Endocrinology Consultation Research Articles

Graves’ Disease in 100 Cases in Conakry: Epidemiological, Clinical, Therapeutic, and Evolutionary Aspects

Context and Objective: Graves’ disease is an autoimmune disorder of the thyroid gland that occurs in genetically predisposed individuals. It represents the most frequent cause of hyperthyroidism with a clear female predominance. The objective of our work was to report the sociodemographic, clinical, therapeutic, and evolutionary characteristics of Graves’ disease at the University Hospital of Conakry. Methods: This was a cross-sectional, descriptive study, over the period from December 2016 to June 2021, at the endocrinology consultation of Donka University Hospital. Epidemiological, clinical, therapeutic, and evolutionary variables of patients followed up for Graves’ disease were collected and analyzed. The diagnosis of Graves’ disease was based on the presence of clinical signs of thyrotoxicosis, diffuse goiter, exophthalmos, and or T-RAK positivity. Results: Graves’ disease was related to 33% of thyroid consultations and 64% of hyperthyroidism. The sex ratio M/F was 0.07. The median age of the patients was 39.4 ± 13 years. The main reason for consultation was thyrotoxicosis syndrome, dominated by cardiovascular signs (92%). TRAK was performed in 38 patients with a positive result in 89%, i.e., a mean level of 17.93 mUI/l. All patients were treated with synthetic antithyroid drugs, with a favorable clinical evolution. Surgery was considered in 4 patients after the stabilization of the thyroid function. The follow-up was considered regular in 49 patients (49%). Conclusion: Graves’ disease is the most frequent hyperthyroidism in Conakry with a clear predominance of women, especially young women. Efforts should be focused on improving diagnosis and the access to treatment for better patient compliance.

Hypothyroidism in Conakry: Epidemiological, Clinical and Therapeutic Aspects

Hypothyroidism is a frequent endocrine disorder that can occur at any age and predominantly affects women. The etiologies are diverse and may vary according to the geographical and socio-demographic context. The objective of our work was to describe the epidemiological, clinical and therapeutic characteristics of hypothyroidism in Conakry, Guinea. Materials and Method: This was a descriptive study with prospective data collection, over the period from December 2016 to May 2021. It focused on patients seen at the endocrinology consultation of Conakry University Hospital. Epidemiological, clinical, etiological, therapeutic, and evolutionary variables of patients diagnosed or followed-up for hypothyroidism were collected and analyzed. The diagnosis of hypothyroidism was defined by elevated TSH and/or decreased FT4/FT3. Results: Out of a total of 290 patients who consulted for thyroid pathology, hypothyroidism concerned 49 patients, i.e. , a frequency of 14%. Women were the most affected with a sex ratio of 0.13. The mean age of patients was 48.65 ± 19.93 years with extremes of 2 years and 80 years. Hypo-metabolic syndrome was the main clinical sign and was manifested mainly by constipation found in 48.89% of cases. TSH was elevated in all cases with a mean level of 24.56 ± 14.17 mIU/ml. Hypertension was the most frequently associated pathology (57%). Three etiological groups of hypothyroidisms were found. These were thyroidectomy in 42.85% of cases, thyroiditis in 34.69% of cases and post synthetic antithyroid hypothyroidism. All patients were treated with L-thyroxin, with a favorable clinical course. Follow-up was regular in 16 patients (32.65%). Conclusion: Hypothyroidism is common in this population, and primarily affects women. Thyroid surgery was the main cause of hypothyroidism in this work.

Inflammatory Cytokine IFNγ, IL-6, and IL-10 Association with Childhood Obesity

Abstract Childhood obesity carries a high risk of serious life-threatening cardiometabolic diseases in adulthood, which are associated with low-grade inflammation. The aim of the present study was to measure serum cytokine concentrations in obese children recruited during endocrinology consultations and compared to lean control the results. Blood serum concentrations of interferon gamma (IFNγ), IL-1β, Interleukin 6 IL-6, IL-10, and TNF-α were analysed applying Luminex xMap technology with Millipore reagent kits. Statistical analyses were performed using t-test comparisons and Spearman correlations. Obese children had highly significant increased levels of circulating IFNγ (p < 0.0001), IL-6 (p < 0.0001), and IL-10 (p < 0.0001), compared to lean controls. IL-1β and TNFα levels, however, were not elevated. Significant correlation of serum cytokines to per cent excess body mass was only observed with IL-6 (rs = 0.21, p < 0.03), although IL-1β (rs = 0.18, p < 0.08) results were suggestive of a trend. A significant association of obesity in childhood with serum concentrations of IFNγ, IL-6, and IL-10 is consistent with a role for low-grade inflammatory processes early in the aetiology of this disease. IL-6 further appears to be a candidate cytokine for assessment of degree of sub-acute inflammation associated with excess weight in the young.

Growth hormone deficit. Does the first year of treatment influence adult height?

IntroductionShort stature is the most frequent reason for Pediatric Endocrinology consultations and sometimes requires treatment with growth hormone. ObjectiveThe possible correlation of a good response to any early response factor with a better final response was studied, and also whether there was a difference in response to treatment according to the type of deficit. Patients and methodsThis was a longitudinal, retrospective and observational study of 139 patients treated for idiopathic growth hormone deficiency up to adult height. There were good response criteria in the first year of treatment: a) an increase in growth rate ≥3 cm/year, b) a growth rate ≥1 standard deviation (SD), c) an increase in height ≥0.5 SD, d) an increase in height ≥0.3 SD. Study of the Index of Responsiveness to treatment in the first and second year. Final response variables: adult height with respect to target height, adult height with respect to initial growth prediction and adult height with respect to initial height at the start of treatment. The possible correlation of a good response to any of the early response factors with a better final response to treatment was studied, and also whether there was a difference in the response to treatment according to the type of deficit. ResultsThe treatment produced a gain in adult height with respect to genetic height of 0.06 ± 0.7 SD. Patients considered good responders in the first year of treatment presented a better final response (growth rate ≥3 cm: p = 0.000, growth rate ≥1 SD: p = 0.008, height gain ≥0.5 SD: p = 0.007, height gain ≥0.3 SD: p = 0.006), as well as patients with a severe deficit (p = 0.04). The index of responsiveness to treatment during the first year was associated with a better final response (r = 0.249, p = 0.003), with this correlation being maintained in the second year (r = 0.294, p = 0.01). ConclusionsGrowth hormone treatment increased height in the genetic target. The percentage of good responders varied depending on the criteria used. The response in the first year of treatment and a severe deficit were determining factors for achieving a good long-term response.

HEART FAILURE WITH LOW EJECTION FRACTION AS A PRESENTATION OF SEVERE PRIMARY ADRENAL INSUFFICIENCY

Addison’s disease or primary adrenal insufficiency is a condition where there is decreased production of glucocorticoid and mineralocorticoid from adrenal cortex and it’s prevalance is around 100- 140 cases per millions in western societies. It has wide range of clinical features and is a serious condition. If diagnosed and treated in time, patient’s condition can improve significantly. Here we present 37 years old female who presented with wide range of vague clinical features and was in shock and on investigation, her serum sodium was low and potassium level was high. With usual treatment of shock, patient condition didn’t improve. So, echocardiography was done which showed global Left Ventricular wall hypokinesia with left ventrical ejection fraction of 25- 30%. She was also taking treatment for hypothyroidism. Endocrinology consultation was done for her hypothyroidism, hyponatremia and possible adrenal crisis. Serum Cortisol was sent which was found low. With treatment with glucocorticoids and mineralcorticoids, patient improved significantly. She recovered from shock, her serum sodium and potassium became normal and after one month, left ventricular ejection fraction improved to 50%. So, with timely diagnosis and proper treatment, Addison’s disease can be treated easily.

PATIENT SATISFACTION WITH TELEMEDICINE VISITS FOR REPRODUCTIVE ENDOCRINOLOGY PATIENTS IN THE ERA OF COVID-19

Due to the COVID-19 pandemic, video-based telemedicine visits have become the standard in many clinical practices. Many reproductive endocrinology consultations do not require a physical exam, allowing for integration of telemedicine. The purpose of this study is to evaluate patient satisfaction with telemedicine visits in the Reproductive Endocrinology and Infertility (REI) office. This is a prospective cross-sectional study that includes any person undergoing a new patient visit at Washington University’s Reproductive Endocrinology clinic from March 1st-April 20th 2021. After the visit, patients were contacted via telephone to obtain consent to participate in an online one-time research survey. A link was sent to their email with the survey through RedCap secure web application. The survey is 25 questions which includes the telehealth usability questionnaire (TUQ) survey, a previously published tool to evaluate usability and quality of telehealth interaction, along with questions specific to the REI clinic and the participation of learners during visits. Baseline patient demographics including age, race/ethnicity, BMI, distance from clinic, and recommended treatment were collected. 117 participants were contacted, 78% (n=91) agreed to participate in the study, and 45% (n=41) completed the survey. There were no significant differences in age, BMI, distance from clinic or length of infertility with response to survey. 92.5% responders would use telemedicine services again and were satisfied with the telehealth system. Telehealth improved access to healthcare for 82.5% and travel time for 95%. The mean distance from clinic was 76 miles, and there was no significance difference in satisfaction with telemedicine services (p=0.46) or perceived access to healthcare services (p= 0.43) between those living closer or further than 76 miles. Those living further also had no preference for telemedicine visits over in person visits (p=0.134). In the era of COVID-19, healthcare implementation has dramatically changed with a drastic increase in telemedicine services. Based on our survey, majority of patients were satisfied with telemedicine visits and believed it saved travel time while improving access to REI care. Despite no differences in patient preference for in person versus telemedicine depending on their distance from clinic, this finding is reassuring because patients are satisfied with telemedicine for reasons other than distance from clinic.

Use of Endocrine Consultation for Hemoglobin A1C ≥9.0% as a Standardized Practice in an Emergency Department Observation Unit

ObjectiveSeverely uncontrolled diabetes mellitus (DM) is associated with poor long-term outcomes and may remain unrecognized. A high frequency of uncontrolled DM has been identified in the acute-care setting, including the emergency department observation unit (EDOU). We assess the use of standardized endocrine consultation in the EDOU for hemoglobin A1C (HbA1C) levels ≥9%. MethodsStandard practice in our EDOU includes universal HbA1C screening and endocrine consultation for HbA1C levels ≥9.0%. As part of a quality improvement program, EDOU patients with HbA1C levels ≥9.0% had an endocrinology consult. One-month follow-up phone calls assessed the effects of consultation after discharge. ResultsHbA1C tests were administered to 3688 (95.7%) of 3853 EDOU patients, of which 7.0% (n = 258) were found to have an HbA1C level ≥9% (mean ± SD, 11.7 ± 1.8%; range, 9%-16.6%). Endocrine consults were completed for 73.6% (190/258) patients with severely uncontrolled DM. Among the 190 patients, 92.1% (n = 175) had discharge DM medication adjustments. For known patients with DM (n = 142), injectable diabetes medication prescriptions increased from 47.2% (67/142) on EDOU arrival to 78.2% (111/142) upon discharge. Newly diagnosed DM injectable prescriptions increased from 0% (0/48) on arrival to 72.9% (35/48) upon discharge. A total of 72.6% (n = 138) were contacted at a 1-month follow-up and 94.9% (n = 131) reported taking DM medications, compared with 68.2% (n = 94) before consult. ConclusionHbA1C screening coupled with endocrine consultation for HbA1C levels ≥9.0% was assessed as a performance improvement study and is shown to have valuable results. Further investigation is required to determine the long-term clinical impact and cost analysis for this novel approach.

827-P: Pioneering a Novel Inpatient Diabetes Consult Service in the COVID Era

Hospitalized patients often do not reach the ADA-recommended glucose targets, which in turn increases complications, costs, length of stay, and readmission rate. The ADA supports the availability of trained specialists and teams to improve outcomes. Partly in response to the SARS CoV-2 pandemic, we instituted an inpatient “virtual care” initiative by electronic medical record (EMR) review. The ProActive Glucose Advice Team (pGAT) utilizes specialist expertise, automated computerized detection of hyperglycemia, and feedback to the primary service. The pGAT team members consist of an endocrinologist, a nurse diabetes care and education specialist, and a clinical dietician. The team reviewed a computer-generated report of inpatients with either 2 or more blood glucose values ≥180 mg/dl within the last 24 hours, and/or a hemoglobin A1c (A1c) ≥8%. We proposed to enter a brief, structured “pGAT Note” in the EMR, followed by a “gentle reminder” note the next day, including advice for a formal diabetes education and an endocrinology consultation. This proactive approach to the management of hyperglycemia would provide a summary review of the patient’s glucose state, determine the level of patient’s self-care skills, and steps to improve inpatient glycemic control. For preliminary data during the first 4-month phase after implementation of the pGAT initiative, we examined individualized discharge management and timely outpatient follow-up with endocrinology. Of 37 patients (28 males, 9 females; average age 60.4 years), 34 were treated with intensive insulin therapy with multiple daily insulin injections, 31 were seen in f/u within 2 weeks of discharge, and 25 were begun on Continuous Glucose Monitoring. The average A1c fell from an inpatient value of 11.6% to 8.4% measured between 2-4 months later. During the next pGAT phase, we intend to study inpatient therapy parameters, notably appropriate use of computerized insulin order sets, titration of basal insulin, and prandial-correction bolus insulin use. Disclosure A. A. Rizvi: None. A. O. Rich: None. R. Eldridge: None.

Parameters of successful telephone endocrinology consultation during covid-19 pandemic

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

Déficit de hormona de crecimiento: influencia de la pubertad en la respuesta al tratamiento

IntroductionShort stature is the most frequent reason for consultation in Pediatric Endocrinology consultations and sometimes requires treatment with growth hormone. The aim of the study was to analyze the response to treatment based on its onset in pubertal or prepubertal stages and to analyze the possible benefit of an early onset. Patients and methodsLongitudinal, retrospective and observational study in 139 patients treated for idiopathic growth hormone deficiency up to adult height. Main variables studied: (a) genetic background: maternal, paternal and genetic height; (b) perinatal history; (c) anthropometry during follow-up and at pubertal onset: weight, height, body mass index; (d) variables during follow-up and at pubertal onset: growth rate, bone age and growth prognosis. Final response variables: adult height, adult height with respect to target height, adult height with respect to initial growth prediction, adult height with respect to initial height at the start of treatment and adult height with respect to height at pubertal onset. ResultsTotal pubertal gain was 0.84±0.6 SD. 61.9% of the patients started treatment with rhGH in prepuberty. The initiation of treatment in the prepubertal stage and a higher total pubertal gain are correlated with a better final height (P=.001 and r=0.507, P=.00, respectively). Furthermore, a longer duration of treatment in pre-puberty is correlated with a better final response (r=0.328, P=.00). ConclusionsThe start of treatment in the prepubertal stage and its longer duration during this period are determining factors to achieve a good long-term response. Total pubertal gain was greater in patients who started treatment in the pubertal stage.

The Endocrine Hospitalist: Enhancing the Quality of Diabetes Care

The endocrine hospitalist and inpatient diabetes management team increases access to endocrinology consultations and improves glycemic control and quality metrics such as length of stay and hospital readmission. Enhanced glycemic care is needed in both academic and community hospital settings. Endocrine fellowship programs should implement endocrine hospitalist rotations with emphasis on training endocrine fellows to deliver fast-paced inpatient endocrine care. Entrepreneurship, innovation, and a "start-up" culture within the field of Endocrinology should be encouraged and supported by healthcare systems.

Endocrine and Metabolic Comorbidities in Hospitalized Psoriasis Patients in the United States

Introduction: Psoriasis is a chronic immune-mediated, genetic disease manifesting in the skin or joints or both. Studies have shown an association between psoriasis and metabolic syndrome [1]. However, there is a scarcity of studies on metabolic and endocrine co-morbidities of hospitalized psoriasis patients. This study aims to compare the prevalence of metabolic and endocrine co-morbidities in hospitalized psoriasis patients to hospitalized non-psoriasis patients. Methods: Data were abstracted from the National Inpatient Sample (NIS) 2016 and 2017 Database. NIS is the largest inpatient hospitalization database in the United States. The NIS was searched for hospitalizations for adult patients aged 18 years or above with a principal or secondary diagnosis of psoriasis and those without any diagnosis of psoriasis. Chi-square test was used to compare the prevalence of common metabolic and endocrine comorbidities between psoriasis and non-psoriasis hospitalized patients. Co-morbidities were obtained from secondary diagnoses. We used ICD-10 codes to obtain psoriasis hospitalizations and co-morbidities. STATA, version 16 was used for analysis. Results: There were over 71 million discharges in the combined 2016 and 2017 NIS database. Out of this, 323,405 hospitalizations had a diagnosis of psoriasis. Psoriasis hospitalizations had a higher prevalence of dyslipidemia (41.8% vs 31.8%, p<0.0001), hypothyroidism (15.6% vs 12.0%, p<0.0001), hyperthyroidism (0.6% vs 0.5%, p=0.0133), type 2 diabetes mellitus (31.1% vs 24.5%, p<0.0001), obesity (24.4% vs 14.3%, p<0.0001), Non-alcoholic fatty liver disease (0.9% vs 0.3%, p<0.0001) and similar prevalence of type 1 diabetes mellitus (0.9% vs 0.9%, p=0.1567) compared to non-psoriasis hospitalizations. Conclusion: Hospitalized psoriasis patients have a higher prevalence of dyslipidemia, hypothyroidism, hyperthyroidism, type 2 diabetes mellitus, obesity and non-alcoholic fatty liver disease compared to non-psoriasis hospitalized patients. Endocrinology consultation during hospitalization will be helpful in managing these comorbidities in psoriasis patients.

Understanding Facilitators and Barriers in the Hospital Discharge Processes of Newly Prescribed Insulin: A Mixed-Methods Study

Patients, newly prescribed insulin, being discharged from the hospital are at high risk of adverse outcomes. An electronic enterprise data warehouse (EDW) algorithm was created and validated to identify these inpatients electronically. Qualitative interviews were also conducted to assess barriers in the discharge process. The EDW algorithm to identify inpatients (09/01/18-08/31/19), newly prescribed insulin at discharge, was created by identifying screening indicators (e.g., admission/discharge medication lists, discharge summary). Iterative adjustments to the algorithm were made after chart review and included review of medication reconciliation (med rec), admission/discharge orders, and insulin orders (types/delivery). The EDW list was compared to the list of patients who received insulin teaching from the Certified Diabetes Care and Education Specialist (CDCES), during the same period. Providers (N=8, 3 endocrine attending MDs, 2 fellow MDs, 3 resident MDs) were interviewed in key informant interviews (N=3) and focus groups (N=2); transcripts were independently coded by 2 coders, utilizing a constant comparative method to generate key themes. The EDW list (N=554) was audited by EHR review (n = 42, 8%); 83% (35/42) were correctly identified as newly discharged on insulin. Of the 7 incorrectly identified, 4 likely had incomplete med rec. The EDW algorithm was unable to correctly identify patients with inaccurate/incomplete med rec, patients transferring from outside hospitals or those without e-Rx at discharge (vouchers, call-in). The CDCES list (N=257) was audited (n=25, 10%), and of patients not meeting criteria (n=15), some had prior insulin prescribed (n=5), and most ended up not discharged on insulin after CDCES insulin teaching (n=9). Comparison of the EDW and CDCES lists had 177 patients (32% of EDW list) in common, with 377 on the EDW list with no CDCES consultation. An audit (n=21/377, 5%) of these EDW patients, who did not have CDCES or endocrinology consultation, revealed patients across service lines, with minimal formal documentation of insulin training/education. Key identified themes from interviews identified barriers including lack of availability of a CDCES after-hours and on weekends, low health literacy/numeracy, and lack of time during stay. In training MDs noted variability in discharge prescribing by supervising MDs and the need to assess “chart lore,” given cut and paste documentation in EHR. This study suggests that an EDW algorithm can be used to identify patients newly being discharged on insulin, for whom teaching by a CDCES is recommended. The data suggest the need for more targeted and increased CDCES capacity as only a portion of those eligible for insulin teaching were seen while others were seen but then not discharged on insulin. Additional resources for insulin teaching are needed and standardized training and documentation need to be developed.

Coincidence? - Graves’ Disease &amp; Thyroid Cancer

Abstract Background: DG coincidently with thyroid carcinoma has been reported as a rare phenomenon. It was thought that DG would be a protective condition in the development of cancer. However, published studies indicate the opposite, reporting an increased prevalence of differentiated thyroid cancer in DG compared to the general population. Some authors even report greater aggressiveness of this type of cancer in the presence of DG, with higher rates of, multifocality, metastatic disease and with a higher risk of recurrence. Clinical Case: Female, 46 years old, smoker 10 U.M.A., sent to the Endocrinology consultation due to symptomatic hyperthyroidism. No history of exposure to cervical radiotherapy, contact with iodinated products or cervical pain. Analytically, TSH &amp;lt;0.008 uUI / mL (0.27-4.2), free T4 4.09 ng/dL(0.93-1.70), free T3&amp;gt;20 pg/mL(2.57-4, 43), high levels of anti-thyroid and anti-TSH receptors 11.4IU/L (N &amp;lt;1.75), diagnosing with Graves’ disease. The thyroid ultrasound revealed a globose and hypervascularized thyroid. In the right hemithyroid, an echogenic nodular area of ​​ill-defined limits of about 12mm was identified, associated with some hyperechogenic elements. Bilateral cervical and submandibular lymph nodes were visualized with a short 8 mm axis, highlighting a ganglion in the right jugular chain, questioning the presence of millimeter echogenic foci. She started metibasol, with improved thyroid function and opted for ultrasound surveillance. Four months later, she repeated the ultrasound of the thyroid, maintaining a hypercogenic area, with ill-defined limits in the right lobe, with a 13mm longest axis. She also maintained adenopathies in the right jugulo-carotid chain, rounded, without hilum, the largest one with 13x9x17mm, and it was performed a fine needle aspiration of the ganglion. There was no measurement of thyroglobulin in the wash. The morphological changes were compatible with ganglion metastasis due to papillary thyroid carcinoma with a predominantly follicular pattern. She started 5% lugol solute, 7 drops every 8 hours for 8 days before surgery and underwent total thyroidectomy and central and lateral lymphadenectomy, with the identification of a mixed, multifocal papillary carcinoma. in the right lobe and isthmus, the microscopic size of the largest focus was 40mm, without invasion of the capsule or vascular invasion, with ganglion metastases in the lateral (9/46) and central district (6/6) (pT2N1b). She underwent treatment with I131 at a dose of 120mCi. Conclusion: This clinical case stands out for its uniqueness, given the simultaneity of Graves’ disease and thyroid cancer. The presence of cervical adenomegaly, which is rare in DG, increased clinical suspicion. Due to the increase of the adenopathy in a short period of time, we decided to perform a biopsy, which in this case was essential for the diagnosis and subsequent treatment.

Diabetes Medication Reconciliation at Hospital Discharge

Background: During hospital discharge, patients are at high risk for medication discrepancies as they transition from hospital to home. This study aims to evaluate the prevalence of medication errors at hospital discharge for diabetes medications in patients who received an endocrinology consultation for diabetes and explore interventions to improve the accuracy of discharge medication reconciliation. Methods: All patients (n=3018) who received an endocrinology consultation for diabetes at a tertiary care medical center from October 2017 to December 2019 were included. A retrospective chart review was performed to collect the following information on each patient: primary service from which the patient was discharged, hospital site, month and year of discharge date, and whether each patient’s medication reconciliation for diabetes medications at hospital discharge was in agreement with the inpatient diabetes team’s recommendations. Patients who were discharged on medications discordant from those recommended by the inpatient diabetes service were subcategorized into three groups: 1) one medication incorrect 2) more than one medication incorrect and 3) the primary service did not notify the consult team of patient’s discharge or request final recommendations for diabetes medications prior to discharge. Based on the findings of this study, an educational intervention was implemented in November 2019 to the Hospital Medicine services regarding diabetes discharge medication reconciliation. Results: Of the 3018 patients who received an endocrinology consultation for diabetes at a tertiary university medical center, 2279 patients (76%) were discharged on correct medications, 165 patients (5%) were discharged with one incorrect medication, 443 patients (15%) were discharged with more than one incorrect medication, and 121 patients (4%) were discharged without final discharge recommendations from the diabetes service. There was no significant variation based on discharging service or month of the year. After an educational intervention was implemented in November 2019 to the Hospital Medicine service on the existence and use of a comprehensive diabetes discharge order set, the percentage of patients discharged on correct medications improved to 92% (11/12 patients) compared to prior 81% (44/54 patients). Conclusion: Despite detailed discharge medication recommendations including patient education detailing the recommended regimen by the endocrinology diabetes service, a significant number of patients were discharged by providers across all services on diabetes medications discrepant with the diabetes service’s recommendations. Educational efforts improved the rate of correct medications at discharge on the Hospital Medicine service, and additional educational interventions with other services may be helpful in improving medication reconciliation accuracy.

Treatment of Polyostotic Fibrous Dysplasia With Intravenous Ibandronate

Introduction: Fibrous Dysplasia (FD) is proliferation of fibrous tissue within the bone marrow causing osteolytic lesions and pathologic fractures. Polyostotic FD in combination with a thigh myxoma is consistent with Mazabraud syndrome (MS). Bisphosphonates have shown promise in treatment and prevention of progression of FD. Clinical Case: A 34-year-old male with an unremarkable family history developed left thigh pain shortly after Whipple’s procedure for pancreatic cancer in 2017. Imaging revealed a 9cm left thigh mass and multiple femoral and pelvic intramedullary lesions compatible with FD. The thigh mass was removed and final pathology revealed an intramuscular myxoma with +GNAS mutation. Given clinical picture, genetics raised concern for MS and recommended endocrinology consultation. Patient reported chronic pain in chest, abdomen, back and multiple joints requiring spinal stimulator placement. Labs displayed subclinical hyperthyroidism and thyroid uptake scan revealed a right toxic MNG. Hence ablation was performed. Labs also displayed elevated alkaline phosphatase (ALP) bone isoenzyme of 103 IU/L (RR 0–72). Thoracic X-ray revealed chronic endplate vertebral compression fracture with no history of trauma and normal DEXA scan. NM bone scan was consistent with FD in skull, humerus, scapula, ribs, pelvis, femur and tibia. Given chronic pain at multiple sites and compression fractures, therapy with IV Zoledronic acid was given after Vitamin D was repleted. Within several hours, patient developed acute phase reaction (APR) with severe bone pain requiring hospitalization. ALP levels normalized within 1 year of therapy. 1.5 years post therapy, patient experienced a grand mal seizure. MRI brain revealed multifocal abnormal bone marrow within the calvarium, facial bones and skull base. Labs again displayed elevated ALP but new hypophosphatemia and an elevated serum FGF23. Given progression of skeletal disease as indicated by elevated FGF23, additional off-label injectable treatment options were reviewed and patient agreed to Ibandronate. Discussion: Majority of evidence for bisphosphanate treatment in FD is derived from observational studies, which report variable symptomatic improvement despite improvement of bone turnover markers. Oral anti-resorptives are commonly used but were not an option for our patient given history of Barrett’s esophagus and Whipple’s surgery. Pamidronate was first used in the treatment of FD with variable success rates. Denosumab is also being considered as a therapeutic option in FD however there are insufficient case reports to outline safety profile. Zoledronic acid is commonly used however our patient developed APR to the first dose and refused retrial. Given progression of disease, treatment was recommended. Therefore a milder anti-resorptive such as Ibandronate was considered which warrants further investigation in the treatment of FD.

Vision improvement after trans-sphenoidal resection of pituitary macroadenoma

Introduction: Pituitary adenomas are tumours that occur in the Pituitary gland. Depending on the size it can be divided into Microadenoma (10mm). It can present with endocrine manifestations secondary to hypo or hyper function of pituitary gland and ophthalmological manifestations due to mass effect. Case Report: A 36-year-old female was admitted to our institution with complaints of loss of vision of right eye, headache and amenorrhea for 3 months, which were progressive in nature. Her MRI Scan revealed a well-defined sellar mass, measuring 27 x 23.18 mm, with suprasellar extension, causing expansion of pituitary fossa and superiorly extending into Hypothalamus with mild compression over optic chiasma. Prolactin level was 72.16 ng/ml. Surgery was done under general anesthesias, by Endoscopic assisted transsphenoidal approach. The adenoma was completely removed. Sella opening was closed by synthetic graft. On awakening from anesthesias visual acuity in right eye was immediately and completely restored. Conclusion: Pituitary adenoma is a complex set of benign tumours that present with hypersecretory syndrome and mass effect. An appropriate imaging of pituitary region using MRI and endocrinological consultation is the standard for detection of pituitary adenoma. Although, medical management and radiotherapy offer effective treatment for these tumours in specific situations, Endoscopic Trans-sphenoidal approach continues to provide optimal outcomes with low incidence of morbidity. Keywords: Pituitary macroadenoma, Vision loss, TransSphenoidal resection.

Late diagnosis of classic congenital adrenal hyperplasia: long-term consequences during adulthood.

SummaryCongenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders related to enzyme deficiencies in the adrenal steroidogenesis pathway leading to impaired corticosteroid biosynthesis. Depending on the extension of enzyme defect, there may be variable severities of CAH – classic and non-classic. We report the case of a 37-year-old male patient with a previously unknown diagnosis of classic CAH referred to Endocrinology evaluation due to class III obesity and insulin resistance. A high diagnostic suspicion was raised at the first Endocrinology consultation after careful past medical history analysis especially related to the presence of bilateral adrenal myelolipomas and primary infertility. A genetic test confirmed the presence of a variant of the CYP21A2 in homozygous with an enzymatic activity of 0–1%, corresponding to a classic and severe CAH form. Our case represents an unusually late definitive diagnose of classic CAH since the definition was established only during adulthood in the fourth decade of life. The missing diagnosis of classic 21 hydroxylase deficiency during infancy led to important morbidity, with a high impact on patients’ quality of life. Learning pointsCongenital adrenal hyperplasia (CAH) refers to a group of autosomal recessive enzyme disorders responsible for an impaired cortical adrenal hormonal synthesis.CAH may be divided into two major forms: classic and non-classic CAH. If untreated, CAH may be fatal or may be responsible for important multi-organ long-term consequences that can be undervalued during adulthood. Adrenal myelolipomas are associated with chronic exposure to high ACTH levels and continuous androgen hyperstimulation typically found in undertreated CAH patients.Testicular adrenal rest tumours (TART) and primary infertility can be the first manifestation of the disease during adulthood.

Déficit de hormona de crecimiento, ¿influye el primer año de tratamiento en la talla final?

IntroductionShort stature is the most frequent reason for Pediatric Endocrinology consultations and sometimes requires treatment with growth hormone. ObjectiveThe possible correlation of a good response to any early response factor with a better final response was studied, and also whether there was a difference in response to treatment according to the type of deficit. Patients and methodsThis was a longitudinal, retrospective and observational study of 139 patients treated for idiopathic growth hormone deficiency up to adult height. There were good response criteria in the first year of treatment: a) an increase in growth rate≥3cm / year, b) a growth rate≥1 standard deviation (SD), c) an increase in height≥0.5 SD, d) an increase in height≥0.3 SD. Study of the Index of Responsiveness to treatment in the first and second year. Final response variables: adult height with respect to target height, adult height with respect to initial growth prediction and adult height with respect to initial height at the start of treatment. The possible correlation of a good response to any of the early response factors with a better final response to treatment was studied, and also whether there was a difference in the response to treatment according to the type of deficit. ResultsThe treatment produced a gain in adult height with respect to genetic height of 0.06±0.7 SD. Patients considered good responders in the first year of treatment presented a better final response (growth rate≥3cm: p=0.000, growth rate≥1 SD: p=0.008, height gain≥0.5 SD: P=0.007, height gain≥0.3 SD: P=0.006), as well as patients with a severe deficit (P=0.04). The index of responsiveness to treatment during the first year was associated with a better final response (r=0.249, P=0.003), with this correlation being maintained in the second year (r=0.294, P=0.01). ConclusionsGrowth hormone treatment increased height in the genetic target. The percentage of good responders varied depending on the criteria used. The response in the first year of treatment and a severe deficit were determining factors for achieving a good long-term response.

Abstract P395: High Risk Diabetics Risk of Recurrent Stroke and Cardiovascular Disease Persists Even With Patient Personalized Subspecialty Care

Introduction: Diabetes management is an important aspect of stroke prevention. To our knowledge, studies that focus specifically on the role of multidisciplinary teams for adjusting diabetes medications and diabetes education for stroke and cardiovascular disease prevention to compliment standard stroke prevention and nursing education are lacking. Here we sought to evaluate whether high risk diabetics, hemoglobin A1c (HA1c) &gt; 8%, admitted secondary to stroke would benefit from a multidisciplinary team model that also incorporates endocrinology consultation and diabetes education to personalized nursing education and education and management of the admitting service. Methods: Data was obtained from our Institutional Review Board approved stroke admission database from 2017 to November 2019. Regression analysis was used to identify significant associations between diabetes education (DE) and endocrine consultation (EC) with readmission rates with 30 days, re-admission within 30 days secondary to stroke, cardiovascular event or stroke within a year of the stroke admission, and medication change after controlling for age, sex, NIHSS, HbA1c, low density lipoprotein (LDL), reperfusion therapy for acute stroke. Follow-up HbA1c post hospitalization was available for only 17% of the population, and was not included in the regression models. Results: A total of 202 patients were included, median age 66 (interquartile range 56-75), 43% women, NIHSS median 5 (interquartile range (IQR, 2-9), LDL median 105 (IQR, 69-155), A1c median 9.5 (IQR, 8.5 -11.1), and 24% received reperfusion therapy. EC was associated with higher likelihood of a medication change (odds ratio (OR) 9.43, 95% confidence interval (CI) (3.22-30.69). DE was associated with younger age (OR 0.96, 95% CI 0.92-0.99); higher A1c value (OR 1.47, 95% CI 1.18 - 1.87) and higher likelihood of cardiovascular event within a year of the stroke (OR 3.38, 95% CI 1.23 - 9.70). Conclusion: While the endocrine consultation does lead to medications changes with the intent of improving post discharge glycemic control, cardiovascular events were still more likely, possibly from DM disease severity. Further continuation of follow up of these patients with EC and DE after hospital discharge may be needed.