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Background Mentorship during residency training is correlated with improved outcomes. Many residency programs have implemented formal mentorship programs; however, reported data for these programs have not been previously synthesized. Thus, existing programs may fall short on delivering effective mentorship. Objective To synthesize current literature on formal mentorship programs in residency training in Canada and the United States, including program structure, outcomes, and evaluation. Methods In December 2019, the authors performed a scoping review of the literature in Ovid MEDLINE and Embase. The search strategy included keywords relevant to mentorship and residency training. Eligibility criteria included any study describing a formal mentorship program for resident physicians within Canada or the United States. Data from each study were extracted in parallel by 2 team members and reconciled. Results A total of 6567 articles were identified through the database search, and 55 studies met inclusion criteria and underwent data extraction and analysis. Though reported program characteristics were heterogenous, programs most commonly assigned a staff physician mentor to a resident mentee with meetings occurring every 3 to 6 months. The most common evaluation strategy was a satisfaction survey at a single time point. Few studies performed qualitative evaluations or used evaluation tools appropriate to the stated objectives. Analysis of data from qualitative studies allowed us to identify key barriers and facilitators for successful mentorship programs. Conclusions While most programs did not utilize rigorous evaluation strategies, data from qualitative studies provided insights into barriers and facilitators of successful mentorship programs, which can inform program design and improvement.

Pregnancy results in significant alteration of pituitary anatomy and hormone physiology. Prolactin-producing lactotroph cells undergo progressive and significant hyperplasia throughout pregnancy contributing to increase in size of the anterior pituitary. Changes in pituitary hormone production, binding protein levels and target hormone action occur during pregnancy. As a result of these alterations, the assessment of pituitary status in the pregnant woman is complex and differs from the non-pregnant state. Disorders of hormone function may be well established prior to pregnancy or less frequently develop during pregnancy. These conditions may impact on maternal and fetal outcomes and influence pregnancy management. The physiology of pregnancy may also influence behaviour of endocrine conditions. Several disorders are specifically associated with pregnancy, lymphocytic hypophysitis, and Sheehan’s syndrome being particular examples.

Pituitary surgery is the first-line treatment for the majority of pituitary adenomas; close monitoring and safe management of the endocrine status of the patients is a vital element of their peri- and early postoperative care. Consensus on the optimal strategy of assessment and management of central adrenal insufficiency is not currently available and various approaches are adopted ranging from perioperative stress dose glucocorticoids with gradual tapering, to steroid-sparing protocols with careful observation. Water balance disorders, mainly diabetes insipidus and syndrome of inappropriate antidiuretic hormone secretion, are also relatively common in the early postoperative period. Monitoring of fluid balance together with measurement of serum electrolytes and plasma/urine osmolality (or urinary specific gravity) are required for prompt recognition and treatment of these disorders. Finally, reliable assessment of cortisol status in the early postoperative period in patients with Cushing's disease is of major importance for determining further management plans.

Neuroendocrine neoplasms are known to have heterogeneous biological behavior. G3 neuroendocrine tumours (NET G3) are characterized by well-differentiated morphology and Ki67 > 20%. The prognosis of this disease is understood to be intermediate between NET G2 and neuroendocrine carcinoma (NEC). Clinical management of NET G3 is challenging due to limited data to inform treatment strategies. We describe clinical characteristics, treatment, and outcomes in a large single centre cohort of patients with gastroenteropancreatic NET G3. Data was reviewed from 26 cases managed at Queen Elizabeth Hospital, Birmingham, UK, from 2012 to 2019. Most commonly the site of the primary tumour was unknown and majority of cases with identifiable primaries originated in the GI tract. Majority of cases demonstrated somatostatin receptor avidity. Median Ki67 was 30%, and most cases had stage IV disease at diagnosis. Treatment options included surgery, somatostatin analogs (SSA), and chemotherapy with either platinum-based or temozolomide-based regimens. Estimated progression free survival was 4 months following initiation of SSA and 3 months following initiation of chemotherapy. Disease control was observed following treatment in 5/11 patients treated with chemotherapy. Estimated median survival was 19 months; estimated 1 year survival was 60% and estimated 2 year survival was 13%. NET G3 is a heterogeneous group of tumours and patients which commonly have advanced disease at presentation. Prognosis is typically poor, though select cases may respond to treatment with SSA and/or chemotherapy. Further study is needed to compare efficacy of different treatment strategies for this disease.

ObjectiveTo review and summarise the available literature regarding breastfeeding experiences of medical students, residents and physicians.Eligibility criteriaArticles of any design, including non-peer reviewed data that examine the experiences of breast feeding of medical students, residents and staff physicians.Information sourcesOvid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid EMBASE, Scopus and Web of Science.Risk of biasAll peer-reviewed studies underwent risk-of-bias assessment using relevant tools, depending on the study design.Included studiesWe included 71 citations; 51 surveys, 3 narrative descriptions, 9 editorials or letters to the editor, and 3 reviews.Synthesis of resultsIncluded articles were heterogeneous with respect to their study design, target population and outcomes reported. Most articles had a high risk of bias. Only five articles reported the impact of an intervention.Description of effectDespite heterogeneity, the majority of articles described important barriers to breast feeding for physicians, residents and medical students. These barriers were similar across studies, and included inadequate and inaccessible space, time constraints and inflexible scheduling, and lack of colleague support. The consequences of these barriers included low milk supply and early discontinuation of breast feeding.Strengths and limitations of evidenceDue to the observed heterogeneity of articles identified in this review, we are unable to assess trends in barriers or duration of breastfeeding over time.InterpretationInterventions to overcome systemic and cultural barriers to breast feeding are needed to meet legal obligations of workplaces for physicians and trainees. These interventions should be formally evaluated using implementation science or quality improvement methods.

Purpose Highlight and characterize manifestations, diagnostic/management approaches and outcomes in a contemporary cohort of patients with pituitary metastases (PM) from a large European pituitary center—over 10 years. Methods Retrospective review of PM cases between 1/2009 and 12/2018. Clinical, laboratory, imaging data at PM detection and during follow-up were analysed. Results 18 cases were identified (14 females; median age at diagnosis 61.5 years). Most common primary malignancies were lung (39%) and breast (32%). Most frequent presenting manifestation was visual dysfunction (50%). Gonadotrophin, ACTH, TSH deficiency were diagnosed in 85%, 67%, 46% of cases, respectively; diabetes insipidus (DI) was present in 17%. 33% of cases were detected during investigation for symptoms unrelated to PM. PM management included radiotherapy (44%), transsphenoidal surgery (17%), transsphenoidal surgery and radiotherapy (6%) or monitoring only (33%). One-year survival was 49% with median survival from PM detection 11 months (range 2–47). Conclusions In our contemporary series, clinical presentation of PM has evolved; we found increased prevalence of anterior hypopituitarism, decreased rates of DI and longer survival compared with older literature. Increased availability of diagnostic imaging, improvements in screening and recognition of pituitary disease and longer survival of patients with metastatic cancer may be contributing factors.

This cross-sectional study examines the association of the proportion of women on a medical conference planning committee with the proportion of women speakers at the conference.

Background Xanthogranulomatous pyelonephritis is a rare and serious manifestation of chronic kidney inflammation that can be life-threatening if not recognized and treated appropriately, often with antibiotics and surgery. Affected patients are most commonly females in their fifth or sixth decade of life with a background of obstructive uropathy, nephrolithiasis, or recurrent urinary tract infections who present with vague nonspecific symptoms. Case presentation A 43-year-old woman of Russian ethnicity with a history of nephrolithiasis presented to our emergency department with new left-sided pleuritic chest pain amid a 6-week history of constitutional symptoms including fevers, night sweats, and 7 kg of weight loss. Workup for acute coronary syndrome and pulmonary embolism in our emergency department was negative. Given that she was clinically unwell, she was admitted to internal medicine to expedite workup for the cause of her symptoms. A broad differential diagnosis for various infectious, inflammatory/autoimmune, and neoplastic processes was considered. Based on classic radiographic and histopathologic findings, she was ultimately diagnosed with xanthogranulomatous pyelonephritis of her left kidney, which was a direct consequence of chronic inflammation. This inflammation exhibited spread to local tissues and across her left hemidiaphragm, resulting in a unilateral pleural effusion which explained her chest discomfort. She was treated with antibiotics administered intravenously and urgent total nephrectomy with a good functional outcome. Conclusions Our case illustrates an uncommon but clinically important do-not-miss diagnosis that underlies a common clinical presentation of pleuritic chest pain. The case underscores the importance of maintaining a broad differential diagnosis and organized approach when treating patients with undifferentiated clinical presentations.

Visual dysfunction is an important element in the morbidity encountered in patients with pituitary adenoma leading to functional impairment and compromised quality of life. It consists of many parameters (even in the absence of reported symptomatology) as a result of tumour growth in proximity to structures critical for vision (anterior visual pathway, cranial nerves within cavernous sinuses), and as an adverse consequence of therapeutic interventions. Adenoma resection leads to high rates of visual improvement and possibly continues beyond a year post surgery, but the exact timing of maximum effect requires elucidation. Retinal nerve fibre layer measurement may be a reliable, objective parameter predicting favourable visual outcomes, although its prognostic value when pathological, needs to be confirmed. For compromised vision after pituitary apoplexy, early surgical decompression remains usual practice until evidence-based guidance becomes available. The risk of radiation-induced visual toxicity is mainly influenced by total and per fraction dose of radiation and treatment modality. Careful selection of cases and of radiotherapy technique/planning are of major importance in minimising this risk. Dopamine agonists lead to visual recovery in a considerable number of prolactinoma patients. Visual morbidity should be considered a vital indicator in the metrics of quality of service/care in pituitary disease making regular, full ophthalmic examination an essential component of modern management of pituitary pathology at all time points of patient pathway. Well-designed studies minimising effects of bias and using tools and scoring systems reliably reflecting visual status will provide robust evidence on valid prognostication and patient stratification guiding clinical decision making.

Background Growth hormone deficiency is a recognized consequence of traumatic brain injury. The aim of this study was to determine adherence to human growth hormone therapy among patients with traumatic brain injury compared with patients with hypothalamic or pituitary disease. Methods A retrospective chart review of patients with traumatic brain injury referred for growth hormone stimulation testing since December 2013. Within the same electronic medical record, patients who were started on human growth hormone for aetiologies other than traumatic brain injury were reviewed. Adherence to therapy at 1-year followup was compared. Results Of the patients with traumatic brain injury, 12/23 (52%) returned for follow-up at 1 year to continue human growth hormone treatment, whereas 11/23 (48%) did not return at 1 year. Amongst the patients with non-traumatic brain injury: 25/29 (86%) continued human growth hormone treatment, vs 4/29 (14%) who did not return. A higher proportion of patients with non-traumatic brain injury continued human growth hormone treatment; x2 (1, n = 52)p = 7.238, p = 0.007. Conclusion There may be differences in the patient-perceived benefits of human growth hormone between these patient populations. However, it is important to consider the potential influences of cognitive and psychosocial dysfunction that can occur in patients with brain injuries. LAY ABSTRACT Traumatic brain injuries can damage the pituitary gland and cause hormone deficiencies. Growth hormone deficiency is the most common hormone deficiency in patients with head injuries. These patients have adverse symptoms and poor quality of life, but it is not known whether these issues can be reversed or improved by growth hormone replacement therapy. This study investigated how many patients who started on growth hormone therapy after brain injury continued the treatment long-term. This allowed us to estimate whether the patients perceived such treatment to be beneficial. More than half (52%) of the patients with traumatic brain injury chose to continue growth hormone therapy for one year or longer. However, while some patients with brain injury may experience benefit from growth hormone replacement, it is possible that not all patients find growth hormone therapy helpful.

Background Growth hormone deficiency (GHD) is a potential consequence of traumatic brain injury (TBI), including sport-related concussion (SRC). GH stimulation testing is required for definitive diagnosis; however, this is resource intensive and can be associated with adverse symptoms or risks. Measurement of serum IGF-1 is more practical and accessible, and pituitary tumour patients with hypopituitarism and low serum IGF-1 have been shown to have a high probability of GHD. We aimed to evaluate IGF-1 measurement for diagnosing GHD in our local TBI population. Methods We conducted a retrospective chart review of patients evaluated for GHD at the TBI clinic and referred for GH stimulation testing with insulin tolerance test (ITT) or glucagon stimulation test (GST) since December 2013. We obtained demographics, TBI severity, IGF-1, data pertaining to pituitary function, and GH stimulation results. IGF-1 values were used to calculate z-scores per age and gender specific reference ranges. Receiver operator curve analysis was performed to evaluate diagnostic threshold of IGF-1 z-score for determining GHD by GST or ITT. Results Sixty four patient charts were reviewed. 48 patients had mild, six had moderate, eight had severe TBI, and two had non-traumatic brain injuries. 47 patients underwent ITT or GST. 27 were confirmed to have GHD (peak hGH

A 22-year-old man presented with a 3-week history of increased thirst, polydipsia, and polyuria. He described consuming large volumes of water and waking up multiple times throughout the night to drink and urinate. He also endorsed symptoms of fatigue and frequent headaches. Prior to this, he had been well. There was no history of diuretic use, lithium use, or renal disease. There was no prior head trauma, cranial irradiation, or intracranial pathology. He denied consumption of nutritional or protein supplements. Clinical exam revealed a well appearing young man with normal heart rate and blood pressure. Visual fields and general neurologic exam were grossly normal.Baselines investigations revealed serum sodium ranging from 141–142 mmol/L (reference range 133–145 mmol/L), creatinine 92 umol/L (50–120 umol/L), random glucose 5.4 mmol/L (3.3–11.0 mmol/L), potassium 4.0 (3.3–5.1 mmol/L) and ionized calcium 1.25 mmol/L (1.15–1.35 mmol/L). A 24-hour urine collection was arranged, and returned a urine volume of 5.6L (normal less than 3 litres/24 hours). Further investigations revealed a serum sodium of 142 mmol/L, serum osmolality 306 mmol/kg (280–300 mmol/kg), and urine osmolality of 102 mmol/kg (50–1200 mmol/kg). AM cortisol was 372 nmol/L (200–690 nmol/L).These results demonstrated inability to concentrate the urine, despite the physiologic stimulus of hyperosmolarity. Based on this, a presumptive diagnosis of diabetes insipidus was made. The patient was instructed to drink as much as he needed to satiate his thirst, and to avoid fluid restriction. The patient was started on DDAVP intranasal spray, which provided immediate relief from his symptoms. Magnetic resonance imaging of the brain revealed an unremarkable pituitary gland with abnormal thickening of the pituitary stalk and loss of the posterior pituitary bright spot. This confirmed the diagnosis of central diabetes insipidus, presumed secondary to infiltrative disease affecting the pituitary stalk.IntroductionPolyuria is defined as inappropriately high urine output relative to effective arterial blood volume and serum sodium. In adults, polyuria can be objectively quantified as urine output in excess of 3–3.5 L per day with a low urine osmolality (

Hyperprolactinaemia is one of the most common problems in clinical endocrinology. It relates with various aetiologies (physiological, pharmacological, pathological), the clarification of which requires careful history taking and clinical assessment. Analytical issues (presence of macroprolactin or of the hook effect) need to be taken into account when interpreting the prolactin values. Medications and sellar/parasellar masses (prolactin secreting or acting through “stalk effect”) are the most common causes of pathological hyperprolactinaemia. Hypogonadism and galactorrhoea are well-recognized manifestations of prolactin excess, although its implications on bone health, metabolism and immune system are also expanding. Treatment mainly aims at restoration and maintenance of normal gonadal function/fertility, and prevention of osteoporosis; further specific management strategies depend on the underlying cause. In this review, we provide an update on the diagnostic and management approaches for the patient with hyperprolactinaemia and on the current data looking at the impact of high prolactin on metabolism, cardiovascular and immune systems.

Gender equity is a prominent issue in the medical profession. Representation of female physicians at academic meetings has been identified as an important component of gender equity; however, this topic has not been systematically assessed.To determine the trend during the last decade in the proportion of speakers who were women at major academic medical conferences held in Canada and in the United States.A cross-sectional analysis was conducted examining the gender of speakers listed in meeting programs of medical conferences held in Canada and in the United States in 2007 and from 2013 through 2017. Eligible conferences were identified using a sensitive search strategy, and a previously validated tool was used to analyze each meeting speaker list and to assign a proportion of female speakers. Conferences held in English language, hosted in Canada or the United States, and targeted to a physician audience with 100 or more attendees were included. The comparison group was active physicians in Canada and in the United States.The mean of the proportion of female speakers at each conference per year.In total, 181 conferences with 701 individual meetings were analyzed, including 100 medical and 81 surgical specialty conferences. The proportion of women ranged from 0% to 82.6% of all speakers. The mean (SD) proportion of female conference speakers for all meetings analyzed significantly increased from 24.6% (14.6%) for 40 meetings in 2007 to 34.1% (15.1%) for 181 meetings in 2017 (P .001). The mean proportion of female speakers at medical specialty conferences was 9.8% higher (SE, 1.9%; P .001) than the mean proportion of female speakers at surgical specialty conferences for all years analyzed. The mean proportion of female speakers at conferences was similar to the mean proportion of active female physicians across all specialties in the United States and in Canada for all years analyzed.Although our findings indicate that the proportion of female speakers at medical conferences increased during the last decade, women continue to be underrepresented. Speaker invitation and selection at conferences represent important opportunities to influence gender equity within medicine.

Understanding memory function amounts to identifying how events (cognitive and neural) at study eventually influence events at test. Many of the proposed cognitive correlates of memory-related event-related potentials (ERPs) at study resemble proposed cognitive correlates of other memory-related ERPs, recorded at test. We wondered whether a given known ERP feature at study might in fact reflect an effective-encoding process that is, in turn, tapped by another specific ERP feature, recorded at test. To this end, we asked which pairs of known memory-related ERP features explain common variance across a large sample of participants, while they perform a word-recognition task. Two early ERP features, the Late Positive Component (study) and the FN400 (test), covaried significantly. These features also correlated with memory success (d' and response time). Two later ERP features, the Slow Wave (study) and the Late Parietal Positivity (test), also covaried when lures were incorporated into the analysis. Interestingly, these later features were uncorrelated with memory outcome. This novel approach, exploiting naturally occurring subject variability (in strategy and ERP amplitudes), informs our understanding of the memory functions of ERP features in several ways. Specifically, they strengthen the argument that the earlier ERP features may drive old/new recognition (but perhaps not the later features). Our findings suggest the Late Positive Component at study, in some degree, may cause the FN400 to increase at test, together producing effective recognition memory. The Slow Wave at study appears to relate the Left Parietal Positivity at test, but these may play roles in more complex memory judgments and may be less critical for simple old/new recognition.