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Endocrinology:
Diabetes:
5-25% of diabetics are type I diabetics
Diabetes affects about 2-6 %of the population in the UK.
Only 50% of diabetics are thought to have been diagnosed.
Worldwide 100 million people have diabetes. (2002 statistics) Diabetes incidence
is thought to double by the year 2010.
Diabetes affects 1child in every 400 by the age of 16 and adults of all ages,
but becomes more common in advancing years - reaching a peak in people aged
65-74.
Diabetes affects about 3 %of the population in the UK.
Poorly managed, it reduces life expectancy by between 10 and 20 years.
accounting for perhaps 9% of acute NHS expenditure and bed days
NHS expenditure on diabetes is about 2 billion a year
NHS expenditure on diabetes is pounds 165 per
second.(2002)
Type 2 dm presently costs the NHS about £2000 per patient per year
6-16%of beds in the NHS is occupied by diabetic patients
£5.2 billion was spent on diabetes in 2000.
Waiting time for 1st appointments as bad as 14 weeks.
10% of people in residential care have diabetes.
One in 10 acute medical beds is occupied by diabetic patients.
The audit commission found that:
50%of hospitals had no comprehensive patient education services
60%of hospitals had no access to psychology services.
30% of hospitals had no diabetes register.
30%of GPs had no routine access to dietetic or podiatric services.
A recent survey by the Association of British Clinical Diabetologist revealed:
30% of units had no diabetic hospital register.
25% had no coordinated retinopathy screening.
27%had no dedicated dietitian services.
54% had no access to psychology services.
Up to 40% of patients have retinopathy at diagnosis of type 2 diabetes
20years after diagnosis, 100% of type1 and 60% of type 2 patients will have some
degree of retinopathy;.60% of TYPE1 patients have already suffered proliferative
retinopathy
At any time up to 10% of people with diabetes will have retinopathy requiring
ophthalmological follow up or treatment.
Untreated, between 6-9% of the people with proliferative retinopathy or severe
non-proliferative disease would become blind each year
With appropriate medical and ophthalmological care blindness may be prevented in
at least one eye, by treating both eyes, in 60-70% with macular oedema and over
90% with proliferative retinopathy.
15% of patients with diabetes develop foot ulcers.
200,000 patients are on insulin pump in US
1000 patients are on insulin pump in UK
30 patients on insulin pump in the Mersey region.
There are 30 different insulin types, 10 pen devices, and 11 BGMs.
IN the UKPDS, mean HBA1C fell from 9 to 7% and weight by 4.5% after 3 months of dietary modification. Every year of diabetes adds about 5% of increased CVS risk
Type 1 diabetes
5-25% of patients with diabetes in the UK have type 1 dm.
Incidence of type I diabetes in the UK is 20 per 100,000. (2005)
The overall lifetime risk in white populations of developing type I diabetes is 0.4%.
The lifetime risk for type I diabetes is 1-2% if mother is diabetic; 3-6% if father is diabetic, and 6% if siblings are diabetic. The lifetime risk of type 1 diabetes in a first degree relative is six percent, but this rises to 25-50 percent in identical twins. When a first degree relative as a high titre of islet cell antibody the risk increases to 8% per year with an accumulated risk of 70 percent in ten-years. The concordance rate for type I dm in dizygotic twins is 5-10% while that in monozygotic twins is 27-36%
Presence of all three antibodies (islet cell antibodies, antiglutamic acid decarboxylase antibodies and anti tyrosine phosphatase antibodies) produces a 88% chance of developing type I diabetes in the next 10 years.
The cumulative incidence of microalbuminuria in patients with type 1 diabetes at 30 years disease duration is approximately 40%.
Approximately 20% of type 1 patients develop proteinuria after a disease duration of 25 years.
90% of type I diabetics in the UK have either HLA DR3, DR4 or both.
25% of type I dm will have evidence of thyroid disease, with about 5% being clinically hypothyroid.
7% of type I dm will have coeliac disease, but upto 40% can be asymptomatic for it. 20% of type I dm has pernicious anaemia.
2% of type I dm has antibodies to 21 hydroxylase, the marker for addisons disease.
40% of children with congenital rubella will develop islet antibodies, and 50% of these will develop type I dm.
MODY:
MODY 1: (HNF 4alpha) :Accounts for <0.0001% of all type 2 patients and about 5% of cases of MODY. 20% need insulin therapy. 40% need Oral hypoglycemic therapy.
MODY 2: (Glucokinase) <0.2% of type 2 patients. This type accounts for 10% of cases of MODY. 90% are controlled with diet alone.
MODY 3: ( HNF1alpha) : 1-2% of type 2 patients. This subgroup accounts for 70% of MODY patients. One third require insulin and one third require oral agents.
The human pancreas has 1 million islet cells, weighing 1 gm, and containing 1 mg insulin.
6% of presumed type 2 dm have positive ICA antibodies, while 10% of presumed type 2dm have positive GAD antibodies (UKPDS), causing LADA. 94% of patients with ICA and 84% of patients with GAD antibodies required insulin at 6 year follow up.
Prevalence of type 2 dm
in the UK is 3%.
The cumulative incidence of microalbuminuria in patients with type 2 diabetes at
10 years disease duration is approximately 20-25%.
20% of microalbuminuric type 2 patients who survive for 10 years develop proteinuria.
The prevalence of proteinuria in patients with type 2
diabetes is approximately 15%.
Treated proteinuric, hypertensive type 2 patients lose glomerular function at a
rate of approximately 8 ml/min/year.
Patients with microalbuminuria have a two to fourfold increase in cardiovascular
morbidity and mortality.
The 4-year mortality of microalbuminuric type 2 patients is
32% and 50% of proteinuric type 2 patients have died within 4 years.
1 in 20 people above the age of 65 have diabetes.
1 in 5 people above the age of 85 have diabetes.
The presence of Diabetes complications doubles the chance of ending up with a
carer, and increases personal expenditure 3 fold.
Diabetic patients are twice as likely to be admitted to hospital, with twice
longer stays in hospital. Diabetic complications make this chance of admission 5
fold higher.
Intensive treatment of diabetes during acute MI reduces death by 30%.
15% of diabetics develop foot problems, and 15% of these need amputations.
Diabetes is associated with a 3 fold increased risk of coronary heart disease
and stroke.
50% of type 2 diabetics have complications at diagnosis.
Perinatal mortality is still 4 times higher in diabetic pregnancies.
Erectile dysfunction is 3 times commoner in diabetics.
Control of obesity may reduce new type 2 dm by 50%
Effective eye screening can reduce blindness by 50%
Blood glucose control can reduce eye disease by 25%and renal problems by one
third.
BP control reduces death from long term complications and strokes by one third.
Early intervention can reduce amputations by two thirds.
Diabetes is the commonest medical problem complicating pregnancy.
One in 250 pregnancies is complicated by diabetes.
Perinatal mortality is 5 times higher in babies of diabetic
mothers. (- due to congenital malformations)
In the UK around 3,200 people with diabetes are on renal replacement therapy
(dialysis and transplant), with an average 1,000 new diabetic patients beginning
renal replacement therapy each year.
The UKPDS established that 50%of patients needed combination therapy by 3 years
for diabetic control.
In a Newcastle study, 17.9% of South Asians aged 25-74 years were found to have
diabetes, with a further 18.7% having impaired glucose tolerance, which implies
a 30-50% higher risk of the development of diabetes in 5-10 years.
UKDIABS: the mean HbA1c in UK in 2000 for type I patients was 8.6% and for
type 2 patients was 7.8%.
The diabetes NSF was commissioned in nov 1999. First report submitted in July
2000,
Standard published in :
Delivery published in :
Source: Testing times
2% of UK diabetic population is registered blind (2002).
A diabetic has a 10-20 fold increased risk of blindness.
2% of type I diabetics have retinopathy at diagnosis and 8% by 5 years.
30 years after diagnosis 98% of type I diabetics have retinopathy with 30% of these having proliferative retinopathy.
14% of T1DM who become blind do so because of maculopathy.
20-40% of T2DM have retinopathy at diagnosis.
Among T2DM, 85% of those on insulin and 60% of those not on insulin are expected to have retinopathy at 15 years.
T2DM patients are 10 times more likely to have maculopathy than T1DM.
Cataracts occur in 60% of diabetic 35-55 years age.
15% of patients undergoing cataract surgery can have diabetes
In the DCCT, intensive glycaemic control in type I DM slowed the rate of progression of existing retinopathy by 54% and the risk of severe NON PDR or PDR was reduced by 47%.
In the UKPDS intensive glycaemic control in T2DM patients reduced progression of retinopathy by 21% and produced a 29% reduction in the need for laser therapy.
50% of patients entering End stage renal disease have T2DM. 18% of patients entering ESRD and replacement programmes have diabetes.
Nephropathy is the cause of 15% of all deaths in diabetics <50 years of age.
The cumulative incidence of microalbuminuria in patients with type 2 diabetes at 10 years disease duration is approximately 20-25%.
20% of microalbuminuric type 2 patients who survive for 10 years develop proteinuria.
The prevalence of proteinuria in patients with type 2 diabetes is approximately 15%.
Treated proteinuric, hypertensive type 2 patients lose glomerular function at a rate of approximately 8 ml/min/year.
Patients with microalbuminuria have a two to fourfold increase in cardiovascular morbidity and mortality.
The 4-year mortality of microalbuminuric type 2 patients is 32% and 50% of proteinuric type 2 patients have died within 4 years.
The cumulative incidence of microalbuminuria in patients with type 1 diabetes at 30 years disease duration is approximately 40%.
2/3rd of type 1 diabetics with proteinuria will subsequently develop renal failure.
85% of type I patients with nephropathy are hypertensive.
Captopril in type 1 patients reduces progression of microalbuminuria to albuminuria by 68%.
In the DCCT, intensive glycaemic control reduced progression to microalbuminuria by 30% and further progression to albuminuria by 54%.
Nerve conduction studies show abnormalities in 80% of patients with diabetes.
Erectile dysfunction affects 40% of men with diabetes. Sildenafil therapy is effective in 60% of diabetics.
Pancreatic Transplantation:
Diabetes affects 6% of the population of developed countries.
A doubling in incidence is predicted with the projected total exceeding 300 million people within the next 25 years.
The societal cost estimates for diabetes and inevitable sequelae are enormous consuming between nine percent and 15% of healthcare expenditure in developed countries.
Early attempts at whole pancreas transplantation had a mortality rate exceeding 60 percent, and fewer than 3% grafts remained functional at one-year.
There have been over 447 islet allografts performed worldwide, 394 in the past decade.
Fewer than 10% patients have been able to remain free of insulin for sustained periods.
Less than 20 percent of patients remained free of insulin beyond the first year when cyclosporine azathioprine and steroids were used. 50 percent of the infused islet mark was destroyed to autoimmune inflammatory pathways and apoptotic mechanisms.
A total of 15 patients with type 1 diabetes have now being treated using the Edmonton protocol. sustained insulin independence has been achieved in 85 percent of these recipients.
Cardiovascular disease accounts for 75% of deaths in T2DM and 35% in T1DM.
Overall 10% of patients have peripheral vascular disease. Diabetics with PVD have a 15 fold higher risk of a non traumatic amputation.
Thromboembolic Cerebrovascular events Strokes account for 15% of death in T2DM.
Lactic acidosis occurs in 0.024-0.15 cases/1000 patient years in Metformin treated patients. (Swedish study)
Cardiovascular statistics: (General)
2% of US population have CCF
1 million admissions occur in the US for CCF every year
50% of patients with CCF get readmitted within 6 months
mortality rate for CCF is estimated at 50% within 6 months
17% of Subclavian and 8% of jugular lines
attempts are unsuccessful.
Only 30% Of patients presenting with DVT
symptoms have DVT.
300,000 cases of DVT occur per year in the
US.
Venography is associated with a 5% risk of
allergic reactions and 1-2% risk of thrombophlebitis.
B mode real time venous compression
ultrasound has 97% sensitivity and 94% specificity for identification of
thrombosis of the proximal leg veins which is greater than that of doppler.
NEJM sept 25 2003
Sensitivity for B mode venous compression USG
for calf veins is 73%.
30% of patients with DVT have subsequent
extension of clot into the proximal system.
The incidence of chronic AF in the UK was estimated to be 1.7
per 1,000 person years.
In patients older than 60 years, it was 3 per 1,000 person years.
About 1 in 20 people aged 65 years or older have AF (4.7%).
The authors calculated that of the 21,000 strokes annually in patients with AF, 3,000 are probably prevented by anticoagulation, but that another 3,000-5,000 could be prevented if there was wider use of anticoagulant therapy. Bandolier
The autopsy
prevalence of adrenal masses is 2-9%.
Approximately 80% of
adrenal adenomas are nonfunctioning and benign.
Phaeochromocytoma:
About 10 percent of the tumors are extraadrenal, but 95 percent are within the abdomen.
Although any site containing paraganglionic tissue may be involved, the most common extraadrenal locations are the superior and inferior paraaortic areas (75 percent of extraadrenal tumors), the bladder (10 percent), the thorax (10 percent), and the head, neck, and pelvis (5 percent).
In approximately 60% of cases the hypertension is sustained, and half of patients with sustained hypertension have distinct crises or paroxysms. The other 40% have blood pressure elevations only during an attack.
The 5-year survival rate after surgery is usually over 95%, the recurrence rate is <10%.
For malignant pheochromocytoma, the 5-year survival rate is <50%.
Maternal mortality is 17% while fetal mortality is 30% if not treated urgently.
The incidence of pheochromocytoma in some kindred with von Hippel-Lindau disease may be as high as 10 to 25%
Addisons disease:
Incidence is 40-60 cases per 1,000,000 persons.
75% of orally administered thyroxine is absorbed. 90% of orally administered T3 is absorbed.
0.5% to 1% of the population suffers from hyperthyroidism.
20% of elderly thyrotoxic patients do not have a goitre.
Graves disease complicates 0.1% of pregnancies.
Graves ophthalmopathy affects about 25-50% of graves patients.
1-5% of patients with graves disease have significant ophthalmopathy.
Untreated mortality in Myxoedema coma is 100%.
25% of women with lymphocytic thyroiditis postpartum have a recurrence in a subsequent pregnancy.
Hypothyroidism develops in 25% and recurrent hyperthyroidism in 10% post subtotal thyroidectomy.
1% incidence of hypoparathyroidism or injury to laryngeal nerve.
The overall incidence of thyroid nodules in the population is 4%.
12,000 new cases of thyroid cancer develop each year in the US.
Less than 0.2% of thyroid cancers become clinically obvious every year.
More than 87% of subjects with thyroid cancer have intrathyroidal or extra thyroidal spread at the time of surgery.
In single nodules the incidence of thyroid carcinoma is 20%.
In MNG the incidence of thyroid cancer is only 4.8%.
7% develop recurrent clinical cancer in the remaining thyroid lobe.
43% of metastases in thyroid cancer develop within 1 year of diagnosis, 23% develop between 1 and 5 years, and 9% beyond 10 years (Cancer1988: 61:1-6).
Sporadic PHPT in general population is
0.5- 10%. Male: female ratio for sporadic PHPT is 3:1. 50% of PHPT
patients are discovered incidentally- asymptomatic.
Nephrocalcinosis is present in 50% of patients with symptomatic PHPT. Less than
5% of calcium stone formers have PHPT. Hypertension occurs in 30-50% of patients
with PHPT. Hypophosphataemia is present in 50% of PHPT patients. Success rates
of first time PHPT surgery is 95%. USG localises parathyroid enlargement in upto
80% of cases. Sensitivity of sestamibi for adenomas is 80%.
Success rate of four gland exploration by an experienced endocrine surgeon for primary hyperparathyroidism is 95% (CE 59: 539-554 2003). A 50% decrease in Intraoperative PTH levels predict a cure in more than 95%. 27% of asymptomatic patients with PHPT show disease progression requiring surgical intervention over 10 years. (Silverberg et al 1999).
In primary hyperparathyroidism, 85% present with a
single adenoma, 5% with multiple adenomata, 3-5% with a carcinoma, and 10% with
hyperplasia of multiple glands.
MEN1 and MEN 2 :
M E N 1 mutation has been found in about 20 percent of reported FIHPT.
25% of MEN 1 mutations are nonsense, 45 percent are small deletions, 15 percent are small insertions, and less than 5% are donor splice mutations.
No germ line mutation is found in 10-20 percent of index cases for familial MEN 1.
Parathyroid hyperplasia or multiple adenomas occur in 90% of patients with MEN 1.
Pituitary lesions occur in 50% of patients with MEN
1.75% of patients with MEN 1 have pancreatic tumours. 40% develop adrenal adenomas, and 20% have thyroid adenomas.
After 8-12 years of successful total parathyroidectomy in men one,50% will have recurred.
Anterior pituitary adenoma is the first clinical manifestation of MEN 1 in up to 25 percent of sporadic cases. its prevalence in MEN 1 varies from 10-60 percent.
Adrenocortical lesions occur in 20-40 percent of MEN.
Multiple facial angiofibromas occur in 40-80% of MEN 1. 50% of cases have five or more angiofibromas.
MTC occurs in 90% of MEN 2A.
Phaeochromocytoma occurs in 70% of MEN 2A .
Hyperparathyroidism occurs in 20-30%. The RET oncogene is 100% predictive for development of medullary thyroid carcinoma in MEN 2A and 2B. 98% of subjects with MEN 2A carry a known RET mutation. Early thyroidectomy has lowered the mortality from hereditary MTC to less than 5%.
MEN 2B: MCT and multiple gangliomas occur in 100%. Phaeochromocytoma occurs in 33%. Hyperparathyroidism in 5%.
The likelihood of RET germline mutation in patients with apparently sporadic MTC is 1-7%.
Hereditary etiology among apparently sporadic cases of pheochromocytoma is a far 5-15%.
Familial Hypocalciuric hypercalcaemia represents 1-2% of cases of asymptomatic hypercalcaemia.
Tumor associated local osteolysis accounts for hypercalcaemia in 20-40% of hypercalcaemia in malignant cases.
Humoral hypercalcaemia accounts for 40-50% cases.
Hypercalcaemia occurs in 10% of patients with sarcoidosis.
Hypercalciuria occurs in 50% of sarcoidosis.
Hypercalcaemia occurs in 25% of patients with thyrotoxicosis.
Hypercalcaemia occurs in 5% of lithium treated patients.
Adrenal Radiology:
As regards Phaeochromocytoma, positive and negative predictive values of CT were 69 and 98 percent.
Both CT and MRI are quite sensitive (98 to 100 percent), but are only about 70 percent specific because of the higher prevalence of adrenal "incidentalomas.
Multiple tumors are found in approximately 10 percent of patients, particularly those with extra adrenal tumors.
Localisation of Phaeochromocytoma is right adrenal 25%; left adrenal 17%; bilateral adrenal 17%; intra-abdominal extra adrenal 32%. I123
MIBG imaging has revealed that upto 46% of patients with Phaeochromocytoma develop metastatic disease, and only 21% is detected at surgery.
Following surgery, there is a 50% local recurrence and subsequent dissemination.
Phaeochromocytoma investigations:
|
TESTS |
SENSITIVITY % |
SPECIFICITY % |
|
Octreotide scan |
54 |
|
|
Chromogranin |
83 |
96 |
|
I123 MIBG |
82 |
99 |
|
CT |
89 |
70 |
|
Urinary metanephrine |
95 |
45 |
|
Plasma metanephrine |
96 |
82 |
|
Urinary catecholamines |
97 |
70 |
|
MRI |
98 |
70 |
Thyroid Radiology :
13% of persons exposed to low dose therapeutic irradiation (6.5 to 3000 rad calculated dose to the thyroid) develop thyroid cancer.
40% of persons exposed to low dose therapeutic radiation who have a discrete thyroid nodule have thyroid cancer in the gland. In 60% the index nodule is the cancer and in 40% the cancer is elsewhere in the thyroid.
60% of pulmonary metastases from the thyroid, take up radioactive iodine.
Dose of radioiodine should be increased by 25% in patients who have had anti thyroid drugs within the previous 10 days.
The hypothyroidism post radioiodine in the first 6 months is transient in 25% of patients.
The incidence of hypothyroidism is 10-20% after 1 year and increases at a rate of 2% and 4% every year.
Pure cystic lesions are malignant in 7% of cases. Cystic lesions atleast 4 cm in diameter are more frequently malignant. Solid lesions are malignant in 21% of cases.
If iodine isotope is used:16% of cold nodules turn out to be
malignant; Combined malignancy rate in hypo-functioning and normo-functioning
nodules was 9%. 4% of hyper functioning nodules is associated with malignancy.
If 99mTc is used as isotope: 22% of nonfunctioning, 13% of hypo or normo
functioning, and 29% of hyper functioning nodules are found to be malignant.
Parathyroid Radiology:
CT or USG has a sensitivity of 50-75% in detecting parathyroid disease
Reproductive:
Ultrasound has a sensitivity of 91% for PCOS. Transvaginal ultrasound witll identify 90% of ovarian virilizing tumours.
MTC has a poorer prognosis (50% dead in 10 years) than
papillary or follicular thyroid cancer (20% dead in 15 years).
PCOD
95% of women presenting with hirsutism have PCOD.
Estimated prevalence of PCOS is 8% based on clinical criteria, and 22% based on ultrasonic diagnosis.
Oligomenorrhea is seen in 70% of PCOS patients and hirsutism in 60%.
25% of women with PCOS have acne or alopecia.
Obesity is seen in 35% and infertility in 30%.
LH is raised in 50-70% of patients with PCOS.
SHBG is low in 50% of PCOS patients.
Hyperprolactinemia is present in 30%.
40% of PCOS have IGT and 10% have DM.
A loss of 5% of weight improves hirsutism by 40%.
MEN 1
the prevalence of enteropancreatic islet tumours in men 1 individuals varies from 30-75 percent.
one-third of sporadic and men one associated ZES cases eventually die from their malignancy.
16% of MEN 1 patients were free of disease immediately after gastrinomas surgery and at 5 years this had declined to 6%.
The disease free rates in gastrinomas without MEN 1 is 45 percent and 40 percent respectively.
Audit commission report
Manual of endocrinology and metabolism 3rd
edition
Oxford Handbook of clinical endocrinology and diabetes
.
This page was last updated on: 07/03/2007
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