A prospective longitudinal study of Pasireotide in Nelson's syndrome.

PURPOSE: Nelson's syndrome is a challenging condition that can develop following bilateral adrenalectomy for Cushing's disease, with high circulating ACTH levels, pigmentation and an invasive pituitary tumor. There is no established medical therapy. The aim of the study was to assess the effects of pasireotide on plasma ACTH and tumor volume in Nelson's syndrome. METHODS: Open labeled multicenter longitudinal trial in three steps: (1) a placebo-controlled acute response test; (2) 1 month pasireotide 300-600 µg s.c. twice-daily; (3) 6 months pasireotide long-acting-release (LAR) 40-60 mg monthly. RESULTS: Seven patients had s.c. treatment and 5 proceeded to LAR treatment. There was a significant reduction in morning plasma ACTH during treatment (mean ± SD; 1823 ± 1286 ng/l vs. 888.0 ± 812.8 ng/l during the s.c. phase vs. 829.0 ± 1171 ng/l during the LAR phase, p < 0.0001). Analysis of ACTH levels using a random intercept linear mixed-random effects longitudinal model showed that ACTH (before the morning dose of glucocorticoids) declined significantly by 26.1 ng/l per week during the 28-week of treatment (95% CI - 45.2 to - 7.1, p < 0.01). An acute response to a test dose predicted outcome in 4/5 patients. Overall, there was no significant change in tumor volumes (1.4 ± 0.9 vs. 1.3 ± 1.0, p = 0.86). Four patients withdrew during the study. Hyperglycemia occurred in 6 patients. CONCLUSIONS: Pasireotide lowers plasma ACTH levels in patients with Nelson's syndrome. A longer period of treatment may be needed to assess the effects of pasireotide on tumor volume. TRIAL REGISTRATION: Clinical Trials.gov ID, NCT01617733.

Procalcitonin: A New Biomarker for Medullary Thyroid Cancer? A Systematic Review.

Medullary thyroid cancer (MTC) is a rare but aggressive thyroid malignancy. The gold-standard biomarker for its diagnosis and follow-up is calcitonin (CT); however, it has a variable half-life dependent on its circadian variability. It has been suggested that a more stable hormone, procalcitonin (PCT), may overcome these problems and its introduction to routine practice may give more accurate results in the diagnosis and follow-up of MTC. We systematically reviewed Pubmed, Scopus, Biosis Previews and Embase databases up to March 2016. A total of 15 out of 184 articles were retrieved and analyzed. Of these 15 studies, 3 were case reports. In these 15 studies, the values of CT and PCT were assessed in both patients with MTC and patients that were either healthy volunteers or with benign/malignant thyroid nodular disease or with bacterial infection. Our search suggests that PCT seems to be a useful biomarker for the diagnosis and follow-up of MTC when used in conjunction with CT, particularly in a small proportion of tumors that are CT-negative or secrete low levels of CT. So far, there has not been enough data to suggest a specific threshold for normal PCT. However, most studies indicate a value of 0.1 ng/ml as an acceptable cut-off in everyday clinical practice. At present, CT should continue to be the primary biomarker in MTC with the addition of PCT in some patient groups. Nevertheless, larger patient series need to be conducted in order to provide safer and more accurate results.

Assessing the impact older people from care homes place on the emergency services.

OBJECTIVE: The increasing size of our older population will provide more pressure to UK emergency services. Studies show that older people are more likely to be admitted from the emergency department (ED). This study aimed to evaluate the impact care home (CH) patients have on the ED within a large urban UK city and whether end-of-life planning and alternative pathways can improve quality of care for these patients. METHODS: Data were collected for 11760 patients of over 65 years of age. CH and non-care home patients attending the ED were compared and an in-depth analysis of the sickest patients was carried out. RESULTS: CH patients were more likely to arrive by ambulance, odds ratio (OR) of 8.09 [95% confidence interval (CI) 6.17-10.6; P<0.001]; have an investigation, OR of 1.51 (95% CI: 1.28-1.77; P<0.001); present with a medical condition or fall, OR of 2.05 (95% CI: 1.75-2.40; P<0.001); to spend more than 4 h in the ED, OR of 1.48 (95% CI: 1.30-1.69; P<0.001); to be admitted, OR of 1.32 (95% CI: 1.16-1.50; P<0.001). Of the sickest CH patients admitted (n=73), 63.9% (46 of 72) died within 24 h of admission, 8.3% (6 of 72) had a postmortem, 90.4% (66/73) had a 'do not attempt resuscitation' order after admission. Most, however, had investigations and treatments: venous blood (60 of 73), arterial blood gases (38 of 73), X-rays (48 of 73), intravenous fluids (52 of 73), and intravenous antibiotics (24 of 73). CONCLUSION: This reflects the demand that CH patients place on emergency services compared with non-care home patients. The results also highlight the importance of end-of-life decisions before ED attendance. Further work is required to identify alternative pathways to improve the quality of care and reduce the impact on secondary care.