A marketing matrix for health care organizations.

Irrespective of the formal marketing structure successful marketing for health care organizations requires the input on many people. Detailed here is the Marketing Matrix used at the Cleveland Clinic Foundation in Cleveland, Ohio. This Matrix is both a philosophy and a tool for clarifying and focusing the organization's marketing activities.

Adrenal insufficiency secondary to carcinoma metastatic to the adrenal gland.

Four patients are reported in whom adrenocortical insufficiency developed consequent to carcinoma metastatic to the adrenal glands. Recognition and treatment of this entity may lead to palliation of symptoms and prolongation of useful life. The computerized axial tomographic scanner is a valuable diagnostic aid in diagnosing adrenal enlargement.

Hyperparathyroidism after radioactive iodine therapy for Graves disease.

The association of external ionizing radiation to the head and neck and the subsequent development of hyperfunctioning parathyroid glands has been documented in recent years. This also has been demonstrated experimentally in animals. Despite the numbers of patients with Graves disease who have been treated with radioactive iodine, there are no reports in the literature of parathyroid surgery for hyperparathyroidism secondary to earlier treatment with radioactive iodine for Graves disease. This report describes the operative and pathologic findings in four patients with hyperparathyroidism. These patients had previously been treated with radioactive iodine for Graves disease. The pathologic findings at surgery included in three cases a single enlarged hyperplastic gland consistent with a parathyroid adenoma. One patient had hyperplasia of all four glands. The two largest glands and halves of the two remaining glands were removed. In a long-term follow-up of children and adolescents treated with radioactive iodine for Graves disease, Levy and Schumacher found calcium elevations in 10 of 159 patients. The increased incidence of hyperparathyroidism following radioactive iodine treatment for Graves disease in children and adolescents would seem several times higher than normal. Whether adults who have radioactive iodine treatment for Graves disease have a similar increase incidence is not known. Meanwhile it would seem reasonable to suggest that patients whose hyperthyroidism is treated with radioactive iodine should have their serum calcium levels determined at 5-year intervals.

Acromegaly, hyperparathyroidism, and pheochromocytoma in the same patient. A multiple endocrine disorder.

In the course of follow-up of a patient with primary hyperparathyroidism, signs and symptoms of acromegaly developed. The patient subsequently was found to have recurrent primary hyperparathyroidism and, later, pheochromocytoma was discovered. The patient seems to have an overlap of features found in the multiple endocrine neoplasia syndromes, type 1 and type 2 as previously classified.

Watery diarrhea syndrome. Two unusual cases and further evidence that VIP is a humoral mediator.

Two unusual cases of the watery diarrhea syndrome are presented. In one patient an adrenal medullary tumor, a pheochromocytoma that produced vasoactive intestinal polypeptide (VIP) was excised with total relief of symptoms. The second patient a 65-year-old man with abrupt onset of massive watery diarrhea that led to acidosis and coma was symptomatically controlled for one year on 10 mg/day of prednisone. Elevated levels of VIP returned to normal after prednisone therapy was started. A benign islet cell tumor not localized by angiography was removed by distal pancreatic resection. Tissue levels of VIP were markedly elevated. VIP is a humoral mediator of the water diarrhea syndrome. Both benign and malignant pancreatic and extrapancreatic tumors may cause the watery diarrhea syndrome. Steroids may cause symptomatic relief of the diarrhea by lowering peptide levels to normal. The term watery diarrhea syndrome may be more accurate than the pancreatic cholera syndrome.