Severe pituitary Cushing's disease of sudden onset after 18 years of unsuccessful treatment for a previously non-functioning chromophobe adenoma is described in a middle-aged woman. Initial presentation with symptoms of optic nerve compression had been preceded by two years of amenorrhoea. Transfrontal resection of a chromophobe adenoma followed by radiotherapy, performed both at this time and again after a recurrence eight years later, failed to eradicate the tumour. Ten more years elapsed before she rapidly developed florid features of Cushing's syndrome. Plasma ACTH levels were markedly elevated and were only partially reduced by further transfrontal surgery, complete removal of the tumour proving impossible. Subsequent bilateral adrenalectomy was performed to control her hypercortisolism and a course of cytotoxic chemotherapy was administered in an attempt to treat the tumour recurrence. Immunocytochemical staining of tumour obtained at surgery demonstrated ACTH immunoreactivity both before and after the development of Cushing's disease. Although silent corticotrophic adenomas of the human pituitary, including chromophobic tumours, have been previously described, this is the first report of such a tumour becoming functional, sufficient to cause clinically evident Cushing's disease.

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KingdomCorresponding author's email: jonathan.fuld@addenbrookes.nhs.uk RATIONALEThere are problems with the current approach to do not attempt resuscitation (DNAR) decisions and documentation. These include ad-hoc completion (making futile resuscitations inevitable) and misconception of the meaning of DNAR orders (clinician and lay perception of less care being appropriate). Yet DNAR does not necessarily mean, "about to die": over 50% of patients with DNAR orders are discharged. For all patients there is evidence that the care they receive is not of the same standard as those with similar illness without the DNAR order in place. This misconception is widely acknowledged, resulting in some clinicians withholding DNAR orders for fear that their patients care will be worsened. METHODSWe conducted a cohort study at an acute hospital to assess the impact of our proposed solution to the problems identified above; the "Universal Form of Treatment Options" (UFTO), (Figure 1). The UFTO is designed to be completed on all patients, placing the resuscitation decision within a broader consideration of best care. The UFTO was developed by an iterative process involving consultation with doctors, nurses and patients, both individually and in focus groups. Initial data collection, through individual case note review, took place over three months and examined standard practice (May-July 2010) This was followed by a period of education about the UFTO in August, and a period of bedding in during September-October 2010 . Data after the introduction of the UFTO was collected during Nov 2010 -Jan 2011. RESULTSThere was no change in whole ward mortality: Overall deaths 56/550 (DNACPR group) versus 58/544 (UFTO group) chi-squared statistic of 0.0 with p=0.872. There was a statistically significant increase in the number of patients in whom a decision not to resuscitate was made 113/587 in the DNACPR group and 140/573 in the UFTO group. Comparison of these proportions gives a =4.27 with p=0.04. Characteristics of patients in whom a decision not to resuscitate was made were similar in terms of Modified early warning score on admission, Charlson comorbidity score, and age (see table 1 ). CONCLUSIONThe UFTO is a feasible alternative to the current DNAR order. The UFTO increased the proportion of patients not for resuscitation with no apparent change in the characteristics of those patients, in keeping with removal of the ad hoc nature of DNAR use. This suggests that the UFTO would lead to fewer inappropriate resuscitation attempts, which has ethical and health economic implications. Figure 1