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A 67-year-old male with metastatic cholangiocarcinoma presented with dehydration and delirium approximately 6 weeks after participating into a Rare Cancer Trial utilising combination of immune checkpoint inhibitors (ICIs), i.e., ipilimumab and nivolumab. His electrolytes were normal but cortisol was 36 nmol/L (185-625) and ACTH was 2 pmol/L (<10). Sixty-minute post-Synacthen cortisol was 153 nmol/L (>530). Secondary hypoadrenalism was diagnosed on the basis of low ACTH and baseline cortisol with poor response to Synacthen. Thyroid function tests revealed thyrotoxicosis, while TPO, thyroglobulin and TSH receptor antibodies were all negative. ICIs have been increasingly implicated in autoimmune endocrinopathies. Combination of ipilimumab and nivolumab can give rise to hypopituitarism or hypophysitis, and thyroid dysfunction. In healthy individuals, immune checkpoints maintain immunological tolerance to self-antigens. By inhibiting these immune checkpoints, ICIs cause auto-immune like manifestations against multiple organs. Typically, complications develop in susceptible patients 6-15 weeks after introduction of ICIs. The preferred screening test for hypophysitis is morning cortisol and ACTH, followed by Synacthen test.1 In oncology, ICIs are the most rapidly expanding class of drugs alternatives to traditional chemotherapy. Therefore, oncologists, endocrinologists and pathologists need to understand their mechanism of action, side effects, importance of monitoring ICI usage to detect and investigate the associated endocrine disorders. Reference 1. Barroso-Sousa R, Ott PA, Hodi FS, et al. Endocrine dysfunction induced by immune checkpoint inhibitors: practical recommendations for diagnosis and clinical management. Cancer 2018; 124: 1111-21. Copyright © 2020

A 67-year-old male with metastatic cholangiocarcinoma presented with dehydration and delirium approximately 6 weeks after participating into a Rare Cancer Trial utilising combination of immune checkpoint inhibitors (ICIs), i.e., ipilimumab and nivolumab. His electrolytes were normal but cortisol was 36 nmol/L (185-625) and ACTH was 2 pmol/L (<10). Sixty-minute post-Synacthen cortisol was 153 nmol/L (>530). Secondary hypoadrenalism was diagnosed on the basis of low ACTH and baseline cortisol with poor response to Synacthen. Thyroid function tests revealed thyrotoxicosis, while TPO, thyroglobulin and TSH receptor antibodies were all negative. ICIs have been increasingly implicated in autoimmune endocrinopathies. Combination of ipilimumab and nivolumab can give rise to hypopituitarism or hypophysitis, and thyroid dysfunction. In healthy individuals, immune checkpoints maintain immunological tolerance to self-antigens. By inhibiting these immune checkpoints, ICIs cause auto-immune like manifestations against multiple organs. Typically, complications develop in susceptible patients 6-15 weeks after introduction of ICIs. The preferred screening test for hypophysitis is morning cortisol and ACTH, followed by Synacthen test.1 In oncology, ICIs are the most rapidly expanding class of drugs alternatives to traditional chemotherapy. Therefore, oncologists, endocrinologists and pathologists need to understand their mechanism of action, side effects, importance of monitoring ICI usage to detect and investigate the associated endocrine disorders. Reference 1. Barroso-Sousa R, Ott PA, Hodi FS, et al. Endocrine dysfunction induced by immune checkpoint inhibitors: practical recommendations for diagnosis and clinical management. Cancer 2018; 124: 1111-21. Copyright © 2020

Background and objectives This audit investigates the utility of a Monash Health endocrinology directed androgen depravation therapy (ADT) clinic and the role it plays in supporting the urology service with ADT adverse effects management. Materials and methods A 5-year retrospective chart analysis compared the workload of Monash Health's urology and ADT clinics, including breadth of counselling and the adherence to the Medical Journal of Australia (MJA) 2011 ADT management recommendations. Results 87 patients (mean age 72), initiated on ADT by a urologist, were seen in ADT clinic over a 5-year period. 46% had pre-existing diabetes, 80% hypertension, 68% dyslipidaemia, 63% cardiovascular disease and 55% osteopenia or osteoporosis. In urology clinic, adequate ADT counselling was limited to adverse effects (bone mineral density > cardiovascular disease > hot flushes/ gynaecomastia/sexual dysfunction). Employment of patient directed risk mitigation was inadequately utilised; only 21% of patients were educated regarding the use of vitamin D and calcium supplementation. Medical examination (blood pressure, etc.) was never performed and baseline metabolic workup was only initiated in 1/44 patients. The endocrinologist-led ADT clinic established by Monash Health provided superior medical care. All patients underwent thorough medical examination (100% blood pressure checks, 45% breast exam), all patients had a baseline metabolic workup (100% DEXA scan, 96% fasting lipids), and the counselling was more comprehensive compared to urology counterparts. A significant imbalance in workload was demonstrated between clinics. The urology clinics averaged 15-20 min per patient compared to 45- min appointments in ADT clinic. A mean of 239 patients were reviewed in a 12-month period in ADT clinic, while between 926 and 2064 patients were reviewed per annum in urology clinics. Conclusion ADT clinic relieves the urologist of the unfair expectation to provide adequate counselling in an ina

Background and objectives This audit investigates the utility of a Monash Health endocrinology directed androgen depravation therapy (ADT) clinic and the role it plays in supporting the urology service with ADT adverse effects management. Materials and methods A 5-year retrospective chart analysis compared the workload of Monash Health's urology and ADT clinics, including breadth of counselling and the adherence to the Medical Journal of Australia (MJA) 2011 ADT management recommendations. Results 87 patients (mean age 72), initiated on ADT by a urologist, were seen in ADT clinic over a 5-year period. 46% had pre-existing diabetes, 80% hypertension, 68% dyslipidaemia, 63% cardiovascular disease and 55% osteopenia or osteoporosis. In urology clinic, adequate ADT counselling was limited to adverse effects (bone mineral density > cardiovascular disease > hot flushes/ gynaecomastia/sexual dysfunction). Employment of patient directed risk mitigation was inadequately utilised; only 21% of patients were educated regarding the use of vitamin D and calcium supplementation. Medical examination (blood pressure, etc.) was never performed and baseline metabolic workup was only initiated in 1/44 patients. The endocrinologist-led ADT clinic established by Monash Health provided superior medical care. All patients underwent thorough medical examination (100% blood pressure checks, 45% breast exam), all patients had a baseline metabolic workup (100% DEXA scan, 96% fasting lipids), and the counselling was more comprehensive compared to urology counterparts. A significant imbalance in workload was demonstrated between clinics. The urology clinics averaged 15-20 min per patient compared to 45- min appointments in ADT clinic. A mean of 239 patients were reviewed in a 12-month period in ADT clinic, while between 926 and 2064 patients were reviewed per annum in urology clinics. Conclusion ADT clinic relieves the urologist of the unfair expectation to provide adequate counselling in an ina

Background: Familial hypercholesterolemia (FH) is a common hereditary lipid disorder associated with high risk of cardiovascular disease. Emerging evidence suggests, FH is often both underdiagnosed and undertreated by health care providers. The prevalence of identified FH in a tertiary laboratory was assessed in this study. Method(s): We reviewed serum LDL-C level measured by a tertiary laboratory in Melbourne Australia over a six months period (July to December 2016). The prevalence of possible FHbasedonrecommendedLDL-Cthresholdsof5mmol/Las employed by the Dutch Lipid Clinic Network (DLCN) score was evaluated. Result(s): 4943 individuals had serum LDL-C assessment within this period, 106 patients; male/female ratio of 46/60 and mean age of 56, had LDL cholesterol of >= 5mmol/L after exclusion of five patients (0.1%) with secondary causes. Despite a poor documentation of family history and physical examination, 1.8% had DLCNS of 3-5, 0.3% a score of 6-8 and 0.1% a score of >8 indicating a possible, probable and definite diagnosis of FH respectively. The cumulative prevalence of likely phenotypical FH based on an LDL-C >=5.0mmol/L was 2.1% (1: 50). General practitioners referred 37.1% of the total patients followed by cardiologists and endocrinologists equally 12.2% and remaining 38.5% by other specialists. Conclusion(s): This study highlights the potential role of a tertiary laboratory in an opportunistic screening for index cases of FH. These data support the benefit of establishing an efficient "alert system" along with a trigger "reflex testing" to facilitate screening and ensuring further referral to a lipid disorder specialist.

Background: Pregnancy has a significant impact on the thyroid gland with alterations in thyroid stimulating hormone (TSH) and thyroid hormone levels. New guidelines proposed by the American Thyroid Association1 suggest that thyroxine replacement is not required in pregnant women with TSH <4mIU/L, and negative thyroid peroxidase (TPO) and thyroglobulin (Tg) autoantibodies. Aim(s): 1. To assess the range of TSH values and autoantibody status of women with newly diagnosed hypothyroidism in pregnancy 2. To identify the proportion of women in whom thyroxine treatment will no longer be recommended Methods An audit of women reviewed in the Monash Health Endocrine in Pregnancy Clinic between March 2012 and December 2015 was performed. Data collected included gestational history, plurality of pregnancy, past history of thyroid disease, thyroid function tests (TFTs) and antibody status. Result(s): Two hundred and eighty-nine women were reviewed for hypothyroidism; 148 (51.2%) of these women were newly diagnosed with hypothyroidism in pregnancy, currently defined by TSH > 2.5 mIU/L in the first trimester, with a mean gestation at first TFTs of 10.8 weeks. All were confirmed singleton pregnancies. Amongst these women, 49 (33.1%) had an initial TSH measurement of 2.5-4.0mIU/L, 80 (54.1%) had a TSH of 4.1-9.99 mIU/L and 19 (12.8%) had a TSH >= 10.0 mIU. Of those with TSH values of 2.5-4.0 mIU/L, 17 (35%) were identified as positive for either TPO or Tg antibodies, 26 (53%) were both TPO and Tg antibody negative with the remaining 6 patients' antibody status unknown. Conclusion(s): New guidelines proposed by the American Thyroid Association suggest that thyroxine during pregnancy is not required in women with a TSH <4 mIU/L and negative thyroid autoantibodies. Based on these recommendations, approximately 20% of women overall, but 50% of those with TSH 2.5-4.0 mIU/L, currently referred to our service may not require thyroxine or specialist Endocrinologist review during pregnancy.

Background: Pregnancy has a significant impact on the thyroid gland with alterations in thyroid stimulating hormone (TSH) and thyroid hormone levels. New guidelines proposed by the American Thyroid Association1 suggest that thyroxine replacement is not required in pregnant women with TSH <4mIU/L, and negative thyroid peroxidase (TPO) and thyroglobulin (Tg) autoantibodies. Aim(s): 1. To assess the range of TSH values and autoantibody status of women with newly diagnosed hypothyroidism in pregnancy 2. To identify the proportion of women in whom thyroxine treatment will no longer be recommended Methods An audit of women reviewed in the Monash Health Endocrine in Pregnancy Clinic between March 2012 and December 2015 was performed. Data collected included gestational history, plurality of pregnancy, past history of thyroid disease, thyroid function tests (TFTs) and antibody status. Result(s): Two hundred and eighty-nine women were reviewed for hypothyroidism; 148 (51.2%) of these women were newly diagnosed with hypothyroidism in pregnancy, currently defined by TSH > 2.5 mIU/L in the first trimester, with a mean gestation at first TFTs of 10.8 weeks. All were confirmed singleton pregnancies. Amongst these women, 49 (33.1%) had an initial TSH measurement of 2.5-4.0mIU/L, 80 (54.1%) had a TSH of 4.1-9.99 mIU/L and 19 (12.8%) had a TSH >= 10.0 mIU. Of those with TSH values of 2.5-4.0 mIU/L, 17 (35%) were identified as positive for either TPO or Tg antibodies, 26 (53%) were both TPO and Tg antibody negative with the remaining 6 patients' antibody status unknown. Conclusion(s): New guidelines proposed by the American Thyroid Association suggest that thyroxine during pregnancy is not required in women with a TSH <4 mIU/L and negative thyroid autoantibodies. Based on these recommendations, approximately 20% of women overall, but 50% of those with TSH 2.5-4.0 mIU/L, currently referred to our service may not require thyroxine or specialist Endocrinologist review during pregnancy.