Michael D. Brennan

Determination of thigh muscle stiffness using magnetic resonance elastography.

To measure the elastic properties of the vastus lateralis (VL), vastus medialis (VM), and sartorius (Sr) muscles using magnetic resonance elastography (MRE).

Invasive Hürthle cell carcinoma of the thyroid: natural history and management

Debate surrounds the natural history and appropriate management of Hürthle cell neoplasms of the thyroid. Some of the uncertainty stems from difficulty in the differentiation of benign from malignant lesions. We report the presentation, management, and outcome of patients with invasive Hürthle cell carcinoma who were examined at this institution between 1946 and 1971. We believe that our review allows us to make reasonable recommendations concerning the management of patients with this type of carcinoma.

Thigh muscle stiffness assessed with magnetic resonance elastography in hyperthyroid patients before and after medical treatment.

To measure the stiffness of the vastus medialis (VM) in hyperthyroid patients before and after treatment.

Surgical Management of Amiodarone-associated Thyrotoxicosis: Mayo Clinic Experience

Amiodarone-associated thyrotoxicosis (AAT) is often poorly tolerated owing to underlying cardiac disease, and it is frequently refractory to conventional medical treatment. The goal of this study was to describe the patient characteristics, management, and outcomes of all the patients treated surgically for AAT at a single institution. We conducted a retrospective chart review of all patients managed surgically for AAT (April 1985 through November 2002) at the Mayo Clinic in Rochester, Minnesota. Altogether, 29 men and 5 women, ages 39 to 85 years (median 60 years), treated with amiodarone for 3 to 108 months underwent near-total or total thyroidectomy. Frequent symptoms were worsening heart failure, fatigue, weight loss, and tremor. Altogether, 12 patients failed medical management of their AAT, and 21 received no preoperative medical therapy. One patient had been successfully managed medically but required definitive treatment. Common indications for operation were the need to remain on amiodarone, cardiac decompensation, medically refractory disease, and severe symptoms, both hyperthyroid and cardiac, necessitating prompt resolution. The median ± SD American Society of Anesthesiologists (ASA) classification (1 = healthy through 5 = moribund) was 3.00 ± 0.58. A total of 27 specimens had histology consistent with AAT. Complications included death (n = 3), rehospitalization (n = 3), symptomatic hypocalcemia (n = 2), pneumonia (n = 2), cervical hematoma (n = 1), prolonged ventilatory wean (n = 1), and stroke (n = 1); one patient developed hypotension, adult respiratory distress syndrome, and sepsis. Of the 31 surviving patients, 25 (80%) remained on amiodarone postoperatively. The median follow-up was 29 months, at which time all surviving patients were free of hyperthyroid symptoms. Thyroidectomy is an effective treatment for AAT but has a high incidence of perioperative morbidity and mortality. The cardiovascular co-morbidities and high operative risk in this group of patients may account for the increased complication rate.

Endocrinopathy in POEMS syndrome: the Mayo Clinic experience.

OBJECTIVE To determine the prevalence and characteristics of endocrinopathies at diagnosis of POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) syndrome. PATIENTS AND METHODS From January 1, 1960, through June 30, 2006, we identified 170 patients with POEMS syndrome in the Mayo Clinic dysproteinemia database. We abstracted information about endocrine abnormalities from their medical records. RESULTS Of the 170 patients with POEMS syndrome during the entire study period, the 64 patients seen after 2000 had more complete endocrine evaluations; of these 64 patients, 54 (84%) had a recognized endocrinopathy (38 men; median age, 50 years; interquartile range, 43-59 years). Hypogonadism was the most common endocrine abnormality; 26 (79%) of 33 men had subnormal total testosterone levels, and 10 men had gynecomastia. Among the 35 patients with measured prolactin levels, 7 men and 3 women had elevated levels. Hypothyroidism was noted in 17 men and 11 women. Abnormalities in glucose metabolism were present in 24 (48%) of 50 patients; 16 patients had impaired fasting glucose levels, and 8 were diagnosed as having diabetes. Adrenal insufficiency (defined by an abnormal response of cortisol to stimulation with standard high-dose [250 microg] synthetic adrenocorticotropic hormone) was noted in 6 of 9 patients tested. Fourteen (27%) of 51 patients tested had hypocalcemia. Twenty-nine (54%) of 54 patients had evidence of multiple endocrinopathies in the 4 major endocrine axes (gonadal, thyroid, glucose, and adrenal). CONCLUSION The high prevalence of endocrinopathy in our study, to our knowledge the largest published series of POEMS cases, calls for a thorough endocrine investigation in patients presenting with this syndrome.

Changes in body composition in women following treatment of overt and subclinical hyperthyroidism.

OBJECTIVE To determine changes in weight, body composition, and bone density after treatment of overt hyperthyroidism (OH) and subclinical hyperthyroidism (SCH) in women. METHODS Women with OH and SCH referred to the Mayo Clinic Thyroid Clinic were recruited. Hyperthyroid patients and euthyroid control women were matched for age (within decade) and body mass index. Patients with OH and SCH were treated to normalize thyroid function test results and were restudied after 6 months of normal thyroid function. Baseline and posttreatment studies included measurement of height, weight, bone density, lean mass, fat mass, and thigh muscle cross-sectional area. All participants had normal thyroid function test results for at least 6 months before completion of the posttreatment studies. RESULTS Twenty-four patients with OH, 21 patients with SCH, and 36 control patients were studied. In the OH group, fat-free mass increased from a mean of 36.8 kg (95% confidence interval [CI], 34.8-38.8) to 40.4 kg (95% CI, 38.5-42.3); in the SCH group, fat-free mass increased from a mean of 40.3 kg (95% CI, 38.1-42.5) to 42.2 kg (95% CI, 39.7-44.7). In both groups, fat mass increased to approximately the same extent, and both groups experienced significant weight gain with no change in percent body fat. Thigh muscle cross-sectional area increased in both groups -- from 100.6 cm(2) (95% CI, 92.7-108.5) to 113.3 cm(2) (95% CI, 105.5-121.1) in the OH group and from 106.1 cm(2) (95% CI, 96.7-115.5) to 112.2 cm(2) (95% CI, 102.0-122.4) in the SCH group. Bone density increased in patients with OH (P<.01) and in patients with SCH (P<.05). CONCLUSIONS Treatment of OH and SCH leads to increases in muscle area and bone density. Weight gain reflects increases in both fat and fat-free mass. While these results provide some support for actively treating SCH in women, further prospective studies are needed to determine whether the changes documented translate into real patient benefit.

Heterophilic Serum Antibodies: A Cause for Falsely Elevated Serum Thyrotropin Levels

We report two cases of euthyroid patients with inappropriately elevated serum levels of thyrotropin (TSH) in whom investigation led to the detection of heterophilic antibodies. In addition, we compare the performance of two TSH immunometric assay systems in this setting. Even when monoclonal assay systems are used, TSH results must be critically interpreted when they are at variance with clinical and other biochemical findings.

Body mass index and the development of amiodarone-induced thyrotoxicosis in adults with congenital heart disease—A cohort study

INTRODUCTION Amiodarone-induced thyrotoxicosis (AIT) is a recognized complication of amiodarone treatment with limited management options. Its predisposing factors are incompletely defined yet a higher prevalence was reported in adults with congenital heart disease (CHD). Therefore we sought to determine the incidence and risk factors for AIT in adults with CHD. METHODS At a tertiary care center we followed a historical cohort of amiodarone-treated CHD patients for the period 1987-2009. Follow-up concluded at AIT diagnosis or with last thyroid assessment on amiodarone. Cumulative incidence of AIT was calculated. AIT association with nutritional status was hypothesized a priori. RESULTS AIT developed in 23/169 patients or 13.6%. The AIT incidence peaked in the 3rd year at 7.7%. AIT patients had a lower body mass index (BMI) at AMIO initiation compared with the rest of the cohort (mean ± standard deviation: 21.9 ± 2.9 vs. 25.1 ± 5.0; p<0.001). Patients with BMI<21 were more likely to develop thyrotoxicosis (RR=6.1) compared to those with BMI>25 (p<0.001). Presence of goiter was strongly associated with AIT (RR 3.6, p=0.002). Affected patients had a trend for higher cyanotic heart disease prevalence (34.8% vs. 17.8%, p=0.059). On multivariate analysis body mass index and goiter remained independent predictors of outcome. CONCLUSIONS BMI<21 at initiation of amiodarone therapy and presence of goiter are strong predictors of AIT in this population. Its incidence is time dependent. These predictors can be used clinically in assessing overall impact of amiodarone therapy in congenital heart disease patients.

Professionalism: Good for Patients and Health Care Organizations

Professionalism is an indispensable element in the compact between the medical profession and society that is based on trust and putting the needs of patients above all other considerations. The resurgence of interest in professionalism dates back to the 1980s when health maintenance organizations were formed and proprietary influences in health care increased. Since then, a rich and comprehensive literature has emerged in defining professionalism, including desirable individual attributes and behaviors and how they may be taught, promoted, and assessed. More recently, scholarship has shifted from individual to organizational professionalism. This literature addresses the role that health care organizations can play to establish environments that are conducive to the consistent expression of professionalism by individuals and health care teams. We reviewed interdisciplinary empirical studies from health care effectiveness and outcomes, organizational sciences, positive psychology, and social psychology, finding evidence that organizational and individual professionalism is associated with a wide range of benefits to patients and the organization. We identify actionable organizational strategies and approaches that, if adopted, can foster and promote combined organizational and individual professionalism. In doing so, trust in the medical profession and its institutions can be enhanced, which in turn will reconfirm a commitment to the social compact.

Standardized care processes to improve quality and safety of patient care in a large academic practice: the Plummer Project of the Department of Medicine, Mayo Clinic

There are opportunities to improve quality and safety of care provided to adult patients. The Plummer Project of the Department of Medicine at the Mayo Clinic (Rochester, MN, USA) is an initiative to redesign outpatient practice. We used multidisciplinary teams to standardize the tasks essential to improve patient care. With the initiative to standardize the rooming process, patient care and safety improved with greater accuracy of the medication list. The standardization also improved physician efficiency because trained clinical assistants helped address the needs of the patient. Physicians were satisfied by the new process and the technology enhancements. Clinical assistants were also highly satisfied by the training process. The quality and safety of patient care can be significantly improved by practice redesign. This practice redesign was satisfying for all, especially the patients, physicians and support team in our practice.