Endocrine Service Research Articles

Ten year analysis of the clinic profile of the tertiary paediatric endocrine service in Western Australia.

There is a paucity of information regarding the profile of entire paediatric endocrine clinics and how they are changing. This study aimed to analyse the clinic profile of the Western Australian tertiary paediatric endocrine outpatient service over 10 years and compare to national and international data. Retrospective analysis of the Western Australian Paediatric Endocrine Database (WAPED) between 2007 and 2017 looking at the frequency, proportion andlongitudinal change of diagnosis categories, specific diagnoses, and gender breakdown. In total, 2,791 endocrine diagnoses were recorded for 2,312 patients. The most frequent reason for referral (22.1% of patients), was for evaluation of abnormalities in thyroid function. The most common diagnosis being hypothyroidism (76.7%). Evaluation of short stature was the reason for referral in 19.2% of patients, 14.6% of whom were diagnosed with growth hormone deficiency. Evaluation of puberty disorders, syndromes with endocrine features and disorders of calcium and phosphate metabolism were other common reasons for clinic referral, seen in 11.3,9.8 and 8.2% of patients respectively. Between 2007 and 2017, the odds ratio of a thyroid diagnosis increased by 1.07 per year (95% CI: 1.02-1.12), whilst the odds ratio of a short stature diagnosis decreased by 0.91 per year (95% CI: 0.87-0.95). The profile of the WAPED is similar to previously published national and international data. The analysis of the profile of diagnoses and its longitudinal change over a ten-year period offer a unique opportunity to guide clinic planning, resource allocation and future research.

Endocrine services for children disrupted by COVID-19 – A fellow’s perspective

The COVID-19 pandemic has been disrupting our lives for the past 2 years. During my tenure as a fellow in pediatric endocrinology at a tertiary care center in India from September 2020, we faced several challenges in managing chronic endocrine disorders especially type 1 diabetes mellitus. However, with time, and the availability of newer methods of communication technology and supportive services, it became possible to adapt to a “new normal.”

Baseline and Peak Cortisol Response to the Low-Dose Short Synacthen Test Relates to Indication for Testing, Age, and Sex.

Meta-analyses report that the low dose short Synacthen test (LDSST) is more sensitive but less specific than the standard dose test for the diagnosis of adrenal insufficiency, and there are concerns regarding the accuracy of dosing in the LDSST. Perform a retrospective, observational study to review the outcomes of LDSSTs performed in a tertiary endocrine service from 2008 to 2014 (N = 335) and 2016 to 2020 (N = 160), and examine for relationships between cortisol measurements and indication for testing, age and sex. LDSST were performed by endocrine nurses. Synacthen 500 ng/1.73m2 administered as IV bolus, sampling at 0, 15, 25, and 35 minutes. Mean (± 1SD) baseline cortisol was 221 ± 120 nmol/L, peak 510 ± 166 nmol/L and increment 210 ± 116 nmol/L. 336 (70%) patients had a normal response (baseline cortisol >100 nmol/L, peak >450 nmol/L), 78 (16%) a suboptimal response (peak cortisol 350-450 nmol/L) and were prescribed hydrocortisone to during periods of stress only, 67 (14%) an abnormal response (baseline <100nmol/L or peak <350nmol/L) and were prescribed daily hydrocortisone. Basal, peak, and incremental increases in cortisol were higher in females (P = .03, P < .001, P = .03, respectively). Abnormal results occurred most frequently in patients treated previously with pharmacological doses of glucocorticoids or structural brain abnormalities (P < .001). The low prevalence and strong association of abnormal results with indication for testing, suggests that over diagnosis occurred infrequently in this clinical setting.

Detecting primary aldosteronism in Australian primary care: a prospective study.

To assess the identification of primary aldosteronism (PA) in newly diagnosed, treatment-naïve patients with hypertension by screening in primary care. Prospective study. General practices in the South Eastern Melbourne PrimaryHealth Network with at least three general practitioners and general practices elsewhere in Victoria that had referred patients to the Endocrine Hypertension Clinic at Monash Health, 2017-2020. Adults (18-80 years) with newly diagnosed hypertension (measurements of systolic blood pressure >140mmHg or diastolic blood pressure >90mmHg on at least two occasions) and not taking antihypertensive medications were screened for PA by assessing their aldosterone-to-renin ratio (ARR). Participants with two ARR values exceeding 70pmol/mU underwent saline suppression testing at the Endocrine Hypertension Service (Monash Health) to confirm the diagnosis of PA. Prevalence of PA (number of patients with confirmed PA divided by number screened). Sixty-two of 247 screened participants had elevated ARR values on screening (25%); for 35 people (14%; 95% CI, 10-19%), PA was confirmed by saline suppression testing. Baseline characteristics (mean age, sex distribution, median baseline blood pressure levels, and serum potassium concentration) were similar for people with or without PA. PA was diagnosed in 14% of patients with newly diagnosed hypertension screened by GPs, indicating a potential role for GPs in the early detection of an important form of secondary hypertension for which specific therapies are available.

A collaborative model aligning adult sexual health and endocrine gender health services.

The Hunter New England (HNE) endocrinology and sexual health service commenced a co-located gender community clinic in 2018. This paper describes this novel model of service delivery, including the sociodemographics, clinical characteristics, and STI screening rates of trans and gender diverse (TGD) adults attending for gender-affirming hormone treatment (GAHT) and identifies patients accessing the broader skill set of both specialty services in 2018-19. This study was a retrospective audit of medical records of all patients with initial consultations for GAHT at the endocrine and sexual health gender clinics from 1 January 2018 to 31 December 2019. A further data set included any adult TGD patient with any attendance, initial or subsequent, between 1 January 2018 and 31 December 2019. Patients with dual attendance at the endocrine gender clinic and sexual health service were further explored. Baseline sociodemographic data of participants were comparable in both gender clinics attended. Endocrinologists were more likely to use spironolactone for androgen blockade than the sexual health physician (77.8% vs 43.8%, P =0.0096), but prescribing patterns were otherwise similar. STI screening was more frequently performed in patients accessing GAHT through sexual health than endocrine gender clinics (35% vs 0.9%, P =0.00). Twenty patients (8.0%) had an attendance at both the sexual health and endocrine services and accessed STI screening, contraception, cervical screening, HIV pre- or post-exposure prophylaxis and estradiol implants. Co-located gender clinics staffed by endocrinology and sexual health physicians provide care for a similar patient population and facilitate access to GAHT, estradiol implants, STI screening, contraception, and cervical screening for the TGD population.

Adrenal glands and diabetes

Adrenal glands and diabetes

Thyroid Endocrine Nurse Service: Improving patient experience

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Improving referrals to survivorship: A patient-driven initiative.

44 Background: Patients often feel lost in the transition from cancer patient to survivor. As cancer treatment improves, the number of survivors in the US is expected to approach 22 million by the year 2029. Smaller increases in the MD workforce coupled with long-term effects of new treatments necessitate the creation survivorship clinics led by advanced practice providers (APP) who are disease-specialized and specifically trained to manage unique survivor needs. Although the institutions Survivorship program was established more than a decade ago, the average referral rate to the program is only 30%. Given the high levels of patient satisfaction with the program, we sought to understand and address clinician awareness and referral obstacles. Methods: Based on patient input, members of our Patient &amp; Family Advisory Council for Quality (PFACQ) put forth a proposal aimed at increasing referrals to the Survivorship program. A multidisciplinary working group comprising patients, clinicians, administrators and process engineers was assembled. Process Improvement training was conducted, and a primary goal was developed: increase Survivorship referrals by 25%. Central to the approach was engagement with referring physicians and APPs on a service-by-service basis. A four-question survey was developed to address timing of initial discussion, challenges to referring, knowledge of visit elements, and materials needed to support referrals. A customized ‘roadshow’ presentation was created and delivered by a PFACQ member at a faculty meeting. Highlights included: the importance of Survivorship care to patients and details of the visit, survey responses, and additional faculty discussion and input. Results: Four roadshows were completed from August 2020-June 2021: Gynecologic Surgery, Endocrine, Breast Medicine and Lymphoma. Based on survey responses and dialogue with providers, new material to support patient discussions and education have been developed: a patient-facing brochure, clinician- &amp; patient-facing video, and clinician talking points. Methods to facilitate identifying eligible patients were also discussed, as well as automatic referrals to Survivorship for selected services. Data reveal a significant increase in referral rates from GYN and Endocrine services (follow up &gt; 6 months) of 63% and 228%, respectively. (Breast Medicine and Lymphoma with shorter follow up will be reported.) Engagement with other services is underway. Conclusions: Results have exceeded the goal of increasing referral rates to the program. This process suggests that ongoing engagement with referring clinicians is essential to achieving and maintaining higher referral rates. The patient voice throughout this process has been a powerful tool in raising clinician awareness of their experiences and expectations for comprehensive follow up care, which can be delivered on a greater scale by survivorship providers.

Impact of Victoria's first dedicated endocrine hypertension service on the pattern of primary aldosteronism diagnoses.

Primary aldosteronism (PA) accounts for 3.2-12.7% of hypertension in primary care but is often diagnosed late, if at all. A delayed or missed diagnosis leads to poor blood pressure control and greater cardiovascular risk. To analyse the impact of Victoria's first dedicated endocrine hypertension service (EHS) on the pattern of PA diagnosis. Socio-demographic and clinical data from all patients who attended the EHS since July 2016 (n = 267) was collected prospectively. Patients were divided into Year 1 (Y1), Year 2 (Y2) and Year 3 (Y3), based on their first visit. The proportion of primary care referrals increased (20% in Y1, 47% in Y2, 52% in Y3) with more referrals being made for treatment-naive hypertension (3% in Y1, 14% in Y2, 19% in Y3). Among PA patients, the median duration of hypertension prior to their first visit decreased (11 years in Y1, 10 years in Y2, 7 years in Y3), and the prevalence of end-organ damage decreased (44% in Y1, 42% in Y2, 33% in Y3). Targeted management of PA improved clinical and biochemical outcomes. The average blood pressure reduction following targeted management increased from 16/12 mmHg in Y1 to 23/12 mmHg in Y3. The EHS, with its strong component of general practitioner engagement, led to increased primary care referrals and PA detection earlier in the course of hypertension. Referred patients were on fewer antihypertensives and had less end-organ damage which simplified the diagnostic process, allowing targeted treatment to be commenced earlier and patient outcomes optimised.

Artificial intelligence in the endocrine clinic: automated bone age analysis in arabic children from UAE

Objective: Artificial intelligence (AI) is playing an increasing role in patient assessment. AI bone age analysis is such a tool, but its value in Arabic children presenting to an endocrine clinic has not been explored. We compared results from an experienced pediatric radiologist and the AI bone age system, BoneXpert (BX), (Visiana, Denmark) to assess its utility in a cohort of children presenting to the Al Jalila Children’s Specialty Hospital endocrine service.&#x0D; Materials and Methods: We conducted a retrospective chart review of 47 children with growth disorders, initially assessed by a single experienced radiologist and subsequently by BX, to confirm the usefulness of the BX system in our population. The results of the analyses were analysed using a Bland-Altman plot constructed to compare differences between the radiologist’s interpretation and BX across the available range of bone age.&#x0D; Results: Forty-four of the patient x-ray images were analysed by BX. Three X-ray images were rejected by BX due to post-processing artifacts, which prevented computer interpretation. For the remaining 44 X-rays, there was a close correlation between radiologist and BX results (r=0.93; p &lt;0.00001). Two radiographs were identified with a large discrepancy in the reported bone ages. Blinded, independent re-evaluation of the radiographs showed the original manually interpreted bone age to have been erroneous, with the BX results corresponding closely to the amended bone age. A small positive bias was noted in bone age (+0.39 years) in the BX analyses, relative to manual interpretation.&#x0D; Conclusions: AI bone age analysis was of high utility in Arabic children from UAE presenting to an endocrine clinic, with results highly comparable to an experienced radiologist. In the two cases where a large discrepancy was found, independent re-evaluation showed AI analysis was correct.

Peer Review of Paediatric Endocrine Services in the UK: A Template for Quality and Service Improvement

Background: Independent peer review of healthcare services can complement existing internal-, institutional-, and national-level regulatory mechanisms aimed at improving quality of healthcare. However, this has not been reported for paediatric endocrinology services in the UK. We aimed to test feasibility and acceptability through a first cycle of a national peer review of paediatric endocrine services. Methods: Tertiary centres in paediatric endocrinology across the UK were assessed against 54 quality standards, developed by the British Society for Paediatric Endocrinology and Diabetes (BSPED) in five domains of healthcare by a team comprising paediatric endocrinologists and specialist nurses. The evaluation was supported by a self-assessment. A post-peer-review questionnaire was used as feedback. Results: All 22 centres in the UK underwent independent peer review between 2011 and 2017. Each served a median population of 2.6 million (range 1–8 million) and offered 1,872 (range 779–6,738) outpatient consultations annually. A total of 43 (range 30–49) standards were met in combined evaluation of all centres. Variance of adherence for essential standards ranged from 52 to 97% at individual centres with 90% adherence demonstrated by 32% of centres. Post-review feedback showed 20/22 (95%) validating the utility of the peer review. Conclusions: The BSPED peer review of all UK centres providing paediatric endocrine services is shown to be feasible and provides a quality benchmark for replication by national services.

A 65-Year-Old Man with Parathyroid Independent Hypercalcemia Due to Renal Cell Carcinoma and Resolution of Hypercalcemia Following Nephrectomy; Proposed Mechanisms of Hypercalcemia With Renal Cell Carcinoma

We report a case of a 65-year-old man who presented to the Endocrine service for hypercalcemia. He had painful joints, muscle aches, joint stiffness, and incidentally discovered elevated calcium levels on two separate occasions. A lab evaluation indicated non-parathyroid mediated hypercalcemia with calcium levels in the range of 10.1-10.5mg/dl. Parathyroid hormone related peptide (PTHrP) level was undetectable. His PTH and 25-OH Vitamin D levels were normal. But his 1, 25 Dihydroxy Vitamin D levels were low. Initial imaging revealed a heterogeneously enhancing mass on the posterolateral left kidney. Our patient underwent a left nephrectomy, and the mass was identified as RCC on surgical pathology. We illustrated the differential diagnosis of hypercalcemia and the evaluation of hypercalcemia occurring with RCC. This case explains that we need to carefully evaluate, interpret, and review all the data, especially when the patient has borderline elevated calcium levels and does not have a typical presentation of malignancy.

Endoscopic laryngeal findings in patients undergoing thyroid and parathyroid surgery.

This study aimed to report the pre- and post-operative laryngeal endoscopic findings in patients referred by non-otolaryngologists who are undergoing thyroid and/or parathyroid surgery, and to determine the number and nature of referrals before and after the release of the clinical practice guideline for improving voice outcomes after thyroid surgery. This retrospective cohort study, conducted at a tertiary care academic hospital, comprised adult patients referred by the endocrine surgery service for laryngoscopy from 2007 to 2018 (n = 166). Data regarding patient demographics, reason for referral and endoscopic findings were recorded. The number of referrals increased significantly after the release of the practice guideline. The most common indication for referral pre- and post-operatively was voice change. The most common finding during laryngoscopy was normal examination findings (pre-operatively) and unilateral vocal fold immobility (post-operatively). Peri-operative thyroid and/or parathyroid patients have laryngoscopic findings other than vocal fold immobility. Laryngoscopy to detect structural and functional pathology is warranted.

Evaluating transition in Turner syndrome in the West of Scotland

A Turner Syndrome (TS) Transition clinic, Royal Hospital for Children Glasgow (RHCG), with paediatric and adult endocrinology/gynaecology teams was established in 1998 with an aim of improving health outcomes in TS throughout the lifespan. To evaluate the success of our TS transition service, focussing on evaluating established follow-up after transfer to adult services. Girls attending the TS Transition clinic at Royal Hospital for Children Glasgow, 1998-2017, were identified. Attendance data were obtained from patient records and an electronic appointment system. We assessed good and late early attendance in our cohort of TS patients as well as established endocrine follow-up, defined as those still attending adult endocrine services 3 years after transfer. Success of TS transition was determined by the proportion of girls in established endocrine follow-up. Forty-six girls (median age 18.3 yrs) were identified. Thirty-six, 36/46 girls transferred prior to 2015 and 26 of those (72%) were in established follow-up at 3 years, 22/36 girls had met with an Adult specialist prior to transfer and 14/36 had not met with an adult specialist prior to transfer. Twenty-one (80.7%) were good early attenders (p=0.10). In the early attenders' cohort, there was no significant difference between those that had and had not met an adult specialist prior to transfer. A significant proportion of girls with TS are currently lost to endocrine follow-up following transfer to adult clinics. Early attendance at an adult clinic appears topredict established long-term follow-up. Strategies to improve early attendance and long-term endocrine follow-up are needed to ensure lifelong health needs are addressed.

Central Hypothyroidism due to Pituitary Iron Overload

A 90-year-old man was seen by the inpatient endocrine service for hypothyroidism. He had been admitted for exertional dyspnea and chest pain 2 days before. He had an extensive medical history, including coronary artery disease, end-stage renal disease on peritoneal dialysis, pulmonary embolism, diabetes, and chronic obstructive pulmonary disease. He did not have a history of head trauma or visual changes. He had been found to have pure red cell aplasia 5 months before and required weekly transfusion of 1 to 2 units of red blood cells in the previous 5 months.

Prevalence, Patterns, and Predictors of Multimorbidity in Adults With Acquired Brain Injury at Admission to Staged Community-Based Rehabilitation

ObjectivesTo describe the prevalence, patterns, and predictors of multimorbidity in adults with an acquired brain injury (ABI) on presentation to a community-based neurorehabilitation service. DesignRetrospective cohort study using routinely collected admissions and clinical data. SettingCommunity-based neurorehabilitation. ParticipantsIndividuals (N=263) with non-traumatic brain injury (NTBI; n=187 [71.1%]) versus traumatic brain injury (TBI; n=76 [28.9%]). InterventionsNot applicable. Main Outcome MeasuresComorbidity was defined as the co-occurrence of at least one chronic condition in conjunction with a primary diagnosis of ABI. Multimorbidity was defined as the co-occurrence of 2 or more chronic conditions across 2 or more body systems, in conjunction with a primary diagnosis of ABI. ResultsComorbidity was present in 72.2% of participants overall, whereas multimorbidity was present in 35.4% of the cohort. The prevalence of comorbidity (76% vs 63%; P=.036) and multimorbidity (40% vs 24%; P=.012) was higher in NTBI compared with participants with TBI. Participants with NTBI had a higher prevalence of physical health multimorbidities, including cardiovascular (44% vs 6%; P<.001) and endocrine (34% vs 10%; P=.002) disease, whereas participants with TBI had a higher prevalence of mental health conditions (79% vs 48%; P<.001). Depression (36.3%) and hypertension (25.8%) were the most common diagnoses. Increasing age was the only significant predictor of multimorbidity. ConclusionsMost participants experienced multimorbidity. Effective management of multimorbidity should be included as part of individual rehabilitation for ABI and planning of resource allocation and service delivery. The results of this study can help guide the provision of treatment and services for individuals with ABI in community-based rehabilitation. Our study highlights access to mental health, cardiovascular, endocrine, and neurology services as essential components of rehabilitation for ABI.

‘I would say this is a good clinic for friends &amp; family to be looked after in if they need similar treatment or care’ – Young Adult Endocrine (YAE) Service Evaluation

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

1171-P: Endocrine Final Recommendation Note (EFR) Embedded in the Electronic Medical Record (EMR) Improves the Discharge Process for Hospitalized Patients with Diabetes (DM)

Hospitalized patients with DM represent a group at high risk for readmission. Variability in how instructions for home DM management are provided at discharge can contribute to this risk. At our institution, recommendations made by the endocrine consult service were not always accurately translated into patient discharge orders by the primary service. Therefore, the EFR embedded within the EMR was developed. We investigated its effectiveness by reviewing the EMR of 48 patients discharged with insulin prior to (group 1) and following implementation (group 2) for fidelity of recommendations carried out by the primary service. Accuracy of the diabetes-related discharge regimen was defined as correct type and dose of insulin, correct administration supplies (syringes vs. pen needles), and provision of appropriate glucose monitoring supplies by the primary team. About 50% of patients had a change in their DM regimen at discharge. Insulin was added as a new medication in 29% vs. 44% of patients in groups 1 and 2 respectively. There was significant improvement in the accuracy of the diabetes-related discharge regimen (68% vs. 96%, p = 0.001). These results demonstrate that deficiencies in the discharge process can be ameliorated by EMR tools which facilitate a safer transition of care from inpatient to outpatient settings for patients with DM. Disclosure D. Pinkhasova: None. A. Donihi: None. K. Feterik: None. M.T. Korytkowski: None. E. Karslioglu French: None.

AFES A.S.-O.N.E.: ASEAN Survey Of Needs in Endocrinology in the Time of the COVID-19 Pandemic.

ObjectivesThe COVID-19 pandemic has made a major impact on hospital services globally, including the care of persons with diabetes and endocrine disorders. The aim of this study is to describe the epidemiology of COVID-19 in the ASEAN Federation of Endocrine Societies (AFES) member countries; to describe challenges, changes and opportunities in caring for patients with endocrine diseases, as well as in fellowship training programs, and endocrinerelated research in the AFES countries.MethodologyThe AFES ASEAN Survey Of Needs in Endocrinology (AFES A.S.-O.N.E.) was an open-ended questionnaire that was sent to the presidents and representatives of the AFES member countries by email. Responses from Societies were collated and synthesized to obtain perspectives on the emergent issues in endocrinology in the Southeast Asian region during this pandemic.ResultsThe burden of COVID-19 cases varied widely across the AFES member countries, with the least number of cases in Vietnam and Myanmar, and the greatest number of cases in either the most populous countries (Indonesia and the Philippines), or a country with the highest capability for testing (Singapore). The case fatality rate was also the highest for Indonesia and the Philippines at around 6%, and lowest for Vietnam at no fatalities. The percentage with diabetes among patients with COVID-19 ranged from 5% in Indonesia to 20% in Singapore, approximating the reported percentages in China and the United States. The major challenges in managing patients with endocrine diseases involved inaccessibility of health care providers, clinics and hospitals due to the implementation of lockdowns, community quarantines or movement control among the member countries. This led to disruptions in the continuity of care, testing and monitoring, and for some, provision of both preventive care and active management including surgery for thyroid cancer or pituitary and adrenal tumors, and radioactive iodine therapy. Major disruptions in the endocrine fellowship training programs were also noted across the region, so that some countries have had to freeze hiring of new trainees or to revise both program requirements and approaches to training due to the closure of outpatient endocrine clinics. The same observations are seen for endocrine-related researches, as most research papers have focused on the pandemic. Finally, the report ends by describing innovative approaches to fill in the gap in training and in improving patient access to endocrine services by Telemedicine.ConclusionThe burden of COVID-19 cases and its case fatality rate varies across the AFES member countries but its impact is almost uniform: it has disrupted the provision of care for patients with endocrine diseases, and has also disrupted endocrine fellowship training and endocrine-related research across the region. Telemedicine and innovations in training have been operationalized across the AFES countries in an attempt to cope with the disruptions from COVID-19, but its over-all impact on the practice of endocrinology across the region will only become apparent once we conquer this pandemic.

AORN Position Statement on Managing Distractions and Noise During Perioperative Patient Care

<scp>AORN</scp> Position Statement on Managing Distractions and Noise During Perioperative Patient Care