A Rare Case When Acromegaly Meets Cushing Syndrome.

Acromegaly is very uncommon, as is non-iatrogenic Cushing syndrome; we discuss a patient who was found to have both a pituitary adenoma causing acromegaly and a cortisol-producing adrenal adenoma causing Cushing syndrome within 1 year. She was a healthy, 44-year-old woman who presented with visual changes and was found to have bitemporal hemianopsia and a 3.3-cm pituitary mass along with central hypogonadism, central hypothyroidism, and suppressed adrenocorticotropin and discrepant cortisol. After transsphenoidal resection she had declining, but persistently elevated, insulin-like growth factor 1 (IGF-1), raising concern for persistent acromegaly. She also was experiencing several cushingoid symptoms and was found to have elevated salivary and urinary cortisol. An abdominal computed tomography scan showed a 3.1-cm adrenal adenoma, and she subsequently underwent adrenalectomy. Following adrenalectomy, her cortisol levels normalized, and her IGF-1, growth hormone, and oral glucose tolerance test showed substantial improvement consistent with previous reports linking hypercortisolism and elevated IGF-1 levels. Combinations of pituitary and adrenal disease are seen in a handful of genetic syndromes; however, her clinical presentation and genetics do not fit with known syndromes. This case describes two rare endocrine tumors in one patient and associated limitations of routine laboratory testing.

Giant Pheochromocytoma Diagnosis Confounded by Amphetamine Use.

Objective: Diagnosis of giant pheochromocytoma is difficult; patients often lack the classic triad and presence of gross biochemical positivity. At times, presence of sympathetic stimulant drugs can further complicate the clinical picture. Here, we present a case of giant "functional" pheochromocytoma with a history of amphetamine use. Case Description. 37-year-old female presented with a 1-day history of abdominal pain. CT abdomen identified a 12.5 cm heterogeneously enhancing left adrenal mass. Plasma/urine catecholamine and metanephrine levels were markedly elevated with evidence of elevated serum/urine cortisol. However, the patient's subsequent urine toxicology was found to be positive for amphetamines, which she later admitted to using, 1 week prior to admission. Repeat biochemical workup after 1 week drug washout period showed improvement in both catecholamine and cortisol levels. Given the high degree of suspicion for PCC, an open laparoscopic adrenalectomy was performed with histology confirming SDHB gene mutation positive giant pheochromocytoma. Discussion. Diagnosis of PCC in a patient with a history of amphetamine abuse remains an enigma, to which addition of it being a giant PCC that are rare and typically silent further confounds the clinical picture as seen in this case. Conclusion: PCC could be termed a "chameleon" tumor given its varied clinical presentations and lack of standardized biochemical and radiological data (giant, pheochromocytoma, and amphetamine).

Novel Therapeutics for Type 2 Diabetes, Obesity, and Heart Failure: A REVIEW AND PRACTICAL RECOMMENDATIONS FOR CARDIAC REHABILITATION.

BACKGROUND: Cardiac rehabilitation (CR) has evolved over time not only to improve cardiorespiratory fitness through exercise but also to promote lifestyle-related behaviors to manage cardiovascular disease risk factors. Given the prevalence of obesity, diabetes mellitus, metabolic syndrome, and heart failure, CR serves as an ideal setting to monitor and, when indicated, intervene to ensure that individuals are optimally treated. PURPOSE: The objective of this report was to review current antihyperglycemic agents and discuss the role for these medications in the care and treatment of individuals participating in CR. CONCLUSION: There is strong evidence that the benefits provided by some antihyperglycemic medications go beyond glycemic control to include general cardiovascular disease risk reduction. Health care professionals in CR should be aware of the cardiovascular benefits of newer antihyperglycemic agents, as well as the treatment approach to patients with type 2 diabetes, obesity, and heart failure.

Predictors and Consequences of Inappropriate Thyroid Ultrasound in Hypothyroidism.

Introduction In 2012, the American Board of Internal Medicine Foundation established the Choosing Wisely® initiative, partnering with specialist societies to promote evidence-based care. Under this program, the Endocrine Society recommends against ordering thyroid ultrasounds in individuals with subclinical or overt hypothyroidism and a normal neck exam. We sought to understand the prevalence, predictors, and consequences of thyroid ultrasound performed at our academic medical center that are not in compliance with this recommendation. Methods We conducted a retrospective cohort study of electronic health record data from January 1, 2016 to July 31, 2018. Data were extracted from records of all patients who underwent thyroid ultrasonography. Ultrasounds were considered inappropriate if they were ordered based on hypothyroidism, without other clear indications. Results A total of 2,021 patients underwent thyroid ultrasonography, of which 572 (28.3%) were diagnosed with hypothyroidism. Among the patients with hypothyroidism, 40 were identified as having received an inappropriate ultrasound (7.0%). Of those patients who received inappropriate ultrasounds, 42.5% had subsequent medical encounters, with a mean charge of $851 (standard deviation = $271) per patient. Using a multivariable model, the odds of receiving an inappropriate ultrasound were significantly higher for patients younger than 50 years of age (odds ratio: 2.37, 95% confidence interval: 1.01-5.58). Conclusion Seven percent of thyroid ultrasounds were inappropriately ordered in a cohort with hypothyroidism. Patients aged <50 years were at an increased risk of inappropriate ultrasound. Sequelae of inappropriate ultrasound included further medical encounters and financial burdens. Systems to reduce the inappropriate use of thyroid ultrasound may lessen the consequences of unnecessary medical imaging.

Improving Management of Type 2 Diabetes Mellitus in Hospitalized Adults: A Quality Initiative.

ABSTRACT: The American Diabetes Association recommends scheduled basal and nutritional insulin doses as the preferred treatment for noncritically ill hospitalized patients with type 2 diabetes; however, the adoption of these practices remains suboptimal. We sought to understand current diabetes management practices and improve glycemic control in patients with type 2 diabetes on the Hospital Medicine Services at our academic medical center. We surveyed resident and attending physicians to understand barriers to guideline-based practice. We conducted educational sessions, developed pocket-card decision aids, encouraged discussion on rounds, and provided periodic performance feedback to attending physicians. Results of the barriers survey identified "fear of causing hypoglycemia" as the most common barrier to guideline-based practice. Compared with the preintervention 12-month period, these interventions were associated with doubling of the use of guideline-based insulin therapy regimens, a significant reduction in the rate of severe hyperglycemia days, and a nonsignificant reduction in the rate of hypoglycemia days over a 12-month period. These results demonstrate that a simple, low-cost intervention can be associated with an increase in guideline-concordant insulin ordering with improvement in glycemic outcomes for patients with type 2 diabetes.

Effects of Behavioral Weight Loss and Weight Loss Goal Setting in Cardiac Rehabilitation.

PURPOSE: Obesity is prevalent among participants in cardiac rehabilitation (CR). Establishing a weight loss goal is an important strategy for promoting weight loss. We evaluate the association between a pre-program weight loss goal and change in weight during CR. METHODS: Body weight was measured at CR entry and at exit from CR. Overweight/obese participants were categorized as having: (1) established a weight loss goal and attended behavioral weight loss sessions (G + BWL); (2) set a weight loss goal but did not attend BWL (G); (3) and neither set a weight loss goal nor attended BWL (NoG). RESULTS: The cohort consisted of 317 overweight/obese participants; 52 of whom set a weight loss goal and attended BWL, 227 patients set a goal but did not attend BWL, and 38 did neither. The G + BWL group lost more weight than the G group (-6.8 + 4.3 vs -1.1 + 3.5) (P < .0001). Both groups that established a weight loss goal lost more weight than the NoG group. CONCLUSIONS: For overweight/obese individuals in CR, participating in BWL classes and setting a weight loss goal leads to more weight loss than G alone. Setting a weight loss goal alone leads to greater weight loss than not setting a weight loss goal.