Thyroid and Parathyroid Conditions: Hyperthyroidism.

Hyperthyroidism is an excess in thyroid hormone production caused by such conditions as Graves disease, toxic multinodular goiter, and toxic adenoma. Overt hyperthyroidism is defined as a low or undetectable thyrotropin (TSH) level with elevated triiodothyronine (T3) or thyroxine (T4) values, whereas subclinical hyperthyroidism is defined as low or undetectable TSH with normal T3 and T4 levels. Symptoms of hyperthyroidism include nervousness, heat intolerance, weight loss, and fatigue. The long-term consequences of unmanaged or poorly managed hyperthyroidism include increased risk of all-cause mortality, cardiovascular events, atrial fibrillation, sexual dysfunction, and osteoporosis. Overt and subclinical hyperthyroidism can be managed effectively with antithyroid drugs (eg, propylthiouracil, methimazole) or with definitive therapies (eg, radioactive iodine ablation, thyroidectomy). Subclinical hyperthyroidism is not always treated, although close monitoring is needed to prevent disease complications or progression to overt hyperthyroidism. Treatment for subclinical hyperthyroidism is recommended for patients 65 years or older with TSH levels lower than 0.10 mIU/L. Treatment also is recommended for symptomatic patients or those with cardiac or osteoporotic risk factors. Thyroid storm is a life-threatening complication of unmanaged or inadequately managed hyperthyroidism that warrants urgent treatment in a hospital setting.

Thyroid and Parathyroid Conditions: Hypothyroidism.

Hypothyroidism is caused by deficient thyroid hormone production secondary to autoimmune disease or insufficient iodine consumption or as a complication of hyperthyroidism management. Signs and symptoms include fatigue, weight gain, dry skin, constipation, and cold intolerance. The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against screening for hypothyroidism, but some organizations support screening in special populations. If hypothyroidism is suspected, initial laboratory evaluation consists of a serum thyrotropin (TSH) measurement with reflex testing of free thyroxine (T4). Thyroid function tests must be interpreted carefully because acute illness, diet, and drugs may alter values. Overt hypothyroidism occurs when a patient has an elevated TSH level and a low free T4 level with symptoms of hypothyroidism. Management includes thyroid hormone replacement, ideally levothyroxine. Subclinical hypothyroidism is characterized by an elevated TSH level with a normal T4 value. The decision to treat subclinical hypothyroidism should be based on patient characteristics and shared decision-making discussions. Special consideration should be taken in treating patients with high-risk conditions, including heart disease, pregnancy, and myxedema coma, and in patients requiring high-dose levothyroxine. Thyroid hormone should be titrated based on goal TSH values, symptoms, and potential treatment adverse effects.

Thyroid and Parathyroid Conditions: Thyroid Nodules, Cysts, and Malignancies.

Thyroid nodules are identified incidentally on imaging in most patients. Controversy exists on which patients warrant evaluation of an incidental thyroid nodule. If further assessment of a nodule detected on imaging or examination is pursued, thyroid ultrasonography with cervical lymph node survey and measurement of serum thyrotropin (TSH) may guide management decisions. When the TSH level is low, a nuclear medicine thyroid scan is necessary. Based on size, ultrasonographic features, and nuclear medicine results, patients with thyroid nodules may undergo ultrasonographic surveillance or biopsy with fine-needle aspiration. When fine-needle aspiration is performed, the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) provides a classification system for biopsy results. Molecular testing can be considered in the case of nodules with indeterminate findings based on biopsy. Malignant thyroid nodules and indeterminate nodules with suspicious molecular test results warrant surgical evaluation, whereas others may be monitored with periodic ultrasonography. Approximately 10% of nodules are clinically significant malignancies, and a small number of nodules cause compressive symptoms or progress to functional thyroid disease. Thyroid cancer overall has a 5-year survival of 98%.

Thyroid and Parathyroid Conditions: Parathyroid Conditions.

Parathyroid hormone (PTH) helps regulate calcium homeostasis in a complex relationship with the gastrointestinal tract, kidneys, bone, and parathyroid glands. Abnormalities in PTH production can result in many conditions, including hypoparathyroidism, and primary, secondary, and tertiary hyperparathyroidism. Management of each abnormality centers on maintaining normal or near-normal serum calcium values to prevent complications. Most cases of hypoparathyroidism are caused by neck surgery and may result in acute hypocalcemia. Patients with chronic hypoparathyroidism are treated with a combination of calcium, vitamin D analogs, and, occasionally, exogenous PTH. A single parathyroid adenoma causes most cases of primary hyperparathyroidism, with multiglandular disease and cancer as other possible etiologies. All patients with symptomatic primary hyperparathyroidism and many with asymptomatic hyperparathyroidism undergo partial or full parathyroidectomy to correct the underlying condition. Chronic kidney disease-mineral and bone disorder (CKD-MBD) is the most common cause of secondary and tertiary hyperparathyroidism, in which hypocalcemia stimulates PTH production. Most patients with CKD-MBD are treated medically with phosphate binders, vitamin D analogs, and calcimimetics, but rare cases are managed with parathyroidectomy. Severe calcium or vitamin D deficiency also causes secondary hyperparathyroidism and is managed with calcium and vitamin D replacement.

Implementation of a Hepatitis C Treatment Program Into a Primary Care Residency Clinic.

BACKGROUND AND OBJECTIVES: Hepatitis C (HCV) is a commonly diagnosed disease state in primary care. Regimen simplification has made eradication possible with improvements in treatment and improved access through primary care physician (PCP) education. Little has been published discussing the role of resident physicians in the treatment of HCV. We implemented an HCV treatment program to increase access to HCV care, identify effective training methods, and examine the efficacy of resident physician treatment. Objectives were to increase the number of patients treated, improve resident confidence in ability to treat HCV, and increase the likelihood that they will continue to treat patients after graduation. METHODS: A curriculum to train physicians to treat HCV was developed and implemented in a large family medicine residency program. This was a single-center implementation, with a retrospective chart review of patient data and anonymous survey of clinicians for curriculum assessment. We analyzed data using descriptive statistics. RESULTS: The resident physician survey had a 92.3% response rate (n=36). Precurriculum, 94.4% of residents were not confident in their ability to treat HCV. After program implementation, 25% of residents were confident in treating HCV. The most effective educational interventions involved the multidisciplinary team. To date, 30 patients have started treatment since 2017. Of the patients who completed treatment, 23 patients achieved a virologic cure. CONCLUSION: Treating patients for HCV at a residency clinic increased physician confidence in evaluating and addressing this chronic disease and resulted in a cure of all patients treated.