Introduction: Transsphenoidal surgery is the current treatment for mass reduction in patients with non-functional pituitary adenomas (NFPAs). The surgical procedure may deteriorate or recover pituitary endocrine function. The aim of this study was to systematically assess the benefits and harms of transsphenoidal surgery on pituitary endocrine function in patients with NFPAs. Methods: This systematic review and meta-analysis was registered with PROSPERO (registration number: CRD42020210853). We searched Pubmed and EMBASE for studies reporting on pituitary function before and after transsphenoidal surgery in patients with NFPAs having a minimum follow-up of one month. The pre-specified primary outcomes were the proportions of patients with improved or deteriorated pituitary function after surgery reported as weighted mean using random effects meta-analysis or in case of considerable heterogeneity, i.e. I2 ≥ 75%, as a range of reported proportions. Subgroup analyses was planned for the primary outcomes on study level. Results: Of the 6597 identified records, 24 studies enrolling 3816 participants were eligible for assessment. Twenty-three studies were judged to have serious or critical risk of bias. The range of proportions of patients with recovery of at least one pituitary axis was between 10.2 % and 97.7 % (I2= 93 %), while the range of proportions of patients experiencing loss of at least one axis after pituitary surgery was between 0.0 % and 36.6 % (I2= 91 %). Conclusions: The current systematic review finds that the endocrine effect of pituitary surgery is unclear both in terms of the chance of recovery and the risk of pituitary failure and hypopituitarism should be considered only a relative indication for surgery. However, the range of effects does include potentially clinically relevant rates of pituitary recovery calling for more systematic collection of data in future studies.
Background:GCA and PMR are challenges with regard to diagnosis and effective treatment because of varied and vague symptom presentations and overlapping pathologies that often require specialist for diagnostic investigations and specific treatment. Long-term glucocorticoids (GC) dependency is common, and GC side effects occur in approximately 50% of patients emphasizing the need for continued monitoring and symptom control (1).Objectives:To present the development and the implementation of a nurse-led, rheumatologist-supported model of care in the outpatient management of adults diagnosed with GCA or PMR.Methods:Initially, available evidence about symptom regulated GC tapering in the treatment of GCA and PMR was identified. Subsequent, a fixed phase-out schedule for high dose GC therapy following either of three pathways (GCA with/without eye symptoms and PMR) was agreed on in a multidisciplinary working group. Furthermore, the group developed a nurse-managed protocol for nurse-led outpatient consultations to ensure systematic treatment and proper response to relapse. Prior to the implementation rheumatology nurses were taught and trained by rheumatologists in pertinent regulation of medication and identification of adverse signs and symptoms essential for providing appropriate support and patient education. Overall patient satisfaction was assessed on-site by an anonymous iPad questionnaire.Results:An individual, initial GC dose are set by the rheumatologist based on clinician diagnosis, supported by currently available diagnostic and classification criteria. Subsequently, a nurse-led protocol reassures patient education and support during approximately one year of steroid therapy. The protocol includes close and continues observation and assessment by planned rheumatology nursing consultations followed by reassuring telephone calls. A rheumatologist can be consulted if doubt arises. Further, the rheumatology nurse is responsible for allocating final tapering (approximately 24 weeks) in the individualized PMR-management-plan for general practitioner. Patient overall self-reported satisfaction first nine month was high indicated by patients’ experience of confidence, being heard and having questions resolved. Within the first 18 months, n=190 patients (GCA, n=82/PMR, n=108) with a mean aged of 73.2 (SD 8.4) years have been enrolled into nurse-led managed protocols for GC tapering.Conclusions:A nurse-managed protocol for systematic and individualized GC tapering and patient support was developed as well as implemented successfully for individualized treatment of GCA and PMR. The extensive supportive patient education and involvement in symptom management secured by the rheumatology nurse provided high satisfaction. Also, the protocol executes rapid and direct access to advice for patients as recommended by EULAR for the management of PMR (2).References1. Buttgereit F, Dejaco C, Matteson EL, et al. Polymyalgia Rheumatica and Giant Cell Arteritis. A Systematic Review. JAMA2016;315(22):2442–2458.2. Dejaco C, Singh YP,...
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