Instilling Hope and Resiliency: A Narrative Photo-Taking Intervention During an Intercultural Exchange Involving 9/11 Survivors in Post 3/11 Japan.

On March 11, 2011 ("3/11"), a magnitude 9.0 earthquake in Northeastern Japan triggered a tsunami and nuclear power plant meltdown that killed 16,000 people and displaced more than 470,000 people. Since 2012, a group of volunteer docents from the September 11th Families Association in New York City has traveled throughout Northeastern Japan and held organized meetings where 9/11 and 3/11 survivors share their experiences and stories of trauma as part of an intercultural exchange to promote posttraumatic recovery. We sought to elucidate whether participating 9/11 docents developed a sense of increased resiliency by participating in this international outreach. This study employed photo-taking as well as framing questions, which were developed by 9/11 docents from the August 2016 trip. These questions guided photo-taking and resulting photographs informed discussion in individual and group sharing sessions. This process helped identify codes that guided analysis. Participants acquired a deeper appreciation of their own ability to overcome adversity and experienced a gratifying desire to help 3/11 survivors better cope with their experiences. This narrative photo-taking and group sharing experience demonstrates that a cross-cultural exchange between survivors of different disasters can instill feelings of resilience among participants. It additionally provides early evidence of the efficacy of such an exchange in benefitting disaster survivors in the long term.

Medical Student Reactions to Disaster after the 2011 Great East Japan Earthquake: Motivation and Posttraumatic Growth.

Medical students often become involved as post-disaster emergency responders despite incomplete training, and in doing so may suppress their immediate experiences as victims and survivors. This experience, however, may lead them to increase their motivation to help others. We examined how cognitive and emotional reactions to disaster correlated with posttraumatic growth (PTG) in medical students in Fukushima, Japan after the Great East Japan Earthquake of March 11, 2011. To date, Fukushima continues to suffer from radiation concerns following the nuclear power plant meltdown. In a survey three years after the onset of a long-term disaster, with a cross-sectional research design, medical students (N = 494) reported their negative post-disaster reactions, desire to help, and demonstrations of capability, and completed the Posttraumatic Growth Inventory (PTGI). We conducted hierarchical regression analyses and found that the addition of variables pertaining to negative post-disaster reactions (e.g. confusion, anger, and sadness) led to the largest increase in predictive value for PTGI scores; students reporting a past traumatic experience were also more likely to experience PTG. Our results indicate that weathering stressful disaster circumstances created opportunities for positive personal growth and reinforcement at a crucial time in medical students' professional development.

RAPID EVOLUTION OF THYROID DYSFUNCTION IN PATIENTS TREATED WITH NIVOLUMAB.

OBJECTIVE: To describe the evolution of thyroid dysfunction in a series of patients with cancer treated with the immune checkpoint inhibitor anti-programmed cell death protein-1 (PD-1) monoclonal antibody, nivolumab. METHODS: Cases of thyroid dysfunction after initiation of checkpoint inhibitor treatment were identified from the Division of Endocrinology clinical practice at Mount Sinai Hospital, New York from April 2016 to February 2017. Charts were reviewed to identify patients treated with nivolumab with new onset of thyroid dysfunction. RESULTS: Nine cases of thyroid function in patients who were treated with nivolumab were identified. There were 4 male and 5 female patients, with a mean age of 66 years (range 50-76 years). Seven patients ultimately developed hypothyroidism. Five of the 7 patients developed abnormal thyroid function tests within the first 90 days of starting therapy (range 21-84 days), 3 of whom had transient hyperthyroidism. Transient hyperthyroidism evolved rapidly to hypothyroidism; elevated thyroid-stimulating hormone (TSH) levels were detected within 16 to 32 days of the last documented low TSH. In the 2 patients without a hyperthyroid phase, TSH levels >50 were found 18 to 28 days after the last normal TSH value. CONCLUSION: As the use of immune checkpoint inhibitor therapy increases, the need for prompt diagnosis and treatment of drug-induced thyroid disease will become more important. As illustrated in this case series, in contrast to other causes of auto-immune thyroiditis, hypothyroidism can develop rapidly within 3 months of treatment. Close monitoring is necessary to detect the development of thyroid dysfunction and avoid preventable morbidity. ABBREVIATIONS: Anti-TPO Abs = anti-thyroglobulin antibodies; CT = computed tomography; CTLA-4 = cytotoxic T-lymphocyte-associated protein 4; FDA = U.S. Food & Drug Administration; FDG-PET = fluorodeoxyglucose-positron emission tomography; PD-1 = programmed cell death protein-1; PD-L1 = programmed death-ligand 1; T3 = triiodothyronine; T4 = thyroxine; TG = thyroglobulin; TPO = thyroperoxidase; TSH = thyroid-stimulating hormone.

Thyroid and parathyroid surgery in pregnancy.

The consideration of surgery during pregnancy requires weighing the benefit of urgent surgery against the risk to mother and fetus. Surgery during pregnancy involves an increase in both maternal and fetal risks. Thyroid and parathyroid surgery involves physiological risks to both mother and fetus specific to the disease and function of these endocrine glands. Evaluation of a thyroid mass is similar in pregnant patients with ultrasound and fine-needle aspiration biopsy providing the most important information, while the use of radiographic imaging is severely constrained except when specifically required. In general, thyroid surgery can be delayed until after delivery except in cases of airway compromise or aggressive cancer. In contrast, parathyroid surgery is recommended during pregnancy to avoid adverse effects to the neonate.

Metabolic syndrome and type 2 diabetes: can we stop the weight gain with diabetes?

Many patients with type 2 diabetes also have the metabolic syndrome with its cardinal features of central adiposity, insulin resistance, dyslipidemia, and hypertension. Although there is strong evidence for the importance of tight glycemic control in minimizing the microvascular complications of diabetes, many of the current therapies used for optimizing glycemic control also cause weight gain. With this treatment-induced weight gain, there is a risk of worsening the patient's insulin resistance. Physicians need to be aware of this vicious cycle in their overweight type 2 diabetic patients. This article reviews the strategies currently available to achieve glycemic control while at the same time minimizing weight gain and the associated complications.

Bariatric surgery for morbid obesity--a cure for metabolic syndrome?

At present there is no single medication that targets the metabolic syndrome directly. Bariatric surgery, a treatment option for morbidly obese individuals who fail medical therapy, has been shown to be very effective in treating multiple aspects of the metabolic syndrome. The decrease in insulin resistance is because of significant weight loss and by enhancing secretion of gut hormones such as glucagon-like peptide-1 (GLP-1).

Quality of life in the patients with central diabetes insipidus assessed by Nagasaki Diabetes Insipidus Questionnaire.

Central diabetes insipidus (CDI) is characterized by polyuria and polydipsia due to a deficiency of vasopressin. Currently, the treatment goal for CDI is improvement of quality of life (QOL) by desmopressin (DDAVP) without developing hyponatremia. However, there is no reliable measure for QOL in CDI patients. We evaluate our original questionnaire for QOL, consisting of 12 questions focusing on polyuria, polydipsia, and DDAVP treatment, in CDI patients who underwent a switch from nasal spray to oral disintegrating tablets of DDAVP. Twenty-five CDI patients under nasal DDAVP treatment, six with newly developed CDI, and 18 healthy individuals without known polyuric/polydipsic disorders as control subjects were enrolled. QOL scores were determined by our questionnaire at the enrollment and 3 months after the start of oral DDAVP treatment and were examined by the Wilcoxon signed-rank test. Eleven questions detected improvement in QOL. The sum of the QOL scores of the eleven questions increased from 29.2 ± 5.6 under nasal to 36.8 ± 4.5 under oral DDAVP (p < 0.001). There were no clinically relevant changes in serum levels of Na. After eliminating two questions about DDAVP treatment, the sum of QOL scores was 15.3 ± 6.5 in untreated CDI patients, 24.4 ± 5.2 in those with nasal treatment, 28.9 ± 4.9 in those with oral DDAVP, and 29.5 ± 3.6 in healthy controls. The difference among groups was significant (p < 0.05 in Steel-Dwass test) except between patients treated with oral DDAVP and healthy controls. Our questionnaire can be used to accurately assess QOL in CDI patients.

Apathetic thyrotoxicosis secondary to atypical subacute thyroiditis.

OBJECTIVE: To report a case of apathetic thyrotoxicosis with an etiology of subacute thyroiditis. METHODS: We describe the patient's clinical findings, laboratory findings, and clinical course. RESULTS: An 85-year-old woman with no history of thyroid disease presented with severe obtundation and altered mental status. Laboratory testing documented elevated free thyroxine and free triiodothyronine concentrations and a suppressed thyrotropin concentration. Thyroid antibodies were absent. A radioactive iodine study revealed severely diminished uptake, suggestive of thyroiditis. After a short course of steroids, the patient's mental status returned to baseline. Follow-up laboratory testing showed normalizing thyroid function. CONCLUSION: Even in the absence of a history of thyroid disease, we recommend considering thyroid dysfunction in the differential diagnosis of patients who present with altered mental status, particularly in the elderly population.

Excess thyroid hormone and carbohydrate metabolism.

OBJECTIVE: To review the pertinent basic and clinical research describing the complex effects of excess thyroid hormone on carbohydrate metabolism. METHODS: We performed a MEDLINE search of the English-language literature using a combination of words (ie, "thyrotoxicosis and diabetes," "diabetic ketoacidosis and thyroid storm," "carbohydrate metabolism and hyperthyroid," "glucose homeostasis and thyrotoxicosis") to identify key articles addressing various aspects of the thyroid's influence on carbohydrate metabolism. RESULTS: Thyroid hormone affects glucose homeostasis via its actions on a variety of organs including increased hepatic glucose output, increased futile cycling of glucose degradation products between the skeletal muscle and the liver, decreased glycogen stores in the liver and skeletal muscle, altered oxidative and non-oxidative glucose metabolism, decreased active insulin output from the pancreas, and increased renal insulin clearance. Thyroid hormone also affects adipokines and adipose tissue, further predisposing the patient to ketosis. CONCLUSIONS: Thyrotoxicosis can alter carbohydrate metabolism in a type 2 diabetic patient to such an extent that diabetic ketoacidosis develops if untreated. Based on the current understanding of this relationship, all diabetic patients should be screened for thyroid dysfunction because correcting hyperthyroidism can profoundly affect glucose homeostasis. Similarly, patients presenting in diabetic ketoacidosis should undergo a thyroid function assessment.