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Pituitary Masterclass 1.45pm Monday 14th Sept 2020 - Shared screen with speaker view
Ross
01:37:25
Would it have been appropriate to stop the test earlier ? Do you use a body weight loss criteria as a reason to stop the test ?
Muhammad Shakeel Majeed
01:37:52
any history of sarcoidosis
SUGANYA GIRI RAVINDRAN
01:38:03
sarcoifosis
Ross
01:43:41
Is it possible to speak up please?
Ahmed Hanafy
01:44:12
Why not to do TSS to debulk the mass given the patient is already hypopit? SE of medications are significant
Kalyan Mansukhbhai Shekhda
01:44:24
should we be screening all patients with DI for GPA ?
Neena Kamran
01:45:32
why we thought of GPA on first instance
Miles Levy
01:46:28
Any surgeons here to say if they’d operate? Often granulomatous pituitary disease is a post-op finding and don’t tend to re-grow.
Natasha Thorogood
01:47:33
water dep test - why not copeptin measurement?
Ross
01:50:55
You can see unusual inflammatory sequelae following removal of ACTH producing tumours. Anything to suggest in previous case history that this macroadenoma was producing?
Ross
01:51:11
Prior to apoplexy
Shemitha Rafique
01:58:50
Any reason why T3 is much higher than T4 in the TSH oma lady?
Mohsin Sohail Siddiqui
01:59:34
Did she have follow-up imaging to assess the response on tumour size, with Octreotide?
Kasi Subbiah
02:02:53
Do somatostatin analogues shrink the tumor, in addition to decreasing TSH production?
george alias
02:03:47
can we continue Octreotide indefinitely if they chose not to have surgery?
IM
02:04:13
FT3 is disportionately elevated compared to TSH, indicating degree of feedback or is there a co-existent autoimmune
Olufunmilayo Adeleye
02:05:17
what about the approach for the control of hyperthyroidism in the patient?
amina khanam
02:06:12
thyroid hormone resistance, the dose of levothyroxine to use varies according to different guidelines that I have seen some base on weight - can we clarify what dosages we should be using please
Muna Guma
02:07:42
1
Umme Parveen
02:07:51
2
Jey
02:10:33
cannot see the screen
Muna Guma
02:10:52
2
Kasi Subbiah
02:13:56
With TSHoma's, does the amount of TSH produced by the tumor correlate with the size of the tumor (like for example in a prolactinoma)?
Muna Guma
02:16:08
TRH
Raghav Bhargava
02:16:10
May I know the menti code please
Umme Rubab
02:16:20
tshoma
Amir Sam
02:16:28
You could see what happens to the signal on the C11 meth PET with Octreotide.
Ibtihal
02:16:54
clinically was the pt symptomatic?
Daniel Isemede
02:17:58
Did you consider T3 suppression test
Hafiz Muhammad Zubair Ullah
02:18:09
How to differentiate thyrotroph hypertrophy secondary to persistent feedback in thyroid hormone resistance from adenoma?
Neena Kamran
02:20:30
but patient responded to octreo
Neena Kamran
02:20:58
both can coexist
Souha El Abd
02:21:01
is there a place for pituitary Bx ?
Neena Kamran
02:22:47
both can coexist
Bernard Freudenthal
02:23:27
is TRH test not more for investigating TSH deficiency/TSH reserve?
Bernard Freudenthal
02:24:01
I.e. why would/shoult TRH test differentiate TSHoma from RTH?
Daniel Isemede
02:24:07
TSH receptor alpha is rarely mutated because it is present in the brain, a mutation would result in severe learning disability and cretinism
Ross
02:25:51
Tired at 91, maybe is a Medical SpR?
Mohsin Sohail Siddiqui
02:32:51
leave well alone
Kasi Subbiah
02:33:17
Not sure whether Ix like visual evoked potentials or others would help to differentiate between the nerve damage from glaucoma and the nerve damage from external compression by a pituitary tumor?#
Raya Almazrouei
02:33:22
Would OCT help in deciding regarding surgery in this case?
Vikram Aarella
02:34:52
good cases till now 👍🏽
Muna Guma
02:41:51
yes
Beenish Inayat
02:44:09
but she already has complications due to hypercortisolism
Shirin Patel
02:44:41
Did she have a High Dose DST? Is there any role in this particular case?
Nazia Ayub
02:45:23
why not TSS as she has visual lost And probably Cushing as well...
Tariq Ahmad
02:46:12
Sensitivity of High dose DMST in Obese patient for ? Cushing disease
Neena Kamran
02:46:19
surgery will improve everything
Ben Field
02:46:32
Did you tell us whether she has obesity-related sleep apnoea?
Beenish Inayat
02:46:55
have you done MRI adrenals
Muhammad Shakeel Majeed
02:47:23
can we give octreotide if surgery is unlikely
Neena Kamran
02:47:37
obesity lead to pseudo or true cushings lead to obesity
Bijal Patel
02:47:56
Did she have a DEXA scan?
Mohsin Sohail Siddiqui
02:48:05
Would DEXA be useful in this case?
Kasi Subbiah
02:48:26
Losing weight with all that coke?
Ross
02:48:38
Had a CRH test been considered?
Fatima Bahowairath
02:48:45
Any role of cabergoline?
Vladimir Vaks
02:49:26
one more option: medical treatment of hypercorticism and weight loss prir pituitary surgery
Victoria Tyndall
02:49:56
IPSS?
Dimitris Papamargaritis
02:51:05
Very unlikely to achieve significant weight loss in order to make a difference for the surgery (with Cushing's and T2DM)
valmiki
02:51:13
GLP1a for the weight loss?
Miles Levy
02:51:28
IPSS won’t tell you if it’s a normal obese person or cushing’s - isn’t it easy given she’s got a macro-adenoma? She just needs an operation at some stage?
Mohammed Iqbal
02:51:47
why not do bariatric surgery? loose weight and reassess?
Almokhtar Otman
02:51:54
IPSS
Tariq Ahmad
02:52:02
Pickwikian synd ? Bariatric surgery
Ben Field
02:52:10
Agree - you don't know how long she has had the pituitary tumour and visual field defect so not an emergency
Lucy Owusu-Darkwah
02:52:26
j
Miles Levy
02:53:52
Anticoagulation probably most important thing to prevent bad things.
Victoria Tyndall
02:54:45
agreed, she has several reasons for significant VTE risk even outside of hospital
Ben Field
02:54:51
I'd be concerned about causing adrenal crisis if she doesn't in fact have Cushing's syndrome - hence reluctant re metyrapone
Neena Kamran
02:55:26
agreed
Ahmed Hanafy
02:55:40
We have seen a patient dealt with as NFPA, not cushingoid clinically but tumour stain positive to ACTH. actually patient has not had ONDST as Cushing's was not suspected. So might be there is a spectrum between silent and fully blown picture in ACTH secreting tumour
parez.namiq1
02:56:41
IPSS not indicated as she got pituitary lesion as you said but is there no chance to have ectopic secretion co-coexistwith pituitary lesion ?
meenakshi parsad
02:57:00
click on slideshow
Mohsin Sohail Siddiqui
02:57:09
or press F5
Inamullah Khan
02:57:24
enable editing first
Raghav Bhargava
02:57:26
need to enable editing first
Raghav Bhargava
02:57:50
after which go on custom slide show
Bijal Patel
03:03:40
What was ki67 index
Miles Levy
03:07:47
This is a really aggressive tumour and we should have a national group to discus this sort of patient in real time - the sort of patient that might need temozolamide.
Amber khan
03:07:55
further radiotherapy
Umar Raja
03:08:19
I was thinking about temozolamide as well for this patient
Ahmed Hanafy
03:08:25
?Temozolomide
Umar Raja
03:08:59
However there r 2 different things in this patient
Umar Raja
03:09:19
Excessive cortisol production where we can think about B/L adrenelectomy
Amber khan
03:09:22
bilateral adrenalectomy? is it an option
Miles Levy
03:09:35
Definitely don’t taketh adrenals out!
Vladimir Vaks
03:09:41
total adrenaletc +Paseriotide + Temoz
Umar Raja
03:09:45
and aggressive tumour where temozolamide might be an option
Souha El Abd
03:10:15
Temozolomide and radiotherapy?
george alias
03:10:21
bilateral adrenalectomy + paseriotide
Karim Meeran
03:10:30
answer on menti please
Karim Meeran
03:10:38
6775522
Hessa Boharoon
03:10:57
what about companying ketoconazole and metarypone?
Ben Field
03:12:01
Once upon a time... Yttrium needles
Clara Limbaeck
03:12:16
AGREE on the MGMT
Ben Field
03:14:09
With lead gloves
Clara Limbaeck
03:16:46
Avastin after temozolamide?
Ben Field
03:17:16
Why not press Go on all three and use the one that becomes available first? She is in imminent risk of death from tumour expansion
Vladimir Vaks
03:18:23
very aggessive tumour, obveously not possible to stop hypersecrition, so - total adrenalectomy asap, and than to deal with pituitary growth
Ahmed Hanafy
03:19:33
Also high risk of Nelson
Ahmed Hanafy
03:20:20
Thanks Victoria. Nice case
Tariq Ahmad
03:20:51
Thanks to all. Very good cases
Nasrullah Ghuman
03:23:45
Can you please share the link of next week meeting just announced by on oof the colleagues
Karim Meeran
03:24:43
you can see the links on http://imperialendo.co.uk
Karim Meeran
03:25:17
RSM virtual
sahar iftikhar
03:25:37
This link has some error
Umar Raja
03:26:08
You can see the link on society for endocrinology website as well
Karim Meeran
03:26:09
link works, just tested
Miles Levy
03:26:57
https://www.rsm.ac.uk/events/endocrinology-and-diabetes/2019-20/edn50/
Amber khan
03:29:32
have you done other pituitary profile
Amber khan
03:30:17
need to do all inflammatory cause work up for DI
Marcus Martineau
03:32:02
we had excactly the same at West Mid (loss of posterior pit bright spot and treatmemt resistant hypernatermia to large volumes of IVF & DDAVP Rx over several weeks. MM
Ahmed Hanafy
03:32:29
There are a lot of factors in acutely unwell patients that can cause polyurea e.g. hypokalaemia, polyuric phase of AKI
Amir Sam
03:33:43
There are reports of increased hypernatraemia in ICU patients with COVID (due to insensible losses from pyrexia and increased resp rate)
re1b
03:34:47
I had similar case with significant DI post COVID with encephalitic features on MRI pituitary involving the posterior pituitary
mubin
03:34:55
Did the patient stop/restart valproate? Could this be an unmasking?
Marcus Martineau
03:34:57
we thought /concluded that our case was probabily secondary to ATN collecting tubule damage which subsequently resolved over time
Ahmad Aziz
03:36:20
Any eye q’s?
Ahmad Aziz
03:36:27
Sorry I was super late
Nazia Ayub
03:36:31
Thank you all!
meenakshi parsad
03:36:35
thank you for a brilliant session
Zeenat Banu
03:36:41
thank you
Heloise Tarrant
03:36:45
Thank you for a superb collection of cases, and teaching.
Victoria Tyndall
03:36:47
thank you for a great session
Jey
03:36:48
thank you
Neena Kamran
03:36:48
Thank you
Ahmed Hanafy
03:36:49
Thank you all.
Inamullah Khan
03:36:50
Fantastic session. many thanks
Sheba Jarvis
03:36:51
Thank you, great session.
Venkatram Subramanian
03:36:53
thank you very much for the session. Great work imperial team
RAMESH KUMAR
03:36:54
Excellent cases and arrangement
Souha El Abd
03:37:03
Thanks for the great cases
Ibtihal
03:37:08
Great cases and discussion. thank u!
Htet Htet Aung
03:37:09
Thank you so much for giving me the chance to participate.
Kagabo Hirwa
03:37:16
Thank you for interesting cases
Ahmad Moolla
03:37:23
Thank you very much
Kasi Subbiah
03:37:24
Fantastic session. Thanks Prof. Meeran
Daniel Isemede
03:37:26
would the option to join remotely still be available next year if you return to campus
Vladimir Vaks
03:37:26
Brilliant as always!!! Thank you very much for organizing and give access to review later
Yin Yin
03:37:30
thanks for excellent cases and brilliant presentation
Ben Field
03:37:32
Thank you very much - excellent
Ramjan Sanas Mohamed
03:37:39
Thank you
Sreelakshmi Sivakumar
03:37:39
thank you for the brilliant session!!
pmanghat
03:37:49
thank you
Clara Limbaeck
03:37:52
great cases thank you Clara
Jessica Maynard
03:37:55
Thank you so much