Mabel A. Charles-Davies
Department of Chemical Pathology, College of Medicine, University of Ibadan, Ibadan, Nigeria;
The endocrine system controls the flow of information between cells and tissues, governed by complex regulatory mechanisms (1). Hormones exert widespread influences on various metabolic processes which ensure regulatory, morphogenic and integrative function (2).
Signs and symptoms of endocrine disorders span the entire clinical spectrum. Manifestations of endocrine diseases are frequently due to non-endocrine or unknown causes such as fatigue, malaise, weakness, headache, anorexia, depression, weight gain or loss. Endocrine diseases are therefore, easily recognisable in their extreme forms and arriving at clear diagnosis can sometimes be difficult (1) .
Early diagnosis and management of endocrine diseases are essential and can be achieved by the combination of targeted endocrine testing, imaging, careful history, physical examination and sound clinical judgement (1,3). Adequate knowledge and understanding of basic science and principles of endocrinology are important tools for the enhancement of efficiency and accuracy-goals of endocrine function testing. The perfect strategy (3) for targeted endocrine investigation would achieve the ideals of reaching specific diagnosis in the shortest time, with minimum inconvenience and cost on the patient. It is generally accepted that agreed strategies done in stages and could vary with location are needed for maximum efficiency which include:
The initial clinical investigations comprise of detailed clinical history and physical examination. The selection of appropriate initial laboratory tests will be determined by the outcome of the initial clinical investigations. Interpretation of initial laboratory tests requires acquaintance with reference intervals appropriate to specific laboratories and methods since immunoassays are method dependent. Second line investigations could be determined from results of the initial investigations and should either confirm or clarify an endocrine basis or monitor response to treatment. They are of a wide range and most conveniently, may be recorded in series of algorithms because many patients will not require further endocrine tests. A wide range of hormone assays is thus needed.
Various analytical techniques are used for measuring hormones including bioassay, receptor assay and immunoassays. Bioassays and radioreceptor assays were used for quantitation of biological activity in the 1950s. Since 1960, radioimmunoassay and immunoradiometric assays in 1980s (in the advent of monoclonal antibodies) have been used for quantitation of immunoreactivity (4).
Isotopic and non-isotopic immunometric assays are methods of choice for most hormone measurements. They are simple to perform but can create pitfalls to the scientist because the designs have inbuilt compromises (3).
Recombinant DNA methods-southern blot, oligonucleotide specific hybridisation, polymerase chain reaction and restriction length polymorphisms are also applied to the study of endocrine disorders (1,2).
Many resource poor settings are thickly populated and people live below the one dollar per day mark (5,6). Non-communicable diseases including endocrine disorders are on the increase. However, not much attention is paid to this group of diseases because of the enormous burden posed by infections. Despite this threat, endocrine disorders still constitute a significant cause of morbidity and mortality (5,6,7).
Most endocrine testing (including genotyping) often involves considerable cost. Conventional treatment for endocrine disorders is expensive and may not be easily affordable in many developing countries (5,7). Consequent implications in these regions include compromise in patient care and quality of laboratory, research and development and the future of laboratory medicine.
The practice of endocrinology can be appropriate and fulfilling when there is adequate clinical skill, facilities for various investigations and treatment modalities including: medical, surgical, hormonal and radiotherapy. Inability to practise properly, hinge largely on poverty, ignorance and exploitation and could lead to frustration.
In Nigeria Anumah (5) reported that there were less than 60 trained endocrinologists for a population of more than 140 million people and most of them are in the tertiary health care centres in the cities. Majority of the patients present to the non-specialists who have limitations but make great impact. Thus, the availability of skilled personnel for accurate clinical diagnosis, investigative facilities and affordability of treatment by the patients pose a great challenge in most centres in Nigeria, where endocrinology is practised (5,8).
Cost of treatment is inaffordable by patients who are left to their fate. Patients visit charlatans/drug shops (where hormonal preparations are sometimes given) and return to hospital with complications or are lost to follow up and many times die.
Funding is a major issue. Many endocrinology laboratories that were vibrant in the late 1980s and early 1990s are now moribund. There is reduced capacity building and exposure to technological advancement in science in developed countries. Facilities are absent many times. Reagents are usually out of reach. Interested researchers many times spend out of their meagre salary (8) to fund research and students spend out of personal funds. These experiences can be very frustrating for most researchers
In the developed world, there is a considerable advancement in endocrine function testing (1,8). New hormones and receptors are still being discovered. Advancement in the field of endocrinology is progression from discovery of hormones to identification of receptors. With the advent of molecular biology and large scale genomic sequencing, many receptors have been identified based on sequence homology before the hormone was identified. This approach shifts endocrinology to the reverse and gives rise to a search for new hormones and their signaling pathways (1).
In Nigeria, there is currently, no future. We are rather looking at the past (8) and the gap is getting wider. The complexity of endocrinology demands integrated input of all stake holders in laboratory medicine to necessarily bridge the gap between developing and developed countries.
There should be easy access to funding in research, training, and exposure to advances in technology. Age limit for application for funds should be increased particularly for individuals in developing countries. Registration fees at international conferences/ workshops/courses should be subsidized and travel grants awarded for increased participation of individuals in developing regions. Funding should also be provided to support patients by reducing cost of service.
Patients should be educated on health care at various levels to enable informed decisions in communities, schools and hospitals. More endocrinologists should be trained. Capacity building of scientists at various levels in the field of endocrinology-theory and practice is essential .Moreover, hands on training in endocrine function testing should be mandatory in the curriculum of laboratory personnel.
Selected centres that are well equipped with state of the art facilities for training, research and routine testing, spread over the various regions should be provided.
Diagnostic Industry should tailor their services to the specific needs of the country as well as provide quality control material in test kits
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