Colum A. Gorman

Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940-1999): Temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients

It is uncertain whether more extensive primary surgery and increasing use of radioiodine remnant ablation (RRA) for papillary thyroid carcinoma (PTC) have resulted in improved rates of cause-specific mortality (CSM) and tumor recurrence (TR). Details of the initial presentation, therapy, and outcome of 2444 PTC patients consecutively treated during 1940–1999 were recorded in a computerized database. Patients were followed for more than 43,000 patient-years. The 25-year rates for CSM and TR were 5% and 14%, respectively. Temporal trends were analyzed for six decades. During the six decades, the proportion with initial MACIS (distant Metastasis, patient Age, Completeness of resection, local Invasion, and tumor Size) scores <6 were 77%, 82%, 84%, 86%, 85%, and 82%, respectively (p = 0.06). Lobectomy accounted for 70% of initial procedures during 1940–1949 and 22% during 1950–1959; during 1960–1999 bilateral lobar resection (BLR) accounted for 91% of surgeries (p <0.001). RRA after BLR was performed during 1950–1969 in 3% but increased to 18%, 57%, and 46% in successive decades (p <0.001). The 40-year rates for CSM and TR during 1940–1949 were significantly higher (p = 0.002) than during 1950–1999. During the last 50 years the 10-year CSM and TR rates for the 2286 cases did not significantly change with successive decades. Moreover, the 10-year rates for CSM and TR were not significantly improved during the last five decades of the study, either for the 1917 MACIS <6 patients or the 369 MACIS ? 6 patients. Increasing use of RRA has not apparently improved the already excellent outcome, achieved before 1970, in low risk (MACIS <6) PTC patients managed by near-total thyroidectomy and conservative nodal excision.

Impact of a Diabetes Electronic Management System on the Care of Patients Seen in a Subspecialty Diabetes Clinic

OBJECTIVE To compare the compliance with diabetes care performance indicators by diabetes specialists using a diabetes electronic management system (DEMS) and by those using the traditional paper medical record. RESEARCH DESIGN AND METHODS A DEMS has been gradually introduced into our subspecialty practice for diabetes care. To assess the value of this DEMS as a disease management tool, we completed a retrospective review of the medical records of 82 randomly selected patients attending a subspecialty diabetes clinic (DC) during the first quarter of 1996. Eligible patients were defined by the suggested criteria from the American Diabetes Association Provider Recognition Program. During the first quarter of 1996, ∼ one half of the providers began using the DEMS for some but not all of their patient encounters. Neither abstractors nor providers were aware of the intent to examine performance in relationship to use of the DEMS. RESULTS Several measures were positively influenced when providers used the DEMS. The number of foot examinations, the number of blood pressure readings, and a weighted criterion score were greater (P < 0.01) for providers using the DEMS. There was evidence, although not statistically significant, for lower mean diastolic blood pressures (P = 0.043) in patients and for number of glycated hemoglobins documented (P = 0.018) by users of the DEMS. CONCLUSIONS Performance and documentation of the process of care for patients with diabetes in a subspecialty clinic are greater with the use of a DEMS than with the traditional paper record.

Radiation Dose in the Selection of 131I or Surgical Treatment for Toxic Thyroid Adenoma

Clinicians, by their patterns of referral to colleagues in nuclear medicine or surgery, may strongly influence the selection of 131I versus surgical treatment for patients with toxic thyroid adenoma. The information presented here is intended to aid them in making an informed choice. As nodule size of an adenoma increases from 2 cm to 6 cm, the amount of radioiodine administered to the patient to deliver the same dose (30 000 rads to the nodule center, assuming a 30% uptake) increases from 5.6 mCi to 135 mCi. Concurrently, the suppressed thyroid tissue receives a radiation dose as high as 2300 rads. Despite these potentially carcinogenic doses, few patients with radioiodine-induced thyroid tumors have been reported; we discuss possible reasons for this. For young patients with large nodules, surgery is preferred.

L-Thyroxine contamination of pharmaceutical D-thyroxine: Probable cause of therapeutic effect

Studies have shown that pharmaceutic preparations of the stereo isomers of thyroxine differ with respect to thyromimetic potency and lipid level‐lowering effects. We applied a stereospecific assay for dextrothyroxine (DT4) and levothyroxine (LT4) to determine whether the biologic effects observed after the administration of DT4 (Choloxin; Flint Laboratories) resulted from inherent biologic activity of DT4, conversion of DT4 to LT4 in vivo, or LT4 contamination of Choloxin tablets. Choloxin was administered in a dose of 8 mg/day for 5 mo to nine athyreotic subjects who were then treated with pharmaceutic LT4 (Synthroid), 0.2 mg/day for an additional 5 mo. Analysis showed that LT4 contamination of Choloxin tablets ranged from 0.50% to 2.30%. This degree of contamination resulted in physiologically significant doses of LT4 in the 8 mg/day doses of Choloxin. During the treatment with two different lots of Choloxin, serum LT4 accounted for 33% to 53% of the measurable serum total thyroxine. The degree of LT4 contamination in Choloxin tablets was sufficient to account for the observed serum LT4 levels and casts doubt on the conclusions derived from previous studies in which Choloxin was used as the source of “DT4.”

Optic neuropathy of graves's disease. Treatment by transantral or transfrontal orbital decompression.

Abstract Patients with ophthalmopathy of Gravess disease accompanied by impaired visual acuity and visual-field defects were treated by transantral (10 patients) or transfrontal (nine patients) orbital decompression (one patient was treated by both approaches). The two procedures seemed equally effective in improving visual acuity and visual-field defects, and both induced a mean recession of proptosis of 4 mm. Diplopia developed after operation in three patients with transantral but not in any with transfrontal decompression. The transantral procedure is accomplished without an externally visible incision; the transfrontal operation requires head shaving and bilateral frontal craniotomies. Hospitalization time was shorter in the transantral (five to six days) than in the transfrontal group (10 to 12 days). The transfrontal procedure is indicated when orbital exploration is advisable. The transantral procedure is contraindicated if the sinuses are infected. Seven patients apparently were never thyrotoxic...

DEMS — a second generation diabetes electronic management system

Diabetes electronic management system (DEMS) is a component-based client/server application, written in Visual C++ and Visual Basic, with the database server running Sybase System 11. DEMS is built entirely with a combination of dynamic link libraries (DLLs) and ActiveX components - the only exception is the DEMS.exe. DEMS is a chronic disease management system for patients with diabetes. It is used at the point of care by all members of the diabetes team including physicians, nurses, dieticians, clinical assistants and educators. The system is designed for maximum clinical efficiency and facilitates appropriately supervised delegation of care. Dispersed clinical sites may be supervised from a central location. The system is designed for ease of navigation; immediate provision of many types of automatically generated reports; quality audits; aids to compliance with good care guidelines; and alerts, advisories, prompts, and warnings that guide the care provider. The system now contains data on over 34000 patients and is in daily use at multiple sites.

Interpretation of Serum Tri-Iodothyronine Levels Measured by the Sterling Technic

Abstract The mean serum tri-iodothyronine (T3) level was 243 ± 40 (S.D.) ng per 100 ml in 26 normal subjects, 187 ± 92 in 12 hypothyroid patients, and 671 ± 253 in 16 patients with Gravess disease. In hypothyroid patients rendered euthyroid by oral T3 treatment, serum T3 was as much as three times normal when serum thyroid-stimulating hormone was just suppressed. In hypothyroid subjects given thyroxine (T4), serum T3 was normal. Seven patients with proved hyperthyroidism and normal serum total T4 all had marked increases of serum T3. The inappropriately normal T4 value was not explained by deficiency of T4-binding globulin. Availability of serum T3 determinations adds validity to the diagnosis of hyperthyroidism in such patients, but an elevated serum T3 value should not be considered proof of hyperthyroidism without supporting evidence.

Simultaneous determination of d- and l-thyroxine in human serum by liquid chromatography with electrochemical detection

A method for the determination of D- and L-thyroxine in human serum is described. The method involves extraction of thyroxine from serum and the separation of thyroxine enantiomers on a reversed-phase, high-performance liquid chromatographic column by use of a chiral eluent containing L-proline and cupric sulfate. Satisfactory resolution of the enantiomers of thyroxine, triiodothyronine, and reverse triiodothyronine can be achieved in 12 min and, employing amperometric detection to monitor the separation, the detection limit for serum thyroxine is in the range of 1--3 ng per injected sample.

Orbital radiotherapy for Graves' ophthalmopathy: Useful or useless? Safe or dangerous?

Treatment of Graves’ ophthalmopathy does not always provide favorable results. After several decades of efforts, glucocorticoids, orbital radiotherapy (OR) and surgery (orbital decompression) remain the milestones in the management of this disease. OR produce favorable results in about 55–60% of patients. Its effectiveness is increased by the association with systemic glucocorticoids. Recent studies have cast some doubts on its real effectiveness and this is discussed by participants in this Forum. Selection of patients is particularly important to assess treatment outcome, because OR is unlikely to provide beneficial effects in patients with longstanding and inactive eye disease. OR is a safe procedure, with very limited side-effects. It should be used in patients older than 35 years of age. It is recommended that a large, multi-center, prospective, randomized and controlled study with well defined inclusion criteria be carried out to draw sound conclusions on the role of OR in the management of Graves’ ophthalmopathy.

Orbital decompression in Graves’ ophthalmopathy associated with pretibial myxedema

Pretibial myxedema (thyroid dermopathy), an uncommon autoimmune manifestation of Graves’ disease, is almost always associated with significant ophthalmopathy and may be a marker for an unusually prolonged or different course for the ophthalmopathy. However, it is not known if the response to therapy for eye disease is different in patients with pretibial myxedema. We compared the results of orbital decompression in 385 patients without and 52 patients with pretibial myxedema operated on between 1969 and 1989. Preoperative and postoperative characteristics of severe Graves’ ophthalmopathy did not differ in patients with or without pretibial myxedema except for slightly, but not significantly, more proptosis and diplopia in the pretibial myxedema group. In response to a 1989–1990 questionnaire (83% response rate, n=364), 89.1% without (n=319) and 88.9% with (n=45) pretibial myxedema reported satisfactory or acceptable appearance of the eyes. Self-assessment of visual acuity, eye comfort, diplopia, and overall rate of satisfaction with the status of the eyes did not differ between the groups. The presence of pretibial myxedema does not herald an unsatisfactory response to transantral orbital decompression.