ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update.

Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Hürthle cell thyroid carcinoma presenting as a "hot" nodule.

OBJECTIVE: To report an unusual clinical scenario and a rare histopathologic finding of Hürthle cell thyroid carcinoma in a patient with an autonomous thyroid nodule. METHODS: We describe the presentation and clinical course leading to the surprising histopathologic diagnosis of Hürthle cell carcinoma in a pediatric patient who was diagnosed with hyperthyroidism presenting as a solitary toxic nodule. RESULTS: A 13-year-old white girl presented with a recent history of a palpable thyroid nodule during a routine primary care clinic visit. She was asymptomatic, and thyroid function tests revealed a suppressed thyrotropin concentration, high-normal free thyroxine concentration, and elevated triiodothyronine concentration. The patient underwent dedicated thyroid ultrasonography revealing a 3.5-cm complex mass in the left lobe with increased central vascularity. Iodine 123 imaging of the thyroid demonstrated homogenous, hyperintense activity in the left lobe. The right lobe was not visualized. A solitary toxic nodule was diagnosed, and, considering her age, she was referred for surgical management. The patient underwent a left lobectomy with isthmusectomy. Pathologic examination revealed a 5-cm, encapsulated, well-differentiated Hürthle cell carcinoma with negative margins and no lymphovascular invasion. The patient underwent subsequent completion thyroidectomy with no evidence of residual carcinoma in the right thyroid lobe. CONCLUSIONS: Malignancy in autonomously functioning thyroid nodules is rare. Most of the thyroid nodules presenting as "hot" on radioiodine scintigraphy are benign follicular adenomas. However, this case represents a rare clinical entity, and it highlights the need for clinicians to be vigilant and aware that occasionally carcinomas can masquerade as scintigraphic "hot" nodules.

Inpatient glycemic control: an evolving paradigm.

In 2001, Van den Berghe et al published a landmark study of intensive insulin therapy in the setting of a surgical intensive care unit (ICU). Increased attention was also focused on the observational evidence indicating that hyperglycemia is associated with increased morbidity and mortality among diverse patient populations. Because of the dramatic reduction in mortality with normalization of glucose levels in the single center, the Van den Berghe study led to widespread adoption of this practice in ICUs worldwide. Hospitals also began to implement rational subcutaneous insulin protocols based on the American Diabetes Association technical review, replacing the ineffective practice of sliding-scale insulin. Logistical challenges have included coordination of multiple hospital departments and achieving multidisciplinary consensus on goals and methods. Subsequent to the initial Van den Berghe study, other multicenter trials have been fraught with an increased frequency of hypoglycemia and have failed to consistently demonstrate improved outcomes with intensive insulin therapy. Hospitals and expert panels are in the process of examining the combined evidence and considering modifying treatment goals. We recommend continued focus on avoiding hyperglycemia with less aggressive glycemic targets in the critically ill and rational subcutaneous insulin in the noncritically ill, avoiding a return to the obsolescence of sliding-scale insulin.