Ectopic acromegaly due to a pancreatic neuroendocrine tumor producing growth hormone-releasing hormone.

OBJECTIVE: To present a case of acromegaly due to ectopic growth hormone-releasing hormone (GHRH) secretion from a pancreatic neuroendocrine tumor in the context of multiple endocrine neoplasia type 1 (MEN 1). METHODS: We describe the clinical, imaging, and pathologic findings of the study patient. RESULTS: A 46-year-old woman presented with clinical and biochemical findings diagnostic of acromegaly. Magnetic resonance imaging showed a 1.2-cm sellar mass. Following resection of the macroadenoma, serum insulin-like growth factor 1 (IGF-1) and growth hormone (GH) levels remained unchanged. Pathologic examination revealed adenomatous changes, including a nonsecretory focus and a prolactin immunopositive area (GH stain negative in both). Octreotide long-acting release was ineffective. Search for an ectopic tumor included normal octreoscan and abdominal computed tomography. GHRH was greater than 1000 pg/mL. Repeated abdominal computed tomography documented a 6.2-cm mass in the tail and body of the pancreas. Distal pancreatectomy revealed a pancreatic neuroendocrine tumor that stained positive for GHRH. Postoperatively, serum GHRH and IGF-1 normalized. Re-evaluation of the initial pituitary pathologic specimen revealed additional somatotroph hyperplasia of the adjacent, normal pituitary gland. Primary hyperparathyroidism was diagnosed, and multigland parathyroid hyperplasia was noted at surgery. Genetic testing was positive for a mutation in the MEN1 gene. CONCLUSION: This patient's acromegaly was resistant to somatostatin analogue therapy, reflecting the negative octreoscan imaging. In addition, this case is novel because the patient presented with pituitary adenomatous changes, which were presumably associated with MEN 1 and/or possibly the elevated GHRH levels.

A bedside ultrasound sign of cardiac disease: the left atrium-to-aorta diastolic diameter ratio.

PURPOSE: This study evaluated a simple ultrasound method to detect left atrial (LA) enlargement by comparing the diameters of the LA and aortic root. PROCEDURES: The LA and aortic diameters, the LA volume index (LAVI), and significant echo findings were analyzed in 101 consecutive echocardiograms. Mean LAVI and the prevalence of an abnormal echo were compared between groups in which the ratio of the LA diameter to aortic diameter in diastole was >1 vs < or = 1. FINDINGS: Left atrial-to-aortic diameter ratio increased with LAVI (r = 0.64, P < .001). Left atrial-to-aortic diameter ratio >1 vs < or = 1 was noted in 45% vs 55% of patients and had a mean (+ or - SD) LAVI = 39 + or - 12 vs 27 + or - 7 mL/m(2) (P < .001) and a 78% vs 43% prevalence of an abnormal echo (P < .001). CONCLUSION: The left atrium-to-aorta diastolic diameter ratio can detect LA enlargement and may be useful as a quick bedside technique to screen for cardiac disease.

Disrupting the transmission of influenza a: face masks and ultraviolet light as control measures.

In the event of an influenza pandemic, where effective vaccine and antiviral drugs may be lacking, disrupting environmental transmission of the influenza virus will be the only viable strategy to protect the public. We discuss 2 such modalities, respirators (face masks) and ultraviolet (UV) light. Largely overlooked, the potential utility of each is underappreciated. The effectiveness of disposable face masks may be increased by sealing the edges of the mask to the face. Reusable masks should be stockpiled, because the supply of disposable masks will likely prove inadequate. UV light, directed overhead, may be beneficial in hospitals and nursing homes.