evidence.) Bilateraladrenocorticotropichormone(ACTH)–independent CS can be due to either macronodular or micronodular adre- nal hyperplasia.",
+    "tokenCount": 55,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "4840f3a4edd45241e8d3c7ffe152815d1e4b4cced18cf3a77a01e9ca4c0f7932"
+  },
+  {
+    "text": "20,21 There has been growing interest in whether unilateral adrenalectomy of the larger gland may produce bio- chemical normalization of hypercortisolism in select pa- tients. While surgical morbidity and mortality are minimal 17 and resolution of hypercortisolism occurs in 84% to 100% of pa- tients, recurrence can be seen in 13.3% to 68% of patients at 4 years.",
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+    "pageStart": 4,
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+    "hash": "16e84622b4baf8e81eae999c9f2a678e2955e49441150164c269689f601a3e59"
+  },
+  {
+    "text": "22,23 Recommendation 3.2. In patients with bilateral mac- ronodular hyperplasia, we suggest consideration of unilat- eral laparoscopic adrenalectomy in patients with CS as an at- tempt to achieve biochemical remission of hypercortisolism without causing permanent adrenal insufficiency.",
+    "tokenCount": 67,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "d868765f190d35f42a7860e85ce29a09bf46ae73887d210631ec7a5432ee64e0"
+  },
+  {
+    "text": "(Weak rec- ommendation, low-quality evidence.) ACTH-dependent CS results from pituitary Cushing dis- ease or an ectopic ACTH source. Although CS can be resolved in most patients with treatment of the primary source, a sub- set of patients experience persistent, symptomatic CS from in- curable pituitary disease or metastatic or occult ectopic ACTH production.",
+    "tokenCount": 84,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "fe5bee6ca6e7debefb795773f09124feaf341f3e3529b189a7e00575617916b4"
+  },
+  {
+    "text": "Modern surgical techniques permit most pa- tients who require bilateral adrenalectomy to be managed with laparoscopic surgery, and operative morbidity in these pa- tients is approximately 10% with surgical mortality at 3%.",
+    "tokenCount": 44,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "9f0d90338a6069cde9d958ad42a83549b5496dc07bd57887628040e34967a893"
+  },
+  {
+    "text": "24-26 Recommendation 3.3. We suggest that patients with mod- erate to severe ACTH-dependent hypercortisolism refractory to source control undergo bilateral laparoscopic adrenalec- tomy to ameliorate cortisol excess and improve disease-free survival and mortality.",
+    "tokenCount": 62,
+    "pageStart": 4,
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+    "hash": "925afa99b1f35afb27760a7a6cb65e609462eca48c67bb00adc06fcd55a34df8"
+  },
+  {
+    "text": "Postoperative adrenal insufficiency is a life-threatening condition that should be prevented and promptly managed in patients undergoing adrenalectomy. Symptoms include fa- tigue, hypotension, anorexia, abdominal pain, weakness, syn- cope, back pain, nausea, vomiting, fever, and confusion.",
+    "tokenCount": 62,
+    "pageStart": 4,
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+    "hash": "d294211e1f9b5831483aed9d0377c3c3c708c31251587b6047b13b8254cdd349"
+  },
+  {
+    "text": "27 (Weak recommendation, low-quality evidence.) Recommendation 3.4. The incidence of adrenal insuffi- ciency after unilateral adrenalectomy is nearly 100% in pa- tients with overt CS and about 60% in patients with MACS.",
+    "tokenCount": 54,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "d5c5a21e6899c6f155b5b542e98fa5cfb464da8be22dbac9fffd52ef55c540e5"
+  },
+  {
+    "text": "We recommend empirical postoperative glucocorticoid replace- ment therapy for all patients with overt CS after undergoing unilateral adrenalectomy. However, we r ecommend that in patients with MACS, postoperative day 1 morning cortisol or corticotropin stimulation testing could be used to determine the need for glucocorticoid replacement therapy (eTable 4 American Association of Endocrine Surgeons Guidelines for Adrenalectomy Original Investigation Research jamasurgery.com (Reprinted) JAMA Surgery October 2022 Volume 157, Number 10 873 © 2022 American Medical Association.",
+    "tokenCount": 117,
+    "pageStart": 4,
+    "pageEnd": 4,
+    "hash": "386b00dda3bd3ce64ded5905603ab0f31679070df3117b93d7493576380b5c3c"
+  },
+  {
+    "text": "Downloaded from jamanetwork.com by University of Wisconsin -Madison user on 02/20/2026 in the Supplement ). (Strong recommendation, low-quality evidence.) 4. Adrenocortical Carcinoma Adrenocortical carcinoma is a rare cancer and complete sur- gical resection is the only potential curative therapy (eTable 3 in the Supplement ).",
+    "tokenCount": 78,
+    "pageStart": 4,
+    "pageEnd": 5,
+    "hash": "461f6eb58786e7c79f737d80850e36f3430ebd5e5c7494a0dc6c92411a8948bc"
+  },
+  {
+    "text": "28 Given limited adjuvant therapies and the overall poor prognosis associated with recurrent ACC, com- plete resection to negative margins at the index operation is a key tenet of ACC management.",
+    "tokenCount": 40,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "1e246b22272e5bd6ec58654d50f9815de94e868c77b1a55f7accf56fe9ac9df3"
+  },
+  {
+    "text": "29 While radical surgery with en bloc resection and preservation of an intact tumor capsule is the standard of care for locoregionally invasive disease, the operative technique hinges on skill and experience. Recommendation 4.1.",
+    "tokenCount": 45,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "b948f36ac8a57da1097e8436b22071b7b0b214e621a1675961f76306f76bfcf8"
+  },
+  {
+    "text": "We recommend that patients with clinical and radiographic findings consistent with ACC should be treated at high-volume multidisciplinary centers to im- prove recurrence outcomes; data on overall survival are in- conclusive.",
+    "tokenCount": 41,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "e630d536600f5fd9cf77217b2b6e8dbf54513719c0dd778e8c224f1fea9506dd"
+  },
+  {
+    "text": "(Strong recommendation, low-quality evidence.) Recommendation 4.2. Regardless of operative approach, we recommend an en bloc radical resection with an intact cap- sule to microscopically negative (R0) margins because of im- proved survival.",
+    "tokenCount": 52,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "262e4a4ab959a189432ebb6241aee15cd4f850b08a114ac960f17e9711b05446"
+  },
+  {
+    "text": "Although open resection is preferred when ACC is suspected, the choice of operative approach should be based on the certainty of a complete R0 resection without tumor disruption. (Strong recommendation, low-quality evidence.) Approximately 22% to 35% of patients with ACC have evi- dence of distant metastatic disease at initial presentation. 29,30 Cases with oligometastatic but potentially resectable ACC pre- sent a challenge, as the benefits of primary resection and/or metastasectomy are incompletely understood.",
+    "tokenCount": 106,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "bb776c54f9a27950224e56f00b0a92f9628efaa808af8c13c715f2bc27161e15"
+  },
+  {
+    "text": "Careful pa- tient selection and clinical judgment should be integrated with the patient’s goals of care. Recommendation 4.3. We suggest that patients with sys- temic disease be offered resection of the primary tumor if all sites of disease are reasonably amenable to resection or local treatment and if performance status allows.",
+    "tokenCount": 68,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "b68386c0cbd3bcaa37f93c6b6d5923514109b2918cfd1849806b4d645efe8e45"
+  },
+  {
+    "text": "Surgery may also be considered in patients with hormone excess medically re- fractory to steroidogenic inhibition. (Weak recommenda- tion, low-quality evidence.) In ACC, the goal of systemic neoadjuvant therapy is pri- marily to reduce the burden of disease to facilitate later po- tential complete resection.",
+    "tokenCount": 67,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "342efccfd421b6687dd9970ece0d1b7ecd4a2c56569147024e285e1963a4de4d"
+  },
+  {
+    "text": "Although neoadjuvant therapy for advanced ACC has not been systemically evaluated, the ratio- nale for neoadjuvant treatment is extrapolated from the data on adjuvant therapy. Recommendation 4.4.",
+    "tokenCount": 45,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "9239cc63714d358d864201d071a05cf4352a6ebd2a523de11fc4dfef5f7d5c7a"
+  },
+  {
+    "text": "We recommend that neoadjuvant systemic therapy be administered for advanced ACC when R0 surgical resection is not initially feasible. We recommend up- front surgical intervention when R0 resection is possible. (Strong recommendation, low-quality evidence.) 5.",
+    "tokenCount": 51,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "92fe805a8292e81c7268cd53063aaf7faa09b9805a40a5c624700ad4c35c3f48"
+  },
+  {
+    "text": "Metastasis to the Adrenal Gland Adrenal metastases may have imaging features that make them potentially indistinguishable from other pathologies. Func- tional evaluation is imperative prior to biopsy, ablation, or re- section and should aim, at a minimum, to exclude excess hor- mone production.",
+    "tokenCount": 64,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "df2a17bbef30b6d79d56dbf0804be84f3e4e6968b2b0530693d44f5e8f2ca8c3"
+  },
+  {
+    "text": "If the indeterminate adrenal mass is the only site of potential metastatic disease and appears resectable in an otherwise fit operative candidate, surgical resection rather than biopsy may be considered for both diagnostic purposes and potential therapeutic benefit.",
+    "tokenCount": 48,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "70d7e0d95d5c2f0006bd950b6c35229153b4014ee6ab4fbe26a574f8aac7c5f3"
+  },
+  {
+    "text": "Recommendation 5.1. We recommend that a directed hor- monal evaluation should be performed in patients with an ad- renal mass regardless of history of extra-adrenal malignancy.",
+    "tokenCount": 40,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "86310af75420788ba0ba84fc3aa5ce9a7c4faed982fc04c61a476a15af377ed3"
+  },
+  {
+    "text": "(Strong recommendation, low-quality evidence.) Recommendation 5.2. We suggest that in the setting of a radiographically indeterminate mass, image-guided biopsy be rarely performed and reserved for patients in whom results would change overall disease management and that it be per- formed only after confirming lack of hormone excess.",
+    "tokenCount": 65,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "b9556d07e109d49da12efb1f84477dfecf5e53af8d46c6115b7028726175168a"
+  },
+  {
+    "text": "(Strong recommendation, low-quality evidence.) Adrenal metastasis commonly occurs in patients with ma- lignancy from the lung, kidney, breast, melanoma, and colon but may occur from many other primary sites.",
+    "tokenCount": 45,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "eef4d353a4af01666f84ab446687a3d55423bce4be2a18f252ae424f40958e41"
+  },
+  {
+    "text": "While there are currently no established criteria guiding patient selection for adrenal metastasectomy, consideration should be given to pa- thology, synchronous vs metachronous presentation, disease- free interval, and tumor size to help select appropriate surgi- cal candidates.",
+    "tokenCount": 54,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "d9091a1d115fed3c8b7c1a836979d2f7b7c2034ceb90131ae6a8683d04ba464e"
+  },
+  {
+    "text": "Adrenal metastasectomy may be more difficult because of reaction from systemic treatment but can be per- formed either open or minimally invasive with equivalent oncologic outcomes. Recommendation 5.3.",
+    "tokenCount": 41,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "4f3acbe37331994ef45661226e7d555bdbbd15066d001a46bea988703544f4c4"
+  },
+  {
+    "text": "We suggest that after multidisci- plinary review, resection may be offered to highly selected pa- tients to improve survival compared with systemic therapy alone. (Weak recommendation, low-quality evidence.) 6.",
+    "tokenCount": 44,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "8f0eaf36b7a51575cd2bfcb37e60f622a66fdae78b7f273e9285acb9f9accb5f"
+  },
+  {
+    "text": "Pheochromocytoma and Paraganglioma As recommended in the Endocrine Society clinic practice guideline for pheochromocytoma and paraganglioma (PPGL), initial biochemical testing for PPGLs should include measure- ment of plasma-free or urinary fractionated metanephrines and are typically more than 2 to 3 times the upper limit of normal in functional PPGLs.",
+    "tokenCount": 89,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "f54396e6d7564c302d2d151f08b6a502ec0487addd318966b58f4d479cf1f365"
+  },
+  {
+    "text": "31,32 Following the diagnosis, preopera- tive blockade for at least 7 days is routinely recommended to prevent dangerous perioperative hemodynamic instability. Recommendation 6.1. We recommend either selective or nonselective α blockade to safely prepare patients for surgical resection of PPGL, depending on the drug availability/cost, ex- perience, and preference of the care team.",
+    "tokenCount": 81,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "440635cdbc2d5050bafe0a5459bc9c8c2e006c02362e192bcfb4878f6a388f1d"
+  },
+  {
+    "text": "While there is no sig- nificant difference in morbidity or mortality between selective and nonselective α blockade, selective blockade (doxazosin, prazosin, terazosin) is associated with more intraoperative he- modynamic instability while nonselective blockade (phenoxy- benzamine) results in more postoperative hypotension.",
+    "tokenCount": 73,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "c3f172b7268c49795447deee8884f30245995c4e45dc2300108ad54a5c1d891a"
+  },
+  {
+    "text": "(Strong recommendation, moderate-quality evidence.) Pheochromocytomas (PCCs) and paragangliomas (PGLs) have the highest heritability of all adrenal tumors (about 40% are due to germline mutations), 33,34 and genetic testing is rec- ommended (eTable 3 in the Supplement ).",
+    "tokenCount": 73,
+    "pageStart": 5,
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+    "hash": "74e258671c535a3c7527a7444f816c335b4e2a2d977777ac5d6f7471270ce452"
+  },
+  {
+    "text": "In the presence of bilateral or familial PCC, cortical-sparing adrenalectomy has been successfully used to preserve adrenal cortical tissue, pre- venting lifelong adrenal insufficiency. Studies report steroid dependency rates between 9% and 30% with recurrence rates from 9% to 30%.",
+    "tokenCount": 60,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "7527a06201975e06e9912e8c3c4d02267a2f0bc15e9d7445af6173ca20be4100"
+  },
+  {
+    "text": "35,36 While there are benefits to cortical- Research Original Investigation American Association of Endocrine Surgeons Guidelines for Adrenalectomy 874 JAMA Surgery October 2022 Volume 157, Number 10 (Reprinted) jamasurgery.com © 2022 American Medical Association.",
+    "tokenCount": 54,
+    "pageStart": 5,
+    "pageEnd": 5,
+    "hash": "52b12de2bae72600673ef2237d4d2e84c662290ffdbb3435f557bf7b18cc7ce5"
+  },
+  {
+    "text": "Downloaded from jamanetwork.com by University of Wisconsin -Madison user on 02/20/2026 sparing adrenalectomy, considerations must include the in- creased technical difficulty and risk of recurrence in the adrenal remnant, which could necessitate a reoperative adre- nalectomy.",
+    "tokenCount": 63,
+    "pageStart": 5,
+    "pageEnd": 6,
+    "hash": "380838bf0e10bd19c9bae074dafd9803d10bb212e8e51048abd4ce58d5a09236"
+  },
+  {
+    "text": "If an attempt at cortical-sparing adrenalectomy in- creases concern for tumor disruption or incomplete resec- tion, it may not be appropriate. Recommendation 6.2. Because of the decreased rate of ste- roid dependence, we recommend consideration of cortical- sparing adrenalectomy in patients with bilateral PCCs if tech- nically feasible.",
+    "tokenCount": 74,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "a0b89cee560db9a3e644de4313973d22fcc61ccbc29e5d283a45c905d0274629"
+  },
+  {
+    "text": "However, the pa tient’s goals of care and a higher risk of recurrent pheochromocytoma should also be con- sidered. (Strong recommendation, low-quality evidence.) Approximately 2% to 25% of PCCs are metastatic, as com- pared with 2% to 60% of PGLs, and several studies suggest a sur- vival benefit associated with resection of the primary tumor in the presence of metastatic disease.",
+    "tokenCount": 98,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "b72e3523630183ab42e733b26fb4eee6a8ff1e42fff3c3a72e92d214b227d328"
+  },
+  {
+    "text": "However, more data are needed before potential positive effects of surgery, such as de- creasing symptoms of catecholamine excess and improving re- sponsetosystemicradiotherapies,canbeevaluatedandvalidated.",
+    "tokenCount": 49,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "d7c8de9aad486587e10c0f401c9a38b77fb338306c71c4ee06d5b708e004071e"
+  },
+  {
+    "text": "Recommendation 6.3. We suggest that in selected cases of metastatic PPGLs, resection of the primary tumor may be performed to improve overall survival. Patients should be care- fully evaluated by a multidisciplinary care team to determine if the benefits of resection of the primary tumor outweigh the risks.",
+    "tokenCount": 64,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "3678b8ff87f19f0210df120ecbd5aa46240c061bd0ebbe8cccb3d390b74dda93"
+  },
+  {
+    "text": "(Weak recommendation, low-quality evidence.) 7. Technical Aspects Adrenalectomy may be technically accomplished using either open or minimally invasive techniques via one of several ap- proaches (eTable 5 in the Supplement ).",
+    "tokenCount": 45,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "203aedc297b297de5b13a3eaf5ed62c4f9427e20554e58f5f7aecb30afd885c6"
+  },
+  {
+    "text": "Minimally invasive ad- renalectomy has become accepted as the gold-standard ap- proach for most small benign adrenal pathology because of multiple studies demonstrating decreased pain, shorter hos- pitalizations, and more rapid recovery compared with open adrenalectomy.",
+    "tokenCount": 54,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "708ab692be697349b17b36d2184f9496c07891aa0cd9deb0502765840a4f09ee"
+  },
+  {
+    "text": "37,38 There have been no prospective random- ized trials comparing laparoscopic to open adrenalectomy. Both laparoscopic transabdominal adrenalectomy and posterior ret- roperitoneal adrenalectomy (PRA) are effective and safe mini- mally invasive approaches.",
+    "tokenCount": 60,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "9ed6771f1c3eda823257c1dbffa5ab873661614e4bd19b20f6b1ed63a7121705"
+  },
+  {
+    "text": "Some studies suggest less pain and faster recovery after PRA, and in patients with extensive ab- dominal surgical history and/or bilateral tumors, PRA offers additional advantages (eTable 6 in the Supplement ).",
+    "tokenCount": 42,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "b3a9a33006fd4296aa35d08159601fe01ef994a358237b9c2364527c3bf6be8f"
+  },
+  {
+    "text": "Recommendation 7.1. When patient and tumor character- istics are appropriate, we recommend minimally invasive ad- renalectomy over open adrenalectomy because of improved perioperative morbidity.",
+    "tokenCount": 40,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "77f80668471edf7004a0e9e90836f2062fbde9763e1978a2212f8c1c24bb996c"
+  },
+  {
+    "text": "(Strong recommendation, low- quality evidence.) Recommendation 7.2. We recommend either a retroperito- neal or transperitoneal approach because of similar periopera- tive outcomes.",
+    "tokenCount": 43,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "19880ddd92a047418415da083faa9513ca1f2ba161533f244496f8c0c6beaa12"
+  },
+  {
+    "text": "The choice of approach should be determined by surgeon expertise and guided by tumor and patient character- istics. (Strong recommendation, moderate-quality evidence.) Several definitions of what would be a high volume for an adrenal surgeon have been proposed, ranging from 4 to 7 an- nual adrenalectomies.",
+    "tokenCount": 63,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "04232d560f4110948ef59bad5839f8583662713af814460fb3f307cf3c421bd0"
+  },
+  {
+    "text": "A threshold of 6 or more adrenal resec- tions per year was shown in assessment of the National Inpa- tient Sample to be associated with improved patient outcomes, including lower rates of complications, reduced in-hospital mortality, decreased cost of care, and shorter hospital stay.",
+    "tokenCount": 58,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "c85a878250942376eefae84695b37e2701cd4f9bda06883cdd2706b0c133d7db"
+  },
+  {
+    "text": "39 Since not all patients have access to high-volume adrenal sur- geons, lower-volume surgeons should exercise judgment and careful patient selection to provide safe care at their own cen- ter vs seeking referral or consultation with a more experi- enced adrenal surgeon when appropriate.",
+    "tokenCount": 59,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "58c5a5622c0814748cc32c61cf6d7d255086febb39da53b6f6a8535d14744eea"
+  },
+  {
+    "text": "Recommendation 7.3. We recommend that adrenalec- tomy be preferentially performed by a high-volume adrenal sur- geon to optimize outcomes, including lower rates of morbid- ity and mortality.",
+    "tokenCount": 46,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "d2f9b58f5e3bc5a87c08ed5b6213d5c36baf0b08a8e7d9191c710895dad4dd5b"
+  },
+  {
+    "text": "(Strong recommendation, moderate quality evidence.) The utility of percutaneous ablation, mainly with radio- frequency ablation, and stereotactic body radiation therapy for the destruction of hormonally active and inactive tumors and adrenal metastasis has been investigated in small retrospec- tive studies.",
+    "tokenCount": 60,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "37286cdf8bd6613001c3c65ca7e1e950a920336d5e5449ad35df06d8448481f3"
+  },
+  {
+    "text": "The studies suffer from small sample sizes and heterogeneity. Recommendation 7.4. We conditionally suggest ablation and stereotactic radiation not be used as an alternative to adrenalectomy for patients with adrenal lesions because there are inadequate data to support these modalities.",
+    "tokenCount": 54,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "dea750eb62d7325f452b52eb180fafbf348eb9be0e16ffdbbf9c2a2f7b98773c"
+  },
+  {
+    "text": "Sur- geons should be involved in the decision-making early in the treatment algorithm. (Weak recommendation, low-quality evidence.) Strengths and Limitations The study is limited in some sections by the paucity of strong evidence-based data available in the English literature.",
+    "tokenCount": 57,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "eba98fa00c1747d8c53741eddfad6959c0bb1860335f988a402f25361bef06d2"
+  },
+  {
+    "text": "In ad- dition, the PICO format (Population, Intervention/Exposure, Comparison, and Outcome) for comparing outcomes limited the sample size for which recommendations were crafted. How- ever, the strength of the article lies in the extensive review and rigorous attention to bias, strength of the literature that was reviewed, and the comprehensive considerations made by a diverse group of experts in the field.",
+    "tokenCount": 80,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "6f23de19faf63571abacad1b745c62ea472057b17ce779f12c85fcd8fc83e72a"
+  },
+  {
+    "text": "Conclusions We provide 26 evidence-based recommendations with clini- cally meaningful data to primarily assist surgeons with peri- operative adrenal care. Clinicians from multiple disciplines and patients may also find these recommendations useful.",
+    "tokenCount": 44,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "e2bf79afb93efa81180f681c1bb7a4ec38eb31d4b310484ac6f3d6f84c74a098"
+  },
+  {
+    "text": "We highlight topics that have low-quality data or little evidence available and propose these topics as opportunities for fur- ther research. ARTICLE INFORMATION Accepted for Publication: April 30, 2022. Published Online: August 17, 2022. 10.1001/jamasurg.2022.3544 Author Affiliations:",
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+    "hash": "cc0fb31ae7a231c27e37f468cf0781fa8f9d27fb91001d300d3af5667bf03e1f"
+  },
+  {
+    "text": "Division of Endocrine Surgery, University of Pittsburgh, Pennsylvania (Yip); Department of Surgery, University of California, San Francisco (Duh); Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia (Wachtel); Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston (Jimenez); Department of Surgery, American Association of Endocrine Surgeons Guidelines for Adrenalectomy Original Investigation Research jamasurgery.com (Reprinted) JAMA Surgery October 2022 Volume 157, Number 10 875 © 2022 American Medical Association.",
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+    "hash": "4b7a602a1c826d1e4d76b877186e397406e0d8df3fe4ab02dab5dc94ec3adbcd"
+  },
+  {
+    "text": "Downloaded from jamanetwork.com by University of Wisconsin -Madison user on 02/20/2026",
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+  },
+  {
+    "text": "Section of Endocrine Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Sturgeon); Department of Surgery, University of Kentucky College of Medicine, Lexington (C. Lee); National Institute for Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico (Velázquez-Fernández); Center for Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio (Berber); Department of Internal Medicine, University of Michigan, Ann Arbor (Hammer); Department of Cell & Developmental Biology, University of Michigan, Ann Arbor (Hammer); Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor (Hammer); Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota (Bancos); Department of Surgery, Department of Internal Medicine, Columbia University College of Physicians and Surgeons, New York, New York (J. A. Lee); Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland (Marko); Division of Endocrine Surgery, Johns Hopkins Medicine, Baltimore, Maryland (Morris-Wiseman); Division of Surgical Oncology, Department of Surgery, Eastern Virginia Medical School, Norfolk (Hughes); Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, California (Livhits); Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, Korea (Han); Department of Surgery, University of Virginia, Charlottesville (Smith); Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Wilhelm); Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio (Asa); Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, Weill Cornell Medical College, New York– Presbyterian Hospital, New York (Fahey); Division of Endocrine and Metabolic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota (McKenzie); Department of Surgery, Gastric and Mixed Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York (Strong); Section of Surgical Endocrinology, Department of",
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+  },
+  {
+    "text": "Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston (Perrier). Author Contributions : Drs Yip and Perrier had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Yip, Jimenez, C. Lee, Velázquez-Fernández, Berber, Bancos, J. Lee, Hughes, Han, Smith, Wilhelm, Fahey, McKenzie, Perrier. Acquisition, analysis, or interpretation of data: Duh, Wachtel, Jimenez, Sturgeon, C. Lee, Velázquez-Fernández, Hammer, Bancos, J. Lee, Marko, Morris-Wiseman, Hughes, Livhits, Han, Smith, Asa, Fahey, McKenzie, Strong, Perrier. Drafting of the manuscript: Yip, Duh, Wachtel, Jimenez, Sturgeon, C. Lee, Velázquez-Fernández, Berber, Bancos, J. Lee, Morris-Wiseman, Hughes, Livhits, Han, Smith, Fahey, McKenzie, Strong, Perrier. Critical revision of the manuscript for important intellectual content: Duh, Wachtel, Jimenez, Sturgeon, C. Lee, Velázquez-Fernández, Berber, Hammer, Bancos, J. Lee, Marko, Morris-Wiseman, Hughes, Livhits, Han, Smith, Wilhelm, Asa, Fahey, McKenzie, Strong, Perrier. Statistical analysis: Yip, Velázquez-Fernández, J. Lee, Livhits, McKenzie. Administrative, technical, or material support: Yip, Jimenez, Velázquez-Fernández, Marko, Hughes, Han, Wilhelm, Fahey, McKenzie, Perrier. Supervision: Duh, Jimenez, Sturgeon, Velázquez-Fernández, Berber, Hammer, Hughes, Fahey, McKenzie, Strong,",
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+  },
+  {
+    "text": "Perrier. Conflict of Interest Disclosures: Dr Wachtel reported grants from the National Institutes of Health (NIH), National Center for Advancing Translational Sciences (KL2 TR001879), during the conduct of the study. Dr Jimenez reported research support from Lantheus Pharmaceuticals, Progenics, Exelixis, MSD, and Pfizer and serving on an advisory board for HRA Pharma and Pfizer during the conduct of the study. Dr Berber reported consulting for Medtronic, Aesculap, and Ethicon outside the submitted work. Dr Hammer reported being a founder of and consultant for Vasaragen, having patents for diagnostics via Vasaragen and the University of Michigan, and being the editor or associate editor of two textbooks outside the submitted work. Dr Bancos reported grants from the NIH and fees to her institution from HRA Pharma, Corcept, Lantheus, Recordati, Spruce, Sparrow, and Adrenas outside the submitted work. Dr Asa reported serving as an advisor for Leica Biosystems, Ibex Medical Analytics, and Iron Mountain outside the submitted work. Dr Fahey reported being a consultant and investor in Mediflix Inc. No other disclosures were reported. Additional Contributions: The Adrenalectomy Guidelines Committee acknowledges the support and dedication of all contributors for the voluntary time and diligence of acquiring the detailed data and constructing the manuscript. In addition, we thank the American Association of Endocrine Surgeons (AAES) membership for their careful review of the manuscript and insightful feedback. We are also grateful for the National Adrenal Disease Foundation (NADF) for representing the voice of our patients as we constructed these guidelines. Many thanks to Yasmin J. Khawaja, MA, Department of Surgical Oncology, MD Anderson Cancer Center, for orchestrating the committee’s activities and her excellent administrative support and reference management. Written permission to include names has been obtained. No compensation was received by any of the individuals who worked on this manuscript. Additional Information: The International Association of Endocrine Surgeons (IAES), the American Association of Clinical Endocrinology (AACE), and the Society of",
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+    "text": "Abdominal Radiology’s Adrenal Neoplasm Disease Focused Panel have fully endorsed the guidelines. REFERENCES 1 . Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol . 2011;64(4):401-406. doi: 10.1016/j. jclinepi.2010.07.015 2 . Fassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol . 2016;175 (2):G1-G34. doi: 10.1530/EJE-16-0467 3 . Zeiger MA, Thompson GB, Duh QY, et al; American Association of Clinical Endocrinologists; American Association of Endocrine Surgeons. American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: executive summary of recommendations. Endocr Pract . 2009;15(5):450- 453. doi: 10.4158/EP.15.5.450 4 . Dinnes J, Bancos I, Ferrante di Ruffano L, et al. Management of Endocrine Disease: imaging for the diagnosis of malignancy in incidentally discovered adrenal masses: a systematic review and meta-analysis. Eur J Endocrinol . 2016;175(2):R51-R64. doi: 10.1530/EJE-16-0461 5 . Ichijo T, Ueshiba H, Nawata H, Yanase T. A nationwide survey of adrenal incidentalomas in Japan: the first report of clinical and epidemiological features. Endocr J . 2020;67(2):141- 152. doi: 10.1507/endocrj.EJ18-0486 6 . Ebbehoj A, Li D, Kaur RJ, et al.",
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+    "text": "JAMA Netw Open . 2019;2(8):e198898. 10.1001/ jamanetworkopen.2019.8898 37 . Assalia A, Gagner M. Laparoscopic adrenalectomy. Br J Surg . 2004;91(10):1259-1274. 10.1002/bjs.4738 38 . Kebebew E, Siperstein AE, Duh QY. Laparoscopic adrenalectomy: the optimal surgical approach. J Laparoendosc Adv Surg Tech A . 2001;11 (6):409-413. 10.1089/10926420152761941 39 . Anderson KL Jr, Thomas SM, Adam MA, et al. Each procedure matters: threshold for surgeon volume to minimize complications and decrease cost associated with adrenalectomy. Surgery . 2018; 163(1):157-164.",
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+    "text": "10.1016/j.surg.2017.04.028 Invited Commentary Importance of a Multidisciplinary and Comprehensive Approach to Management of Adrenal Tumors Tracy S. Wang, MD, MPH; Carmen C.",
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+  {
+    "text": "Solórzano, MD The American Association of Endocrine Surgeons Guidelines for Adrenalectomy, published in this issue of JAMA Surgery , represent a series of 26 carefully composed recommenda- tions on the surgical management of patients with adrenal disease.",
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+    "text": "1 The authors are to be congratulated for this compre- hensive update, which focuses on 7 areas of clinical concern to the practicing adrenal surgeon. We would like to highlight the recommendations for a com- prehensive biochemical evaluation of patients with inciden- tally identified adrenal nodules more than 1 cm on cross- sectional imaging (recommendations 1.1-1.3) and emphasize the need for a multidisci- plinary approach to adrenal tumors.",
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+    "hash": "b947644760fd9f021a60464526e646488bf86d0f0dfcf6e4dd05c6ddfd25720f"
+  },
+  {
+    "text": "A systemwide algo- rithm for adrenal incidentalomas, including standardized ter- minology in the radiological assessment for evaluation and re- ferral to a multidisciplinary clinic (staffed by endocrinology and adrenal surgeons) at our institution(s), has resulted in an increase in the number of patients who have appropriate evalu- ation of adrenal incidentalomas; this anecdotal experience is supported by others.",
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+    "hash": "9fc3cfbcd807dc584c318450ee358791873007736d678a1e8d4b09f15e5c100f"
+  },
+  {
+    "text": "2-4 We encourage adrenal surgeons to lead the implementation of similar processes and the multidisci- plinary discussion of patients with adrenal tumors including those being considered for unconventional treatments (rec- ommendation 7.4), a point emphasized by the authors through- out these guidelines.",
+    "tokenCount": 60,
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+    "hash": "86fdda45022bb434a88ded685add4b541e6fd2c47e8c0e6030e3e570b3b6d547"
+  },
+  {
+    "text": "Multidisciplinary care is particularly important in deter- mining the appropriate follow-up, both radiographic and bio- chemical, in patients who have nonfunctional adrenal tu- mors with benign imaging characteristics.",
+    "tokenCount": 42,
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+  },
+  {
+    "text": "While the authors do not recommend routine scheduled follow-up in these pa- tients (recommendation 1.4), due to the low risk of malig- nancy and low incidence of developing hormonal excess, the level of evidence is “low quality” and the follow-up remains Related article page 870 American Association of Endocrine Surgeons Guidelines for Adrenalectomy Original Investigation Research jamasurgery.com (Reprinted) JAMA Surgery October 2022 Volume 157, Number 10 877 © 2022 American Medical Association.",
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+  {
+    "text": "Downloaded from jamanetwork.com by University of Wisconsin -Madison user on 02/20/2026",
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Adrenal Nodule information/Unveiling the Silent Threat_ Disparities in Adrenal Incidentaloma Management.pdf_semantic.json

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+    "text": "categorizing clinical notes using our established themes with the ability to create new classifications if necessary. Following completion, we again reviewed our results as a team to finalize our results. All statistical analyses were performed with SAS software.",
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+  {
+    "text": "A bivariate analysis was performed using chi-squared and Student’s t-test analysis. Multivariate logistic regression was performed to evaluate factors associated with biochemical workup. Results Study cohort During the study period, 9022 patients had a qualifying CT scan performed and 533 (5.9%) individuals with IAMs were identified.",
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+    "hash": "48e6d284db8724a0d7cfccb4485df7f221e2fe8d996c7a2552615e5580283175"
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+  {
+    "text": "After applying exclusion criteria, 245 (46.0%) of 533 patients were included in our final analysis ( Fig. Demographics Overall, the final patient cohort was 58.8% female, 58.0% over 65 y of age, and 86.1% White ( Table 1 ).",
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+    "hash": "b03d62fdae2ccbf0412688febb834c1f73df27df25d68e82297eaa561a979ac9"
+  },
+  {
+    "text": "The patient population was generally healthy with 50.6% reporting a CCI of 0 or 1. Most patients were covered by Medicare (49.0%) or private insurance (43.3%). The most common ADI deciles were 4 or 5, making up 17.0% and 17.4% respectively.",
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+    "hash": "89d0bc4bac06fee3b5115403a704fad91beeb33c047bd4dc42daa5ad2b49c191"
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+  {
+    "text": "A total of 135 pa- tients (56.0%) were from advantaged neighborhoods (lower 50th percentile ADI). Imaging and ordering provider characteristics The majority of the imaging which discovered the IAM was ordered by EM providers (50.6%), followed by subspecialists (36.7%), and PCPs (12.7%).",
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+    "text": "A total of 77.1% of ordering providers were physicians, while the remainder were physician assis- tants or nurse practitioners. The vast majority of the CTs or- dered were with contrast (93.1%).",
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+    "text": "Rate of IAM workup Most (71%) IAM patients received no further workup, 18% had partialevaluation,and11%hadfullassessment( Fig. A chi-square test revealed statistically significant associations between sex, neighborhood disadvantage, and ordering provider with IAM workup.",
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+    "text": "More specifically, female (71.8% versus 28.2% males, P < 0.01) and advantaged (67.1% versus 32.9% disadvantaged, P ¼ 0.03) patients had a significantly higher rate of workup, while patients with imaging ordered by EM providers had a significantly lower rate of workup compared to those ordered by primary care (54.6% received no workup versus 7.5% from PCPs, P < 0.01).",
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+    "text": "Among advan- taged patients, 54.8% had scans ordered by EM providers and 17.8% had scans ordered by PCPs ( Table 2 ). Of the disadvan- taged patients, scans ordered by EM providers and PCPs were 45.3% and 6.6%, respectively.",
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+    "text": "Comparison of patients who hadapartialorfullworkupispresentedin Supplementary Table 1 . Factors associated with biochemical evaluation Logistic regression demonstrated disadvantaged patients were less likely to undergo any workup compared to advan- taged patients (odds ratio [OR] 0.51, confidence interval [CI] 0.26-0.98) ( Table 3 ).",
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+    "text": "Other factors significantly associated with receiving any workup included female sex (OR 2.26, CI 1.19- 4.31) and scans ordered by PCPs (OR 4.08, CI 1.69-9.81) compared to EM providers.",
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+    "text": "There was no statistically signifi- cant difference in workup based on age, race, ethnicity, in- surance status, or CCI. Secondary chart review Examination of physician notes and radiology reports from 30 disadvantaged patients without IAM workup revealed three main themes which may have contributed to the lack of evaluation ( Table 4 ).",
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+    "text": "The most common theme of missed evaluation related to radiology reports recom- mending no further workup. While this was likely meant to signal that the lesion needed no further radiographic workup to evaluate for malignant potential, this was often interpreted as no further workup was needed at all, including biochemical workup.",
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+    "text": "For instance, a communi- cation from one PCP to a patient with an adrenal nodule noted that the scan demonstrated an adrenal lesion that was “benign,” and echoed the report that no further evaluation was needed, even though a functional workup was never performed.",
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+    "text": "Second most common was PCPs not acknowledging the nodule nor ordering additional tests, suggesting these incidental findings were missed. Lastly, Fig. 1 e Included patients flowchart. o’connor et al \u0001 adrenal incidentaloma management 145",
+    "tokenCount": 49,
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+  {
+    "text": "patients were frequently lost to follow-up after imaging and never completed biochemical testing when recommended. Discussion In our study, the rates of complete guideline-concordant biochemical workup or partial evaluations of adrenal inci- dentalomas were 11% and 18%, respectively.",
+    "tokenCount": 56,
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+    "text": "These alarmingly low rates align with other publications, confirming absent or incomplete IAM evaluations are commonplace. 2 , 12 , 20 For instance, Ebbehoj et al . (2020) reported appropriate workup of IAMs was completed in only 15.2% of cases.",
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+    "text": "2 These low rates of workup undoubtedly lead to poor patient outcomes, as untreated hormonally active adrenal incidentalomas have been tied to higher rates of cardiovascular events and even mortality. 10 , 11 , 21 Workup rates were particularly low for patients living in disadvantaged neighborhoods.",
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+    "text": "We found patients from these neighborhoods had roughly half the odds of obtaining any IAM workup compared to those from advantaged neighbor- hoods. Our findings are consistent with literature linking neighborhood-level disadvantage with poorer health out- comes and disease management.",
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+    "text": "22 , 23 Similarly, Schut and Mortani Barbosa (2020) reported racial/ethnic disparities in incidental pulmonary nodule management. 24 Differences in care of IAMs may have downstream effects, potentially exacerbating preexistent disparities in comorbidities such as diabetes and hypertension.",
+    "tokenCount": 58,
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+  {
+    "text": "25 , 26 The relationship is likely multifactorial and involves patient access to PCPs, reliance on safety net programs or emergency departments (EDs), and more fragmented care. 23 , 27 Furthermore, our secondary chart analysis revealed lack of follow-up as a common theme among patients in disadvantaged neighborhoods, reinforcing that many of the issues revolve around the ability to access Table 1 e Demographics.",
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+  {
+    "text": "No workup (n ¼ 174) % Any workup (n ¼ 71) % Total cohort (n ¼ 245) % P value Sex < 0.01 Female 53.5 71.8 58.8 Male 46.5 28.2 41.2 Age 0.10 < 65 54.6 66.2 58.0 > 65 45.4 33.8 42.0 Race/Ethnicity 0.68 White 86.2 85.9 86.1 Black 5.2 7.0 5.7 Hispanic 2.9 4.2 3.3 Asian 3.5 2.8 3.3 Other/Unknown 2.3 0.0 1.6 CCI 0.96 0 22.4 21.1 22.0 1 28.2 29.6 28.6 2 þ 49.4 49.3 49.4 ADI 0.03 Advantaged ( < 50 percentile) 51.5 67.1 56.0 Disadvantaged ( > 50 percentile) 48.5 32.9 44.0 Ordering provider < 0.001 EM 54.6 40.9 50.6 PCP 7.5 25.4 12.7 Specialist 37.9 33.8 36.7 Insurance 0.06 Private 38.5 54.9 43.3 Medicaid 1.7 4.2 2.5 Medicare 52.9 39.4 49.0 Uninsured 5.8 1.4 4.5 Tricare 1.2 0.0 0.8 146 journalofsurgicalresearch \u0001 july 2025 (311) 143 e 150",
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+  },
+  {
+    "text": "primary care and navigate the health-care system. Addition- ally, clinics serving disadvantaged patients typically have limited resources, and as a result, prioritization of other ur- gent health matters may supersede evaluation of incidentalomas.",
+    "tokenCount": 46,
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+  {
+    "text": "28 While our study demonstrated poor IAM workup compli- ance across all medical/surgical fields, investigations were significantly lower when diagnoses were established during ED visits. Similarly, Feeney et al .",
+    "tokenCount": 43,
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+  {
+    "text": "(2020) reported a three-fold lower rate of follow-up imaging if the index study was per- formed while the individual was an inpatient or in the ED compared to outpatient. 29 Interestingly, several previous publications focused on poor IAM workup compliance in pri- mary care outpatient settings.",
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+  {
+    "text": "30 , 31 The authors suggested PCPs may lack time and/or knowledge of appropriate biochemical evaluations to adequately address IAMs. However, our study suggests the emergency room as a potentially larger source of missed IAM management.",
+    "tokenCount": 45,
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+  {
+    "text": "Although disadvantaged patients had higher rates of detection by EM providers, ordering pro- vider remained a significant factor even when controlling for socioeconomic deprivation. Our chart review noted PCPs failing to acknowledge the nodule as a major reason for missed workup, and suggests that communication between EM and PCPs remains a challenge to properly addressing IAMs.",
+    "tokenCount": 68,
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+    "hash": "dee4876e1ac34eb478cf92cbeabebfc82fe4509dd0bd5824ef5e290534e8491d"
+  },
+  {
+    "text": "One strategy to improve coordination of care is the develop- ment of an adrenal nodule identification system which uses artificial intelligence natural language processing to create automated messages for PCPs regarding the nodule and guidelines for next steps.",
+    "tokenCount": 44,
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+    "hash": "e1655261096c861a9dc037fd45f6c7e083686ebcae0472ca4617fd433c537fa1"
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+  {
+    "text": "A recent study utilized artificial in- telligence technology to flag patient electronic health records with adrenal nodules 32 and pairing similar technology with notifications to PCPs can be an effective way to reduce the amount of IAMs lost during the transition of care.",
+    "tokenCount": 52,
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+  {
+    "text": "Another problem contributing to incomplete IAM evalua- tion is radiologists recommending no further workup. Although radiologists rule out malignant potential and label the nodule as “benign”, biochemical workup is required to understand the functional potential.",
+    "tokenCount": 52,
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+  {
+    "text": "To combat the issue, the use of radiology reporting templates which encourage addi- tional testing and provide specific follow-up recommenda- tions have led to increased rates of follow-up imaging and biochemical testing.",
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+    "text": "33-35 While modifications to radiology reporting language (e.g., low concern for malignancy, could consider a functional workup) are a step in the right direction, additional protocols and interdisciplinary teams are neces- sary to ensure even more patients are adequately evaluated.",
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+    "text": "Recently, a program combining standardized radiologic reporting, chart-based messages to PCPs, and easier referrals to a multispecialty adrenal clinic resulted in an approximate 4x increase in the number of biochemical testing orders placed by PCPs.",
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+    "text": "36 Similarly, interdisciplinary collaboration between radiologists, EM physicians, nurse case managers, and PCPs resulted in 95% of ED patients with incidental radi- ology findings having follow-up plans for evaluation after discharge.",
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+    "text": "37 While these interventions highlight the promising out- comes for incidentaloma management using providers from multiple areas of health care, no studies to date have examined if these interventions have reduced disparities in Fig. 2 e IAM workup. DST [ dexamethasone suppression test; HTN [ hypertension. Table 2 e ADI and ordering provider.",
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+    "text": "Ordering provider ADI Advantaged ( < 50 percentile) Disadvantaged ( > 50 percentile) N% n % EM 74 54.8 48 45.3 PCP 24 17.8 7 6.6 Subspecialist 37 27.4 51 48.1 o’connor et al \u0001 adrenal incidentaloma management 147",
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+  {
+    "text": "the workup of adrenal nodules. It is not hard to imagine positive resources directed to identify IAM patients may be unequally distributed and benefit well-resourced clinics. Thus, to further improve health outcomes and equity, in- terventions must consider the patient population and setting.",
+    "tokenCount": 60,
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+  {
+    "text": "One relevant model to help achieve these goals is the Health Disparities Framework, developed by the National Institute on Minority Health and Health Disparities. 38 The adaptation of the socioecological model evaluates five domains (biological, behavioral, physical/built environment, sociocul- tural environment, and health-care system) and drives research and interventions toward solutions which address the fundamental causes of disparities.",
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+    "text": "Building upon this and the findings of our study, we encourage researchers and doctors to consider patient and neighborhood-level dispar- ities when implementing subsequent interventions. We found a major obstacle for patients in disadvantaged com- munities is following up with PCPs after the identification of an IAM.",
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+  {
+    "text": "Although we cannot determine the exact reason for each patient, one proposal could be the use of patient navi- gators who can help overcome environmental and neigh- borhood factors such as transportation, costs, and insurance coverage.",
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+    "text": "This strategy has demonstrated success in improving cancer management and treatment. 39 , 40 For instance, one randomized control trial found patient navi- gation led to significantly greater compliance with follow-up among minority women with abnormal mammograms.",
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+    "text": "41 As a result, navigators remain a promising method through which to eliminate disparities in care for IAMs, although obvious barriers such as costs and workflow burden require more in-depth investigation. Overall, the low rates of IAM follow-up, particularly among patients from disadvantaged neighborhoods, suggest the need for new protocols consid- ering health disparities to ensure more patients are adequately evaluated.",
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+  {
+    "text": "Our study had a number of limitations. For one, retro- spective data and inherent inaccuracies in the electronic medical record may skew results. The data were only from a single institution and the population skewed more toward White and insured, making the results less generalizable.",
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+    "text": "Including a greater percentage of non-White or Medicaid patients could allow for further elucidation of barriers to workup which specifically constrain these populations. In addition, due to the retrospective nature, we cannot deter- mine the direction of the relationship between neighbor- hood disadvantage and lower rates of biochemical workup.",
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+    "text": "We are also unable to determine any verbal or other communication provided to the patient regarding their identified nodule. Table 3 e Factors associated with workup. Variable OR (95% CI) Sex Male ref Female 2.26 (1.19-4.31) Age > 65 ref < 65 1.34 (0.54-3.32) CCI 0 ref 1 1.03 (0.43-2.48) 2+ 1.16 (0.49-2.73) Race/Ethnicity White ref Black 1.54 (0.40-5.97) Hispanic 1.96 (0.37-10.49) Asian 0.68 (0.12-3.88) Other * Ordering provider ED ref PCP 4.08 (1.69-9.81) Subspecialist 1.48 (0.73-3.01) ADI < 50 ref > 50 0.51 (0.26-0.98) Insurance Private ref Medicaid 2.10 (0.35-12.67) Medicare 0.63 (0.25-1.55) Uninsured 0.16 (0.02-1.48) Tricare * * Not enough patients for analysis.",
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+  {
+    "text": "Table 4 e Common themes for lack of workup among disadvantaged patients Radiologist recommended no workup PCP did not acknowledge nodule Patient lost to follow-up Number of patients 11 13 6 Selected quote from Electronic Health Record “Benign 1.6 cm left adrenal adenoma.",
+    "tokenCount": 59,
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+  },
+  {
+    "text": "No follow-up imaging is necessary” “Partially imaged, indeterminant 4.6 cm right adrenal mass, likely adenoma or adrenal myelolipoma, both benign.",
+    "tokenCount": 44,
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+    "hash": "148443087747107abc145b2d1a1f73b5c1c831a90c7a1298be40de680095076a"
+  },
+  {
+    "text": "Consider nonurgent adrenal protocol CT or MR for further characterization.” “Incidental indeterminate 1.4 cm adrenal nodule. Consider follow-up in 12 mo if no history of malignancy versus nonurgent evaluation with adrenal protocol CT or MRI.” “Discussed the need to complete testing for evidence of hypercortisolism or pheochromocytoma.” MR ¼ magnetic resonance; MRI ¼ magnetic resonance imaging.",
+    "tokenCount": 102,
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+    "hash": "5de7efddedc2d1f9f8a53dbda4e9e1ddd830a1467010754a72d635c53eab364f"
+  },
+  {
+    "text": "148 journalofsurgicalresearch \u0001 july 2025 (311) 143 e 150",
+    "tokenCount": 17,
+    "pageStart": 6,
+    "pageEnd": 6,
+    "hash": "f268f8628097f5cc57ec181b8c29963c5dc7e2cb077a88ac61f03e4f4116104c"
+  },
+  {
+    "text": "Conclusions Overall, the rates of complete or partial guideline-based biochemical workup of adrenal incidentalomas in our study population were low at 11% and 18%, respectively. Patient neighborhood disadvantage and studies ordered by EM pro- viders were associated with lower rates of biochemical workup. Further investigation into barriers to IAM workup and focused interventions to improve the rate of IAM workup for patients in disadvantaged settings are needed. Supplementary Materials Supplementary data related to this article can be found at https://doi.org/10.1016/j.jss.2025.04.031 . Disclosure John P. O’Connor reports that financial support was provided by Herman and Gwendolyn Shapiro Foundation. Amy Kind reports financial support was provided by National Institute on Aging. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding None. CRediT authorship contribution statement John P. O’Connor: Writing e review & editing, Writing e original draft, Investigation, Formal analysis, Data curation. Alekya Poloju: Investigation, Formal analysis, Data curation. Samantha K. Pabich: Project administration, Methodology, Data curation. Betty Allen: Investigation, Data curation. Rebecca Sippel: Supervision, Project administration, Method- ology. Amy Kind: Supervision, Methodology. Alexander Chiu: Writing e review & editing, Validation, Supervision, Project administration, Methodology, Formal analysis, Data curation, Conceptualization. references 1. Sherlock M, Scarsbrook A, Abbas A, et al. Adrenal incidentaloma. Endocr Rev . 2020;41:775 e 820 . 2. Ebbehoj A, Li D, Kaur RJ, et al. Epidemiology of adrenal tumours in Olmsted County, Minnesota, USA: a population- based cohort study. Lancet Diabetes Endocrinol . 2020;8:894 e 902 . 3. Geelhoed GW, Druy EM. Management of the adrenal “incidentaloma.”. Surgery .",
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+  {
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+    "text": "adrenal incidentalomas that are either non-secreting or associated with intermediate phenotype or subclinical Cushing’s syndrome: a 15-year retrospective study. Lancet Diabetes Endocrinol . 2014;2:396 e 405 . 12. Feeney T, Madiedo A, Knapp PE, Gupta A, McAneny D, Drake FT. Incidental adrenal masses: adherence to guidelines and methods to improve initial follow-up: a systematic review. J Surg Res . 2022;269:18 e 27 . 13. Cho JK, Zafar HM, Lalevic D, Cook TS. Patient factor disparities in imaging follow-up rates after incidental abdominal findings. Am J Roentgenol . 2019;212:589 e 595 . 14. Liao GJ, Liao JM, Lalevic D, Zafar HM, Cook TS. Location, location, location: the association between imaging setting and follow-up of findings of indeterminate malignant potential. J Am Coll Radiol . 2019;16:781 e 787 . 15. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis . 1987;40:373 e 383 . 16. Singh GK. Area deprivation and widening inequalities in US mortality, 1969-1998. Am J Public Health . 2003;93:1137 e 1143 . 17. Kind AJH, Buckingham WR. Making neighborhood- disadvantage metrics accessible d the neighborhood atlas. N Engl J Med . 2018;378:2456 e 2458 . 18. Hu J, Kind AJH, Nerenz D. Area deprivation index predicts readmission risk at an urban teaching hospital. Am J Med Qual . 2018;33:493 e 501 . 19. Shen J, Fuemmeler BF, Sheppard VB, et al. Neighborhood disadvantage and biological aging biomarkers among breast cancer patients. Sci Rep . 2022;12:11006 . 20. Maher DI, Williams E, Grodski S, Serpell JW, Lee JC. Adrenal",
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+    "text": "incidentaloma follow-up is influenced by patient, radiologic, and medical provider factors: a review of 804 cases. Surgery . 2018;164:1360 e 1365 . 21. Morelli V, Reimondo G, Giordano R, et al. Long-term follow-up in adrenal incidentalomas: an Italian multicenter study. J Clin Endocrinol Metab . 2014;99:827 e 834 . 22. Durfey SNM, Kind AJH, Buckingham WR, DuGoff EH, Trivedi AN. Neighborhood disadvantage and chronic disease management. Health Serv Res . 2019;54:206 e 216 . o’connor et al \u0001 adrenal incidentaloma management 149",
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+    "text": "Kirby JB, Kaneda T. Neighborhood socioeconomic disadvantage and access to health care. J Health Soc Behav . 2005;46:15 e 31 . Schut RA, Mortani Barbosa EJ. Racial/ethnic disparities in follow-up adherence for incidental pulmonary nodules: an application of a cascade-of-care Framework. J Am Coll Radiol . 2020;17:1410 e 1419 .",
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+    "text": "Racial and ethnic disparities in hypertension: barriers and opportunities to improve blood pressure control. Curr Cardiol Rep . 2023;25:17 e 27 . Hassan S, Gujral UP, Quarells RC, et al. Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward. Lancet Diabetes Endocrinol . 2023;11:509 e 524 . Hussein M, Diez Roux AV, Field RI. Neighborhood socioeconomic status and primary health care: usual points of access and temporal trends in a major US urban area. J Urban Health Bull N Y Acad Med . 2016;93:1027 e 1045 . Nwana N, Chan W, Langabeer J, Kash B, Krause TM. Does hospital location matter? Association of neighborhood socioeconomic disadvantage with hospital quality in US metropolitan settings. Health Place . 2022;78:102911 . Feeney T, Talutis S, Janeway M, et al. Evaluation of incidental adrenal masses at a tertiary referral and trauma center. Surgery . 2020;167:868 e 875 . Becker J, Woloszyn J, Bold R, Campbell MJ. The adrenal incidentaloma: an opportunity to improve patient care. J Gen Intern Med . 2018;33:256 e 257 . Talutis SD, Childs E, Goldman AL, et al. Strategies to optimize management of incidental radiographic findings in the primary care setting: a mixed methods study. Am J Surg . 2022;223:297 e 302 . Schumm M, Hu MY, Sant V, et al. Automated extraction of incidental adrenal nodules from electronic health records. Surgery . 2023;173:52 e 58 . Woods AP, Godley F, Feeney T, et al. A standardized radiology template improves incidental adrenal mass follow-up: a prospective effectiveness and implementation study. JAm Coll Radiol . 2023;20:87 e 97 . Hamilton AE, Green RL, Gao TP, et al. To report hounsfeld units or not: there is no question. Am J Surg . 2024;229:111 e 115 .",
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+    "text": "Watari J, Vekaria S, Lin Y, et al. Radiology report language positively influences adrenal incidentaloma guideline adherence. Am J Surg . 2022;223:231 e 236 .",
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+    "text": "Woods AP, Feeney T, Gupta A, Knapp PE, McAneny D, Drake FT. Prospective study of a system-wide adrenal incidentaloma quality improvement initiative. J Am Coll Surg . 2024;238:961 e 970 . Barrett TW, Garland NM, Freeman CL, et al. Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings. Ann Emerg Med . 2022;80:235 e 242 .",
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+    "text": "Alvidrez J, Castille D, Laude-Sharp M, Rosario A, Tabor D. The national Institute on minority health and health disparities research Framework. Am J Public Health . 2019;109:S16 e S20 . Freund KM, Battaglia TA, Calhoun E, et al. Impact of patient navigation on timely cancer care: the patient navigation research program. JNCI J Natl Cancer Inst . 2014;106:dju115 . Shusted CS, Barta JA, Lake M, et al. The case for patient navigation in lung cancer screening in vulnerable populations: asystematicreview. Popul Health Manag . 2019;22:347 e 361 . Ell K, Vourlekis B, Lee PJ, Xie B. Patient navigation and case management following an abnormal mammogram: a randomized clinical trial. Prev Med . 2007;44:26 e 33 . 150 journalofsurgicalresearch \u0001 july 2025 (311) 143 e 150",
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Adrenal Nodule information/primary-aldosteronism Family Medicine Clinical Guidelines.pdf_semantic.json

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+    "text": "September 2023 ◆ Volume 108, Number 3 www.aafp.org/afp American Family Physician 275 ORAL SALT LOADING TEST For the oral salt loading test, a high-salt diet supplemented with sodium chloride tablets is consumed for three days with a goal sodium intake of 6 g per day. High salt intake should cause physiologic suppression of the RAAS and a marked decrease in aldosterone levels. A 24-hour urine col - lection is performed on the third day. Persistently elevated 24-hour urine aldosterone levels (more than 12 mcg in 24 hours) are consistent with nonphysiologic production of aldosterone and confirm the diagnosis of primary aldoste - ronism. The saline infusion test can also confirm pathologic aldosterone production if plasma aldosterone concentra - tion is greater than 10 ng per dL after an infusion of 2 L of normal saline. FLUDROCORTISONE TEST The fludrocortisone test involves administration of the syn - thetic mineralocorticoid fludrocortisone at a dosage of 0.1 mg every six hours for four days. Exogenous mineralocor - ticoid administration should suppress serum aldosterone levels. A plasma aldosterone concentration of greater than 6 ng per dL on day 4 confirms the diagnosis of primary aldosteronism. Subtyping Once primary aldosteronism has been diagnosed, the next step is to determine if aldosterone production is unilateral or bilateral. 13,18,19 Unilateral production is typically caused by an aldosterone-producing adenoma and should be treated surgically, whereas bilateral production is typically from idiopathic hyperplasia and is treated medically. This differentiation, termed subtyping, is accomplished with adrenal computed tomography (CT) and adrenal vein sampling. 13,18,19 Adrenal CT has three phases: an initial scan without contrast media, a scan at 60 to 75 seconds after con - trast media administration, and again at 15 minutes. By assessing baseline nodule density, as well as contrast media uptake and subsequent washout, benign",
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+    "text": "adenomas can be reliably distinguished from malignant masses. 20 CT has lim - ited sensitivity for the detection of sub-centimeter nodules. Additionally, CT is unable to distinguish nonfunctioning adenomas from functioning adenomas. A systematic review showed an almost 40% rate of discordance between CT and adrenal vein sampling in subtyping patients with primary aldosteronism. 21 Therefore, adrenal vein sampling is consid - ered the preferred method of subtyping. A systematic review and meta -analysis performed in 2022 found a statistically FIGURE 1 Suggested interpretation of initial case detection testing for primary aldosteronism. Note: An aldosterone-renin ratio > 30 is the most common cutoff during initial case detection when plasma aldosterone concentration and plasma renin activity are in conventional units (ng per dL and ng per mL per hour, respectively). Values above the threshold should not be viewed in isolation because the aldosterone-renin ratio may be exaggerated in cases of very low renin levels without significant elevation of aldosterone. Information from references 10, 13, and 15. Aldosterone-renin ratio Plasma renin activity > 1 ng per mL per hour Diagnosis unlikely Plasma renin activity 0.6 to 1 ng per mL per hour Perform confirmatory testing Plasma renin activity < 0.6 ng per mL per hour Plasma aldosterone concen - tration 20 to 29 ng per dL Plasma aldosterone con - centration ≥ 30 ng per dL Diagnosis confirmed Plasma aldosterone concen - tration 11 to 19 ng per dL Perform confirmatory testing Plasma aldosterone con - centration ≤ 10 ng per dL Diagnosis unlikely Potassium < 3.5 mEq per L Diagnosis confirmed Potassium ≥ 3.5 mEq per L Perform confirmatory testing > 30 Diagnosis unlikely ≤ 30",
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+    "text": "276 American Family Physician www.aafp.org/afp Volume 108, Number 3 ◆ September 2023 significant higher rate of complete biochemical success when adrenalectomy was guided by adrenal vein sampling com - pared with adrenalectomy guided by CT alone (odds ratio = 2.78; 95% CI, 1.88 to 4.12).",
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+    "text": "18 Adrenal vein sampling is a nuanced procedure. Blood samples are taken from a peripheral vein and the right and left adrenal veins and tested for aldosterone and cortisol lev - els. 22 Success rates for adequate sampling range from 30.5% 23 to 99.2%.",
+    "tokenCount": 57,
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+    "text": "24 Operator experience at a center that performs at least 12 procedures per year has been shown to be associated with higher sampling adequacy. 25,26 An experienced and dedicated laboratory is necessary for a successful adrenal vein sampling program, 27 and the results should be interpreted based on expert consensus guidelines.",
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+    "text": "28,29 Treatment UNILATERAL ALDOSTERONE PRODUCTION Adrenalectomy is recommended in cases of uni - lateral aldosterone production. Although hyper - tension is cured in only approximately one-third of cases, biochemical cure is achieved in 94% of cases.",
+    "tokenCount": 57,
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+    "text": "30 Compared with medical management, adrenalectomy reduces the rate of composite adverse cardiovascular outcomes by one-half 31 and is associated with superior quality of life. 32 BILATERAL ALDOSTERONE PRODUCTION When aldosterone production is bilateral, medi - cal therapy is necessary.",
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+    "text": "Mineralocorticoid recep - tor antagonists are the cornerstone of therapy for patients with primary aldosteronism. They are often used concurrently with other antihyper - tensives. Dietary sodium restriction of less than 1,500 mg per day is recommended.",
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+    "text": "33 Spironolactone is a nonselective mineralocorti - coid receptor antagonist and is the initial medica - tion of choice. Typical starting dosages are 12.5 to 25 mg per day and are increased, as needed, to a maximum dosage of 400 mg per day.",
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+    "text": "10 Its dose - dependent antiandrogenic properties can lead to adverse effects, such as gynecomastia (more than 10%), erectile dysfunction, decreased libido, and irregular menses (1% to 10%).",
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+    "text": "34 If these adverse effects occur, eplerenone, a more selective but less potent and more expensive mineralocorticoid receptor blocker, may be used. 13,34 Recent observational studies have shown that titrating mineralocorticoid receptor antagonists based on plasma renin concentrations may lead to better outcomes.",
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+    "text": "35,36 Therefore, future guidelines may include interval measurements of renin as part of the mineralocorticoid receptor antagonist dosing strategy. 36 Data Sources: A PubMed search of clinical trials, meta-analyses, randomized controlled trials, and systematic reviews from 2000 to 2022 was completed using the key terms primary hyperaldo - steronism, primary aldosteronism, and hyperaldosteronism.",
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+    "text": "We also searched the Cochrane database, Agency for Healthcare Research and Quality (AHRQ), and Essential Evidence Plus using the same terms, but with limited results. If studies used race and/ or gender as a patient category but did not define how these TABLE 3 Medications to Hold Before Primary Aldosteronism Te s t in g* Medications Hold priority Duration of hold (weeks) Mineralocorticoid receptor antagonists † Mandatory 4 Angiotensin-converting enzyme inhib - itors, angiotensin receptor blockers, beta blockers, diuretics, dihydropyridine calcium channel blockers Optional 2 to 4 Alpha blockers, nondihydropyridine cal - cium channel blockers, vasodilators Continue — Note:",
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+    "text": "Because of interference with the renin -angiotensin-aldosterone system, certain antihypertensive medications may alter renin and angiotensin levels. *—Based on the 2016 Endocrine Society Guidelines.",
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+    "text": "† —Low-dose mineralocorticoid receptor antagonists may not need to be held before aldosterone-renin ratio testing, especially if renin levels are not suppressed. Information from reference 13.",
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+    "text": "TABLE 2 Clinical Criteria for Patients Who Require Case Detection Testing for Primary Aldosteronism Controlled hypertension (any one of the following) Adrenal nodule Atrial fibrillation* Family history of early stroke (i.e., younger than 40 years) First-degree relative with primary aldosteronism Hypokalemia Obstructive sleep apnea Resistant hypertension † All patients Note:",
+    "tokenCount": 83,
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+  {
+    "text": "Criteria are based on the 2016 Endocrine Society Guidelines. *—The Endocrine Society does not distinctly list atrial fibrillation as criteria, but it acknowledges that some centers recommend testing given its association with primary aldosteronism.",
+    "tokenCount": 49,
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+    "text": "† —Resistant hypertension is hypertension that persists despite the concurrent use of three different classes of antihypertensive medications or the use of four antihypertensive medications to achieve adequate blood pressure control.",
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+    "text": "Information from reference 13. September 2023 ◆ Volume 108, Number 3 www.aafp.org/afp American Family Physician 277 PRIMARY ALDOSTERONISM categories were assigned, they were excluded. Studies may not represent all populations. Physicians may need to exercise caution in applying such guidelines to populations not included (e.g., patients of color, younger individuals). Search dates: Octo - ber 2, 2022, and May 19, 2023. The Authors KEITH B. QUENCER, MD, is an associate professor in the Department of Interventional Radiology at Oregon Health & Science University, Portland. J. B. (BRUIN) RUGGE, MD, is an associate professor in the Department of Family Medicine at Oregon Health & Science University. OLGA SENASHOVA, MD, is an assistant professor of otolar - yngology at Oregon Health & Science University. Address correspondence to Keith B. Quencer, MD, Oregon Health & Science University Hospital, 3181 SW Sam Jack - son Park Rd., Portland, OR 97239 (kbquencer@ gmail.com",
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+  {
+    "text": "Reprints are not available from the authors. References 1. Conn JW, Louis LH. Primary aldosteronism, a new clinical entity. Ann Intern Med . 1956; 44(1): 1-15. 2. Monticone S, Burrello J, et al. Prevalence and clinical manifestations of primary aldosteronism encountered in primary care practice. J Am Coll Cardiol . 2017; 69(14): 1811-1820. 3. Brown JM, Siddiqui M, et al. The unrecognized prevalence of primary aldo - steronism: a cross-sectional study. Ann Intern Med . 2020; 173(1): 10-20. 4. Cohen JB, Cohen DL, et al. Testing for primary aldosteronism and min - eralocorticoid receptor antagonist use among U.S. veterans: a retro - spective cohort study. Ann Intern Med . 2021; 174(3): 289-297. 5. Jaffe G, Gray Z, et al. Screening rates for primary aldosteronism in resis - tant hypertension: a cohort study. Hypertension . 2020; 75(3): 650-659. 6. Lim YY, Shen J, et al. Current pattern of primary aldosteronism diagno - sis: delayed and complicated. Aust J Gen Pract . 2018; 47(10): 712-718. 7. Gilbert KC, Brown NJ. Aldosterone and inflammation. Curr Opin Endo - crinol Diabetes Obes . 2010; 17(3): 199-204. 8. Brown NJ. Contribution of aldosterone to cardiovascular and renal inflammation and fibrosis. Nat Rev Nephrol . 2013; 9(8): 459-469. 9. Rosa J, Somlóová Z, et al. Peripheral arterial stiffness in primary aldostero - nism. Physiol Res . 2012; 61(5): 461-468. 10. Young WF Jr. Diagnosis and treatment of primary aldosteronism: prac - tical clinical perspectives. J Intern Med .",
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+  {
+    "text": "2019; 285(2): 126-148. 11. Monticone S, D’Ascenzo F, et al. Cardiovascular events and target organ damage in primary aldosteronism compared with essential hyperten - sion: a systematic review and meta-analysis. Lancet Diabetes Endocri - nol . 2018; 6(1): 41-50. 12. Monticone S, Sconfienza E, et al. Renal damage in primary aldosteronism: a systematic review and meta-analysis. J Hypertens . 2020; 38(1): 3-12 . 13. Funder JW, Carey RM, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab . 2016; 101(5): 1889-1916. 14. Rossi GP, Bernini G, et al.; PAPY Study Investigators. A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol . 2006; 48(11): 2293-2300. 15. Kawashima J, Araki E, et al. Baseline plasma aldosterone level and renin activity allowing omission of confirmatory testing in primary aldostero - nism. J Clin Endocrinol Metab . 2020; 105(5): dgaa117. 16. Umakoshi H, Sakamoto R, et al. Role of aldosterone and potassium levels in sparing confirmatory tests in primary aldosteronism. J Clin Endocrinol Metab . 2020; 105(4): dgz148. 17. Wu S, Yang J, et al. Confirmatory tests for the diagnosis of primary aldo - steronism: a systematic review and meta-analysis. Clin Endocrinol (Oxf) . 2019; 90(5): 641-648. 18. Yan Y, Sun HW, et al. Prognosis of adrenalectomy guided by computed tomography versus adrenal vein sampling in patients with primary aldo -",
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