Naoki Higashibeppu

The ectopic secretion of growth hormone (GH) or growth hormone-releasing hormone (GHRH) is responsible for fewer than 1% of acromegaly cases. Furthermore, within this small population, GHRH-secreting pheochromocytomas/paragangliomas (PPGLs) are even rarer. A 57-year-old Japanese woman presented to our hospital for treatment of a large left-sided pheochromocytoma (PCC). A physical examination revealed enlargement of the nose and lips as well as macroglossia, thereby raising the suspicion of acromegaly, which was biochemically confirmed by a 75-g oral glucose tolerance test. Magnetic resonance imaging demonstrated a slightly enlarged pituitary gland but no definitive tumor. A left adrenalectomy was performed after careful dose titration of doxazosin and metyrosine. Postoperative biochemical improvement of GH excess and immunohistochemical analysis of the resected tumor confirmed the diagnosis of GHRH-secreting PCC. Given the possibility that PPGLs produce various ectopic hormones and peptides, thorough physical examinations remain fundamental for the accurate diagnosis and optimal management of patients with these tumors.

Background: Patients with critical illness may present with disease‐related malnutrition upon intensive care unit (ICU) admission. They are at risk of development and progression of malnutrition over the disease trajectory because of inflammation, dysregulated metabolism, and challenges with feeding.Methods: The Global Leadership Initiative on Malnutrition (GLIM) convened a panel of 36 clinical nutrition experts to develop consensus‐based guidance statements addressing the diagnosis of malnutrition during critical illness using a modified Delphi approach with a requirement of ≥75% agreement.Results: (1) To identify pre‐existing malnutrition, we suggest evaluation within 48 h of ICU admission when feasible (100% agreement) or within 4 days (94% agreement). (2) To identify the development and progression of malnutrition, we suggest re‐evaluation of all patients every 7–10 days (97% agreement). (3) To identify progressive loss of muscle mass, we suggest evaluation of muscle mass as soon as feasible (92% agreement) and again after 7–10 days (89% agreement). (4) To identify the development and progression of malnutrition before and after ICU discharge, we suggest re‐evaluating nutrition status before ICU discharge and during clinical visits that follow (100% agreement).Conclusion: Research using consistent etiologic and phenotypic variables offers great potential to assess the efficacy of nutrition interventions for critically ill patients with malnutrition. Assessment of these variables during and beyond the ICU stay will clarify the trajectory of malnutrition and enable exploration of impactful treatment modalities at each juncture. GLIM offers a diagnostic approach that can be used to identify malnutrition in critically ill patients.