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Objective: Critical illness causes a decrease in serum free triiodothyronine (T3) levels. This condition, known as nonthyroidal illness syndrome (NTIS), is associated with poor outcomes. The association of NTIS and outcomes in patients in the intensive care unit (ICU) requiring mechanical ventilation has not been well studied. This study aimed to determine the impact of NTIS on the outcomes of these patients. Methods: This prospective study included 162 patients in the ICU who underwent mechanical ventilation. Serum free T3 levels were tested on the day of initiation of mechanical ventilation. The rates of in-hospital mortality and ventilator-free days (VFDs) at day 28 after the initiation of mechanical ventilation were compared between patients with low (<2.3 pg/mL) and normal (≥2.3 pg/mL) free T3 levels. Patients who died while on mechanical ventilation were assigned a VFD of 0. Results: Low T3 was present in 60% of study patients. The in-hospital mortality rate of the entire cohort was 39%, and the mean and median VFDs at day 28 were 13.5 and 21 days, respectively. Compared to patients with normal free T3, patients with low free T3 had higher in-hospital mortality (52% vs 19%, P < .001) and less mean and median VFDs at day 28 (10.7 vs 18 and 0 vs 23, respectively. P < .001 for both mean and median VFDs). Conclusions: The presence of low T3 due to NTIS in patients in the ICU requiring mechanical ventilation is associated with poor outcomes.

The results of this study suggest that biliary dyskinesia should be considered as part of the spectrum of symptomatic gallbladder disease that can be successfully treated with cholecystectomy and that biliary dyskinesia is associated with GERD and gastritis.

Background Diabetes is a known risk factor for severe coronavirus disease 2019 (COVID-19). We conducted this study to determine if there is a correlation between hemoglobin A 1c (HbA 1c ) level and poor outcomes in hospitalized patients with diabetes and COVID-19. Methods This is a retrospective, single-center, observational study of patients with diabetes (as defined by an HbA 1c ≥ 6.5% or known medical history of diabetes) who had a confirmed case of COVID-19 and required hospitalization. All patients were admitted to our institution between March 3, 2020 and May 5, 2020. HbA 1c results for each patient were divided into quartiles; 5.1-6.7% (32-50 mmol/mol), 6.8-7.5% (51-58 mmol/mol), 7.6-8.9% (60-74 mmol/mol), and >9% (>75 mmol/mol). The primary outcome was in-hospital mortality. Secondary outcomes included admission to an intensive care unit, invasive mechanical ventilation, acute kidney injury, acute thrombosis, and length of hospital stay. Results Five hundred and six patients were included. The number of deaths within quartiles 1 through 4 were 30 (25%), 37 (27%), 34 (27%) and 24 (19%), respectively. There was no statistical difference in the primary or secondary outcomes between the quartiles except acute kidney injury was less frequent in quartile 4. Conclusions There is no significant association between HbA 1c level and adverse clinical outcomes in patients with diabetes who are hospitalized with COVID-19. HbA 1c should not be used for risk stratification in these patients.

Background: Thyroid nodules are commonly found by screening, and the clinical implications are unclear. Methods: We retrospectively studied 460 patients who were evaluated for thyroid nodules. Medical records were queried to determine how the nodules were detected. We compared the rates of fine needle aspiration (FNA) and malignancy between nodules detected clinically, incidentally on imaging, or by screening. Results: Nodules were detected clinically in 184 patients (40%), incidentally in 121 patients (26%), and by screening in 155 patients (34%). The rates of FNA and malignancy were lower for patients with nodules detected by screening (28% and 1%, respectively), compared to patients with clinically apparent nodules (75% and 15%) and patients with incidental nodules (69% and 8% [P < .001]). Conclusion: Thyroid nodules detected via screening has a lower rate of FNA and is less likely to be diagnosed as a malignancy compared to nodules detected clinically or incidentally on imaging. Thyroid ultrasound examinations should be reserved for nodules that are clinically apparent or to evaluate nodules found incidentally on imaging.

OBJECTIVE: We report a case of thyrotoxic periodic paralysis (TPP) in a bodybuilder who developed paralysis secondary to thyrotoxicosis factitia (TF) after taking a supplement containing thyroid hormone. Interestingly, the patient had no intrinsic thyroid disease. Prompt recognition of thyrotoxicosis is critical to avoid progression of paralysis and subsequent complications. METHODS: We discuss a 27 year-old body builder who presented after a 3-day bodybuilding competition with sudden upper and lower extremity paralysis. He admitted to taking anabolic steroids, a supplement containing an unknown amount of thyroid hormone for two weeks, and furosemide 40 mg twice daily with near-complete fluid restriction for three days. RESULTS: Laboratory results showed a thyroid-stimulating hormone level of <0.010 mIU/L (0.3–5.8 uIU/mL), normal total T3 level, elevated free T4 level of 3.6 ng/dL (0.8–1.9 ng/mL), and potassium level of 1.9 mEq/L (3.7–5.2 mEq/L). Thyroid peroxidase antibody, thyroid stimulating immunoglobulin and thyroglobulin antibody levels were normal. Thyroid uptake was 1% (8–25%) after administration of I-123 and thyroglobulin level was 9 ng/mL (1.4 – 29.2 ng/mL). The patient was treated withnormal saline infusion, magnesium supplementation and a total of 230 mEq of potassium within 12 hours of hospitalization. Muscle weakness resolved within this time period and potassium level normalized. By the third day of hospitalization free thyroxine level also normalized and TSH improved to 0.1 mIU/L. CONCLUSION: TPP is a rare complication of thyrotoxicosis that should be considered in bodybuilders who are presenting with acute muscle weakness.

Objective: Paragangliomas (PGLs) are one of the many neoplasms associated with von Hippel-Lindau (VHL) disease. VHL disease type 2C is a unique subtype characterized by the presence of a PGL or pheochromocytoma without other VHL-associated neoplasms. This report describes a rare germline mutation in the VHL gene in a patient with isolated PGL. Methods: The clinical presentation, urinary metanephrines and normetanephrines, computed tomography scan, meta-iodobenzylguanidine scintiscan, surgical pathology, and genetic testing of a patient with PGL and a rare VHL gene mutation are described. A literature review is also presented. Results: A 23-year-old, Indian woman was incidentally found to have an indeterminate 4.2 × 3.6 × 3.2-cm mass adjacent to the liver. A 36-year-old first cousin was recently diagnosed with a PGL. Her 24-hour urinary metanephrines were 6,886 μg/g creatinine (reference range is 81 to 330 μg/g creatinine) and normetanephrines were 6,810 μg/g creatinine (reference range is 20 to 158 μg/g creatinine). Surgical pathology revealed a PGL adjacent to a normal adrenal gland. Genetic testing revealed a mutation in VHL p.L163F. Surveillance for other tumors associated with VHL disease has been negative thus far. Her cousin has not undergone genetic testing despite recommendations to do so. Conclusion: We present the first reported case of PGL in a patient with VHL disease caused by a missense mutation in VHL p.L163F. To date, reports of this rare mutation have only involved patients with pheochromocytoma and without other tumors associated with VHL disease, suggesting that VHL p.L163F mutation may cause a VHL disease type 2C phenotype.

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