Revista Colombiana de Endocrinología, Diabetes & Metabolismo

Choosing Wisely in Endocrinology

Manuel Giraldo, Wendy Levinson — Sun, 30 Jun 2024 00:00:00 -0500

Choosing Wisely (CW) is a clinician-led campaign committed to help patients and medical practitioners to engage in conversations about unnecessary care. It has raised awareness of the problem of overuse or low-value interventions in diagnostic procedures and medical treatments. This international movement began in the United States in 2012 and in Canada in 2014. The campaign engages physicians and other health care professionals, including nursing, dentistry, lab medicine, and pharmacy among others. It also engages with medical students to help them establish good practices early in their careers. Nowadays, the campaign has spread over to 35 countries, including Brazil, Colombia, and Argentina, who joined in October 2023.

In Colombia, under the leadership of the Colombian Association of Scientific Societies (ACSC for its acronym in Spanish), 11 scientific societies, including ACE, have joined “Decisiones Acertadas” since its inception. The list of recommendations of unnecessary tests and medications that ACE has released supports strong evidence that low-value care may lead to adverse events or further testing, which may increase anxiety for patients and caregivers and increase the likelihood of false-positives or other preventable harms. For example, ACE recommends that Vitamin D levels should not be routinely ordered in the general population, because this measurement does not change management. Other recommendations relate to overuse of thyroid ultrasound, basal insulin measurement, and bone markers in osteoporosis as well as limiting the utility of prescribing Vitamin D to patients with specific risk factors of deficiency.

Choosing wisely and medical self-regulation

Dora Patricia Bernal Ocampo — Sun, 30 Jun 2024 00:00:00 -0500

"Choosing Wisely" is an initiative of self-regulation of the medical profession that is fully consistent with article 17 of the Statutory Law, which establishes the autonomy of the profession, but with self-regulation.
The Colombian Association of Scientific Societies adopts the initiative as a mechanism to carry out self-regulatory actions, taking advantage of this space opened by the Statutory Law, because it is a way of showing society that medical organizations are concerned about self-regulation, which has a very important effect: that of contributing to the preservation of society's trust in its physicians.
This initiative corresponds to one with a broader international scope, which began in the United States in 2012, "Choosing Wisely", and which has spread to various countries around the world. Currently, more than 30 nations have adopted this same proposal with other names, but with the same content and sense: to generate recommendations about medical behaviors that should be questioned or eliminated, either because there is no evidence that they work or because there is evidence that they do harm. Always based on the best available evidence.

Clinical characteristics and factors associated with amputation in patients with diabetic foot disease

Juan Matamoros Matamoros, Sebastian Barragán Barreto — Fri, 28 Jun 2024 00:00:00 -0500

Background: Diabetic foot disease is an undesirable outcome in the course of diabetes, and it is necessary to clinically characterize local patients and identify factors associated with the need for amputation.

Purpose: Determine the clinical characteristics and factors associated with amputation of patients with Diabetic Foot disease.

Methodology: This is a retrospective cross-sectional study, based on the review of 154 medical records of patients who who were treated at the Emergency Service of the Departmental Hospital of Villavicencio, Colombia in the period from July 2022 to June 2023. The following data were collected: age, sex, clinical history, residence, blood glucose, glycosylated hemoglobin, creatinine, type and level of amputation.

Results: Of the 154 patients included, 84 (54.5%) were men, with an average age of 64.2 years, and 41 patients (26.6%) resided in rural areas. Seventy-six (49.3%) underwent amputations, with 32 (20.7%) having a toe amputation, 15 (9.7%) transtibial, and 29 (18.8%) supracondylar. Sixty-six (42.8%) were smokers, and 102 patients (66.2%) were hypertensive. The average HbA1c was 10.1%, higher in the amputated group at 11.3%. The average creatinine level was 2.3 mg/dl, with 3.5 mg/dl in the amputated group. Hypertension was present in 72.3% of the amputated patients, showing a significant association with the risk of amputation (OR 2.2, CI = 1.10 - 4.37, P = 0.0244). Additionally, there was a positive association between a history of amputation and the risk of another amputation during hospitalization (OR 3.41, CI = 1.56 - 7.45, P = 0.002).

Conclusion: Diabetic foot disease and eventual amputation is related to clinical variables such as hypertension and previous amputation associated to paraclinical variables of patients such as their glycemic control and creatinine levels.

A Cross-sectional Study on Dietary Diversity and Diet Cost in Type 2 Diabetic Population

Kruti Rathore, Geetha Santhosh — Sat, 29 Jun 2024 00:00:00 -0500

Background: Globally, Type 2 Diabetes Mellitus is considered a major public health disease, influenced by nutrition and lifestyle patterns. The majority of people worldwide consume nutritionally poor, cereal-based diets. Therefore, assessing dietary diversity, macronutrient intake, and food costs is essential for better diabetes management.

Objective: To compare the dietary diversity of the Type 2 diabetic population with estimated dietary costs and other relevant parameters.

Methodology: A descriptive cross-sectional study was conducted among 150 adult Type 2 adult diabetic population. A pre-structured questionnaire was used to elicit information on dietary diversity using the Individual Dietary Diversity Score (IDDS), Food Variety Score (FVS) and diet cost estimation using semi-quantitative food frequency questionnaire. FVS was associated with nutrition status, Glycated Haemoglobin (HbA1c), macronutrient consumption, socio economic status and the average daily diet cost of the study population.

Results: The majority of the population were overweight. 50% of the population had low dietary diversity and had uncontrolled diabetes with HbA1c of 7-8%. Dietary diversity influenced the nutritional status of diabetic people. There was no difference between socioeconomic and living status, HbA1c and FVS. Females had higher per day cost when compared to males. Mean per day increased with the increase in the macronutrient consumption.

Conclusion: Diabetic patients often have low dietary diversity, which affects their nutritional status. Therefore, dietary diversity, along with diet cost, is integral to the effective nutritional care of the diabetic population.

Choosing Wisely in Endocrinology: Recommendations from an Expert Panel of the Colombian Association of Endocrinology, Diabetes, and Metabolism

Thu, 06 Jun 2024 00:00:00 -0500

Context: In 2022, the Colombian Association of Endocrinology, Diabetes, and Metabolism (ACE) joined the Choosing Wisely initiative to prevent low-value medical practices.

Objective: To generate five evidence-based recommendations to decrease inappropriate clinical practices.

Methodology: A reviewing committee was established to identify "do not do" recommendations from ACE members. The most frequent recommendations were pre-selected, and a systematic literature search was conducted. Subsequently iterative rounds were conducted using the Delphi methodology to select the five recommendations that achieved the highest consensus among the panel of experts.

Results: Between October 2022 and April 2023, 117 active ACE members submitted a total of 211 recommendations. Of these, 109 were selected for further analysis. Subsequently, a Delphi panel identified five key recommendations, four of which addressed the excessive use of diagnostic tests, while the remaining one focused on therapeutic intervention.

Conclusions: To avoid unnecessary procedures, routine thyroid ultrasounds should not be performed on the general population or on hypothyroid individuals without changes in their physical examination. Requesting markers of bone turnover in patients with osteoporosis is also discouraged. Additionally, measuring basal insulin and/or post-glucose load in individuals who are overweight, obese, or have signs of insulin resistance is discouraged, along with indiscriminate measurements of vitamin D and unnecessary prescription of vitamin D supplements in the general population. The implementation of these recommendations could lead to a reduction in overdiagnosis and overtreatment of patients with endocrine conditions. This would help to improve resource management, quality of care, and clinical outcomes, benefiting both patients and the healthcare system.

Unreported variant of the THRB gene in a patient with resistance to thyroid hormone

Fri, 10 May 2024 00:00:00 -0500

Introduction: Variants in the beta thyroid hormone receptor gene are the main cause of thyroid hormone resistance syndrome. The inheritance is autosomal dominant and is characterized by decreased sensitivity of tissues to thyroid hormones. The clinical manifestations are variable with symptoms of hyperthyroidism or hypothyroidism.

Purpose: To document a potentially pathogenic genetic variant of the thyroid hormone receptor beta gene related to RHT syndrome not reported in the literature and provide information on the diagnostic approach.

Case presentation: A 43-year-old man presented with symptoms of hyperthyroidism and who was found to have persistently elevated free T4 levels with an inappropriately normal TSH. Simple and contrast-enhanced magnetic resonance imaging of the sella turca showed a pituitary gland without lesions. A TRH stimulation test was performed, obtaining an adequate response indicating a presumptive diagnosis of THR. The genetic study revealed a variant c.1046_1047insCCTGGT(p.Val349_Ser350insLeuVal) in the THRB gene, the bioinformatic analysis of the protein was carried out, indicating that it was pathogenic with a confidence of 89.4%.

Discussion: The diagnostic suspicion is given by the discrepancy in the values of thyrotropin, thyroxine and triiodothyronine. A complete diagnostic approach must be carried out, ruling out interference in the tests, abnormalities in the transport of thyroid hormones and thyrotropinoma; The TRH stimulus test guides the diagnosis and the genetic test its confirmation.

Conclusion: We report a new mutation related to the thyroid hormone resistance syndrome phenotype. This case demonstrates the importance of emphasizing genetic evaluation.

Hypophysitis with adrenal insufficiency secondary to immune checkpoint inhibitors therapy

Julián Barbosa Arana, José Luis Torres Grajales — Thu, 16 May 2024 00:00:00 -0500

Background: Checkpoint inhibitors are monoclonal antibodies with action against solid and hematologic neoplasia with increasing use, which is why there have been reports of adverse events including endocrine system compromise. We report the case of a patient treated with anti PD-1 who developed an endocrinopathy.

Purpose: To present the case of a patient with an endocrinopathy (hypophysitis) with secondary adrenal compromise associated with the use of checkpoint inhibitor therapy in a clinic in the city of Medellín, Colombia.

Case presentation: 75-year-old male patient with a history of poorly differentiated squamocellular carcinoma of the lung, without lymphovascular invasion, treated with nivolumab, who after 6 months of treatment seeks consultation due to abdominal pain and several emetic episodes. On physical examination, the patient was hypotensive, and hypotonic hyponatremia was documented with decreased morning and afternoon cortisol. A pituitary profile was requested, showing decreased ACTH, prolactin, and luteinizing hormone with a normal TSH. Additionally, a sella turcica MRI was performed without evidence of structural damage, which is why it was concluded to be hypophysitis with a secondary adrenal insufficiency.

Discussion and conclusion: Checkpoint inhibitor therapy offers a great advance in cancer treatment, and its increasing use allows us to watch and describe its adverse effects, making it possible to understand its mechanisms and possible risk factors. This is the first case of hypophystis secondary to anti PD-1 alone without CTLA-4 reported in the country.

It is important to consider the possible adverse effects that patients undergoing immunotherapy treatment may experience, and to have a high index of clinical suspicion to perform appropriate tests for early identification.

Endocrine diseases in infants and adolescents and the exposure to endocrine disruptors

Mon, 17 Jun 2024 00:00:00 -0500

Background: The influence of contact with endocrine disruptors, both in the prenatal and postnatal periods, has generated concern due to its possible relationship with the development of endocrinological diseases in the pediatric population.

Purpose: Compile scientific evidence regarding the presentation of endocrinological diseases in children and adolescents as a consequence of exposure to endocrine disruptors.

Methodology: In this narrative review, we examine the literature published on this topic using electronic databases and handsearching of specialized journals. A total of 33 articles were selected.

Results: A relationship was found between contact with these substances and the development of non-communicable diseases, such as obesity, diabetes, metabolic syndrome, growth and development disorders, and alterations in thyroid function. It has also been shown that exposure to these compounds can have long-term impacts on endocrine and reproductive development.

Conclusions: Additional research needs to be conducted to address gaps in current knowledge and establish a robust scientific basis to support public health decision-making.

Thyroid and Aging

Rubén Hernando de Jesús Fuentes Trespalacios, Jorge Luis Suarez Guerrero — Fri, 26 Apr 2024 00:00:00 -0500

Context: Aging brings with it physiological and pathological changes in different organs and systems, the thyroid being no exception.

Purpose: To carry out a narrative review on thyroid pathology in the elderly.

Methodology: Reviews were carried out in databases (Pubmed, Scielo) in the last 15 years, with keywords such as Graves' disease, aging, old age, hypothyroidism, hyperthyroidism.

Results: Thyroid function presents changes in aging typical of physiology; however, in subclinical or frankly established pathology, the clinical manifestations of the elderly may vary compared to other age groups.

Conclusions: In the elderly, it is important to know the physiological changes, those frankly pathological, as well as those that are in the gray area, being a diagnostic challenge and hence the importance of identifying them, both in hypothyroidism and hyperthyroidism to make a correct diagnosis. approach in this population group. That is why relevant information and key points are presented for the best approach to these patients.

Periodic hypokalemic paralysis as a debut of Graves' disease: Case report

Fri, 28 Jun 2024 00:00:00 -0500

Introduction: Graves' disease is associated with Periodic Hypokalemic Paralysis (PPHC). Given the interesting particularities of this association in medical practice and learning, we have shared the present case.

Purpose: To report the clinical and laboratory findings of a patient who presented with generalized weakness secondary to PPHC as the debut of Graves' disease, without other manifestations of thyrotoxicosis.

Case presentation: A 44-year-old male patient consulted the emergency department for flaccid quadriparesis, previously self-medicated with dexamethasone for lower back pain. Serum potassium of 1.9 mmol/L, TSH level < 0.005 ?UI/mL, positive antiTRAb, and diffuse hypercapillary goiter. PPHC secondary to Graves’ disease was diagnosed. The patient improved with hydroelectrolyte replacement and use of Beta blockers and antithyroid drugs.

Discussion: Hyperthyroidism is associated with multiple systemic manifestations, such as PPHC, which, despite being an infrequent finding in Graves' disease, was the only clinical manifestation in the patient. Patients with PPHC rarely present with paralysis and no signs of hyperthyroidism. However, the exact mechanism of action of PPHC in thyrotoxicosis remains unclear. In this case, it is hypothesized that self-medication with steroids may have worsened the hypokalemia.

Conclusion: Although infrequent, PPHC causes generalized weakness. A high index of clinical suspicion is key to the timely ordering of electrolytes, along with the systematic search for diseases that are associated with hypokalemia and weakness, such as Graves' disease.

Benefits and risks of testosterone pellets in women: A systematic review of the literature

Franklin Espitia de la Hoz — Fri, 14 Jun 2024 00:00:00 -0500

Background: testosterone implants can increase serum testosterone levels.

Purpose: to evaluate the benefits and risks of testosterone implants in women, through a systematic review of the literature.

Methodology: a systematic review of the literature was carried out about the benefits and risks of the use of testosterone implants in women. The search was carried out in different electronic databases (Medline, Central, Embase, among others), with free and standardized search terms. In the benefits, the reactivation of sexual desire was considered as the primary outcome; and in the risks the proportion of acne, spotting, clitoromegaly and hirsutism.

Results: seventy-nine publications were included. We found no randomized controlled trials evaluating the benefits and risks of testosterone implants in women. In few retrospective observational publications, the use of testosterone implants in women was associated with improvement in several domains of sexual function and personal distress. Data on long-term efficacy and safety are scarce and the quality of evidence is low. Common risks and adverse effects were found: acne, alopecia and hirsutism, as well as erythrocytosis (polycythemia), extrusion, cellulitis/infection and hematomas.

Conclusions: The benefits of testosterone implants in women are outweighed by the risks, and the incidence of irreversible adverse effects may be much higher than has been reported. Close monitoring of the rational use of testosterone implants in women is necessary.

Schally, Guillemin and the neuropeptides controlling the adenohypophysis

Alfredo Jácome Roca — Sun, 30 Jun 2024 00:00:00 -0500

Purpose: This narrative review seeks to build on and summarize the story of Andrew Schally and Roger Guillemin, who isolated, demonstrated their function and structure, and then synthesized the hypothalamic peptides that control the adenohypophysis. In an anecdotical way, I summarize my experience with the Tulane-VA endocrine group.

Content: The life and work of these researchers who were influenced during their apprenticeship by well-known figures in science, Harris and Selye among others are described. They worked together at first, but then separately (one at Tulane, the other at Baylor) in a decade of competitive research on hypothalamic hormones, the results of which led to their winning the Nobel Prize in Physiology or Medicine in 1977. In the two groups, there were important researchers that also made valuable investigations in neuropeptides.

Contributions: The studies of these two scientists, and the group of important collaborators who worked with them, began the production of neuropeptides and analogues that are fundamental in certain diagnostic processes or in therapeutics for many diseases, particularly diabetes and cancer.