We have previously reported that there is a strong association between unnecessarily ordered thyroid USGs and unnecessarily requested Endocrinology (Endo) consultations. Unnecessary consults consume time and resources, delay appropriate consults, and have even been proposed as a factor in the over-diagnosis of clinically innocuous thyroid cancers. We have examined the impact on the consumption of clinical resources. The database consisted of 201 new Endo consults, each accompanied by a pre-consult thyroid USG. The consult requests were graded as appropriately requested (APPROP), optionally requested (OPT), or unnecessarily requested (UNNEC). The USG requests were likewise graded as APPROP, OPT, or UNNEC. The USGs were also graded on their degree of contribution to the request for a consultation, specifically, as having a significant role (SIGNIF), a minor role (MIN), or little or no role (NONE). The impact of the UNNEC consults was categorized as (a) the initial Endo consult, a resource that would not have been utilized were an UNNEC consult not submitted, and (b) resources that probably would have been utilized were the UNNEC consults not submitted but would have been managed by and costed to the referring provider instead of to the Endo provider. Such resources included follow-up Endo visits and relevant USGs and blood tests, Of the 201 consults with associated USGs, 156 (77.6%) consults were APPROP, 23 (11.4%) were OPT, and 22 (10.9%) were UNNEC. Conversely, 157 (78.1%) of the USGs were APPROP, 11 (5.5%) were OPT, and 33 (16.4%) were UNNEC. With respect to the association of consults with their accompanying USGs, Among APPROP requested consults, 87.8% of the associated USGs were also APPROP while only 7.7% were associated with UNNEC USGs. Among UNNEC requested consults, 31.8% of the associated USGs were APPROP while 68.2% were associated with UNNEC USGs. Regarding the resource utilization borne by an Endo clinic as a consequence of the submission of 21 UNNEC consults for the two years after the initial consultation, each UNNEC consult had consumed, on average, 5.9 (1 + 2.6 + 2.3) [initial + Yr 1 + Yr 2 follow-ups] Endo clinic visits, 0.9 (0.5 + 0.4) USGs [excludes the USG associated with initial consultation] and 4.1 (2.2 + 1.9) blood work orders and reviews. No follow-up FNAs or thyroid surgeries were performed. Endocrine care from any source would be best served by reducing both the unnecessary utilization and the unnecessary assignment of relevant resources.
Introduction: Hypercalcemia is a rather common clinical problem and a majority of cases are found to be secondary to primary hyperparathyroidism and malignancy. A rare cause of hypercalcemia is associated with high levels of vitamin A and thought to be secondary to the effect of vitamin A on bone to stimulate osteoclastic resorption or inhibit osteoblastic formation. Clinical Case: A 54 year-old male with a past medical history of CKD stage 3 secondary to medullary sponge kidney presented for hypercalcemia. He complained of chronic constipation, joint pain, mood changes and recurrent kidney stones. Reported multivitamin use (including 1000mcg of vitamin A) for years but was discontinued one year prior to visit. Lab work showed calcium of 11.5 mg/dL (8.7–10.2mg/dL), albumin 4.9 g/dL (3.8–4.9g/dL), elevated 24h urine calcium, eGFR 40 mL/min/1.73, parathyroid hormone 5 pg/mL (15-65pg/mL,) normal 1,25-OH vit D and 25-OH vit D, PTHrP <2.0 pmol/L, serum protein electrophoresis unremarkable. His vitamin A level was elevated to 103 ug/dL (20.1–62.0ug/dL). CT chest showed no findings concerning for sarcoidosis. Bone density scan showed normal bone mineral density. Patient diagnosed with hypercalcemia secondary to elevated vitamin A levels. Current limited literature shows stopping the vitamin A supplement will normalize vitamin A levels and correct the hypercalcemia. This patient had discontinued his multivitamin 1 year prior and vitamin A remained elevated, thought to be due to his poor kidney function. Treatment was targeted at improving his hypercalcemia and reducing his symptoms. He was prescribed a one-week course of prednisone 40 mg daily. His calcium level improved to 10.5 mg/dL. Prednisone was reduced to 20 mg daily with normalization of calcium to 10.3 mg/dL (8.7–10.2mg/dL). Conclusion: Hypercalcemia is a rare but known complication of vitamin D toxicity. The liver, kidney and adrenal glands store vitamin A and it is excreted in the urine. Liver and kidney disease pose higher risk of vitamin A toxicity. We present a unique case of Hypercalcemia secondary to elevated vitamin A levels in a patient with moderate chronic kidney disease who was not taking excessive amounts of vitamin A and whose calcium and vitamin A did not normalize once vitamin A supplements were discontinued. The CKD 3 may have reduced vitamin A clearance and increased its toxicity. Hypercalcemia is not the only concern regarding vitamin A toxicity, the increasing use of dietary supplements and over the counter medications may pose significant risks for osteoporosis and bone fractures. A high clinical suspicion and thorough workup to exclude other causes of hypercalcemia is warranted to diagnose hypervitaminosis A as the etiology. Steroids can reduce gastrointestinal absorption of calcium, however, its role in vitamin A toxicity remains unclear. Further research is needed to investigate the appropriate treatment for these patients.
A 55-year-old female with medical history of hypothyroidism and fibrocystic disease of the breast presented with complains of a painful anterior neck mass, difficulty swallowing and hoarseness of the voice. Symptoms had progressed over a period of 5 months. CT neck with contrast indicated the presence of an ectopic thyroid tissue anterior to the thyroid cartilage measuring approximately 1.7 x 1.2 x 3.1 cm, with indistinct inferior margins and internal calcifications. The hyoid bone or thyroid cartilage had no irregularities. The thyroid gland itself was unremarkable except for small complex thyroid nodules in both lobes. No masses within the pharynx or larynx were noted. Family history was significant for lymphoma in her father. On physical exam, a hard, mobile right anterior neck mass was appreciated. Labs showed normal TSH of 1.05 uIU/mL and normal free T4 of 1.2 ng/dL. Further evaluation with a dedicated neck US showed a right submandibular mass, superior to the thyroid, lobulated and heterogeneous measuring 2.0 x 1.0 x 2.3 cm with multiple areas of calcifications and internal Doppler flow. The thyroid gland had normal size and texture with bilateral sub centimeter non-concerning nodules. After ENT evaluation and an unremarkable flexible fiberoptic nasolaryngoscope, patient underwent surgical excisional biopsy of the neck mass. Pathology was consistent with thyroglossal duct cyst with the presence of thyroid follicles. An incidental finding of a 0.9 cm papillary microcarcinoma was noted, which was encapsulated with focal extracapsular follicular structures showing papillary nuclear features with no perineural or lymphovascular invasion. The tumor cells were immunoreactive for TTF-1 and PAX8. Development of papillary thyroid cancer within the thyroglossal duct cyst is a rare event, reportedly occurring in 1% of thyroglossal duct cysts. There are no well-established management guidelines. Current management strategies consist of monitoring with serial neck ultrasound versus total thyroidectomy with consideration of postsurgical I-131 treatment, based on pathology results. Our patient opted for undergoing total thyroidectomy.
Nodule size is commonly referenced by the volume (Vol) of the nodule or by its longest dimension (LD), determined ultrasonically. Vol directly reflects the nodular mass in that a doubling (100% increase) of the nodular mass, for example, manifests as a 100% Change in the nodular Vol but only about a 30% Change in the LD. Referring to nodule size by its LD, though, is probably more intuitive, easier to remember and more convenient since ultrasound reports and clinical parlance typically refer to nodule size by its LD, and perhaps other dimensions, but do not routinely provide a calculated Vol. Though extremely useful in the evaluation of thyroid nodules, the sizing of nodules ultrasonographically is subject to error at multiple steps, e.g., selecting and freezing the images at which the nodular dimensions are at their maximum, drawing the longest axis for each of a nodule’s 3 diameters [Anterior-Posterior, AP; Left-Right, LR; and Superior-Inferior, SI], and the placement of markers at the measuring points of the often vague nodular margins. To determine the magnitude and frequency of sizing errors that affect the calculation of nodular Vol (Vol = 4/3 x pi x AP/2 x LR/2 x SI/2) and LD, three pairs of observers each evaluated the ultrasonographic images of 34 nodules, determining the Vol and LD of each nodule. The “Change” in the Vol and LD for each nodule was determined by randomly regarding one member of the pair as having sized a nodule at a nominal Time 1, and the other member regarded as having sized a nodule at a nominal Time 2. The calculated “Change” in LD was defined as the LD at Time 2 minus the LD at Time 1, and likewise for “Change’ in Vol. Since the set of images evaluated by each observer was the same for each observer at each nominal Time point, there was no actual change in the LD or Vol of any nodule. Any observed change could only be attributable to observer variability in measurements. The %-Change in LD was calculated as 100 x [(LD at Time 2) minus (LD at Time 1)]/(LD at Time 1). The %-Change in Vol was similarly calculated. The greatest observed %-Changes in LD were a 36% increase and a 43% decrease. The greatest observed %-Changes in Vol were a 105% increase and an 81% decrease. The top 5%, 10% and 20% of calculated rank-ordered LD increases were, respectively, errors of 26% or more, 22% or more and 10% or more. The top 5%, 10% and 20% of calculated rank-ordered Vol increases were, respectively, errors of 64% or more, 50% or more and 26% or more. The larger %-errors for Vol changes compared to LD changes expectedly follow from the need to measure (and accumulate error from) 3 dimensions, not 1, to measure Vol. This study demonstrates that it is important to be aware that the %-error reported for changes in nodule LD or Vol may be considerable and not uncommon even for nodules that have not actually changed.
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