Publications
240 results found
Almazrouei R, Meeran K, Palazzo FF, 2020, Visual Vignette, ENDOCRINE PRACTICE, Vol: 26, Pages: 252-252, ISSN: 1530-891X
Sam AH, Wilson RK, Lupton M, et 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.
Farag S, Feeney C, Lee V, et al., 2019, Identifying risk factors for severity & activity of Graves Orbitopathy - a multi-centre analysis of the characteristics and treatment of patients with Thyroid Eye Disease, The 2019 European Association for Vision and Eye Research Conference, Publisher: European Association for Vision and Eye Research (EVER), Pages: 1-2, ISSN: 1395-3907
PurposeEarly diagnosis and treatment of Graves Orbitopathy (GO) is essential to prevent sight-threatening complications and long-term disability and therefore establishing a standard of care is highly desirable. Establishing predictors of a severe disease course are also vital to allow for early intervention.MethodsA retrospective patient-cohort study of 236 patients referred to three GO multidisciplinary (MDT) clinics between 2012–2019. Derived from this cohort, audit standards were compared against TEAMeD-5 guidelines, looking in particular at; (i) time between referral and specialist review (ii) offering of smoking cessation and selenium supplementation where appropriate (iii) time from referral to treatment for moderate-severe active disease. Patient characteristics were also analysed to investigate for any groupwise differences and correlations between variables collected at baseline to help predict subsequent disease activity.ResultsMedian patient age was 48.0 years, 77.5% female, 30.1% White Caucasian. Median initial clinical activity score (CAS) was 1 (range 0–7). Additionally, 80.5% had positive TSH antibody titre. The median time between referral and first MDT clinic was 50.0 days. Of the 254 patients, 80/236 received IVMP for active moderate-severe GO and the mean time to treatment was 9.3 days. All patients with sight-threatening GO were seen and treated within 2 weeks. There were 52/236 (22.0%) current smokers, all of whom received documented smoking cessation advice. A positive correlation was found between TSH antibody titre (R = −0.2902, p = 0.0545).ConclusionThe increasing recognition that an MDT approach is optimal for the management of GO requires a strong clinical governance framework. This work will further define the TEAMeD guidelines before the national implementation. Novel findings relating to the association of disease activtiy with biomarkers of diabetes and antibody titres are worth further investigation.
Meeran K, 2019, Optimising glucocorticoid replacement in adrenal insufficiency, BRITISH JOURNAL OF DIABETES, Vol: 19, Pages: 131-132, ISSN: 2397-6233
Sam SA, Peleva E, Fung CY, et 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.
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
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).
Sam AH, Westacott R, Gurnell M, et 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
Bhatt PS, Sam AH, Meeran KM, et 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.
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.
Sam SA, Fung CY, Wilson R, et 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.
Choudhury S, Machenahalli P, Tan T, et 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.
Di Marco A, Meeran K, Christakis I, et 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.
Almazrouei RA, Sam AH, Meeran K, et al., 2019, PARATHYROID SESTAMIBI REVEALS MENINGIOMA., Endocr Pract, ISSN: 1530-891X
Armeni E, Almazrouei R, Hayes AR, et 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
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
Samarasinghe S, Avari P, Meeran K, et 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.
Abbara A, Clarke S, Eng PC, et 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.
Abbara A, Clarke S, Nesbitt A, et 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.
Maher M, Roncaroli F, Mendoza N, et 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
Choudhury S, Meeran K, 2018, Glucocorticoid replacement in Addison disease., Nature Reviews Endocrinology, Vol: 14, Pages: 562-562, ISSN: 1759-5029
Zheng SL, Roddick AJ, Aghar-Jaffar R, et 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
Sam AH, Field SM, Collares CF, et 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.
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
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Feeney C, Buell KG, Avari P, et al., 2018, Addisonian crisis: assessment and management, BRITISH JOURNAL OF HOSPITAL MEDICINE, Vol: 79, Pages: C34-C37, ISSN: 1750-8460
Wernig F, Hatfield E, Smith C, et 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
Khalil AB, Dina R, Meeran K, et al., 2018, Indeterminate thyroid nodules: a pragmatic approach, European Thyroid Journal, Vol: 7, Pages: 39-43, ISSN: 2235-0802
Background: Fine needle aspiration (FNA) cytology fails to provide a conclusive diagnosis in a subset of thyroid lesions labeled as “indeterminate” (Thy3). In this study, we aimed at ascertaining the prevalence of Thy3 thyroid nodules in a hitherto unreported ethnic group (residents of the United Arab Emirates). Methods: We retrospectively examined 688 FNA of the thyroid performed on 584 patients. Samples were reported using the Royal College of Physicians’ (RCP) Thy classification. The results of the FNA were correlated with the final surgical specimens. Ultrasonography (US) risk stratification was calculated using a web-based US risk of malignancy calculator. Results: Overall sample adequacy was 97%. The indeterminate group Thy3 was found in 7% of the samples. The overall risk of malignancy in the Thy3 category was 20%. This risk was very similar in the 2 subgroups of Thy3 (17% in Thy 3a and 22% in Thy3f). Subdividing the Thy3 group into subgroups becomes less necessary if the US scoring is <24.5% since the negative predictive value, in this case, is 100%. Applying this criterion to our population would have had the potential of reducing the percentage of patients referred to surgery from 61 to 43%. Conclusions: Proper risk stratification of Thy3 lesions should be based on the combined risk assessment of clinical, cytological, radiological, and molecular data. Such a pragmatic approach is expected to reduce the percentage of inappropriate referrals to surgery.
Loh WJ, Tharakan G, Todd J, et 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
Smith DJF, Prabhudev H, Choudhury S, et al., 2017, Prednisolone has the same cardiovascular risk profile as hydrocortisone in glucocorticoid replacement., Endocrine Connections, Vol: 6, Pages: 766-772, ISSN: 2049-3614
INTRODUCTION: Patients who need glucocorticoid replacement in both primary and secondary adrenal insufficiency have the choice of either once daily prednisolone or thrice daily hydrocortisone. A recent European study found no difference between prednisolone and hydrocortisone users in several markers including glucose, weight, body mass index (BMI), systolic and diastolic blood pressure and waist circumference, although an increase in cholesterol and low density lipoprotein (LDL) was suggested in a subgroup of these patients. The aim of this study was to expand the evidence base for the use of these agents as replacement therapy. METHOD: Data from 82 patients on hydrocortisone and 64 patients on prednisolone for adrenal insufficiency at Imperial College Healthcare Trust were analysed. RESULTS: There was no significant difference in total cholesterol, LDL levels or any other risk factors between hydrocortisone and prednisolone patients. Prednisolone was subjectively significantly more convenient than hydrocortisone (p=0.048). CONCLUSIONS: Prednisolone once daily is more convenient than hydrocortisone thrice daily, and there is no difference in the markers of cardiovascular risk measured. Because prednisolone mimics the circadian rhythm better than other glucocorticoids, it should be considered as an alternative to hydrocortisone for adrenal insufficiency.
Khoo B, Boshier PR, Freethy A, et al., 2017, Redefining the stress cortisol response to surgery., Clinical Endocrinology, Vol: 87, Pages: 451-458, ISSN: 1365-2265
BACKGROUND: Cortisol levels rise with the physiological stress of surgery. Previous studies have used older, less-specific assays, have not differentiated by severity or only studied procedures of a defined type. The aim of this study was to examine this phenomenon in surgeries of varying severity using a widely used cortisol immunoassay. METHODS: Euadrenal patients undergoing elective surgery were enrolled prospectively. Serum samples were taken at 8 am on surgical day, induction and 1 hour, 2 hour, 4 hour and 8 hour after. Subsequent samples were taken daily at 8 am until postoperative day 5 or hospital discharge. Total cortisol was measured using an Abbott Architect immunoassay, and cortisol-binding globulin (CBG) using a radioimmunoassay. Surgical severity was classified by POSSUM operative severity score. RESULTS: Ninety-three patients underwent surgery: Major/Major+ (n = 37), Moderate (n = 33) and Minor (n = 23). Peak cortisol positively correlated to severity: Major/Major+ median 680 [range 375-1452], Moderate 581 [270-1009] and Minor 574 [272-1066] nmol/L (Kruskal-Wallis test, P = .0031). CBG fell by 23%; the magnitude of the drop positively correlated to severity. CONCLUSIONS: The range in baseline and peak cortisol response to surgery is wide, and peak cortisol levels are lower than previously appreciated. Improvements in surgery, anaesthetic techniques and cortisol assays might explain our observed lower peak cortisols. The criteria for the dynamic testing of cortisol response may need to be reduced to take account of these factors. Our data also support a lower-dose, stratified approach to dosing of steroid replacement in hypoadrenal patients, to minimize the deleterious effects of over-replacement.
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