Natural history of pituitary apoplexy: a long-term follow-up study.

BACKGROUND AND AIMS: Pituitary apoplexy (PA) is a rare neurosurgical emergency, associated with deficiency of one or more pituitary hormones. Few studies have explored the relative outcomes associated with conservative and neurosurgical intervention. METHODS: A retrospective evaluation of all patients with PA reviewed at Morriston Hospital was undertaken and diagnosis was obtained from Morriston database (Leicester Clinical Workstation database) between 1998 and 2019 from clinic letters and discharge summaries. RESULTS: Thirty-nine patients with PA were identified with a mean age of 74.5 years and 20 (51.3%) patients were women. Patients were followed up for a mean±SD 68.1±61.7 months. Twenty-three (59.0%) patients had a known pituitary adenoma. Commoner clinical presentations of PA were ophthalmoplegia or visual field loss. Following PA, 34 (87.2%) patients were noted to have a non-functioning pituitary adenoma (either pre-existing or new), while 5 (12.8%) patients had a pre-existing functional macroadenoma. Neurosurgical intervention was taken in 15 (38.5%) patients of which 3 (20.0%) patients also received radiotherapy, 2 (13.3%) patients had radiotherapy alone and the remainder managed conservatively. External ophthalmoplegia recovered in all cases. Visual loss remained in all cases. One (2.6%) patient with chromophobe adenoma had a significant second episode of PA requiring repeat surgery. CONCLUSION: PA often occurs in patients with undiagnosed adenoma. Hypopituitarism commonly occurred following conservative or surgical treatment. External ophthalmoplegia resolved in all cases, however, visual loss did not recover. Pituitary tumour recurrence and further PA episodes are rare.

Dapagliflozin is associated with improved glycaemic control and weight reduction at 44 months of follow-up in a secondary care diabetes clinic in the UK.

BACKGROUND AND AIMS: We examined HbA1c and cardiovascular risk factors with a median follow-up of 44 months therapy with dapagliflozin. METHODS: We undertook a clinical practice evaluation of 101 patients attending our clinic. RESULTS: Dapagliflozin resulted in a significant reduction in HbA1c 82.6 ± 15.7 v 68.7 ± 17.8 mmol/mol. CONCLUSION: Dapagliflozin maintains glycaemic control along with sustained improvements in weight and no decline in renal function.

Real-world clinical experience of Xultophy in the management of patients with type 2 diabetes in a secondary care clinic.

AIMS: Xultophy is the first fixed co-formulation pen containing insulin degludec and the glucagon-like peptide-1 (GLP-1) analogue liraglutide, authorized for type 2 diabetes patients since 2014. The aim was to review the clinical effectiveness of Xultophy across two hospitals in Wales. METHODS: Retrospective review of patients commenced on Xultophy between April 2016 and January 2018 was taken. Data related to glycemic control, weight and medication use were collected. RESULTS: Ninety-one patients were initiated on Xultophy, and 60 patients had follow-up for at least 6 months with a mean age of 57.3 years (47% male). Xultophy was well-tolerated, however, abdominal cramps and nausea limited use in three patients. Baseline HbA1c and weight were 84.7 mmol/mol and 101.5 kg. There were significant HbA1c reductions of 9.9 mmol/mol (p < 0.0001) and 13.4 mmol/mol (p < 0.008) at 6 and 12 months, and non-significant changes in weight. Patients with an HbA1c over 84 mmol/mol showed the greatest HbA1c improvement over 6-months. Those prescribed insulin prior to Xultophy had less significant improvements in HbA1c than those previously prescribed GLP-1 analogues. CONCLUSIONS: There were significant reductions in HbA1c and statistically insignificant weight gain over 12 months. Switching from GLP-1 analogues to Xultophy was associated with a greater HbA1c reduction compared to switching from insulin.

Hypophosphataemia: an important cause of collapse.

We present a case of a 44-year-old man, civil servant, who presented to the emergency department (ED) following an episode of collapse. He was usually fit and well and while at work he had developed a headache with pins and needles over his face and subsequently collapsed. On arrival to ED, he had a Glasgow Coma Scale (GCS) of 4/15. There was no history of note apart from being prescribed citalopram for depression. Laboratory investigations revealed severe hypophosphataemia (phosphate 0.19 mmol/L) and no other electrolyte abnormality. He was commenced on intravenous phosphate and his GCS improved to 15 within 4 hours. Further investigations revealed no cause for his severe hypophosphataemia and repeat bloods in clinic follow-up showed a normal phosphate level.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions.

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the centre of the controversy is the addition of a resting ECG to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcome-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs and resources. The decision to implement a cardiovascular screening programme, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions.

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs, and resources. The decision to implement a cardiovascular screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence-base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations, and Future Directions.

Cardiovascular (CV) screening in young athletes is widely recommended and routinely performed before participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for CV screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation CV screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal CV screening strategy for all athletes including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate CV screening strategy unique to their athlete population, community needs, and resources. The decision to implement a CV screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. American Medical Society for Sports Medicine is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

The impact of diagnosis: measuring the psychological response to being diagnosed with serious or potentially lethal cardiac disease in young competitive athletes.

AIM: To determine the psychological impact of athletes diagnosed with cardiac disease. METHODS AND DESIGN: Athletes diagnosed with cardiovascular disorders were recruited to complete the Impact of Event Scale (IES), a validated tool measuring responses to a traumatic event. IES scoring =0-88 (<12= normal, 12-32=recommend monitoring, >33=significant stress reaction). Subscales include: intrusion, avoidance and hyperarousal. RESULTS: 30 athletes (53% male, 83% Caucasian, median age 18.0, median age at diagnosis 15.7) participated. Diagnoses included: 6 hypertrophic cardiomyopathy, 9 Wolff Parkinson White, 4 Long QT syndrome, 3 atrial septal defect, 2 supraventricular tachycardia and 6 other. For the group, the mean IES-Revised (IES-R) score=16.6 (SD=12.1), subscales: intrusion 6.6 (SD=4.3), avoidance=7.4 (SD=6.5), hyperarousal=2.7 (SD=3.5). Higher risk individuals included: permanently disqualified athletes (p<0.01), athletes requiring daily medication (p<0.01), those with genetically inheritable conditions (p<0.01), and athletes undergoing medical management instead of definitive therapy (p<0.01). No differences were reported by gender (male=16.6, female=16.6). Higher IES-R scores were reported in more competitive athletes (college=17.8, high school=13.3; p=0.369) and African-American individuals (African-American=25.8, Caucasian=14.8 p=0.061), although not statistically significant. Athletes with cardiomyopathy (IES-R=24) and channelopathy (IES-R=28) reported the highest IES results. Athletes with high IES-R scores were most likely to psychologically respond through avoidance of feelings/situations/ideas. CONCLUSIONS: Athletes diagnosed with potentially lethal cardiac disorders are at risk for significant psychological distress. These athletes tend to avoid thoughts, feelings and conversations associated with their diagnosis and should be offered consistent emotional support to mitigate psychological morbidity. SIGNIFICANCE: Currently, there are no recommendations to guide physicians on how to support an athlete that is newly diagnosed with a potentially career altering heart condition. Proper planning and use of appropriate support mechanisms can be useful for emotionally vulnerable athletes.

Electrocardiography-inclusive screening strategies for detection of cardiovascular abnormalities in high school athletes.

BACKGROUND: The best protocol for cardiovascular preparticipation screening (PPS) in young athletes is uncertain. OBJECTIVE: The purpose of this study was to determine the value of integrating electrocardiographic (ECG) testing with standard history and physical examination during PPS to identify potentially serious cardiovascular abnormalities in young athletes. METHODS: A total of 2017 high school athletes seeking clearance for competitive sports were prospectively evaluated using a standardized history and physical examination, 12-lead ECG, and two-dimensional echocardiogram (echo). Primary outcome measures included the identification of cardiac disorders associated with sudden cardiac death. Secondary outcome measures included identification of abnormal, but nonlethal, cardiac conditions that required medical follow-up. RESULTS: Of these athletes, 14.7% had an abnormal history or physical examination and 3.1% had an abnormal ECG based on modern ECG interpretation criteria. Five primary outcomes (1 hypertrophic cardiomyopathy, 4 Wolff-Parkinson-White syndrome) and four secondary outcomes were identified. History and physical examination detected 40% of primary and 50% of secondary abnormalities. ECG detected all five primary abnormalities but none of the secondary abnormalities. Echo was abnormal in 1.2% and detected one primary and four secondary abnormalities. The false-positive rates for primary and secondary outcomes for history and physical examination and ECG were 14.5% and 2.8%, respectively. CONCLUSION: ECG adds value to PPS through increased detection of arrhythmogenic and structural cardiovascular conditions associated with sudden cardiac death. Use of modern ECG interpretation standards allows a low false-positive rate. Routine echo may detect other clinically important cardiac abnormalities, but its role in PPS remains uncertain.

Persistent primary hypogonadism associated with anabolic steroid abuse.

OBJECTIVE: To report a case of primary gonadal failure due to the chronic abuse of anabolic steroids used for bodybuilding. DESIGN: Case report. SETTING: Department of Diabetes and Endocrinology, Morriston Hospital, Swansea, Wales, United Kingdom. PATIENT(S): A 40-year-old man. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical symptoms, levels of serum T, FSH, and LH. RESULT(S): Primary gonadal failure resulting from anabolic steroid use. CONCLUSION(S): We describe a case of initially secondary gonadal failure resulting from anabolic steroid use with subsequent primary gonadal failure and infertility. This case adds to the current literature and illustrates that the side effects of anabolic steroids can be prolonged and irreversible.

Is surgical intervention frequently required for medically managed macroprolactinomas? A study of spontaneous cerebrospinal fluid rhinorrhea.

BACKGROUND: The frequency of spontaneous CSF rhinorrhea in macroprolactinoma patients is poorly documented and was previously thought to be a very rare occurrence. METHODS: Thirty patients with macroprolactinomas (>1.0 cm diameter) identified from the Swansea neuroendocrine database were studied retrospectively. RESULTS: At presentation, the median serum prolactin was 28,354 (range, 1844 to >6,000,000) mU/L; radiologically, 4 adenomas were invading the cavernous sinus, one the sphenoid sinus and 5 both the cavernous and sphenoid sinus. After commencement of medical therapy, 4 subjects developed CSF rhinorrhea requiring surgical correction; all 4 had tumors invading both the cavernous and sphenoid sinus and an initial serum prolactin more than 75,000 mU/L. One subject developed an acute psychosis, and a man who presented with delayed puberty committed a serious sexual offense. CONCLUSIONS: Serious adverse effects are not uncommon in medically treated macroprolactinoma patients. Subjects with adenomas invading the sphenoid sinus have a high risk of developing CSF rhinorrhea that requires neurosurgical intervention.

Are blood pressure levels taken during a secondary care diabetic clinic likely to be higher than when measured in primary care?

Blood pressure management guidelines are widely available. Our aim was to examine differences in blood pressure on the same subjects in primary and secondary care. We identified 661 diabetic subjects with measurements with the aid of the SAIL databank. Blood pressure in primary care was significantly lower than secondary care.