The German professional medical associations for endocrinology and diabetes (known by their German acronyms: DGE and DDG) issued a statement complaining about the dwindling number of independent endocrinology chairs at university hospitals. esanum spoke with Prof. Dr. Matthias Weber about the state of endocrinology in the COVID-19 crisis.
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The fall in the numbers of endocrinology chairs in German university hospitals is the consequence of the inertia to save money for its own sake, and of a trend in which medicine is leaning constantly towards a focus on generating revenue. In view of the economic importance of diabetes, obesity, osteoporosis, thyroid diseases, as well as rare serious diseases such as Cushing's syndrome, a rising array of voices from the German medical community considers this as irresponsible. esanum spoke with Prof. Dr. Matthias Weber, media spokesman of the German Society of Endocrinology (German acronym: DGE), about the status of endocrinology in the COVID 19 crisis. He is also head of the Endocrinology and Metabolic Diseases Unit at the Mainz University Medical Center (in German: Universitätsmedizin Mainz).
esanum: Prof. Weber, it is now known that some pre-existing conditions such as diabetes mellitus or obesity have a negative influence on the course of COVID-19. What has been found out about other hormone and metabolic diseases in COVID-19 disease?
Weber: It is known that various, sometimes rare, hormonal diseases can be negatively influenced by COVID-19 disease. This mainly affects people who have problems with the stress hormone cortisol, who have too much or too little of it. And of course, social isolation causes additional problems for patients who need regular medical care and adjustment of their hormonal status. It is all about finding the right balance, caring for the patients closely and yet not having to ask them to see a physician frequently.
esanum: Which patients are you thinking about in particular?
Weber: Patients who have a hyperactivity of stress hormones, i.e. the Cushing's patients, are particularly at risk. This is because cortisol plays an important role in the immune defense. And we know that these patients have an increased tendency to infections. They also have an above-average risk of developing a complicated course.
Patients with a deficiency of this hormone, which they must replace throughout their lives, also have a weakened immune system. And if they have an infection and get a fever like COVID-19, they have to replace an increased concentration of the stress hormone. They have to be trained for this. They have to avoid getting into a life-threatening shortage. This is often a very demanding situation. This deficiency situation can arise if the adrenal glands are missing, for example due to surgery or autoimmune diseases. If cortisone preparations have to be taken due to rheumatic or autoimmune diseases - the body's own production also falls. These people can also fall into a dangerous shortage. Such a prognosis is not at all rare.
esanum: Does this mean that these patients now need to be accompanied particularly closely?
Weber: Correct. Above all, we have to train them very well, because they have to recognize this themselves. If they get a fever or feel ill, they can't sit it out at home; instead, you have to increase the dose of their medication. If they vomit or have diarrhea, the hormones have to be given intravenously. Of course the physician must be informed about this.
esanum: Are these observations not expected to show that certain disease factors have an influence on the infection process?
Weber: That was already clear with regard to other diseases, but is now becoming more dangerous due to social isolation. For example, if the necessary controls are no longer carried out. This then also affects other hormonal diseases, which are related to the water balance, for example.
esanum: Do all these patients now live in danger because they cannot or do not want to go to the physician regularly?
Weber: For my patients I can say that the telephone contact was extensive and sufficient, as was the training process of the patients, so that they know how to behave. You have to stay in frequent contact with them, because they are naturally also concerned. Many of them contact us on their own, so you have to organize the accessibility issue. And with seriously ill patients, you have to be proactive.
esanum: Should your patients be routinely tested for Sars-CoV-2 because of their particular risk?
Weber: That is not necessary as a routine measure. We examine everyone who comes to us as an in-patient anyway. If there is contact with an infected person, of course you have to take appropriate action. The endocrinologist always bears in mind that fatigue and weakness can also be symptoms of hormonal diseases, which can also disguise themselves as an infection. And it is also the clinician's job to keep this in mind.
esanum: Which endocrinology questions are currently urgent? Which gaps need to be researched next?
Weber: The role of hormones in connection with COVID-19 disease is a very exciting topic. The angiotensin-converting enzyme 2, which plays an important role in the hormonal regulation of blood pressure, is also the entry portal for corona viruses and is therefore a particular target. Endocrinology is a very important basic research area to trace the occurrence, spread and treatment of this infection. We endocrinologists are right at the forefront of this field. The discussion about blood pressure medication has also shown how important this topic is. And finally, the question of dexamethasone, a heavy cortisone preparation, as a remedy for serious courses of the disease, also needs more in-depth research. Hormones play a very central role in all this.
esanum: How do you assess the care situation in clinics and practices for your patients?
Weber: Overall, the in-patient care provided by endocrinologists is not such that we can be satisfied. We are still underrepresented. This is partly due to the billing system in Germany. It is more lucrative to install a heart valve than to make a hormonal adjustment. Unfortunately, this not only affects rare-disease hormonal patients, but also widespread endocrinological diseases such as diabetes, osteoporosis, thyroid diseases, so it is very desirable that there is policy control - and that endocrinology once again takes on an appropriate, i.e. more important role in in-patient care.
esanum: Are the lessons of the COVID-19 pandemic perhaps setting things in motion?
Weber: I am not very optimistic about that. Endocrinology is indispensable in the research of COVID-19, but as long as the billing structure remains like this, it will probably continue to play a subordinate role in in-patient care and training. Nevertheless, as a professional society we try to draw attention to the fact that it is not only expensive and complex examinations that are reimbursed accordingly, but also that one has to deal with the patient as an integral question. This is what endocrinology does. The patient is always the focus of attention because hormones affect the whole person and all organs.