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Endocrinology News From Mayo Clinic
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Hypoglycemia —
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Role for the Selective
Arterial Calcium
Stimulation Test
Assessment of Bone Strength In Vivo in Humans:
A Novel Diagnostic Tool for Osteoporosis
in these patients. Thus, there is a critical need
for novel approaches to better identify patients
with osteopenia (T-scores -2.5 to -1) who may
be at increased fracture risk.
Over the past decade, a unique partnerThe Mayo Clinic
ship
involving the clinical research expertise of
Pediatric Endocrine
Sundeep Khosla, M.D., and colleagues at Mayo
Surgery Experience
Clinic and the bioengineering capabilities of Tony
M. Keaveny, Ph.D., and his group at the UniverA Case From
sity of California, Berkeley has contributed to the
the Endocrine
development of one such approach. Dr. Khosla,
Teaching Clinics:
an endocrinologist at Mayo Clinic in Rochester,
An Unusual Cause
Minnesota, explains:“This technology, VirtuOst,
of a Pituitary Mass
is now commercialized by O.N. Diagnostics, a
company started by Dr. Keaveny. VirtuOst, which
has been cleared by the
Food and Drug Administration, utilizes clinical
Bone strength
BMD
computerized tomography
(CT) scans that may have
been obtained for any
Advanced image
purpose (such as standard
CT scan covering
processing
abdominal imaging or CT
the hip or spine
colonography) to obtain
noninvasive measures of
bone strength using finite
Biomechanics
element analysis (FEA).
LOW
HIGH
These bone strength measures at the spine or hip are
Virtual stress
highly correlated with the
testing
true breaking strength of
bone in cadaveric studies.
“The figure depicts
the process by which
Figure. The overall test provides measures of a DXA-equivalent bone mineral density (BMD) at the hip and
CT images are analyzed.
trabecular BMD at the spine, and measures of bone strength at both sites. The input CT scan is processed to
Based on the empirical
separate out the bones of interest to measure BMD. The same bones are then converted into engineering “finite
relationship between
element models” for virtual stress testing, using information on the biomechanical behavior of bone tissue and
its relation to bone density from the CT scan. Strength measurements are computed for the femur in a sidewaysCT density and the yield
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Vol. 11, No. 1, 2016
6
+
Although there is general agreement that
patients with a previous history of a hip or
vertebral fracture or those with bone mineral
density (BMD) T-scores less than or equal to
-2.5 at the femoral neck, total hip or lumbar
spine by dual energy X-ray absorptiometry
(DXA) warrant initiation of drug therapy for
osteoporosis, it is clear that approximately 60
percent of fragility fractures in women and
approximately 80 percent of fragility fractures
in men occur in patients with T-scores above
this value. Not surprisingly, clinicians often see
patients with T-scores above -2.5 who have
had fragility fractures, leading to uncertainty
as to the true extent of skeletal fragility present
=
fall configuration and for the spine for a compressive overload.
Endocrinology Metabolic Bone Group. Standing: Peter J. Tebben, M.D., Ann E. Kearns, M.D., Ph.D., Kurt A. Kennel, M.D., Daniel L.
Hurley, M.D., and Robert A. Wermers, M.D. Seated: Bart L. Clarke M.D., Sundeep Khosla, M.D., and Matthew T. Drake, M.D., Ph.D. Not
pictured: Robert D. Tiegs, M.D.
stress of bone, FEA is used to virtually load the
bone to failure, thereby arriving at the FEAbased bone strength, in units of newtons (N).”
The use of FEA-derived bone strength at
the spine or the hip has now been validated
in a number of retrospective and prospective
fracture-outcome studies whose outcomes
were published in Radiology in 2016, American
Journal of Gastroenterology in
2014, Osteoporosis International
in 2012 and Journal of Bone and
Mineral Research in 2010. Based
on these studies, thresholds
for fragile bone strength at the
spine or the hip, separately in
women and in men, have been
derived.
Dr. Khosla highlights:
“Collectively, these studies
have demonstrated that using
these thresholds, virtually all
patients who fracture with
BMD-defined osteoporosis are
accurately identified. Moreover,
Radiology Bone Group. Mark C. Adkins, M.D., and
Kimberly K. Amrami, M.D. Not pictured: Jeff L. Fidler,
these thresholds also identify a
M.D., and Naveen S. Murthy, M.D.
significant number of patients
with fragility fractures who have osteopenia,
demonstrating that the FEA-derived bone
strength is capturing aspects of bone structure
and strength not evident by conventional DXA.
To identify osteoporosis, this analysis provides
a measurement of trabecular BMD at the spine
that avoids artifacts inherent in DXA due to
degenerative changes or aortic calcification; it
also provides DXA-equivalent measurements
of total hip and femoral neck BMD T-scores at
the hip that are highly correlated with DXA.
Recently, the International Society for Clinical
Densitometry has endorsed these BMD and
bone strength measurements, and their vali-
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MAYO CLINIC | EndocrinologyUpdate
dated thresholds, as a sufficient basis for identifying patients for initiation of pharmacological
therapy.”
The Metabolic Bone Group at Mayo Clinic
has gained experience in using FEA-derived
bone strength as part of its practice in specific
groups of patients. These uses include:
• Patients undergoing CT imaging for other
purposes, for which the bone strength analysis can be an add-on, providing additional
information regarding skeletal fragility. If
the imaging includes the proximal femur, a
DXA-equivalent T-score also is obtained.
• Patients with fragility fractures in the setting
of a DXA BMD T-score of greater than -2.5.
For these patients, a CT scan specifically for
bone strength analysis can be obtained and
the images processed for spine and hipbone
strength. A finding of bone strength in the
fragile range, despite a BMD by DXA that is
not considered osteoporotic, can provide an
explanation for the patient’s fragility fractures.
Dr. Khosla says:“As we gain more experience
with this technology, bone strength analyses
from CT imaging may prove to be useful in
patients with osteopenia who have not yet
fractured, but where fracture risk based on FRAX
or other criteria appear to be increased or remain
ambiguous. A subset of these patients may have
compromised bone strength and thereby warrant
consideration for drug therapy. Moreover, as we
learn more about how bone strength and, in particular, the distribution of bone within the spine
or hip change with various therapies for osteoporosis, this approach also may become useful in
determining the best choice of therapy for particular patients with very low bone strength and
perhaps for monitoring response to therapy. To
the extent that certain medications may replace
bone precisely where it is needed to maximize
bone strength, we may be able to identify optimal
responses to pharmacological therapy.”
Dr. Khosla concludes: “Obtaining an FEAderived bone strength may be useful in the clinical evaluation and management of patients at
risk of fractures. After over a decade of collaboration between Mayo Clinic and the University
of California, Berkeley, this technology is now
clinically available. For selected patients, it could
greatly enhance fracture risk stratification.”
For more information
Fidler JL, et al. Comprehensive assessment of
osteoporosis and bone fragility with CT colonography. Radiology. 2016;278:172.
Weber NK, et al. Validation of a CT-derived
method for osteoporosis screening in IBD
patients undergoing contrast-enhanced CT
enterography. American Journal of Gastroenterology.
2014;109:401.
Srinivasan B, et al. Relationship of femoral neck
areal bone mineral density to volumetric bone
mineral density, bone size, and femoral strength
in men and women. Osteoporosis International.
2012;23:155.
Melton LJ III, et al. Relation of vertebral
deformities to bone density, structure, and
strength. Journal of Bone and Mineral Research.
2010;25:1922.
Hypoglycemia — Role for the Selective
Arterial Calcium Stimulation Test
Hyperinsulinemic hypoglycemia is a disorder
that can be very challenging to evaluate. Adrian
Vella, M.D., an endocrinologist at Mayo Clinic
in Rochester, Minnesota, says: “Once factitious
disease has been excluded (that is, inappropriate
use of hypoglycemic medication), insulinoma is
the most likely cause of hypoglycemia. Noninvasive imaging studies such as abdominal
ultrasound and computerized tomography with
intravenous contrast can identify an insulinoma
in approximately 75 percent of the cases. However, in the remaining instances, more invasive
testing such as endoscopic ultrasound or selective arterial calcium stimulation test (SACST)
is required. These tests alone or in combination
have allowed virtually all insulinomas to be
localized or regionalized preoperatively at Mayo
Clinic since 1998.”
The SACST has been of increasing interest to internists and endocrinologists since
the relatively recent description of two distinct
syndromes characterized by hypoglycemia, an
abnormal SACST and abnormal islet morphology. Noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is a rare disorder
characterized by postprandial hypoglycemia. A
similar presentation has been encountered after
Roux-en-Y gastric bypass (RYGB) and Nissen
fundoplication.
James C. Andrews, M.D., a radiologist at
Mayo Clinic in Rochester, Minnesota, says:
“The SACST was developed by the late John L.
Doppman, M.D., from the National Institutes
of Health in response to the observation that
intravenously administered calcium stimulates
insulin release from insulinoma, but not from
normal beta cells. The test requires cannula-
tion of the femoral
vein and artery with
passage of a sampling
catheter to the right
hepatic vein for sampling for insulin and
sequentially under
fluoroscopic guidance,
a catheter placed into
the splenic, superior
mesenteric and gastroduodenal arteries
to allow injection of
calcium gluconate into
these arteries (Figure 1). Adrian Vella, M.D., and James C. Andrews, M.D.
Two 2015 publications
by our group in Surgery and the Journal of Clinical
Endocrinology and Metabolism have highlighted
the importance of the arterial anatomy and
Selective Arterial Calcium Stimulation Test
Right hepatic vein
Splenic artery
Gastroduodenal
artery (GDA)
Superior mesenteric
artery (SMA)
Figure 1. Graphic representation of the relationships
among the three major arteries (gastroduodenal, superior
mesenteric and splenic) and regions of the pancreas supplied (head, uncinate process and tail, respectively).
MAYO CLINIC | EndocrinologyUpdate
3
Right hepatic vein insulin
as a multiple of basal
Selective Arterial
Calcium Stimulation Test
Splenic artery
4x
GDA
SMA
3x
2x
1x
20
40 60
GDA
20
40 60
SMA
20 40 60
Splenic artery
Seconds
Figure 2. Results from SACST show a less than twofold rise in right hepatic vein
insulin levels when calcium is infused into the gastroduodenal artery (GDA) and
superior mesenteric artery (SMA). The more than fourfold increase in right hepatic
vein insulin concentrations when calcium is infused into the splenic artery (data
shown in orange) is diagnostic of an insulinoma in the tail of the pancreas.
regional perfusion when interpreting results of the
SACST. The anatomy of the celiac axis and superior mesenteric artery is aberrant in approximately
40 percent of patients. Hence it is important to
discuss the results obtained with the interventional radiologist performing the study. Such an
approach significantly improves the sensitivity of
localization for occult insulinoma.”
Dr. Vella adds: “Previously a positive response
to the injection of calcium was defined as at
least a doubling or a tripling of the insulin level
at more than one time point after the injection.
However, consideration of the absolute value of
peak insulin concentrations also is important in
light of the pulsatile nature of insulin secretion
where underlying endogenous insulin pulsatility may mimic a response to calcium injection.
A recent analysis of our experience with SACST
suggests that positive territories usually exhibit
a greater than fourfold response from baseline
concentrations (Figure 2) and the peak insulin
concentrations observed with insulinoma are
higher than those observed in subjects with
NIPHS or post-RYGB hypoglycemia.”
Dr. Vella concludes:“Continuing experience
with SACST at our institution has reinforced the
utility of the test in the management of hypoglycemic disorders when performed selectively.
Close communication between the endocrinologist and the interventional radiologist also is
important to interpret the results correctly and
manage the patient appropriately.”
For more information
Thompson SM, et al. Impact of variant pancreatic arterial anatomy and overlap in regional
perfusion on the interpretation of selective
arterial calcium stimulation with hepatic venous
sampling for preoperative localization of occult
insulinoma. Surgery. 2015;158:162.
Thompson SM, et al. Selective arterial calcium
stimulation with hepatic venous sampling
differentiates insulinoma from nesidioblastosis.
Journal of Clinical Endocrinology and Metabolism.
2015;100:4189.
The Mayo Clinic Pediatric Endocrine Surgery Experience
Endocrine disorders requiring surgical intervention
are rare in childhood:
• Thyroid nodules have an incidence of 1,000
to 2,000 per 100,000 children.
• Primary hyperparathyroidism has an incidence of 2 to 5 children per 100,000.
• Adrenocortical tumors have an incidence of
2 children per 10,000,000.
• Most uncommon are pancreatic neuroendocrine tumors.
Studies to date have shown superior outcomes
when such patients are managed in a tertiary referral center with the availability of a multidisciplinary
team and higher volume surgeons.
Geoffrey B. Thompson, M.D., Endocrine
Surgery section head at Mayo Clinic in Rochester,
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MAYO CLINIC | EndocrinologyUpdate
Minnesota, says:“The Mayo Clinic pediatric
surgery experience over a 20-year period was
published in the Journal of Clinical Endocrinology and
Metabolism in 2014. This report included a total of
241 patients: 177 underwent thyroid surgery, 13
had a neck dissection, 24 had parathyroid surgery,
14 had an adrenalectomy, seven had a resection
of a paraganglioma and six had a neuroendocrine
pancreatic procedure. An average follow-up of 62
months was available.”
Aida N. Lteif, M.D., chair of Pediatric
Endocrinology at Mayo Clinic in Rochester,
Minnesota, explains: “The indications for thyroid
surgery can be broadly divided into thyroidectomy for suspicious thyroid nodules and cancer,
multinodular goiter, hyperthyroidism, and
Standing: Zahraa AlHilli, M.B.,B.Ch., BAO, W. Frederick Schwenk II, M.D., Aida N. Lteif, M.D., Peter J. Tebben,
M.D., Geoffrey B. Thompson, M.D. Seated: Seema Kumar, M.D., Siobhan T. Pittock, M.B., B.Ch. Inset: Anna A.
Kundel, M.D.
prophylactic surgery in patients with multiple
endocrine neoplasia, type 2A (MEN 2A) or
type 2B (MEN 2B). Twenty-six patients were
under 10 years, and four were under 5 years of
age. Of 22 patients with hereditary medullary
thyroid cancer (MTC), 18 had MEN 2A while
four patients had familial MTC. The majority of
thyroidectomies performed had benign disease
(follicular adenoma, Graves’ disease and C-cell
hyperplasia). On final pathology, 45 patients had
a diagnosis of thyroid cancer — papillary thyroid
cancer (PTC) or MTC.”
Zahraa AlHilli, M.B., B.Ch., BAO, an endocrine surgery fellow at Mayo Clinic in Rochester,
Minnesota, adds: “The unique frozen section
practice at Mayo Clinic allows for intraoperative assessment of all specimens, which
spares patients the need for a completion
thyroidectomy. None of our patients required
re-operation. In patients who underwent a neck
dissection, only one child was under the age
of 10 years. Indications for surgery included
12 patients with recurrent or persistent PTC
in the lateral neck nodes and one patient with
recurrent MTC associated with MEN 2A. The
morbidity rates in our thyroidectomy and neck
dissection population were low and comparable
to those in our adult population. Permanent
hypoparathyroidism was noted in 2.3 percent,
cervical hematoma in 0.6 percent and unintentional recurrent laryngeal nerve (RLN) paralysis
in 0 percent.”
Peter J. Tebben, M.D., a pediatric endocri-
nologist at Mayo Clinic in Rochester, Minnesota,
says: “Parathyroid surgery is the second most
common type of endocrine surgery that is
performed in our pediatric population. Out of
24 patients treated at Mayo Clinic in 20 years,
20 had primary hyperparathyroidism as the
cause of their hypercalcemia and the remaining
had tertiary hyperparathyroidism post-renal
transplant. Children more commonly present
with more aggressive sequelae than adults.
Rather than having hypercalcemia identified on
routine laboratory evaluation, children commonly present with nephrolithiasis and fatigue
as their main symptom. Less commonly, other
nonspecific symptoms include depression, panic
attacks, irregular heartbeat, headaches or gastrointestinal symptoms such as nausea, vomiting, constipation and abdominal pain. Sporadic
single gland disease is most commonly found at
surgery. Multigland disease is usually associated
with familial syndromes that include familial
hyperparathyroidism, MEN 1 and MEN 2A.
Our parathyroid cohort additionally included
patients with tertiary hyperparathyroidism after
renal transplantation for end-stage renal failure,
one patient with familial hypophosphatemic
rickets and one with familial hypocalciuric
hypercalcemia.”
Dr. Thompson adds: “Subcutaneous autotransplantation to the anterior chest wall is
routinely carried out in patients treated with
subtotal parathyroidectomy. Tissue is removed
the following day at the bedside if the serum
MAYO CLINIC | EndocrinologyUpdate
5
parathyroid hormone levels are normal or elevated.
Similar to our thyroid data, the rate of surgical
complications is low and comparable with the
literature and complications rates seen in our adult
population. One patient in the pediatric parathyroid cohort had temporary RLN injury and none
had permanent RLN injury or hypocalcemia.”
Dr. Lteif notes:“Adrenal tumors, paragangliomas and pancreatic neuroendocrine tumors were
the least common endocrine tumors seen. The
Mayo Clinic adrenalectomy cohort included six
patients with pheochromocytoma, five with Cushing syndrome, one with adrenocortical carcinoma,
one with 21-hydroxylase deficiency, and one
with an adrenal ganglioneuroma. In those with
paragangliomas, the majority of the tumors were
in abdominal para-aortic or para-caval locations.
These patients presented with hypertension, excessive sweating, palpitations and heat intolerance.
“All paragangliomas were resected via
an open approach. In those who underwent
adrenal surgery, bilateral adrenalectomy was
performed in seven patients and in five the
bilateral adrenalectomy was carried out through
a laparoscopic approach. An open approach was
preferred in four of the seven unilateral adrenalectomies that included a 6.5-centimeter pheochromocytoma, adrenocortical cancer and in a
patient who required a combined adrenal and
pancreas procedure. Genetic testing identified
five germline mutations in those who underwent adrenalectomies, including von Hippel-
Lindau disease, Carney complex, MEN 2B and
primary pigmented nodular adrenocortical disease (PPNAD). Five patients in the paraganglioma group were found to have germline mutations in succinate dehydrogenase subunit B. Six
pancreatic procedures were performed, and all
were for insulinomas that were diagnosed by
presenting symptoms and standard biochemical
testing. Five patients underwent enucleations,
and one had a distal pancreatectomy. No
genetic mutations were identified in this group.
Our outcomes for pediatric patients who have
undergone adrenal surgery or paraganglioma
resection have been excellent with no operative
complications recorded. Nonoperative management of a single intra-abdominal abscess was
noted after one pancreatic procedure.”
Dr. Thompson concludes: “Pediatric endocrine operations are rare even at a large, tertiarycare referral center. During the same 20-year
period, our endocrine surgeons performed
roughly 14,000 operations in our adult population. This experience coupled with a multidisciplinary pediatric team provides optimal care for
children with endocrine surgical disorders.”
For more information
Kundel A, et al. Pediatric endocrine surgery: A
20-year experience at the Mayo Clinic. Journal of Clinical Endocrinology and Metabolism.
2014;99:399.
A Case From the Endocrine Teaching Clinics:
An Unusual Cause of a Pituitary Mass
Blood hormone, unit of measure
Result
Reference range
Morning cortisol, µg/dL
1.3
7-25
ACTH, pg/mL
13
10-60
< 0.3
1.8-8.6
Total testosterone, ng/dL
8.3
240-950
Prolactin, ng/mL
30
4-15
TSH, mIU/L
0.2
0.3-4.2
Free thyroxine, ng/dL
0.9
0.9-1.7
IGF-1, ng/mL
127
64-210
LH, IU/L
Table. Hormonal evaluation at initial presentation with a
pituitary mass.
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MAYO CLINIC | EndocrinologyUpdate
A 43-year-old man presented for evaluation of an incidentally
discovered pituitary mass. His past medical history was notable
for alveolar soft part sarcoma of the thigh resected 19 years
previously. After a disease-free period of 16 years, the patient
developed bilateral lung metastases, which were treated surgically. One year ago, he developed a metastasis in the pancreatic
tail, which was resected, and another metastasis in the left
kidney, treated with radiofrequency ablation. As a part of cancer
surveillance, a brain MRI was obtained and it showed right-sided
pituitary enlargement with mild extension into the suprasellar
cistern and deviation of the infundibulum to the left. The patient
had no symptoms suggestive of pituitary dysfunction except for
minimal fatigue. He did not have headaches or visual symptoms.
Despite his asymptomatic state, laboratory testing demonstrated secondary adrenal insufficiency and hypogonadotropic
hypogonadism (Table). Visual field testing was normal. The patient
was initiated on glucocorticoid and testosterone replacements.
Hypopituitarism is very uncommon with
primary pituitary tumors and in view of his
history of metastatic alveolar soft part sarcoma,
a pituitary metastasis was suspected. Complete
surgical resection of the pituitary mass was not
considered feasible, and the tumor was treated
with Gamma Knife radiosurgery. Six months
after radiosurgery, the pituitary-directed head
MRI showed heterogeneous hypoenhancement
of the central pituitary gland consistent with
post-radiation changes (Figure).
Metastases to the pituitary gland are rare
and usually present with symptoms of pituitary
dysfunction, visual disturbances, cranial nerve
deficits or headaches, as documented in studies
published in the Journal of Neuro-Oncology in 2015
and The Endocrinologist in 2002. In a Mayo Clinic
series of 52 patients with intrasellar metastases
diagnosed between 1950 and 1996, there were 29
women and 23 men with a mean age of 60 years.
Breast and lung carcinomas were the most frequent primary tumors (37 percent and 23 percent,
respectively). The primary tumor was unknown
in 12 percent of patients. In the patients with a
known primary tumor, it was diagnosed after the
pituitary metastasis was discovered in 20 percent.
The mode of discovery of pituitary metastases
was symptom based (visual impairment, diabetes insipidus, hypopituitarism) in 75 percent of
patients. Of the patients in whom prolactin was
measured, 63 percent had hyperprolactinemia.
Pituitary surgery and radiotherapy were performed in 42 percent and 63 percent of patients,
respectively. Mean survival was 17 months
(range, 0-240 months). Overall mortality at one
year was 67 percent.
Histologic confirmation of metastatic disease
is usually performed; however, when the imaging characteristics are suggestive of metastasis
in a patient with a known metastatic disease at
other sites, biopsy is not necessary, especially if
it will not change subsequent management.
Little evidence exists in regards to the best
treatment approach for pituitary metastases.
Because of the poor prognosis associated with
sellar metastases, the most reasonable therapeutic approaches are palliative radiotherapy,
pituitary target hormone replacement therapy
when indicated and primary tumor-directed
chemotherapy. Surgical debulking of the sellar
metastasis may be beneficial in patients with
visual field defects caused by compression of
Figure. Head MRI (coronal image on left and sagittal image on right) shows a 21-by16-millimeter sellar mass causing superior displacement of the optic chiasm and
thickening of the pituitary stalk — new findings when compared with a head CT
obtained two years previously.
the optic chiasm. Total resection of the pituitary
tumor can be difficult because of invasion of
surrounding structures and increased vascularity. Recovery of pituitary function is unlikely to
occur after surgery, but visual symptoms may
improve. Radiosurgery also can be performed
after initial surgical debulking in an attempt
to stop local tumor regrowth. Management of
patients with pituitary metastasis should be
individualized after consideration of presenting symptoms, imaging characteristics, goals of
treatment and patient’s preferences.
For more information
Gilard V, et al. Pituitary metastasis: Is there still
a place for neurosurgical treatment? Journal of
Neuro-Oncology. In press.
Heshmati HM, et al. Metastases to the pituitary
gland. The Endocrinologist. 2002;12:45.
Irina Bancos, M.D., and Ana E. Espinosa De Ycaza, M.D., thirdyear endocrine fellow
MAYO CLINIC | EndocrinologyUpdate
7
Mayo Clinic
Endocrinology Update
2015 Samuel F. Haines Lecturer
Medical Editor:
William F. Young Jr., M.D., ELS
Editorial Board:
M. Regina Castro, M.D.
Bart L. Clarke, M.D.
Meera Shah, M.B., Ch.B.
Geoffrey B. Thompson, M.D.
Endocrinology Update 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.
Contact Us
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and a request to a specific physician is not
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Resources
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Clinical trials, CME, Grand Rounds,
scientific videos and online referrals
Professor Douglas S. Ross, M.D., Harvard Medical School, Massachusetts General Hospital, and members of
the Thyroid Core Group. Seated, left to right: Douglas S. Ross, M.D., and Hossein Gharib, M.D. Standing, left
to right: Diana S. Dean, M.D., Michele M. Merten, APRN, C.N.P., M. Regina Castro, M.D., John C. Morris III,
M.D., Mabel Ryder, M.D., Stefan K. Grebe, M.D, Ph.D., and Marius N. Stan, M.D.
Education Opportunities
16th Annual Mayo Clinic Nutrition and Wellness in Health and Disease 2016
Sept. 30-Oct. 1, 2016, at InterContinental Hotel, Chicago
Nutrition, physical activity and other healthy lifestyle behaviors are vital components in the promotion of
health and the treatment of disease. This course — designed for physicians, advanced practice clinicians,
dietitians, nurses, and health and wellness staff — provides a full-spectrum, in-depth overview of situations
and topics that clinicians encounter in the ambulatory setting, including obesity in adults and children, individual and group-based weight management strategies, prevention of common medical conditions through
healthy lifestyles, nutrition topics in the news, behavior modification, and resilience, plus physical activity and
wellness focus on clinicians. A culinary demonstration highlights techniques to prepare healthy, great-tasting
food. Presentations offer practical clinical management pearls, interactive case studies and panel discussions. The course will be held at InterContinental Hotel, Chicago. For more information, visit https://ce.mayo.
edu/nutrition/content/mayo-clinic-nutrition-and-wellness-health-and-disease-2016 or call 800-323-2688
(toll-free). Course hashtag: #MayoNutrCME
20th Annual Mayo Clinic Endocrine Update
Jan. 30-Feb. 3, 2017, at The Ritz-Carlton, South Beach, Miami Beach, Fla.
Designed for endocrinologists and interested internists and surgeons, this course addresses gaps in medical
knowledge and barriers in clinical practice to improve the outcomes of patients with endocrine and metabolic
disorders. Topics span the full range of endocrinology through lectures, debates, panel discussions, clinicopathologic sessions, clinical pearls sessions, informal breakfast roundtable discussions and small-group discussions
with experts. Attendees have plenty of opportunity for interaction with the course faculty, who are selected
for their expertise and clinical acumen. For more information, visit https://ce.mayo.edu/internal-medicine/
content/20th-annual-mayo-clinic-endocrine-update-2017 or call 800-323-2688 (toll-free).
MC5810-0316