Imperial College London

Professor Karim Meeran

Faculty of MedicineDepartment of Metabolism, Digestion and Reproduction

Professor of Endocrinology
 
 
 
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Contact

 

+44 (0)20 8846 1065k.meeran

 
 
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Location

 

9E05Charing Cross HospitalCharing Cross Campus

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Summary

 

Publications

Publication Type
Year
to

212 results found

Boharoon H, Tomlinson J, Limback-Stanic C, Gontsarova A, Martin N, Hatfield E, Meeran M, Nair R, Mendoza N, Levy J, McAdoo S, Pusey C, Wernig Fet al., 2021, A case series of patients with isolated IgG4-related hypophysitis treated with rituximab, Journal of the Endocrine Society, Vol: 4, Pages: 1-9, ISSN: 2472-1972

ContextThe acute presentation of Immunoglobulin G4 (IgG4)-related hypophysitis can be indistinguishable from other forms of acute hypophysitis and histology remains the diagnostic gold standard. The high recurrence rate necessitates long term immunosuppressive therapy. Rituximab (RTX) has been shown to be effective in systemic IgG4-related disease (IgG4-RD), but experience with isolated pituitary involvement remains limited.Case descriptionWe report three female patients with MRI findings suggestive of hypophysitis. All patients underwent transsphenoidal biopsy and fulfilled diagnostic criteria for IgG4-related hypophysitis. Treatment with GCs (GC) resulted in good therapeutic response in patients 1 and 2, but the disease recurred on tapering doses of GCs. GC treatment led to emotional lability in Patient 3 necessitating dose reduction. All three patients received RTX and Patients 2 and 3 received further courses when symptoms returned and B-cells repopulated. Patient 3 did not receive RTX until 12 months from onset of symptoms. Patient 1 was not able to have further RTX treatments due to an allergic reaction when receiving the second dose. RTX treatment resulted in sustained remission and full recovery of anterior pituitary function in Patients 1 and 2 with complete resolution of pituitary enlargement. By contrast, Patient 3 only showed symptomatic response following RTX treatment, but pituitary enlargement and hypofunction persisted.ConclusionRTX treatment for IgG4-related hypophysitis resulted in sustained remission in two patients treated early in the disease process, but only achieved partial response in a patient with chronic disease suggesting that early therapeutic intervention may be crucial to avoid irreversible changes.

Journal article

Choudhury SM, Tan TMM, Lazarus K, Meeran Ket al., 2021, The Use of Prednisolone versus Dual-Release Hydrocortisone in the Treatment of Hypoadrenalism, Endocrine Connections, ISSN: 2049-3614

<jats:p>The introduction of adrenocortical extract in 1930, improved life expectancy to between two and five years with further increases seen with the introduction of cortisone acetate from 1948. Most patients are now treated with synthetic hydrocortisone, and incremental advances have been made with optimisation of daily dosing and the introduction of multi-dose regimens. Today there remains a significant mortality gap between individuals with treated hypoadrenalism and the general population. It is unclear whether this gap is a result of glucocorticoid over-replacement, under-replacement or loss of the circadian and ultradian rhythm of cortisol secretion, with detrimental risk of excess glucocorticoid at later times in the day. The way forwards involves replacement of the diurnal cortisol rhythm with better glucocorticoid replacement regimens. The steroid profile produced by both prednisolone and dual-release hydrocortisone (Plenadren), provide a smoother glucocorticoid profile than standard oral multidose regimens of hydrocortisone and cortisone acetate. The individualisation of prednisolone doses and lower bioavailability of Plenadren offer reductions in total steroid exposure. Although there is emerging evidence of both treatments offering better cardiometabolic outcomes than standard glucocorticoid replacement regimens, there is a paucity of evidence involving very low dose prednisolone (2-4 mg daily) compared to the larger doses (~7.5 mg) historically used. Data from upcoming clinical studies on prednisolone will therefore be of key importance in informing future practice.</jats:p>

Journal article

Meeran M, Zaman S, 2020, The Vanishing Adrenal Glands: A transient regression of adrenal lymphoma after a single dose of 1 mg dexamethasone, AACE Journal, ISSN: 1551-3696

Journal article

Almazrouei R, Meeran K, Palazzo FF, 2020, Visual Vignette, ENDOCRINE PRACTICE, Vol: 26, Pages: 252-252, ISSN: 1530-891X

Journal article

Sam AH, Wilson RK, Lupton M, Melville C, Halse O, Harris J, Meeran Ket al., 2019, Clinical prioritisation questions: A novel assessment tool to encourage tolerance of uncertainty?, Medical Teacher, Pages: 1-6, ISSN: 0142-159X

Uncertainty is a common and increasingly acknowledged problem in clinical practice. Current single best answer (SBA) style assessments test areas where there is one correct answer, and as the approach to assessment impacts on the approach to learning, these exams may poorly prepare our future doctors to handle uncertainty. We therefore, need to modify our approach to assessment to emphasize reasoning and introduce the possibility of more than one ‘correct’ answer. We have developed clinical prioritization questions (CPQs), a novel formative assessment tool in which students prioritize possible responses in order of likelihood. This assessment format was piloted with a group of medical students and evaluated in comparison with the more traditional SBA question format in a team-based learning setting. Students reported that they felt ongoing use would help improve their tolerance of uncertainty (p < 0.01). Furthermore, over 80% of students felt that CPQs were more reflective of real-life clinical practice. Group based discussions were significantly longer when answering CPQs (p < 0.01), suggesting they may promote richer discourse. CPQs may have a role in formative assessment to help equip students with the skills to cope with ambiguity and strengthen clinical reasoning and decision-making. Institutions may find them more practical to implement compared with other clinical reasoning assessment tools.

Journal article

Meeran K, 2019, Optimising glucocorticoid replacement in adrenal insufficiency, BRITISH JOURNAL OF DIABETES, Vol: 19, Pages: 131-132, ISSN: 2397-6233

Journal article

Sam SA, Peleva E, Fung CY, Cohen N, Benbow EW, Meeran Ket al., 2019, Very short answer questions: a novel approach to summative assessments in pathology, Advances in Medical Education and Practice, Vol: 10, Pages: 943-948, ISSN: 1179-7258

BackgroundA solid understanding of the science underpinning treatment is essential for all doctors. Pathology teaching and assessment are fundamental components of the undergraduate medicine curriculum. Assessment drives learning and the choice of assessments influences students’ learning behaviours. The use of multiple-choice questions is common but is associated with significant cueing and may promote ‘rote learning’. Essay-type questions and Objective Structured Clinical Examinations (OSCEs) are resource-intensive in terms of delivery and marking, and do not allow adequate sampling of the curriculum. To address these limitations, we used a novel online tool to administer Very Short Answer questions (VSAQs) and evaluated the utility of the VSAQs in an undergraduate summative pathology assessment.MethodsA group of 285 medical students took the summative assessment, comprising 50 VSAQs, 50 single best answer questions (SBAQs), and 75 extended matching questions (EMQs). The VSAQs were machine-marked against pre-approved responses, and subsequently reviewed by a panel of pathologists, with the software remembering all new marking judgements.ResultsThe total time taken to mark all 50 VSAQs for all 285 students was 5 hours, compared to 70 hours required to manually mark an equivalent number of questions in a paper-based pathology exam. The median percentage score for the VSA test (72%) was significantly lower than that of the SBAQs (80%) and EMQs (84%), p <0.0001. VSAQs had a higher Cronbach alpha (0.86) than SBAQs (0.76), and EMQs (0.77). VSAQs, SBAQs and EMQs had a mean point-biserial of 0.35, 0.30 and 0.28, respectively.ConclusionsVSAQs are an acceptable, reliable and discriminatory method for assessing pathology, and may enhance students’ understanding of how pathology supports clinical decision-making and clinical care by changing learning behaviour.

Journal article

Meeran K, 2019, In reply to quinkler and Murray: prednisolone replacement therapy mimics the circadian rhythm more closely than other glucocorticoids, The Journal of Applied Laboratory Medicine, Vol: 1, Pages: 755-757, ISSN: 2576-9456

Journal article

Almazrouei R, Model D, Meeran K, 2019, Sheehan's like syndrome in a man, QJM: An International Journal of Medicine, Vol: 112, Pages: 811-812, ISSN: 1460-2393

An 84-year-old physician self-diagnosed that he had a pituitary tumour when he was found to have a bilateral upper quadrantanopia on routine eye testing. Magnetic resonance imaging (MRI) confirmed a large non-functioning pituitary macroadenoma associated with chiasmal compression. Investigation showed partial hypopituitarism with disconnection hyperprolactinaemia [prolactin 1095 mU/L (60–300)]. He was treated with hormonal replacement consisting of thyroxin 100 µg and prednisolone 3 mg and was offered transphenoidal hypophysectomy, but chose a conservative approach. Two years later, his visual fields worsened (Figure 1A) corresponding to an increase in macrodenoma size. Subsequently, he fell and fractured his left shoulder, which became infected, requiring surgery. Immediately after the shoulder surgery, he became hypotensive and vomited several times, and his visual fields became restricted. MRI showed pituitary infarction (Figure 1B), and he did not require surgical intervention. A few weeks later, he noticed dramatic improvement in his vision. His prolactin level dropped from a peak level of 1095 to 48 mU/L (60–300), suggesting lactotroph infarction. Repeated pituitary MRI showed dramatic reduction in the height of the pituitary macroadenoma consistent with the improvement in his visual fields (Figure 1C).

Journal article

Sam AH, Westacott R, Gurnell M, Wilson R, Meeran K, Brown Cet al., 2019, Comparing single-best-answer and very-short-answer questions for the assessment of applied medical knowledge in 20 UK medical schools: Cross-sectional study, BMJ Open, Vol: 9, Pages: 1-7, ISSN: 2044-6055

Objectives The study aimed to compare candidate performance between traditional best-of-five single-best-answer (SBA) questions and very-short-answer (VSA) questions, in which candidates must generate their own answers of between one and five words. The primary objective was to determine if the mean positive cue rate for SBAs exceeded the null hypothesis guessing rate of 20%.Design This was a cross-sectional study undertaken in 2018.Setting 20 medical schools in the UK.Participants 1417 volunteer medical students preparing for their final undergraduate medicine examinations (total eligible population across all UK medical schools approximately 7500).Interventions Students completed a 50-question VSA test, followed immediately by the same test in SBA format, using a novel digital exam delivery platform which also facilitated rapid marking of VSAs.Main outcome measures The main outcome measure was the mean positive cue rate across SBAs: the percentage of students getting the SBA format of the question correct after getting the VSA format incorrect. Internal consistency, item discrimination and the pass rate using Cohen standard setting for VSAs and SBAs were also evaluated, and a cost analysis in terms of marking the VSA was performed.Results The study was completed by 1417 students. Mean student scores were 21 percentage points higher for SBAs. The mean positive cue rate was 42.7% (95% CI 36.8% to 48.6%), one-sample t-test against ≤20%: t=7.53, p<0.001. Internal consistency was higher for VSAs than SBAs and the median item discrimination equivalent. The estimated marking cost was £2655 ($3500), with 24.5 hours of clinician time required (1.25 s per student per question).Conclusions SBA questions can give a false impression of students’ competence. VSAs appear to have greater authenticity and can provide useful information regarding students’ cognitive errors, helping to improve learning as well as assessment. Electronic delivery

Journal article

Bhatt PS, Sam AH, Meeran KM, Salem Vet al., 2019, The relevance of cortisol co-secretion from aldosterone-producing adenomas, Hormones (Athens, Greece), Vol: 18, Pages: 307-313, ISSN: 1109-3099

AIMS AND OBJECTIVES: Adrenal adenomas are usually non-functioning, but can secrete aldosterone or cortisol. It has recently been suggested that many more adenomas than previously thought secrete more than one hormone. This has important implications for their clinical management. Our aim was to determine the frequency of cortisol co-secretion in primary hyperaldosteronism at our institution and investigate the difference in metabolic profiles and clinical outcomes between co-secreting and non-co-secreting patients. DESIGN AND PATIENTS: A retrospective study of 25 patients with primary hyperaldosteronism who also underwent formal dexamethasone suppression tests to determine cortisol co-secretion. MEASUREMENTS: Post-dexamethasone suppression test cortisol, serum ALT, total cholesterol, HDL-cholesterol, LDL-cholesterol, HbA1C (were recorded) and mean arterial pressure are reported in this cohort of patients with primary hyperaldosteronism. RESULTS: Four out of 25 patients with primary hyperaldosteronism failed dexamethasone suppression tests. This suggests a frequency of co-secretion ranging between 4 and 16%. No significant difference was found in serum ALT, total cholesterol, serum HDL-cholesterol, LDL-cholesterol and mean arterial blood pressure at presentation between co-secretors and non-co-secretors. CONCLUSION: A frequency range of 4-16% suggests that a significant proportion of patients with primary hyperaldosteronism co-secrete cortisol. Co-secretors did not have a worse metabolic profile than non-secretors. The impact of co-secretion on metabolic profile and surgical management remains unclear and warrants further study.

Journal article

Choudhury S, Lightman S, Meeran K, 2019, Improving glucocorticoid replacement profiles in adrenal insufficiency, Clinical Endocrinology, Vol: 91, Pages: 367-371, ISSN: 1365-2265

There is an increased mortality associated with adrenal insufficiency despite glucocorticoid replacement therapy with a standardized mortality ratio greater than two. The cause of the increased mortality is yet to be definitively elucidated, but may be due to excess steroid exposure, or replacement regimens that are uncoupled from the normal physiological cortisol profile. Cortisol secretion follows an ultradian pattern which is not possible to reproduce using oral replacement. With the advent of new pumps, it is now possible to mimic the pulsatility of the adrenal glands. While the cognitive and emotional benefits of reproducing the ultradian rhythm are known, the presence of long-term benefits is not yet clear. There is a dearth of evidence and high-quality studies to underline our current understanding of the pathophysiology of adrenal insufficiency and replacement therapy. There is a particular lack of research comparing objective outcomes between patients receiving hydrocortisone replacement (either standard therapy or new sustained release preparations), prednisolone replacement and ultradian pumps. Direct comparative studies are now warranted to understand the optimal approach.

Journal article

Sam SA, Fung CY, Wilson R, Peleva E, Kluth D, Lupton M, Owen D, Melville C, Meeran Met al., 2019, Using prescribing very short answer questions to identify sources of medication errors: a prospective study in two UK medical schools, BMJ Open, Vol: 9, Pages: 1-5, ISSN: 2044-6055

Objective To assess the utility and ability of the novel prescribing very short answer (VSA) question format to identify the sources of undergraduate prescribing errors when compared with the conventional single best answer (SBA) question format and assess the acceptability of machine marking prescribing VSAs.Design A prospective study involving analysis of data generated from a pilot two-part prescribing assessment.Setting Two UK medical schools.Participants 364 final year medical students took part. Participation was voluntary. There were no other inclusion or exclusion criteria.Outcomes (1) Time taken to mark and verify VSA questions (acceptability), (2) differences between VSA and SBA scores, (3) performance in VSA and (4) SBA format across different subject areas and types of prescribing error made in the VSA format.Results 18 200 prescribing VSA questions were marked and verified in 91 min. The median percentage score for the VSA test was significantly lower than the SBA test (28% vs 64%, p<0.0001). Significantly more prescribing errors were detected in the VSA format than the SBA format across all domains, notably in prescribing insulin (96.4% vs 50.3%, p<0.0001), fluids (95.6% vs 55%, p<0.0001) and analgesia (85.7% vs 51%, p<0.0001). Of the incorrect VSA responses, 33.1% were due to the medication prescribed, 6.0% due to the dose, 1.4% due to the route and 4.8% due to the frequency.Conclusions Prescribing VSA questions represent an efficient tool for providing detailed insight into the sources of significant prescribing errors, which are not identified by SBA questions. This makes the prescribing VSA a valuable formative assessment tool to enhance students’ skills in safe prescribing and to potentially reduce prescribing errors.

Journal article

Choudhury S, Machenahalli P, Tan T, Meeran Ket al., 2019, Inadvertent treatment of hypoadrenalism with prednisolone in pemphigus: a case report, Clinical Case Reports, Vol: 7, Pages: 987-989, ISSN: 2050-0904

Pituitary and adrenal insufficiency must not be overlooked when weaning patients down from high‐dose steroids. Prednisolone can be used as glucocorticoid replacement therapy, with most patients needing 3‐4 mg once daily.

Journal article

Di Marco A, Meeran K, Christakis I, Sodhi V, Nelson-Piercy C, Tolley N, Palazzo Fet al., 2019, Seventeen cases of primary hyperparathyroidism in pregnancy: a call for management guidelines, Journal of the Endocrine Society, Vol: 3, Pages: 1009-1021, ISSN: 2472-1972

IntroductionThe risks of primary hyperparathyroidism (pHPT) to pregnant women and their fetuses are well-reported and appear to increase commensurate with serum calcium. The management strategy of pHPT must be adapted in pregnancy and should reflect the severity of hypercalcaemia. However, no guidelines exist to assist clinicians facing this dilemma.MethodsThe experience of a high-volume multidisciplinary endocrine surgical service in managing a consecutive series of pregnant women with pHPT referred for parathyroidectomy is presented and compared to a non-pregnant cohort with pHPT. Evidence in the published literature is explored via a review on pHPT and pregnancy outcomes.ResultsSeventeen pregnant women and 247 age range-matched non-pregnant women with pHPT were referred for surgery over 11 years. Serum calcium was higher in the pregnant cohort 2.89mmol/l vs 2.78mmol/l (p=0.03). Pre-operative localisation with ultrasound succeeded in 8(47%) pregnant women and SestaMIBI in 2/6(33% imaged pre-conception) compared to 84(34%) and 102(42%) controls (NS at 0.36 and 0.59). Parathyroidectomy was performed under general anaesthesia between 12 and 28 weeks gestation, with no adverse pregnancy outcomes resulting. Cure rate was 100% vs 96% in controls.ConclusionspHPT in pregnancy is a threat to mother and child. Medical management may be appropriate in mild disease (serum calcium <0.25mmol/l above the normal range) but in moderate-severe disease, parathyroidectomy under general anaesthesia in the second trimester is safe. Localisation using ionising radiation/MRI is unnecessary as surgical intervention in a high-volume multi-disciplinary setting has excellent outcomes. Guidelines on the topic would assist clinicians in this complex decision-making process.

Journal article

Almazrouei RA, Sam AH, Meeran K, Palazzo Fet al., 2019, PARATHYROID SESTAMIBI REVEALS MENINGIOMA., Endocr Pract, ISSN: 1530-891X

Journal article

Armeni E, Almazrouei R, Hayes AR, Palazzo F, Todd J, Toumpanakis C, Wernig F, Grossman AB, Meeran K, Caplin M, Tan T, Khoo Bet al., 2019, Insight into the Management of Chromaffin Cell Derived Tumours - Experience from Two ENETS Centres of Excellence, 16th Annual ENETS Conference for the Diagnosis and Treatment of Neuroendocrine Tumor Disease, Publisher: KARGER, Pages: 271-271, ISSN: 0028-3835

Conference paper

Al-Essah Z, Meeran K, 2018, Does quality of life differ in patients with Addison's disease on different glucocorticoid therapies?, Endocrine, Vol: 62, Pages: 740-740, ISSN: 1355-008X

Journal article

Samarasinghe S, Avari P, Meeran K, Cegla Jet al., 2018, Management of hypertriglyceridaemic pancreatitis in the acute setting and review of literature., BMJ Case Rep, Vol: 11

Acute pancreatitis (AP) is a potentially life-threatening complication of severe hypertriglyceridaemia, which is the third most common cause of AP after gallstone disease and alcohol excess. Standard therapy involves the use of lipid-lowering agents, low-molecular-weight heparin and insulin infusion. In some cases, when standard medical therapies fail, non-pharmacological methods based on the removal of triglycerides with therapeutic plasma exchange can provide positive results in the acute phase. There are currently no guidelines covering management in the acute phase, however, these approaches should be considered in severe or very severe hypertriglyceridaemia. Here, we report the case of a 37-year-old man with recurrent AP due to hypertriglyceridaemia and review the literature.

Journal article

Abbara A, Clarke S, Eng PC, Milburn J, Devavrata J, Comninos A, Ramli R, Mehta A, Jones B, Wernig F, Nair R, Mendoza N, Sam SH, Hatfield E, Meeran MK, Dhillo W, Martin Net al., 2018, Clinical and biochemical characteristics of patients presenting with pituitary apoplexy, Endocrine Connections, Vol: 7, Pages: 1058-1066, ISSN: 2049-3614

PurposeTo review the clinical and biochemical characteristics and clinical outcome of patients presenting with pituitary apoplexy to a tertiary centre.MethodsWe retrospectively reviewed the clinical features, predisposing factors, biochemistry and clinical outcome of patients presenting with pituitary apoplexy to Imperial College Healthcare NHS Trust between 1991 and 2015.ResultsWe identified 64 patients with pituitary apoplexy (more complete clinical records were available in 52 patients). The median age at presentation was 46.7 years (IQR 31.5–57.0 years). Pituitary apoplexy was the first presentation of pituitary disease in 38/52 of patients and predisposing factors were identified in 28/52. Pituitary apoplexy predominantly occurred in patients with non-functioning pituitary adenomas (47/52). Headache was most commonly described as sudden onset, severe, lateralising to the frontal or temporal regions. Symptoms of meningeal irritation were reported in 7/18 and visual abnormalities in 22/35. A pre-treatment serum cortisol <100 nmol/L was recorded in 12/31 of patients. All patients with visual disturbance had some resolution of their visual symptoms whether managed surgically (14/14) or conservatively (5/5), although pituitary endocrine function did not fully recover in any patient.ConclusionsIn conclusion, these data describe the clinical features of pituitary apoplexy to aid the clinician in diagnosing this rare emergency presentation of pituitary disease. Prospective multicentre studies of the presentation of pituitary apoplexy are required to further characterise presentation and outcomes.

Journal article

Abbara A, Clarke S, Nesbitt A, Ali S, Comninos A, Hatfield E, Martin NM, Sam AH, Meeran K, Dhillo Wet al., 2018, Interpretation of serum gonadotropin levels in hyperprolactinemia, Neuroendocrinology, Vol: 107, Pages: 105-113, ISSN: 0028-3835

Background/Aims: Hyperprolactinemia is a common cause of amenorrhea due to hypogonadotropic hypogonadism. Prolactin is hypothesized to impede the reproductive axis through an inhibitory action at the hypothalamus. However, limited data exists to aid the interpretation of serum gonadotropins in the context of hyperprolactinemia. Methods: Serum gonadotropin values were reviewed in 243 patients with elevated serum monomeric prolactin due to discrete etiologies at a tertiary reproductive endocrine centre between 2012 and 2015. The cause of hyperprolactinemia was categorized by an experienced endocrinologist / pituitary multidisciplinary team, unless superseded by histology. The most frequently encountered diagnoses were Microprolactinoma (n=88), Macroprolactinoma (n=46), Non-Functioning Pituitary Adenoma (NFPA) (n=72), Drug-Induced Hyperprolactinemia (DIH) (n=22) and Polycystic Ovarian Syndrome (PCOS) (n=15). Results: In patients with prolactinoma and modestly raised serum prolactin levels (<4000 mU/L), increasingly FSH-predominant gonadotropin values were observed with rising prolactin level, consistent with a progressive reduction in hypothalamic GnRH pulsatility. Patients with prolactinoma and higher prolactin values (>4000 mU/L) were more likely to have a reduction in serum levels of both FSH and LH, consistent with direct pituitary gonadotrope dysfunction. Patients with macroadenoma and extremes of serum gonadotropin values (either serum FSH or LH >8 IU/L) were more likely to have NFPA than prolactinoma. Patients with polycystic ovarian syndrome (PCOS) and hyperprolactinemia had LH-predominant secretion in keeping with increased GnRH pulsatility despite a raised prolactin level. Conclusion: The pattern of gonadotropin secretion in patients may reflect the etiology of hyperprolactinemia.

Journal article

Maher M, Roncaroli F, Mendoza N, Meeran K, Canham N, Kosicka-Slawinska M, Bernhard B, Collier D, Drummond J, Skordilis K, Tufton N, Gontsarova A, Martin N, Korbonits M, Wernig Fet al., 2018, A patient with a germline SDHB mutation presenting with an isolated pituitary macroprolactinoma, Endocrinology, Diabetes and Metabolism Case Reports, Vol: 2018, ISSN: 2052-0573

Symptomatic pituitary adenomas occur with a prevalence of approximately 0.1% in the general population. It is estimated that 5% of pituitary adenomas occur in a familial setting, either in isolated or syndromic form. Recently, loss-of-function mutations in genes encoding succinate dehydrogenase subunits (SDHx) or MYC-associated factor X (MAX) have been found to predispose to pituitary adenomas in co-existence with paragangliomas or phaeochromocytomas. It is rare, however, for a familial SDHx mutation to manifest as an isolated pituitary adenoma. We present the case of a pituitary lactotroph adenoma in a patient with a heterozygous germline SDHB mutation, in the absence of concomitant neoplasms. Initially, the adenoma showed biochemical response but poor tumour shrinkage in response to cabergoline; therefore, transsphenoidal surgery was performed. Following initial clinical improvement, tumour recurrence was identified 15 months later. Interestingly, re-initiation of cabergoline proved successful and the lesion demonstrated both biochemical response and tumour shrinkage. Our patient's SDHB mutation was identified when we realised that her father had a metastatic paraganglioma, prompting genetic testing. Re-inspection of the histopathological report of the prolactinoma confirmed cells with vacuolated cytoplasm. This histological feature is suggestive of an SDHx mutation and should prompt further screening for mutations by immunohistochemistry and/or genetic testing. Surprisingly, immunohistochemistry of this pituitary adenoma demonstrated normal SDHB expression, despite loss of SDHB expression in the patient's father's paraganglioma. Learning points: Pituitary adenomas may be the presenting and/or sole feature of SDHB mutation-related disease. SDHx mutated pituitary adenomas may display clinically aggressive behaviour and demonstrate variable response to medical treatment.Histological evidence of intracytoplasmic vacuoles in a pituitary adenoma might suggest an SDH-de

Journal article

Choudhury S, Meeran K, 2018, Glucocorticoid replacement in Addison disease., Nature Reviews Endocrinology, Vol: 14, Pages: 562-562, ISSN: 1759-5029

Journal article

Zheng SL, Roddick AJ, Aghar-Jaffar R, Shun-Shin MJ, Francis D, Oliver N, Meeran Ket al., 2018, Association between use of sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 agonists, and dipeptidyl peptidase 4 inhibitors with all-cause mortality in patients with type 2 diabetes: a systematic review and meta-analysis, JAMA: Journal of the American Medical Association, Vol: 319, Pages: 1580-1591, ISSN: 0098-7484

Importance The comparative clinical efficacy of sodium-glucose cotransporter 2 (SGLT-2) inhibitors, glucagon-like peptide 1 (GLP-1) agonists, and dipeptidyl peptidase 4 (DPP-4) inhibitors for treatment of type 2 diabetes is unknown.Objective To compare the efficacies of SGLT-2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors on mortality and cardiovascular end points using network meta-analysis.Data Sources MEDLINE, Embase, Cochrane Library Central Register of Controlled Trials, and published meta-analyses from inception through October 11, 2017.Study Selection Randomized clinical trials enrolling participants with type 2 diabetes and a follow-up of at least 12 weeks were included, for which SGLT-2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors were compared with either each other or placebo or no treatment.Data Extraction and Synthesis Data were screened by 1 investigator and extracted in duplicate by 2 investigators. A Bayesian hierarchical network meta-analysis was performed.Main Outcomes and Measures The primary outcome: all-cause mortality; secondary outcomes: cardiovascular (CV) mortality, heart failure (HF) events, myocardial infarction (MI), unstable angina, and stroke; safety end points: adverse events and hypoglycemia.Results This network meta-analysis of 236 trials randomizing 176 310 participants found SGLT-2 inhibitors (absolute risk difference [RD], −1.0%; hazard ratio [HR], 0.80 [95% credible interval {CrI}, 0.71 to 0.89]) and GLP-1 agonists (absolute RD, −0.6%; HR, 0.88 [95% CrI, 0.81 to 0.94]) were associated with significantly lower all-cause mortality than the control groups. SGLT-2 inhibitors (absolute RD, −0.9%; HR, 0.78 [95% CrI, 0.68 to 0.90]) and GLP-1 agonists (absolute RD, −0.5%; HR, 0.86 [95% CrI, 0.77 to 0.96]) were associated with lower mortality than were DPP-4 inhibitors. DPP-4 inhibitors were not significantly associated with lower all-cause mortality (absolute RD, 0.1%; HR, 1.02 [95% CrI, 0.94 to 1.11

Journal article

Choudhury S, Tan T, Meeran K, 2018, Once-daily, modified-release hydrocortisone in patients with adrenal insufficiency, LANCET DIABETES & ENDOCRINOLOGY, Vol: 6, Pages: 269-270, ISSN: 2213-8587

Journal article

Sam AH, Field SM, Collares CF, van der Vleuten CPM, Wass VJ, Melville C, Harris J, Meeran Ket al., 2018, Very-short-answer questions: reliability, discrimination and acceptability, MEDICAL EDUCATION, Vol: 52, Pages: 447-455, ISSN: 0308-0110

ContextSingle‐best‐answer questions (SBAQs) have been widely used to test knowledge because they are easy to mark and demonstrate high reliability. However, SBAQs have been criticised for being subject to cueing.ObjectivesWe used a novel assessment tool that facilitates efficient marking of open‐ended very‐short‐answer questions (VSAQs). We compared VSAQs with SBAQs with regard to reliability, discrimination and student performance, and evaluated the acceptability of VSAQs.MethodsMedical students were randomised to sit a 60‐question assessment administered in either VSAQ and then SBAQ format (Group 1, n = 155) or the reverse (Group 2, n = 144). The VSAQs were delivered on a tablet; responses were computer‐marked and subsequently reviewed by two examiners. The standard error of measurement (SEM) across the ability spectrum was estimated using item response theory.ResultsThe review of machine‐marked questions took an average of 1 minute, 36 seconds per question for all students. The VSAQs had high reliability (alpha: 0.91), a significantly lower SEM than the SBAQs (p < 0.001) and higher mean item–total point biserial correlations (p < 0.001). The VSAQ scores were significantly lower than the SBAQ scores (p < 0.001). The difference in scores between VSAQs and SBAQs was attenuated in Group 2. Although 80.4% of students found the VSAQs more difficult, 69.2% found them more authentic.ConclusionsThe VSAQ format demonstrated high reliability and discrimination and items were perceived as more authentic. The SBAQ format was associated with significant cueing. The present results suggest the VSAQ format has a higher degree of validity.

Journal article

Feeney C, Buell KG, Avari P, Buckley A, Meeran K, Rees DAet al., 2018, Addisonian crisis: assessment and management, BRITISH JOURNAL OF HOSPITAL MEDICINE, Vol: 79, Pages: C34-C37, ISSN: 1750-8460

Journal article

Wernig F, Hatfield E, Smith C, Mendoza N, nair R, limback-stanic C, gontsarova A, Martin N, Meeran M, Levy J, Pusey Cet al., 2018, Early Treatment With Rituximab Can Improve Clinical Outcomes In Isolated IgG4- related Hypophysitis, The Endocrine Society Annual Meeting, Publisher: Oxford University Press (OUP), ISSN: 0163-769X

Conference paper

Loh WJ, Tharakan G, Todd J, Chahal H, Dhillo W, Martin N, Toumpanakis C, Caplin M, Spalding D, Meeran K, Tan T, Khoo Bet al., 2018, Sensitivity and Specificity of Insulin, C-Peptide and Nadir Glucose during 72 hr Supervised Fast in Diagnosis of Insulinoma, 15th Annual ENETS Conference for the Diagnosis and Treatment of Neuroendocrine Tumor Disease, Publisher: KARGER, Pages: 297-297, ISSN: 0028-3835

Conference paper

Khalil AB, Dina R, Meeran K, Bakir AM, Naqvi S, Al Tikritti A, Lessan N, Barakat MTet al., 2018, Indeterminate Thyroid Nodules: A Pragmatic Approach, EUROPEAN THYROID JOURNAL, Vol: 7, Pages: 39-43, ISSN: 2235-0640

Journal article

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