Consultative endocrinology

Have you noticed the long lines of endocrinologists outside the meet-the-professor sessions at our annual meetings over the past several years? Rooms are filled to capacity, and many physicians endure uncomfortable positions (eg, leaning against the wall or sitting on the floor) to participate. The popularity of these sessions is owed to the opportunity they give clinicians to receive practical advice from a master in a particular field. The characteristic “this is how we do it” approach in these sessions tends to be replete with useful pearls that clinicians can apply to their own practices. It was this approach that inspired this issue of the Endocrinology and Metabolism Clinics of North America, in which a host of experts share their experience and insight as applied to various aspects of consultative endocrinology with an emphasis on perioperative management of the endocrine patient.

Many important clinical questions are addressed in this issue. How does one prepare a patient for pituitary surgery? Are postoperative corticosteroids required? How soon after transsphenoidal surgery should one retest pituitary function? Dr. Vance's article on perioperative management of pituitary patients provides answers to these and many other important questions. Dr. Axelrod's article on perioperative management of patients on chronic corticosteroid therapy addresses questions related to this common and critically important issue; his artful blend of history, pathophysiology, and practical advice provides useful reading for experienced clinicians and fellows alike. The comprehensive article on surgery in the pregnant patient by Drs. Sam and Molitch explores the preoperative evaluation and timing of surgery, as well as perioperative management of pregnant patients with endocrine disease. These authors take on the arduous task of considering the effects of each condition on both the mother and fetus in a highly readable and informative review dealing with a wide range of topics, including thyroid cancer in pregnancy, diagnosis and management of Cushing's syndrome, acromegaly and hypopituitarism in pregnancy, the evaluation and treatment of endocrine hypertension in pregnancy, and many more.

Dr. Nieman's timely article on medical alternatives to estrogen replacement therapy in the postmenopausal woman addresses the many questions asked by patients and primary care providers about this subject. Written concurrently with the release of findings of the Women's Health Initiative, this review critically examines evidence and anecdotes of estrogen therapy alternatives. In addition, Dr. Nieman provides a review of alternatives to androgen therapy in males who are unable to receive testosterone replacement therapy. Dr. Van den Berghe, whose work on intensive insulin therapy in critically ill patients has focused on the metabolic and inflammatory consequences of life-threatening illness, provides an extensive review of the pathophysiology and management of endocrine dysfunction in the critically ill patient. Drs. Janicic and Verbalis provide a fresh look at the evaluation and management of hospitalized patients with disturbances in water and electrolytes. Their organized and logical approach to such issues as the evaluation and management of patients with acute symptomatic hyponatremia provides an excellent resource for clinical endocrinologists. Drs. Glister and Vigersky examine the intricacies of consultative management of type 1 diabetes mellitus in hospitalized and perioperative patients. This comprehensive review covers such important topics as transitioning from outpatient to inpatient insulin therapy, protocols for intravenous insulin administration, assessment of insulin sensitivity, and management of diabetes in patients on total parenteral nutrition. Dr. Stocker provides a comprehensive review of current surgical approaches to morbid obesity through the eyes of an endocrinologist. His primer on bariatric surgery covers available surgical approaches, preoperative evaluation, anticipated adverse effects, and follow-up strategy for the bariatric patient.

Three articles are dedicated to consultative care in patients with thyroid disorders, starting with an article by Drs. Zarnegar, Brunaud, and Clark on operative complications associated with thyroid surgery. This review examines the cause, prevention, and management of common and uncommon complications of thyroid surgery. In addition, these authors review operative strategy in patients with substernal goiters or mediastinal metastases, patients who are professional singers, and in patients undergoing neck reoperation. Drs. Stathatos and Wartofsky discuss the perioperative management of patients with hypothyroidism. This article begins with an overview of the effects of hypothyroidism on critical organ systems, covers the effects of surgery on indices of thyroid function (the euthyroid sick syndrome), and finally reviews the controversial issue of thyroid hormone therapy in euthyroid patients undergoing cardiac surgery. Lastly, Dr. Langley and I review the preoperative preparation and perioperative management of patients with thyrotoxicosis, including individuals requiring rapid preparation for emergency surgery.

I am greatly indebted to the contributing authors for the time and effort they have devoted to the creation of this issue. I would also like to acknowledge the expert editorial assistance provided by Rebecca Schmidt and her staff at W.B. Saunders, whose receptiveness, patience, and editorial skill allowed this issue to be completed. I hope that readers find these articles as informative, practical, and clinically relevant as I do.