Endocrinology

A 48-year-old woman complains of finger and knuckle pain in her right hand of 1 year's duration. She is right-handed. The pain is located over the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the index and middle fingers. The pain has recently become more intense and now makes it difficult to sleep and to grasp objects.

If Rip Van Winkle were a primary care physician who fell asleep a generation ago and woke up today, what would he think? He would have missed the arrival of managed care. He wouldn't know what a hospitalist does. He might ask how this evasive concept called quality is measured . . . and then cringe at the idea of "report cards" and "pay for performance."

If Rip Van Winkle were a primary care physician who fell asleep a generation ago and woke up today, what would he think?

BOSTON -- Building computers may bestow an increased risk of several kinds of cancer, according to an analysis of a large mortality database available.

ROCHESTER, Minn. -- The widely used anti-aging supplement DHEA (dehydroepiandrosterone) has no beneficial effect on body composition, physical performance, insulin sensitivity, or quality of life, according to Mayo Clinic researchers.

NASHVILLE, Tenn. -- Weight, height, and race independently influence prostate-specific antigen (PSA) levels, and each may distort the risk of prostate cancer, researchers here reported.

LOS ANGELES -- PET scans suggest that mental fog and memory problems after chemotherapy and other adjuvant therapy, the chemobrain phenomenon, may be caused by metabolic changes in the basal ganglia and frontal cortex.

The normal thyroid-stimulating hormone (TSH) reference range at our laboratory is 0.35 to 5.5 mIU/L. When I am treating a patient with levothyroxine, I do not adjust the dosage if the TSH level is within this range and the patient is otherwise asymptomatic. A colleague tells me that I should be adjusting the levothyroxine dosage to keep the TSH level below 2 mIU/L. He feels that lower TSH levels are associated with improved lipid profiles.

Recent laboratory guidelines from the National Academy of Clinical Biochemistry indicate that more than 95% of persons with normal thyroid function have a TSH level of less than 2.5 mIU/L.

OTTAWA, Ontario -- A large study of women with cosmetic breast implants found they had a suicide rate over two decades that was 73% higher than the general population -- but the rate was similar to that of women who had other cosmetic procedures.

ABSTRACT: Subclinical hypothyroidism is associated with elevated low-density lipoprotein (LDL) cholesterol levels and several factors related to atherosclerosis, including increased C-reactive protein levels and impaired endothelium-dependent vasodilatation. However, considerable controversy exists about screening for and treating this thyroid disorder. Thyroxine therapy lowers elevated LDL cholesterol levels in patients whose serum thyroid-stimulating hormone (TSH) concentrations are higher than 10 mIU/L ; thus, most experts recommend treatment for such patients. However, there is no consensus regarding the management of patients with TSH levels of less than 10 mIU/L. Although the evidence supporting treatment of these patients is not compelling, it is reasonable to offer a therapeutic trial of thyroxine to those who have symptoms.

ABSTRACT: Our knowledge of chronic diseases has advanced significantly in recent decades, but patient outcomes have not kept pace. This is largely because the traditional acute care model does not adequately address the needs of patients with chronic disease. Patients play an active role in the management of chronic disease, and successful outcomes are highly dependent on adherence to treatment. Thus, clinicians need to have skills in coaching and encouraging as well as an awareness of factors in patients' backgrounds that are likely to affect their ability or willingness to follow treatment plans. Provider- and system-related factors, such as lack of reimbursement for counseling and high copayments, can also act as barriers to compliance. Among the strategies that can improve adherence are the use of community resources, multidisciplinary approaches, and regular follow-up.

The optimal approach to subclinical hypothyroidism continues to be debated. Experts disagree over screening for thyroid dysfunction, the threshold TSH level for treatment, and the upper limit of normal of the TSH reference range.

Over the past few decades, the management of chronic disease has assumed a greater role in health care. Diseases such as diabetes, chronic obstructive pulmonary disease, and depression have replaced acute disorders as the leading cause of morbidity, mortality, and health care expenditures.

CHAPEL HILL, N.C. -- Geneticists are coming to general agreement that they know the future of a breast tumor when they see it.

ATLANTA -- Men in their prime years outnumber women among heat related deaths, accounting for about two-thirds of those who succumbed to heat in the United States over a recent five-year period, according to a CDC report.

abstract: There is increasing evidence that close monitoring and early intervention lead to better outcomes in patients with cystic fibrosis. At each office visit, spirometry should be performed and sputum culture specimens should be obtained; if the patient cannot produce sputum, a throat culture can be done instead. New respiratory symptoms or other evidence of worsening lung disease should prompt antibiotic therapy, increased airway clearance, and adjunctive anti-inflammatory medication as appropriate. Close attention should be paid to the patient's diet, appetite, stooling pattern, and growth measurements. Adolescents should be given additional information about their medications and adjunctive therapies to encourage them to take on a larger role in their own care. (J Respir Dis.2006;27(7):298-305)

Patients with psychiatric disordersoften present a diagnostic challenge-even for psychiatrists. Their demeanormay not readily reveal the nature orseverity of the problem. Nevertheless,there are clues that can help you sortthrough the differential and arrive atthe correct diagnosis.

A 77-year-old woman who had hadanorexia and weakness for 3 monthswas seen after a syncopal episode. Sheappeared pale but alert. Heart rate was110 beats per minute; respiration rate,22 breaths per minute; and blood pressure,170/70 mm Hg. Her hematologicindices were: hemoglobin level, 4.3 g/dL;mean corpuscular volume (MCV), 60fL; mean corpuscular hemoglobin concentration(MCHC), 29 g/dL; red bloodcell count, 1.6 million/μL; white bloodcell count, 7500/μL; and platelet count,452,000/μL.

Anemia is usually detected as an incidentalfinding on a screening completeblood cell (CBC) count. Occasionally,a patient presents with symptoms andsigns that strongly suggest anemia,and a CBC count is ordered. In eithersetting, the next step is to determinethe cause of the anemia.

ABSTRACT: The key features of polycystic ovary syndrome (PCOS) are menstrual bleeding disturbances caused by chronic oligoovulation or anovulation and clinical or biochemical hyperandrogenism. The finding of polycystic ovaries on ultrasonography alone has limited predictive value. Obesity often coexists with PCOS and can exacerbate metabolic disturbances, particularly insulin resistance, but it is not a diagnostic finding. Laboratory results can rule out other conditions in the differential, such as an androgen- producing neoplasm, hypothyroidism, and late-onset congenital adrenal hyperplasia.

The treatment of polycystic ovary syndrome (PCOS) is based on the patient's presenting symptoms and any significant abnormal findings. Symptoms can be managed with combined oral contraceptives (OCs), insulin-sensitizing agents, antiandrogens, and medications used to induce ovulation.

My 46-year-old patient had a fasting plasma glucose level of 115 mg/dL; a followupfasting plasma glucose level was 116 mg/dL.

Diabetes is epidemic! The numbersare truly alarming. In 1997, official datashowed that 16 million people in theUnited States had diabetes. Approximately1 million had type 1 disease,and 10.4 million had type 2 disease; theremainder had undiagnosed diabetes.1If these numbers are projected outagainst an annual increase in diseaseprevalence of about 3.5%, it means thatby the year 2028, 50 million people willhave diabetes. However, the actual rateis closer to 7% each year. As such, approximately100 million Americans-roughly 1 of every 4-will have diabetesby 2028.

What laboratory tests and imaging studies should be included in the workup of a palpable thyroid nodule?

What factors are causing the increased incidence of hypertension and cardiovascular mortality in African Americans, and what can be done to counteract them?

In 2 recent “Dermclinic” cases (CONSULTANT, December 2001, page 1812),Dr David Kaplan describes young women with lesions that arose on their extremitiesafter they used hormonal agents:

An 80-year-old woman complains of left hip painthat started after she fell while feeding her cat. The painis moderately severe and is localized to the left hip; itdoes not radiate. The patient is unable to bear any weighton the injured hip but denies numbness in her left leg.There are no other injuries.

A 79-year-old woman with a 37-year history of type 2 diabetes mellitus complains of head pain that began more thana month ago and is localized to the left frontotemporal region. She characterizes the pain as constant and burning, with minimalfluctuations in intensity. The pain does not increase with any particular activity but is quite disabling; it has causedemotional lability and insomnia. She denies nausea, visual disturbances, weakness of the extremities, dizziness, or tinnitus.Her appetite is depressed; she has experienced some weight loss.

Have any specific genes been identified for type 1 or type 2 diabetes? If so, howmany genes are involved?