This study demonstrates that it is possible to identify primary care physicians (PCPs) who perform better or worse than expected in managing diabetes. Study subjects were 14 033 adult diabetics and their 133 PCPs. Logistic regression was used to predict the odds that a patient would have uncontrolled diabetes (defined as HbA1c ≥8%) based on patient-level characteristics alone. A second model predicted diabetes control from physician-level identity and characteristics alone. A third model combined the patient- and physician-level models using hierarchical logistic regression. Physician performance is calculated from the difference between the expected and observed proportions of patients with uncontrolled diabetes. After adjusting for important patient characteristics, PCPs were identified who performed better or worse than expected in managing diabetes. This strategy can be used to characterize physician performance in other chronic conditions. This approach may lead to new insights regarding effective and ineffective treatment strategies.
Objective: Graves disease is the most common cause of thyrotoxicosis. Medical management is the first-line treatment but may be contraindicated or ineffective. In patients with severe, refractory thyrotoxicosis therapeutic plasma exchange (TPE) may be indicated as a bridge to thyroidectomy. Methods: We present 3 cases of thyrotoxicosis refractory to medical management that were successfully treated with TPE and subsequent total thyroidectomy, and provide an analysis of the response to therapy via a change in free thyroxine (fT4) levels throughout their treatment course. Results: The average change in fT4 per liter of fluid exchanged was 0.37 ng/dL (SD = 0.08) and the average percentage change of fT4 after each treatment was 20.7% (SD = 8.28). The mean decrease in fT4 after 4 TPE treatments was 57.4%. All patients successfully underwent total thyroidectomy without complication and were discharged from the hospital. Conclusion: TPE should be considered for thyrotoxic patients with severe hyperthyroidism or thyroid storm refractory to medical management or contraindications to antithyroid drugs who need a bridge to total thyroidectomy. In these cases, TPE was a safe and effective treatment that enabled definitive management with thyroidectomy and may be considered in other patients with severe refractory hyperthyroidism or thyrotoxicosis.
Background: Giant prolactinomas (GPs) are rare representing 2-3% of prolactinomas and only ~ 0.5% of all pituitary tumors. Various definitions have been proposed for GP but commonly accepted criteria is tumor dimension of ≥4 cm. GP is often associated with very high prolactin (PRL) ranging 1,000 -100,000 ng/ml, significant extrasellar extension and no concomitant growth hormone or ACTH secretion. Patients predominantly present with neurological symptoms rather than endocrine dysfunction, and so the primary goal of treatment is amelioration of neurological symptoms. The literature search reveals approximately 190 papers on this topic and most are single case reports or series describing only unusual clinical manifestations. Hence, evidence based recommendations for treatment are lacking. Dopamine agonist (DA) is considered first line of therapy, as these tumors are highly sensitive to medical therapy. Surgery and radiation may be warranted in special situations. Low starting doses of cabergoline (CAB) are generally recommended due to concern for complications of apoplexy and cerebrospinal fluid (CSF) leak from rapid tumor shrinkage. However, no recommendations for a specific starting dose exist. Objective: Individual tumor and hormonal response were assessed on 15 patients (pts) with GP on low dose CAB; 0.25-0.5 mg weekly to determine the effectiveness of DA therapy. Methods: 15 GP pts from two tertiary care centers, meeting the diagnostic criteria mentioned above, were reviewed. Reduction in tumor volume and maximal tumor diameter along with PRL, after initiation of CAB, at or before 6 months and 1 year post diagnosis, was calculated. Results: Presenting symptom: visual disturbance (56%), headache (20%), apoplexy (13%) and incidental finding (6%). Mean age at diagnosis: 61 years. Male to Female: 4: 1. Basal prolactin concentration: >2000 ng/dl (12/15pts), and > 900 ng/ml (2/15). Initial total CAB dose/week: 0.25-0.5 mg (13/15) and 1-2 mg (2/15). Cranial surgery: 4/15. Complications: CSF leak (1/15). Tumor volume assessed at 6 months (11/15) and 1 year (4/15) along with decrease in maximum tumor diameter in the same period of time. PRL assessed at or before 6 months (13/15) and at 1 year (2/15). Improvement in tumor size occurred promptly even with low dose CAB (0.25-0.5mg/week). 100% of patients initiated on low dose CAB responded to therapy. Mean reduction in tumor volume at or before 6 months was 47% in 11/15, and 52% at 1 year (10/15). Mean decrease in maximal tumor dimension was calculated as 0.95 cm at 6 months (12/15) and 1.4 cm at 1 year (9/15). The overall prolactin response rate at or before 6 months was > 90% in 7/15 patients (53%) and >50% in 11/15 patients (73%). Conclusion: Our data confirms excellent tumor response to low dose cabergoline therapy. Dose as low at 0.25 mg twice weekly is proven to be effective, leading to decrease in both tumor volume and PRL levels.
Background: Neurosarcoidosis (NS) affects ~15% of patients with sarcoidosis. Hypothalamic-pituitary (HP) involvement is even rare and occurs in <1% of sarcoidosis. Clinically, NS presents as neuroendocrine dysfunction in 2.5% and radiologically, it typically manifests as HP lesion with parenchymal disease. The literature review demonstrates increased pituitary volume as the most frequent MRI abnormality observed in more than a half patients with HP involvement. Pituitary stalk thickening (PST) has been reported in combination with parenchymal abnormality but not in isolation. Central diabetes insipidus (CDI) is a known manifestation of stalk involvement. The exact mechanism of anti-diuretic hormone (ADH) dysfunction is not well understood, however CDI is mostly attributed to defective ADH release with direct infiltration of the stalk. Hormonal deficiencies are considered to be irreversible even in the setting of normalization of MRI findings after treatment. We herein report a case of NS associated with isolated PST presenting as CDI, where complete recovery was observed. Case: A 54-year-old male with pulmonary and gastrointestional (GI) sarcoidosis confirmed by gastric biopsy, developed abrupt onset of polyuria-polydipsia [Intake: 11-12 L/d, Output: 8-10 L/d] while treated with prednisone 5 mg/d. Urine osmolality (osm) was 64 mosm/kg, urine sodium (Na) 10 meq/l, serum osm 292 mosm/kg and serum Na 143 mmol/l. MRI of the Sella revealed 3.5 mm PST, absent posterior pituitary bright spot and partial empty sella. Anterior pituitary evaluation showed: Testosterone 122ng/dl, FSH 9.8mIU/ml, LH 3.3mIU/ml, Prolactin 17.8ng/ml, TSH 1.07 mcIU/ml, FT4; 0.7ng/dl, Cortisol 11.3mcg/dl, ACTH 12pg/ml and IGF-1; 129ng/ml. DDAVP 0.2mg bid controlled DI well. GI symptoms were treated with increased prednisone 40 mg/d and hydroxychloroquine. MRI showed decreased PST at 2.6 mm in 1 year and normal stalk thickness 1.8 mm in 2 years. He was successfully weaned off DDAVP, along with a slow taper of steroid. Four years since presentation, symptoms are well controlled on prednisone 3mg/d. Testosterone improved (213 ng/dl) and other anterior pituitary hormones remained in normal range. He has no polyuria, stalk measures 1.9 mm and posterior pituitary bright spot is absent. Conclusion: This case demonstrates a rare manifestation of NS presenting with isolated PST associated with CDI, without parenchymal disease. Furthermore, this is the first case report of complete resolution of CDI that correlated with normalization of MRI finding. In general hormonal deficits with HP sarcoidosis is considered irreversible and no correlation has been reported between the hormonal dysfunction and radiologic outcomes. Hence, in similar patients with isolated PST as the only manifestation of NS a trial off DDAVP may be offered, if improvement in MRI finding is noted over the course of the treatment.
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