Yıl: 2022 Cilt: 14 Sayı: 1 Sayfa Aralığı: 56 - 68 Metin Dili: Türkçe DOI: 10.4274/jcrpe.galenos.2021.2021.0184 İndeks Tarihi: 09-06-2022

17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses

Öz:
Objective: Standard dose synacthen stimulation test (SDSST) is a gold standard screening test for evaluating adrenal gland function. Despite studies using SDSST to identify heterozygosity in CYP21A2, the reliability of the test for this purpose is still controversial. Therefore, the meta-analyses were performed to determine the differences in 17-hydroxyprogesterone (17-OHP) responses to standard dose (0.25 mg) SDSST in the diagnosis of CYP21A2 heterozygous individuals, with or without clinical signs of androgen excess disorders. Methods: PubMed and MEDLINE databases were searched. A total of 1215 subjects (heterozygous carriers n=669, mutation-free controls n=546) were included in the meta-analyses. Results: Basal 17-OHP median/mean levels were 4.156 (3.05-10.5)/5.241 (±2.59) nmol/L and 3.90 (2.20-9.74)/4.67 (±2.62) nmol/L in symptomatic heterozygous carriers and symptomatic mutation-free controls, respectively. Stimulated 17-OHP median/mean levels were 17.29 (14.22-37.2)/19.51 (±7.63) nmol/L and 9.27 (7.32-15.9)/10.77 (±3.48) nmol/L in symptomatic heterozygous carriers and symptomatic mutation-free controls, respectively. Basal 17-OHP median/mean levels were 3.21 (2.64-4.78)/3.33 (±0.84) nmol/L and 3.12 (1.82-3.6)/2.83 (±0.71) nmol/L in asymptomatic heterozygous carriers and asymptomatic mutation-free healthy controls, respectively. Stimulated 17-OHP median/mean levels were 14.16 (12.73-16.37)/14.16 (±1.37) nmol/L and 6.26 (4.9-8.23)/6.48 (±1.2) nmol/L in asymptomatic heterozygous carriers and asymptomatic mutation-free healthy controls, respectively. The cut-off levels for stimulated 17-OHP were 10.48 nmol/L and 13.48 nmol/L for asymptomatic heterozygous and symptomatic heterozygous, respectively. Conclusion: The meta-analyses support the idea that stimulated 17-OHP level has potential for use in identifying CYP21A2 carriers. Besides, considering differences in the basal and stimulated 17-OHP levels in symptomatic heterozygous individuals compared to those who were asymptomatic heterozygous could increase the accuracy of the test.
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  • 1. Azziz R, Sanchez LA, Knochenhauer ES, Moran C, Lazenby J, Stephens KC, Taylor K, Boots LR. Androgen excess in women: experience with over 1000 consecutive patients. J Clin Endocrinol Metabolism 2004;89:453-462.
  • 2. Barber TM, Franks S. Genetics of polycystic ovary syndrome. Front Horm Res 2013;40:28-39. Epub 2012 Oct 18
  • 3. Panda PK, Rane R, Ravichandran R, Singh S, Panchal H. Genetics of PCOS: A systematic bioinformatics approach to unveil the proteins responsible for PCOS. Genom Data 2016;8:52-60.
  • 4. Gharani N, Waterworth DM, Batty S, White D, Gilling-Smith C, Conway GS, McCarthy M, Franks S, Williamson R. Association of the steroid synthesis gene CYP11a with polycystic ovary syndrome and hyperandrogenism. Hum Mol Genet 1997;6:397-402.
  • 5. Kahsar-Miller MD, Nixon C, Boots LR, Go RC, Azziz R. Prevalence of polycystic ovary syndrome (PCOS) in first-degree relatives of patients with PCOS. Fertil Steril 2001;75:53-58.
  • 6. Robyr D, Llor J, Gaudin G, Schneider N. Polycystic ovary syndrome and congenital adrenal hyperplasia: a different entity for comparable phenotypes? Rev Med Suisse 2007;3:1595-1596.
  • 7. Nandagopal R, Sinaii N, Avila NA, Van Ryzin C, Chen W, Finkielstain GP, Mehta SP, McDonnell NB, Merke DP. Phenotypic profiling of parents with cryptic nonclassic congenital adrenal hyperplasia: findings in 145 unrelated families. Eur J Endocrinol 2011;164:977-984. Epub 2011 Mar 28
  • 8. New MI. Extensive clinical experience: nonclassical 21-hydroxylase deficiency. J Clin Endocrinol Metab 2006;91:4205-4214. Epub 2006 Aug 15
  • 9. Siegel SF, Finegold DN, Urban MD, McVie R, Lee PA. Premature pubarche: etiological heterogeneity. J Clin Endocrinol Metab 1992;74:239-247.
  • 10. del Balzo P, Borrelli P, Cambiaso P, Danielli E, Cappa M. Adrenal Steroidogenic Defects in Children with Precocious Pubarche. Horm Res 1992;37:180-184.
  • 11. Leite MV, Mendonça BB, Arnhold IJ, Estefan V, Nunes C, Nicolau W, Bloise W. Identification of nonclassical 21-hydroxylase deficiency in girls with precocious pubarche. J Endocrinol Invest 1991;14:11-15.
  • 12. Azziz R, Owerbach D. Molecular abnormalities of the 21-hydroxylase gene in hyperandrogenic women with an exaggerated 17-hydroxyprogesterone response to short-term adrenal stimulation. Am J Obstet Gynecol 1995;172:914-918.
  • 13. Hasinski S. Assessment of adrenal glucocorticoid function. Which tests are appropriate for screening? Postgrad Med 1998;104:61-64.
  • 14. Azziz R, Rafi A, Smith BR, Bradley EL Jr, Zacur HA. On the origin of the elevated 17-hydroxyprogesterone levels after adrenal stimulation in hyperandrogenism. J Clin Endocrinol Metab 1990;70:431-436.
  • 15. Dacou-Voutetakis C, Dracopoulou M. High incidence of molecular defects of the CYP21 gene in patients with premature adrenarche. J Clin Endocrinol Metab 1999;84:1570-1574.
  • 16. Witchel SF, Aston CE. The role of heterozygosity for CYP21 in the polycystic ovary syndrome. J Pediatr Endocrinol Metab 2000;13(Suppl 5):1315-1317.
  • 17. Blanché H, Vexiau P, Clauin S, Le Gall I, Fiet J, Mornet E, Dausset J, Bellanné-Chantelot C. Exhaustive screening of the 21-hydroxylase gene in a population of hyperandrogenic women. Hum Genet 1997;101:56-60.
  • 18. Witchel SF, Lee PA, Suda-Hartman M, Hoffman EP. Hyperandrogenism and manifesting heterozygotes for 21-hydroxylase deficiency. Biochem Mol Med 1997;62:151-158.
  • 19. Cisternino M, Dondi E, Martinetti M, Lorini R, Salvaneschi L, Cuccia M, Severi F. Exaggerated 17-hydroxyprogesterone response to short-term adrenal stimulation and evidence for CYP21B gene point mutations in true precocious puberty. Clin Endocrinol (Oxf) 1998;48:555-560.
  • 20. Ostlere LS, Rumsby G, Holownia P, Jacobs HS, Rustin MH, Honour JW. Carrier status for steroid 21-hydroxylase deficiency is only one factor in the variable phenotype of acne. Clin Endocrinol (Oxf) 1998;48:209- 215.
  • 21. Polat S, Karaburgu S, Ünlühizarcı K, Dündar M, Özkul Y, Arslan YK, Karaca Z, Kelestimur F. Comprehensive genotyping of Turkish women with hirsutism. J Endocrinol Invest 2019;42:1077-1087. Epub 2019 Feb 27
  • 22. Knochenhauer ES, Cortet-Rudelli C, Cunnigham RD, Conway-Myers BA, Dewailly D, Azziz R. Carriers of 21-hydroxylase deficiency are not at increased risk for hyperandrogenism. J Clin Endocrinol Metab 1997;82:479-485.
  • 23. Escobar-Morreale HF, San Millán JL, Smith RR, Sancho J, Witchel SF. The presence of the 21-hydroxylase deficiency carrier status in hirsute women: phenotype-genotype correlations. Fertil Steril 1999;72:629- 638.
  • 24. Moran C, Azziz R, Weintrob N, Witchel SF, Rohmer V, Dewailly D, Marcondes JA, Pugeat M, Speiser PW, Pignatelli D, Mendonca BB, Bachega TA, Escobar-Morreale HF, Carmina E, Fruzzetti F, Kelestimur F. Reproductive outcome of women with 21-hydroxylase-deficient nonclassic adrenal hyperplasia. J Clin Endocrinol Metab 2006;91:3451- 3456. Epub 2006 Jul 5
  • 25. Potau N, Rique S, Eduardo I, Marcos V, Ibanez L. Molecular defects of the CYP21 gene in Spanish girls with isolated precocious pubarche. Eur J Endocrinol 2002;147:485-488.
  • 26. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 1988.
  • 27. Hariyanto TI, Japar KV, Kwenandar F, Damay V, Siregar JI, Lugito NPH, Tjiang MM, Kurniawan A. Inflammatory and hematologic markers as predictors of severe outcomes in COVID-19 infection: A systematic review and meta-analysis. Am J Emerg Med 2021;41:110-119. Epub 2020 Dec 30
  • 28. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-560.
  • 29. Pillemer RJLaDB. Summing Up: The Science of Reviewing Research. Harvard University Press, Cambridge, MA, 1984.
  • 30. Neocleous V, Fanis P, Toumba M, Phedonos AAP, Picolos M, Andreou E, Kyriakides TC, Tanteles GA, Shammas C, Phylactou LA, Skordis N. Variations in the 3’UTR of the CYP21A2 Gene in Heterozygous Females with Hyperandrogenaemia. Int J Endocrinol 2017;2017:8984365. Epub 2017 Apr 12
  • 31. Settas N, Dracopoulou-Vabouli M, Dastamani A, Katsikis I, Chrousos G, Panidis D, Dacou-Voutetakis C. CYP21A2 mutations in women with polycystic ovary syndrome (PCOS). Horm Metab Res 2013;45:383- 386. Epub 2013 Feb 5
  • 32. Witchel SF, Lee PA, Suda-Hartman M, Trucco M, Hoffman EP. Evidence for a heterozygote advantage in congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Clin Endocrinol Metab 1997;82:2097- 2101.
  • 33. Witchel SF, Lee PA. Identification of heterozygotic carriers of 21-hydroxylase deficiency: sensitivity of ACTH stimulation tests. Am J Med Genet 1998;76:337-342.
  • 34. Oriolo C, Fanelli F, Castelli S, Mezzullo M, Altieri P, Corzani F, Pelusi C, Repaci A, Di Dalmazi G, Vicennati V, Baldazzi L, Menabò S, Dormi A, Nardi E, Brillanti G, Pasquali R, Pagotto U, Gambineri A. Steroid biomarkers for identifying non-classic adrenal hyperplasia due to 21-hydroxylase deficiency in a population of PCOS with suspicious levels of 17OH-proges rone. J Endocrinol Invest 2020;43:1499-1509. Epub 2020 Mar 31
  • 35. Napolitano E, Manieri C, Restivo F, Composto E, Lanfranco F, Repici M, Pasini B, Einaudi S, Menegatti E. Correlation between genotype and hormonal levels in heterozygous mutation carriers and non-carriers of 21-hydroxylase deficiency. J Endocrinol Invest 2011;34:498-501. Epub 2010 Jul 29
  • 36. Bachega TA, Billerbeck AE, Marcondes JA, Madureira G, Arnhold IJ, Mendonca BB. Influence of different genotypes on 17-hydroxyprogesterone levels in patients with nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Clin Endocrinol (Oxf) 2000;52:601-607.
  • 37. Costa-Barbosa FA, Tonetto-Fernandes VF, Carvalho VM, Nakamura OH, Moura V, Bachega TA, Vieira JG, Kater CE. Superior discriminating value of ACTH-stimulated serum 21-deoxycortisol in identifying heterozygote carriers for 21-hydroxylase deficiency. Clin Endocrinol (Oxf) 2010;73:700-706.
  • 38. Paris F, Tardy V, Chalançon A, Picot MC, Morel Y, Sultan C. Premature pubarche in Mediterranean girls: high prevalence of heterozygous CYP21 mutation carriers. Gynecol Endocrinol 2010;26:319-324.
  • 39. Bidet M, Bellanné-Chantelot C, Galand-Portier MB, Tardy V, Billaud L, Laborde K, Coussieu C, Morel Y, Vaury C, Golmard JL, Claustre A, Mornet E, Chakhtoura Z, Mowszowicz I, Bachelot A, Touraine P, Kuttenn F. Clinical and molecular characterization of a cohort of 161 unrelated women with nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency and 330 family members. J Clin Endocrinol Metab 2009;94:1570-1578. Epub 2009 Feb 10
  • 40. Grodnitskaya E, Kurtser M. The prevalence of non-classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency in Russian women with hyperandrogenism. Hum Fertil (Camb) 2018;21:281-287. Epub 2017 Jul 3
  • 41. Admoni O, Israel S, Lavi I, Gur M, Tenenbaum-Rakover Y. Hyperandrogenism in carriers of CYP21 mutations: the role of genotype. Clin Endocrinol (Oxf) 2006;64:645-651.
  • 42. Strott CA, Lipsett MB. Measurement of 17-hydroxyprogesterone in human plasma. J Clin Endocrinol Metab 1968;28:1426-1430.
  • 43. Barnes ND, Atherden SM. Diagnosis of congenital adrenal hyperplasia by measurement of plasma 17-hydroxyprogesterone. Arch Dis Child 1972;47:62-65.
  • 44. Laureti S, Arvat E, Candeloro P, Di Vito L, Ghigo E, Santeusanio F, Falorni A. Low dose (1 microg) ACTH test in the evaluation of adrenal dysfunction in pre-clinical Addison’s disease. Clin Endocrinol (Oxf) 2000;53:107-115.
  • 45. Dökmetaş HS, Colak R, Keleştimur F, Selçuklu A, Unlühizarci K, Bayram F. A comparison between the 1-microg adrenocorticotropin (ACTH) test, the short ACTH (250 microg) test, and the insulin tolerance test in the assessment of hypothalamo-pituitary-adrenal axis immediately after pituitary surgery. J Clin Endocrinol Metab 2000;85:3713-3719.
  • 46. Unlühizarci K, Bayram F, Güven M, Kula M, Colak R, Kelestimur F. Cortisol responses to low (1 microg) and standard (250 microg) dose ACTH stimulation tests in patients with primary hypothyroidism. Clin Endocrinol (Oxf) 2001;54:700-702.
  • 47. Kirnap M, Colak R, Eser C, Ozsoy O, Tutus A, Kelestimur F. A comparison between low-dose (1 microg), standard-dose (250 microg) ACTH stimulation tests and insulin tolerance test in the evaluation of hypothalamo-pituitary-adrenal axis in primary fibromyalgia syndrome. Clin Endocrinol (Oxf) 2001;55:455-459.
  • 48. Colak R, Keleştimur F, Unlühizarci K, Bayram F, Sahin Y, Tutuş A. A comparison between the effects of low dose (1 microg) and standard dose (250 microg) ACTH stimulation tests on adrenal P450c17alpha enzyme activity in women with polycystic ovary syndrome. Eur J Endocrinol 2002;147:473-477.
  • 49. Turner EI, Watson MJ, Perry LA, White MC. Investigation of adrenal function in women with oligomenorrhoea and hirsutism (clinical PCOS) from the north-east of England using an adrenal stimulation test. Clin Endocrinol (Oxf) 1992;36:389-397.
  • 50. Armengaud JB, Charkaluk ML, Trivin C, Tardy V, Bréart G, Brauner R, Chalumeau M. Precocious pubarche: distinguishing late-onset congenital adrenal hyperplasia from premature adrenarche. J Clin Endocrinol Metab 2009;94:2835-2840. Epub 2009 May 19
  • 51. Peter M, Sippell WG, Lorenzen F, Willig RP, Westphal E, Grosse-Wilde H. Improved test to identify heterozygotes for congenital adrenal hyperplasia without index case examination. Lancet 1990;335:1296- 1299.
  • 52. Gutai JP, Kowarski AA, Migeon CJ. The detection of the heterozygous carrier for congenital virilizing adrenal hyperplasia. J Pediatr 1977;90:924-929.
  • 53. Handelsman DJ, Howe CJ, Conway AJ, Turtle JR. Heterozygote detection in congenital adrenal hyperplasia. Clin Chem 1983;29:48-50. 54. Speiser PW, White PC. Congenital adrenal hyperplasia. N Engl J Med 2003;349:776-788.
  • 55. Dracopoulou-Vabouli M, Maniati-Christidi M, Dacou-Voutetakis C. The spectrum of molecular defects of the CYP21 gene in the Hellenic population: variable concordance between genotype and phenotype in the different forms of congenital adrenal hyperplasia. J Clin Endocrinol Metab 2001;86:2845-2848.
  • 56. New MI, Lorenzen F, Lerner AJ, Kohn B, Oberfield SE, Pollack MS, Dupont B, Stoner E, Levy DJ, Pang S, Levine LS. Genotyping steroid 21-hydroxylase deficiency: hormonal reference data. J Clin Endocrinol Metab 1983;57:320-326.
  • 57. Fiet J, Villette JM, Galons H, Boudou P, Burthier JM, Hardy N, Soliman H, Julien R, Vexiau P, Gourmelen M, Kuttenn F. The application of a new highly-sensitive radioimmunoassay for plasma 21-deoxycortisol to the detection of steroid-21-hydroxylase deficiency. Ann Clin Biochem 1994;31:56-64.
  • 58. Maffazioli GDN, Bachega TASS, Hayashida SAY, Gomes LG, Valassi HPL, Marcondes JAM, Mendonca BB, Baracat EC, Maciel GAR. Steroid Screening Tools Differentiating Nonclassical Congenital Adrenal Hyperplasia and Polycystic Ovary Syndrome. J Clin Endocrinol Metab 2020;105:369.
  • 59. Temeck JW, Pang SY, Nelson C, New MI. Genetic defects of steroidogenesis in premature pubarche. J Clin Endocrinol Metab 1987;64:609-617.
  • 60. Escobar-Morreale HF, Sanchón R, San Millán JL L. A prospective study of the prevalence of nonclassical congenital adrenal hyperplasia among women presenting with hyperandrogenic symptoms and signs. J Clin Endocrinol Metab 2008;93:527-533. Epub 2007 Nov 13
  • 61. Gönç EN, Ozön ZA, Alikaşifoğlu A, Engiz O, Bulum B, Kandemir N. Is basal serum 17-OH progesterone a reliable parameter to predict nonclassical congenital adrenal hyperplasia in premature adrenarche? Turk J Pediatr 2011;53:274-280.
  • 62. Miller WL, Auchus RJ. The molecular biology, biochemistry, and physiology of human steroidogenesis and its disorders. Endocr Rev 2011;32:81-151. Epub 2010 Nov 4
  • 63. Kulle AE, Riepe FG, Hedderich J, Sippell WG, Schmitz J, Niermeyer L, Holterhus PM. LC-MS/MS based determination of basal- and ACTHstimulated plasma concentrations of 11 steroid hormones: implications for detecting heterozygote CYP21A2 mutation carriers. Eur J Endocrinol 2015;173:517-524.
  • 64. Barr M. A study of genetic variability at the CYP11B2/B1 locus and its importance in human hypertension. University of Glasgow, 2006;1- 296.
  • 65. Nishi H, Kimura A, Harada H, Koga Y, Adachi K, Matsuyama K, Koyanagi T, Yasunaga S, Imaizumi T, Toshima H, Sasazuki T. A myosin missense mutation, not a null allele, causes familial hypertrophic cardiomyopathy. Circulation 1995;91:2911-2915.
  • 66. Gotoda Y, Wakamatsu N, Kawai H, Nishida Y, Matsumoto T. Missense and nonsense mutations in the lysosomal alpha-mannosidase gene (MANB) in severe and mild forms of alpha-mannosidosis. Am J Hum Genet 1998;63:1015-1024.
APA Polat S, ARSLAN Y (2022). 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. , 56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
Chicago Polat Seher,ARSLAN YUSUF KEMAL 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. (2022): 56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
MLA Polat Seher,ARSLAN YUSUF KEMAL 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. , 2022, ss.56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
AMA Polat S,ARSLAN Y 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. . 2022; 56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
Vancouver Polat S,ARSLAN Y 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. . 2022; 56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
IEEE Polat S,ARSLAN Y "17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses." , ss.56 - 68, 2022. 10.4274/jcrpe.galenos.2021.2021.0184
ISNAD Polat, Seher - ARSLAN, YUSUF KEMAL. "17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses". (2022), 56-68. https://doi.org/10.4274/jcrpe.galenos.2021.2021.0184
APA Polat S, ARSLAN Y (2022). 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. Journal of Clinical Research in Pediatric Endocrinology, 14(1), 56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
Chicago Polat Seher,ARSLAN YUSUF KEMAL 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. Journal of Clinical Research in Pediatric Endocrinology 14, no.1 (2022): 56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
MLA Polat Seher,ARSLAN YUSUF KEMAL 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. Journal of Clinical Research in Pediatric Endocrinology, vol.14, no.1, 2022, ss.56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
AMA Polat S,ARSLAN Y 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. Journal of Clinical Research in Pediatric Endocrinology. 2022; 14(1): 56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
Vancouver Polat S,ARSLAN Y 17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses. Journal of Clinical Research in Pediatric Endocrinology. 2022; 14(1): 56 - 68. 10.4274/jcrpe.galenos.2021.2021.0184
IEEE Polat S,ARSLAN Y "17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses." Journal of Clinical Research in Pediatric Endocrinology, 14, ss.56 - 68, 2022. 10.4274/jcrpe.galenos.2021.2021.0184
ISNAD Polat, Seher - ARSLAN, YUSUF KEMAL. "17-Hydroxyprogesterone Response to Standard Dose Synacthen Stimulation Test in CYP21A2 Heterozygous Carriers and Non-carriers in Symptomatic and Asymptomatic Groups: Meta-analyses". Journal of Clinical Research in Pediatric Endocrinology 14/1 (2022), 56-68. https://doi.org/10.4274/jcrpe.galenos.2021.2021.0184