Endocrine Notes - Cleveland Clinic · Endocrine Notes The Cleveland Clinic Foundation Endocrinology & Metabolism Institute Endocrine Notes 9500 Euclid Avenue / AC311 Cleveland, OH

2011

Updates for physicians on practices, advances and research from Cleveland Clinic’s Endocrinology & Metabolism Institute

Endocrine Notes

The Cleveland Clinic Foundation Endocrinology & Metabolism Institute Endocrine Notes 9500 Euclid Avenue / AC311 Cleveland, OH 44195

In This Issue:

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clevelandclinic.org /ic.

MyChart®Cleveland Clinic MyChart® is a secure, online personal health-

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their medical record at any time of day or night. Patients may

view test results, renew prescriptions, review past appoint-

ments and request new ones. A new feature, Schedule My

Appointment, allows patients to view their primary physician’s

open schedule and make appointments online in real time.

Patients may register for MyChart® through their physician’s

office or by going online to ccf.org/mychart.

Critical Care Transport WorldwideCleveland Clinic’s critical care transport teams and fleet of

mobile ICU vehicles, helicopters and fixed-wing aircraft serve

critically ill and highly complex patients across the globe. Trans-

port is available for children and adults. To arrange a transfer

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(intracerebral hemorrhage), SAH (subarachnoid hemorrhage)

or aortic syndromes, call 877.379.CODE (2633). For all other

critical care transfers, call 216.448.7000 or 866.547.1467

or visit clevelandclinic.org/criticalcaretransport.

Physician Directory

View all Cleveland Clinic staff

online at clevelandclinic.org/staff.

Outcomes Data View the latest clinical Outcomes

books from Cleveland Clinic’s Endo-

crinology & Metabolism Institute at

clevelandclinic.org/quality/outcomes.

Referring Physician Center

For help with service-related issues,

information about our clinical special-

ists and services, details about CME

opportunities and more, email

[email protected], or call 216.448.0900

or 888.637.0568.

CME Opportunities: Live & Online

Cleveland Clinic’s Center for Continuing Education’s website offers convenient, complimentary learning opportunities, from patient simulations, webcasts and podcasts to a host of medical publica-tions and a schedule of live CME courses. Physicians can manage CME credits using the myCME.com Web portal available 24/7. Visit ccfcme.org.

C l E v E l a N d C l I N I C r E s o u r C E G u I d E

Track Your Patient’s Care onlineDrConnect is a secure online service providing our phy-

sician colleagues with real-time information about the

treatment their patients receive at Cleveland Clinic. To

receive your next patient report electronically, establish

a DrConnect account at clevelandclinic.org/drconnect.

request Medical records216.445.2547 or 800.223.2273, ext. 52547

EMI referralsEndocrinology & Metabolism Institute 216.444.6568 or 800.223.2273, ext. 46568

Bariatric Surgery 216.445.2224 or 800.223.2273, ext. 52224

2 New Entity: Primary Hyperparathyroidism with Normal PTH

4 a rare Case of acromegaly diagnosed during Pregnancy

6 robotic approach Preferred for adrenalectomy

8 sTaMPEdE substudy asks Whether Gastric Bypass reverses Beta Cell dysfunction

9 sTaMPEdE II study Now Enrolling Patients

10 Bariatric surgery Now standard Treatment for Morbidly obese diabetic Patients

11 Gastric Plication Holds Promise for Extreme Weight loss

12 Adult Growth Hormone Deficiency: Study Compares Glucagon stimulation Test to Insulin Tolerance Test

14 Publications

18 live and online CME

19 Current Clinical Trials

20 staff directory

11-ENd-008

Cleveland Clinic’s diabetes & Endocrinology Program is ranked 5th in the nation in U.S.News & World Report’s annual america’s Best Hospitals survey.

77763_CCFBCH_Cover_ACG.indd 1 11/15/11 7:36 AM

hio

Endocrine Notes

Chairman, Endocrinology & Metabolism Institute

James B. Young, MD

Managing Editor

Cora M. Liderbach

Art Director

Mike Viars

Marketing

Bill Sattin, PhD

Mary Anne Connor

Endocrine Notes updates physicians on clinical prac-

tices, advances and research from Cleveland Clinic’s

Endocrinology & Metabolism Institute. It is written for

physicians and should be relied upon for medical education

purposes only. It does not provide a complete overview of

the topics covered and should not replace the independent

judgment of a physician about the appropriateness or risks

of a procedure for a given patient.

© 2011 The Cleveland Clinic Foundation

Contact usGeneral Patient Referral

24/7 hospital transfers or physician

consults – 800.553.5056

Endocrinology & Metabolism Institute

Appointments/Referrals

216.444.6568 or 800.223.2273,

ext. 46568

Bariatric Surgery


216.445.2224 or 800.223.2273,

ext. 52224

On the Web at

clevelandclinic.org/endonotes

Endocrinology & Metabolic Institute locationsMain Campus

9500 Euclid Ave./F20

Cleveland, Ohio 44195

216.444.6568

Endocrinology & Metabolic

Institute Diabetes Center

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216.444.6568

Ashtabula County Medical Center

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440.997.6969

Cleveland Clinic Beachwood

Family Health and Surgery Center

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Cleveland Clinic Independence

Family Health Center

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Cleveland Clinic Lorain


5700 Cooper Foster Park Road

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Cleveland Clinic Solon

Family Heath Center

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Cleveland Clinic Stephanie

Tubbs Jones Health Center

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East Cleveland, Ohio 44112

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Health and Surgery Center

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Leila Khan, MDSpecialty Interest(s): General endocrinology, diabetes, calcium/bone disordersLocation(s): Main campus; Willoughby Hills Family Health CenterOffice: 216.445.1598 | Fax: 216.445.1656Appointments: Main campus, 216.444.6568; Willoughby Hills, 440.943.2500

M. Cecilia Lansang, MD, MPHSpecialty Interest(s): General endocrinology, diabetesLocation(s): Main campusOffice: 216.445.5246 | Fax: 216.445.1656Appointments: 216.444.6568

Melissa Li-Ng, MDSpecialty Interest(s): General endocrinology, diabetesLocation(s): Main campus; Solon Family Health CenterOffice: 216.444.1949 | Fax: 216.445.1656Appointments: Main campus, 216.444.6568; Solon, 440.519.6800

Vinni Makin, MDSpecialty Interest(s): General endocrinology, diabetes, hirsutism, acne, thyroid disordersLocation(s): Main campus; Solon Family Health CenterOffice: Main campus, 216.444.0539; Solon, 440.519.6800 | Fax: Main campus, 216.445.1656; Solon, 440.519.6908Appointments: Main campus, 216.444.6568; Solon, 440.519.6800

Adi Mehta, MDSpecialty Interest(s): Diabetes mellitus, thyroid disorders, gynecologic endocrinology, endocrine complications of pregnancy, menopause, lipid disorders, general and adolescent endocrinologyLocation(s): Main campus; Beachwood Family Health Center (Reproductive Endocrinology only)Office: 216.445.5312 | Fax: 216.445.7261Appointments: Main campus, 216.444.6568; Beachwood, 216.839.3000

Guy Mulligan, MDSpecialty Interest(s): General endocrinology, diabetesLocation(s): Main campus; Twinsburg Family Health and Surgery Center; South Pointe/Charles Miner Medical BuildingOffice: 330.888.4000 | Fax: 330.963.4561Appointments: Main Campus, 216.444.6568; Twinsburg, 330.888.4000; South Pointe, 216.295.1010

Christian Nasr, MDCo-director, Thyroid CenterSpecialty Interest(s): Thyroid nodules, thyroid cancers, flushing syndromesMain campus; Lorain Family Health and Surgery Center (Thyroid cancer only)Office: 216.445.1788 | Fax: 216.445.1656Appointments: Main campus, 216.444.6568; Lorain, 440.204.7400

Leann Olansky, MDSpecialty Interest(s): Diabetes and diabetes complica-tions, gestational diabetes, general endocrinologyLocation(s): Main campus; Stephanie Tubbs Jones Health CenterOffice: 216.444.2642 | Fax: 216.445.1656Appointments: Main campus, 216.444.6568; Stephanie Tubbs Jones Health Center, 216.767.4242

Richard Shewbridge, MDSpecialty Interest(s): Endocrinology, diabetes, thyroid disorders, hyperlipidemia, osteoporosisLocation(s): MedinaOffice: 330.725.3713 | Fax: 330.725.2141Appointments: 330.725.3713

Mario Skugor, MDCo-director, Thyroid CenterAssociate Director, Endocrinology Fellowship ProgramSpecialty Interest(s): Osteoporosis and calcium metabolism, obesity and diabetes, multiple endocrine neoplasia syndromes, thyroid disorders, thyroid cancerLocation(s): Main campusOffice: 216.445.0739 | Fax: 216.445.1656Appointments: 216.444.6568

David Shewmon, MDSpecialty Interest(s): General endocrinology, diabetes, high cholesterol, osteomalacia, osteoporosis, pituitary tumors, thyroid conditions, thyroid cancerLocation(s): Wooster Family Health CenterOffice: 330.287.4690 | Fax: 330.287.4876Appointments: 330.287.4690

Mariam Stevens, MDSpecialty Interest(s): Diabetes, gestational diabetes, goiter, Graves’ disease, Hashimoto’s disease, hirsutism, hyperthyroidism, hypoglycemia, hypothyroidism, polycystic ovary syndrome, thyroid disease, thyroid noduleLocation(s): Independence Family Health CenterOffice: 216.986.4000 | Fax: 216.986.4995Appointments: 216.986.4000

Robert Zimmerman, MDDirector, Cleveland Clinic Diabetes CenterVice Chairman, Department of Endocrinology, Diabetes and MetabolismProgram Director, Endocrinology Training ProgramSpecialty Interest(s): Diabetes, thyroid disorders, growth hormone in adultsLocation(s): Main campusOffice: 216.444.9428 | Fax: 216.445.1656Appointments: 216.444.6568

Department of Endocrine Surgery

Eren Berber, MDDirector, Robotic Endocrine SurgerySpecialty Interest(s): Endocrine surgery (thyroid and parathyroid), laparoscopic solid-organ surgery, advanced laparoscopic surgery, laparoscopic radiofrequency ablation of liver tumors, pancreatic neuroendocrine tumors, robotic thyroid and parathyroid surgery, laparoscopic and robotic adrenalectomy and liver surgeryLocation(s): Main campusOffice: 216.445.0555 | Fax: 216.636.0662Appointments: 216.444.6568

Kresimira (Mira) Milas, MDDirector, Thyroid CenterSpecialty Interest(s): Endocrine surgery (thyroid and parathyroid), thyroid cancer, multiple endocrine neoplasia syndromes, hereditary thyroid disordersLocation(s): Main campusOffice: 216.444.4985 | Fax: 216.636.0662Appointments: 216.444.6568

Jamie Mitchell, MDSpecialty Interest(s): Endocrine surgery (thyroid, parathyroid and adrenal), laparoscopic solid organ surgery, advanced laparoscopic surgery, laparoscopic radiofrequency ablation of liver tumorsLocation(s): Main campus; Independence Family Health Center; Solon Family Health CenterOffice: 216.445.9713 | Fax: 216.636.0662Appointments: Main campus, 216.444.6568; Independence, 216.986.4000; Solon, 440.519.6800

Joyce J. Shin, MDSpecialty Interest(s): Endocrine surgery (thyroid and parathyroid), advanced laparoscopic surgery, laparoscopic adrenalectomy, neuroendocrine tumors, thyroid/parathyroid ultrasound, intra-abdominal ultrasound, laparoscopic radiofrequency thermal ablation of liver tumorsLocation(s): Main campus; Willoughby Hills Family Health CenterOffice: 216.636.9365 | Fax: 216.636.0662Appointments: Main campus, 216.444.6568; Willoughby Hills, 440.943.2500

Allan Siperstein, MD Department ChairSpecialty Interest(s): Endocrine surgery (thyroid and parathyroid), advanced laparoscopic surgery, laparoscopic adrenalectomy, laparoscopic thermal ablation of liver tumors, pancreatic endocrine tumorsLocation(s): Main campusOffice: 216.444.5664 | Fax: 216.636.0662Appointments: 216.444.6568

Bariatric and Metabolic Institute

Stacy Brethauer, MDSpecialty Interest(s): Bariatric surgery, laparoscopic surgery, gastrointestinal surgery, hernia repair, endoscopy, surgery for GERD, hiatal hernia, solid-organ endoluminal surgery, single-incision laparoscopic surgeryLocation(s): Main campusOffice: 216.444.9244 | Fax: 216.445.1586Appointments: 216.445.2224

Derrick Cetin, DOSpecialty Interest(s): Bariatric medicine, medical weight management, nutrition sciences, obesity management, preoperative evaluation, diabetes careLocation(s): Main CampusOffice: 216.445.4255 | Fax: 216.636.1588Appointments: 216.445.2224

Bipan Chand, MDSpecialty Interest(s): Advanced laparoscopy and endoscopy, endoscopy in the obese patient, gastric surgery focusing on reflux disease, hiatal hernia, bariatric operations and gastric cancer, biliary and spleen surgery, natural orifice transluminal endoscopic surgery (NOTES), endoluminal surgeryLocation(s): Main campusOffice: 216.444.6668 | Fax: 216.445.1586Appointments: 216.445.2224

Karen Cooper, DOSpecialty Interest(s): Bariatric medicine, family medicine, kinesiology and nutrition sciences, exercise instructionLocation(s): Main campusOffice: 216.445.1114 | Fax: 216.445.1586Appointments: 216.445.2224

Matthew Kroh, MDSpecialty Interest(s): Advanced laparoscopic surgery, bariatric surgery, gastrointestinal surgery, endoscopy, single-incision laparoscopic surgeryLocation(s): Main campus Office: 216.445.9966 | Fax: 216.444.2153Appointments: 216.445.2224

Tomasz Rogula, MD, PhDSpecialty Interest(s): Advanced laparoscopic surgery, bariatric surgery, gastrointestinal surgery, endoscopy, single-incision laparoscopic surgeryLocation(s): Main campus; Strongsville Family Health and Surgery CenterOffice: 216.445.0255 | Fax: 216.445.1586Appointments: Main campus: 216.445.2224; Strongsville: 440.878.2500

Philip Schauer, MDDepartment ChairSpecialty Interest(s): Bariatric surgery, laparoscopic surgery, gastrointestinal surgery, colon surgery, weight management, hernia surgery, biliary surgery, surgery for GERDLocation(s): Main campusOffice: 216.444.4794 | Fax: 216.445.1586Appointments: 216.445.2224

Endocrinology & Metabolism Institute | staff Directory

Visit clevelandclinic.org/EndoStaff for the most current staff listings and locations.

77763_CCFBCH_Cover_ACG.indd 2 11/8/11 12:14 PM

Endocrine Notes | 1 | 2011 800.223.2273, ext. 46568 | 1 | clevelandclinic.org/endonotes

Dear Colleagues,

I am pleased to present the 2011 edition of Endocrine Notes from Cleveland Clinic’s Endocrinology & Metabolism Institute.

Inside, we offer highlights from our multidisciplinary team’s most recent work:

• Our report on a new parathyroid disease entity: primary hyperparathyroidism with normal PTH levels.

• A rare case of acromegaly that was diagnosed during pregnancy.

• A report on our experience with robotic adrenalectomy, which has become the preferred surgical approach.

• A STAMPEDE substudy examining the clinical and metabolic factors involved in remission and non-remission of diabetes after gastric bypass surgery.

• Information about the STAMPEDE II trial.

• The designation of bariatric surgery as a first-line treatment for type 2 diabetes in the morbidly obese and the promise that gastric plication holds for drastic weight reduction.

• A study evaluating the glucagon stimulation test as an alternative to the insulin tolerance test for determining growth hormone deficiency in adults.

The Endocrinology & Metabolism Institute is one of 26 Cleveland Clinic institutes that group related specialties together to provide integrated, patient-centered care. Collaboration among endocrinologists, endocrine surgeons, bariatricians, bariatric surgeons and a cardiologist allows us to transcend the traditional borders between disciplines to improve patient care.

Throughout our institute, our staff remains committed to Cleveland Clinic’s core ideology: “Patients First.” Our institute comprises:

• The Department of Endocrinology, Diabetes and Metabolism, which manages specialized centers of care for patients with diabetes, thyroid disorders and pituitary disorders.

• The Department of Endocrine Surgery, which performs the highest number of surgical procedures in the region.

• The Bariatric and Metabolic Institute, which has been designated a Bariatric Surgery Center of Excellence by the American Society for Metabolic and Bariatric Surgery.

I hope that you find this issue of Endocrine Notes useful for your practice. Your comments and questions are always welcome. Please feel free to contact me at 216.444.6568 or 800.223.2273, ext. 46568.

Sincerely,

James B. Young, MDChairman, Endocrinology & Metabolism Institute Professor of Medicine and Executive Dean, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University George and Linda Kaufman Chair Physician Director, Institutional Relations and Development

77763_CCFBCH_Text_ACG.indd 1 11/15/11 7:16 AM

Endocrine Notes | 2 | 2011

We conducted a review of 843 patients who had undergone

initial bilateral parathyroid exploration at Cleveland Clinic

between January 2005 and December 2010. Of the study

population, 46 patients (5.5 percent) were found to have

preoperative iPTH values within the normal reference range

(10-60 mg/mL at Cleveland Clinic, or the normal range

at the testing laboratory). All 46 had hypercalcemia, with

values up to 12.5 mg/dL.

A review of medical histories found that PHP had been

discovered incidentally in 74 percent of patients. However,

70 percent had at least one symptom of PHP, 50 percent

had abnormal bone density studies, 17 percent had a history

of nephrolithiasis, and 37 percent reported neuropsychiatric

symptoms such as fatigue, irritability, altered mood, poor

concentration or declining memory. None had a family history

of PHP or hypercalcemia. Preoperative localization studies

accurately detected parathyroid disease in 80 percent.

The study also noted three subgroups of NHPHP:

consisted of 7 patients with preoperative iPTH

values < 40 pg/mL, the lowest measuring 5 pg/mL.

consisted of 19 patients, all having

consisted of 20 patients who occasionally

demonstrated iPTH values > 60 pg/mL, even though most

In Cleveland Clinic’s Department of Endocrine Surgery, we

have described another entity of PHP, which we have desig-

nated normohormonal primary hyperparathyroidism (NHPHP).

Patients with this entity have high calcium levels but normal-

to-low PTH levels – as low as 5 pg/mL. Knowledge of this

subgroup may help the diagnosis of PHP to be made earlier.

We feel it is appropriate to accept this atypical biochemistry

-

tation. These patients have clearly enlarged parathyroids,

classical patient. This is a real subtype of the disease.

Primary hyperparathyroidism (PHP) is not rare. One percent of the population and 2 percent of women

over age 55 develop this condition. When they do, they normally manifest the classical picture of high

calcium and high parathyroid hormone (PTH) measurements in the blood. But atypical presentations

are becoming more appreciated; a case in point is normocalcemic PHP. Ten percent of patients will have

normal calcium levels and high PTH, making PHP hard to differentiate from other causes of elevated PTH.

Primary HyperparathyroidismWith Normal PTH Levels: A Modern Parathyroid Disease Entity

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800.223.2273, ext. 46568 | 3 | clevelandclinic.org/endonotes

Other than the preoperative iPTH values, there were no

classical PHP patients for any of the following features: age,

gender, degree of hypercalcemia, 24-hour urinary calcium

value and vitamin D levels, rate of parathyroid adenoma

(74 percent) versus multi-gland disease (24 percent), and

size of abnormal parathyroids. All NHPHP patients had

resolution of hypercalcemia following surgery.

A few distinct subgroup differences are interesting to

highlight. For example, patients in subgroups I and II were

more commonly diagnosed by the endocrine surgeon after

being referred for thyroid disease, as compared with patients

who had higher iPTH values. Subgroup I had the lowest

prevalence of bone loss and neuropsychiatric symptoms.

Preoperative localization studies failed to detect abnormal

parathyroid glands more often in patients with lower iPTH

values, despite a similar prevalence of parathyroid adenomas

and abnormal gland volumes.

Given such differences among the subgroups, we initially

wondered whether we were simply diagnosing PHP at an

earlier phase of disease evolution. However, when we found

similar degrees of hypercalcemia, morphology of parathyroid

disease and abnormal gland volume among all subgroups,

we became convinced that NHPHP is a real entity – a

distinct phenotype of PHP.

In our publication, we suggest several possible explanations for

the NHPHP phenomenon. One hypothesis is derived from PTH

patterns before and after surgery (illustrated in the graph on

page 2.) These patterns suggest that some patients may have

parathyroids that simply function at a lower “set-point” for PTH.

At Cleveland Clinic, the usual practice is to proceed to

diagnosis of PHP. NHPHP patients had multiple additional

data points of serum calcium and iPTH before proceeding

to surgery. Some were given more elaborate tests, such as

PTHrp measurement, SPEP, selective venous sampling or CT

scanning to evaluate for malignancy. The additional testing

did not elucidate other etiologies of hypercalcemia, and all

patients had PHP.

Having performed this study and having this data to refer-

ence, we are comfortable recommending an imaging workup

hypercalcemia will be more likely so that expensive additional

tests will be mandatory for all. However, we believe that

additional testing should be performed selectively based on

an individual patient’s medical history.

The study suggests that when patients have high calcium

levels but iPTH levels < 60 pg/mL and even < 40 pg/mL,

the diagnosis of primary hyperparathyroidism should be

considered, particularly if no other etiology of hypercalcemia

and surgery is curative.

Dr. Milas is Director of the Thyroid Center; Dr. Wallace worked

with her and other Cleveland Clinic endocrine surgeons on this

study as a fellow in the Department of Endocrine Surgery.

For more information, please contact Dr. Milas at

216.444.4985 or at [email protected].

By Mira Milas, MD, and Lucy B. Wallace, MD



A 30-year old woman, G2P1, 13 weeks’ gestation, was referred to specialists in

Cleveland Clinic’s Endocrinology & Metabolism Institute and Ob/Gyn & Women’s

Health Institute. She presented with clinical features suggestive of acromegaly,

including worsening headache, coarse facial features, acne, increased jawline,

and enlargement of the hands and feet over two years. The IGF-1 level of

816 ng/mL was elevated (nonpregnant reference range: 138-410). A pregnancy

two years earlier was uneventful.

The labs revealed a prolactin of 99 ng/mL (2.0-17.4); a repeat IGF-1 of

1,085 ng/mL; and basal and nadir GH of 13.9 and 12.8 ng/mL, respectively,

during oral glucose tolerance testing. Glucose levels, blood pressure and visual

field tests were normal. Pituitary MRI without contrast revealed a 1.5 cm

macroadenoma with no impingement on the optic chiasm.

Severe headache prompted therapy, but the patient was unable to tolerate the

dopamine receptor agonist bromocriptine. She was then started on 50 μg of the

Pregnancy in patients with acromegaly is rare, with less than 150 cases

reported in the literature. Currently, there are no guidelines regarding the

diagnosis or management of acromegaly during pregnancy.

The diagnosis and monitoring of acromegaly during pregnancy are complicated

by the presence of a placental growth hormone (GH) source, resulting in

physiologic changes in pituitary GH secretion and insulin-like growth factor-1

(IGF-1) production. Commercial assays cannot distinguish between pituitary

GH and placental GH.

Fertility is decreased in women with acromegaly due to altered gonadotropin

secretion, but the following case illustrates that when pregnancy does occur, its

outcome is usually favorable. Metabolic complications are uncommon, and most

patients do not experience an increase in the size of their pituitary adenomas.

A Rare Case of AcromegalyDiagnosed During Pregnancy



somatostatin analog octreotide every eight hours at 19

weeks’ gestation, which resulted in significant headache

relief and clinical improvement. The IGF-1 level decreased

to 671 ng/mL and remained relatively stable during the

rest of the pregnancy, while the GH level progressively

increased, peaking at 43.9 ng/mL at 33 weeks’ gestation.

At 38 ½ weeks’ gestation, the patient delivered a healthy

baby girl (3355 g). Breastfeeding was unsuccessful due

to lack of milk production. At one week postpartum, while

the patient remained on octreotide, the GH level declined

inexplicably to 1.13 ng/mL. At four weeks postpartum,

the GH and IGF-1 levels were 15.2 ng/mL and 1090

ng/mL, respectively.

Scheduling surgery after delivery

Pituitary MRI at four weeks postpartum showed that the

patient’s adenoma was stable. She underwent transsphe-

noidal resection of the adenoma, which immunostained

positively for GH, but surgery failed to achieve a biochem-

ical cure. Postoperatively, the GH level was 7.5 ng/mL,

and the IGF-1 level was 892 ng/mL. She was started on

a long-acting somatostatin analog.

Treatment considerations during pregnancy

As was true for this patient, the majority of pregnancies in

patients with acromegaly are uneventful, and newborns

are unaffected. Even without treatment, research to date

shows that little change in the size of pituitary adenomas

and no worsening of visual fields during pregnancy are to

be expected.

Dopamine agonists and somatostatin analogs appear to be

safe during pregnancy, but because safety data are sparse,

their usage is generally reserved for symptomatic patients.

The use of the GH receptor antagonist pegvisomant seems

promising during pregnancy when somatostatin analogs

and surgery fail to control tumor growth. However, experi-

ence with pegvisomant is extremely limited, so its use will

require further study.

Surgery can be safely postponed until after delivery for

most patients except when it is needed in an emergency

for acute visual loss or pituitary apoplexy.

About the authors

Dr. Cheng worked on this case as a fellow in the Department of

Endocrinology, Diabetes and Metabolism with Laurence Kennedy, MD,

Chair, and endocrinologists Amir Hamrahian, MD, Charles Faiman, MD,

and Betul Hatipoglu, MD; and with obstetrician Fadi Khoury, MD.

For further information, contact Dr. Hamrahian at

216.445.8538 or [email protected], or Dr. Kennedy at

216.445.8645 or [email protected].

Imaging

MRI of the pituitary without contrast revealed a macroadenoma measuring1.0 x 1.5 x 1.0 cm with noimpingement of the optic chiasmMRI of the pituitary without contrast revealed a macroadenoma that measured 1.0 x 1.5 x 1.0 cm with no impinge-ment of the optic chiasm.

IMAGING

By Vicky Cheng, MD, and Laurence Kennedy, MD

Based on poster presentation at American Association of Clinical Endocrinologists (AACE)

20th Annual Meeting and Clinical Congress, San Diego, Calif., April 13-17, 2011.



After several years’ experience in performing

robotic adrenalectomies, Cleveland Clinic endo-

crine surgeons have found that robotic surgery

provides significant advantages over conven-

tional laparoscopy. To date, they have performed

more than 71 robotic adrenalectomies with no

complications and no mortality.

“Increased dexterity from articulating instruments

and 3-D vision makes dissection faster and easier.

As a result, we are able to remove larger tumors

minimally invasively that would have otherwise

required an open operation,” says Cleveland Clinic

endocrine surgeon Eren Berber, MD, below, who

spearheads the technology and is training other-

Endocrinology & Metabolism Institute surgeons.

“Moreover, when we compared the robotic series

with past laparoscopies, it became clear that

the duration of the surgery was similar, if not

shorter, despite removing larger tumors.

“We also noticed a trend toward a shorter hospi-

tal stay. Overall, both immediate postoperative

pain and length of stay were slightly less with

the robotic approach.”

Robot ideal for posterior approach

Additionally, robotic technology has enabled the surgeons

to refine the posterior approach, which Dr. Berber and his

colleagues were first in the world to describe.

“Rigid laparoscopic instruments made the procedure cumber-

some, but the articulated instrumentation provided by the

robot makes the operation more ergonomic,” he explains.

“With the robot, we have fewer instrument collisions and

can reach difficult angles more easily.

“Although the posterior approach is technically more demand-

ing, we prefer it over the lateral transabdominal approach.

Because we do not enter the intra-abdominal cavity, patients

have less postoperative pain and may recover faster.”

The surgeons especially favor the posterior approach in

certain patients with bilateral tumors or significant abdominal

scarring. However, they prefer the lateral transabdominal

approach for patients with thicker back tissue or with

tumors larger than 6 cm.

The robotic approach also compares favorably to the

laparoscopic approach in posterior procedures. “Posterior

Now the Preferred Approach to Adrenalectomy

Robotic Surgery



robotic adrenalectomy is about 30 minutes faster than

posterior laparoscopic adrenalectomy,” notes Dr. Berber.

Large volume of adrenal procedures

Cleveland Clinic’s volume of adrenal operations is one of

the largest in the world, notes Dr. Berber, who believes that

a comprehensive adrenal surgery program should offer

a variety of surgical options.

Open adrenalectomy is available for tumors that have

invaded surrounding structures. Dr. Berber and colleagues

also offer radiofrequency ablation, a technique they pio-

neered in the treatment of adrenal tumors. Patients with

unresectable tumors and patients too sick for surgery are

ideal candidates for radiofrequency ablation.

Other robotic procedures offered

Cleveland Clinic endocrine surgeons offer a comprehensive

spectrum of surgical procedures, including robotic alterna-

tives. For example, besides robotic adrenalectomy, Cleveland

Clinic endocrine surgeons have amassed one of the largest

experiences with robotic thyroidectomy and robotic parathy-

roidectomy in the United States.

These procedures are performed through axillary incisions

to eliminate visible scarring on the neck.

Tracking adrenal tumor patients’ outcomes

Data from all adrenal tumor patients is entered into an

IRB-approved registry that is used to evaluate outcomes

and compare surgical options. The registry, started in 2000,

now contains information on 300 cases.

Dr. Berber directs a weekly multidisciplinary adrenal diseases

clinic with Cleveland Clinic endocrinologists and radiologists.

To refer patients for evaluation or for further information,

please contact Dr. Berber at 216.445.0555 or at

[email protected].

The posterior robotic approach avoids the intra-abdominal cavity, reduces immediate postoperative pain and shortens length of stay.

Dissection during a robotic adrenalectomy.



“Weight loss is a key component in the resolution of type 2 DM,

and bariatric surgery can be highly effective in inducing

weight loss,” says Cleveland Clinic endocrinologist Sangeeta

Kashyap, MD. “However, DM does not always resolve with

bariatric surgery, even with optimal weight loss.”

A Cleveland Clinic study, Surgical Therapy and Medications

STAMPEDE), is

bypass surgery, sleeve gastrectomy and advanced medical

percent) among diabetic patients who are moderately obese

(BMI 27-43 Kg/m2). Philip Schauer, MD, Director of the

Bariatric and Metabolic Institute (pictured above), is

principal investigator.

STAMPEDE

in helping many patients achieve glycemic control, yet a

number of patients have been unable to achieve or maintain

DM remission despite dramatic weight loss. This prompted Dr.

Kashyap to launch a substudy of STAMPEDE, funded by the

American Diabetes Association, to examine the clinical and

metabolic factors determining DM non-remission after either

Roux-en-Y gastric bypass or sleeve gastrectomy.

“As endocrinologists, we need to understand which patients

patient selection and determine the point at which surgery

should be recommended,” says Dr. Kashyap.

“Data from this study, in conjunction with clinical trial data,

changes in intestinal hormones and fat-generated hormones

following various bariatric procedures.”

This will help to further understanding of the potential bariat-

ric surgery holds for the treatment of DM in moderate obesity.

The study may also be useful in establishing appropriate

expectations, because patients with DM expect their disease

to resolve following bariatric surgery.

After surgery, not all patients are likely to achieve com-

plete remission. Dr. Kashyap believes this may be due to

poor baseline residual B-cell function and a lack of incretin

stimulation induced by either procedure. It is currently

unclear whether weight loss alone or incretin-related effects

on B-cell function is the dominant mechanism related to

long-term DM remission.

“Given their potential to enhance insulin secretion, promote

B-cell growth and induce weight loss, understanding the dif-

ferential response of incretin hormones to the various bariatric

procedures in patients who achieve DM remission versus

non-remission is critical,” she says.

The ability of bariatric surgery to reverse DM may depend on

disease duration and severity. Patients with recent-onset DM

and mild hyperglycemia who do not require insulin are likely

to have the greatest baseline B-cell function. Those with poor

Bariatric surgery is now widely accepted for the

treatment of severe obesity, with approximately

200,000 procedures performed in the United

States yearly. With more than 50 percent of type 2

surgery has tremendous therapeutic potential.

STAMPEDE Substudy Examines Factors Underlying Diabetes Remission or Non-Remission



residual B-cell function at baseline may not experience the

improvements in insulin sensitivity and thus achieve only

partial remission or nonremission.

A second issue to evaluate is the effect of weight regain on

DM. Although most patients experience substantial weight

loss in the 12 months following bariatric surgery, weight

regain beginning in year two does occur in some patients.

Dr. Kashyap hopes to determine how weight regain leads to

non-response by establishing the weight-related effects on

lipotoxicity-mediated insulin resistance 12 and 24 months

following bariatric surgery.

Lipotoxicity plays a central role in inducing B-cell dysfunction

and insulin resistance, which lead to the development of DM.

Therefore, “the impact of bariatric surgery on the weight-

related and non-weight-related effects of lipotoxicity must be

determined in patients achieving longer-term, complete DM

remission versus non-remission,” she says. “Since weight

regain is associated with an increase in fat mass, we expect

to see a direct impact of weight regain on impairing insulin

sensitivity and glucose tolerance.”

One-year outcomes for the study will be available in 2012,

and two-year outcomes will be available in 2013.

For more information, please contact Dr. Kashyap (above) at


STAMPEDE IINow Enrolling

Cleveland Clinic is currently enrolling patients for the

STAMPEDE II (Surgical Therapy and Medications Potentially

Eradicate Diabetes Efficiently) study. The randomized,

controlled trial will examine short- and long-term outcomes of

advanced medical therapy versus advanced medical therapy

combined with Roux-en-Y gastric bypass.

The effect of each approach on disease progression,

complications and organ damage will be evaluated. Sixty

men and women with type 2 diabetes are sought for the

study. Candidates must be between 20 and 60 years of age

and have a body mass index between 27 and 43 kg/m2.

Co-investigators for STAMPEDE II are Philip Schauer, MD,

Director of the Cleveland Clinic Bariatric and Metabolic

Institute; Sangeeta Kashyap, MD, of the Department of

Endocrinology, Diabetes and Metabolism; and John Kirwan,

PhD, of the departments of Gastroenterology and Hepatology,

and Pathobiology.

For more information about STAMPEDE II,

call 800.223.2273, ext. 53983,

or visit clinicaltrials.gov.



“The value of bariatric procedures in helping morbidly

obese patients achieve glycemic control has been con-

option, because diabetes in severely obese patients is often

refractory to conventional therapy with insulin and oral

agents, due to severe insulin resistance,” explains Philip

Schauer, MD, Director of the Cleveland Clinic Bariatric and

Metabolic Institute and a member of the IDF expert panel

that authored the position statement.

The IDF statement also says that patients with a BMI of

30–35 kg/m2 should be considered for surgery when

hemoglobin A1c is > 7.5 percent despite optimal therapy,

and particularly if weight is increasing or in the presence

of other weight-responsive co-morbidities that are not

achieving targets using conventional therapies, including

hypertension, dyslipidemia and obstructive sleep apnea.

The IDF writing group reviewed the data related to other

conventional, standard bariatric operations and novel

interventional procedures and considered gastric banding

(above left), sleeve gastrectomy (above middle), gastric bypass

(Roux-en-Y, above right), biliopancreatic diversion and

duodenal switch in its clinical recommendations.

In March 2011, the International Diabetes Federation (IDF) issued

a position statement upgrading bariatric surgery from an option

to a priority for morbidly obese patients (BMI > 35 kg/m2) with

type 2 diabetes mellitus (DM).

Bariatric Surgery Now Standard Treatment for Morbidly Obese Diabetic Patients



Philip Schauer, MD, Director of the Cleveland Clinic Bariatric

and Metabolic Institute, and colleagues have helped pioneer

the procedure and have published initial results showing

“Depending on their preoperative weight, patients can expect

to lose 40 to 70 percent of their excess body weight in the

diabetes as well as hypertension, obstructive sleep apnea and

hypercholesterolemia in the postoperative period,” he says.

In LGCP, the surgeon makes several incisions (< 1 cm) in the

abdomen as portals for the video camera and instrumentation.

One or more folds are made in the stomach, reducing volume

to approximately 75 percent to enhance satiety and reduce

appetite. No stapling or cutting is involved; the folds are

sutured in place.

Neither the stomach nor intestines are removed, enabling the

plication to be reversed or converted to another procedure at

a later time, if desired. The entire procedure can be completed

in less than one hour. Most patients leave the hospital after a

few hours in recovery and can return to work within seven to

10 days. Problems are rare, and major complications occur in

fewer than 1 percent of cases.

LGCP is considered investigational as a primary procedure

for weight loss and is being offered to patients at Cleveland

For more information about gastric plication, contact

Dr. Schauer at 216.444.4794 or at [email protected].

Gastric Plication Holds Promisefor Extreme Weight Loss

Gastric plication, called laparoscopic greater curvature plication (LGCP)

when performed laparoscopically, is a promising investigational bariatric

procedure that may be useful in achieving weight loss and metabolic

goals with very low morbidity.



With current availability of GHRH limited to research use only, there is no satisfactory

(GHD) in adults. The glucagon stimulation test (GST) has been recommended as

an alternative. Cleveland Clinic is one of four institutions participating in a study

comparing the GST to the ITT for this purpose.

Study Compares Glucagon Stimulation Test to Insulin Tolerance Test in Evaluating Adult

“Our hypothesis is that the GST can accurately and safely diagnose GHD in patients with hypothalamic-

pituitary disorders. It is readily available, relatively inexpensive and well-tolerated,” says Cleveland Clinic

endocrinologist Amir Hamrahian, MD. “Unlike the ITT, it is not labor-intensive, and there are few contra-

indications to its use. This is particularly important for clinical endocrinologists who are not comfortable

between GHD and normal growth hormone levels, the study has been designed with one ITT and

two glucagon arms. One glucagon arm evaluates the standard GST; the other evaluates glucagon

dosage based on weight.

The GST may also be used to evaluate the integrity of the hypothalamic-pituitary-adrenal axis by

provoking ACTH and cortisol secretion. “Cortisol release in response to glucagon seems to be ACTH-

dependent. Similar to the ITT, the GST examines the entire HPA axis. Whether the test can accurately

evaluate the integrity of the hypothalamic-pituitary-adrenal axis and use the same cutoff values for

cortisol as the ITT and ACTH stimulation tests is unknown,” says Dr. Hamrahian.

It is normal to give 1 or 1.5 mg glucagon if the patient’s weight is greater than 90 kg. In this study,

participants are given 0.03 mg/kg, up to a maximum of 3 mg, to determine whether increasing the dose

improves the ability of the test to use the same cutoff values as the ITT and ACTH stimulation tests.

“This would assure us that the GST will provide results closer to the current gold standard,” he explains.

The study is recruiting 30 patients with adult-onset hypothalamic-pituitary disorders: 15 with one

controls matched for age, sex and body mass index are also being recruited. The ITT and two GSTs

levels will be measured at baseline and every 30 minutes, up to 240 minutes.



Other centers participating in this study are Massachusetts General Hospital, the University of

Oregon and Allegheny Hospital.

All patients will receive a small stipend for travel expenses. To refer candidates to Cleveland Clinic or

to obtain further information about inclusion and exclusion criteria, please contact Dr. Hamrahian at


“Our hypothesis is that the GST can accurately and safely

-

thalamic-pituitary disorders...Whether the test can accurately

evaluate the integrity of the hypothalamic-pituitary-adrenal

axis and use the same cutoff values for cortisol as the ITT

and ACTH stimulation tests is unknown.”



Journals

Below are peer-reviewed journal articles and

book chapters published within the past year by

Endocrinology & Metabolism Institute staff.

Solomon TPJ, Haus JM, Kelly KR, Cook MD, Filion J, Rocco

M, Kashyap SR, Watanabe RM, Barkoukis H, Kirwan JP. A

low-glycemic index diet combined with exercise reduces insulin

resistance, postprandial hyperinsulinemia, and glucose-depen-

dent insulinotropic polypeptide responses in obese, prediabetic

humans. Am J Clin Nutr. 2010 Dec;92(6):1359-1368.

Flechner SM, Berber E, Askar M, Stephany B, Agarwal A, Milas

M. Allotransplantation of cryopreserved parathyroid tissue

for severe hypocalcemia in a renal transplant recipient. Am J

Transplant. 2010 Sep;10(9):2061-2065.

Shewmon DA, Craig JM. Creatine supplementation prevents

statin-induced muscle toxicity. Ann Intern Med. 2010

Nov 16;153(10):690-692.

Jarrar AM, Milas M, Mitchell J, LaGuardia L, O’Malley M,

Berber E, Siperstein A, Burke C, Church JM. Screening for thy-

roid cancer in patients with familial adenomatous polyposis.

Ann Surg. 2011 Mar;253(3):515-521.

Milas M, Shin J, Gupta M, Novosel T, Nasr C, Brainard J,

Mitchell J, Berber E, Siperstein A. Circulating thyrotropin

receptor mRNA as a novel marker of thyroid cancer: clinical

applications learned from 1758 samples. Ann Surg. 2010

Oct;252(4):643-651.

Abdelmalak B, Abdelmalak JB, Knittel J, Christiansen E, Mascha

E, Zimmerman R, Argalious M, Foss J. The prevalence of undiag-

nosed diabetes in non-cardiac surgery patients, an observational

study. Can J Anaesth. 2010 Dec;57(12):1058-1064.

Abdelmalak B, Zimmerman R, Foss J. Reply [Diagnosing preop-

erative hyperglycemia in non-diabetic patients: a challenge and

an opportunity]. Can J Anaesth.2011;58(6):583.

Albashir S, Olansky L, Sasidhar M. Progressive muscle

weakness: More there than meets the eye. Cleve Clin J Med.

2011 Jun;78(6):385-391.

Hamaty M. Insulin treatment for type 2 diabetes:

When to start, which to use. Cleve Clin J Med. 2011

May;78(5):332-342.

Kashyap SR. In reply [Bariatric surgery, vitamin C, and

kidney stones]. Cleve Clin J Med. 2010 Dec;77(12):844.

Olansky L. Q: Do incretin drugs for type 2 diabetes increase

the risk of acute pancreatitis? Cleve Clin J Med. 2010

Aug;77(8):503-505.

Pantalone KM, Nasr C. Approach to a low TSH level: Patience is

a virtue. Cleve Clin J Med. 2010 Nov;77(11):803-811.

Bhatwadekar AD, Guerin EP, Jarajapu YPR, Caballero S,

Sheridan C, Kent D, Kennedy L, Lansang MC, Ruscetti FW,

Pepine CJ, Higgins PJ, Bartelmez SH, Grant MB. Transient

inhibition of transforming growth factor-beta 1 in human diabetic

CD34+ cells enhances vascular reparative functions. Diabetes.

2010 Aug;59(8):2010-2019.

Pop-Busui R, Evans GW, Gerstein HC, Fonseca V, Fleg JL,

Hoogwerf BJ, Genuth S, Grimm RH, Corson MA, Prineas R.

Effects of cardiac autonomic dysfunction on mortality risk in the

Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.

Diabetes Care. 2010 Jul;33(7):1578-1584.

Solomon TPJ, Haus JM, Kelly KR, Rocco M, Kashyap SR,

Kirwan JP. Improved pancreatic beta-cell function in type 2

diabetic patients after lifestyle-induced weight loss is related to

glucose-dependent insulinotropic polypeptide. Diabetes Care.

2010 Jul;33(7):1561-1566.

Publications



Reasner C, Olansky L, Seck TL, Williams-Herman DE, Chen M,

Terranella L, Johnson-Levonas AO, Kaufman KD, Goldstein BJ.

sitagliptin and metformin compared with metformin monotherapy

in patients with type 2 diabetes mellitus. Diabetes Obes Metab.

2011 Jul;13(7):644-652.

Rhoads GG, Dain MP, Zhang Q, Kennedy L. Two-year

glycaemic control and healthcare expenditures following

initiation of insulin glargine versus neutral protamine Hagedorn

insulin in type 2 diabetes. Diabetes Obes Metab. 2011

Aug;13(8):711-717.

Cheng V, Doshi KB, Falcone T, Faiman C. Hyperandrogenism in

a postmenopausal woman: diagnostic and therapeutic challenges.

Endocr Pract. 2011 Mar;17(2):e21-e25.

Mulligan GB, Eray E, Faiman C, Gupta M, Pineyro MM, Makdissi

A, Suh JH, Masaryk TJ, Prayson R, Weil RJ, Hamrahian AH.

Reduction of false-negative results in inferior petrosal sinus sam-

pling with simultaneous prolactin and corticotropin measurement.

Endocr Pract. 2011 Jan-Feb;17(1):33-40.

Nyalakonda K, Sharma T, Ismail-Beigi F. Preservation of

Beta-cell function in type 2 diabetes. Endocr Pract. 2010

Nov-Dec;16(6):1038-1055.

Pantalone KM, Faiman C, Olansky L. Insulin glargine use during

pregnancy. Endocr Pract. 2011 May;17(3):448-455.

Hatipoglu BA, Kennedy L. Postradiation therapy hypopituitarism.

Expert Rev Endocrinol Metab. 2011 Mar;6(2):187-194.

Tariq N, Chand B. Presurgical evaluation and postoperative care

for the bariatric patient. Gastrointest Endosc Clin N Am. 2011

Apr;21(2):229-240.

Berber E, Akyildiz HY, Aucejo F, Gunasekaran G, Chalikonda S,

Fung J. Robotic versus laparoscopic resection of liver tumours.

HPB (Oxford). 2010 Oct;12(8):583-586.

Yusupov E, Li-Ng M, Pollack S, Yeh JK, Mikhail M, Aloia JF.

Vitamin D and serum cytokines in a randomized clinical trial.

Int J Endocrinol. 2010;2010:305054.

Attaluri V, Lebeis C, Brethauer S, Rosenblatt S. Advanced lapa-

dialysis catheters. J Am Coll Surg. 2010 Dec;211(6):699-704.

Tritos NA, Greenspan SL, King D, Hamrahian A, Cook DM,

Jonsson PJ, Wajnrajch MP, Koltowska-Haggstrom M, Biller BMK.

lower IGF-I are associated with lower bone mineral density in

-

sis. J Clin Endocrinol Metab. 2011 May;96(5):1516-1523.

Zerikly RK, Amiri L, Faiman C, Gupta M, Singh RJ, Nutter B,

Kennedy L, Hatipoglu B, Weil RJ, Hamrahian AH. Diagnostic

characteristics of late-night salivary cortisol using liquid chroma-

tography-tandem mass spectrometry. J Clin Endocrinol Metab.

2010 Oct;95(10):4555-4559.

Berber E, Siperstein A. Re: Robot-assisted posterior retroperito-

neoscopic adrenalectomy (From: Ludwig AT, Wagner KR, Lowry

PS, et al. J Endourol 2010;24:1307-1314). J Endourol. 2011

Mar;25(3):541-542.

Tamimi TI, Elgouhari HM, Alkhouri N, Yerian LM, Berk MP,

Lopez R, Schauer PR, Zein NN, Feldstein AE. An apoptosis

panel for nonalcoholic steatohepatitis diagnosis. J Hepatol. 2011

Jun;54(6):1224-1229.

El-Hayek KM, Chand B. Biologic prosthetic materials for hernia

repairs. J Long Term Eff Med Implants. 2010;20(2):159-169.

Kashyap SR, Roman LJ, Mandarino L, DeFronzo R, Bajaj M.

Hypoadiponectinemia is closely associated with impaired nitric

oxide synthase activity in skeletal muscle of type 2 diabetic

subjects. Metab Syndr Relat Disord. 2010 Oct;8(5):459-463.

Milas Z, Shin J, Milas M. New guidelines for the management

of thyroid nodules and differentiated thyroid cancer. Minerva

Endocrinol. 2011 Mar;36(1):53-70.

continued on next page



Wang Z, Klipfell E, Bennett BJ, Koeth R, Levison BS, Dugar B,

Feldstein AE, Britt EB, Fu X, Chung YM, Wu Y, Schauer P, Smith

JD, Allayee H, Tang WHW, DiDonato JA, Lusis AJ, Hazen SL.

-

cular disease. Nature. 2011 Apr 7;472(7341):57-63.

Marko NF, Hamrahian AH, Weil RJ. Immediate postoperative

cortisol levels accurately predict postoperative hypothalamic-

pituitary-adrenal axis function after transsphenoidal surgery for

pituitary tumors. Pituitary. 2010 Sep;13(3):249-255.

Akyildiz HY, Morris-Stiff G, Aucejo F, Fung J, Berber E. Techniques

of radiofrequency-assisted precoagulation in laparoscopic liver

resection. Surg Endosc. 2011 Apr;25(4):1143-1147.

Alasfar F, Chand B. Intraoperative endoscopy for laparoscopic

Roux-en-Y gastric bypass: leak test and beyond. Surg Laparosc

Endosc Percutan Tech. 2010 Dec;20(6):424-427.

Harvey A, Bohacek L, Neumann D, Mihaljevic T, Berber E.

Robotic thoracoscopic mediastinal parathyroidectomy for persis-

tent hyperparathyroidism: case report and review of the literature.

Surg Laparosc Endosc Percutan Tech. 2011 Feb;21(1):e24-e27.

Mitchell J, Siperstein A, Milas M, Berber E. Laparoscopic

resection of abdominal paragangliomas. Surg Laparosc Endosc

Percutan Tech. 2011 Feb;21(1):e48-e53.

Ashton K, Heinberg L, Windover A, Merrell J. Positive response

to binge eating intervention enhances postoperative weight loss.

Surg Obes Relat Dis. 2011 May-Jun;7(3):315-320.

Brethauer SA, Chand B, Schauer PR, Thompson CC. Transoral

gastric volume reduction for weight management: technique

and feasibility in 18 patients. Surg Obes Relat Dis. 2010

Nov-Dec;6(6):689-694.

Brethauer SA, Harris JL, Kroh M, Schauer PR. Laparoscopic

gastric plication for treatment of severe obesity. Surg Obes

Relat Dis. 2011 Jan-Feb;7(1):15-22.

Gatmaitan P, Huang H, Talarico J, Moustarah F, Kashyap S,

Kirwan JP, Schauer PR, Brethauer SA. Pancreatic islet isolation

after gastric bypass in a rat model: technique and initial results

for a promising research tool. Surg Obes Relat Dis. 2010

Sep-Oct;6(5):532-537.

Ransom D, Ashton K, Windover A, Heinberg L. Internal consis-

tency and validity assessment of SCL-90-R for bariatric surgery

candidates. Surg Obes Relat Dis. 2010 Nov-Dec;6(6):622-627.

Windover AK, Merrell J, Ashton K, Heinberg LJ. Prevalence and

psychosocial correlates of self-reported past suicide attempts

among bariatric surgery candidates. Surg Obes Relat Dis. 2010

Nov-Dec;6(6):702-706.

Akyildiz HY, Mitchell J, Milas M, Siperstein A, Berber E.

Laparoscopic radiofrequency thermal ablation of neuroendo-

crine hepatic metastases: Long-term follow-up. Surgery. 2010

Dec;148(6):1288-1293.

Greenlee C, Burmeister LA, Butler RS, Edinboro CH, Morrison

SM, Milas M. Current safety practices relating to I-131 admin-

istration for diseases of the thyroid: a survey of physicians and

allied practitioners. Thyroid. 2011 Feb;21(2):151-160.

Shin J, Chute D, Milas M, Mitchell J, Siperstein A, Berber E. A

rare case of chronic lymphocytic leukemia/small lymphocytic

lymphoma presenting in the thyroid gland. Thyroid. 2010

Sep;20(9):1019-1023.

Sisson TA, Freitas J, McDougall IR, Dauer LT, Hurley JR, Brierley

JD, Edinboro CH, Rosenthal D, Thomas MJ, Wexler JA, Asamoah

E, Avram AM, Milas M, Greenlee C. Radiation safety in the

treatment of patients with thyroid diseases by radioiodine (131)i:

practice recommendations of the American Thyroid Association.

Thyroid. 2011 Apr;21(4):335-346.

Karabulut K, Berber E. Robotik endokrin cerrahi [Robotic endo-

crine surgery] [Turkish]. Ulusal Cerrahi Dergisi. 2011;27(1):1-5.

Book ChaptersAshton K, Budur K. Scared to sleep: A Hurricane Katrina survi-

vor. In: Foldvary-Schaefer N, Krishna J, Budur K, eds. A Case a

Week: Sleep Disorders From the Cleveland Clinic. Oxford; New

York, NY: Oxford University Press; 2011. Chapter 3. p. 43-48.

Ashton K, Streem D. Smoking cessation. In: Carey WD, ed.

Current Clinical Medicine. 2nd ed. Philadelphia, PA: Saunders/

Elsevier; 2010. p. 977-980.

continuedPublications



Babar T, Skugor M. Diabetes mellitus treatment. In: Carey

WD, ed. Current Clinical Medicine. 2nd ed. Philadelphia, PA:

Saunders/Elsevier; 2010. p. 358-363.

Brethauer S, Kashyap S, Schauer P. Obesity. In: Carey WD, ed.


Elsevier; 2010. p. 391-396.

Chikunguwo SM, Brethauer SA, Schauer PR. Bariatric surgery.

In: Cameron JL, Cameron AM, eds. Surgery of the Esophagus

and Stomach. London; New York, NY: Springer; 2011. Chapter

16. p. 217-232.

Chinnappa P, Mehta A. Hirsutism. In: Carey WD, ed. Current

Clinical Medicine. 2nd ed. Philadelphia, PA: Saunders/Elsevier;

2010. p. 376-379.

Diab DL, Hamrahian AH. Clinical detection and treatment of be-

nign and malignant pituitary diseases. In: Hunt JL, ed. Molecular

Pathology of Endocrine Diseases. New York, NY: Springer; 2010.

Chapter 17. p. 169-174.

Faiman C. Male hypogonadism. In: Carey WD, ed. Current

Clinical Medicine. 2nd ed. Philadelphia, PA: Saunders/Elsevier;

2010. p. 397-401.

Gatmaitan P, Brethauer SA, Schauer PR. Obesity and presenta-

tions after anti-obesity surgery. In: Talley NJ, Kane SV, Wallace

MB, eds. Practical Gastroenterology and Hepatology. Small

and Large Intestine and Pancreas. Chichester, West Sussex ;

Hoboken, NJ: Wiley-Blackwell; 2010. Chapter 24. p. 169-175.

Gopan T, Hamrahian A. Adrenal disorders. In: Camacho PM, ed.

A Color Handbook of Clinical Endocrinology and Metabolism.

London: Manson Pub.; 2011. Chapter 5. p. 113-147.

Harvey AM, Siperstein AE, Berber E. Clinical detection and

treatment of adrenal disease. In: Hunt JL, ed. Molecular

Pathology of Endocrine Diseases. New York, NY: Springer; 2010.

Chapter 19. p. 197-203.

Hoogwerf BJ. Diabetes mellitus: Disease management. In: Carey



Ioachimescu AG, Hamrahian AH. Diseases of the adrenal

gland. In: Carey WD, ed. Current Clinical Medicine. 2nd ed.

Philadelphia, PA: Saunders/Elsevier; 2010. p. 336-349.

Mitchell JC. Clinical detection and treatment of pancreatic

neuroendocrine tumors. In: Hunt JL, ed. Molecular Pathology of

Endocrine Diseases. New York, NY: Springer; 2010. Chapter 22.

p. 229-235.

Mitchell JC, Milas M. Clinical detection and treatment of thyroid

diseases. In: Hunt JL, ed. Molecular Pathology of Endocrine

Diseases. New York, NY: Springer; 2010. Chapter 4. p. 27-35.

Moustarah F, Brethauer SA, Schauer PR. Laparoscopic surgery

for severe obesity. In: Cameron JL, Cameron AM, eds. Current

Surgical Therapy. 10th ed. Philadelphia, PA: Saunders/Elsevier;

2011. p. 1304-1316.

Nasr C. Flushing. In: Carey WD, ed. Current Clinical Medicine.

2nd ed. Philadelphia, PA: Saunders/Elsevier; 2010. p. 369-375.

Reddy SSK. Hypothalamic-pituitary disorders. In: Camacho PM,

ed. A Color Handbook of Clinical Endocrinology and Metabolism.

London: Manson Pub.; 2011. Chapter 4. p. 91-112.

Schirmer B, Schauer PR. The surgical management of obesity.

In: Brunicardi FC, ed. Schwartz’s Principles of Surgery. 9th ed.

New York, NY: McGraw-Hill; 2010. Chapter 27. p. 949-978.

Skugor M. Section 4: Endocrinology [Section editor]. In: Carey



Skugor M. Hypocalcemia and hypercalcemia. In: Carey WD, ed.


Elsevier; 2010. p. 380-386.

Skugor M. Osteoporosis. In: Carey WD, ed. Current Clinical

Medicine. 2nd ed. Philadelphia, PA: Saunders/Elsevier; 2010.

p. 402-407.

Skugor M, Fleseriu M. Hypothyroidism and hyperthyroidism. In:

Carey WD, ed. Current Clinical Medicine. 2nd ed. Philadelphia,

PA: Saunders/Elsevier; 2010. p. 416-420.

Skugor M, Hamrahian AH. Pituitary disorders. In: Carey WD, ed.


Elsevier; 2010. p. 408-415.

Zimmerman R. Microvascular complications of diabetes. In:

Carey WD, ed. Current Clinical Medicine. 2nd ed. Philadelphia,

PA: Saunders/Elsevier; 2010. p. 355-357.



The 9th Annual Dr. Roizen’s Preventive Care and Integrative Medicine ConferenceFocus: Reversing Metabolic and Endocrine Disorders, including Metabolic Syndrome, Type 2 Diabetes and Thyroid Disorders, and Increasing Sexual Enjoyment

December 9-11, 2011

This activity has been approved for AMA PRA Category 1 Credits.™ To register, please call 216.448.0777, email [email protected] visit www.ccfcme.org/wellness11.

Live and OnlineCME Opportunities

Online webcasts of interest to endocrinologists and approved for AMA PRA Category 1 Credits™ include:

For a full list of all Cleveland Clinic CME opportunities, please visit ; to manage your CME credits, use the Web portal, available 24/7.

“Can We Develop a Viable PPAR Agonist for Diabetic Patients?” and “Challenges in Developing New Therapies for Risk Reduction in Diabetes”

Diabetic Patient and Plaque Progression in Diabetic Patients: Insights from Arterial Wall Imaging”

“New and Novel Therapies for Low Bone Mass”

“Robotic Endocrine Surgery”


800.223.2273, ext. 46568 | 19 | clevelandclinic.org/endonotes| | 800.223.2273, ext. 46568 | 19 | clevelandclinic.org/endonotes

TITLE PI CONTACT/NUMBER

International Metabolic Study (KIMS®)Melanie Williams216.444.5410

A Proof of Concept, Open-Label, Forced Titration, Multicenter Study to Assess the Safety/Tolerability and Melanie Williams216.444.5410

A Blinded, Placebo-Controlled, Single Ascending Dose, Phase 1 Trial for Safety, Tolerability, Pharmacokinetics and Pharmacodynamics after Subcutaneous Administration of VRS-317 in Adults

Melanie Williams216.444.5410

A Phase III, Multinational, Randomized, Double-Blind, Placebo-Controlled Parallel-Group Study Melanie Williams216.444.5410

A Randomized, Double-Masked, Placebo-Controlled, Multicenter, Phase 2 Study to Evaluate the Safety and Melanie Williams216.444.5410

TECOS: A Randomized, Placebo-Controlled Clinical Trial to Evaluate Cardiovascular Outcomes after Treatment with Sitagliptin in Patients with Type 2 Diabetes Mellitus and Inadequate Glycemic Control on Mono- or Dual-Combination Oral Antihyperglycemic Therapy


The Global Hypopituitary Control and Complications Study (HypoCCS)Melanie Williams216.444.5410

The Diagnostic Accuracy of the Glucagon Stimulation Test for Evaluation of Adult Growth Hormone Melanie Williams216.444.5410

ACROSTUDY - A Multicenter, Post-Marketing Surveillance Study of Somavert Therapy in Patients with Acromegaly in the USA and Europe


Pelvic Floor Disorders in Bariatric Surgery PatientsSharon O’Keefe216.445.8461

A Prospective, Randomized, Controlled Trial Comparing Advanced Practice Medical Management vs. Ad-vanced Practice Medical Management Plus Bariatric Surgery in The Treatment of Type 2 Diabetes Mellitus

Chytaine Hall216.445.3983

Prospective Randomized Comparison of Bilateral vs. Focal Neck Exploration for Sporadic HyperparathyroidismLinda Heil216.444.2262

in Patients with Primary and Secondary HyperparathyroidismLinda Heil216.444.2262

T1D Exchange Type 1 Diabetes Network Denise Rose 216.444.8824

Gastric Plication for the Treatment of Obesity and Related Conditions Sharon O’Keefe, 216.445.8461

Effect of a Portion-Controlled, Commercially Available Diet on Pre-Surgical Weight Loss and Metabolic Outcomes in Patients Undergoing Laparoscopic Bariatric Surgery

Sharon O’Keefe, 216.445.8461

Is Nipple Stimulation by a Piercing Capable of Increasing Serum Prolactin Concentrations? Melanie Williams, 216.444.5410

ACCORDION: Action to Control Cardiovascular Risk in Diabetes Trial Melanie Williams, 216.444.5410

Exenatide Study of Cardiovascular Event Lowering (EXSCEL)Melanie Williams, 216.444.5410

Current Clinical Trials


Department of Endocrinology, Diabetes and Metabolism

Sanjit Bindra, MDSpecialty Interest(s): General endocrinology, diabetesLocation(s): Lakewood Hospital Professional BuildingOffice: 216.529.5300 | Fax: 216.529.5301Appointments: 216.529.5300

Kevin Borst, DOSpecialty Interest(s): Endocrine disorders in pregnancy, general endocrinology, diabetesLocation(s): Lakewood Hospital Professional BuildingOffice: 216.529.5300 | Fax: 216.529.5301Appointments: 216.529.5300

Krupa Doshi, MDSpecialty Interest(s): General endocrinology, diabetes, parathyroid and calcium disorders, hirsutism, thyroid disorders, adrenal disorders, osteoporosisLocation(s): Main campusOffice: 216.445.0741 | Fax: 216.445.1656Appointments: 216.444.6568

Revital Gorodeski Baskin, MDSpecialty Interest(s): Endocrinology, thyroid disorders, thyroid cancerLocation(s): Independence Family Health CenterOffice: 216.986.4000 | Fax: 216.986.4995Appointments: 216.986.4000

Marwan Hamaty, MDSpecialty Interest(s): General endocrinology, diabetesLocation(s): Main campus; Strongsville Family Health and Surgery CenterOffice: 216.445.7568 | Fax: 216.445.1656Appointments: Main campus, 216.444.6568; Strongsville, 440.878.2500

James Young, MDInstitute Chairman Endocrinology & Metabolism Institute216.444.2333

Laurence (Ned) Kennedy, MDChairman, Department of Endocrinology, Diabetes and Metabolism 216.445.8645

Allan Siperstein, MDChairman, Department of Endocrine Surgery216.444.5664

Philip Schauer, MDChairman, Bariatric and Metabolic Institute 216.444.4794

Amir Hamrahian, MDSpecialty Interest(s): Pituitary and adrenal disordersLocation(s): Main campusOffice: 216.445.8538 | Fax: 216.445.1656Appointments: 216.444.6568

Betul Hatipoglu, MDSpecialty Interest(s): Diabetes, thyroid disorders, pituitary disorders, adrenal disorders, alternative medicineLocation(s): Main campusOffice: 216.445.6709 | Fax: 216.445.1656Appointments: 216.444.6568

Suman Jana, MDSpecialty Interest(s): General endocrinology, diabetes, thyroid disease, thyroid cancerLocation(s): Main campus; Medina Office: 216.444.0567 | Fax: 216.445.1656Appointments: Main campus, 216.444.6568; Medina, 330.725.3713

Sangeeta Kashyap, MDSpecialty Interest(s): Endocrinology, diabetes, metabolism, insulin resistance and cardiovascular risk prevention, obesity, metabolic syndrome and diseases, hyperlipidemiaLocation(s): Main campusOffice: 216.445.2679 | Fax: 216.445.1656Appointments: 216.444.6568

Laurence (Ned) Kennedy, MDDepartment ChairSpecialty Interest(s): General endocrinology, diabetes, pituitary disorders, hyperthyroidism, hypothyroidism, thyroiditisLocation(s): Main campus; Ashtabula County Medical Center; Cleveland Clinic Florida, WestonOffice: 216.445.8645 | Fax: 216.445.1656Appointments: Main Campus, 216.444.6568; Ashtabula, 440.997.6910; Florida, 954.659.6038


Staff Directory


E N D O C R I N O L O G Y & M E T A B L O L I S M I N S T I T U T E L E A D E R S H I P


hio

Endocrine Notes


James B. Young, MD

Managing Editor

Cora M. Liderbach

Art Director

Mike Viars

Marketing

Bill Sattin, PhD

Mary Anne Connor












consults – 800.553.5056



216.444.6568 or 800.223.2273,

ext. 46568

Bariatric Surgery


216.445.2224 or 800.223.2273,

ext. 52224

On the Web at





216.444.6568



10685 Carnegie Ave.


216.444.6568


2420 Lake Ave.


440.997.6969



26900 Cedar Road


216.839.3000



5001 Rockside Road

Crown Center II


216.986.4000




Lorain, Ohio 44053

440.204.7400


Family Heath Center


Solon, Ohio 44139

440.519.6800



13944 Euclid Ave.


216.767.4242





440.878.2500



8701 Darrow Road


330.888.4000





440.943.2500



1740 Cleveland Road

Wooster, Ohio 44691

330.287.4500

Lakewood Hospital


14601 Detroit Road


216.529.5300

Medina Hospital



Medina, Ohio 44256

330.725.3713


Medical Building

20600 Harvard Road


216.295.1010



Weston, Fla. 33331

877.463.2010































hio

Endocrine Notes


James B. Young, MD

Managing Editor

Cora M. Liderbach

Art Director

Mike Viars

Marketing

Bill Sattin, PhD

Mary Anne Connor












consults – 800.553.5056



216.444.6568 or 800.223.2273,

ext. 46568

Bariatric Surgery


216.445.2224 or 800.223.2273,

ext. 52224

On the Web at





216.444.6568



10685 Carnegie Ave.


216.444.6568


2420 Lake Ave.


440.997.6969



26900 Cedar Road


216.839.3000



5001 Rockside Road

Crown Center II


216.986.4000




Lorain, Ohio 44053

440.204.7400


Family Heath Center


Solon, Ohio 44139

440.519.6800



13944 Euclid Ave.


216.767.4242





440.878.2500



8701 Darrow Road


330.888.4000





440.943.2500



1740 Cleveland Road

Wooster, Ohio 44691

330.287.4500

Lakewood Hospital


14601 Detroit Road


216.529.5300

Medina Hospital



Medina, Ohio 44256

330.725.3713


Medical Building

20600 Harvard Road


216.295.1010



Weston, Fla. 33331

877.463.2010































2011


Endocrine Notes


In This Issue:




[email protected].






















Physician Directory













or 888.637.0568.




















14 Publications



20 staff directory

11-ENd-008


77763_CCFBCH_Cover_ACG.indd 1 11/15/11 7:36 AM

2011


Endocrine Notes


In This Issue:




[email protected].






















Physician Directory













or 888.637.0568.




















14 Publications



20 staff directory

11-ENd-008



Documents

Endocrine Notes - Cleveland Clinic · Endocrine Notes The Cleveland Clinic Foundation Endocrinology & Metabolism Institute Endocrine Notes 9500 Euclid Avenue / AC311 Cleveland, OH