Biochemical follow-up of nonfunctioning benign thyroid nodules.

OBJECTIVE: For the biochemical follow-up of benign thyroid nodules, some authors recommend periodic lifelong measurement of thyroid-stimulating hormone (TSH) to assess for the development of toxic nodules over time. The purpose of this retrospective study was to assess the incidence of thyroid dysfunction over time in patients with benign thyroid nodule(s), with a normal TSH at diagnosis and to identify any factors that may predict biochemical dysfunction over time. METHODS: Medical records of patients with the diagnosis of thyroid nodule(s) between January 2011 and August 2014 were reviewed. Patients who had TSH measurement within 1 year of initial diagnostic ultrasound (US) were included. RESULTS: One-hundred fifty-seven patients identified with thyroid nodule(s) satisfied inclusion criteria. At a median follow-up of 45 (34-63) months, 13 (8.3%) patients developed thyroid dysfunction. The mean initial TSH in the group which developed subclinical hyperthyroidism (0.65 mIU/mL) was statistically different from the group that did not develop thyroid dysfunction (1.37 mIU/mL, P: 0.007). More patients with TSH <1 mIU/L developed thyroid dysfunction as compared to subjects with TSH ≥1 mIU/L (P: .022). There was no significant difference in the incidence of thyroid dysfunction on the basis of gender, race, smoking status, TPO Ab positivity and number of nodules at diagnosis. CONCLUSIONS: We recommend re-examining the current practice and clinical utility of frequent TSH monitoring in all patients with thyroid nodules, particularly if initial TSH level is ≥1 mIU/L.

Diagnosing Pheochromocytoma in the COVID-19 Era: A Case Report.

INTRODUCTION: Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that secrete catecholamines. Symptoms of these tumors are related directly to catecholamine excess but can be intermittent and easily misattributed to other, more common pathologies. Identification in the emergency department (ED) is inherently difficult. During the coronavirus 2019 (COVID-19) pandemic, physicians have had to account for both the disease itself as well as associated increased prevalence of cardiac, pulmonary, and vascular complications. Such shifting of disease prevalence arguably makes rarer diseases like pheochromocytoma less likely to be recognized. CASE REPORT: We report a case of pheochromocytoma in a patient who presented to the ED in the fall of 2020, at a regional height of the COVID-19 pandemic, with complaints of fatigue, tachycardia, and diaphoresis. The differential diagnosis included pulmonary embolism, cardiomyopathy, congestive heart failure, and infectious causes. A broad workup was begun that included serology, electrocardiogram, computed tomography angiogram (CTA), and COVID-19 testing. Imaging was consistent with COVID-19 infection, and laboratory testing confirmed the diagnosis. A tiny retroperitoneal tumor was reported on CTA as "incidental" in the setting of multifocal pneumonia from severe acute respiratory syndrome coronavirus 2 infection. Additional history-taking revealed many years of intermittent symptoms suggesting that the tumor may have been more contributory to the patient's presentation than originally suspected. Subsequent magnetic resonance imaging and surgical pathology confirmed the dual diagnosis of pheochromocytoma and COVID-19 pneumonia. CONCLUSION: This case presentation highlights the importance of careful history-taking, keeping a broad differential, and examining incidental findings in the context of the patient's presentation.

Antispasmodic and Antidiarrheal Activities of Valeriana hardwickii Wall. Rhizome Are Putatively Mediated through Calcium Channel Blockade.

Valeriana hardwickii is indigenous to Pakistan, Burma and Ceylon, where it is traditionally being used as an antispasmodic and antidiarrheal, besides its culinary use as spice. The aim of this paper was to provide pharmacological validation to these medicinal uses. The crude aqueous-methanolic extract of Valeriana hardwickii rhizome (Vh.Cr) was studied on isolated rabbit jejunum and castor oil-induced diarrhea in mice for spasmolytic and antidiarrheal properties, respectively. Vh.Cr caused concentration-dependent (0.01-1 mg/mL) relaxation of spontaneous contractions in isolated rabbit jejunum and inhibited K(+)-induced contractions (0.01-0.3 mg/mL), similar to verapamil, suggestive of calcium channel blockade (CCB). The CCB effect was confirmed when pretreatment of the jejunum preparations with Vh.Cr produced a concentration-dependent (0.03-0.1 mg/mL) rightward shift in the Ca(++) concentration-response curves, as caused by verapamil. Vh.Cr exhibited dose-dependent (100-300 mg/kg) protection against castor oil-induced diarrhea in mice. Loperamide, a standard antidiarrheal drug, similarly prevented the diarrhea. These data indicate the presence of CCB effect in the extract of Valeriana hardwickii rhizome, possibly mediating its antispasmodic and antidiarrheal activities and provide a scientific base for its traditional use in hyperactive gut disorders.

Knowledge of Hemoglobin A1c and Glycemic Control in an Urban Population.

AIM: Our study aims to assess the knowledge of hemoglobin A1c (HbA1c) and glycemic control in patients with diabetes mellitus (DM) at an urban academic institution. METHODS: This was a retrospective cross-sectional study that included a survey of 100 adult patients with DM. Our patient cohort was divided into those with recent HbA1c < 8.0% and those with HbA1c ≥ 8.0% for subgroup analysis. RESULTS: The majority (71%) of patients correctly defined HbA1c and half were aware of their HbA1c target, but they were unable to correlate the correct average blood glucose for an HbA1c level of 7%. Worse control, defined as an HbA1c level of ≥ 8%, was associated with co-morbid disease, but was not associated with understanding HbA1c definition, target or socioeconomic disparities. Perceived glycemic control was congruent with the actual control in 46% of our patients. Ninety percent of those with HbA1c ≥ 8% perceived their control to be better than it actually was, and 97% of those with HbA1c < 8% perceived their control worse than it actually was (P < 0.00001). CONCLUSION: Although most patients knew the definition of HbA1c, they were unable to correlate HbA1c with average blood sugar. There remain opportunities to increase education for this vulnerable population with co-morbid disease on the use of the HbA1c disease marker as an education tool.

Thyroid storm presenting as psychosis: masked by diabetic ketoacidosis.

INTRODUCTION: While extremely uncommon, diabetic ketoacidosis (DKA) and thyroid storm (TS) are endocrine emergencies that can coexist. We describe a case with a confounding clinical presentation that identifies these two emergencies within the setting of sepsis and influenza. CASE: A 69-year-old diabetic female was found by the paramedic staff to be disoriented. She demonstrated tachycardia and had a foul-smelling abdominal wound. Laboratory evaluation revealed DKA, leukocytosis, influenza B, and urinary tract infection. After appropriate management in the intensive care unit, the DKA resolved the following morning. However, the patient developed a fever, and her psychosis became more pronounced. Extensive analysis was performed but did not explain her mental status. The patient was found to have thyroid stimulating hormone of 0.06 mIU/mL, free T4 (thyroxine) of 2.38 ng/dL, and total T3 (triiodothyronine) of 72 ng/dL. Based on the Burch and Wartofsky criteria (score of 65), TS was diagnosed. Based on more recent diagnostic criteria suggested by Akamizu et al., the patient met criteria for TS grade 1. Within several hours of initiating treatment, the patient's mental state and tachycardia improved, and her psychosis resolved by the third day. CONCLUSION: This case highlights the importance of recognizing the clinical diagnosis of TS, as the magnitude of thyroid hormone derangements may not correlate with clinical severity. While rare, DKA and TS can simultaneously occur and are associated with increased morbidity and mortality if not promptly recognized and treated.