テスト・セキュリティのスキル

This skill recommends re-evaluating the need for treatment of other pituitary hormone deficiencies in the postoperative period following surgical intervention for Cushing's syndrome. It is triggered when assessing a post-op CS patient for ongoing pituitary function, evaluating for hypopituitarism, or checking HPA axis recovery with morning cortisol/ACTH stimulation tests and pituitary MRI within 1–3 months.

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This skill recommends localizing and resecting ectopic ACTH-secreting tumors with node dissection when ectopic ACTH secretion is suspected or confirmed. Clinical triggers include unexplained persistent hypercortisolism after pituitary surgery, elevated ACTH with negative pituitary MRI, or identification of occult ectopic ACTH syndrome (EAS) on biochemical testing.

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This skill recommends follow-up morning cortisol and/or ACTH stimulation tests or insulin-induced hypoglycemia to assess HPA axis recovery in postoperative Cushing's syndrome patients with at least one intact adrenal gland. Triggers include postoperative remission (morning cortisol <5 µg/dL or UFC <28–56 nmol/d) and the need to evaluate HPA recovery before glucocorticoid discontinuation.

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This skill recommends lifelong follow-up tests for cardiac myxoma and associated disease (testicular tumors, acromegaly, thyroid lesions) in patients with Carney complex. Use when managing a Cushing’s syndrome patient with a confirmed or suspected Carney complex diagnosis (e.g., spotty skin lentigines, cardiac myxoma, endocrine tumors).

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This skill suggests follow-up tests for specific comorbidities associated with Cushing's syndrome in patients with adrenal adenoma when CT density is less than 10 Hounsfield units. Use when managing a post-adrenalectomy Cushing's syndrome patient with confirmed adrenal adenoma pathology and low-density imaging (<10 HU).

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Determines when to pursue genetic testing for glucocorticoid-remediable aldosteronism (FH-I/GRA) in patients with confirmed primary aldosteronism (PA). Indicated when PA onset is before age 20 or there is a family history of PA or stroke before age 40.

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Identifies patients with adrenal tumors on CT who should undergo dexamethasone suppression test to evaluate for autonomous cortisol co-secretion. Triggers include when a clinician finds an adrenal tumor on CT and asks 'Should I test for cortisol co-secretion?' or is planning AVS for a tumor >3.0 cm.

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This skill determines whether confirmatory testing can be omitted after a positive aldosterone-to-renin ratio (ARR) in patients with suspected primary aldosteronism. It is applied when a patient exhibits spontaneous hypokalemia, undetectable renin, and a plasma aldosterone concentration ≥20 ng/dL (550 pmol/L).

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Recommends antihypertensive therapy including mineralocorticoid receptor antagonists (MRAs) for patients with a positive primary aldosteronism (PA) screening test who decline confirmatory testing. Triggers include when a patient has positive screening but refuses additional tests and asks "What should I treat with?" or initiates empiric therapy, with preference for MRAs in typical PA presentations (e.g., spontaneous hypokalemia, resistant hypertension, adrenal tumor on CT).

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Identifies patients with a positive aldosterone-to-renin ratio screening who may proceed directly to subtype testing without confirmatory testing based on specific clinical criteria. Triggers include spontaneous hypokalemia, baseline plasma aldosterone concentration >100 pg/mL (CLEIA), renin suppression, or a clinician questioning the need for a confirmatory test after a positive screen.

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Guides selection of the optimal confirmatory test (CCT, SIT, FUT, OSLT) for primary aldosteronism based on patient safety and feasibility. Triggers include when a clinician asks “Which confirmatory test should I use?” or evaluates patient comorbidities before testing.

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Determines when to test for germline KCNJ5 mutations indicating familial hyperaldosteronism type III in very young patients with primary aldosteronism. Triggered by severe early-onset hypertension with hypokalemia in infants or young children (<20 years) with confirmed PA.

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Determines if PAC/PRA ratio and PAC levels indicate positive or provisionally positive screening for primary aldosteronism. Triggered when a clinician has PAC and PRA results and asks “Is this screening test positive for PA?” or needs to interpret borderline results.

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Evaluates likelihood of primary aldosteronism by measuring plasma aldosterone suppression after oral captopril; normal suppression ≥30% makes PA unlikely, while lack of suppression with persistently suppressed plasma renin activity suggests PA. Use when assessing captopril challenge test (CCT) results for PA diagnosis in patients with positive aldosterone-to-renin ratio.

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Recommends performing a dexamethasone suppression test to evaluate for autonomous cortisol secretion in patients with primary aldosteronism and adrenal adenoma. Triggered when a clinician considers whether to perform a dexamethasone suppression test in a patient with PA and adrenal adenoma.

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Interprets the saline infusion test (SIT) to assess the probability of primary aldosteronism when a patient has a positive aldosterone-to-renin ratio (ARR) and requires confirmatory testing. Triggers include evaluating post‑infusion plasma aldosterone concentration (PAC) after a positive ARR, hypertension work‑up, or when deciding whether to proceed to adrenal venous sampling (AVS).

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Interprets the postural stimulation test to detect angiotensin II‑unresponsive aldosterone‑producing adenoma (APA) or familial hyperaldosteronism type I (FH‑I) when aldosterone fails to rise with upright posture. Triggered by clinical cues such as “postural stimulation test shows no aldosterone increase”, “suspected APA with non‑responsive aldosterone”, or “evaluating FH‑I in young patients with early‑onset hypertension and hypokalemia”.

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This skill interprets the oral sodium loading test for primary aldosteronism by evaluating 24‑hour urinary aldosterone excretion after a high‑sodium diet. Use when reviewing results of an "oral sodium loading test" for PA diagnosis; trigger phrases include "urinary aldosterone excretion ≤10 g/24 h" (PA unlikely) or "≥12 g/24 h (Mayo) / ≥14 g/24 h (Cleveland)" (PA highly likely).

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Selects the aldosterone-to-renin ratio (ARR) method over hypokalemia for screening hypertensive patients for primary aldosteronism. Use when a clinician asks what test to use for screening hypertensive patients with resistant hypertension or unexplained hypokalemia for PA.

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Recommends correcting serum potassium to the laboratory reference range and repeating aldosterone-to-renin ratio (ARR) screening when the initial screen is negative in a hypertensive patient with hypokalemia. Use when a clinician encounters a negative PA screen in a hypertensive patient with hypokalemia and wonders whether to repeat testing after potassium repletion.

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Determines when to avoid aldosterone suppression testing in hypertensive patients with a positive PA screen who have normokalemia and suppressed aldosterone below assay‑specific cutoffs (<11 ng/dL immunoassay or <8 ng/dL LC‑MS/MS), indicating low likelihood of primary aldosteronism. Use when a clinician asks whether to skip confirmatory suppression testing based on low pretest probability.

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Recommends diagnostic testing to exclude primary adrenal insufficiency (PAI) in acutely ill patients presenting with otherwise unexplained volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain, hyperpigmentation, or hypoglycemia (especially in children). Use when clinical suspicion arises from these suggestive signs or symptoms suggestive of PAI.

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The Endocrine Society recommends a standard-dose corticotropin (ACTH) stimulation test to confirm primary adrenal insufficiency when clinical suspicion arises from symptoms such as hypotension, hyponatremia, hyperkalemia, or unexplained fatigue. Dosing is weight/age based: 250 µg for adults and children ≥2 years, 15 µg/kg for infants, and 125 µg for children <2 years.

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Suggests using morning cortisol ≤140 nmol/L (5 µg/dL) in combination with ACTH as a preliminary test suggestive of primary adrenal insufficiency when a corticotropin stimulation test is not feasible. Use when patients present with indicative symptoms such as hypotension, hyponatremia, hyperkalemia, or fatigue and corticotropin stimulation testing cannot be performed.

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