Pitfalls of using denosumab preoperatively to treat refractory severe hypercalcaemia.

A 40-year-old man, with a history of metastatic parathyroid carcinoma, status post primary tumour resection and lung metastasectomy, was hospitalised for persistent severe hypercalcaemia and elevated parathyroid hormone levels despite conventional management and escalating doses of cinacalcet. A single dose (120 mg) of denosumab was given and his calcium level plummeted from 14.8 mg/dL to 5.5 mg/dL. After second lung metastasectomy, he developed prolonged hypocalcaemia that required calcium and vitamin D supplements for more than 3 years. In patients with severe hypercalcaemia refractory to conventional therapies, denosumab has been used off-label with some success. A known side effect of denosumab is hypocalcaemia, which is often short-lived. The risk of prolonged hypocalcaemia should be fully evaluated before using denosumab preoperatively, especially in patients with renal insufficiency, prolonged hyperparathyroidism or anticipated tumour debulking surgery.

In-Plane Anisotropy in Mono- and Few-Layer ReS2 Probed by Raman Spectroscopy and Scanning Transmission Electron Microscopy.

Rhenium disulfide (ReS2) is a semiconducting layered transition metal dichalcogenide that exhibits a stable distorted 1T phase. The reduced symmetry of this system leads to in-plane anisotropy in various material properties. Here, we demonstrate the strong anisotropy in the Raman scattering response for linearly polarized excitation. Polarized Raman scattering is shown to permit a determination of the crystallographic orientation of ReS2 through comparison with direct structural analysis by scanning transmission electron microscopy (STEM). Analysis of the frequency difference of appropriate Raman modes is also shown to provide a means of precisely determining layer thickness up to four layers.

18F-fluorodeoxyglucose and 131I radioguided surgical management of thyroid cancer.

OBJECTIVE: To describe a technique that assists in the surgical management of recurrent local regional well-differentiated thyroid cancer (WDTC). STUDY DESIGN: Case series with chart review. SETTING: Two academic health centers from 2001 to 2009. SUBJECTS AND METHODS: Patients operated upon by the senior surgeon (BCS) for recurrent WDTC. RESULTS: Thirteen patients with recurrent WDTC were operated upon with radioguided surgical (RGS) technique to indentify recurrence for excision. Eight patients had iodine avid disease and were candidates for RGS with (131)I. The remaining 5 patients had cancer with a proven loss of iodine avidity and were, therefore, operated upon with a fluorodeoxygluocose (FDG) RGS technique. CONCLUSION: RGS is a feasible approach to identify recurrent disease in an operated field and ensure its successful excision. Although focal disease may be identified with this technique, this is not a tool for limited excisions ("berry picking").

Management of hyperglycemia in the non-intensive care patient: featuring subcutaneous insulin protocols.

OBJECTIVE: To provide insulin protocols and adjustment guidance for management of hyperglycemia in common inpatient clinical scenarios. METHODS: We performed a PubMed search of pertinent existing literature from 1980 to 2010. RESULTS: Hyperglycemia is frequently encountered in general medical and surgical wards and has been linked to adverse clinical outcomes, prolonged hospital length of stay, and increased institutional care needs after discharge. No randomized controlled trial has been conducted to define optimal glycemic goals or to investigate the effects of intensive glycemic control in the non-intensive care unit (ICU) setting. Nonetheless, it is advocated by the American Association of Clinical Endocrinologists and the American Diabetes Association, in their 2009 Consensus Statement on Inpatient Glycemic Control, that optimization of glycemia in hospitalized patients with diabetes and hyperglycemia be judiciously offered. This approach is clinically sound, in light of the known deleterious consequences of hyperglycemia in critically and noncritically ill patients and the benefits observed with improved glycemic control in intensive care settings. The approach to hyperglycemia in non-ICU inpatients should follow the principles of provision of basal-nutritional-supplemental insulin. Herein we provide insulin protocols and adjustment guidance for management of hyperglycemia in common clinical scenarios. Recommendations reflect the opinion of national experts in the field and our departmental consensus at Penn State Institute for Diabetes and Obesity. CONCLUSION: Glycemic control in the non-ICU setting is a relevant clinical situation that should be addressed and managed effectively and prudently. We present a practical guide for management of hyperglycemia individualized to various clinical scenarios encountered in the general hospital wards.

The cost-effectiveness of iodine 131 scintigraphy, ultrasonography, and fine-needle aspiration biopsy in the initial diagnosis of solitary thyroid nodules.

OBJECTIVE: To compare the cost-effectiveness of fine-needle aspiration biopsy, iodine 131 scintigraphy, and ultrasonography for the initial diagnostic workup of a solitary palpable thyroid nodule. DESIGN: A deterministic cost-effectiveness analysis was conducted using a decision tree to model the diagnostic strategies. SETTING: A single, mid-Atlantic academic medical center. MAIN OUTCOME MEASURES: Expected costs, expected number of cases correctly diagnosed, and incremental cost per additional case correctly diagnosed. RESULTS: Relative to the routine use of fine-needle aspiration biopsy, the incremental cost per case correctly diagnosed is 24,554 dollars for the iodine 131 scintigraphy strategy and 1212 dollars for the ultrasound strategy. CONCLUSIONS: A diagnostic strategy using initial fine-needle aspiration biopsy for palpable thyroid nodules was found to be cost-effective compared with the other approaches as long as a payor's willingness to pay for an additional correct diagnosis is less than 1212 dollars. Prospective studies are needed to validate these finding in clinical practice.

Surgical management of amiodarone-induced thyrotoxicosis.

OBJECTIVE: Amiodarone can cause thyroid dysfunction in patients with or without previous thyroid disease. With increased use from its placement in advanced cardiac life support guidelines and cardiac transplant programs, the incidence of amiodarone-induced thyrotoxicosis (AIT) will likely increase. Medical management is complex and nonuniform and frequently fails. This study investigates the role of surgery in AIT and proposes indications for surgical management. STUDY DESIGN AND SETTING: Two AIT case reports at a tertiary care institution and 31 surgical AIT cases in the world literature are reviewed. METHODS: The 2 AIT cases involved patients with cardiomyopathy and resistant arrhythmias. Despite medical therapy, both patients' conditions failed to improve. Thirty-one surgical cases of AIT in the literature are evaluated with respect to symptoms and onset, medical therapy, AIT classification, pathology, perioperative management, and complications. RESULTS: Both patients underwent total thyroidectomy without difficulty or complication, one as an overnight stay and one as an inpatient with an intraaortic balloon pump. One patient received a successful cardiac transplant and the other remains a viable candidate. In the literature, the majority (80%) of surgical cases are AIT type II (less common type) with no underlying thyroid disease. Range and duration of symptoms varied, in addition to type and duration of medical management. Almost all patients underwent total thyroidectomy, and all were successful with no mortality and minimal morbidity. CONCLUSION: AIT can develop in any patient during or after amiodarone therapy. Medical management is extremely difficult due to the absence of a proven therapeutic armamentarium, and surgery offers a safe, viable option. Surgical management should play a larger role in treatment algorithms and should be strongly considered for patients whose conditions necessitate continuation of amiodarone, or with severe symptoms resistant to medical therapy.