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Four Web-Based Interactive Endocrine Case Studies for Use in Undergraduate Medical Education

1 Professor, Department of Biochemistry and Molecular Biology, Rutgers, Robert Wood Johnson Medical School

Stephen Schneider

2 Professor, Department of Medicine, Division of Endocrinology and Metabolism, Rutgers, Robert Wood Johnson Medical School

Robert Lebeau

3 Assistant Professor, Department of Psychiatry and the Cognitive Skills Program, Rutgers, Robert Wood Johnson Medical School

4 Curriculum Development/Instructional Design Specialist, Rutgers, Robert Wood Johnson Library of The Health Sciences

Associated Data

B. Case 2 folder

C. Case 3 folder

D. Case 4 folder

All appendices are peer reviewed as integral parts of the Original Publication.

Introduction

This resource is a collection of four case-based exercises intended to provide medical students with structured and focused opportunities to link basic science with clinical application. The cases are designed to help students self-evaluate their knowledge and develop a robust and well- integrated understanding of endocrine physiology and pathophysiology in the context of a representative range of endocrine disorders involving adrenal cortical, thyroid, and reproductive function. Although these cases were designed for, and used by, first-year students, they are also suitable for more advanced students.

Each case opens with a brief vignette containing a patient presentation and a history of present illness. The student first formulates a differential diagnosis and then sequentially narrows the differential by selecting from lists of diagnostic tests; correct answers with feedback are provided at each step. A diagnosis is ultimately required, and the student may be prompted to propose a treatment plan.

End-of-course survey results from 128 first-year medical students suggest that the use of these interactive case studies was considered to be a worthwhile use of study time, and that knowledge gained in the correlate endocrine course was required to work through the cases. Students indicated that the levels of case and task complexity, along with feedback, were appropriate and helpful.

These cases provide a resource for meeting the need for clinically relevant scenarios in the preclerkship years.

Educational Objectives

By the end of this session, learners will be able to:

• 1. Describe the predominant signs and symptoms of Cushing's syndrome, hypothyroidism, male hypogonadism, and Addison's disease.
• 2. Utilize the information provided in a focused patient presentation and history to develop a differential diagnosis.
• 3. Explain the rationale for the most useful tests that will aid in narrowing the differential diagnosis, drawing upon relevant endocrine physiology and pathophysiology concepts commonly taught in preclerkship medical school curricula.
• 4. Explain the contribution of particular physical exam and diagnostic test data to a final diagnosis, utilizing relevant endocrine physiology and pathophysiology concepts commonly taught in preclerkship medical school curricula.
• 5. Propose an appropriate treatment plan for the purpose of restoring the normal physiologic state.

Given the widespread adoption of integrated curricula across medical schools worldwide, 1 it is increasingly imperative to implement specific teaching resources and approaches that help learners link basic science and clinical application in meaningful and timely ways. Medical schools often invest much time and effort in juxtaposing basic and clinical science content, but are not always as consistent in creating specific learning experiences that are “conducive to teaching the content… to ensure that the material creates explicit and discernible linkages for students.” 2 The online interactive cases presented here are designed to help students develop a robust and well integrated understanding of endocrine physiology and pathophysiology in the context of a representative range of endocrine disorders. Although these cases were designed for, and used by, first-year medical students as part of the first-year Renal, Endocrine, and Reproductive Systems course at Robert Wood Johnson Medical School, they are also suitable for more advanced students seeking to strengthen and revisit basic science knowledge in clinical contexts.

Each case opens with a brief vignette containing a patient presentation and a history of present illness. The student must first formulate a differential diagnosis by choosing from a provided list of diagnoses. Next, the student sequentially narrows the differential by selecting from lists of diagnostic tests; correct answers with feedback and causal explanations are provided at each step. A diagnosis is ultimately required and the student may be prompted to propose a treatment plan. The cases are encountered online, individually, and at the student's own pace.

We developed the cases in this fashion partly in response to observed needs among our students. Observation of our students revealed that many were using internally prepared and commercially available questions to self-evaluate as they worked their way through our integrated curriculum. We have found that many students tend to rely almost exclusively on this method. For all the strengths of these questions in helping students build recognition of common presentations, students can become too comfortable with item-stem content and similar answer choices across resources. In addition, an insufficient number of the commonly used questions are application-oriented, and they do not fully tap into knowledge of integrated concepts. We thus observed a mismatch between the level at which we were teaching and the resources students were using for practice and self-assessment.

In addition, our use of cases and questions was informed by the unique potentialities of case-based learning as a means for helping students move from surface to deep learning, and as a complementary opportunity to retrieve and apply facts and concepts from lecture and independent study. 3 The sequential, step-wise approach we adopted is meant to capitalize on the balance of structured inquiry intrinsic to some of the positive outcomes of case-based learning, and achieve a desirable level of difficulty 4 and feedback that can help students engage in the advanced elements of these cases without being overwhelmed.

We could not identify similar web-based interactive exercises based upon internet searches. Again, the vast majority of so called self-evaluation resources are in the form of question banks, the limitations of which have been previously discussed. This suggests that this interactive endocrine-based self-study tool is unique, and it thus offers an exciting and challenging addition to the existing materials.

This interactive exercise has been designed to provide first-year medical students with an application-based method to self-evaluate their competency in endocrine physiology and pathophysiology. The exercise was made available to students via the course website as part of the Robert Wood Johnson Medical School first-year Renal, Endocrine, and Reproductive Systems course. Students may access the exercise at any time during the course; however, they are encouraged to use this exercise for self-evaluation once the endocrine and reproductive physiology sections have been completed.

This exercise is comprised of four case studies, collectively representing a range of endocrine disorders, which are tested in the Robert Wood Johnson Medical School internal end-of-course exam, and likely represent high-yield concepts within the USMLE Step 1 exam. Importantly, since these cases do not represent obscure pathologies, any long-term retention of this information has the potential benefit of assisting students with clinical reasoning skills well beyond their preclinical education.

Case one features a 35-year-old woman with menstrual irregularities, weight gain, and hirsutism. The diagnosis is Cushing's syndrome. Case two features a 40-year-old woman with oligomenorrhea, amenorrhea, and fatigue. The diagnosis in this case is hypothyroidism. Case three features a 52-year-old man with decreased libido, decreased muscle strength, and fatigue. The diagnosis is hypergonadotropic hypogonadism. Finally, case four features a 29-year-old woman with long-standing weakness, lightheadedness, nausea, and vomiting. The diagnosis for this case is Addison's disease.

Technical Aspects

To use the cases, first extract the case .zip folders. Select a case by opening the case folder and clicking on the index.html file. If prompted, choose a Web browser to view the file. Begin the case by clicking the “Start” link at the bottom of the first page. Navigate through the entire case by clicking the “Next,” “Previous,” or “Start Over” links on each subsequent page.

Running the Exercise

Each case study begins with a short vignette containing the initial patient presentation and a history of the present illness. The information provided in this first section is typical given the final diagnosis. However, as is the case with these pathologies, many of the signs and symptoms overlap among numerous endocrine and nonendocrine disease states. Thus, the consideration of numerous physiologic and pathophysiologic mechanisms of action is critical in order to form the differential diagnosis, which is the first step in this exercise. To accomplish this, a list of several pathologies is provided, and the learner is prompted to choose, by checking boxes, “Which of the following should be included as part of your differential diagnosis?” The question and answer portion of each case is interactive. The choices have radio buttons next to each. The correct answers and the incorrect answers are displayed when the user clicks on the “Check Answers” button. A “Try Again” button refreshes the individual page and removes all user responses, which allows the user to repeat the same question. Once the student is ready to proceed, a second screen appears showing the correct answers with feedback describing why the listed correct answer choices are the best answers and why the incorrect answers are not.

By clicking on “Next” at the bottom of the screen, a subsequent screen appears which, when appropriate, may include some initial diagnostic test results, and prompts the selection of one or more diagnostic tests that will best aid in narrowing the differential diagnosis. Once this is complete, the “Check Answers” button is clicked, and the next screen appears, showing diagnostic results that will aid in further narrowing the differential as well as the best answers with feedback. This process continues, ultimately leading to a screen which asks for the selection of the most accurate diagnosis. Once the diagnosis is established, the student may be asked to choose the most appropriate treatment plan.

In addition to feedback, in some cases, additional enrichment is also included. Certain sections prompt the student to provide short answer responses. At all points throughout each case, the student has the option to move to the next screen, return to the previous screen, try again, or start over.

The following subset of items were included within the end-of-course survey which was made available to the students following the Robert Wood Johnson Medical School first-year Renal, Endocrine, and Reproductive Systems course. One hundred and twenty eight out of the 188 first-year medical students who completed this course also completed the following survey, items of which are based upon a 5-point Likert scale with one indicating strong disagreement, five indicating strong agreement.

Item one stated, “I found the online interactive endocrine cases a worthwhile use of my self-study time.” On average, students rated this statement on the Likert scale as a 4.2, with 86% either agreeing or strongly agreeing, 2% disagreeing, and 1% strongly disagreeing.

Item two stated “I was required to utilize the knowledge obtained in this course to work through these cases.” On average, students rated this statement on the Likert scale as a 4.28, with 84% either agreeing or strongly agreeing, 1% disagreeing, and 0.5% strongly disagreeing.

Item three stated “The content of these cases was at an appropriate level to reinforce and/or extend course content.” On average, students rated this statement on the Likert scale as a 4.07, with 80% either agreeing or strongly agreeing, 4% disagreeing, and no students strongly disagreeing.

An opportunity to provide written comments was also provided. Feedback from the written comments represented a wide range of opinions, but was overwhelmingly supportive of this exercise as being a useful learning mechanism.

The following are direct quotes from a representative sampling of survey comments in response to the question of “What did you find was/were the MOST useful aspect(s) of the cases?”

• • “Having to actually narrow down the differential diagnosis, as well as walking through multiple different tests. Actually getting some kind of results back from tests helps to cement the information in our minds.”
• • “Content of these cases accurately reflected the course content's level of difficulty.”
• • “I think they may have sometimes just slightly pushed the boundaries into what I expect M2 year will be about, but other than that they were great.”
• • “The integrated nature and the real-life applicability - seeing how the diseases we learned about in class would present in the clinic, as well as how to go about diagnosing and treating them.”
• • “The explanations for why a diagnosis or potential symptom was unlikely/incorrect were very helpful.”
• • “I found the answer explanations to be most useful (although somewhat incomplete since they did not explain every one of the answer choices) - especially why the wrong answers were considered incorrect. I liked how the cases were broken up into steps and required application of many different concepts learned throughout the block.”
• • “Good to see the cases reflect real world situations!”
• • “Starting to make a differential, and what labs to order… helps you to think through what's wrong, how it presents and start to work toward acting like a real doctor.”
• • “The most useful aspects were synthesizing knowledge/information to solve a problem.”

The following are direct quotes from a representative sampling of survey comments in response to the question of “What did you find was/were the LEAST useful aspect(s) of the cases?”

• • “There were a lot of details I wasn't sure we needed to know. When the cases were so vague that anything and everything could be the cause of the vague symptoms, but I know [you] did that for learning purposes…I'm just someone who likes clear cut answers.”
• • “The first few questions of each case had way too many right answers. I prefer shorter practice questions that are more similar to the format of questions on exams. The cases that were presented online were very similar to what we do in lecture, and I felt that they were redundant. However, I could see how they would be useful for other students who prefer practicing questions in that format.”
• • “Sometimes the explanation for why certain choices were incorrect were lacking.”
• • “More of the wrong answers could have been explained, there were a few answers that I got wrong that the explanation wasn't long.”
• • “Addressed too much material in each individual question.”
• • “The length of time it took to go through each one.”

Students were asked to estimate the amount of time that they devoted to completing the case studies. Sixty-four percent of the students spent 20 minutes or less using this exercise. Approximately 28% spent between 20 and 60 minutes. Seven percent spent 60 minutes or greater.

We developed this case-based exercises in order to provide first-year medical students with an early, structured, and focused opportunity to link basic science with clinical application. Our initial motivation for doing so was to meet student demand for self-evaluation resources by providing practice materials that corresponded more closely to the manner in which we were teaching. However, we also saw these cases as learning experiences in and of themselves.

The challenges we faced were how to achieve appropriate levels of case and task complexity and a beneficial balance of structure, inquiry, and feedback. One index of success in meeting these challenges is whether students found the cases to be useful and acceptable. End-of-course survey results strongly suggest that the use of interactive case studies was well received by the students. The majority of survey respondents posted positive comments regarding the usefulness of the cases. The time needed to complete the cases was not excessive and perhaps contributed to the high level of agreement indicated by students regarding whether the cases were a worthwhile use of their time.

On a more specific level, students indicated that the levels of case and task complexity were appropriate and helpful. Student comments reflected their appreciation for the “real-world” feeling of the cases and the authenticity of the step-wise progression from differential diagnosis to treatment plan. Many students indicated that they felt they were able to engage in thinking through the case, and therefore synthesize knowledge from class and self-study to make decisions and explain findings. In particular, many found the greatest value in the explanations provided for incorrect answers. This is further evidence that the advanced clinical elements of these cases were framed and supported in ways that did not overwhelm the majority of students. Our choice to prompt students to choose among options, rather than asking them to generate diagnostic possibilities, tests, and treatment plans was helpful in this regard.

Nonetheless, some students did find that some aspects of these cases were too advanced for them. This is true to a limited degree (at least based upon our curriculum). However, the intent was to allow students to work through real endocrine cases that were not artificially simplified. The advanced nature of the cases is by design so as to challenge students to apply and integrate physiologic concepts and pathophysiologic mechanisms, rather than having them rely upon rote memorization of facts and figures. As several students indicated, there are those who preferred “clear-cut answers” or fewer “right answers.” There is inherent uncertainty in a case-based approach that raises complex topics and not all students will resonate with this, perhaps because of differences in prior knowledge or orientation toward learning. 3 Still, other students were comfortable with the complexity of the cases, but sought more and/or fuller explanations.

The primary limitation to our evaluation of these exercises is that the feedback that we received was based upon student perceptions of whether or not they found this exercise useful. Limitations of this feedback have to be considered in that, at our institution, we currently have no way of tracking how many actually used the exercise, nor to what extent; and of those who used the exercise, how many completed the evaluation. Future studies are being considered in which more definitive outcomes data can be analyzed, such as a study comparing exam item performance on those areas testing thyroid, adrenal cortical, and reproductive endocrine function between students who completed the activity and those who did not. But again, this would rely upon accurate reporting by students regarding to what extent the case studies were utilized.

We believe that these online interactive cases in their current form can help students embrace the fact that a firm understanding of physiology is essential in clinical practice. Student feedback supports this rationale. Although we used these cases with first-year medical students, we believe these same cases can be used across the undergraduate medical education continuum. The advanced elements of the cases would be easily recognizable to clerkship students, but would provoke them into revisiting and reviving the casual mechanisms they learned in their preclerkship years in a timely and context-specific manner.

A. Case 1 folder

Disclosures

None to report.

Funding/Support

Ethical approval.

Reported as not applicable.

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Endocrinology Case Studies

Endocrinology is the branch of medicine dealing with the conditions of endocrine glands and their secreted hormones. There are several endocrine glands in the human body namely, the Pituitary, Hypothalamus, Thyroid, Parathyroid, Thymus, Pancreas, Adrenal glands, Testis, and Ovary.

Common endocrine diseases

• Diabetes type 1 & 2
• Hyperthyroidism and Hypothyroidism
• Addison’s disease
• Cushing syndrome
• Osteoporosis
• Hypopituitarism and Hyperpituiterism .
• Acromegaly etc.

Common signs and symptoms

• Unexplained weight loss or gain
• Infertility
• Nausea & vomiting
• Diarrhea or constipation
• High or low blood pressure
• High or low blood sugar
• Heat or cold intolerance
• Menstrual abnormality etc.

Common investigations

• Serum hormone levels
• Ultrasonogram
• Positron emission tomography or PET scan
• Scintigraphy

Creative Commons License

This post is adapted for the Health & Medical Case Studies created by the Master of Medical Biotechnology program of the University of Windsor. This work licensed under a Creative Commons Attribution-NonCommercial (CC BY-NC-ND) 4.0 International License .

An overactive thyroid, occurring when the thyroid gland produces an excess amount of hormone thyroxine.

Hypothyroidism is a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream.

Osteoporosis is a disease that weakens bones to the point where they break easily—most often, bones in the hip, backbone (spine), and wrist.

Obesity is a complex disease involving an excessive amount of body fat.

Pituitary gland fails to produce one or more hormones, or doesn't produce enough hormones.

High activity in pituitary or create/release more pituitary hormones than normal.

Positron emission tomography (PET is a functional imaging technique that uses radioactive substances known as radiotracers to visualize and measure changes in metabolic processes, and in other physiological activities including blood flow, regional chemical composition, and absorption.

Scintigraphy (from Latin scintilla, "spark"), also known as a gamma scan, is a diagnostic test in nuclear medicine, where radioisotopes attached to drugs that travel to a specific organ or tissue (radiopharmaceuticals) are taken internally and the emitted gamma radiation is captured by external detectors (gamma cameras) to form two-dimensional images in a similar process to the capture of x-ray images.

Fine-needle aspiration cytology

HEALTH & MEDICAL CASE STUDIES (V1.01) Copyright © by Afnan Binte Liaquat; Alicia Higgison; Angela Awada; Aniza Augnesh Mrong; Dr. Tranum Kaur; and Wei Liu is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License , except where otherwise noted.

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• © 2008

A Case-Based Guide to Clinical Endocrinology

• Terry F. Davies 0

Mount Sinai School of Medicine, The Mount Sinai Hospital and the James J. Peters VA Medical Center, New York

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• Written by expert panel of endocrinologists
• Reflects much of the curriculum for clinical endocrine training recommended by the Association of Program Directors in Clinical Endocrinology
• Thought-provoking, concise cases are followed by multiple choice questions to enhance learning
• Valuable for students, residents, fellows, and practitioners

Part of the book series: Contemporary Endocrinology (COE)

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Table of contents (55 chapters)

Front matter, the pituitary gland, pituitary apoplexy.

• Steven Jon Russell, Karen Klahr Miller

When and How to Stop Cabergoline Treatment in Microprolactinomas

• Annamaria Colao

Cushing’s Disease

• Kawaljeet Kaur, James W. Findling

Thyroid Overactivity

Amiodarone-induced hyperthyroidism.

• Paul Aoun, David S. Cooper

Interferon-Induced Hyperthyroidism

Subclinical hyperthyroidism due to a multinodular thyroid, subacute (de quervain’s) thyroiditis, thyroid underactivity, amiodarone-induced hypothyroidism.

• Ramzi Ajjan

Autoimmune Hypothyroidism with Persistent Elevation of TSH

• Amit Allahabadia

Hashimoto’s Thyroiditis and Type 1 Diabetes

• Mark P.J. Vanderpump

Thyroid Cancer

Papillary thyroid cancer.

• Nicole Ehrhardt, Victor Bernet

Metastatic Papillary Thyroid Cancer

• Henry B. Burch

Medullary Thyroid Cancer

• Jacqueline Jonklaas

Follicular Thyroid Carcinoma with Pulmonary and Osseous Metastases

• Jason A. Wexler, Kenneth D. Burman
• Case-basaed
• Diabetes mellitus
• Endocrine disorders
• Endocrinology
• Metabolic syndrome
• Problem-based

Terry F. Davies

Book Title : A Case-Based Guide to Clinical Endocrinology

Editors : Terry F. Davies

Series Title : Contemporary Endocrinology

DOI : https://doi.org/10.1007/978-1-60327-103-5

Publisher : Humana Totowa, NJ

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Humana Press 2008

eBook ISBN : 978-1-60327-103-5 Published: 06 June 2008

Series ISSN : 2523-3785

Series E-ISSN : 2523-3793

Edition Number : 1

Number of Pages : XXII, 504

Topics : Endocrinology

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• Published: 01 April 2006

Making the case for Case Studies

• Julie Solomon 1  

Nature Clinical Practice Endocrinology & Metabolism volume  2 ,  page 179 ( 2006 ) Cite this article

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Nature Clinical Practice Endocrinology & Metabolism is a journal designed to lighten the reading load for busy doctors; why, then, does it include Case Studies? Isn't the case study just a bit of light reading? It depends on what it is designed to do. For readers of this journal, it may be helpful to revisit and update the ideas I previously outlined (Solomon J Nat Clin Pract Gastroenterol Hepatol 2005, 2: 117). So, what is the role of the Case Study?

Case Studies should act as instructive examples to people who might encounter similar problems. Ideally, in medicine, Case Studies should detail a particular medical case, describing the background of the patient and any clues the physician picked up (or should have, with hindsight). They should discuss investigations undertaken in order to determine a diagnosis or differentiate between possible diagnoses, and should indicate the course of treatment the patient underwent as a result. As a whole, then, Case Studies should be an informative and useful part of every physician's medical education, both during training and on a continuing basis.

It's debatable whether they always achieve this aim. Many journals publish what are often close to anecdotal reports (if they publish articles on individual cases at all), rather than detailed descriptions of a case; furthermore, the cases described are often esoteric or the conditions present on such an infrequent basis that a physician working outside a teaching-hospital environment would be hard-pressed to apply their new knowledge. It would be difficult, therefore, to say whether any conclusions could confidently be drawn by readers as a result of these reports. Most physicians would probably want to do some extra research—either in the literature or by canvassing opinions of colleagues.

By proposing, peer-reviewing and reading the Case Studies, you and your fellow physicians could gain a broader understanding of clinical diagnoses, treatments and outcomes

In this light, then, Nature Clinical Practice Endocrinology & Metabolism Case Studies have a specific aim: to help established physicians as well as trainees to improve patient care, without adding to their workload. Rather than being merely anecdotal, they include the etiology, diagnosis and management of a case. Importantly, they give an indication of the decision-making process, so that other physicians can apply lateral thinking to their own cases. Decisions on which of a range of treatment options to follow might involve input from the patient, or might be purely objective, but ideally a Case Study should outline why a particular course was followed. Readers should not have to resort to the Internet or to out-of-date textbooks to find basic background information explaining the reasons for approaching the case in that way; the reasons should be fully explained in the article itself.

Nature Clinical Practice Endocrinology & Metabolism Case Studies represent an opportunity to spread the benefit of knowledge across the physical boundaries imposed by looking at one case, in one place, at one time. It's not so that fingers can be pointed at 'incorrect' treatment but instead so that geographical differences in practice can be highlighted, for example, or clearer descriptions be reached to explain a case more completely and accurately.

By proposing, peer-reviewing and reading the Case Studies, you and your fellow physicians could gain a broader understanding of clinical diagnoses, treatments and outcomes. So, we're inviting you to contribute to the further education of your colleagues. Will you meet the challenge?

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• Published: 10 February 2023

Endocrinology specialty service for inpatients: an unmet growing need

• Esther Osher 1 , 2 ,
• Naomi Even Zohar 1 ,
• Michal Yacobi-Bach 1 ,
• Dror Cantrell 3 ,
• Merav Serebro 1 ,
• Yael Sofer 1 , 2 ,
• Yona Greenman 1 , 2 ,
• Karen Tordjman 1 , 2 &
• Naftali Stern 1 , 2  

BMC Health Services Research volume  23 , Article number:  142 ( 2023 ) Cite this article

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There is recent concern regarding the documented mismatch between demand and supply, vis-à-vis the growing need for trained endocrinologists unmet by parallel rise in the world workforce of endocrinologist. Due to the increasing complexity of disease in inpatients, in recent years we have experienced a growing demand for inpatient endocrine consults. Surprisingly, the need for the endocrinology subspecialty in the overall care of inpatients in the current setting of general hospitals has received little attention.

A retrospective analysis of endocrine consult service based on solicited consults carried out during 3 consecutive months.

During 3 months, there were 767 consults, comprised of 156 diabetes referrals and 611 endocrine/metabolic consult requests. The 611 "non-glucocentric" consult requests were related to 295 inpatients (2.1 ± 2.7 consults/patient). Mean patient age was 58.9 ± .18 years (range 21–92), with some F/M preponderance (58/42%). Requests for endocrine consults were evenly distributed (49.8%, 50.2%) between internal medicine and surgery wards. Case distribution was as follows: thyroid 45.4%, calcium & bone 11.5%, pituitary 12%, adrenal 10% and all others 8.1–0.7%. The mean response time was 4.4 ± 2.7 h. The consults had a discernible effect on the patients' disease management in 60% of the patients. Of these, the consults modified the hospital treatment in 74%, the discharge treatment recommendations in 19% and the diagnosis in 7%.

At a large medical center, endocrine consults were requested for ~ 3.3% of all admitted inpatients. The endocrine consults modified pre-consult diagnosis or treatment in ~ 60% of the cases. Contrary to its common image as an exclusively outpatient-based subspecialty, endocrinology practiced by specialists and endocrine trainees has a notable role in the daily care of inpatients admitted to a referral general hospital.

Peer Review reports

Introduction

The educational need for the involvement of endocrinologists and endocrine fellows in the care of hospitalized patients has been highlighted by a recent update of the requirements for training in endocrinology by the European Union of Medical Specialists [ 1 ]. According to this expert consensus document, hospitals comprise the organizations, which are sufficiently enriched with the supportive environment needed for training in terms of highly specialized teams and sufficiently intensive interactions with other subspecialties, equipment and laboratories [ 1 ]. On the patients' receiving end, the input offered by the endocrine subspecialty may favorably affect each phase of the hospitalization in many cases, from admission via the emergency department, in-hospital diagnosis and treatment, culminating in discharge preparation and instructions. However, the actual role of endocrinology in the current care of hospitalized subjects has received little attention and was not targeted as an independent subject of study. Historically, this void has been aggravated by the fact that with the exception of some dedicated clinical research facilities or subspecialty–based wards in a few European countries, inpatient endocrine wards are nearly extinct and the bulk of endocrine practice has shifted to the outpatient setting, mostly in the community.

Because low level of awareness of the role of endocrinology in inpatient care may lead to improper allocation of personnel in hospital endocrinology centers, we set out, in the present report, to assess 1) the endocrine patient load, disease profile, and service availability during hospital admissions; 2) the impact of the endocrine consults on patient care during in-hospital stay. The general setting was our center, which is a tertiary referral, 1400 bed hospital, with a well-developed endocrine group.

Data collection

This study was approved by the Review Board at our center. We carried out a retrospective analysis of the adult endocrine consult service based on solicited consults carried out during 3 consecutive months (April 1 through June 30, 2015) at the Medical Center. All consecutive consults placed during that period were reviewed and the parameters of interest extracted.

Mode of operation of the endocrine consult service

The consult service operates via a computerized system such that request for consults, when are placed continuously by hospital staff, usually by residents or fellows from all adult wards, with the approval of attending physicians. Requests are submitted when a new endocrine diagnosis is under consideration or when changes in treatment are entertained and the team believes that input from the endocrine service would benefit the patient.

Diabetes consult service

The diabetes unit is integrated into the Institute of Endocrinology and diabetes consults are provided by either the diabetes unit staff or the entire endocrine, staff as needed.

The endocrine consult service operates with a three-tier system comprised of a fellow, rotating senior endocrinologist in charge and endocrine subspecialists (e.g., neuroendocrine tumors). Eventually, the vast majority of requests for consultations originate in general medicine and surgery, specialized wards (such as cardiology, neurology, dermatology, neurosurgery, oncology, orthopedic/oncological surgery, head and neck surgery etc.), general and specialized intensive care units, as well as the emergency department. Finally, no financial restrictions/reimbursement considerations are applied with regard to the use of professional advice during hospitalization in this system, which is typical for a public hospital operating within a nationalized health care system.

Data Analysis

The following parameters were evaluated: 1) number of consults/day or source (hospital unit) of the request; 2) number of consults per patient/admission during study period; 3) the response time of the consultation, from the placement of the request to the written endocrine report; 4) patients' age and gender; 5) reason for consultation, categorized by the endocrine disorder addressed; 6) overall disease severity, ranked by the first author's judgment (EO), using the patient's entire medical file as constructed during the hospitalization period. Electronic files include daily ward staff notes, laboratory and imaging reports, consults from other disciplines, nursing notes and admission and discharge reports. For the purpose of this analysis, the severity of illness during the consultation time was also assessed. Severity rank was adopted from published models and sets of criteria [ 2 ] and scored as follows: mild=1; moderate=2; severe=3 (Table 1 a). 7) effect of the consult on diagnosis and treatment, using the following categories: change in diagnosis (recorded as 1), change in treatment during hospitalization days (recorded as [ 2 ] or change in the discharge treatment instructions, recorded as [ 3 ]. 8) effect of the consultation ranked according to the level of the documented change in the endocrine condition during hospitalization as assessed at the time of data analysis, categorized as follows: no change, deterioration; partial improvement in illness severity status; improvement in illness severity status. We only graded the changes that could be reasonably linked to consult- related actions. For example, if hypoadrenalism related to immune checkpoint modulators was corrected and stress doses were used, but the patient succumbed to ascending cholangitis with pseudomonas sepsis following chemotherapy, the deterioration was not ascribed to the consult.

Analysis was done by SPSS software, analysis included, descriptive measures frequencies, means, ranges, and medians and correlation using non parametric test spearman correlation test. Results are presented as means+/-SD.

The overall trend in the number of total endocrine consults at our center is depicted in Figure 1 , showing, in essence, an increase from ~1800 consults in 2010 to ~2700 consults in 2022( p <0.001). There was also an increase in the number of diabetes consults (which comprised ~15% of total consults), between 2010-2022 from~380 to 540( p <0.001). However, despite the increase in patient hospital admissions during COVID19 pandemic, there was no significant increase in the number of total consults between end of 2019 to 2022. Zooming on the 3 months surveyed here, there were 767 endocrine consults, which amounted to 8.4 requests/day, or 11.8 requests /day if only the 5 full working days of the week are considered. 156 of these requests (20.3%) were to assist in the control of glucose in patients with diabetes. Hence, there were 611 "non-glucocentric" consult requests, relating to 295 inpatients (on the average, ~2 consults/patient during the hospital stay).

Number of endocrine inpatient consults in the years 2010–2022. The number of endocrine consults at our center showing, an increase from 1814 ~ in 2010 to ~ 2664consults in 2022

In all, endocrine consults were requested and received for 0.013% of the adult subjects hospitalized at the center during the survey period, of which 0.66% centered on glucose control and 2.6% addressed endocrine/metabolic issues that did not mainly deal with glucose control. In the non-diabetes consults, mean patient age was 58.9±18yrs. (range 18-95), with some F/M preponderance (58 /42%).

Requests for endocrine consults were evenly distributed (49.8%, 50.2%) between internal medicine and surgery wards. With the exclusion of diabetes, the primary reason for the acute admission in subjects for whom an endocrine consult was requested during hospitalization was endocrine in 40%, oncologic in 14%, neurologic in 10%, with the remaining third (36%) linked to variety of multiple other conditions, each accounting for 0.3-6% of the admissions (Figure 2 ). The distribution of the underlying reason for requesting the endocrine 611 "non-glucocentric" consult was as follows: thyroid- 45.4%, calcium & bone-11.5%, pituitary-11.9%, adrenal-9.8% with all other fields accounting for 0.7-8.1% each (Figure 3 ). Finally, the distribution of the severity of disease during the time of actual consultation was as follows: grade 1(mild or less); in ~80%, grade2 (moderate) in ~19% and severe in ~2%.

Distribution (%) of the primary causes for admission in the study cohort by medical categories. The primary reason for the acute admission in subjects for whom an endocrine consult was requested during hospitalization was endocrine in 40%, oncologic in 14%, neurologic in 10%, with the remaining third (36%) linked to variety of multiple other conditions

HTN = hypertension. Endocrine consults case distribution(%) The distribution of the underlying reason for requesting the endocrine consult was as follows: thyroid- 45.4%, calcium & bone-11.5%, pituitary-11.9%, adrenal-9.8% with all other fields accounting for 0.7–8.1% each. This sub-analysis is limited to the non-glucocentric consults only

Overall, there were 2.1±2.7 consultations per patient and the mean response time was 4.4±2.7h. There was a modest correlation between disease severity and the number of consults requested per patient (R=0.3; P <0.05). There was also a modest correlation between the number of per patient consultations and the estimated effect of the intervention as defined above (R=0.33; P <0.05).

Finally, we assessed, in each case, whether or not the management in the course of the patient's hospitalization was modified by the suggestions offered in the endocrine consults. In all, the interventions initiated by the consults led to a change in the endocrine care in 60 % of the patients seen. Of this subset of patients, a change in treatment during the hospitalization took place in 74 %; a change in their discharge treatment instructions was recorded in 19%; and a change in diagnosis occurred in in 7% (Table 2 ).

The effect of the consultation was also ranked by to the level of change in the endocrine condition during hospitalization. As judged at the time of data analysis, no change/no improvement in the condition for which the consult was requested was seen in 37 % of the patients; partial improvement in 50 % whereas a clear improvement was noted in 13%. We did not identify cases in which consult-related intervention result in deterioration in patients' clinical status. This assessment is admittedly subjective as we did not have a "case control" setup.

Notwithstanding that nearly all major endocrine discoveries were made in hospital-based endocrinology centers, endocrinology/metabolism is now generally viewed as an "outpatient subspecialty". This most likely reflects the chronic nature of some of the commonest endocrine diseases such as hypothyroidism, diabetes, osteoporosis and obesity and the shrinkage of hospital endocrinology units. In 1998, describing the profile of the inpatient endocrine activity in the Mayo Clinic, Brennan et al [ 3 ] stated that "the nationally experienced decline in both hospital admission rates and length of stay has resulted in a reduction in the number of primary endocrine services at Mayo hospitals from three in 1980 to one currently". We were able to identify only a single previous report, in an abstract form, that formally quantified current endocrine workload in the setting of a general hospital. [ 4 ]. In all, the inpatient endocrine service at University Hospitals Birmingham NHSFT (IES@UHB) during 2010-2105 handled 2,817 inpatient referrals, amounting to an annual average of 470 cases. Importantly, referral volume grew at an average annual rate of 49.2% year-on-year, from 127 in 2010 to 885 in 2015, which is reminiscent of the trend at our institution, albeit with a smaller case load and a steeper annual increment. The trend was observed both in endocrine and diabetes consults, that comprised~15% of total consults. Interestingly at the COVID -19 pandemic period, there was no significant change in consult number of either endocrine or diabetes. It is possible that the extreme work overload secondary to the acute rise in critically ill, respirated patients, reduced the medical staff's time to communicate with consulting services which were limited to the most acutely critical dilemmas.

A report in 2008 indicated that nearly one in five adult patients admitted to a large general hospital had unrecognized probable diabetes, based on elevated HbA1c levels [ 5 ]. In an editorial published in 2011, Toledo and Stewart strongly objected to the possibility that primary care providers independently manage patients with diabetes, osteoporosis and thyroid disease [ 6 ]. Their key point was that endocrine care in times of explosion in the number of procedures, devices and particularly diabetes and osteoporosis drugs, often used in combination was too complex to circumvent professional endocrine advice. Ten years later, with the ongoing increase in life expectancy, gradual introduction of molecular and genetic testing and the advent of many oncology drugs with endocrine sequels [ 7 ] this has become even more complicated.

In a multi-authored e-handbook of inpatient endocrinology [ 8 ], Garg et al covered several dozens of specific emergency endocrine inpatient dilemmas. These critical instances take place on the background of the high prevalence of endocrinopathies in the general population. Golden et al [ 9 ] reported more than 10 endocrine/metabolic disorders whose prevalence in US adults exceeded 5 % including diabetes mellitus, impaired fasting glycaemia, impaired glucose tolerance, obesity, osteoporosis, osteopenia, vitamin D deficiency, erectile dysfunction, lipid disorders and autoimmune thyroiditis. Childhood cancer survivors were at increased long-term risk for diseases requiring inpatient treatment decades after their initial and 11% of these cases were due to endocrine disorders [ 10 ]. Endocrine disorders, then, afflict a sizable part of the population and, owing to clustering of conditions (e.g., obesity, diabetes, hypogonadism), many subjects would present with several endocrinopathies. Consequently, many hospital admissions not primarily related to endocrine disorders, such as ICU admissions [ 11 ], systemic or local infection, non-endocrine cancer or fractures necessitate reassessment and changes in the pre-admission treatment of the background endocrine conditions. Additionally, newly diagnosed endocrine disorders such as those elicited by immune checkpoint modifiers (e.g., thyroiditis) may emerge during, or complicate the course of hospital admissions. Mild hyponatremia (Na OF 130–135 mmol/L) is seen in up to 30% of hospitalized patients [ 12 ], whereas moderate to severe hyponatremia (Na+] <130) has been reported in 7% of inpatients [ 13 ]. In a prospective study of patients with syndrome of inappropriate anti diuretic hormone secretion (SIADH) who are often undertreated and mostly discharged with persistent hyponatremia, the involvement of endocrinologists improved the required time for correction of hyponatremia and shortened length of hospitalization [ 14 ]. Even if endocrine consultation is requested in a small fraction of such cases, the cumulative burden would appear significant. With the increasing fraction of older subjects in the general population, a disproportional rise in their hospital admissions associated age-related endocrinopathies and metabolic derangements are on the rise, among which previously undiagnosed diabetes is particularly common.

This manuscript describes the endocrine consultation service at our medical center, a 1400 bed tertiary referral center. Since consults were requested for ~1/33 (3.6) of admitted patients, the importance of providing an inpatient endocrine consultation service is almost self-evident. Keeping in mind the much higher rate of endocrine disease in the general population [ 9 ] and that hyponatremia alone afflicts nearly one third of inpatients [ 12 ], it is obvious that a marked degree of selectivity and restraint was applied by the hospital's staff in the use of requests for endocrine consultation. For example, if, as reported by Golden et al [ 9 ], the prevalence of hypo- and hyperthyroidism in the general population is ~6%, and requests for consults on thyroid disorders in at our center amounted to ~1.17% (2.6%X0.45) of the patients admitted during the study period, the advice of an endocrinology was asked in only 1/5 of the patients with known thyroid disease. A similarly calculated rate for hyponatremia, as one additional example, would have yielded a much lower rate of requests per hyponatremia cases. It is likely, but impossible to determine with certainty in a retrospective analysis, that suspicion of endocrine etiology instigated the interest in the opinion of an endocrinologist.

It is notable that in about 40 % of the patients for whom endocrine consultation was requested, an endocrine disorder was the primary cause of admission. This highlights the difficulty in managing some patients with endocrine disease in the outpatient setting.

The involvement of an endocrinologist had a notable impact on the care in 60% of the cases. The most prevalent effect was change in treatment in hospital and out of hospital. In the absence of a comparator group, such as might be offered by a parallel hospital lacking an active endocrine service, it is impossible to assess the effect of the endocrine service on tangible measures such as hospital stay or the admission outcome. Still, missed or delayed diagnoses during the short time window of hospitalization may be not only detrimental to patients' health, but severely aggravate the burden of later health and financial cost owing to complications and disability. The results are therefore valuable in that they portray, for the first time, the nature of current hospital endocrine work using several quantitative and semi quantitative measures. At the least, this report provides a clear justification for further in-depth studies and policy changes.

Recent reports have provided important information on the positive impact of a specialized diabetes team on short term outcome measures in patients with diabetes such as length of in-hospital stay and the number diabetes-related prescriptions [ 15 , 16 , 17 ]. Here we focused on the role of a general endocrine inpatient service.

Our analysis may be directly relevant only for large public hospitals providing the full range of current medical care. Nevertheless, many of the clinical dilemmas leading to the consult types included in the present survey are most certainly encountered in smaller hospitals which are set up for extended hospitalization or connected to neighboring daycare specialty centers such as oncological services.

Finally, mid-to-large hospitals, particularly those with academic affiliation, have traditionally undertaken the mission of training endocrine fellows. The demand for endocrinologists is presently unmet and the gap is projected to widen even further [ 18 ]. Further, recent concerns that the gap is still growing, were abetted by an anticipated sequel of this gap, a projected growing shortage in endocrine mentors and educators [ 19 , 20 ]. To date, the latter could be bred only in the setting of strong endocrine hospital services.

In summary, this report underscores the important role of endocrinology in the hospital setting as an expanding aspect of the art of the endocrine profession. Identification and referral of patients requiring in-hospital endocrine advice is critical for patients, whereas adequate endocrine inpatient case load is essential to provide a comprehensive and contemporary training for future endocrinologists. We are hopeful that this report can generate more interest in current endocrine inpatient care and encourage further studies and reports of existing working models.

Availability of data and materials

All data and materials used in the writing are described in the manuscript and are available and no additional data exist.

The data that support the findings of this study are available from Dr. Esther Osher, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable re-quest and with permission of Tel Aviv Sourasky Medical Center Helsinki Committee.

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Patient informed consent was waived by the Tel-Aviv-Sourasky Review Board (Approval ID 0028-16-TLV), due to retrospective nature of the study.

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Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

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EO,NEZ,MYB,DC,MS,YS,YG,KT,NS contributed to the study conception and design. EO,YS and MS contributed to data collection and analysis. The first draft of the manuscript was written by (EO). All authors commented on previous versions of the manuscript and all authors read and approved the final manuscript (EO,NEZ,MYB,DC,MS,YS,YG,KT,NS).

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Osher, E., Zohar, N.E., Yacobi-Bach, M. et al. Endocrinology specialty service for inpatients: an unmet growing need. BMC Health Serv Res 23 , 142 (2023). https://doi.org/10.1186/s12913-023-09134-y

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DOI : https://doi.org/10.1186/s12913-023-09134-y

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New & Custom Home Builders in Elektrostal'

Location (1).

• Use My Current Location

Popular Locations

• Albuquerque
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• Elektrostal', Moscow Oblast, Russia

Professional Category (1)

• Accessory Dwelling Units (ADU)

Featured Reviews for New & Custom Home Builders in Elektrostal'

• Reach out to the pro(s) you want, then share your vision to get the ball rolling.
• Request and compare quotes, then hire the Home Builder that perfectly fits your project and budget limits.

Before choosing a Builder for your residential home project in Elektrostal', there are a few important steps to take:

• Define your project: Outline your desired home type, features, and layout. Provide specific details and preferences to help the builder understand your vision.
• Establish a budget: Develop a comprehensive budget, including construction expenses and material costs. Communicate your budgetary constraints to the builder from the beginning.
• Timeline: Share your estimated timeline or desired completion date.
• Site conditions: Inform the builder about any unique site conditions or challenges.
• Local regulations: Make the builder aware of any building regulations or permits required.
• Land Surveying

What do new home building contractors do?

Questions to ask a prospective custom home builder in elektrostal', moscow oblast, russia:.

If you search for Home Builders near me you'll be sure to find a business that knows about modern design concepts and innovative technologies to meet the evolving needs of homeowners. With their expertise, Home Builders ensure that renovation projects align with clients' preferences and aspirations, delivering personalized and contemporary living spaces.

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