Management of Hyperglycemia in the Noncritical Care Setting: A Real-World Case-Based Approach With Alternative Insulin- and Noninsulin-Based Strategies.

Insulin remains the mainstay of treatment for inpatient hyperglycemia in the United States and Canada. However, some other countries commonly use noninsulin agents such as metformin and sulfonylureas, and several trials have demonstrated the efficacy and safety of incretin-based agents in patients with type 2 diabetes who are admitted to noncritical care medicine and surgery services. There is a high degree of interest in alternative glucose-lowering strategies to achieve favorable glycemic outcomes with lower risks of hypoglycemia. In this case series, we highlight the challenges of inpatient glycemic management and the need for alternatives to the traditional basal-bolus insulin regimen. Additional investigation will be imperative to validate the safety and efficacy of appropriate insulin and noninsulin treatments and to further develop guidelines that are applicable in real-world hospital settings.

Clinical Features in Differentiated Thyroid Carcinoma Stratified By Lymph Node Status.

OBJECTIVE: Cervical lymph node (CLN) metastases (mets) often occur in differentiated thyroid cancer (DTC), especially in the central compartment, and are a major predictor of local recurrence. We examined clinical endpoints in three groups of patients based on status of lymph node involvement: those with definite lymph node involvement (N1), negative lymph nodes (N0), and no lymph nodes resected (Nx). We correlated these endpoints with clinical and pathologic features of these patients. METHODS: Medical records of 261 patients with DTC who underwent thyroidectomy between 2006 and 2018 at our center were reviewed. Lymph node status of patients was categorized based on American Joint Committee on Cancer (AJCC) 8th edition criteria as N1, N0, and Nx. We performed statistical analysis to assess the differences among these groups, using one-way analysis of variance. When significant differences were found, pairwise comparisons were conducted among the three groups. Statistical significance was defined as 2-tailed P<.05 for all tests. RESULTS: There were significant differences among the groups in tumor multicentricity, tumor category/size, AJCC stage, and the presence of thyroglobulin auto-antibodies (TgAbs). There were no difference in age, gender, or histopathology. N1 patients had a higher incidence of multicentricity, larger tumor sizes, and were more likely to have elevated TgAbs. There were no significant differences between the N0 and Nx groups. CONCLUSION: This study shows that larger and multi-centric tumors are associated with increased likelihood of CLN mets in DTC. We suggest increased vigilance for CLN mets in tumors >2 cm, multicentric tumors, and patients with elevated TgAbs. ABBREVIATIONS: AJCC = American Joint Committee on Cancer; CLN = cervical lymph node; DTC = differentiated thyroid cancer; FTC = follicular thyroid cancer; mets = metastases; N0 = no cancer in any lymph nodes; N1 = cancer in a lymph node; N1a = cancer in a central compartment lymph node; N1b = cancer in a lateral neck lymph node; Nx = lymph nodes not resected or examined; PTC = papillary thyroid cancer; TgAb = thyroglobulin auto-antibody.

LOWER RATES OF RESIDUAL/RECURRENT DISEASE IN PATIENTS WITH INCIDENTALLY DISCOVERED THYROID CARCINOMA.

OBJECTIVE: Incidentally discovered thyroid cancers (IDTCs) have contributed to the rapid rise in thyroid cancer incidence over the past 20 years. Since death rates from thyroid cancer are not increasing, we hypothesized that IDTCs are less aggressive compared to clinically apparent thyroid cancer (CATC). METHODS: A retrospective study of patients and tumor characteristics of IDTCs and their rates of residual/recurrent (R/R) disease were determined at a median follow-up of 27 months in the setting of a large academic medical center. Patient analysis groups (IDTC [n = 46] and CATC [n = 126]) were based upon how the cancer was initially discovered. Patients were followed clinically and by biochemical testing and ultrasonography. We also compared time to progression between these groups. RESULTS: Patients in the two groups had similar demographic and tumor characteristics. At the close of the study, R/R status in the IDTC group was 6.7%, compared to 20.8% in the CATC group (P = .04). Of the 28 individuals in our overall cohort who had R/R disease, 3 were from the IDTC group and 25 were from the CATC group (P = .04). All three of the IDTC recurrences occurred within the first 6 months of follow-up. Using Kaplan-Meier analysis, there was a nonsignificant trend for longer progression-free survival in the IDTC group (P = .08). CONCLUSION: Compared to CATC patients, IDTC patients have a significantly less aggressive course and a trend toward longer progression-free survival. If confirmed by further studies, it may be reasonable to subject them to less intense surveillance and more conservative therapeutic approaches. ABBREVIATIONS: CATC = clinically apparent thyroid cancers CT = computed tomography HMH = Houston Methodist Hospital IDTC = incidentally discovered thyroid cancer MRI = magnetic resonance imaging PET = positron emission tomography PTMC = papillary thyroid microcarcinoma R/R = residual/recurrent RRA = radioiodine remnant ablation Tg = thyroglobulin TgAb = anti-thyroglobulin antibody TSH = thyroid-stimulating hormone US = ultrasonography.

Recurrent Pleural Effusion Associated With Candida Albicans Infection in Transplanted Kidney: A Case Report.

Recurrent pleural effusions are associated with significant morbidity and mortality. Pleural effusions are frequently seen in patients with chronic renal failure due to fluid retention. Pleural effusions in renal transplant patients are usually related to secondary pulmonary infections, surgical complications, drug toxicities, or post-transplant lymphoproliferative disorder (PTLD). We describe an unusual cause of recurrent pleural effusion attributed to fungal infection in a transplanted kidney due to activation of the renin-angiotensin-aldosterone system (RAAS), successfully treated with antifungal medications that led to complete resolution of pleural effusion.

Impact of Blood Products Transfusion on Patients in the Immediate Post-Lung Transplant Period: A Cohort Study.

BACKGROUND Anemia is common in post-transplant patients. Blood product transfusion is associated with mortality and rejection in solid organ transplants. In lung transplant recipients, transfusion predisposes to primary graft dysfunction (PGD). The adverse effects and associated mortality of perioperative transfusions in lung transplant recipients have not been evaluated. This study examined the effects of perioperative blood transfusions in lung transplant recipients. MATERIAL AND METHODS We conducted a retrospective study of the effects of blood product transfusions in patients who received single- or double-lung transplantation at Houston Methodist Hospital between August 2017 and September 2019. Univariable and multiple logistic regression modeling were used to determine the characteristics associated with single events as well as a composite outcome within 30 days (including mortality, acute myocardial infarction, acute stroke, lower respiratory tract infection, urinary tract infection, surgical site infections, or PGD). RESULTS A total of 232 patients received lung transplants between December 2015 and September 2019 at our center. Univariable analysis revealed an increased risk of PGD (P<0.001), more mechanical ventilation days (P<0.001), more ICU days post-transplant (P<0.001), and greater need for ECMO support (P=0.001) in patients who received blood product transfusions. In univariate analysis, the composite outcome was also more common (P=0.01) in patients who received any transfusion perioperatively. A total of 7 patients died within 30 days from transplant, and they were all in the transfused group. CONCLUSIONS Among lung transplant recipients, PGD, ICU days, need for mechanical ventilation and ECMO support, and total composite events were significantly greater in patients who received blood transfusion perioperatively.

A Woman with Bilateral Pheochromocytoma and Tuberous Sclerosis Complex.

Background/Objective: Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors. Here, we report an unusual case of synchronous PPGL in an asymptomatic patient with tuberous sclerosis complex (TSC). Case Report: A 49-year-old woman with a history of TSC and end-stage renal disease was referred for evaluation of bilateral adrenal and retroperitoneal masses. She denied chest pain, palpitations, headaches, or previous hypertensive crisis. The laboratory test results showed a plasma normetanephrine level of 20.20 nmol/L (normal range, 0.00-0.89 nmol/L) and plasma chromogranin A level Chromogranin A (CgA) levels of 1518 ng/mL (normal range, 0-103 ng/mL). The plasma metanephrine level was normal. After α-blockade, the patient underwent bilateral adrenalectomy and retroperitoneal mass excision. Pathology confirmed these lesions to be pheochromocytoma and composite paraganglioma/ganglioneuroma, respectively. Her plasma normetanephrine level normalized postoperatively, and the chromogranin A levels improved to 431 ng/mL. Discussion: Routine imaging has increased the incidental diagnosis of PPGL. Diagnostic workup includes measurement of the urinary and/or plasma metanephrine and catecholamine levels followed by tumor localization. Patients with young age, syndromic lesions, bilateral PPGL, or unilateral disease with a positive family history should have genetic testing. Definitive treatment is surgical after α-blockade. Conclusion: This case highlights a rare presentation of bilateral PPGL in a patient with TSC.

MEN1 in a Patient With Nonsyndromic Familial Nonmedullary Thyroid Carcinoma.

Clinical syndromes involving multiple endocrine glands have been well recognized for over a century. Multiple reports describing hereditary multiple endocrine neoplasia (MEN) syndromes involving pituitary, parathyroid, and pancreatic neuroendocrine tumors have been published. Differentiated (nonmedullary) thyroid cancer can also present as a hereditary syndrome with or without a specific genetic predisposition. We report the case of a man with nonsyndromic familial nonmedullary thyroid carcinoma, a pituitary adenoma, hyperparathyroidism, an adrenal adenoma, and pancreatic adenocarcinoma. Genetic testing did not reveal mutations in the commonly reported genes associated with MEN syndromes. MEN1 is characterized by endocrine neoplasia in at least 2 of the following glands: pituitary, parathyroid, and the gastro-entero-pancreatic (GEP) tract. Co-occurrence of MEN1 with familial nonmedullary thyroid carcinoma, however, has not been reported in the medical literature. This unique case of MEN1 co-existing in a patient with nonsyndromic familial thyroid carcinoma was not associated with any common MEN syndrome germline mutations.

SGLT2 Inhibitors in Patients with Chronic Kidney Disease and Heart Disease: A Literature Review.

Sodium-glucose transport protein 2 inhibitors, commonly referred to as SGLT2i, are a group of prescription pharmaceuticals that are approved by the United States Food and Drug Administration for use with diet and exercise to lower blood glucose in adults with type 2 diabetes. Diabetes is a well-recognized major contributor to cardiovascular and renal disease burden. In addition to blood glucose control, SGLT2i have been shown to provide significant cardiovascular and renoprotective benefits in patients with and without diabetes. In this review, we describe current evidence related to the renal and cardiovascular benefits of using SGLT2i.

Minoxidil-associated exudative pleural effusion.

Recurrent pleural effusions are associated with significant morbidity and mortality. Drug-related reactions causing pleural effusions are not common, but their identification can potentially improve patient outcome. Minoxidil has been implicated in pleuropericardial effusions in patients with chronic kidney disease. The exact mechanism by which pleural effusion occurs is still unclear. We report a case of isolated exudative pleural effusion associated with minoxidil in a patient without underlying kidney disease that almost completely resolved after the drug was discontinued.

A BRAF V600E Mutation in RET-Negative Medullary Thyroid Cancer.

We report the case of a woman with a sporadic medullary thyroid carcinoma. Genomic analysis found that her tumor did not contain any common RET mutations but did harbor a BRAF V600E mutation. Only one other well-confirmed example of the BRAF V600E mutation has been reported in an MTC patient. We conclude that this common BRAF mutation may independently drive neoplastic transformation of human parafollicular C cells.

Update on Management of Type 2 Diabetes for Cardiologists.

The management of type 2 diabetes mellitus has evolved over the last several years as new antidiabetic agents continue to arrive and change the goals of diabetes care. In 2008, the U.S. Food and Drug Administration mandated that all new antidiabetic agents must demonstrate cardiovascular (CV) safety, which has led to a series of CV outcome trials. In this article, we review the key findings from these CV outcome trials and their impact on diabetes care guidelines.