United States

Introduction: Graves disease and Hashimoto thyroiditis represent the two ends of the autoimmune thyroid spectrum. Spontaneous conversion from one to the other is a rare phenomenon, especially in children, and the underlying mechanism is unknown. Changes in the predominance of stimulating versus blocking TSH receptor antibodies (TRAb) has been proposed as a potential etiology.Method: We describe a series of cases of autoimmune thyroid disease in children that converted from one end of the biochemical spectrum to the other Result: Eleven patients of whom 55% were girls and 36% had Down syndrome (DS) were identified. Five (46%) presented with hyperthyroidism (hyper) that spontaneously converted to hypothyroidism (hypo). Four patients (36 %) had hypo which converted to hyper while the remaining 2 (18%) presented with Hashitoxicosis (HT) with negative TRAb titers which later converted to hyper. In those who went from hyper to hypo, mean duration of antithyroid drug therapy was 1.8 ± 1.4 years and mean age at initial presentation was 11.0 ± 4.8 years (5-16). Before conversion, all 5 patients had positive TRAb titers with mean of 15.0 ± 4.2 and a mean thyroid peroxidase antibody level of 287.5 ± 389. A period of euthyroidism lasting 2.0 ± 0.8 years was present prior to the development of hypo with a mean TSH of 17.0 ± 25 mU/L (5.8-62). Mean duration of hypo in the second group was 5.0 ± 5.2 years and mean age at initial diagnosis was 6.7 ± 2.8 years (3-10). TSH became suppressed in all 4 patients, TRAb was elevated, and mean free T4 off levothyroxine was 3.3 ± 1.2 ng/dL (2.4-4.6). The two patients with initial HT were 12 ± 2.8 years at diagnosis and converted to hyper after 6.5 ± 0.7 months. Initial mean free T4 was 1.3 ± 0.2 ng/dL and after conversion was 4.6 ± 0.4 ng/dL along with strongly positive TRAb titers (mean of 6.9 ± 6.5). TSH became further suppressed after conversion to hyper (&lt;0.01). More of our patients with DS converted from hypo to hyper than the other direction (75% vs 20%, p=0.01). However, two of them proceeded to have a wavering course between hyper and hypo requiring intensive monitoring and frequent changes in management. Conclusion: Although oscillating thyroid function in children with autoimmune thyroid disease is uncommon, it is important for parents and providers to be aware of this entity. The natural history of these cases is extremely variable and clinical management is challenging. Our findings suggest that DS may be a risk factor for the phenomenon of vacillating thyroid function in pediatric patients.

ENDO 2022

Conversion from one side of the autoimmune thyroid spectrum to the other: a pediatric clinical challenge

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ENDO’s comprehensive program provides attendees the opportunity to learn about the latest developments in hormone science and medicine from renowned investigators, expert clinicians, and educators from all over the world. 

This year’s education program features:
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six plenary sessions including plenaries on Envisioning Future Therapies for Type 1 Diabetes and Addressing Challenges in Fertility and Reproduction;
over 20 Meet the Professor sessions presented both in-person and live-streamed virtually and another 20+ presented live in Atlanta;
four Basic Science Pathways, including Diabetes and Metabolism; Neuroendocrinology; Nuclear Receptors and Signaling; and Reproductive Endocrinology; and
more than 30 oral sessions and a robust virtual poster hall for accepted scientific abstracts.

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Product theaters and the Communications and Career Center will also include hybrid content delivery.

**Plenaries**
Spanning the spectrum of science, clinical care, and social implications, an outstanding slate of world-renowned speakers will showcase the most cutting-edge advances on research and medicine.

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Our ENDO 2022 lineup of sessions offers a unique opportunity to dive into topics from nearly every major therapeutic area of endocrinology and hormone science. Listen, learn, and be inspired by world-class faculty who are at the forefront of scientific discovery and high-quality health care.

**Basic Science Pathways**

These special “meeting-within-a-meeting” tracks integrate focused discussions, poster sessions, and networking opportunities to provide you with the latest research in:
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Nuclear Receptors and Signaling
Reproductive Endocrinology

**Meet the Professor & Meet the Scientist**
Discover insights from experts on treating a variety of endocrine conditions and emerging science in the field of endocrinology, and learn the latest in patient care and scientific research.

ENDO’s comprehensive program provides attendees the opportunity to learn about the latest developments in hormone science and medicine from renowned investigators, expert clinicians, and educators from all over the world. 

Introduction: Graves disease and Hashimoto thyroiditis represent the two ends of the autoimmune thyroid spectrum. Spontaneous conversion from one to the other is a rare phenomenon, especially in children, and the underlying mechanism is unknown. Changes in the predominance of stimulating versus blocking TSH receptor antibodies (TRAb) has been proposed as a potential etiology.Method: We describe a series of cases of autoimmune thyroid disease in children that converted from one end of the biochemical spectrum to the other Result: Eleven patients of whom 55% were girls and 36% had Down syndrome (DS) were identified. Five (46%) presented with hyperthyroidism (hyper) that spontaneously converted to hypothyroidism (hypo). Four patients (36 %) had hypo which converted to hyper while the remaining 2 (18%) presented with Hashitoxicosis (HT) with negative TRAb titers which later converted to hyper. In those who went from hyper to hypo, mean duration of antithyroid drug therapy was 1.8 ± 1.4 years and mean age at initial presentation was 11.0 ± 4.8 years (5-16). Before conversion, all 5 patients had positive TRAb titers with mean of 15.0 ± 4.2 and a mean thyroid peroxidase antibody level of 287.5 ± 389. A period of euthyroidism lasting 2.0 ± 0.8 years was present prior to the development of hypo with a mean TSH of 17.0 ± 25 mU/L (5.8-62). Mean duration of hypo in the second group was 5.0 ± 5.2 years and mean age at initial diagnosis was 6.7 ± 2.8 years (3-10). TSH became suppressed in all 4 patients, TRAb was elevated, and mean free T4 off levothyroxine was 3.3 ± 1.2 ng/dL (2.4-4.6). The two patients with initial HT were 12 ± 2.8 years at diagnosis and converted to hyper after 6.5 ± 0.7 months. Initial mean free T4 was 1.3 ± 0.2 ng/dL and after conversion was 4.6 ± 0.4 ng/dL along with strongly positive TRAb titers (mean of 6.9 ± 6.5). TSH became further suppressed after conversion to hyper (<0.01). More of our patients with DS converted from hypo to hyper than the other direction (75% vs 20%, p=0.01). However, two of them proceeded to have a wavering course between hyper and hypo requiring intensive monitoring and frequent changes in management. Conclusion: Although oscillating thyroid function in children with autoimmune thyroid disease is uncommon, it is important for parents and providers to be aware of this entity. The natural history of these cases is extremely variable and clinical management is challenging. Our findings suggest that DS may be a risk factor for the phenomenon of vacillating thyroid function in pediatric patients.

technical paper

Introduction: Pediatric Graves' disease (GD) is associated with hyperthyroid symptoms broadly impacting psychosocial functioning. Total thyroidectomy (TT) is a definitive treatment option that replaces long-term antithyroid medication (ATD) for GD. While studies have examined health-related quality of life (hrQOL) in adults, there are no data describing impacts of definitive surgery in pediatrics. In this prospective, longitudinal study, we explored the impact of definitive surgery on hrQOL and psychosocial functioning in adolescent patients with GD. Methods: Patients 12-19 years old pursuing definitive surgery for GD and their parents were recruited to complete surveys before and at least six months following TT. Parents pre-operatively completed a demographic questionnaire, parent rating scale assessing perceived symptom severity, and motivations for pursuing TT questionnaire. Patients pre- and post-operatively completed the Pediatric Quality of Life Scales (PedsQL), Quality of Life Questionnaire for Patients with Thyroid Disease (ThyPRO), Perceived Stigmatization Questionnaire (PSQ), Body Esteem Scale for Adolescents and Adults (BESAA), and European Group on Graves' Orbitopathy GO Quality of Life Questionnaire (EUGOGO-QOL). Patients and parents post-operatively completed the Patient and Observer Scar Assessment Scale (POSAS) and a post-surgical satisfaction scale. Longitudinal paired scores were compared using Wilcoxon rank-sum test with Bonferroni-Holm correction. Survey subscore associations were assessed using Spearman tests with Benjamin-Hochberg correction. P-values < 0.10 for survey association analyses and all other p-values < 0. 05 were considered statistically significant. Results: Thirty-six patient/parent dyads completed baseline surveys, including 19 patient/parent dyads completing both pre- and post-TT surveys. Families reported that patients' GD and ATD significantly interfered with quality of life. Motivations for definitive surgery included ease of monitoring hypothyroidism as opposed to hyperthyroidism, access to a 'high-volume' surgeon, desire to reduce goiter symptoms, and opposition to radioactive medication. At baseline, patients reported high physical and cognitive GD symptomology via ThyPRO, specifically hyperthyroid symptoms, tiredness, anxiety, and emotional susceptibility. Psychosocial functioning via PedsQL, specifically in school settings, was depressed. Disease-specific hrQOL (ThyPRO) significantly improved following TT, with notable improvements in goiter (p=0. 002), hyperthyroid symptoms (p=0. 002), tiredness (p=0. 003), and anxiety (p=0. 003). Physical (p=0. 006) and school-related functioning (p=0. 003) improved post-TT (PedsQL), while variables captured by PSQ, BESAA, and EUGOGO-QOL were not significant pre- and post-TT. Reported GD-associated eye symptomology was minimal at baseline and further improved following surgery (p=0. 007). ThyPRO and PedsQL subscores were significantly associated at baseline and change after surgery, suggesting interconnectedness between disease-specific hrQOL and psychosocial functioning. Patients and parents reported median recovery of two months and high satisfaction with the outcomes of definitive surgery, with minimal scar appearance concerns. Conclusions: In the setting of a high-volume surgeon with low complication rates, definitive surgery for GD in pediatric populations has substantial, beneficial effects on disease-specific hrQOL and psychosocial functioning, with minimal adverse scar appearance complaints.

Impact of Definitive Surgery for Graves' Disease on Adolescent Health-Related Quality of Life and Psychosocial Functioning

Background: DICER1 syndrome, a rare autosomal dominant disorder, places affected individuals at risk for benign and malignant tumors of multiple organs, including thyroid, ovaries, lungs, kidneys, CNS. These tumors occur in childhood and usually before 40 years of age. Clinical Case: A 15-year old female presented with worsening abdominal pain and vomiting. She noted a "hard spot" on her abdomen and reported secondary amenorrhea with worsening acne and development of hirsutism over the previous 12 months. Imaging evaluation showed a 9 cm x 19 cm x 13 cm right ovarian mass with no enlarged lymph nodes. Initially, tumor markers and hormone levels were elevated: Alpha Fetoprotein 424 ng/mL [0-7], Testosterone 208 ng/dL [12-60], Free Testosterone 6.03 ng/dL [0.04-1.09], Inhibin A 129 pg/mL [97.5], Inhibin B 817 pg/mL [< 136], LDH 742 unit/L [370-645]. Patient underwent right salpingo-oophorectomy, lymph node and omentum biopsy; pathologic exam showed Stage 1C Sertoli-Leydig tumor of the right ovary (intermediate to poorly differentiated). She received chemotherapy with Cisplatin, Etoposide, Bleomycin. Genetic analysis revealed that she is heterozygous for a likely pathogenic variant, c.343del (p.Thr115Leufs*13) in DICER1, consistent with a diagnosis of autosomal dominant DICER1-associated disease. After therapy ended, her tumor markers and hormone levels normalized. Patient was found to have a multinodular goiter with benign pathology; her thyroid function remained normal. A 2 mm right middle lobe pulmonary nodule, stable, has been present on chest CT. Family history is significant for an euthyroid multinodular goiter with benign nodules in her 2-year older brother who has the same DICER1 pathogenic variant. Their mother and maternal grandmother also had total thyroidectomy for multinodular goiter. Conclusion: A cluster of certain tumors in family members involving successive generations, should prompt evaluation for a genetic cause, as early diagnosis, management and appropriate surveillance improve patients' quality of life.

Ovarian Malignancy, Familial Multinodular Goiter Associated with DICER1 Mutation

Growth hormone (GH) replacement therapy usually requires daily subcutaneous (s.c.) injections that can be burdensome for patients and their caregivers. Somapacitan, a long-acting reversible albumin-binding GH derivative, is in development for once-weekly s.c. administration in children with GH deficiency (GHD). REAL4 is a randomised, multi-national, open labelled, and active-controlled parallel group phase 3 trial, comprising a 52-week main phase and three-year extension period (NCT03811535). Two-hundred GH-treatment-naïve, prepubertal children with GHD (74.5% male) were randomly assigned in a 2: 1 ratio to receive 0.16 mg/kg/week s.c. somapacitan (n=132) or daily s.c. GH (0.034 mg/kg/day Norditropin®; n=68). The 52-week main trial results are presented here. The primary endpoint was annualized height velocity (HV) after 52 weeks of treatment. At week 52, the estimated mean HV was 11.2 cm/year for somapacitan compared to 11.7 cm/year for daily GH. The estimated treatment difference was -0.5 [95% CI -1.1 to 0.2] cm/year, confirming non-inferiority (non-inferiority threshold: -1.8 cm/year). Secondary height-related endpoints supported the primary endpoint. Insulin-like growth factor-I standard deviation score (IGF-I SDS) showed consistent increases for both somapacitan and daily GH over the 52 weeks, with change differences from baseline not statistically significant between treatment groups. At week 52, mean IGF-I SDS levels were similar between somapacitan (+0.28) and daily GH (+0.10) and within normal range (-2 to +2). Somapacitan was well tolerated, with no safety or local tolerability issues identified. There were no clinically relevant findings with respect to changes in glucose metabolism, no neutralizing anti-somapacitan or anti-GH antibodies were detected, and a low number of patients reported injection-site reactions, with similar proportions for somapacitan (5.3%) and daily GH (5.9%). In both treatment groups, 1.5% of patients reported injection site pain. Adherence was high for both treatments. The mean and median adherence for somapacitan treatment were 95.8% and 100%, respectively. The mean and median adherence for the daily GH group were 88.3% and 96.9%, respectively. In conclusion, once-weekly somapacitan has a similar efficacy and safety profile as daily GH with similar mean IGF-I levels in treatment-naïve children with GHD.

Once-weekly Somapacitan Is Effective And Well Tolerated In Children With GH Deficiency: A Randomized Phase 3 Trial

Prostate cancer (PCa) is the second leading cancer in the world in men. The major therapeutic target in advanced PCa is the ligand-binding pocket (LBP) of the androgen receptor (AR). The anti-androgens used to treat cancer are binding to this domain and compete with the natural agonist. Over time the cancer grows resistant towards this therapy. Nevertheless, the cancer still typically depends on the AR, indicating other sites of the AR may still serve as drug targets. The DNA binding domain (DBD) is a likely good therapeutic target as it is involved in essential processes such AR dimerization, translocation to the nucleus and binding to the androgen response elements (AREs). However the structure and the DNA binding interactions with AREs are not fully explored yet. Only one crystal structure (pdb: 1R4I) is available. In this structure, the DBD is bound to an artificial direct repeat DNA sequences (ADR3), resulting in an unexpected dimeric head-to-head arrangement. A better understanding on how the AR recognizes and binds to different native DNA sequences which are mainly organized as semi inverted repeats is crucial for rational drug design. Here, we performed protein crystallography of the DBD in complex with various natural ARE sequences, including the mouse mammary tumour virus (MMTV-GRE) motif. Surprisingly, this latter element is still able to be activated by a dimerization deficient AR.
Our first crystal structures were hallmarked by a high degree of disorder and appeared to bind both in a head-to-head as a head-to-tail fashion. Rational engineering of the DNA duplexes used for crystallography yielded well diffracting crystals for two different complexes. These two structures were diffracted to a range of 2 to 2.7 Å. Both structures with natural sequences appeared to bind in the head-to-head arrangement including the MMTV-GRE which consist out of semi inverted repeat DNA, whereas the C3(1)ARE contains the canonical fully inverted repeats. The structure reveals a slightly bend arrangement from the previously reported structure. The displacement is most visible at the DNA recognition helix bound to the half site and the so-called lever arm, which positions this helix in this region with a RMSD difference of 1.3 A. This indicates that the structural conformation changes of the protein is driven towards improved DNA-base pair recognition. Indeed the protein is able to make an additional set of non-covalent interactions with the base pairs of MMTV-GRE, leading to higher affinity. Both these extra interactions and conformational change lead to a higher affinity binding of protein-DNA, which seems to overcome the barrier introduced by the dimerization breaking mutations. This interaction surface could be a druggable site for structure-based drug design in the future, targeting AR-DBD dimerization.

Crystal Structures of Androgen DNA Binding Domain Interacting with its Response Elements (C3(1) ARE and MMTV-GRE)

Absorption of ultraviolet B (UVB) radiation by the B ring of 7-dehydrocholesterol (7-DHC) leads to the transformation of 7-DHC to previtamin D₃, which after absorption of additional UVB isomerizes to tachysterol₃ (T₃) and lumisterol3 (L₃). Previously we demonstrated that CYP11A1 can hydroxylate the side chain of vitamin D₃ (D₃), 7-DHC and L₃. Similarly CYP27A1 can hydroxylate the side chain of L₃ to biologically active hydroxyderivatives. In a continuation of these studies, we report that CYP11A1 and CYP27A1 hydroxylate T₃ to 20S(OH)T₃ and 25(OH)T₃, respectively, plus minor unidentified hydroxyderivatives. Both 20S(OH)T₃ and 25(OH)T₃were detected in the human epidermis and serum. T₃ was also detected in human serum and was present at a concentration of 7.3±2.5 ng/ml. 20S(OH)T₃ and 25(OH)T₃ inhibited the proliferation of epidermal keratinocytes and dermal fibroblasts and stimulated the expression of differentiation and anti-oxidative genes in keratinocytes in a similar manner to 1,25-dihydroxyvitamin D3 . They acted on the vitamin D receptor (VDR) as demonstrated by image flow cytometry and the translocation of VDR-coupled GFP (VDR-GFP) from the cytoplasm to the nucleus of melanoma cells, as well as by the stimulation of CYP24A1 expression. Functional studies using a human aryl hydrocarbon receptor (AhR) reporter assay revealed marked activation of AhR by 20S(OH)T₃, a smaller effect by 25(OH)T3 and only minimal activation by T₃. The T₃ hydroxyderivatives showed high affinity binding to the ligand binding domain (LBD) of the liver X receptor (LXR) α and β, and to the peroxisome proliferator-activated receptor γ (PPARg) in LanthaScreen TR-FRET coactivator assays. Molecular docking using crystal structures of the LBDs of VDR, AhR, LXRs and PPARγ revealed high docking scores for 20S(OH)T₃ and 25(OH)T₃, comparable to their previously characterized ligands. The scores for binding to the non-genomic site of the VDR were very low indicating a lack of interaction with hydroxy-T₃ ligands. In conclusion, we have identified 20S(OH)T₃ and 25(OH)T₃ in the human epidermis and serum, identified CYP enzymes responsible for their production, demonstrated phenotypic effects on skin cells, and identified VDR, AhR, LXRs and PPARγ, and possibly RORs, as their genomic receptor targets. Thus CYP11A1, aside from its role in steroidogenesis, not only metabolizes vitamin D₃, 7-DHC and L₃ to biologically active metabolites, but also activates T₃ to biologically active 20S(OH)T₃. Similarly, CYP27A1, previously reported to act on L₃, D₃ and 7DHC, also activates T₃ via hydroxylation at C25. We believe that these novel findings open new areas for future studies on the role of active forms of T₃, not only in the skin, but also in systemic physiology and pathology.

Metabolic activation of tachysterol to biologically active hydroxyderivatives that act on VDR, AhR, LXRs and PPARγ receptors

Duchenne muscular dystrophy is a genetic disorder that shows chronic and progressive damage to skeletal and cardiac muscle leading to premature death. Anti-inflammatory corticosteroids targeting the glucocorticoid receptor (GR) are the current standard of care but drive adverse side effects such as deleterious bone loss. Through subtle modification to a steroidal backbone, a recently developed drug, vamorolone, appears to preserve beneficial efficacy but with significantly reduced side effects. We use combined structural, biophysical, and biochemical approaches to show that loss of a receptor-ligand hydrogen bond drives these remarkable therapeutic effects. Moreover, vamorolone uniformly weakens coactivator associations but not corepressor associations, implicating partial agonism as the main driver of its dissociative properties. Additionally, we identify a critical and evolutionarily conserved intramolecular network connecting the ligand to the coregulator binding surface. Interruption of this allosteric network by vamorolone selectively reduces GR-driven transactivation while leaving transrepression intact. Our results establish a mechanistic understanding of how vamorolone reduces side effects, guiding the future design of partial agonists as selective GR modulators with an improved therapeutic index.

Disrupting a Key H-bond Network Drives Glucocorticoid Receptor Gene Suppression Without Off-target Gene Activation for Duchenne Muscular Dystrophy Treatment

Background: Severe insulin resistance syndromes including lipodystrophy and pathogenic variants in the insulin receptor (INSR) lead to diabetes that is challenging to control. Oral antidiabetic agents have been used to control hyperglycemia, however the efficacy of these treatments has not been studied systematically. This study explores safety and efficacy of sodium glucose cotransporter 2 inhibitors (SGLT2i) in these patients.
Methods: This was a retrospective chart-review assessing safety (N=31) and efficacy (N=18) of SGLT2i use in patients with clinically or genetically confirmed diagnosis of lipodystrophy or INSR pathogenic variants at our institute. Efficacy outcomes included HbA1c, insulin dose, C-peptide, fasting insulin and 24-hour urine glucose at 12 months and throughout follow-up from 2 to 24 months. Glycemic parameters were analyzed as change from baseline (prior to SGLT2i) adjusted for baseline values after 12 months of SGLT2i and across all timepoints using linear mixed models with post-hoc Dunnett-adjusted comparison of each time point compared to baseline.  For HbA1c, additional models were conducted including change in insulin dose as a covariate.
Results: HbA1c did not significantly change after 1 year of SGLT2i (baseline 9.5±2.5 [80.3±27.7]; 12 months 8.8±2.3% [72.6±25.3 mmol/mol]; p=0.093), or across all time points (p=0.11). However, most patients (83%) were taking insulin, and SGLT2i treatment led to 35% reduction in total daily dose of insulin after 12 months (baseline 186 [100,1010]; 12 months 120 [75,260] units/day; p=0.07) and across all visits (p=0.035), which may have mitigated the reduction in HbA1c. Reduction in HbA1c was significant after adjustment for changes in insulin dose over time (p=0.0498). No significant change was noted in C-peptide, however fasting insulin decreased after 12 months (p=0.021) and across all visits (p=0.005). Urinary glucose excretion increased greater than 5-fold after 12 months of SGLT2i, to over 80 grams per day after 1 year (p=0.04). Adverse effects occurring in >1 subject included hypoglycemia, fungal infections, and extremity pain.
Conclusions: SGLT2i reduced insulin dose, insulinemia, and insulin dose-adjusted HbA1c in patients with severe insulin resistance, with a similar safety profile compared to type 2 diabetes. SGLT2i use may lead to overall better glycemic control and should be considered as part of the treatment armamentarium for these rare forms of diabetes, but larger trials are needed to confirm these findings.

Clinical Effects of Sodium Glucose Transporter Type 2 Inhibitors in Patients with Severe Insulin Resistance

Introduction: Outpatient consultations comprise the majority of referrals in endocrinology. Patients with diabetes require constant follow-up and medication adjustments to achieve optimal glycemic targets. The COVID-19 pandemic made interruption and delays in healthcare delivery inevitable. This placed a great strain on monitoring patients with diabetes, placing greater importance on patient self-management. Telemedicine was introduced in our country to bridge the gap between physician and patient that was created by community quarantines and travel restrictions. However, our country was not ready for telemedicine as it has never been used in our healthcare system. This caused apprehension among doctors and patients as not everyone was technologically adept to understand the system. However, as months went by, telemedicine was eventually accepted as a "new normal" way of seeking medical care.
Objective: To determine if there is a difference in patient's self-care activities before and after using telemedicine using the Diabetes Self-Management Questionnaire (DSMQ)
Methodology: A descriptive cross-sectional study of patients with type 2 diabetes mellitus who consulted via telemedicine using different available platforms were included. Patients were asked to accomplish the Diabetes Self-Management Questionnaire (DSMQ) as a measure of self-care activities before and after the use of telemedicine. Clinical profile and glycemic control before and after telemedicine were secondary outcomes. With the goal of improving and tailoring telemedicine for our countrymen, patient satisfaction and opinions regarding telemedicine (i.e, accessibility, ease of use, areas to improve on) were also assessed using a patient satisfaction survey.
Results: Fifty-five patients were included in the study. An improvement in self-care practices was demonstrated by significantly higher mean DSMQ scores after telemedicine consultations (6.79 + 1.33 to 7.32 + 1.21, p = 0.0015), with dietary control and physical activity subscales obtaining the highest scores. There was a statistically significant reduction in HbA1c on follow up (8.37 + 2.31 to 7.31 + 1.36; p < 0.00001). In terms of clinical profile, majority of patients had poorly controlled diabetes at baseline. Those with well-controlled diabetes (n = 14) at baseline remained to have good control while the proportion of those with poorly controlled diabetes (n = 34) showed improvement on follow up (p = 0.0045). Most patients were highly satisfied with telemedicine experience and were likely to recommend it to others and avail of the service in the future.
Conclusion: As far as we know, there has been no previously published study in our country regarding telemedicine and its effect on diabetes management. This paper showed that the use of telemedicine by patients with type 2 diabetes mellitus significantly improved both self-care practices and glycemic control. These findings, together with the positive responses in patient satisfaction, may deem it necessary that telemedicine be mainstreamed as part of diabetes care in our country.

The Effect of Telemedicine on the Self-Care Activities of Patients with Type 2 Diabetes Mellitus and Patient Satisfaction during the COVID-19 Pandemic at the University of Santo Tomas Hospital

Background
The Endocrine Society recommends preconception counseling be provided to all women with DM who are considering pregnancy; the ADA recommends counseling women of childbearing age with DM on the importance of tight pregnancy glycemic control and appropriate use of contraception at pubertal onset. However, only 25% of women receive contraception and preconception counseling (PCC). As most studies are retrospective chart reviews, what is cited may not reflect the PCC offered.
Methods
Physicians and advanced care providers (n=97) at one institution were surveyed on their behaviors in offering and documenting PCC provided to women with T1DM and T2DM.
Women with T1DM and T2DM (n=15) receiving care at the same institution were contacted after a recent endocrine visit and surveyed on the PCC they received. A retrospective chart review examined how the women's perception of the PCC provided correlated with documentation.
Additionally, similar surveys were distributed to women aged 18 to 50 via diabetes groups on a social media platform (n=202).
Results
Overall, 37% of providers reported offering PCC < 5% of the time; PCPs and pediatric endocrinologists were least likely to offer PCC (p<0.01 between all groups). The majority of OBGYNs and endocrinologists shared PCC up to 25% of the time (p >0.05).
Providers were most likely to educate on or prescribe contraception. Half said they document counseling >75% of the time.
Of all the women surveyed (n=217), 89% had T1DM, 91% were White and the average HbA1c was in the 6.6%-6.9% range. 59% of women reported previous pregnancies and 6.9% were pregnant. There was no difference in HbA1cs for those planning or considering pregnancy and those who were not (HbA1c 7% v 6.7%, p >0.05 in chart review survey; HbA1c 6.6-6.9% in both groups in social media survey, p >0.05).
55% reported receiving PCC in the past, most likely from their endocrinologist or OBGYN.
The most frequently reported forms of contraception were OCPs (22%) followed by barrier contraception (18%)–generally with other methods—followed by no form of contraception (15%).
In the chart review survey (n=15), none were currently pregnant but 13% were planning pregnancy in the next year and 47% were unsure of their plans. Two reported PCC was discussed at their most recent visit; one reported receiving PCC at the penultimate visit. Of these three visits, PCC was documented twice. Topics commonly discussed were glycemic targets, preconception planning, and contraception.
Conclusion
This study suggests the rates of lifetime PCC are higher than described and lower reported rates may be related to deficiencies in documentation. However, the small size of the chart review survey limits the ability to draw definitive conclusions. This study may also be limited by self-selection bias and over-representation of White patients among survey respondents.

Providing Contraception and Preconception Counseling to Women with Diabetes: Health Care Provider Behaviors and Patient Perception

Prevalence of Fournier's Gangrene in T2DM Treated with Oral Antiglycemic Medications

Conversion from one side of the autoimmune thyroid spectrum to the other: a pediatric clinical challenge

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Impact of Definitive Surgery for Graves' Disease on Adolescent Health-Related Quality of Life and Psychosocial Functioning

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