Radiology report language positively influences adrenal incidentaloma guideline adherence.

BACKGROUND: Adrenal incidentalomas are common radiographic findings. Guidelines recommend biochemical and radiographic surveillance of adrenal incidentalomas. We investigated if patients were appropriately referred for outpatient evaluation. METHODS: Retrospective chart review was performed to identify patients with adrenal masses on imaging between November 7, 2016 and November 7, 2017. Demographic information, medical history, and outpatient referral information was collected. RESULTS: 11,723 computed tomography (CT) scans of the chest and/or abdomen/pelvis were performed. 246 patients were noted to have adrenal incidentalomas and met inclusion criteria. The CT report recommended follow-up in 63/246 cases (25.6%). 38/246 (15.4%) patients were referred for evaluation. Age, adrenal nodule size, and type of evaluating provider did not affect referral. A radiology report recommending follow-up was associated with increased referral rate (OR 5.441, 95% CI: 2.491-11.887). CONCLUSION: There was low outpatient referral for adrenal incidentalomas. Language in the radiology report significantly influenced referral rates and may be an important resource for improving guideline adherence.

CONVERSION OF HYPOTHYROIDISM TO HYPERTHYROIDISM: A RARE CLINICAL PHENOMENON.

OBJECTIVE: We present a patient with long standing hypothyroidism who developed hyperthyroidism secondary to Graves disease. Recognition of this disease phenomenon is crucial to ensure prompt diagnosis and close follow-up. METHODS: The patient was evaluated with thyroid function testing and thyroid antibody testing. Further evaluation included ophthalmologic examination and radioactive iodine uptake imaging. RESULTS: A 56-year-old female with past medical history of human immunodeficiency virus, hepatitis C infection, and hypothyroidism presented for evaluation of thyroid disease. She had been off of levothyroxine for the last 8 months due to biochemical findings of thyrotoxicosis. Her family history was significant for hyperthyroidism and hypothyroidism. Laboratory tests were consistent with hypothyroidism so levothyroxine was restarted. Physical exam showed lid lag and proptosis. Ophthalmologic evaluation found bilateral 23 mm proptosis. Additional lab testing was positive for thyroid peroxidase antibody and thyroid stimulating immunoglobulin. Following levothyroxine use, the patient developed subclinical hyperthyroidism and thyroid replacement was stopped. The patient remained euthyroid for 1 year off of levothyroxine. Following 1 year, she developed mild hyperthyroidism with increased radioactive iodine uptake. She was placed on propranolol for symptomatic relief. Months later, thyroid function testing normalized. CONCLUSION: In Graves disease, hypothyroidism and conversion of hypothyroidism to hyperthyroidism are rare, yet important to recognize, clinical phenomenon. The stimulatory and inhibitory properties of thyroid-stimulating hormone receptor antibodies are speculated to play a role in individuals with alternating hypothyroidism and hyperthyroidism. These individuals can present a diagnostic and therapeutic challenge. Clinicians must maintain a high clinical suspicion for this disease entity.

ZO-1 protein is required for hydrogen peroxide to increase MDCK cell paracellular permeability in an ERK 1/2-dependent manner.

Hydrogen peroxide (H2O2) increases paracellular permeability of Madin-Darby canine kidney (MDCK) cells, but the mechanism mediating this effect remains unclear. Treatment of MDCK cells with H2O2 activated ERK 1/2. Inhibition of ERK 1/2 activation blocked the ability of H2O2 to increase paracellular permeability. Knockdown of zonula occludens-1 (ZO-1) protein but not occludin eliminated the ability of H2O2 to increase paracellular permeability. H2O2 treatment did not, however, affect the total cell content or contents of the Triton X-100-soluble and -insoluble fractions for occludin, ZO-1, or ZO-2. H2O2 treatment decreased the number of F-actin stress fibers in the basal portion of the cells. Similar to wild-type MDCK cells, H2O2 increased ERK 1/2 activation in ZO-1 knockdown and occludin knockdown cells. Inhibition of ERK 1/2 activation blocked the increase in paracellular permeability in occludin knockdown cells. ZO-1 knockdown cell paracellular permeability was regulated by PP1, an src inhibitor, indicating that the loss of response to H2O2 was not a general loss of the ability to regulate the paracellular barrier. Inhibition of myosin ATPase activity with blebbistatin increased paracellular permeability in ZO-1 knockdown cells but not in wild-type MDCK cells. H2O2 treatment sensitized wild-type MDCK cells to inhibition of myosin ATPase. Knockdown of TOCA-1 protein, which promotes formation of local branched actin networks, reproduced the effects of ZO-1 protein knockdown. These results demonstrate that H2O2 increases MDCK cell paracellular permeability through activation of ERK 1/2. This H2O2 action requires ZO-1 protein and TOCA-1 protein, suggesting involvement of the actin cytoskeleton.