Misleading medical reporting in the media: Over-diagnosis of low testosterone levels in men

A story published on Monday 9 September in the Guardian has provoked outrage at the Society for Endocrinology.

Dr Richard Quinton, Dr Channa Jayasena and Dr Ahmed Al-Sharefi, three of our expert Media Ambassadors, contacted the Society Press Office to express their concerns over the lack of accuracy and impartiality in the article: ‘My energy is back: how testosterone replacement therapy is changing men’s lives’ by .

They feel that this article is written and presented in an irresponsible manner that is misleading to the reader and potentially exploitative. The Society is committed to helping promote accurate and responsible reporting of endocrinology-related topics in the media, so we have backed their concerns, in the form of the open letter below, as our official position, and call on the Guardian to retract the article, pending appropriate revisions.

“Dear Guardian,

This article published in the Guardian addresses the important issue of treating hypogonadism. However, we are concerned that the article will (inadvertently) serve as an advertisement for “fringe” private medical healthcare services that contradict the advice and experience of qualified NHS specialists, who have specifically trained in hormone medicine (endocrinology),  with no platform offered to provide a more informed viewpoint.

It is easy to do a blood test for testosterone but it is equally easy for a non-specialist doctor (such as those quoted in the article) to misinterpret the result, and thereby misdiagnose hypogonadism.  In healthy, normal men, testosterone levels peak in the early morning and fall during the day; they also fall after meals, so it’s vital for accurate diagnosis that the blood test (preferably 2 of them on different days) be performed fasted and before 10-11 am. Moreover, testosterone levels also fall naturally below “normal” after a sleepless night, or during any form of illness, and men who are overweight or obese typically have low levels of the testosterone-binding protein, such that their levels of biologically-active free testosterone may be normal, even when total testosterone is slightly low.

What doctors lacking training in hormone medicine may also fail to appreciate is that properly documenting two separate low testosterone levels (total and calculated-free) is not a final diagnosis in itself, but rather an entry point to making a proper diagnosis, which may even involve MRI scanning the pituitary gland. Thus, just starting a man with “low testosterone” on testosterone replacement, not only exposes them to the risks of unnecessary treatment – testosterone-induced infertility, shrinkage of testes, or an abnormal rise in haemoglobin that can predispose to heart attacks, along with the costs to them or the NHS of drugs and monitoring blood tests – but also to the risk of a serious underlying condition being missed, such as a pituitary gland tumour, which could expand and cause blindness.

There has been an explosion in testosterone prescribing in the UK over the past 20 years, much of which has been exploitative of the vulnerabilities and insecurities of middle-aged and older men, but which has sadly passed other men completely by, whose genuine hypogonadism has not yet come to specialist medical attention.

We therefore highlight, four simple red flag features that should make any doctor take the finding of a low testosterone level (fasted & early morning) that much more seriously and refer to an appropriately qualified specialist:

– the presence of anaemia or low haemoglobin
– a history of osteoporosis or fracture
– a history of infertility
– raised levels of pituitary hormones LH or prolactin”

Dr Richard Quinton MA MD FRCP(Edin), Consultant Endocrinologist, Newcastle-upon-Tyne Hospitals & University 

Dr Channa N. Jayasena PhD FRCP FRCPath, Clinical Senior Lecturer in Endocrinology, Imperial College London

Dr Ahmed Al-Sharefi MBChB , MRCP (UK), Senior higher specialty trainee in endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation trust

Declaration: Both Richard Quinton and Channa Jayasena are Investigators on the National Institute of Healthcare Research (NIHR) funded Testosterone Efficacy and Safety (TestES) Consortium, and Media Ambassadors for the Society for Endocrinology*

Our Media Ambassadors have successfully worked with Health and Science correspondents at the Guardian in the past to ensure accurate and responsible reporting, and we look forward to continuing to work with them on endocrine-related stories in the future.

The Society is committed to engaging journalists, patients and the public with hormone science to encourage informed health decisions, and to demonstrate the value of endocrinology to the wider world. Our Media Ambassadors are experts that work alongside the press office to help provide expertise, context and analysis to promote accurate and responsible reporting.

If you are interested in helping to improve the quality of science and health reporting, read our Media Ambassador guide or email media@endocrinology.org to find out how you can get involved.

Resolving Uncertainties in Diagnosis & Management of Thyroid Neoplasia

CARLA MORAN WEB IMAGES 1 (3)Dr Carla Moran is a Consultant Endocrinologist at the University of Cambridge and a convenor of the Society’s Thyroid Endocrine Network. In 2017 she was awarded a Society Themed Scientific Meeting Grant to hold the one-day meeting, Resolving Uncertainties in Diagnosis & Management of Thyroid Neoplasia, on 8 March 2019 at Churchill College in Cambridge. The meeting brought together international and UK experts, as well as practicing clinicians and non-clinical scientists, to discuss advances in the field. Here Carla gives us a report of the day.

Need for the meeting
The landscape of investigation for thyroid neoplasia and management of low risk thyroid cancer is changing. Overascertainment of thyroid nodules has fuelled an epidemic of thyroid neoplasia but the death rate from thyroid cancer is unchanged. Many of these nodules are unnecessarily over-investigated, and if cancer is detected, may be overtreated. It has been suggested that more than 200,000 cases of thyroid cancer have been unnecessarily detected in the USA between 1988 and 2007, and the UK has not avoided this phenomenon of overdiagnosis[1]. In addition, in the UK, almost all radiologically and cytologically indeterminate nodules undergo surgery for diagnosis, resulting in high rates of unnecessary surgery for benign disease. Although our international colleagues are using RNA and DNA diagnostic techniques to stratify the likelihood of malignancy in these nodules, such tests have not been evaluated in UK clinical practice. Pathological definitions of thyroid neoplasia are being revised, such as redesignation of follicular variant of papillary thyroid cancer to noninvasive follicular neoplasm with papillary-like nuclear features (NIFTP). Lastly, management of thyroid cancer is evolving, with surgical extent, radioiodine use and dose and TSH suppression all being tailored to disease risk. This suggests that a stratified approach, with use of better markers (radiological, cytological, molecular) to select nodules for investigation and treatment, is required.

Overview of the day
Current guidelines advocate a multidisciplinary approach to thyroid nodules and cancer, with input from endocrinologists, radiologists, pathologists, surgeons, oncologists and nurse specialists, however no national meetings are held with all these disciplines in attendance. Led by the Society Thyroid network, in partnership with the British Thyroid Association and UK Endocrine Pathology Society, this meeting gathered international and UK experts in all these disciplines, as well as practicing clinicians and non-clinical scientists, to discuss current UK practice and advances in the field. Invitations extended to members of other societies (e.g British Association of Endocrine and Thyroid Surgeons) and patient groups (British Thyroid Foundation, Butterfly Thyroid Cancer Trust) interested in the field.

Topics reviewed included: the thyroid cancer epidemic (Krishna Chatterjee, Cambridge), ultrasonographic classification (Steve Colley, Birmingham), cytological categorisation (Sarah Johnson, Newcastle), molecular pathogenesis (Chris McCabe, Birmingham), nodule molecular diagnostics (Bryan McIver, USA), pathological risk stratification (David Poller, Portsmouth), surgical management of low risk tumours (Dae Kim, London), papillary microcarcinoma (Carla Moran, Cambridge) and stratified management of thyroid cancer (Jonathan Wadsley, Sheffield). Oral presentations demonstrated that high quality UK research is being performed in this field.

Collaboration is key
Collaboration between disciplines was essential for this meeting; the primary speciality leading diagnosis & management of nodules varies widely between centres across the UK, such that specialist society (e.g. endocrine, surgery, pathology, radiology) meetings often exclude many interested professionals; it is exceptionally rare for all relevant disciplines to meet to discuss the topic. Discussing areas of uncertainty identified by all specialties allowed us to compare approaches. Internationally, variation in practice variation is also substantial, most notably with regard to the use of molecular diagnostic techniques. Clinicians in the UK do not have any significant experience of using such diagnostic tools, such that Dr McIver’s experience and opinion of this area was highly informative. Lastly, attendees were individuals experienced and interested in the field; this ensured that discussions were highly applicable and informative.

Funding was crucial
When organising this meeting, funding received from the Society for Endocrinology was invaluable; without it we would not have been able to attract such high-quality speakers from the UK and US. Feedback from the meeting was universally strongly positive, with many attendees expressing a desire to attend a similar meeting in future.

Future
A unique aspect of the meeting was the workshop held the day after the main programme, attended by those interested in pursuing research aiming to identify solutions to challenging areas of current practice. We hope the meeting will inform scientific design of a UK-wide, multicentre, prospective study to evaluate diagnostic utility of new molecular technologies alongside current cytological/pathological practice. In addition, participants in this meeting are likely to be key members of a working group which will formulate national guidance on the diagnosis & management of thyroid nodules in the UK.

References
1. Vaccarella S, Franceschi S, Bray F, Wild CP, Plummer M, Dal Maso L. N Engl J Med. 2016 Aug 18;375(7):614-7.

Meet the editor – Professor Martin Haluzík

Meet Professor Martin Haluzík, Professor of Internal Medicine at the Charles University in Prague, Deputy Head of Centre for Experimental Medicine and Head of the Department of Experimental Diabetology at the Institute for Clinical and Experimental Medicine in Prague, Czech Republic. Professor Haluzík is a deputy editor of the Journal of Endocrinology and Journal of Molecular Endocrinology. His major research focus is on the etiopathogenesis of obesity, insulin resistance and type 2 diabetes. In this interview, Professor Haluzík tells us more about his research and career.

Tell us about your particular field and research?

Our lab explores the etiopathogenesis of obesity and type 2 diabetes aiming to find preventive and treatment strategies. We are particularly interested in bariatric surgery and endoscopic methods of treatment along with novel pharmaceutical targets. Our research is both experimental and clinical, involving patients with obesity and type 2 diabetes.

What techniques do you use in your research?

At the moment, a lot of our research is focused on immunometabolism/subclinical inflammation in adipose tissue using flow cytometry and continuously trying to refine it. We are also using metabolomic and proteomic methods in collaboration with other laboratories. In patients, we often use glucose clamps to characterise insulin sensitivity before and after interventions. We are also testing numerous novel endoscopic methods for treatment of obesity/type 2 diabetes in both experimental models and in patients.

What inspired you into endocrinology?

It was primarily my mentor, Professor Vratislav Schreiber, who was a leading, internationally-recognised, experimental endocrinologist. His primary focus was hypothalamus/hypophysis research but he was the one who, after discovery of adipose tissue hormone leptin, came up with the idea that we should focus on the endocrine function of fat.

What do you enjoy most about work?

I really enjoy its variability – doing both experimental and clinical research brings some challenges but this combination is never boring. I very much like scientific discussion with my colleagues about our results and brainstorming how to explain it and put it into context. I also like writing the papers, especially when nobody is calling and I have a couple of hours to focus on thinking about data and writing.

What does your day-to-day work life involve?

I do both clinical work (seeing patients with diabetes/endocrine diseases) and experimental research. Nevertheless, I have to admit that I am not very useful in the lab anymore. My job is mostly to write grant applications, organize things, write and refine the papers and support my colleagues and PhD students.

What are you most looking forward to in becoming an editor?

I am very much looking forward to a chance to contribute to shaping and refining the focus of such well-respected journals of Journal of Endocrinology and Journal of Molecular Endocrinology. Also, I really like interaction with the Editorial Board and other members of the team that bring most interesting ideas that help us to improve the journal.

Who/what research has inspired you the most?

My first mentor, Professor Vratislav Schreiber, who contributed to the discovery of TRH. He was very inspiring by a combination of being extremely smart and modest at the same time, while having an unforgettable sense of humour.

What is the best feedback or advice you have ever received?

“Work smart not hard” although I am still learning how to do it, which involves a lot of hard work.

Is there any advice you can give to someone just starting off in science?

Go for it! I would make the same choice again if I could start over. It is a lot of work but you don’t really need any other hobbies. You can think about science all the time.

How can we inspire our future leaders in endocrinology and the Society?

Graham Williams with Award winners SfE BES 2017
Prof Graham Williams (centre) with Award winners SfE BES 2017

The Society has launched a new Leadership & Development Awards Programme, to recognise and nurture emerging talent in endocrinology and help Awardees become the future leaders of our discipline. In our interview, Prof Graham Williams, President of the Society for Endocrinology, introduces the Awards Programme and explains how it will be used to inspire and support our leaders of tomorrow, and why early career endocrinologists should apply.

What are the aims of the new Awards programme?

My main priorities as President of the Society have been to ensure that we cater for every member and that we are prepared for the future by being able to develop and respond to change. An important part of that is to support people who are enthusiastic and dedicated to endocrinology so they are equipped to be our future leaders. The Society Officers and Council have introduced the Leadership & Development Awards Programme to help identify these individuals and prepare them; by providing opportunities to learn more about how the Society works, how it is governed, how the committees work and what its strategic aims are. The main purpose is to give everybody an equal opportunity to become more involved, and to ensure that all categories of our membership are well represented in the future.

Towards this goal, the Awards Programme is open to clinicians, clinicians-in-training and research scientists. We are also considering, with the Nurse Committee, how to bring forward a similar initiative that will suit our nurse members, who have different career pathways and needs, and will require an alternative selection process.

The overall aim is to ensure the Society is in a strong position for the future, by securing the engagement of our most dedicated members to help grow and develop our community.

Why do we need an Awards Programme to identify our future leaders?

Our members have always been engaged with endocrinology but the discipline is rapidly changing. It is no longer so easy for people to identify themselves as endocrinologists. There has been a move away from a traditional organ and disease based focus, with increasing emphasis towards interdisciplinary science, whole organism physiology and cellular and molecular signalling. This means many more people are dipping in and out of endocrinology as a discipline, which in turn impacts on the Society. We need to move with the times and ensure we include cross-cutting disciplines that are integrated fully within the Society and endocrine community.

What are your hopes for the Awards Programme in the longer term?

I don’t want to predict the future but I think the Society needs to be agile and responsive as the discipline changes. So we aim to equip Awardees with the skills they need to influence Society strategy and develop our plans as the field advances. Endocrinology is also global discipline and I think that building collaborations with other medical disciplines will be essential both in the UK and also with colleagues all over the world.

What advice would you give to applicants for the Award?

Answer all the questions as completely as possible but most importantly be yourself. When people answer honestly, it allows them to express their true sense of excitement and enthusiasm – and that is what we are looking for – people who are the ‘enthusiastic doers’.  Of course we are looking for those who can demonstrate clinical and scientific excellence in endocrinology, but they need to be excellent communicators and ambassadors as well.

What qualities do you think are important in our future leaders?

I think openness, honesty and the ability to listen to, and to take advice from, others are some of the most important leadership qualities. By sitting on lots of committees you can learn a lot from the chairs. The best ones are great listeners, adept at summing up and have the ability to direct people towards a sensible consensus. Excellent communication skills and wanting to help others are essential qualities for all leaders.

Apart from a dedication to endocrinology, it is important that Awardees are rounded individuals with other outside interests . Working hard is important but it is important to switch off at times and enjoy other interests.  For me this has come from sport and the great outdoors, but whatever it is “work hard and play hard” and you won’t go far wrong!  Having diverse interests also helps with networking, getting to know colleagues and in developing long-lasting friendships that cement the endocrine family together.   

What have you enjoyed most while serving on Committees and as President?

It has to be the people. I feel in a really privileged position to be able to work in the field I love, but serving the Society has extended that experience into being part of a community. Being able to meet and work with like-minded and fantastic people, from different disciplines, from all over the world, and who all want to achieve similar things has been very inspiring.

Who were your early mentors?

I have been fortunate to have had many outstanding mentors over the years but here are the early ones that inspired me into endocrinology and then research. As a medical student, I loved anatomy and was all set to be a surgeon.  However, my first house job was with Professor David London at the Queen Elizabeth Hospital in Birmingham.  He is an eminent clinical endocrinologist and long-standing Society member.  During my time as his houseman, we had lots of interesting endocrine challenges and his infectious enthusiasm got me hooked, so I decided to change and take up a career in endocrinology.

After completing general medical training, I was encouraged to move into the laboratory to work on thyroid hormone action with Michael Sheppard and Jayne Franklyn.  They subsequently encouraged me to branch out and go to Boston to continue my research training at Harvard Medical School, and this move inspired me to pursue an academic career in basic clinical science.  Throughout my career many people have been inspirational and provided support and this never stops; you develop an expanding network that brings new ideas, collaborations and opportunities.  It is here that the Society makes such a difference and will continue to do so as the next generation takes the reins and leads us into the future.

I feel strongly that the new Leadership & Development Awards Programme will serve the future of the Society and the future of endocrinology well.  It will provide unique opportunities for those who apply and I hope it will help to support the careers of our talented trainees.  The applications are open to all so please don’t feel inhibited – just go for it!

Are you an early career endocrinologist interested in developing your leadership skills and becoming more involved with the Society? Applications for the Leadership & Development Awards Programme are open 1 April – 14 May 2019.

Full details of the selection process, benefits and how to apply are on our website.

Tackling inaccurate and misleading reporting on science in the media

A story published on Saturday in The Times has provoked outrage amongst some Society members.

Dr Richard Quinton and Dr Channa Jayasena, two of our expert Media Ambassadors, contacted the Society Press Office to express their grave concerns over the article: The £195 hormone cream that’s changed my life by Olivia Falcon.

Both Dr Quinton and Dr Jayasena feel that this article is written and presented in an irresponsible way that is misleading to the reader, on a potentially unsafe and improperly tested product. The Society is committed to helping promote accurate and responsible reporting of endocrinology-related topics in the media, so we passed their concerns, in the form of the open letter below, to The Times.

Dear Editor

In 1916, a $20 fine was levied in Rhode Island, USA for the misbranding of Clark Stanley’s Snake Oil Liniment to treat rheumatism and bunions and animal bites. The term ‘snake oil salesman’ is still used today to describe someone who knowingly sells fraudulent goods. Anti-ageing products are in ever-increasing demand. Whereas, cosmetic (i.e. non-medicinal) products are established in the market, there is growing speculation that hormone (endocrine) supplementation could provide additional benefit for older men and women. However, it is critical to understand that products claiming to alter the endocrine (hormone) system should be termed drugs, and are quite rightly subject to rigorous safety regulation. Crucially, the websites from which Endo-Test cream can be purchased explicitly state that “it is for scientific or laboratory use only and not for human consumption”.

Endo-Test cream described in last Saturday’s edition claims to ‘increase testosterone levels dramatically’ and nearly double sperm count and The Times’ journalist reported that these claims were based on an independent study by the manufacturer. However, we were unable to find any evidence of scientific peer review or publication of these findings. Furthermore, there is currently no medication in existence known to increase a man’s sperm count, so the findings appear improbable.

Interestingly, whereas The Times’ journalist correctly described Endo-Test cream as a “hormone cream”, the AQ company website claims prominently that Endo-Test is “hormone-Free”. For the record, the cited ingredients include a human androgen (testosterone-precursor) hormone (DHEA), a major insect moulting hormone (20-hydroxyecdysone) and a synthetic hormone (Gonadorelin) whose clinical application in humans is to shut down reproductive hormones entirely for men with prostate cancer and women with endometriosis, or as part of hormone treatment of trans-gender individuals. The extent to which these are absorbed through the skin, as opposed to through their conventional routes of administration, has likewise not been substantiated. 

To protect the interests of the public, it is important that manufacturers make substantiated claims and that journalists scrutinise evidence of these claims prior to publication. Without this, how would people know whether or not ‘snake oil’ was indeed the fountain of youth?

Dr Richard Quinton MA MD FRCP, Consultant Endocrinologist, Newcastle-upon-Tyne Hospitals

Dr Channa N. Jayasena PhD FRCP FRCPath, Clinical Senior Lecturer in Endocrinology, Imperial College London

Declaration: Both are Investigators on the National Institute of Healthcare Research (NIHR) funded Testosterone Efficacy and Safety (TestES) Consortium, and Media Ambassadors for the Society for Endocrinology*

*Please note these views are of expert members Channa Jayasena and Richard Quinton, and do not necessarily reflect the official position of the Society for Endocrinology.

The Times is now looking into the matter and will report back to us on how this will be addressed shortly. Our Media Ambassadors have successfully worked with Health and Science correspondents at The Times in the past to ensure accurate and responsible reporting, and we look forward to continuing to work with them on endocrine-related stories in the future.

UPDATE 8 March 2019 – The Times have now taken this article down, we thank them for their assistance with this matter and taking this positive action.

The Society is committed to engaging journalists, patients and the public with hormone science to encourage informed health decisions, and to demonstrate the value of endocrinology to the wider world. Our Media Ambassadors are experts that work alongside the press office to help provide expertise, context and analysis to promote accurate and responsible reporting.

If you are interested in helping to improve the quality of science and health reporting, read our Media Ambassador guide or email media@endocrinology.org to find out how you can get involved.

 

 

 

 

 

 

Meet the Endocrinologist: Stafford Lightman, expert on regulation of the hypothalamo-pituitary-adrenal axis

Meet Stafford Lightman, Professor of Medicine at the University of Bristol. His research focuses on understanding the role of the hypothalamo-pituitary-adrenal (HPA) axis in health and disease, and in particular its interface with stress and circadian rhythms and its effects mediated through glucocorticoid signalling. He has been awarded the SfE Medal and will be delivering his Medal Lecture at SfE BES 2018, 19-21 November in Glasgow. In our latest interview, he tells us more about his career, research and what he is looking forward to at the SfE BES 2018 conference.

*Prof Lightman is pictured at the Goroka Festival, Papua New Guinea’s equivalent of Glastonbury! 

Can you tell us a little about your current position and research?

When I was appointed Professor of Medicine at the University of Bristol, very little endocrine research was going on there, which had the great advantage of providing me with a clean slate and the ability to develop my own research theme. Now I have a lab group that ranges from the very basic cell and molecular science through physiology, right up to clinical research. I really enjoy being able to translate up to humans and then back translate down again to animal models. Having a group of scientists and clinicians working together is a really exciting environment to work in.

Can you tell us a little about what inspired you into endocrinology?

I was always interested in human biology and my earliest research was in anthropology, which naturally led into human behaviour and to neuroscience. I initially wanted to be an academic clinical neurologist but at that time neurology research centred around the peripheral nervous system, and I was interested in the brain! The one way I could investigate brain function was through the window of hypothalamic-pituitary function, therefore I became a neuroendocrinologist. Since then I have been working at the interface of endocrinology and neuroscience, which I find fascinating.

What you are most proud of in your career so far?

I am most proud of the people that I have helped to train, who have gone on to do well afterwards. It is also really rewarding to have set up lots of collaborations with mathematicians, and fascinate them in the dynamics of hormones. They have of course also been very both for me and the subject, developing   the concept of hormone dynamics. With the exception of GnRH, endocrinology was often considered a homeostatic but relatively static science, where hormone levels are measured and found to be either too high or too low. This is clearly far from reality and trying to bring the idea of dynamic hormonal systems into the mainstream is something I have been very involved with.

Tell us what you enjoy about your role as President of the British Neuroscience Association (BNA)?

I love meeting lots of really interesting people. The brain is such an interesting area and I enjoy understanding how it interacts with all aspects of our lives. The BNA 2019 Festival of Neuroscience will be held in Dublin on 14-17 April 2019, and will be in collaboration with the British Society for Neuroendocrinology, and include a scientific symposium sponsored by the Society for Endocrinology. So, there will also be a strong element of endocrinology running throughout the meeting. However, it is a great event for bringing together lots of diverse areas of neuroscience.

What are you presenting in your Medal Lecture at SfE BES 2018?

I will be discussing how aspects of HPA physiology are governed by dynamics, from the stress response to the circadian rhythm. The underlying dynamics of this system are what allow us to be flexible and to maintain a homeostatic state. I will also be talking about improved ways of diagnosing endocrine disorders. If we can harness novel technologies to measure dynamic changes in hormone levels in patients at home, we can gather much better information for diagnosis and treatment.

What are you looking forward to at this year’s conference?

From my own point of view the best part of the conference will be discussing posters with young, enthusiastic scientists right at the start of their careers. The posters are a really exciting area where people are putting out new ideas, in all areas of endocrinology. I like to be educated, so enjoy going to posters in areas where I don’t know much and hearing about what people are doing and why they find it exciting.

What do you think are the biggest challenges in endocrinology right now?

I think there are two main challenges, one of which I alluded to earlier.

  1. In terms of HPA the challenge lies around how we can measure dynamic changes in hormone levels in patients at home. I think the whole field of medicine is moving away from keeping people in hospital, to do lots of blood tests, sending them home, calling them back in to discuss results and finding you don’t have the right answer. Diagnosis can then be prolonged, inaccurate and very expensive, all of which is bad for patient care. The real challenge is finding better ways of doing this, and doing it in patients at home.
  2. Another challenge concerns the best way to give glucocorticoid replacement therapy. There is currently great debate on this in the field but it is important that we find the answer. Poorly managed glucocorticoid replacement is associated with considerable morbidity and mortality, so lots of attention is focused on finding a better way of doing it.

What do you think will be the next major breakthrough in your field?

I think the ability to monitor patients’ hormone levels over a 24 hour period will be a major breakthrough, and will provide the basis for better understanding of normal physiology and better diagnostic methodologies.

We have been developing a wearable collecting device that can be worn by patients at home. Using this device, patients would need only a quick visit to have it fitted and another, 24 hours later to have it removed. This is sufficient to provide full tissue biochemistry over a 24 hour period. This would minimise the time in hospital and provide a personalised medicine approach with a wealth of data that gives an overall picture of the individual’s health. This type of approach could revolutionise diagnostics and really improve patient care.

Once we understand how to apply this technology we will have better more rational ways of targeting and timing treatments, to address the challenges mentioned in the previous question.

What do you enjoy most about your work?

I love the challenge of new ideas and using them to work out answers to important questions. It is also a pleasure and privilege to have the opportunity to work with great colleagues.

Who do you admire most in the world of endocrinology?

The first piece of endocrinology that ever excited me was Vincent Wigglesworth’s work on the hormone, ecdysone. He was a brilliant entomologist and his beautifully designed experiments on the extraordinary process of metamorphosis was a real eye opener. He was my first endocrine hero!

Any words of wisdom for aspiring endocrinologists out there?

Enjoy, enjoy, enjoy! You really need to enjoy your work, or you should be doing something else. I describe what I do as privileged play!

You can hear Professor Lightmans’s SfE Medal Lecture, “HPA activity: Don’t forget the dynamics” on Monday 19 November, in the Lomond Auditorium at 17:30. Find out more about the scientific programme for SfE BES 2018.

Meet the Endocrinologist: Ursula Kaiser, expert in neuroendocrine regulation of puberty

Meet Ursula Kaiser, Professor at Harvard Medical School and Chief of the Division of Endocrinology, Diabetes and Hypertension at Brigham and Women’s Hospital. Her research is focused on neuroendocrine regulation of puberty, reproductive health and fertility. She has been awarded the SfE International Medal and will be delivering her Medal Lecture at SfE BES 2018, 19-21 November in Glasgow. In our latest interview, she tells us more about her work and what she is looking forward to at the SfE BES 2018 conference.

Can you tell us a little about your current position and research?

At Harvard Medical School and as Chief of the Division of Endocrinology, Diabetes and Hypertension at Brigham and Women’s Hospital, I lead and direct a group of over 60 clinical and research endocrinologists at a large academic medical center. My laboratory studies the genetic and molecular mechanisms underlying the neuroendocrine regulation of reproductive development and function, with an emphasis on the mechanisms regulating gonadotropin-releasing hormone (GnRH) and gonadotropin production. We use translational approaches including clinical and laboratory observations in humans, investigations in mouse models, and molecular and cellular studies to elucidate the molecular and biological underpinnings of reproductive disorders.

Can you tell us a little about what inspired you into endocrinology?

I grew up in Canada, where I received my undergraduate degree in biology at University of New Brunswick followed by my medical degree at University of Toronto. Early in medical school, I became fascinated by the feedback loops of endocrinology and by the many systems affected by hormones, and was quickly convinced that endocrinology was my calling. I completed my clinical training and licensure in internal medicine and in endocrinology in Toronto, but became intrigued by the molecular underpinnings of endocrine disorders. I moved to Harvard Medical School and Brigham and Women’s Hospital to pursue basic science research training in the regulation of gonadotropin gene expression under the mentorship of Dr. William Chin in the Genetics Division. My initial research focused on the mechanisms of differential regulation of luteinising hormone and follicle stimulating hormone; more recently, I have moved “further up” the hypothalamic-pituitary-gonadal axis to study the neuroendocrine regulation of GnRH secretion.

What you are most proud of in your career so far?

Scientifically, I’m most proud of our discovery that mutations in a gene known as MKRN3, or Makorin Ring Finger Protein 3, cause central precocious puberty. This was the first major genetic cause of precocious puberty to be identified and is now recognized to explain close to half of all cases of familial central precocious puberty. This discovery has identified the first known inhibitor of human GnRH secretion and has opened up an entirely new field of investigation. It is also important translationally and has highlighted the role of genetic imprinting in the control of human pubertal timing. I’m particularly proud of this accomplishment because of its collaborative and multidisciplinary nature – it has involved an international network of collaborators and has helped to launch the careers of several of our trainees.

What are you presenting in your Medal Lecture at SfE BES 2018?

I will be talking about our discovery of the role of MKRN3 in the timing of puberty and the link of loss of function mutations in MKRN3 with central precocious puberty.  In particular, I will expand on the studies we have performed since discovering this link in order to better understand the role and mechanisms of action of MKRN3 in puberty onset.

What are you looking forward to at this year’s conference?

I’m particularly looking forward to seeing my British and other international friends and colleagues, to catch up and hear about their new work, and to discuss ongoing and potential future collaborations. One thing that I would recommend to others is to take maximum advantage of the opportunity to catch up with new advances in their fields and to network with colleagues. It’s a great opportunity to meet new colleagues and make new connections!

What do you think are the biggest challenges in endocrinology right now?

Two of the biggest challenges in endocrinology are addressing the rising rates of obesity and diabetes mellitus. The prevalence of these metabolic disorders is rapidly increasing, not only in developed countries, but also in the developing world. We need more research to better understand the pathogenesis of these metabolic disorders. Interestingly, neuroendocrinology is increasingly recognized to play a key role in metabolic disorders, with neuropeptides and neural circuits playing key roles both in appetite and energy homeostasis, as well as linking metabolism to other areas of physiology such as reproduction and growth.

What do you think will be the next major breakthrough in your field?

I believe that neuroscience is an incredibly exciting area that is poised for major breakthroughs. The combination of advances in human genetics together with advances in our abilities to study the brain are allowing neural circuits to be mapped in detail and are leading to new discoveries in mechanisms underlying neurological and neuroendocrine diseases. I am hopeful that these advances will in turn lead to new treatments for these disorders. Endocrinology is particularly important for our understanding of sex differences in predisposition to and responses to treatments for neurological disorders, such as Alzheimer’s and Parkinson’s disease.

In addition, advances in our understanding of neuroendocrine circuits will lead to new therapies targeting neuroendocrine pathways controlling metabolism and reproduction. The recent discovery that menopausal vasomotor symptoms (i.e., hot flashes) are mediated by the neuropeptide, neurokinin B, and that neurokinin B antagonists can effectively target and reduce the frequency of these vasomotor symptoms, is a great example of such a breakthrough.

What do you enjoy most about your work?

I’m so fortunate to have one of the best jobs in the world! My work is intellectually and socially stimulating. No two days are alike – between teaching students, doing research, and seeing patients, I’m learning new things every day. I have wonderful opportunities to meet and interact with a broad variety of interesting and kind people.

Any words of wisdom for aspiring endocrinologists out there?

Endocrinology is a fantastic field! The diversity of endocrine disorders and the multi-system effects of hormones leads to a very integrative field that is intellectually stimulating and satisfying. There is still so much to be learned and so many research questions to be answered. Furthermore, the endocrine specialty provides the opportunity to have sustained, long-term relationships with patients and to observe the impact of treatment on their health and quality of life.

You can hear Professor Kaiser’s International Medal Lecture, “Puberty: what are the neuroendocrine triggers for the biological end of childhood?” on Monday 19 November, in the Lomond Auditorium at 14:15-14:45. Find out more about the scientific programme for SfE BES 2018.

Meet the Endocrinologist: Matthew Simmonds, expert in pancreatic transplant genomics

Meet the Endocrinologist: Meet Dr Matthew Simmonds a Senior Lecturer in Biomedical Science at the University of Lincoln. His research is focused on the genetics of pancreatic transplant function and he will be presenting at the Early Career session at SfE BES 2018, 19-21 November in Glasgow. In our latest interview, he tells us more about his work and what he is looking forward to at the SfE BES 2018 conference.

Can you tell us a little about your current position and research?

I am a Senior Lecturer at the University of Lincoln where I have been now for just over two years.  My research career has revolved around trying to identify genetic contributors to a series of autoimmune endocrine diseases including autoimmune thyroid disease and type-1 diabetes.  My current research is specifically focused on looking at genetic predictors of long-term pancreas transplant function in people with severe type 1 diabetes.

What inspired you in to this field?

The immune system is amazing and without it we would never have survived and evolved on this earth. What I find so interesting about the autoimmune endocrine diseases is how the immune system, which is meant to protect us, actually starts to attack parts of the body leading to changes in how the endocrine system works.  I am passionate about understanding how disease pathways are triggered/progress and how we can use these insights to inform better treatments for people with these different conditions.

What do you think are the biggest challenges in your field of research?

I think the major challenge within pancreas transplantation is both the number of donor organs available for transplantation into people with severe type-1 diabetes and trying to ensure that the transplanted organ remains functional throughout the recipient’s life to ensure the benefits these transplants provide, of retuning insulin production and halting/reversing secondary diabetes related complication in that person, remain for as long as possible.

What do you think will be the next major breakthrough in your field?

I think both the advances being made in using induced pluripotent stem cells, combined with gene editing, to create new beta cells, will provide unparalleled new opportunities for transplantation purposes. Combined with the decreased costs around genome and other proteomic screening for patients and our increased understanding of how genetic variation impact upon autoimmunity and transplant success this will give us new understanding of disease progression and provide better individual tailoring of therapeutics.

What will you be doing at SfE BES 2018 in Glasgow?

Well as you have asked – nothing like a bit of shameless plugging – I will be doing a talk on the Tuesday as part of the Early Careers session ‘Navigating the Academic Pathway’.  My talk is entitled ‘The lectureship route’ where I will be providing some insights into this career pathway, the challenges and benefits of this route and some tips on how to be get such a position.

What are you looking forward to at this year’s conference?

I think as an early career researcher I loved going to conferences to be able to present my work and network with others working in the field – which is the same reason I enjoy attending conferences to this day. Whilst there are lots of fantastic talks, plenaries and other sessions throughout the conference with something to suit everyone’s research interests, one thing I would suggest to early career researchers is to take time to speak to other early career researchers at the poster sessions and after their talks.  You would be surprised how much you have in common with other researchers and how random conversations at conferences can lead to new collaborations and possibly job offers in the future.

Who do you most admire and why?

 I have been really lucky to have worked with some of the most amazing researchers in diabetes and endocrinology throughout my career so far – both in the centres I have worked and through numerous collaborations. I have been very lucky to have some amazing mentors throughout the years, and think that whatever stage in your career you are at it is important to keep listening, learning and being inspired by researchers at every level.

What words of wisdom do you have for someone starting out in research?

These type of questions always make me feel old.  Joking aside, I think the best advice I can give to any early career researcher is to think about where you want your career to go but don’t be so rigid in your approach that you may miss out on some unexpected opportunities that come your way. Also listen to your gut feeling about career decisions.  Whilst is it perfectly normal to be scared to take on new challenges be it new techniques, moving into different project areas or new jobs, sometimes you instantly know if something is a good or a bad move. From my own experience I have learnt that sometimes saying no to something that is not right for you is as important as the opportunities you say yes to.

You can hear Dr Simmonds presentation, “The lectureship route” on Tuesday 20 November, as part of the Early Career: Navigating the Academic Pathway session at 16:00-17:30. Find out more about the scientific programme for SfE BES 2018.

 

 

Meet the Endocrinologist: Jeremy Turner, expert in bone and calcium endocrinology

Prof Jeremy Turner is a consultant endocrinologist at Norfolk and Norwich University Hospitals NHS Foundation Trust. He has a particular clinical interest in calcium and metabolic bone disorders and is a convenor of the Society’s Bone and Calcium Endocrine Network.

What inspired you into endocrinology, and bone and calcium in particular?

I was fortunate enough to undertake my early postgraduate training in endocrinology at the (then) Royal Post Graduate Medical School/Hammersmith Hospital in the mid-1990s, where I worked with some inspirational colleagues in the bone and calcium field. I then went on to undertake an MRC clinical training fellowship in Raj Thakker’s lab in Oxford. The latter experience firmly cemented the place of calcium and bone endocrinology in my endocrine repertoire.

Can you tell us a little about your current work?

I have been consultant endocrinologist for the last 9 years in Norwich and was more recently promoted to honorary professor at the Norwich Medical School. I run the clinical metabolic bone/calcium service in Norwich with my great friend and colleague Professor Bill Fraser. We have established a good reputation for our clinical service and referrals come in from far and wide. We provide over 120 consultant delivered lists per annum and have succeeded in getting Norwich recognised as a Paget’s Association Centre of Excellence.

Historically, bone and calcium disorders have been somewhat “Cinderella” conditions in the wider context of endocrine services and I particularly enjoy advocating for this population of patients and developing services in this area. I am medical advisor to Hypopara UK and of course promote the charity and its work to our large population of hypoparathyroid patients. I have led the writing of a number of clinical guidelines including a post-operative hypocalcaemia avoidance and management guideline, have developed services such as a one-stop osteoporosis clinic and am currently working with colleagues in Cambridge to set up a rare bone disease network in the East of England. Naturally, the achievement I am proudest of is being appointed as a network convenor for the Bone and Calcium Endocrine Network of the Society for Endocrinology!

Over the last decade or so, what do you think have been the most useful/impactful advances in bone and calcium?

As a pure endocrinologist, the single most exciting advance has been the arrival of recombinant human parathyroid hormone (PTH) for the treatment of hypoparathyroidism. Finally, clinical endocrinologists now have a “full set” of replacement hormones to use in hormone deficiency states and this day has been a long time coming. However, no answer to this question would be complete without reference to the arrival of the many new therapies for osteoporosis and perhaps, as importantly, the expansion in understanding of treatment of osteoporosis that has occurred in recent years. This has included appreciation of risks of treatments as well as benefits, how to use the different therapies, where they fit in relative to each other, the growing use of bone markers, fracture risk calculators and so on – all of which are driving more nuanced, considered and targeted clinical approaches to treatment of osteoporosis.

What do you think are the biggest challenges faced by endocrinologists?

In my opinion, the biggest challenge faced by all endocrinologists has to be management of remorselessly growing demand. The population is expanding and ageing and at the same time more treatments are available across endocrinology. Awareness is growing amongst patients and general practitioners and thus referral rates are rising. This is a good thing, it means that our specialty is able to help more and more people for whom perhaps help was not always available in the past and also means that the place of endocrinology in clinical medicine as a whole is better recognised and appreciated. However, it is up to us to manage this demand, find new ways to see and treat as many people as possible and to modernise aspects of our practice. Not changing how we work is probably not an option!

Are there any controversies in bone and calcium endocrinology?

Of course there are many controversies but one of the greatest at the moment is probably the recent recognition of the end-of-treatment effect of anti-RANK ligand therapy whereby fracture rates may rise quite fast in some patients upon withdrawal of this therapy. This is a very pressing clinical challenge as numbers on this exciting and novel treatment are quite large, we have been using this for a period of time that means that some are already arriving at what was originally intended to be the end of treatment but now we know that simply stopping the treatment is probably not the best option for many patients. At the same time, there is a relative lack of evidence base to inform us with regard to what we should be doing next. While it is helpful that some guidance is beginning to emerge, this is largely based on expert opinion and it will be very interesting to see how this controversy unfolds over the next few years.

What do you enjoy about being an Endocrine Network convenor?

 So far it is early days but I am enjoying working with my co-convenor (Caroline Gorvin), with colleagues in the society and am looking forward to playing my own very small part in further raising the profile of bone and calcium medicine and research within endocrinology.

Do you have any words of wisdom for aspiring endocrinologists?

Yes, this is perhaps the easiest question; Enjoy your endocrinology! If you are enjoying your clinical practice you will be happy and more importantly your patients will be happy, correctly diagnosed and correctly treated.

 

The Endocrine Networks are platforms for knowledge exchange and collaboration amongst basic and clinical researchers, clinical endocrinologists and endocrine nurses. The Networks enable members to discuss and find solutions to challenges within their specialist field.

To join an Endocrine Network login to the ‘My profile’ section of the Members’ Area and select ’Endocrine Networks’.

Meet the Endocrinologist: Petros Perros, thyroid disease expert

Dr Petros Perros is Honorary Clinical Senior Lecturer at Newcastle University, and a consultant in endocrinology at Newcastle Hospitals. His clinical and research interests focus on the study of thyroid disease, and he is a convenor of the Society’s Thyroid Network.

What inspired you into medicine and why did you focus on thyroid disease?

I got inspired into medicine through observing the impact of successful treatments on people’s lives and the misery brought onto those who are incurable. Appreciating that science was the key to solving those problems was my main motivator to pursue a career in medicine.

As a student, I was attracted by the relevance of endocrinology in every system and organ, and the beauty and elegance that was revealed from studying it. The frequency of thyroid conditions and the interests of my mentors contributed towards my focusing in this area. However, I can also recall how impressed I was when I read about the discovery of the therapeutic role of radioiodine in hyperthyroidism and thyroid cancer: a perfect marriage of physics and clinical medicine leading to the first “magic bullet” treatment in medicine.

Can you tell us a little about your work?

Graves’ orbitopathy (GO), also known as thyroid eye disease (TED), has been the focus of my clinical and academic interests. This has enabled me to work closely with colleagues in other disciplines, which has been immensely rewarding.

There are rapid advances in understanding the pathophysiology of GO, and a plethora of biologics are already available and beginning to be used with impressive results. Besides the high tech available, the realisation that low cost, conventional interventions can influence the course of this disease has also made the topic of implementation very interesting and challenging. Now is a fascinating time for people working in this area.

What do you think have been the most impactful advances in thyroid clinical practice and research?

For thyroid research, one of the most relevant outcomes of the Human Genome Atlas has been the demonstration that the commonest thyroid cancer (papillary) has one of the simplest genetic mutational repertoires, so the scope for therapeutic interventions to silence driver mutations is a realistic expectation. I anticipate that prognostic evaluations and novel thyroid cancer treatments will reach the clinical arena in the next decade as a direct result of this.

What will be the next breakthrough for treatment or diagnosis of thyroid conditions?

In my opinion, targeted therapies in advanced thyroid cancer are at the top of the list. Immunotherapies for autoimmune thyroid disease are also emerging. In basic research, we can expect to learn more about the application of regenerative medicine in thyroidology, and we will hear a lot more about the role of thyroid hormones in dementia.

What are the biggest challenges faced by your clinical specialty?

We need to reverse the tide of unnecessary investigations and treatments relating to endocrinology, as this has an enormous negative impact on patient care and wastes large amounts of resources. Another challenge is attracting the brightest doctors and scientists to our discipline, and strengthening the links between endocrinology as a clinical specialty and as a scientific area.

Are there any controversies in your practice area?

Some decades ago, we thought that we had solved the problem of thyroid hormone replacement. Yet, some patients remain dissatisfied, seek alternatives, and have recently launched a war against “conventional” endocrinologists. Unfortunately this is exacerbated by self-appointed experts from the dark alleys of alternative medicine, who exploit human suffering and desperation. However, on the bright side of things, this controversy has raised some valid research questions that are answerable by scientific investigation, and the new knowledge gained from it will help resolve some of these issues.

What do you enjoy about being a Network convenor?

I particularly enjoy the interaction with colleagues, especially the young ones. Endocrine networks have a great potential for bringing individuals with similar interests together and promoting research in endocrinology.

Do you have any words of wisdom for aspiring endocrinologists?

If you find endocrinology intriguing, delve into it and have a taste. Don’t be put off if it seems too complicated – it only means there is more to discover. Endocrinology is a great specialty full of surprises and rewards.

Find out more about the Society’s Endocrine Networks, and how they can provide a platform for knowledge exchange in your area of focus.