Endocrine Practice最新文献

Objective: Most patients with differentiated thyroid cancer have low-risk disease and excellent prognosis. Thyroid stimulating hormone (TSH) suppression therapy after initial treatment may be unnecessary and potentially harmful for survivors with recurrence-free, low- or intermediate-risk thyroid cancer. Little is known about clinician-reported barriers and facilitators to reducing thyroid cancer survivors' thyroid hormone dose with the goal of aiming for TSH in the normal reference range.

Methods: Clinicians from the fields of endocrinology (n = 8) and primary care (n = 7) were recruited through convenience/snowball sampling to participate in semistructured focus groups. Data collection and analyses were informed by the Theoretical Domains Framework for behavior change, a valuable integrative framework which can facilitate comprehensive assessment of behavioral determinants in qualitative studies. Deductive coding and inductive thematic analysis were conducted.

Results: Participants were majority female (73%) and averaged 14 years in clinical practice (range, 1-22). Barriers and facilitators emerged at the patient-level, clinician-level, and system-level. Key clinician-reported barriers included patient distress/anxiety and misinformation, unclear shared patient survivorship goals and plans between specialties, and clinic visit time constraints. Clinician-reported facilitators included building a trusting relationship, delivery of patient-centered education, and communication and collaboration between specialties to establish shared long-term survivorship plans.

Conclusions: We identified barriers and facilitators to de-escalating TSH suppression therapy in thyroid cancer survivors at multiple levels. Understanding these factors will enable clinicians to provide high-value, patient-centered care in order to reduce overtreatment, patient harm and improve quality of life in thyroid cancer survivors.

Objective: Transitions of care at hospital discharge are critical time periods for people with diabetes, but little is known about glycemia in the immediate postdischarge period.

Methods: In this observational study, participants wore blinded Dexcom G6 Pro CGM during hospital admission on nonintensive care floors and then continued wearing blinded continuous glucose monitoring (CGM) for up to 10 days posthospital discharge. Clinical data were extracted from the electronic medical record. Percent time in range 70-180 mg/dl (TIR), above range, and below range from the inpatient and postdischarge periods were calculated. The percentage of participants achieving TIR ≥50% and ≥70%, incidence of hypoglycemia after discharge, change in inpatient and postdischarge CGM metrics, and predictors of postdischarge glycemia were determined.

Results: A total of 24 adults (mean age 65.7 ± 13.6 years, 37.5% female) wore CGM after discharge with mean TIR 43.9 ± 33.2%, mean time above range 55.9 ± 33.3%, and median time below range 0% (0, 0.04). Of these participants, 41.7% had TIR ≥50%, and 29.2% had TIR ≥70%. Glycemia predischarge and postdischarge was similar (postdischarge vs inpatient TIR -3.7 ± 22.5%, P = .4). Of the clinical factors assessed, only inpatient glycemia was associated with achieving postdischarge glycemic targets. CGM detected 13 episodes of hypoglycemia occurring in 6 participants (25%) postdischarge.

Conclusions: Glycemia during the postdischarge period is suboptimal and glucose levels in the hospital may be an important predictor of glycemia after hospitalization. CGM may be useful in identifying hypoglycemia after discharge. Further studies are needed to understand the utility of CGM after hospital discharge.

Objective: To evaluate the effect of approved weight loss medications on binge eating (BE) episodes in individuals with obesity.

Methods: We systematically searched databases for randomized clinical trials and prospective interventional studies assessing BE episodes in patients with obesity treated with weight loss medications. Eligibility, data extraction, and risk of bias assessment were performed independently and in duplicate. Extracted data included baseline characteristics, therapy, BE scales, and study duration.

Results: Eight randomized controlled trials (870 participants) were included. Most participants were women (>63%), mean age 45 years, body mass index 35 to 40 kg/m². Liraglutide (n = 231) showed a greater weight loss (-4.95 kg [-7.12, -2.77]) and a reduction in BE episodes in most individual studies but did not reach statistical significance in the meta-analysis. Naltrexone/bupropion (n = 378) reduced BE episodes in individual studies, but inconsistent reporting limited pooled analysis. Orlistat (n = 448) showed no significant effect on BE episodes or weight loss.

Conclusion: Liraglutide was an effective intervention for weight loss in patients with obesity who experience BE. The use of liraglutide and naltrexone/bupropion as seen in individual studies may be an effective intervention to improve BE severity in this population; however, meta-analysis was not feasible due to the heterogeneous assessment tools used to measure response in BE episodes. Larger randomized and prospective studies with a longer follow-up are needed to evaluate the consistency of the data presented in this review.

Objectives: To compare the efficacy of thermal ablation (TA) with thyroid lobectomy (TL) for clinical node-negative(cN0) subcapsular papillary thyroid microcarcinoma (PTMC) and to assess the impact of occult lymph node metastasis (LNM) or pathologic local invasion on clinical outcomes.

Methods: This retrospective study was conducted at three referral centers. It included patients with unifocal cN0 subcapsular PTMC who underwent TA (n=536) or TL (n=740) from June 2014 to December 2020. The TL group was divided into occult LNM-positive, occult LNM-negative, pathologic local invasion-positive, and pathologic local invasion-negative subgroups based on pathologic findings. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to control for potential confounders. Primary outcomes were disease progression and progression-free survival (PFS). Secondary outcomes included complications and treatment parameters.

Results: The median follow-up duration of the primary cohort was 60.1(42.0) months. After PSM (519 patients per group), no significant differences were observed in disease progression rates (4.0% vs. 2.7%) or 5-year PFS rates (95.8% vs. 97.2%) between the TA and TL groups (P>0.05). After IPTW, the TA group exhibited no significant difference in PFS rates compared to the occult LNM-positive (P=0.97) or the pathologic local invasion-positive (P=0.66) subgroups. Additionally, TA was associated with lower complication rates compared with TL (0.4% vs. 2.1%, P=0.01) CONCLUSIONS: In eligible patients with subcapsular PTMC, TA and TL exhibit comparable 5-year disease progression rates and PFS rates. TA may be an alternative option for eligible patients with subcapsular PTMC who are ineligible for or refuse lobectomy.

Objectives: Sodium-glucose co-transporter-2 inhibitors (SGLT2is) reduce major adverse cardiovascular events and mortality in patients with type 2 diabetes mellitus, but kidney transplant recipients (KTRs), a high-risk group, were excluded from major trials. We aimed to evaluate the association between SGLT2i use and cardiovascular outcomes in KTRs with diabetes.

Methods: In this retrospective matched-cohort study at a large transplant center, KTRs with diabetes treated with SGLT2i were compared to matched controls receiving other antihyperglycemic agents. Major outcomes were: (1) a composite of acute coronary syndrome, stroke/transient ischemic attack, or all-cause mortality; and (2) a composite of heart failure hospitalizations (hHFs) or all-cause mortality.

Results: A total of 480 patients (240 per group; 20% women; median age 63-64 years) were included. Treatment with SGLT2i was started 5.9 years (IQR 2.0-13.9) after the transplant surgery, and patients were followed for up to 3 years. The incidence of acute coronary syndrome, stroke/transient ischemic attack, or death was 7.9 vs 13.6 events per 100 person-years in the SGLT2i and control groups, respectively (adjusted hazard ratio 0.64, 95% confidence interval 0.42-0.97, P = .039). HHFs or death occurred less frequently in SGLT2i users (5.7 vs 11.6 events per 100 person-years), though the difference was not statistically significant after adjustment (hazard ratio 0.82, 95% confidence interval 0.50-1.32, P = .410).

Conclusions: SGLT2i use was associated with lower rates of major cardiovascular events in KTRs with diabetes, without a significant reduction in hHF. Given the elevated cardiovascular risk in KTRs, these findings support further investigation of SGLT2i therapy in this population.

Objective: To assess reproductive urologists' sperm extraction preferences for patients with congenital bilateral absence of the vas deferens (CBAVD) and CBAVD with cystic fibrosis (CF).

Methods: A survey was sent to the Society for the Study of Male Reproduction: "A 30-year old male presents with his 28-year-old wife for infertility evaluation. On exam he has CBAVD, with bilateral testicular volume of 24 cc and normal epididymal head bilaterally, no varicocele. His wife's evaluation is normal. You send him for a cystic fibrosis transmembrane conductance regulator panel, which is positive for homozygous delta F 508 mutation." Responses were collected, and descriptive and comparative statistics using Χ² analyses were performed.

Results: We received 51 survey responses: 39.2% elected for testicular extraction, 29.4% epididymal, and 31.4% a combination. Office was more common (56.9%) versus 41.2% would perform in the operating room; 68.6% would perform extraction with onsite andrology lab. On Χ² analysis, there was no significant difference between onsite lab and extraction preference. Fertility labs would be collected by 90.2%. For a postvasectomy patient who chose sperm retrieval over reversal, 70.6% would not change their practice.

Conclusion: There is an array of sperm extraction techniques in CF, which often can be managed similarly to a non-CF patient with obstructive azoospermia. Technique preference is unrelated to procedure location or andrology lab access. As there are many options for this population, further research is needed on outcomes and resource utilization in assisted reproductive technology for these patients to define clinical guidelines and improve access to care.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly prevalent worldwide, contributing to rising morbidity and mortality. In the United States, MASLD is among the most common chronic liver diseases, affecting an estimated 75-100 million individuals. Estimated prevalence and outcomes differ significantly across racial and ethnic groups. Understanding the factors underlying these disparities and their impact on treatment response is essential for improving patient outcomes. A comprehensive literature search was performed using PubMed, Embase, Scopus, Web of Science, Scientific Electronic Library Online, and the Cochrane Library. This narrative review summarizes evidence on racial and ethnic differences in MASLD prevalence and treatment response, emphasizing pharmacologic agents with emerging therapeutic potential. Hispanic populations demonstrate the highest MASLD prevalence, followed by non-Hispanic White and non-Hispanic African American populations. Therapeutic classes reviewed include thyroid hormone receptor-β agonists (eg, resmetirom), glucagon-like peptide-1 receptor agonists (eg, semaglutide), dual glucagon-like peptide-1/glucose-dependent insulinotropic polypeptide receptor agonists (eg, tirzepatide), and sodium-glucose cotransporter-2 inhibitors (eg, empagliflozin). Reported benefits span reductions in hepatic steatosis, improvements in liver stiffness and fibrosis-assessed by histology, transient elastography, and other noninvasive indices-and favorable lipid parameter changes. Overall, this review highlights the persistent underrepresentation of diverse racial and ethnic populations in MASLD clinical trials and underscores the influence of genetics, environmental exposures, diet, and physical activity on disease expression and therapeutic outcomes.

Objectives: We aim to summarize the current knowledge of fertility in males with cystic fibrosis (MwCF) including reproductive outcomes, the role of the cystic fibrosis transmembrane conductance regulator mutation in sperm function, patient perspectives for MwCF, and review future directions.

Methods: This narrative review synthesizes current literature and clinical guidance regarding male infertility in MwCF. Primary sources were identified through targeted database searches and cross-referencing bibliographies of landmark studies. Emphasis was placed on high-impact original research and clinical research that have shaped current practice.

Results: MwCF must undergo surgical sperm retrieval along with intracytoplasmic sperm injection (ICSI) to have a biological child. Emerging research suggests that this anatomic anomaly may not be the only contributing factor to male fertility outcomes. Several studies have demonstrated spermatogenic dysfunction in MwCF. Limited data exists regarding assisted reproductive outcomes in MwCF and much of this data was published prior to the advent of modulator therapy (MT), raising the question as to whether these findings are applicable to today's patients. Additionally, hypogonadism may be more prevalent in MwCF compared to the general population, yet no guidance exists on screening, leading to missed opportunities to improve quality of life and other physiologic benefits.

Conclusions: Given the necessity for assisted reproduction for MwCF, early diagnosis and referral to a reproductive urologist are critical for helping patients navigate the logistical challenges of biological fatherhood. Proactive counseling from adolescence ensures that families can realistically prepare for the emotional, surgical, and financial complexities of the reproductive journey.

Objectives: Thyroid eye disease (TED) is a debilitating autoimmune condition frequently associated with Graves' disease (GD). Both disorders may impair glucose metabolism, yet the risk of hyperglycemic events and complications remain unknown. We evaluated the incidence, prevalence, and predictors of these outcomes in patients with TED or GD versus the general population (GP).

Methods: This retrospective cohort study using the Merative MarketScan Research Claims Database (2014-2019) identified adults (≥18 years) in TED, GD, or GP cohorts via diagnostic codes. The primary outcome was a composite of hyperglycemic events and complications (ie, nephropathy, neuropathy, retinopathy, ketoacidosis, prediabetes, impaired fasting glucose, and hyperosmolarity). Age- and sex-standardized cumulative incidence, incidence (per 10 000 person-years), and prevalence were estimated using 2020 US census data. Kaplan-Meier analyses and multivariable Cox proportional hazards models assessed time-to-event risk, and predictors and hazard ratios, respectively.

Results: The study included 38 723 individuals with TED; 171 831 with GD; and 20 283 009 from the GP. Cumulative incidence of the composite outcome was 14.9% in TED, 15.4% in GD, and 9.6% in GP; incidence was 786.4, 764.4, and 414.0 per 10 000 person-years, respectively. Prevalence was 21.7%, 20.4%, and 11.6%. After adjustment, TED and GD were each associated with a 60% increased risk compared with GP (hazard ratio 1.6). Additional predictors included diabetes, advanced age, obesity, hypertension, and statin use.

Conclusions: TED and GD are independently associated with elevated risk of hyperglycemic events and complications. Routine metabolic monitoring and multidisciplinary care are warranted in this population.

Objectives: Continuous glucose monitoring (CGM) improves glycemic control in patients with type 2 diabetes, but real-world sustainability following hospital discharge remains unclear. We evaluated factors associated with CGM continuation after transitioning from structured study support to routine care.

Methods: This 12-week observational follow-up study included hospitalized patients with insulin-requiring type 2 diabetes (HbA1c > 8.0%) who had received study-provided CGM for 12 weeks postdischarge. After the intervention, participants could continue CGM through usual care if desired. Primary outcomes included CGM continuation, glycemic parameters, health care utilization, and patient-reported barriers.

Results: Of 108 participants, 66 completed 12 week assessments and 59 were using CGM. At 24 weeks, data were available for 57 participants, 17 of whom maintained CGM use. Median HbA1c improved from baseline to 24 weeks (11.6% [IQR 10.0 to 13.4] to 7.4% [IQR 6.7 to 9.5], 103 to 57 mmol/mol, P < .0001), with similar reductions among users and nonusers. Among CGM users, median time in range (70 to 180 mg/dL) increased from 43% at 12 weeks to 62% at 24 weeks (P = .66), while time above range (> 180 mg/dL) decreased from 57% to 37% (P = .67). Cost and insurance barriers were the most reported challenges (46%), occurring more often among those who discontinued versus continued CGM (75% vs 32%, P = .007).

Conclusions: HbA1c improved from baseline to 24 weeks among participants, regardless of continued CGM use. However, discontinuation was common, with financial barriers representing the predominant obstacle, underscoring the need for improved coverage and support.