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Background Thyroid nodules classified as atypia of uncertain significance (AUS) on fine-needle aspiration cytology are heterogeneous. Prior studies reported a higher risk of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP)/cancer among AUS nodules that had cytologic (AUS-C) versus architectural (AUS-A) atypia; however, such studies were generally confined to resected cohorts, introducing bias into risk calculations. The authors hypothesized that combined histologic and molecular end points would permit clinically meaningful calculations of NIFTP/malignancy risk among AUS nodules. Methods The study consisted of 279 thyroid nodules classified as AUS on initial fine-needle aspiration and tested by the Afirma Gene Expression Classifier (GEC) between June 2013 and October 2017. Results of GEC testing and histopathologic diagnoses were stratified by AUS classifiers. The AUS-A category was further subclassified as 1) hypocellular microfollicular or 2) cellular with mixed but predominantly microfollicular architecture. NIFTP/cancer risk was calculated for each subgroup, with the inclusion of unresected nodules that had benign GEC results as low-risk end points comparable to histologically benign nodules. Results When only histologic end points were considered, there was no difference in NIFTP/cancer risk (25% vs 23%; P = .82). By using molecular and histologic end points, AUS cases with cytologic atypia trended toward higher NIFTP/cancer risk than AUS-A cases (14% vs 6%; P = .06). Furthermore, AUS-A cases showed a trend toward lower NIFTP/cancer risk for hypocellular microfollicular aspirates (3%) compared with cellular samples that had mixed/predominantly microfollicular architecture (13%; P = .18). Conclusions The inclusion of unresected benign GEC nodules in risk-of-malignancy calculations provides more accurate results, which may be helpful for informing patient management as well as quality improvement in the cytopathology laboratory.

Background: Molecular testing (MT) refines risk stratification for thyroid nodules that are indeterminate for cancer by fine needle aspiration (FNA) cytology. Criteria for selecting nodules for MT vary and remain largely untested, raising questions about the best strategy for maximizing the usefulness of MT while minimizing the harms of overtesting. We used a unique data set to examine the effects of repeat FNA cytology-based criteria for MT on management decisions and nodule outcomes. Methods: This was a study of adults (age 25–90 years; 281 women and 72 men) with cytologically indeterminate (Bethesda III/IV) thyroid nodules who underwent repeat FNA biopsy and Afirma Gene Expression Classifier (GEC) testing (N = 363 nodules from 353 patients) between June 2013 and October 2017 at a single institution, with follow-up data collected until December 2019. Subgroup analysis was performed based on classification of repeat FNA cytology. Outcomes of GEC testing, clinical/sonographic surveillance of unresected nodules, and histopathologic diagnoses of thyroidectomies were compared between three testing approaches: (i) Reflex (MT sent on the basis of the initial Bethesda III/IV FNA), (ii) SemiRestrictive (MT sent if repeat FNA is Bethesda I–IV), and (iii) Restrictive (MT sent only if repeat FNA is Bethesda III/IV) testing approaches. Results: Restricting MT to nodules that remain Bethesda III/IV on repeat FNA would have missed 4 low-risk cancers and 3 noninvasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP) (collectively 2% of the test population) but would have avoided diagnostic surgery for 42 benign nodules (12% of the test population). The Restrictive testing strategy was more specific (delta 0.126 confidence interval [CI 0.093 to 0.159] and 0.129 [CI 0.097 to 0.161], respectively) but less sensitive (delta −0.339 [CI −0.424 to −0.253] and −0.340 [CI −0.425 to −0.255], respectively) than the Reflex and SemiRestrictive approaches for detecting NIFTP or cancer. Conclusions: Repeat FNA cytology can guide the selection of cytologically indeterminate thyroid nodules that warrant MT. The Restrictive model of performing Afirma GEC only on nodules with two separate biopsies showing Bethesda III/IV cytology would reduce the rate of diagnostic surgery for histologically benign nodules while missing only rare low-risk tumors. Given the low but nontrivial risks of thyroidectomy, the higher specificity of the Restrictive testing approach disproportionately outweighs the potential harms.

All patients should ideally be seen by an endocrinologist before admission for transsphenoidal pituitary surgery. Once admitted, hormone evaluation for cortisol status is the most important test. Depending on the preoperative cortisol adequacy, insufficiency, excess, or unknown status, perioperative and postoperative treatment with hydrocortisone is often indicated. Peri- and postoperative treatment should also include monitoring and treatment for diabetes insipidus or inappropriate secretion of antidiuretic hormone. Close monitoring of water and sodium balance is required. Finally, the patient should follow up with an endocrinologist 1–2 weeks after surgery so that pituitary hormone status can be reevaluated and proper treatment and follow-up arranged.

Despite the centrality of regret in medicine, studies have largely failed to capture its complexity and consequences. Many proposed instruments for measuring it fail to differentiate it from disappointment, and it is still largely absent from the medical curriculum.

To describe a patient presenting with the rare constellation of synchronous parathyroid carcinoma, parathyroid adenoma, and papillary thyroid carcinoma.We summarize the clinical presentation, diagnostic work-up, surgical management, and pathologic features of our patient and review the pertinent literature.The patient was a 59-year-old man who presented with severe clinical manifestations of long-standing primary hyperparathyroidism, a serum calcium concentration of 14.4 mg/dL, and a parathyroid hormone level of 2,023 pg/mL. He was found to have a 3.4-cm parathyroid carcinoma on the left side and a 3.2-cm papillary carcinoma in the right thyroid lobe. In addition, a 917-mg parathyroid adenoma was found on the right side.Synchronous parathyroid and thyroid carcinomas are extremely rare. To our knowledge, our patient is the first documented case with a parathyroid adenoma in addition to synchronous parathyroid and thyroid carcinomas. The presence of concurrent parathyroid carcinoma and parathyroid adenoma can cause diagnostic confusion and should be considered in patients presenting with severe hyperparathyroidism. Any concomitant thyroid nodules must be investigated to rule out thyroid carcinoma.

In classic medical decision analysis, when outcomes are uncertain and risk is involved, the “best” choice is the one with the “highest expected utility.” The outcome usually measured is death, which is readily determined and quantified. But what of other key outcomes?

Drs. Pamela Hartzband and Jerome Groopman argue that assigning a monetary value to every aspect of a physician's time and effort may actually reduce productivity, impair the quality of performance, and thereby even increase costs.

Method: Recombinant human growth hormone (rhGH) is a newly approved treatment for weight loss and wasting in patients with AIDS. We report a male patient with advanced AIDS who developed hypercalcemia 2 weeks after institution of rhGH therapy. Results: Parathyroid hormone, parathyroid hormone-related peptide and 1,25-dihydroxyvitamin D levels were suppressed, suggesting that hypercalcemia was mediated through alternative mechanisms. The hypercalcemia responded to discontinuation of rhGH and a single dose of intravenous pamidronate disodium and has not recurred in 8 months of follow-up. Conclusion: We believe this to be the first reported case of rhGH-induced hypercalcemia in an HIV-infected patient.

In May 2015, the U.S. Preventive Services Task Force issued a guideline on screening for thyroid disease that included a systematic evidence review and an update of its 2004 recommendations. The review assessed the effect of treating screen-detected subclinical thyroid dysfunction on health outcomes. It found adequate evidence that treating subclinical hypothyroidism does not provide clinically meaningful improvements in blood pressure, body mass index, bone mineral density, lipid levels, or quality-of-life measures. The review also concluded that evidence was inadequate to determine whether screening for thyroid dysfunction reduced cardiovascular disease or related morbidity and mortality. In separate guidelines, the American Association of Clinical Endocrinologists and American Thyroid Association advocated aggressive case-finding and recommended screening persons with certain clinical conditions or characteristics rather than the general population. These societies argue that subclinical hypothyroidism adversely affects cardiovascular outcomes and thus merits case-finding. Here, 2 experts discuss their perspectives on whether treating subclinical hypothyroidism reduces morbidity and mortality, whether there are harms of treatment, and how they would balance the benefits and harms of treatment both in general and for a specific patient.

The Web is profoundly changing communication between doctor and patient. Drs. Pamela Hartzband and Jerome Groopman write that, nonetheless, the core relationship should not change.

Drs. Pamela Hartzband and Jerome Groopman write that two major movements, the medical humanism movement and evidence-based practice, will now play out in the context of national health care reform. Today, when it is most important for these two movements to coalesce, they are poised to collide.

The ultimate goal of the electronic medical record is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient. Drs. Pamela Hartzband and Jerome Groopman write that before blindly embracing electronic records, we should consider their current limitations and potential downsides.

Cushing's syndrome (CS) due to ectopic ACTH secretion (EAS) has a high morbidity and mortality, because of the underlying tumor and the sequelae of severe hypercortisolemia. Therefore, rapid treatment of ectopic CS is mandatory. Scintigraphy shows that up to 80% of ectopic ACTH-producing tumors have somatostatin receptors. While this suggests that somatostatin analogs may reduce ACTH production and treat patients with EAS, the therapeutic role of these agents is still evolving. Here we demonstrate the spectrum of responses to octreotide therapy in 3 patients with EAS. Diagnostic imaging with the 111In-pentetreotide scan did not predict the therapeutic response to octreotide. Two patients with positive somatostatin receptor scintigraphy failed to respond to octreotide, while one with a negative scan reached eucortisolemia on a maintenance dose of 75 microg octreotide twice daily or octreotide LAR 30 mg per month. We conclude that octreotide is not a first line agent to control hypercortisolemia but may be a useful agent when other inhibitors of steroidogenesis fail or parenteral administration is required. Before therapy an octreotide challenge test may predict therapeutic response. Cortisol levels should be monitored regularly on somatostatin analog therapy, because of its unpredictable long-term pharmacodynamic profile.

In the new language of medicine, patients are “customers” or “consumers”; doctors and nurses are “providers.” The words we use to explain our roles set expectations and shape behavior. This change in the language of medicine has important and deleterious consequences.

We describe a premenopausal white woman with symptomatic acute primary hyperparathyroidism and marked osteoporosis. After undergoing a parathyroidectomy, the patient experienced not only rapid symptomatic relief, but also marked improvement in bone mineral density, which increased by 25% in the hip and by 22% in the lumbar spine 1 year after the surgery. Acute primary hyperparathyroidism should be considered in any patient with severe symptomatic hypercalcemia. Appropriate treatment with early parathyroidectomy can result in significant and rapid improvement in bone mineral density.

The human T-lymphotropic virus type III (HTLV-III) is the primary cause of the acquired immunodeficiency syndrome (AIDS) and related disorders (ARC). Prior studies have reported that nearly all symptomatic patients with AIDS or ARC manifest antibody to HTLV-III. This observation has engendered efforts to screen for HTLV-III, especially prior to blood donation, with assays for antibody to HTLV-III. We report the first two cases, one with AIDS and one with ARC, that are HTLV-III virus positive but antibody negative. Accurate diagnosis of HTLV-III infection in some cases may require direct virus culture or tests for antigen. In addition, lack of HTLV-III antibody may indicate an atypical clinical course of AIDS.

We report a patient with a lingual mass clinically diagnosed as lingual thyroid. Due to marked distortion of the normal thyroidal architecture from prior 131I therapy, pathological examination of the mass was consistent with a mixed salivary gland tumor. Immunoperoxidase staining for thyroglobulin was utilized to correctly characterize the lingual mass as ectopic thyroid.

Acromegaloidism is a syndrome characterized by features of acromegaly without biochemical evidence of excessive GH or somatomedin production. We searched for a growth factor in the serum of patients with this syndrome. Growth-promoting activity was measured by determining the stimulatory effect of whole and fractionated serum on colony formation by human erythroid progenitors in vitro. Sera from five subjects with acromegaloidism gave a mean (+/- SEM) stimulated colony growth of 211 +/- 4.0 colonies, in contrast to normal sera which yielded a mean colony growth of 100 +/- 11.0 (n = 9; P less than 0.001). When serum was chromatographed on a Sephadex G-200 column, the maximal stimulation of colony growth was found in the fractions coinciding with the descending slope of the second protein peak. Based on gel filtration chromatography, the estimated molecular weight was 70,000 daltons. Epidermal growth factor, nerve growth factor, fibroblast growth factor, and platelet-derived growth factor resulted in no substantial stimulation of colony growth under the conditions used. Although the erythroid progenitor cells of a Laron dwarf were unresponsive to 200 ng/ml human GH, they were clearly stimulated by serum from a patient with acromegaloidism. The present study describes the presence of a heretofore unidentified growth factor in the serum of subjects with acromegaloidism. This factor also stimulated the erythroid precursor cells of a Laron dwarf whose cells were unresponsive to GH. The physiological role of this growth factor in normal man as well as its pathogenic role in subjects with acromegaloidism remain to be established.

The response to ACTH stimulation, insulin-hypoglycemia and metyrapone in patients with suspected HPA axis dysfunction due to corticosteroid therapy (Group I, n = 10), or pituitary surgery (Group II, n = 7) and in a control population (Group III, n = 8) was studied. Group I patients had been maintained on a stable low dose of prednisone 5.0–7.5 mg/day for 1 month-16 yr (mean = 31 mos) prior to testing. Basal 08:00 h cortisol levels in this group were not different from control values. However, the mean responses to all three testing procedures were suppressed (Group I vs III, ACTH p < 0.001, insulin p< 0.01, metyrapone p< 0.05). Group II patients had undergone surgery 1–26 months (mean = 10 mo) prior to testing and had been maintained subsequently on a stable dose of prednisone 5.0–7.5 mg/day. In this group basal mean 08:00 h cortisol and the cortisol response to ACTH and insulin-hypoglycemia were not significantly different from control values while the response to metyrapone was suppressed (Group II vs III p< 0.02). Basal serum DHEA-S levels were suppressed in both Groups I and II when compared to Group III (p< 0.001 ). Discordant responses to the three testing procedures were noted in 6 patients with suspected HPA dysfunction with abnormal test results in 1/6 using cortrosyn, 3/6 using insulin-hypoglycemia and 4/6 using metyrapone. We conclude that: (1) Low doses of prednisone cause subtle, but significant HPA axis suppression, (2) DHEA-S levels do not correlate with standard tests of the HPA axis, and (3) Although no single test identified every subject with an abnormal HPA axis, metyrapone was more useful in detecting subtle degrees of HPA dysfunction than ACTH or insulin-hypoglycemia. Metyrapone is simple, safe and may be the test of choice in assessing patients with suspected secondary adrenal insufficiency.

Circular dichroism and difference spectroscopy have been used to study dilute aqueous solutions of oxygenated, deoxygenated, and carbamoylated deoxygenated hemoglobins A and S (HbA and HbS, respectively). The spectra of HbA and HbS, in comparable state of oxygenation or carbamoylation, are identical, strongly implying identical conformations about the heme groups of the respective proteins. The spectra of the oxygenated forms change little upon addition of KCNO, which is known to carbamoylate the NH2 terminals of the individual chains (Cerami and Manning, 1971). The spectra of the deoxygenated forms, on the other hand, are markedly altered. The decreased magnitude of the 430-nm extremum with increased cyanate concentration can be used to calculate an addition curve which becomes asymptotic at a cyanate:heme molar ratio of approximately 10(3). This conformational change occurs in the absence of O2 and has been predicted (Njikam et al.,1973); it can also be demonstrated by difference spectroscopy techniques, whereby a comparable addition curve can be constructed from changes in the 555-nm absorption, while the 541-nm absorption remains invariant. The change described corresponds to the formation of a new conformation, corresponding to carbamoyldeoxyhemoglobin, carrying one carbamoyl group per chain. In the presence of a small quantity of oxygen, however, the above reported changes in CD are accompanied by a concomitant rise in the 415-nm peak-corresponding to the formation of oxyhemoglobin-while those in the difference spectra reflect not only a change in the 555-nm band but also a parallel one at 541 nm, confirming the formation of oxyhemoglobin. Thus the conformation achieved upon carbamoylation of deoxyhemoglobin has the higher oxygen affinity predicted by Nigen et al. (1974) for carbamoyldeoxyhemoglobin. Cyanate has been used (Cerami and Manning, 1971) as an antisickling reagent in vivo and in vitro, but, although it has been shown that it binds covalently to the NH2-terminal residues of hemoglobin (Lee and Manning, 1973), its effect on hemoglobin conformation has not been previously shown nor has its mechanism of action been fully clarified. The results presented here show that the effect of cyanate on hemoglobin is the formation of a new conformation with heightened oxygen affinity. Since oxyHbS does not aggregate while deoxyHbS does, in a temperature-dependent fashion, the formation of carbamoyldeoxyHbS interferes with such aggregation in vitro in deoxygenated samples. In vivo, where there are generally low residual concentrations of O2, the formation of oxyHb is favored by the higher O2 affinity of carbamoyldeoxyHbS, and aggregation with concomitant red cell sickling is therefore disfavored.