Telemedicine for neurosurgery consultations at a Pituitary Center of Excellence: Patient preference and willingness to proceed with surgery

Objective The purpose of this study was to evaluate pituitary tumor patient satisfaction with telemedicine, patient preference for telemedicine, potential socioeconomic benefit of telemedicine, and patients’ willingness to proceed with surgery based on a telemedicine visit alone. Methods 134 patients who had pituitary surgery and a telemedicine visit during the COVID-19 pandemic (4/23/20-3/4/21) were called to participate in a 13-part questionnaire. Chi-square, ANOVA, and Wilcoxon Rank Sum were used to determine significance. Result Of 134 patients contacted, 90 responded (67%). 95% were “satisfied” or “very satisfied” with their telemedicine visit, with 62% stating their visit was “the same” or “better” than previous in-person appointments. 82% of patients rated their telemedicine visit as “easy” or “very easy.” On average, patients saved 150 minutes by using telemedicine compared to patient reported in-person visit times. 77% of patients reported the need to take off work for in-person visits, compared to just 12% when using telemedicine. 49% of patients preferred in-person visits, 34% preferred telemedicine, and 17% had no preference. 50% of patients said they would feel comfortable proceeding with surgery based on a telemedicine visit alone. Patients with both initial evaluation and follow-up conducted via telemedicine were more likely to feel comfortable proceeding with surgery based on a telemedicine visit alone compared to patients who had only follow-up telemedicine visits (p=0.051). Conclusion Many pituitary patients patients are satisfied with telemedicine visits and feel comfortable proceeding with surgery based on a telemedicine visit alone. Telemedicine is an important adjunct to increase access to care.

Effects of Pituitary Surgery and High-Dose Cabergoline Therapy on Metabolic Profile in Patients With Prolactinoma Resistant to Conventional Cabergoline Treatment

ObjectiveControl of prolactin excess is associated with the improvement in gluco-insulinemic and lipid profile. The current study aimed at investigating the effects of pituitary surgery and medical therapy with high dose cabergoline (≥2mg/week) on metabolic profile in patients with prolactinoma resistant to cabergoline conventional doses (<2mg/week).DesignThirty-four patients (22 men, 12 women, aged 33.9 ± 12.5 years) with prolactinoma (4 microadenomas and 30 macroadenomas) were included in the present study. Among them 17 (50%) received pituitary surgery (PS, Group1) and 17 (50%) medical therapy with high dose cabergoline (Group 2).MethodsIn the whole patient cohort, anthropometric (weight, BMI) and biochemical (fasting glucose and insulin, triglycerides, total, HDL and LDL-cholesterol, HOMA-IR, HOMA-β and ISI0) parameters were evaluated before and within 12 months after treatment.ResultsIn Group 1, prolactin (p=0.002), total cholesterol (p=0.012), and triglycerides (p=0.030) significantly decreased after pituitary surgery compared to the baseline. Prolactin significantly correlated with fasting glucose (r=0.056, p=0.025). In Group 2, fasting insulin (p=0.033), HOMA-β (p=0.011) and ISI0 (p=0.011) significantly improved compared to baseline. Postoperative cabergoline dose significantly correlated with Δfasting glucose (r=-0.556, p=0.039) and ΔLDL cholesterol (r=- 0.521, p=0.046), and was the best predictor of ΔLDL cholesterol (r2 = 0.59, p=0.002) in Group 1.ConclusionsThe rapid decrease in PRL levels induced by PS might improve lipid metabolism, whereas HD-CAB might exert a beneficial impact on both insulin secretion and peripheral sensitivity, thus inducing a global metabolic improvement.

Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery

Purpose There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery. Methods Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009–2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence. Results 651 Patients included with a median age of 55 years (range 16–86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1–5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing’s disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher’s Exact, p = 0.99) or epistaxis (Fisher’s Exact, p > 0.99). Conclusions Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.

Postoperative Pain Management and Perceived Patient Outcomes Following Endoscopic Pituitary Surgery

Objectives: Pain management remains a point of emphasis given the ongoing opioid crisis. There are no studies in the literature interrogating opioid prescribing and use following endoscopic pituitary surgery. This study investigate provider prescribing tendency, patient utilization of analgesics, and patient outcomes regarding pain management after endoscopic pituitary surgery. Methods: We identified 100 patients undergoing endoscopic pituitary surgery at one institution from 2016 – 2018 in the electronic medical record (EMR) and state narcotic database to determine postoperative analgesic regimens. A telephone survey was used to characterize postoperative analgesic use and satisfaction with prescribed regimens. Results: 52 different pain control regimens were prescribed to study patients. 93% of study patients were prescribed an opioid postoperatively. The average quantity of opioids prescribed per patient in morphine milligram equivalents (MME) was 625 (equivalent 83 oxycodone 5 mg tablets) with an average MME/day of 59 (equivalent 8 oxycodone 5 mg tablets). Average total MME, MME/day, and pills/tablets per opioid prescription decreased significantly over the study period. 71% of survey respondents who used opioids reported using <25% of their prescription. The majority of prescription narcotic users consumed >50% of their postoperative opioid intake in the first 24-48 hours after discharge. There were no significant differences in pain outcome between opioid users and non-opioid users. Conclusions: Vast heterogeneity exists in narcotic prescribing by providers at our institution following endoscopic pituitary surgery. Narcotic prescribing patterns exceeded most patients’ analgesic needs. Opioid analgesics were not superior to non-opioids regimens in patient-reported pain outcomes in this study population.

Practical and nursing aspects of endocrine conditions

Endocrinology nursing is an ever-evolving specialty. This chapter provides expert and innovative practice-based nursing information. It provides nursing care for thyroid surgery and disorders, facilitating investigation and education about pituitary function and specialist nurse management of different conditions. Education on visual field deficits and minimum driving standards are covered. The full roles of the nurse in pituitary surgery is explained, from pre-op to post-op care. Diabetes insipidus is covered. Responsibilities and possible pathways for managing male fertility, testosterone replacement, and gender dysphoria are all described. Finally, role development and nurse led clinics are examined.