Peri-adrenal hemangioma mimicking a pheochromocytoma on metaiodobenzylguanidine (MIBG) scan.

Pheochromocytomas account for less than one percent of hypertension and are usually suspected because of clinical manifestations, confirmed by laboratory evaluation and subsequently localized by radiology. Higher HU units on pre-contrast CT and hyperintense signal on T2 weighted MRI images are often seen in pheochromocytoma. Metaiodobenzylguanidine (MIBG) scans have been widely used to localize pheochromocytoma and false-positive scans are reported to be rare. We report a hypertensive patient with symptoms consistent with a pheochromocytoma, with a left adrenal mass with a pre-contrast HU of 8 but a 70 HU post-contrast value. No biochemical evidence of catecholamine excess was noted. A MIBG scan was reported as highly suspicious for a pheochromocytoma. Laparoscopic resection of the mass confirmed the presence of a peri-adrenal hemangioma with both capillary and cavernous components. We postulate that the accumulation of MIBG because of the hemangioma was responsible for the false-positive MIBG scan.

Can a model predictive of vitamin D status be developed from common laboratory tests and demographic parameters?

OBJECTIVES: Vitamin D deficiency is highly prevalent and has been linked to increased morbidity and mortality. There has been an increase in testing for vitamin D with a concomitant increase in costs. While individual factors are significantly linked to vitamin D status, prior studies have not yielded a model predictive of vitamin D status or 25(OH)D levels. The purpose of this investigation was to determine if a prediction model of vitamin D could be developed using extensive demographic data and laboratory parameters. METHODS: Patient data from 6 Veterans Administration Medical Centers were extracted from medical charts. RESULTS: For the 14,920 available patients, several factors including triglyceride level, race, total cholesterol, body mass index, calcium level, and number of missed appointments were significantly linked to vitamin D status. However, these variables accounted for less than 15% of the variance in vitamin D levels. While the variables correctly classified vitamin D deficiency status for 71% of patients, only 33% of those who were actually deficient were correctly identified as deficient. CONCLUSION: Given the failure to find a sufficiently predictive model for vitamin D deficiency, we propose that there is no substitute for laboratory testing of 25(OH)D levels. A baseline vitamin D 3 daily replacement of 1000-2000 IU initially with further modification based on biannual testing appears to factor in the wide variation in dose response observed with vitamin D replacement and is especially important in high-risk groups such as ethnic minorities.

Race and vitamin D status and monitoring in male veterans.

African Americans have lower vitamin D levels and reduced health outcomes compared to white Americans. Vitamin D deficiency may contribute to adverse health outcomes in African Americans. We hypothesized that race would be associated with vitamin D status and testing in African Americans veterans, and that vitamin D status is a major contributor to health care costs in African American veterans compared to white veterans. A retrospective analysis of the medical data in the Veterans Integrated Service Network 9 (southeastern United States) was performed, and 14148 male veterans were identified. Race was designated by the patient and its relationship to vitamin D levels/status and costs was assessed. Vitamin D levels were significantly lower and the percent of patients with vitamin D deficiency was significantly higher in African American veterans. This difference was independent of latitude and seasonality. Vitamin D testing was done significantly more in white veterans compared to African American veterans (5.4% vs 3.8%). While follow-up testing was 42% more likely if a patient was found to be vitamin D deficient, white veterans were 34% more likely than African American veterans to have at least 1 follow-up 25-hydroxyvitamin D performed. African American veterans had significantly higher health care costs, which were linked to lower vitamin D levels; however, the cost differential persisted even after adjusting for vitamin D status. Vitamin D deficiency is highly prevalent in African American veterans and needs improved management within the Veteran Administration system. Vitamin D status appears not to be the sole contributor to increased health care costs in African American veterans.

Vitamin D: Lessons from the veterans population.

Vitamin D deficiency (25(OH)D < 20 ng/mL) is likely to be present in about 40% of veterans and is associated with much higher health care costs and service use. The prevalence of vitamin D deficiency is likely to be higher in certain subgroups such as ethnic minorities, those who are chronically ill, and nursing home residents. The lack of adequate sunlight exposure and poor dietary intake are common contributors to this deficient state. Moreover, vitamin D deficiency has also been noted in individuals taking vitamin D supplements within the recommended daily intake. To achieve a 25(OH)D value in the normal range (30-100 ng/mL), many studies indicate a much higher daily oral intake than currently recommended is needed. Inadequate vitamin D dosing may account for failure of some studies to show a benefit. Testing for vitamin D insufficiency levels remains suboptimal and serial monitoring in veterans to assess if a vitamin D-replete state has been achieved also remains less than adequate. The lack of evidence-based guidelines for testing and monitoring has hampered optimal management of this very common condition. The cardiovascular, immunologic, anti-infective, and oncologic benefits of a vitamin D-replete state are becoming recognized. Achieving a vitamin D-replete state may prolong longevity. Achieving adequate vitamin D status in US veterans is an important health measure that should be undertaken.

The relationship of vitamin D status to cardiovascular risk factors and amputation risk in veterans with peripheral arterial disease.

OBJECTIVES: Peripheral arterial disease (PAD) is a common and often overlooked entity responsible for considerable morbidity and mortality. Recent evidence suggests that nontraditional risk factors such as vitamin D may contribute to atherosclerosis. We hypothesized that vitamin D status was associated with cardiovascular risk factors and that vitamin D deficiency (25(OH)D <20 ng/mL) enhanced the risk of amputation. DESIGN: We reviewed medical records of 1435 veterans between 2000 and 2008 in Tennessee via retrospective chart analysis using correlations, logistic regressions, t tests, and χ(2) analyses. RESULTS: Vitamin D status was significantly and inversely correlated with body mass index (BMI), glucose, and triglyceride values. Hypertension and diabetes but not smoking also emerged as significantly associated. Of the sample population, 5.2% (n = 75) had an amputation performed. Those individuals who were vitamin D deficient had a significantly higher amputation rate (6.7%) compared with patients who were nondeficient (4.2%). BMI, triglyceride, total cholesterol, hypertension, and diabetes were found to account for 5.7% of the variation in amputation status. Vitamin D concentration and deficiency status accounted for a nonsignificant amount of additional variance. CONCLUSIONS: We conclude that vitamin D deficiency is closely linked to increased adiposity, triglyceride, and glucose measurements. Vitamin D deficiency was associated with an increased amputation risk in veterans with PAD and appears to mediate its effects through traditional risk factors.

Vitamin D deficiency: an increasing concern in peripheral arterial disease.

Peripheral arterial disease is a common and often overlooked entity responsible for considerable morbidity and mortality. Recent evidence suggests that nontraditional risk factors such as vitamin D deficiency may contribute to atherosclerosis and increased cardiovascular morbidity and mortality, hence monitoring of vitamin D status is essential. This review tries to examine this entity.

Testing for vitamin D deficiency in veterans-is there a seasonal bias?

OBJECTIVE: The present study was undertaken to determine if a seasonal bias was present for vitamin D testing among Northeast Tennessee veterans, in whom vitamin D deficiency is common. DESIGN: Medical chart review. SETTING: VA Medical Center. PARTICIPANTS: Participants were 9447 patients with initial 25(OH) vitamin D levels obtained over a 3-year period. MEASUREMENT: Serum 25-hydroxyvitamin D (25[OH]D) level, date of testing, patient background factors. RESULTS: Vitamin D testing occurred more frequently in September, October, November, and December, whereas the lowest levels of 25(OH) vitamin D levels were found in January, February, and March. Similar results were observed in quarterly data with the greatest number of tests noted in the last quarter of the year, yet the lowest 25(OH) vitamin D levels were noted in the first quarter. The average monthly 25(OH) vitamin D levels were below 30 ng/mL throughout the year in the study population, consistent with highly prevalent vitamin D deficiency. CONCLUSION: Clinicians may have a seasonal bias, favoring testing for vitamin D status in the latter part of the year even though the lowest vitamin D levels are observed in the first part of the year. Although an argument could be made to check for peak 25(OH) vitamin D levels in September and trough levels in March, the seasonal contribution to vitamin D deficiency is overshadowed by ongoing vitamin D deficiency throughout the year. Thus, it may be prudent to test for vitamin D deficiency in patients presenting with fatigue, myalgias, and arthralgias regardless of the season of presentation.