Impulse control disorders in patients with dopamine agonist-treated pituitary adenomas: a cross-sectional multicenter study.

BACKGROUND: Impulse control disorders (ICDs) have been described as underrecognized side effects of dopamine agonists (DAs) in neurological disorders but are not sufficiently understood in endocrine conditions. OBJECTIVE: To identify the prevalence of DAs induced ICDs and determine potential risk factors related to these disorders in patients with prolactinoma and non-function pituitary adenomas (NFPAs). METHODS: This is a cross-sectional multicenter study involving 200 patients with prolactinoma and NFPAs, who received follow-ups in tertiary referral centers. DA-induced ICDs were assessed using ICD questionnaires modified from prior studies. RESULT: At least one ICD was reported by 52% of participants, among whom 28.5% mentioned compulsive shopping, 24.5% punding, and 24.5% hypersexuality. Furthermore, 33% of the patients reported the presence of one type of ICD behavior, while 12% specified two and 7% had three types of such behavior. The multivariable logistic regression showed that the significant risk factors of ICD were younger age (adjusted odds ratio [AOR]: 0.92, 95% confidence interval [CI]: 0.88-0.97, p 0.001), being single (AOR: 0.15, 95%CI: 0.03-0.84, p 0.03), and a positive history of psychiatric illness (AOR: 7.67, 95% CI: 1.37-42.97, p 0.021). CONCLUSION: ICDs with a broad range of psychiatric symptoms are common in individuals with DA-treated prolactinoma and NFPAs. Endocrinologists should be aware of this potential side effect, particularly in patients with a personal history of psychiatric disorder.

Assessment of calcium intake and recognition of calcium-rich food sources among the Saudi population.

Calcium is an essential skeletal mineral, and calcium deficiency has a negative impact on bone health. We conducted an online questionnaire to assess the intake and knowledge among the Saudi population. The survey included 950 participants, with 51.1% demonstrating poor knowledge of calcium sources and a mean intake lower than the recommended level. INTRODUCTION: Calcium is an essential mineral and one of the most prevalent in the body. Chronic insufficient calcium intake increases the risk of osteopenia, osteoporosis, and bone fracture. PURPOSE: This study aimed to assess the Saudi population's calcium intake and knowledge of calcium sources as well as to identify factors associated with inadequate calcium intake. METHODS: This cross-sectional study was conducted across Saudi Arabia using an online questionnaire distributed randomly through social media channels. The questionnaire was a validated tool that was previously developed and used by the original author to assess knowledge of calcium food sources and estimate calcium intake in the Saudi population. If an individual answered more than 11 questions correctly, calcium knowledge was considered adequate. Calcium intake was considered sufficient or insufficient based on the recommended dietary allowance (RDA) of 1000 mg/day. RESULTS: The survey included male and female Saudi citizens and residents aged 14 years or older. A total of 950 respondents aged 9-70 completed the questionnaire. A total of 62.9% of the respondents were 26-50 years old. Of the participants, 64.2% were female, 71.7% were married, and 61.9% had a diploma or a bachelor's degree. Of these, 63.8% were from the central region, and 97.6% were from Saudi Arabia. For those aged 9-18, the average calcium consumption was 577 mg/day, whereas it was 479 mg/day for those aged 19-50. The average intake was 479 mg/day for males aged 51-70 (EAR = 1000 mg/day) and 438 mg/day for females (EAR = 1200 mg/day). These calcium consumption values were significantly lower than the estimated average requirement (EAR) and RDA (p < 0.01). Correct response rates for the 19 calcium intake knowledge items ranged from 23.4 to 94.7%. Among the participants, 48.9% had significant calcium intake knowledge, as indicated by a score of > 11 out of 19 correct responses. Age, sex, marital status, educational attainment, and residence were significantly correlated with adequate knowledge of calcium. Demographic characteristics such as age, marital status, and residence were associated with sufficient calcium intake in the study. CONCLUSION: The study findings revealed that a significant proportion (51.1%) of participants demonstrated inadequate knowledge regarding calcium food sources. Additionally, the mean calcium intake was found to be lower than the RDA of 1300 mg/day for males and females 14-18 years old and 1000 mg/day for males and females 19-50 years old and males 51-70 years old; however, the RDA for females 51-70 years old is 1200 mg/day, suggesting an urgent need for interventions aimed at enhancing both calcium knowledge and intake.

Glycaemic Control in People with Type 2 Diabetes Treated with Insulin Degludec: A Real-World, Prospective Non-interventional Study-UPDATES Saudi Arabia.

INTRODUCTION: Insulin degludec (degludec) has proven benefits in type 2 diabetes (T2D), in terms of improved glycaemic control, low risk of hypoglycaemia, and flexibility in dosing time. This prospective non-interventional UPDATES study aimed to investigate whether results obtained from randomised clinical trials and other real-world studies with degludec are generalisable to patients with T2D in routine clinical practice in Saudi Arabia. METHODS: Eligible adults (n = 561) with T2D received degludec for 26-34 weeks, at physicians' discretion and in accordance with local routine clinical practice. The primary endpoint was mean change in HbA1c from baseline to end of study (EOS). Secondary endpoints included mean change from baseline to EOS in fasting plasma glucose (FPG), daily insulin dose and rate of hypoglycaemia. RESULTS: At baseline, mean age, HbA1c and FPG were 55.7 years, 9.4% and 185.6 mg/dL, respectively. Mean (standard error [SE]) changes from baseline to EOS (crude analysis) were statistically significant for HbA1c (- 1.1 [0.08] %-points, 95% CI - 1.29, - 0.98; P < 0.0001), FPG (- 39.1 [3.42] mg/dL, 95% CI - 45.9, - 32.4; P < 0.0001) and total daily insulin dose (+ 4.7 [1.6] units, 95% CI 1.63, 7.86; P = 0.003, insulin-experienced population). In exploratory analysis of patients switching from insulin glargine U100 or U300 to degludec, similar reductions were seen in HbA1c and FPG. The rate of hypoglycaemia was significantly reduced with degludec versus previous treatment, with no apparent or unexpected safety and tolerability issues. The number of insulin-experienced patients utilising resources associated with severe hypoglycaemia was also reduced. Most patients (95.5%) were willing to continue treatment at EOS, and expressed a preference for degludec over their previous regimen (93.0%). CONCLUSION: Patients with T2D treated with degludec in routine clinical practice in Saudi Arabia experienced clinically significant improvements in glycaemic control and a lower rate of hypoglycaemia compared with baseline, with no new safety concerns reported. CLINICAL TRIAL REGISTRATION: NCT03785522.

Proportion and predictors of Hypogonadism Recovery in Men with Macroprolactinomas treated with dopamine agonists.

INTRODUCTION: Hypogonadism is the most common form of hypopituitarism in men with macroprolactinoma. However, evidence on factors related to hypogonadism recovery is limited. OBJECTIVES: We estimated the proportion of hypogonadism in men with macroprolactinoma exclusively treated with dopamine agonists, and we assessed the factors predicting hypogonadism recovery. PATIENTS AND METHODS: This was a multicenter retrospective study of men with macroprolactinoma identified using ICD 9 and 10 codes and treated between 2009 and 2019 in five centers in the United Arab Emirates and Saudi Arabia. We evaluated hypogonadism, defined as low total testosterone (TT) level with normal or low gonadotropins on presentation and during the last clinic visit. RESULTS: A total of 79 patients (median age 32 years) were included in the study. The most common symptoms at presentation were headache (73.7%), erectile dysfunction (55.4%), and low libido (54.3%). The median tumor size was 2.9 cm (1.0-9.7) at diagnosis. Sixty-three patients (79.7%) had hypogonadism at baseline. Growth hormone deficiency (GHD) and hypothyroidism were present in 34.4% and 32.9% of patients, respectively. The median serum prolactin (PRL) level was 20,175 (min-max 2254 - 500,000) mIU/l with a median serum TT of 4.5 (min-max 0.4-28.2) nmol/l. Most patients were treated with cabergoline (n = 77, 97.5%) with a median of 6 (min-max 0.6-22) years. At follow-up, 65% of patients recovered their pituitary-testicular axis. Patients with recovered hypogonadism had smaller median tumor size (2.4 [1-5.4] vs. 4.3 [1.6-9.7], p = 0.003), lower PRL level (18, 277 [2254 - 274, 250] vs. 63,703 [ 3,365-500,000], p = 0.008 ), higher TT level (4.6 [0.6-9.2] vs. 2.3 [0.5-7.3], p = 0.008), lower PRL normalization time on medical therapy (8 months (0.7-72) vs. 24 (3-120), p = 0.009) as well as lower frequency of GHD (17.1% vs. 60%, p = 0.006) and secondary hypothyroidism (17.9% vs. 57.1%, p = 0.003) compared with those with persistent hypogonadism respectively. Age at diagnosis, presenting symptoms and duration of medical therapy did not predict hypogonadism recovery. CONCLUSIONS: About two-thirds of men with macroprolactinoma recover from hypogonadism, mostly with 24 months of therapy. Smaller adenoma size, lower prolactin level, earlier prolactin normalization, and higher testosterone patients were related to testosterone normalization.

Efficacy and Safety of SGLT2 Inhibitors as Adjunctive Treatment in Type 1 Diabetes in a Tertiary Care Center in Saudi Arabia.

Background Adjunctive treatment with sodium-glucose co-transporters 2 inhibitors (SGLT2- I) has been successfully used in patients with type 1 diabetes mellitus (T1DM) in recent years to improve glycemic control and reduce body weight without increasing the risk of hypoglycemia; however, there is a scarcity of evidence for real-world experience in their use in T1DM Saudi patients. The purpose of this study was to evaluate the efficacy and safety of empagliflozin as off-label adjunctive therapy in Saudi patients with T1DM. Methods This study was a retrospective study for T1DM patients, who were prescribed empagliflozin as an adjunctive therapy. Baseline characteristics including age, changes in HbA1c, body weight, total daily insulin dose, lipid profile, and well as side effects such as urinary tract infections (UTIs) and diabetes ketoacidosis (DKA) were evaluated before and after initiation empagliflozin in 37 T1DM patients. Results The mean age was 25.8 ± 8.0 years, mean weight was 75.3 ± 14.8 kg, mean body mass index (BMI) was 28.1 ± 6.7 kg/m 2 , mean duration of diabetes was 10.1 ± 6.5 years, and mean HbA1c was 9.4 ± 1.4%. After a mean follow-up duration of 15.8 ± 6.0 months, the mean reduction in the HbA1c% from baseline was 0.82% ( p = 0.001) and mean weight reduction from baseline was 1.7 kg ( p = 0.097). The total daily insulin dose was decreased by 2.9 units. UTIs and DKA episodes were reported among 2.7% and 10.8% of the participants, respectively. Conclusion Empagliflozin in combination with insulin in overweight Saudi T1DM subjects resulted in a significant improvement in glycemic control, mild non-significant reduction in body weight, and a small but statistically significant reduction in the total daily insulin dose with a slight increase in the risk of DKA and UTIs. Further larger prospective studies are needed for better evaluation of the efficacy and safety of these agents in Saudi T1DM patients.

Management of Diabetes Insipidus following Surgery for Pituitary and Suprasellar Tumours.

Central diabetes insipidus (CDI) is a common complication after pituitary surgery. However, it is most frequently transient. It is defined by the excretion of an abnormally large volume of dilute urine with increasing serum osmolality. The reported incidence of CDI after pituitary surgery ranges from 0-90%. Large tumour size, gross total resection and intraoperative cerebrospinal fluid leak usually pose an increased risk of CDI as observed with craniopharyngioma and Rathke's cleft cysts. CDI can be associated with high morbidity and mortality if not promptly recognised and treated on time. It is also essential to rule out other causes of postoperative polyuria to avoid unnecessary pharmacotherapy and iatrogenic hyponatremia. Once the diagnosis of CDI is established, close monitoring is required to evaluate the response to treatment and to determine whether the CDI is transient or permanent. This review outlines the evaluation and management of patients with CDI following pituitary and suprasellar tumour surgery to help recognise the diagnosis, consider the differential diagnosis, initiate therapeutic interventions and guide monitoring and long-term management.

Plurihormonal pituitary macroadenoma: a case report.

BACKGROUND: Plurihormonal pituitary adenomas are a unique type of pituitary adenomas that secrete two or more pituitary hormones normally associated with separate cell types that have different immunocytochemical and ultrastructural features. Although they represent 10-15% of all pituitary tumors, only a small fraction of plurihormonal pituitary adenomas clinically secrete multiple hormones. The most common hormone combinations secreted by plurihormonal pituitary adenomas are growth hormone, prolactin, and one or more glycoprotein hormones. The most common hormonal symptom is acromegaly (50%). The aim of this case report is to bring awareness about this rare type of pituitary adenomas and to describe the unique presentation of our patient, even though plurihormonal pituitary adenomas are known mostly as a clinically silent tumors. CASE PRESENTATION: Herein, we describe an unusual case of plurihormonal pituitary adenoma with triple-positive staining for adrenocorticotropic hormone, growth hormone, and prolactin. The patient is a 65-year-old Egyptian woman who presented with mass effect symptoms of the pituitary tumor, which primarily manifested as severe headache and visual field defects. She also presented with some cushingoid features, and further analysis confirmed Cushing's disease; slightly high prolactin and normal growth hormone levels were observed. She underwent transsphenoidal surgery and has been in remission thus far. Only a few cases have been reported in the literature, but none has exhibited silent acromegaly or mass effect symptoms as the initial presentation. CONCLUSION: This case highlights an unusual plurihormonal pituitary adenoma case with a rare combination of secreted hormones; mass effect symptoms were dominant, as were uncommon visual field defects. Our case further proves that immunohistochemical analyses of all pituitary hormones are needed to ensure correct diagnosis and to alert clinicians to the need for more rigorous follow-up due to the higher morbidity of these patients. Our case report approval number Federal Wide Assurance NIH, USA is FWA00018774 IRB registration number with OHRP/NIH is IRB00010471.

Glycemic Variability in Type 1 Diabetes Mellitus Saudis Using Ambulatory Glucose Profile.

BACKGROUND: Glucose variability (GV) is a common and challenging clinical entity in the management of people with type 1 diabetes (T1DM). The magnitude of GV in Saudi people with T1DM was not addressed before. Therefore, we aimed to study GV in a consecutive cohort of Saudis with T1DM. METHODS: We prospectively assessed interstitial glucose using FreeStyle® Libre flash glucose monitoring in people with TIDM who attended follow-up in the diabetes clinics at King Fahad Medical City between March and June 2017. Glycemia profile, standard deviation (SD), coefficient of variation (CV), mean of daily differences (MODD), and mean amplitude of glucose excursion (MAGE) were measured using the standard equations over a period of 2 weeks. RESULTS: Fifty T1DM subjects (20 males) with mean age 20.2 ± 6.1 years and mean fortnight glucose 192 ± 42.3 mg/dl were included. The mean SD of 2-week glucose readings was 100.4 ± 36.3 mg/dl and CV was 52.1% ± 13%. Higher levels of glucose excursions were also observed. MODD and MAGE were recorded as 104.5 ± 51.7 and 189 ± 54.9 mg/dl, respectively which is 2 to 4 times higher than the international standards. Higher MODD and MAGE were observed on weekends compared to weekdays (111.3 ± 62.1 vs 98.6 ± 56.2 mg/dl and 196.4 ± 64.6 vs 181.7 ± 52.4 mg/dl, respectively; P ⩽ .001). CONCLUSION: Higher degree of glycemic variability was observed in this cohort of TIDM Saudis. Weekends were associated with higher glucose swings than weekdays. More studies are needed to explore these findings further.

The Relationship Between Thyroid Function and Body Composition, Leptin, Adiponectin, and Insulin Sensitivity in Morbidly Obese Euthyroid Subjects Compared to Non-obese Subjects.

BACKGROUND/OBJECTIVES: Thyroid function tests (TFTs) changes in obese people have been studied with increasing interest, however, studies have been inconsistent hence it remains poorly understood. We compared the TFTs of morbidly obese euthyroid Saudi subjects with non-obese controls and then we examined the influence of leptin, adiponectin, and insulin resistance on TFTs. SUBJECTS/METHODS: Fifty-five euthyroid obese subjects attending bariatric surgery clinic and 52 non-obese age-and gender-matched controls were recruited. We measured body weight, BMI, body composition, thyroid-stimulating hormone (TSH), Free T4 (FT4), Free T3(FT3), thyroid antibodies, fasting leptin, adiponectin, and lipid profile. Insulin resistance was quantified by HOMA-IR. Data are presented as mean ± SEM. RESULTS: Mean BMI was 45.6 ± 1.5 and 23.2 ± 0.5 kg/m2, for the obese and non-obese controls, respectively, P value < 0.001. Mean TSH was 2.7 ± 0.18 mIU/L in obese subjects and 1.7 ± 0.13 mIU/L (0.27-4.2) in the non-obese controls, respectively, P value .014. Mean FT3 was 3.9 ± 0.1 pmol/L (3.1-6.8) in obese subjects compared to 5.0 ± 0.1 pmol/L in non-obese controls, respectively, P value 0.001, however, FT4 was similar in the 2 groups. In the whole group (N = 107), BMI correlated positively with TSH and negatively with FT3. Leptin correlated negatively with both FT4 and FT3 in the non-obese group only while none of the TFTs correlated with HOMA-IR or adiponectin in either group. Binary logistic regression showed that each 1 unit increase in TSH increased the odds of becoming obese by 12.7, P value 0.009, 95 C.I. (1.9-85.0). Conversely, each - unit increase in FT3 decreased the odds of becoming obese by 0.2, P value 0.023, 95% C.I. (0.05-0.80). CONCLUSIONS: We report a small increase in TSH and a small decrease in FT3 within the normal range in obese subjects compared to non-obese controls. We also report a positive correlation between TSH and BMI with increased odds ratio of becoming obese with the increase in TSH and decrease in FT3. These changes may be either causally related or adaptive to the obesity state. FT4 and FT3 seem to correlate with leptin (but not with adiponectin or HOMA-IR) in the non-obese controls only. Larger mechanistic studies are needed to further elucidate the interesting association between obesity and TFTs.

Assessment of calcium intake and perception of calcium-rich food among healthcare students at King Saud bin Abdulaziz University for Health Science (KSAU-HS).

BACKGROUND: Calcium is an essential mineral compound and one of the most abundant minerals in the human body. A long-term low calcium intake predisposes the bones to fractures, osteopenia, and osteoporosis. This study was conducted to assess calcium intake and knowledge of calcium-related information among healthcare students in King Saud bin Abdulaziz University for Health Sciences (KSAU-Hs). METHODS: This cross-sectional survey was conducted using a self-administered questionnaire that has been distributed as a soft copy of 289 participants aged 19 years or older and studied at KSAU-Hs. The questionnaire had three sections assessing demographical data, calcium knowledge, and calcium intake. The knowledge outcome variables were good and poor, and participants were categorized as good knowledge if they answer 11 or more of the 18 questions, while the intake outcome variables were sufficient and insufficient intake based on the Recommended Dietary Allowance (RDA) of 1000 mg. RESULTS: Among all variables, 91.7% of the participants were found to be having an insufficient intake, and 74% were classified to be poor knowledge. As for knowledge, the highest score under the "Good" category were females 32.7% compared to males 22.2%, P = 0.05. The average intake of calcium was 497 mg/day. In terms of sufficient calcium intake, males scored 11.9% compared to females who scored 1.9% with a P value of 0.00. CONCLUSION: The results of this study have shown that there are significantly insufficient calcium intake and poor knowledge about calcium among healthcare students. The results indicate the urge to improve calcium intake and calcium knowledge among the healthcare students.

Contemporary Management of Clinically Non-functioning Pituitary Adenomas: A Clinical Review.

Non-functioning pituitary adenomas (NFPAs) are benign pituitary tumours that constitute about one-third of all pituitary adenomas. They typically present with symptoms of mass effects resulting in hypopituitarism, visual symptoms, or headache. Most NFPAs are macroadenomas (>1 cm in diameter) at diagnosis that can occasionally grow quite large and invade the cavernous sinus causing acute nerve compression and some patients may develop acute haemorrhage due to pituitary apoplexy. The progression from benign to malignant pituitary tumours is not fully understood; however, genetic and epigenetic abnormalities may be involved. Non-functioning pituitary carcinoma is extremely rare accounting for only 0.1% to 0.5 % of all pituitary tumours and presents with cerebrospinal, meningeal, or distant metastasis along with the absence of features of hormonal hypersecretion. Pituitary surgery through trans-sphenoidal approach has been the treatment of choice for symptomatic NFPAs; however, total resection of large macroadenomas is not always possible. Recurrence of tumours is frequent and occurs in 51.5% during 10 years of follow-up and negatively affects the overall prognosis. Adjuvant radiotherapy can decrease and prevent tumour growth but at the cost of significant side effects. The presence of somatostatin receptor types 2 and 3 (SSTR3 and SSTR2) and D2-specific dopaminergic receptors (D2R) within NFPAs has opened a new perspective of medical treatment for such tumours. The effect of dopamine agonist from pooled results on patients with NFPAs has emerged as a very promising treatment modality as it has resulted in reduction of tumour size in 30% of patients and stabilization of the disease in about 58%. Despite the lack of long-term studies on the mortality, the available limited evidence indicates that patients with NFPA have higher standardized mortality ratios (SMR) than the general population, with women particularly having higher SMR than men. Older age at diagnosis and higher doses of glucocorticoid replacement therapy are the only known predictors for increased mortality.

Clinical Features, Therapeutic Trends, and Outcome of Giant Prolactinomas: A Single-Center Experience Over a 12-Year Period.

BACKGROUND: Management of giant prolactinomas presents a different challenge than the management of traditional prolactinomas. OBJECTIVE: The aim of this study was to report the largest long-term single-center study of giant prolactinomas to analyze their clinical features; define epidemiological characteristics, comorbidities, complications, treatment outcomes; and to demonstrate our experience with long-term cabergoline (CAB) treatment of these giant tumors. METHODS: A retrospective case study and clinical review of patients presenting with giant prolactinomas in the pituitary clinic at King Fahad Medical City (KFMC), Riyadh, Saudi Arabia, in the period between 2006 and 2018 were included in the study. Of the charts reviewed, 33 patients (24 men; 9 women) with age of diagnosis between 18 and 63 years (mean = 37.21 years) met the selection criteria for giant prolactinomas. RESULT: The most common presenting features include headache (87.8%), visual defects (69.7%), and hypogonadism (51.5%). The baseline means serum prolactin (PRL) level was extremely high for both sexes (95 615.03 nmol/L), which eventually decreased by as much as 95.4% after CAB treatment. Serum PRL concentrations completely normalized in 11 patients and significantly reduced in 22 patients. The mean tumor volume at baseline was 42.87 cm3, whereas the mean posttreatment tumor volume was 3.42 cm3 (no residual tumor in 2 patients, while in others, it ranged from 0.11 to 16.7 cm3) at the last follow-up visit. The mean change in tumor volume was 88.84%. Tumor volume decreased by an average of 92% for men and 80.4% for women. One patient had no tumor size change with CAB (3.5 mg thrice a week) or radiotherapy and required surgery. The response rate (remission after medical therapy alone) in this series was 84.84%. CONCLUSIONS: Findings reinforce results from our previous study that CAB provides dramatic clinical improvements with an excellent safety profile. The CAB should, therefore, be considered as the primary therapy for giant prolactinomas.

Schwannoma Misdiagnosed as Adrenal Adenoma: A Case Report and Review of the Literature.

Schwannoma is a benign neurogenic tumor originating from the neural sheath of Schwann cells. It is an extremely rare cause of adrenal adenoma which is very difficult to diagnose preoperatively. We report the case of a right adrenal schwannoma discovered incidentally in a 62-year-old woman during evaluation of right flank pain. The biochemical and hormonal evaluations were unremarkable. Radiological examination revealed a 4.8 cm lesion keeping with right adrenal adenoma. Surgical intervention was done due to the large size of the tumor, and laparoscopic right adrenalectomy was performed. The postoperative course was uneventful. Histological examination established the diagnosis of schwannoma, which was further confirmed by immunohistochemical staining. In conclusion, adrenal schwannoma is extremely rare and can be misdiagnosed as nonsecreting adrenal adenoma. Complete surgical excision is the treatment of choice which is associated with favorable outcome and also helps in clarifying its histopathological nature.

Physician' attitudes to growth hormone replacement therapy in adults following pituitary surgery: Results of an online survey.

OBJECTIVE: The aim of this study was to evaluate physician attitudes and practices in the management of adult growth hormone deficiency (GHD) following pituitary surgery. MATERIALS AND METHODS: An online questionnaire survey was sent to a sample group of physicians. RESULTS: A total of 131 respondents provided usable responses. More than three quarters were senior physicians, with most practicing in tertiary care centers (73%). Four-fifths of the respondents see at least 1 to 5 patients with GHD following pituitary surgery per year. Seventy-four percent acknowledge the benefit in principle of growth hormone replacement therapy (GHRT) for patients with GHD after pituitary surgery. Most respondents (84%) would only consider GHRT for symptomatic patients. However, 16% stated that patients with GHD after pituitary surgery generally suffer from the side effects of GHRT. Forty-four percent said that the serum insulin-like growth factor-1 (IGF-1) level is the best screening test for assessing GHD after pituitary surgery but 57% of the respondents would use IGF-I levels, and 29% the insulin tolerance test (ITT), in patients with a documented deficiency in three pituitary axes. The main barriers to long-term GHRT use were that it requires injections (67%), and is costly with limited supply (61%). Other reasons not to use GHRT include an absence of GHD symptoms and apparent GHT ineffectiveness (44%), physician lack of familiarity with the medication (40%), and lack of adherence to available guidelines (38%). CONCLUSION: This survey addressed physician attitudes and practices in recognizing and treating GHD in adult's post-pituitary surgery. Regional guidelines must be developed to help address/tackle these issues and assist physicians in understanding and treating this condition.

Resistance to thyroid hormone-beta co-existing with partially empty sella in a Jordanian male.

Resistance to thyroid hormone-beta (RTHbeta) is a rare inherited syndrome characterized by variable reduced tissue responsiveness to the intracellular action of triiodothyronine (T3), the active form of the thyroid hormone. The presentation of RTHbeta is quite variable and mutations in the thyroid hormone receptor beta (THR-B) gene have been detected in up to 90% of patients. The proband was a 34-year-old Jordanian male who presented with intermittent palpitations. His thyroid function tests (TFTs) showed a discordant profile with high free T4 (FT4) at 45.7 pmol/L (normal: 12-22), high free T3 (FT3) at 11.8 pmol/L (normal: 3.1-6.8) and inappropriately normal TSH at 3.19 mIU/L (normal: 0.27-4.2). Work up has confirmed normal alpha subunit of TSH of 0.1 ng/mL (normal <0.5) and pituitary MRI showed no evidence of a pituitary adenoma; however, there was an interesting coincidental finding of partially empty sella. RTHbeta was suspected and genetic testing confirmed a known mutation in the THR-B gene, where a heterozygous A to G base change substitutes valine for methionine at codon 310. Screening the immediate family revealed that the eldest son (5 years old) also has discordant thyroid function profile consistent with RTHbeta and genetic testing confirmed the same M310V mutation that his father harbored. Moreover, the 5-year-old son had hyperactivity, impulsivity and aggressive behavior consistent with attention deficit hyperactivity disorder (ADHD). This case demonstrates an unusual co-existence of RTHbeta and partially empty sella in the same patient which, to our knowledge, has not been reported before. Learning points: We report the coincidental occurrence of RTHbeta and a partially empty sella in the same patient that has not been previously reported. TFTs should be done in all children who present with symptoms suggestive of ADHD as RTHbeta is a common finding in these children. The management of children with ADHD and RTHbeta could be challenging for both pediatricians and parents and the administration of T3 with close monitoring may be helpful in some cases. Incidental pituitary abnormalities do exist in patients with RTHbeta, although extremely rare, and should be evaluated thoroughly and separately.

Hypocalcemia in Pregnancy: A Clinical Review Update.

Though hypocalcemia in pregnancy is not often reported in the literature, it occurs in cases of hypoparathyroidism and in mothers with severe dietary inadequacy. Hypocalcemia during pregnancy can pose numerous problems to the mother and fetus. It is associated with hypertensive disorders and can increase the risk of numerous problems such as preeclampsia and fetal growth disorders. In this review, we summarize the challenges physicians face diagnosing and managing hypocalcemia during pregnancy. A multidisciplinary team including endocrinologists and obstetricians is warranted to ensure appropriate treatment and optimal outcomes.

Beat the giant: case of a giant prolactinoma during pregnancy on cabergoline.

Giant prolactinomas are a rare entity; during pregnancy, the risk for complications associated with these tumors is higher. Here, we report a case of a young woman who had an invasive, giant prolactinoma post resection with residual disease who became pregnant. This patient was treated with cabergoline to prevent tumor expansion in pregnancy, resulting in the uneventful delivery of a healthy baby boy. LEARNING POINTS: Giant prolactinoma can cause both diagnostic and therapeutic challenges given their atypical presentation.Accurate diagnosis is paramount to avoid unnecessary surgical intervention or pituitary irradiation.This case demonstrates the effectiveness and safety of CAB therapy during pregnancy.

Management of acromegaly: an exploratory survey of physicians from the Middle East and North Africa.

BACKGROUND: Worldwide variations exist in the diagnosis and management of patients with acromegaly. For such a rare condition, the knowledge and perception of physicians would most likely direct the care of patients. However, the adherence of physicians in non-Western regions to guidelines for the diagnosis and management of acromegaly has not been previously ascertained. METHODS: An online survey was conducted to assess the perceptions and practice of physicians regarding acromegaly diagnosis and management as per international guidelines. An electronic questionnaire containing key questions was mailed, initially to physicians in Saudi Arabia (KSA) and later to other countries in the Middle East and North Africa (MENA) region. Additional questions were included to ensure the relevance of the respondents' replies. The responses were captured and summarized anonymously. Descriptive comparisons were made with two similar international and national surveys from other regions. RESULTS: Two hundred forty-seven doctors responded to the survey. Of these, 155 (64.5%) fulfilled the inclusion criteria and, in particular, confirmed having treated acromegaly patients in the previous 12 months, and they constituted the basis of this study. The three most common referring specialties for patients were internists (44; 28.4%), neurosurgeons (46; 29.6%), and family medicine physicians (42; 27.1%), respectively. The combination of growth hormone (GH) nadir during the oral glucose tolerance test (OGTT) and elevated insulin-like growth factor-1 (IGF-1) levels was used by 99 physicians (63.9%) to diagnose acromegaly. The main determinant for treatment choice was tumor mass characteristics confirmed by 117 respondents (75.5%) with neurosurgery as first treatment choice confirmed by 124 respondents (80%). Combined measurement of IGF-1 and GH levels after OGTT at 3 months after surgery was the most widely used criterion for assessment of surgical outcomes, confirmed by 82 physicians (52.9%). The biggest barriers to optimal management of acromegaly as perceived by 38.1% and 35.5% of the respondents were high cost of medications and lack of physicians' awareness, respectively. CONCLUSIONS: The majority of the surveyed physicians reported variable adherence to the international acromegaly guidelines. Clearly, higher awareness is needed among physicians for early diagnosis and timely referral for specialist management.

Clinical and epidemiological characteristics of pituitary tumours in a single centre in Saudi Arabia.

PURPOSE: Pituitary tumours are slowly progressing tumours, mostly benign, with a reported global prevalence of 16.7% (22.5% in radiologic studies and 14.4% in autopsy studies). Clinical and epidemiological data on pituitary adenomas in Saudi Arabia are lacking. We aimed to utilise our database variables to determine clinical and epidemiological characteristics as well as treatment outcomes of pituitary tumours among Saudi patients. METHODS: This retrospective study was conducted in King Fahad Medical City, Riyadh, Saudi Arabia, in patients with pituitary tumours. Data were collected between 2006 and 2017. RESULTS: Overall, 284 patients (females: 38.1 ± 13.9 years; males: 44.1 ± 15.4 years) with pituitary tumours were included. Common pituitary tumours were prolactin-secreting adenomas (45%), non-functioning pituitary adenomas (NFPAs: 35.6%), growth hormone (GH)-secreting adenomas (10.6%), craniopharyngiomas (7%), and adrenocorticotropic hormone (ACTH)-secreting adenomas (1.8%). Prolactin-secreting adenomas were more frequently microadenomas and were common among females. Headaches and visual symptoms occurred commonly in NFPA patients (62.4 and 45.5%, respectively) than in those with prolactin-secreting adenomas (56.3 and 32.8%, respectively) or GH-secreting adenomas (40 and 16.6%, respectively). Medical treatment was the mainstay for prolactin-secreting adenoma patients (69%). Pituitary surgery was the primary therapy in NFPA patients (43.6%) and GH-secreting adenomas (86.7%). CONCLUSION: This study identified the pattern of pituitary tumours in Saudi patients and management strategies. Further, the study highlights the need for a nationwide registry to improve surveillance and physicians' knowledge in Saudi Arabia.

Association of Glycosylated Hemoglobin Levels With Vitamin D Status.

BACKGROUND: The discovery of vitamin D is one of medicine's great achievements. Despite all the positive evidence emerging about the beneficial effect of vitamin D, we still find many are vitamin D deficient. The purposes of this study were to examine the association between serum 25-hydroxyvitamin D (25(OH)D) and glycosylated hemoglobin (HbA1c) levels, to test the hypothesis that lower 25(OH)D levels are associated with poorer glucose control in diabetes mellitus (DM) patients and to investigate the effect of vitamin D supplementation on HbA1c levels. METHODS: This was a prospective observational cohort study of all patients with type 1 and type 2 diabetes (above 12 years) who attended the outpatient clinics of a tertiary center in Riyadh. HbA1c and vitamin D levels were recorded prior to supplementation and after 9 months of supplementation with vitamin D. All patients were divided into four groups according to their vitamin D level and an association between 25(OH)D and HbA1c was tested. RESULTS: Results showed that 73.1% of the patients had 25(OH)D levels < 50 nmol/L. We observed lowering of HbA1c after vitamin D supplementation (from mean HbA1c of 10.55 to 7.70). We found HbA1c to be inversely related to serum vitamin D levels (r = -0.14 (P < 0.0000002) before supplementation and -0.16 (P < 0.000001) after supplementation with vitamin D). CONCLUSIONS: Advising patients with higher HbA1c to test their vitamin D level and correct any deficiency will result in better blood glucose control and benefit the patient's overall health.