Manual Single National Disability Rating to Colombia - Decree 917 of 1999 (Part II of II) - Chapter IX 9. ENDOCRINE 9.1 General

MANUAL SINGLE NATIONAL DISABILITY
(PART II OF II)

CHAPTER IX
9. ENDOCRINE

9.1 General

This chapter defines the criteria for assessing global deficiency diseases of the endocrine glands. Is divided into:

· Axis pituitary-hypothalamic

· Thyroid

Adrenal ·

· Gonads

Parathyroid ·

· Network of pancreatic islets.

9.2 CRITERIA FOR EVALUATION OF PERMANENT IMPAIRMENT HYPOTHALAMIC HYPH..

The hypothalamic-pituitary hormonal changes, are studied using baseline measurement of the hormones involved and try to encourage or cancellation thereof. We also study the hypothalamic-pituitary region by imaging of the skull and visual perimetry, among others, to determine the origin of the changes and their effect on adjacent structures.

9.2.1. Assessment of the deficiency of the anterior pituitary disorders.

TABLE No. 9.1: EVALUATION OF THE CHANGES CAUSED BY DEFICIENCY of the anterior pituitary. GLOBAL STANDARD CLASS GAP (%)

I-The disease is controlled by continuous treatment. In case of tumor, is classified in this class if you manage to control with medical treatment and / or surgery, and in terms of size and symptoms. 1 - 4.90

II When symptoms can not be adequately controlled with treatment. 5.0 - 14.9

III When symptoms and signs persist despite treatment. 15.0 - 25.0 Example: 51 year old woman gradually developed acromegaly since he was 16, also presenting amenorrhea, headache and acne. In recent months intensified concerns headaches and vision changes. Hyperglycemia with glucosuria was found, the visual fields showed a field tubular in the left eye and temporal defect in the right eye. Skull radiography showed growth of the sella. Partial excision was operated on a pituitary tumor. After the intervention showed changes of visual fields and required a strict diet and 40 units of lente insulin to control their diabetes. 

Additionally hypopituitarism require hormone replacement. It was a diagnosis of acromegaly and pituitary adenoma with high hypopituitarism, diabetes mellitus and altered visual fields secondary.

It is considered a deficiency of 15.0% for pituitary dysfunction. Combine Debiéndose 13.0.% For unstable diabetes and 17.0% by visual disturbances. Weighted these diseases pose a global deficiency of 25.53%.

9.2.2. Assessment of impairment by changes in the posterior pituitary.

9.2.2.1 Neurohipofisiaria failure or diabetes insipidus. The study of hypofunction of the posterior lobe of the pituitary gland include:

a) Diagnostic Imaging area hypothalamus - pituitary.

b) Determination of the visual field.

c) Determination of urinary density and osmolality of plasma and urine at baseline and during water deprivation test.

TABLE No. 9.2: EVALUATION OF IMPAIRMENT CAUSED BY ALTERATIONS OF PITUITARY DEFICIENCY POSTERIOR.CLASE GLOBAL APPROACH (%)

I-The condition can be effectively controlled with continuous treatment. 1 - 4.90

II Continuous treatment partially control the symptoms and signs of enfermedad.5.0 - 14.9

III Despite appropriate treatment and well run the signs and symptoms persist. 15.0 - 25.0

9.2.2.2 Assessment of the deficiency pituitary dwarfism. For the assessment of such deficiency should be considered that almost all cases of pituitary dwarfism in Class III of hypothalamic-pituitary deficiency, which corresponds to 15 to 25% when symptoms persist despite treatment.

9.3 CRITERIA FOR THE ASSESSMENT OF THYROID DEFICIENCY.

Hyperthyroidism is not considered a cause of deficiency because the hypermetabolic state can be corrected permanently by treatment in most patients. After remission of hyperthyroidism may be deficient in the visual system or cardiovascular disease, which should be evaluated according to standards. Also, hypothyroidism in most cases can be managed successfully with thyroid hormone administration.

For the evaluation of thyroid function tests should be performed to determine thyroid endocrinologist.

9.3.1 Assessment of the deficiency Hyperthyroidism.

As mentioned hyperthyroidism in itself does not cause impairment, malignant thyrotoxicosis sometimes leads to the emergence of a progressive exophthalmos, which can reach the ophthalmoplegia, which is evaluated in the chapter on ophthalmology.

9.3.2 Assessment of the deficiency hypothyroidism.

TABLE No. 9.3: EVALUATION OF IMPAIRMENT OF HYPOTHYROIDISM. GLOBAL STANDARD CLASS GAP (%)

I-             Just a continuous therapy for the correction of an underactive thyroid, and · no physical or laboratory contraindications for this therapy. 1 - 4.9

II-            There are symptoms of thyroid disease or anatomical abnormalities; • It is necessary continuous thyroid therapy · But you have other diseases that allow the replacement of thyroid hormone only partially. 5.0 - 15.0

NOTE: When the thyroid substitution was started later and permanent sequelae of hypothyroidism occurred that make up the picture of cretinism, the deficiency shall be calculated in accordance with the chapter on mental deficiency.

9.4 CRITERIA FOR EVALUATION OF DEFICIENCY DISORDERS OF THE ADRENAL GLANDS.

9.4.1 Alterations in the adrenal cortex.

The hyper or hyposecretion of this portion of the adrenal deficiency can occur. It is sometimes associated with other endocrine disorders or other organ systems, which requires combining these anomalies according to the provisions in other chapters. Hypersecretion may be caused by hyperplasia of the cortex, or pituitary ACTH excess ectopias either benign or malignant. Among the diseases caused by hypersecretion is Cushing syndrome, adrenogenital syndrome and primary aldosteronism.

Hyposecretion adrenal may be primary, due to destruction or absence of these glands, or secondary as a result of decreased secretion of Corticotrophins. One adrenal gland can compensate for the absence or dysfunction of the other.

For the evaluation of adrenal gland function tests should be performed to determine functional and hormonal endocrinologist.

9.4.1.1. Assessment of the deficiency of the adrenal cortex disorders.

TABLE No. 9.4: EVALUATION OF THE ALTERATIONS Poor adrenal cortex. GLOBAL STANDARD CLASS GAP (%)

I-             • There are anomalies in the discharge and requires prolonged administration of cortical hormones, for loss of the two adrenal; • And you need continuous treatment. 1 - 9.9

II-            • There are an anomaly in the discharge and requires prolonged administration of cortical hormone by loss of the two gland; • And you need continuous treatment. • O is the case of a patient who requires large amounts of cortical hormones to treat another illness base and these will cause Cushing syndrome secundario.10.0 - 19.9

III-           · There is an anomaly in the secretion and requires cortical hormone administration on an ongoing basis. • There are florid Cushing's syndrome not due to the battery therapy currently exists. • There are a Nelson syndrome secondary to resection and the Adrenal Gland Battery is not due to treatment that currently exists. 20.0 - 30.0

9.4.2 Alterations in the adrenal medulla.

The adrenal medulla is not essential to the life or welfare of the individual, and therefore, the lack of it is 0% of overall deficit. The overactivity of the bone marrow can cause alterations in cell hypertrophy whether by tumor or not. The existence of this hyperfunction leads to hypertension in the form of crisis or maintained.

9.4.2.1 Assessment of the deficiency disorders of the adrenal medulla

TABLE No. 9.5: EVALUATION OF THE DEFICIENCY FOR SPINAL ABNORMALITIES Adrenal.

GLOBAL STANDARD CLASS GAP (%)

I-• There are anomalies in the secretion of hormones from the adrenal medullary;

Do not need continuous treatment · can carry out all or almost all activities of daily living. 1 - 9.9

II • There are an anomaly in the secretion of hormones from the adrenal medulla; • The continuous treatment does not control the symptoms and signs completely. 10.0 - 20.0

9.5 CRITERIA FOR EVALUATION OF PERMANENT IMPAIRMENT OF CHANGES IN PRODUCT gonads.

A person with anatomical loss or impairment of the gonads resulting in abnormalities of hormone secretion have a global deficiency of 1 - 5.0.%, Provided that the alteration of gonadal function is permanent and irreversible. The deterioration of reproduction and sexual functions should be evaluated with the rules contained in Chapter VI.

9.6 CRITERIA FOR EVALUATION OF PERMANENT IMPAIRMENT BY PROBLEMS IN THE MAMMARY GLANDS.

A woman of childbearing age without breast or excessive galactorrhea, gynecomastia, or male with pain that interferes with daily activities, have an overall deficit between 1 and 5.0%. Breast cancers are evaluated according to the criteria of Chapter VIII.

9.7 CRITERIA FOR EVALUATION OF PERMANENT IMPAIRMENT OF PARATHYROID DISORDERS.

Hyperparathyroidism with hypercalcemia, unless caused by an inoperable carcinoma is generally considered a disease that can be corrected, although sometimes this correction can be difficult. Persistent hypercalcemia whether or not due to this disease, may require prolonged treatment. Deformities of the bones or kidney damage may persist after treatment and for evaluation of these conditions should be used standards for each chapter of the system involved.

When hypercalcemia with symptoms requiring prolonged treatment, assessment of deficiency must be based on the interference of the disease with the patient's daily activities can vary from 0 to 5.0% of overall deficit. This value must be combined with any other value relevant to the case of deficiency.

TABLE No. 9.6: EVALUATION OF IMPAIRMENT BY Hypoparathyroidism. GLOBAL STANDARD CLASS GAP (%)

I-             • The functioning of the parathyroid gland is deficient, calcium levels are maintained through the treatment, and no symptoms. 1 - 4.9

II-            Absence of the parathyroid calcium level rises and falls intermittently despite adequate treatment. Symptoms may or may not, due to abnormal levels of calcium in the blood. 5.0 - 9.9

III-           · Decrease in plasma calcium below 8 mg/100 ml. despite treatment.

IV-          · Severe recurrent tetany; ° or recurrent generalized convulsions; • O, lenticular cataract, which should be evaluated according to criteria developed in Chapter XIII of the sense organs. 10.0 - 15.0

9.8 ASSESSMENT OF DEFICIENCY OF METABOLISM OF CARBOHYDRATES.

9.8.1 Assessment of impairment caused by diabetes mellitus.

The long-standing diabetes may be associated with other diseases that lead to major deficiencies that diabetes itself. These conditions are referred to the cardiovascular system, neurological, urogenital, renal and visual, with specific degenerative complications such as coronary artery disease, neuropathy, retinopathy and nephropathy. Women of childbearing age may have difficulty completing the pregnancy and men sexual impotence. All these changes should

combined according to the assessment of deficiency issued in the chapter on the changes involved.

TABLE No. 9.7: EVALUATION OF IMPAIRMENT OF DIABETES MELLITUS. GLOBAL STANDARD CLASS GAP (%)

I-           Patient with Diabetes Mellitus, that properly controlled with diet. No evidence of diabetic microangiopathy (retinopathy and / or albuminuria> 30 mg/100 ml). 1 - 4.9

II-            Patient with Diabetes Mellitus, which requires restrictive diet and oral hypoglycemic agents, achieving satisfactory control of glycemia. Has any evidence of microangiopathy (retinopathy and / or albuminuria> 30 mg/100 ml) and the subsequent involvement of other organ systems. 5.0 - 9.9

III-           Patient with Diabetes Mellitus, which requires restrictive diet and oral hypoglycemic agents or insulin, achieving a satisfactory control of glycemia. Has any evidence of microangiopathy (retinopathy and / or albuminuria> 30 mg/100 ml) and the subsequent involvement of other organ systems. 10.0 - 19.9

IV-          Like the previous class, but despite the dietary management and insulin Frequent episodes of hyper or hypoglycemia, without satisfactory control that require hospital management and / or severe disease of other organ systems. 20.0 - 30.0 Example Class I: Man, 45 years on a review of present control glycemia of 190 mg and moderately overweight. Prescribed diet. Three months later his weight and blood glucose levels are normal. Diagnosis = Diabetes mellitus controlled by diet. = 1% overall deficit. Example class II: Man of 66 years in a test, glycemia has 300 mg, moderate overweight and hypertension. Prescribed diet, oral hypoglycemic and hypertensive therapy. Three months later his weight, blood glucose and blood pressure is controlled. Diagnosis = Diabetes Mellitus controlled. Global deficiency = 5%. Example Class III: Patient 25 years suffering from diabetes since age 15. Physical activity can develop varies greatly from day to day. Follows a strict diet and insulin therapy 2 times a day to control blood glucose and urine normal continuous. Lose weight without exceeding the normal range, but no further complications. Diagnosis = Diabetes Mellitus Type I, adequately controlled Deficiency = 15%.

Examples of Class IV: specific situations that fall in this case:

a) Neuropathy demonstrated by a persistent or significant impairment of motor function in two extremities and resulting in movement disorders, gait, postural attitude of the individual, or the last two, or there are changes in sensitivity consequences.

b) total or partial amputation of a limb due to diabetic necrosis or peripheral vascular obstructive disease.

c) severe retinopathy with significant loss of visual acuity and visual field, assessing visual impairment according to the criteria set forth in the chapter on organ of vision.

d) severe nephropathy with renal insufficiency (see corresponding chapter).

9.8.2 Assessment of impairment caused by hyperinsulinism (hypoglycemia Permanente).

Occasionally hyperinsulinism can result from an excess production of insulin, which induces hypoglycemia, which prolonged and repeated or severe attacks of which can lead to brain damage. Depending on the extent of brain damage, a person may suffer a deficiency hypoglycemic global assessment according to the Central Nervous System as defined in that chapter. Only in cases in which the metabolic damage is not controlled despite diet and appropriate medication, will be granted a deficiency of 10.0%.

9.9 EVALUATION OF IMPAIRMENT OF OTHER METABOLIC DISORDERS.

9.9.1 Assessment of the deficiency for metabolic bone diseases.

The metabolic bone diseases such as osteoporosis, osteomalacia resistant to vitamin D and Paget's disease, may require ongoing therapy and when they have symptoms and signs such as pain, skeletal deformities or condition of the peripheral nerves The overall deficit will be 0%. Where are the signs and symptoms mentioned above but get a complete remission of them through continued therapy based on hormones and minerals, the overall deficit can be 1-5%. When therapy is required to relieve the pain continues without achieving complete remission and the subject's daily activities are affected by it or from complications such as fractures,

may be an overall deficit of 5 - 10.0%.

In case of osteoporosis of the spine, should be evaluated with the parameters defined in Chapter I. For more general information about osteoporosis should be reviewed in Chapter III.

9.9.2 Multiple Endocrine Disease

Multiglandulares of autoimmune syndromes, is of particular interest is the association of hypothyroidism, Hashimoto's thyroiditis most adrenal insufficiency, or Addison's disease. Deficiencies are graded according to the provisions of sections that refer to each of the involved hormonal dysfunctions, by combining the

respective values. The multiple endocrine neoplasia (MEN), often generate various glands overactive simultaneously and continuously. The association of medullary thyroid carcinoma with pheochromocytoma is of particular interest. Exhausted the means of treatment, surgical and pharmacological deficiency is calculated according to the pathology of each gland.