Non-Hodgkin lymphoma of the thyroid in a patient with hyperthyroidism.

Primary thyroid lymphoma is incredibly rare with an annual incidence of approximately 2.1 per million persons, accounting for 2% of thyroid malignancies. One of the only known risk factors is autoimmune thyroid disease, specifically Hashimoto's, although there have been a few cases of thyroid lymphoma associated with Graves' disease. Here, we present one such case of a patient with pre-existing hyperthyroidism who developed non-Hodgkin's lymphoma of the thyroid. The patient initially presented with rapidly progressing right-sided neck swelling. He was clinically and biochemically euthyroid with negative thyroid stimulating immunoglobulin, maintained on methimazole. Biopsy of the thyroid nodule with flow cytometry revealed non-Hodgkin lymphoma. Intervention included radiation therapy.

Primary Hyperparathyroidism in Pregnancy: Successful Parathyroidectomy during First Trimester.

Primary hyperparathyroidism in pregnancy can result in significant maternal and fetal complications. When indicated, prompt parathyroidectomy in the early second trimester is considered the treatment of choice. Pregnant patients with primary hyperparathyroidism who have an indication for parathyroidectomy during the first trimester represent a therapeutic challenge. We present the case of a 32-year-old primigravida who presented with symptomatic hypercalcemia from her primary hyperparathyroidism. She remained symptomatic despite aggressive conservative management and underwent parathyroidectomy in her first trimester with excellent outcomes.

Locally Advanced Thyroglossal Duct Cyst Carcinoma Presenting as a Neck Mass.

Thyroglossal duct cyst carcinoma is rare and occurs in just 1% of cases with thyroglossal duct cysts. It is not always possible to distinguish a thyroglossal cyst harboring malignancy from its benign counterparts unless biopsied, thus posing the dilemma. Currently there is no clear consensus on the optimal management of thyroglossal duct cyst carcinoma. Here we present the case of a 69-year-old female who presented with a midline neck mass and dysphagia and was found to have papillary thyroid cancer in the biopsy specimen of the neck mass. She underwent excision of the mass and the thyroglossal duct cyst along with total thyroidectomy; however, the thyroidectomy specimen showed no malignancy. Her lymph node mapping was negative and she is awaiting radioactive iodine treatment.

Use of an electronic health record to identify prevalent and incident cardiovascular disease in type 2 diabetes according to treatment strategy.

BACKGROUND: The increasing use of electronic health records (EHRs) in clinical practice offers the potential to investigate cardiovascular outcomes over time in patients with type 2 diabetes (T2D). OBJECTIVE: To develop a methodology for identifying prevalent and incident cardiovascular disease (CVD) in patients with T2D who are candidates for therapeutic intensification of glucose-lowering therapy. METHODS: Patients with glycated hemoglobin (HbA1c) ≥7% (53 mmol/mol) while receiving 1-2 oral diabetes medications (ODMs) were identified from an EHR (2005-2011) and grouped according to intensification with insulin (INS) (n=372), a different class of ODM (n=833), a glucagon-like peptide receptor 1 agonist (GLP-1RA) (n=59), or no additional therapy (NAT) (n=2017). Baseline prevalence of CVD was defined by documented International Classification of Diseases Ninth Edition (ICD-9) codes for coronary artery disease, cerebrovascular disease, or other CVD with first HbA1c ≥7% (53 mmol/mol). Incident CVD was defined as a new ICD-9 code different from existing codes over 4 years of follow-up. ICD-9 codes were validated by a chart review in a subset of patients. RESULTS: Sensitivity of ICD-9 codes for CVD ranged from 0.83 to 0.89 and specificity from 0.90 to 0.96. Baseline prevalent (INS vs ODM vs GLP-1RA vs NAT: 65% vs 39% vs 54% vs 59%, p<0.001) and incident CVD (Kaplan-Meier estimates: 58%, 31%, 52%, and 54%, p=0.002) were greater in INS group after controlling for differences in baseline HbA1c (9.2±2.0% vs 8.3±1.2% vs 8.2±1.3% vs 7.7±1.1% (77 vs 67 vs 66 vs 61 mmol/mol), p<0.001) and creatinine (1.15±0.96 vs 1.10±0.36 vs 1.01±0.35 vs 1.07±0.45 mg/dL, p=0.001). CONCLUSIONS: An EHR can be an effective method for identifying prevalent and incident CVD in patients with T2D.

Cushing's storm secondary to a rare case of ectopic ACTH secreting metastatic breast cancer.

UNLABELLED: Ectopic ACTH secretion from breast cancer is extremely rare. We report a case of a 30-year-old woman with a history of breast cancer, who presented with psychosis and paranoid behaviour. CT of the head showed white matter disease consistent with posterior reversible encephalopathy syndrome (PRES). Despite using mifepristone with multiple antihypertensives including lisinopril, spironolactone and metoprolol, she was hypertensive. Transaminitis did not allow mifepristone dose escalation and ketoconazole utilization. Etomidate infusion at a non-sedating dose in the intensive care unit controlled her hypertension and cortisol levels. She was transitioned to metyrapone and spironolactone. She was discharged from the hospital on metyrapone with spironolactone and underwent chemotherapy. She died 9 months later after she rapidly redeveloped Cushing's syndrome and had progressive metastatic breast cancer involving multiple bones, liver and lungs causing respiratory failure. LEARNING POINTS: Cushing's syndrome from ectopic ACTH secreting breast cancer is extremely rare.Cushing's syndrome causing psychosis could be multifactorial including hypercortisolism and PRES.Etomidate at non-sedating doses in intensive care setting can be effective to reduce cortisol production followed by transition to oral metyrapone.

Use of an Electronic Medical Record (EMR) to Identify Glycemic Intensification Strategies in Type 2 Diabetes.

BACKGROUND: Current treatment guidelines for type 2 diabetes (T2D) recommend individualized intensification of therapy for glycated hemoglobin (A1C) ≥ 7% in most patients. The purpose of this investigation was to explore the ability of an electronic medical record (EMR) to identify glycemic intensification strategies among T2D patients receiving pharmacologic therapy. METHODS: Patient records between 2005 and 2011 with documentation of A1C and active prescriptions for any diabetes medications were queried to identify potential candidates for intensification based on A1C ≥ 7% while on 1-2 oral diabetes medications (ODM). Patients with follow-up A1C values within 1 year of index A1C were grouped according to intensification with insulin, GLP-1 receptor agonists (GLP-1RA), a new class of ODM, or no intensification. Changes in A1C and continuation of intensification therapy were determined. RESULTS: A total of 4921 patients meeting inclusion criteria were intensified with insulin (n = 416), GLP-1RA (n = 68), ODM (n = 1408), or no additional therapy (n = 3029). Patients receiving insulin had higher baseline (9.3 ± 2.0 vs 8.3 ± 1.2 vs 8.3 ± 1.3 vs 7.6 ± 1.0%, P < .0001) and follow-up A1C (8.1 ± 1.6 vs 7.5 ± 1.2 vs 7.6 ± 1.3 vs 7.2 ± 1.1%, P < .0001) despite experiencing larger absolute A1C reductions (-1.2 ± 2.1 vs -0.8 ± 1.4 vs -0.7 ± 1.4 vs -0.3 ± 1.1%, P < .0001). Patients receiving GLP-1RA were more obese at baseline (BMI: 33.6 ± 7.1 vs 37.7 ± 6.1 vs 33.7 ± 6.8 vs 32.9 ± 7.1 kg/m(2), P < .0001) and follow-up (BMI: 33.9 ± 7.3 vs 36.6 ± 6.1 vs 33.8 ± 7.0 vs 32.4 ± 7.0 kg/m(2), P < .0001) despite experiencing more absolute weight reduction. Insulin was the most and GLP-1RA the least likely therapy to be continued. CONCLUSIONS: An EMR allows identification of prescribing practices and compliance with T2D treatment guidelines. Patients receiving intensification of glycemic medications had baseline A1C >8% suggesting that treatment recommendations are not being followed.

Comparison of insulin infusion protocols targeting 110-140 mg/dL in patients after cardiac surgery.

BACKGROUND: Continuous intravenous insulin infusion (CII) following coronary artery bypass graft (CABG) surgery reduces postoperative complications and hospitalization duration. Because of limited data evaluating outcomes of CII with revised glycemic targets (110-140 mg/dL) in cardiac surgery, this study compared efficacy and safety of two different CII protocols having revised targets. SUBJECTS AND METHODS: This is a retrospective study comparing two different protocols between August 2009 and March 2010. Protocol 1 consists of four algorithms, and Protocol 2 is a table to adjust CII. Blood glucose (BG) and CII rates were recorded for 48 h postoperatively or CII discontinuation. Efficacy was defined by the percentage of BG values in the target range, and safety was defined by the percentage of BG values<40 and 40-69 mg/dL. RESULTS: Protocol 1 (n=117) patients were older (65 vs. 61 years; P=0.006) and had more CABG and fewer valve procedures compared with Protocol 2 (n=130). There were no differences in baseline BG level (149±40.6 vs. 151±38.1 mg/dL), body mass index (30±6.3 vs. 30±6.4 kg/m(2)), hematocrit (28% vs. 28%), percentage of diabetes patients (32% vs. 31%), percentage of patients with glomerular filtration rate of <30 mL/min (5% vs. 6%), CII duration (42 [9-48] vs. 40 [14-48] h), total insulin units received (99 [15-376] vs. 114 [12-457]), hourly insulin rate (median of average rate [range], 2.59 [0-21) vs. 2.96 [0-25] units/h), percentage of BG values 110-140 mg/dL, <40 mg/dL, 40-69 mg/dL, and >180 mg/dL, and BG coefficient of variation (21±6.5 vs. 21±6.1). Shorter time to goal (3.32 [0.22-19.35] vs. 5.03 [0.92-19.80] h; P=0.018) and lower mean BG level (127±12.2 vs. 133±12.1 mg/dL; P<0.001) were noted with Protocol 1. DISCUSSION: CII protocols targeting 110-140 mg/dL were effective in achieving revised targets with low hypoglycemia. Despite differences in mean BG level and time to target, each hospital continued using its existing protocols and identified areas for improvement.