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446Giant pituitary tumours (GPTs) are rare tumours of 30 mm or more, that have major extensions into the suprasellar and parasellar compartments. [1][2][3][4][5][6][7] Despite the major neurosurgical challenge that resecting GPTs presents, [8][9][10][11][12][13][14][15][16] both transsphenoidal and transcranial approaches have been used. 2,17,18 Transsphenoidal approaches offer a more direct route to the sellar components and can stay outside the arachnoid whenever possible. Transcranial approaches offer direct visualization of the suprasellar components but, because they must come from the subarachnoid position, visualizing the sellar contents can be difficult without drilling the planum sphenoidale or mobilizing the optic nerve.Surgical morbidity and mortality for these lesions can be high, although the safety of the surgery has progressively ABSTRACT: Objective: To evaluate the outcomes of patients with giant pituitary tumours (GPTs) who underwent a purely binasal endoscopic transsphenoidal surgery (BETS) and compare their outcomes with those achieved through craniotomy and microscopic transsphenoidal surgery (MTS). Methods: Seventy-two consecutive patients with GPTs (greater than 10 cm 3 in volume) who were treated surgically with BETS, craniotomy, or MTS from October 1994 to July 2009 were reviewed for clinical outcomes, degree of tumor resection, recurrence rates, and surgical complications. Results: The BETS group had significantly better mean reduction of tumor volume (91%) than the craniotomy (63%, p = 0.001), and the MTS (63%, p = 0.010) groups. Gross total resection rates were also higher for BETS patients than for craniotomy patients (p = 0.010). Improvements in vision and headaches were noted in 96% and 100% of patients in the BETS group, respectively; these rates were similar to those in the craniotomy and MTS groups. Of the four patients with hormone-secreting tumours in the BETS group, three remained in remission. The median length-of-stay (four days) for the BETS group was shorter (p = 0.010), and surgical complications were less frequent (p = 0.037) and less severe compared to the craniotomy group. There were no differences in the recurrence rates: 79% percent of patients in the BETS group, 69% in the craniotomy group, and 79% in the MTS group were recurrence free at last follow-up (p = 0.829). Conclusions: Treatment of GPT with BETS offers excellent oncologic and clinical outcomes and can frequently obviate the need for craniotomy in these patients. RÉSUMÉ: Résultats du traitement chirurgical des tumeurs géantes de l'hypophyse (TGH).Objectif : Le but de l'étude était d'évaluer les résultats de la chirurgie transsphénoïdale endoscopique binasale (CTEB), de la craniotomie et de la chirurgie transsphénoïdale par microscopie (CTM) chez des patients atteints de tumeurs géantes de l'hypophyse et de comparer les résultats obtenus suite à ces chirurgies. Méthode : Les dossiers de patients consécutifs atteints de TGH (volume supérieur à 10 cm3), qui ont été traités chirurgicalement soit par CTEB, crani...

BackgroundAdjuvant treatment with radioactive iodine (RAI) is often considered in the treatment of well-differentiated thyroid carcinoma (WDTC). We explored the recollections of thyroid cancer survivors on the diagnosis of WDTC, adjuvant radioactive iodine (RAI) treatment, and decision-making related to RAI treatment. Participants provided recommendations for healthcare providers on counseling future patients on adjuvant RAI treatment.MethodsWe conducted three focus group sessions, including WDTC survivors recruited from two Canadian academic hospitals. Participants had a prior history of WDTC that was completely resected at primary surgery and had been offered adjuvant RAI treatment. Open-ended questions were used to generate discussion in the groups. Saturation of major themes was achieved among the groups.FindingsThere were 16 participants in the study, twelve of whom were women (75%). All but one participant had received RAI treatment (94%). Participants reported that a thyroid cancer diagnosis was life-changing, resulting in feelings of fear and uncertainty. Some participants felt dismissed as not having a serious disease. Some participants reported receiving conflicting messages from healthcare providers on the appropriateness of adjuvant RAI treatment or insufficient information. If RAI-related side effects occurred, their presence was not legitimized by some healthcare providers.ConclusionsThe diagnosis and treatment of thyroid cancer significantly impacts the lives of survivors. Fear and uncertainty related to a cancer diagnosis, feelings of the diagnosis being dismissed as not serious, conflicting messages about adjuvant RAI treatment, and treatment-related side effects, have been raised as important concerns by thyroid cancer survivors.

Scoring written feedback identified that tasks were often specifically described, but performance gaps and action plans were less frequently and specifically mentioned. Educators might improve feedback effectiveness by better articulating to trainees the gap between their performance and an expert standard, as well as by providing them with specific learning plans.

There is a definable body of SSH knowledge that forms the academic underpinning for important physician competencies and is outside the experience of most medical educators. Curricular change incorporating such content is necessary if we are to strengthen the non-Medical Expert physician competencies. Our findings, particularly our cross-cutting themes, also provide a pedagogically useful mechanism for holistically teaching the underpinnings of physician competence. We are now implementing our findings into medical curricula.

KEY MESSAGES • Diabetic ketoacidosis and hyperosmolar hyperglycemic state should be suspected in people who have diabetes and are ill. If either diabetic ketoacidosis or hyperosmolar hyperglycemic state is diagnosed, precipitating factors must be sought and treated. • Diabetic ketoacidosis and hyperosmolar hyperglycemic state are medical emergencies that require treatment and monitoring for multiple metabolic abnormalities and vigilance for complications. • A normal or mildly elevated blood glucose level does not rule out diabetic ketoacidosis in certain conditions, such as pregnancy or with SGLT2 inhibitor use. • Diabetic ketoacidosis requires intravenous insulin administration (0.1 units/ kg/h) for resolution. Bicarbonate therapy may be considered only for extreme acidosis (pH ≤7.0). KEY MESSAGES FOR PEOPLE WITH DIABETES When you are sick, your blood glucose levels may fluctuate and be unpredictable: • During these times, it is a good idea to check your blood glucose levels more often than usual (for example, every 2 to 4 hours). • Drink plenty of sugar-free fluids or water. • If you have type 1 diabetes with blood glucose levels remaining over 14 mmol/L before meals, or if you have symptoms of diabetic ketoacidosis (see Table 1), check for ketones by performing a urine ketone test or blood ketone test. Blood ketone testing is preferred over urine testing. • Develop a sick-day plan with your diabetes health-care team. This should include information on: • Which diabetes medications you should continue and which ones you should temporarily stop • Guidelines for insulin adjustment if you are on insulin • Advice on when to contact your health-care provider or go to the emergency room. Note: Although the diagnosis and treatment of diabetic ketoacidosis (DKA) in adults and in children share general principles, there are significant differences in their application, largely related to the increased risk of lifethreatening cerebral edema with DKA in children and adolescents. The specific issues related to treatment of DKA in children and adolescents are addressed in the Type 1 Diabetes in Children and Adolescents chapter, p. S234. Symptoms Signs Hyperglycemia Polyuria, polydipsia, weakness ECFV contraction Acidosis Air hunger, nausea, vomiting and abdominal pain Altered sensorium Kussmaul respiration, acetone-odoured breath Altered sensorium Precipitating condition See list of conditions in Table 2 Can J Diabetes 42 (2018) S109-S114 Contents lists available at ScienceDirect Canadian Journal of Diabetes j o u r n a l h o m e p a g e : w w w. c a n a d i a n j o u r n a l o f d i a b e t e s. c o m

334Cushing's Disease (CD) is the commonest cause of endogenous hypercortisolemia 1 and is associated with significant morbidity and mortality. [2][3][4] Transsphenoidal pituitary surgery remains the first line treatment for this condition with reported remission rates of 52% to 89%. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Many attempts have been made to identify factors that would predict sustained remission after surgical intervention. Suggested factors include smaller adenomas and the confirmation of adenoma intraoperatively. 18,20 The question of whether the newer endoscopic surgical technique (endo TSS) 21 has improved results compared to the older microscopic technique (micro TSS) remains to be answered. The aim of this report is to study the outcomes of ABSTRACT: Background: Cushing disease (CD) constitutes a challenging condition for the pituitary surgeon. Given the variety of factors affecting outcomes in CD, it is uncertain whether the newer endoscopic technique improves the results of surgery. Methods: A review was conducted of CD cases at our institution between 2000 and 2010. Analysis was done to: determine if surgical technique had an effect on outcome, identify the predictors of outcome and provide details of failed cases. Remission was defined as normal postoperative 24-hour urinary free cortisol (24-h UFC), suppression of morning serum cortisol to <50 nmol/L after 1mg of dexamethasone or being dependent on steroid replacement. Results: Forty-two patients met our inclusion criteria. Average follow-up period was 33 months. There were 15 macroadenomas and 27 microadenomas. Seventeen patients had an endoscopic transsphenoidal surgery and twenty-five patients had a microscopic transsphenoidal procedure. Long-term overall remission was achieved in 26 (62%) patients. There was no significant difference in remission rates between the two techniques (p value 0.757). Patient's subjective symptomatic improvement and drop of morning serum cortisol in the postoperative period to less than 100 nmol/L correlated with longterm remission (p value 0.0031and 0.0101, respectively) while repeat surgery was the only predictor of the lack of postoperative remission (p value 0.0008). Conclusions: Revision surgery predicted poor remission rate for CD. Within the power of our study size, there was no difference in outcome between the endoscopic and microscopic approaches. Surgical outcomes should be reviewed in association with remission criteria used in a study. RÉSUMÉ: Évaluation de l'impact de la technique utilisée, au moyen de critères de rémission rigoureux, sur le résultat de la chirurgie dans le traitement de la maladie de Cushing. Contexte : La maladie de Cushing (MC) présente des défis pour le chirurgien qui la traite. Compte tenu de la variété des facteurs qui influencent le résultat du traitement dans la MC, nous ne savons pas si la nouvelle technique endoscopique améliore le résultat de la chirurgie. Méthode : Nous avons revu les dossiers des patients atteints de la MC traités dans notre instit...

Teaching QI to residents and faculty as co-learners is feasible and acceptable and offers a promising model for programs to teach QI to residents while concurrently building faculty capacity.