Clinical management and outcome of head and neck paragangliomas (HNPGLs): A single centre retrospective study.

CONTEXT: Head and neck paragangliomas (HNPGLs) are rare, usually benign, slow-growing tumours arising from neural crest-derived tissue. Definitive management pathways for HNPGLs have yet to be clearly defined. OBJECTIVE: To review our experience of the clinical features and management of these tumours and to analyse outcomes of different treatment modalities. METHODS: Demographic and clinical data were obtained from The Northern Ireland Electronic Care Record (NIECR) as well from a prospectively maintained HNPGL database between January 2011 through December 2023. RESULTS: There were 87 patients; 50 females: 37 males with a mean age of 52.3 ± 14.2 years old (range 17-91 years old). 58.6% (n = 51) of patients had carotid body tumours, 25.2% (n = 22) glomus vagal tumours, 6.8% (n = 6) tumours in the middle ear, 2.2% (n = 2) in the parapharyngeal space and 1.1% (n = 1) in the sphenoid sinus. 5.7% (n = 5) of patients had multifocal disease. The mean tumour size at presentation was 3.2 ± 1.4 cm (range 0.5-6.9 cm). Pathogenic SDHD mutations were identified in 41.3% (n = 36), SDHB in 12.6% (n = 11), SDHC in 2.2% (n = 2) and SDHA in 1.1% (n = 1) of the patients. Overall treatment modalities included surgery alone in 51.7% (n = 45) of patients, radiotherapy in 14.9% (n = 13), observation in 28.7% (n = 25), and somatostatin analogue therapy with octreotide in 4.5% (n = 4) of patients. Factors associated with a significantly higher risk of recurrence included age over 60 years (p = .04), tumour size exceeding 2 cm (p = .03), positive SDHx variants (p = .01), and vagal and jugular tumours (p = .04). CONCLUSION: The majority of our patients underwent initial surgical intervention and achieved disease stability. Our results suggest that carefully selected asymptomatic or medically unfit patients can be safely observed provided lifelong surveillance is maintained. We advocate for the establishment of a UK and Ireland national HNPGL registry, to delineate optimal management strategies for these rare tumours and improve long term outcomes.

Surgical outcomes in patients with Cushing's disease: the Cleveland clinic experience.

CONTEXT: Transsphenoidal surgery (TSS) to resect a pituitary adenoma is considered first-line treatment for patients with Cushing's disease (CD). Early, post-operative remission rates >80% are expected for patients with a microadenoma (≤ 10 mm) visible on magnetic resonance (MR) imaging. OBJECTIVE: To report surgical outcomes and predictors of remission in a specialist center for patients with CD. PATIENTS AND METHODS: Clinical data was obtained from a prospective CD database in addition to review of all electronic medical, laboratory and surgical patient records. Patients who underwent their first TSS by one neurosurgeon between 2004 and 2013, and had a minimum 1 year follow up, were evaluated. RESULTS: One hundred and one consecutive patients with CD (73F, 28M) underwent TSS. Median (range) age and follow-up were 47 (15-87) and 4.33 (1-9.8) years, respectively. At surgery, 74 (73.2%) patients had a microadenoma, 27 a macroadenoma; six of the latter patients had a planned, subtotal resection to control neurological signs due to mass effect. Initial remission rates were: microadenoma, 89% (66/74); macroadenoma, 63% (17/27); and 81% (17/21) in those macroadenomas where complete surgical removal was anticipated. Initial non-remission occurred in 18 patients, ten macro- and eight microadenoma; six of 18 had residual disease on most recent follow up. Six (2 macro, 4 micro) of the 83 patients with initial remission have had late (>12 months) recurrence of hypercortisolism that required either repeat TSS or adjunctive therapy, three of whom have persistent hypercortisolism. Macroadenoma (p = 0.003) and tumor invasion beyond the pituitary and sella (p < 0.001) were associated with failure to obtain remission with the initial TSS and greater likelihood of late recurrence. Patients in whom no lesion was seen on neuroimaging had rates of initial remission (21/25 or 84%) and a similar late recurrence rate of 4% (1/25) in comparison with those with MR-visible microadenomas (3/49, or 6%). CONCLUSIONS: A team-based approach, in a specialized pituitary center, can lead to initial and durable, long-term remission in patients with CD. The presence of a macroadenoma and tumor extension beyond the pituitary and sella were predictive of initial non-remission as well as risk of late recurrence.

Follow-Up of Patients After Total Pancreatectomy and Islet Cell Autotransplantation at Off-Site Islet Isolation Facility.

CONTEXT: Total pancreatectomy with islet autotransplantation (TPIAT) is a definitive management for intractable pain in patients with chronic pancreatitis (CP). Islet autotransplantation (IAT) allows for the preservation of beta cells to prevent complications of long-term diabetes. OBJECTIVE: Our study follows TPIAT recipients for up to 12 years to determine the efficacy of the procedure completed with an off-site islet isolation facility. METHODS: Patient demographics, mixed meal tolerance test measures, glycosylated hemoglobin, insulin requirements, and homeostatic model assessment for insulin resistance values were collected prior to surgery and at the most recent follow-up assessment. RESULTS: Forty-four patients (median age, 46.0 years; range, 20-78 years) underwent TPIAT for CP. At an overall median follow-up time of 845.5 days (range, 195-4470 days) 8 patients were insulin independent and 36 patients were insulin dependent. At the most recent follow-up time point, islet yield per kilogram was the strongest indicator of insulin independence. Homeostatic model assessment for insulin resistance values were comparable between insulin independent and dependent cohorts. CONCLUSIONS: Our long-term follow-up data suggest that IAT can effectively reduce insulin requirements and improve postoperative glycemic control.

Ultrasound for the assessment of thyroid nodules: an overview for non-radiologists.

Upon discovery of a thyroid nodule (or nodules), a patient is usually referred for evaluation by ultrasound, which is typically performed by a trained radiologist or sonographer. More recently, this technology has been used intraoperatively by endocrine surgeons and also by endocrinologists, often in the context of 'one-stop shops' or point of care ultrasound in the outpatient setting. Although thyroid nodules are common and most will be benign, the subsequent work up of these can cause anxiety for patients and place a burden on radiologists. In the UK, sonographic features of benign, suspicious or malignant nodules are classified by the British Thyroid Association U1-U5 criteria, which decide whether to biopsy the nodule (typically U3 and above). This article provides an overview of ultrasound in assessing the thyroid nodule in the context of this classification. This can be used as a guide to interpretation of thyroid ultrasonography for non-radiologists.

Pituitary metastasis: a clinical overview.

The pituitary gland is an unusual site for metastatic spread and has been associated with a poor prognosis. Clinical presentation is variable but can include visual field defects, cranial nerve palsies, anterior pituitary dysfunction and/ or diabetes insipidus. Management options include surgery or radiotherapy, chemotherapy/immunotherapy or a conservative approach. The pituitary should not be overlooked as a site for metastasis in patients with known cancer and can be the first presentation of neoplastic disease in some patients. Given that patients are now living longer with cancer, clinicians should be alert to the varied presentation of pituitary metastasis. We provide a clinical overview of pituitary metastasis with the aid of illustrative clinical cases.

Screening attendance, prevalence and severity of diabetic retinopathy (DR) in a cohort of patients with diabetes mellitus secondary to chronic pancreatitis (DMsCP) in Northern Ireland.

INTRODUCTION: This study investigated Northern Ireland Diabetic Eye Screening Programme (NIDESP) attendance and diabetic retinopathy (DR) prevalence/severity in patients with diabetes mellitus secondary to chronic pancreatitis (PwDMsCP). RESEARCH DESIGN AND METHODS: Medical/NIDESP records for all PwDMsCP attending the pancreatic diabetes clinic were analyzed in 2017 (n=78) and 2019 (n=94). RESULTS: Between 2017 and 2019, those without DR decreased (76% to 63%); mild non-proliferative DR (NPDR), severe NPDR and PDR were found in 30%, 2% and 5%, respectively (previously 18%, 4%, 2%); diabetic maculopathy (DMac) was present in 12% (previously 10%). There was no significant difference between worst-eye DR/DMac grade and HbA1c, gender, body mass index, pancreatitis etiology and screening attendance (p>0.05). Patients with proliferative DR had longer diabetes and pancreatitis duration than DR-free patients (both p=0.001). CONCLUSIONS: DR prevalence was similar in PwDMsCP and patients with type 2 diabetes of similar disease duration. This work demonstrates the importance of reaching all patients for establishing DR severity reliably and to provide accessible, equitable care to PwDMsCP.

Pitfalls in Performing and Interpreting Inferior Petrosal Sinus Sampling: Personal Experience and Literature Review.

CONTEXT: Inferior petrosal sinus sampling (IPSS) helps differentiate the source of ACTH-dependent hypercortisolism in patients with inconclusive biochemical testing and imaging, and is considered the gold standard for distinguishing Cushing disease (CD) from ectopic ACTH syndrome. We present a comprehensive approach to interpreting IPSS results by examining several real cases. EVIDENCE ACQUISITION: We performed a comprehensive review of the IPSS literature using PubMed since IPSS was first described in 1977. EVIDENCE SYNTHESIS: IPSS cannot be used to confirm the diagnosis of ACTH-dependent Cushing syndrome (CS). It is essential to establish ACTH-dependent hypercortisolism before the procedure. IPSS must be performed by an experienced interventional or neuroradiologist because successful sinus cannulation relies on operator experience. In patients with suspected cyclical CS, it is important to demonstrate the presence of hypercortisolism before IPSS. Concurrent measurement of IPS prolactin levels is useful to confirm adequate IPS venous efflux. This is essential in patients who lack an IPS-to-peripheral (IPS:P) ACTH gradient, suggesting an ectopic source. The prolactin-adjusted IPS:P ACTH ratio can improve differentiation between CD and ectopic ACTH syndrome when there is a lack of proper IPS venous efflux. In patients who have unilateral successful IPS cannulation, a contralateral source cannot be excluded. The value of the intersinus ACTH ratio to predict tumor lateralization may be improved using a prolactin-adjusted ACTH ratio, but this requires further evaluation. CONCLUSION: A stepwise approach in performing and interpreting IPSS will provide clinicians with the best information from this important but delicate procedure.

Point of Care Thyroid Ultrasound (POCUS) in Endocrine Outpatients: A Pilot Study.

BACKGROUND: Thyroid ultrasound is used for the assessment and characterisation of thyroid nodules/goitres and to guide diagnostic biopsy, it is normally performed by radiologists. Point of care ultrasound (POCUS) by trained non-radiologists, has the potential to reduce cost, expedite diagnosis and enhance patient satisfaction if embedded in an outpatient clinic setting. AIM: To perform a pilot of the use of point of care thyroid ultrasound in an endocrine outpatient setting for the assessment of thyroid nodules and goitres. METHODS: Thyroid ultrasound was undertaken with consultant radiologist supervision, over a period of 16 months between January 2017 to April 2018. Using a GE Logic e7 portable thyroid ultrasound machine with 12 MHz linear probe. All scans were performed on patients attending for assessment of thyroid disorders at the Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast. RESULTS: Thyroid ultrasound was performed on 40 patients (M:10,F30), mean age 52 years, range 23-77 years, median follow up 14 months, range 6-18 months. Twenty scans were performed to assess thyroid nodules, 13 for investigation of a goitre and the remaining 7 were for patient preference. 39 patients had benign thyroid disease, 1 patient had a confirmed newly diagnosed papillary thyroid carcinoma (PTC). The ultrasound 'U' classification was U1 and U2 (n=37), U3 and above (n=3). Fine needle biopsy (FNA) was performed on 9 patients with one confirmed as a thyroid carcinoma (Thy1;n=2, Thy2;n=6 and Thy 5;n=1). Thyroid ultrasound reporting was broadly similar between radiologist and non-radiologist (p< 0.01). Time to scan was reduced during the pilot from the existing model (n=40) of a mean of 52 days (range 7-95 days) to 1 day (p<0.01). CONCLUSION: With appropriate training and radiology supervision, point of care thyroid ultrasound can be performed accurately and safely in outpatients by an endocrinologist. There are potential benefits in terms of cost savings, time to scan, reduction in clinic visits, and in expediting diagnosis.

Time to Diagnosis in Cushing's Syndrome: A Meta-Analysis Based on 5367 Patients.

CONTEXT: Signs and symptoms of Cushing's syndrome (CS) overlap with common diseases, such as the metabolic syndrome, obesity, osteoporosis, and depression. Therefore, it can take years to finally diagnose CS, although early diagnosis is important for prevention of complications. OBJECTIVE: The aim of this study was to assess the time span between first symptoms and diagnosis of CS in different populations to identify factors associated with an early diagnosis. DATA SOURCES: A systematic literature search via PubMed was performed to identify studies reporting on time to diagnosis in CS. In addition, unpublished data from patients of our tertiary care center and 4 other centers were included. STUDY SELECTION: Clinical studies reporting on the time to diagnosis of CS were eligible. Corresponding authors were contacted to obtain additional information relevant to the research question. DATA EXTRACTION: Data were extracted from the text of the retrieved articles and from additional information provided by authors contacted successfully. From initially 3326 screened studies 44 were included. DATA SYNTHESIS: Mean time to diagnosis for patients with CS was 34 months (ectopic CS: 14 months; adrenal CS: 30 months; and pituitary CS: 38 months; P < .001). No difference was found for gender, age (<18 and ≥18 years), and year of diagnosis (before and after 2000). Patients with pituitary CS had a longer time to diagnosis in Germany than elsewhere. CONCLUSIONS: Time to diagnosis differs for subtypes of CS but not for gender and age. Time to diagnosis remains to be long and requires to be improved.

Diabetes and Chronic Pancreatitis: Considerations in the Holistic Management of an Often Neglected Disease.

Diabetes secondary to chronic pancreatitis (CP) or type 3cDM refers to a brittle form of diabetes and is often characterised by hypoglycaemic episodes, erratic glycaemic control, and impaired quality of life. It differs from other forms of diabetes and is typically characterised by concurrent pancreatic endocrine and exocrine insufficiency which can present as malabsorption and nutritional deficiencies. In this review, we discuss the pathogenesis, epidemiology, and the practicalities of diagnosis, screening, and management of this condition.

A Survey of Patient's Perceptions and Proposed Provision of a 'Patient Portal' in Endocrine Outpatients.

INTRODUCTION: Patient portals are online electronic medical record applications that allow patients greater control of their own health and encourage meaningful interaction with their healthcare providers. The uptake of this technology is commonplace throughout developed healthcare economies and is on the Northern Ireland Electronic Healthcare Record (NIECR) roadmap. AIM: To assess patients' perceptions and proposed provision of a patient portal in endocrinology outpatients. METHODS: Patients (n=75) attending three endocrinology outpatient clinics were eligible to participate. After discussion at clinic, invited patients were contacted via e-mail to complete a confidential and anonymised online survey. There were a total of 23 questions in the survey which included a mix of free text and categorical responses. The survey duration was conducted over a 6-month period. RESULTS: The survey response rate was 51/75 (68%), M33:F18. 46/51 (90%) had access to smart phones, 45/51 (88%) used the internet daily. 31/51 (60%) of respondents were aged between 18-45, 20/51 (40%) were aged ≥ 45 years. 50/51 (98%) reported they would use the technology if available. 47/51 (92%) felt engaging with a patient portal would enhance communication with their doctor and improve understanding of their medical issues. Reported perceived applications of use included; remote access and advice for test results and medical questions, arranging appointments, requesting prescriptions and health promotion. 90% of respondents said they would be content to access results even if abnormal. Possible barriers to adoption of this technology included data protection and understanding medical terminology. CONCLUSIONS: The overall response to the provision of this technology was positive, although concerns regarding data protection remain prevalent. Perceived benefits included enhanced doctor-patient communication, optimizing workflow and improving patient engagement.

DiGeorge syndrome presenting as late onset hypocalcaemia in adulthood.

We report a 29 year old female with mild dysmorphic facial features, presenting with late onset symptomatic hypocalcaemia in adulthood. The presence of hypoparathyroidism in association with a history of transient neonatal hypocalcaemia and velopharyngeal incompetence during childhood, prompted chromosomal analysis for DiGeorge Syndrome. Fluorescence in situ hybridisation (FISH) analysis revealed a deletion of chromosome 22q11.2. This case is unusual in that the patient remained asymptomatic apart from speech and language delay after the first few months of life and presented in adulthood without any associated immunological, cardiac or renal abnormalities. The diagnosis has important implications for health and family planning.

Placental antioxidant enzyme status and lipid peroxidation in pregnant women with type 1 diabetes: The effect of vitamin C and E supplementation.

AIM: In view of the increased rates of pre-eclampsia observed in diabetic pregnancy and the lack of ex vivo data on placental biomarkers of oxidative stress in T1 diabetic pregnancy, the aim of the current investigation was to examine placental antioxidant enzyme status and lipid peroxidation in pregnant women with type 1 diabetes. A further objective of the study was to investigate the putative impact of vitamin C and E supplementation on antioxidant enzyme activity and lipid peroxidation in type 1 diabetic placentae. METHODS: The current study measured levels of antioxidant enzyme [glutathione peroxidase (Gpx), glutathione reductase (Gred), superoxide dismutase (SOD) and catalase] activity and degree of lipid peroxidation (aqueous phase hydroperoxides and 8-iso-prostaglandin F2α) in matched central and peripheral samples from placentae of DAPIT (n=57) participants. Levels of vitamin C and E were assessed in placentae and cord blood. RESULTS: Peripheral placentae demonstrated significant increases in Gpx and Gred activities in pre-eclamptic in comparison to non-pre-eclamptic women. Vitamin C and E supplementation had no significant effect on cord blood or placental levels of these vitamins, nor on placental antioxidant enzyme activity or degree of lipid peroxidation in comparison to placebo-supplementation. CONCLUSION: The finding that maternal supplementation with vitamin C/E does not augment cord or placental levels of these vitamins is likely to explain the lack of effect of such supplementation on placental indices including antioxidant enzymes or markers of lipid peroxidation.

Spontaneous Hypoglycemia After Islet Autotransplantation for Chronic Pancreatitis.

CONTEXT: Spontaneous hypoglycemia has been reported in patients after total pancreatectomy (TP) and islet autotransplantation (IAT) with maintained insulin independence. Details surrounding these events have not been well described. OBJECTIVE: The objective of the study was to determine the frequency and characteristics of spontaneous hypoglycemia in patients undergoing TP-IAT and/or to ascertain predictive or protective factors of its development. DESIGN: This was an observational cohort study in 40 patients who underwent TP-IAT from August 2008 to May 2014, with a median follow-up of 34 months. SETTING: The study was conducted at a single institution (Cleveland Clinic). PATIENTS: Patients included recipients of TP-IAT. INTERVENTION: The intervention included small, frequent meals in those patients who developed spontaneous hypoglycemia. MAIN OUTCOME MEASURES: Incidence of spontaneous hypoglycemia development, characteristics of the patients developing hypoglycemia, and their response to small, frequent meals were measured. RESULTS: Six of 12 patients, who maintained insulin independence, developed spontaneous hypoglycemia. The episodes could be fasting, postprandial, and/or exercise associated, with the frequency ranging from two to three times daily to once every 1-2 weeks. All patients experienced at least one episode that required external assistance, glucagon administration, and/or emergent medical attention. Patients who developed hypoglycemia had a lower median age and tended to have a lower median islet equivalent/kg body weight but a higher median total islet equivalent, body mass index, and homeostatic model assessment for insulin resistance score. All patients who received small, frequent meal intervention had improvement in severity and/or frequency of the hypoglycemic episodes. CONCLUSIONS: Spontaneous hypoglycemia is prevalent after TP-IAT. Although the underlying pathophysiology responsible for these hypoglycemia events remains to be elucidated, small, frequent meal intervention is helpful in ameliorating this condition.

Lymphocytic infundibulo-neurohypophysitis: a clinical overview.

Lymphocytic infundibulo-neurohypophysitis is an uncommon inflammatory disorder postulated to be autoimmune in origin. Because of the location of inflammation, it selectively affects the posterior lobe of the pituitary (neurohypophysis) and pituitary stalk (infundibulum). The most common presentation is central diabetes insipidus. Although the definitive diagnosis is established histologically by a pituitary biopsy, radiological imaging can be valuable in diagnosing this condition. In this paper, we provide an overview of the pathophysiology, investigations, management, and outcomes of lymphocytic infundibulo-neurohypophysitis.

Chronic Pancreatitis and Diabetes Mellitus.

OPINION STATEMENT: Patients with chronic pancreatitis should be screening at least annually for diabetes. Lifestyle modifications remain to be an important part of treatment for diabetic control. Unless contraindicated or not tolerated, metformin can be initiated and continued concurrently with other anti-diabetic agents or insulin. All anti-diabetic agents should be used based on their physiology and adverse effect profiles, along with the metabolic status of patients. Insulin therapy should be initiated without delay for any of the following: symptomatic or overt hyperglycemia, catabolic state secondary to uncontrolled diabetes, history of diabetic ketoacidosis, hospitalization or acute exacerbation of pancreatitis, or hyperglycemia that cannot be otherwise controlled. Dose adjustment should be done conservatively as these patients are more likely to be insulin sensitive and have loss of counter regulatory hormones. Insulin pump and continuous glucose monitoring should be considered early during therapy in selected patients. For patients undergoing total pancreatectomy or extensive partial pancreatectomy, evaluations to determine the eligibilities for islet cell autotransplantation should be considered.