1
|
Addison J, Razzaghi H, Bailey C, Dickinson K, Corathers SD, Hartley DM, Utidjian L, Carle AC, Rhodes ET, Alonso GT, Haller MJ, Gannon AW, Indyk JA, Arbeláez AM, Shenkman E, Forrest CB, Eckrich D, Magnusen B, Davies SD, Walsh KE. Testing an Automated Approach to Identify Variation in Outcomes among Children with Type 1 Diabetes across Multiple Sites. Pediatr Qual Saf 2022; 7:e602. [PMID: 38584961 PMCID: PMC10997286 DOI: 10.1097/pq9.0000000000000602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/21/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Efficient methods to obtain and benchmark national data are needed to improve comparative quality assessment for children with type 1 diabetes (T1D). PCORnet is a network of clinical data research networks whose infrastructure includes standardization to a Common Data Model (CDM) incorporating electronic health record (EHR)-derived data across multiple clinical institutions. The study aimed to determine the feasibility of the automated use of EHR data to assess comparative quality for T1D. Methods In two PCORnet networks, PEDSnet and OneFlorida, the study assessed measures of glycemic control, diabetic ketoacidosis admissions, and clinic visits in 2016-2018 among youth 0-20 years of age. The study team developed measure EHR-based specifications, identified institution-specific rates using data stored in the CDM, and assessed agreement with manual chart review. Results Among 9,740 youth with T1D across 12 institutions, one quarter (26%) had two or more measures of A1c greater than 9% annually (min 5%, max 47%). The median A1c was 8.5% (min site 7.9, max site 10.2). Overall, 4% were hospitalized for diabetic ketoacidosis (min 2%, max 8%). The predictive value of the PCORnet CDM was >75% for all measures and >90% for three measures. Conclusions Using EHR-derived data to assess comparative quality for T1D is a valid, efficient, and reliable data collection tool for measuring T1D care and outcomes. Wide variations across institutions were observed, and even the best-performing institutions often failed to achieve the American Diabetes Association HbA1C goals (<7.5%).
Collapse
Affiliation(s)
- Jessica Addison
- From the Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, Mass
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Charles Bailey
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Kimberley Dickinson
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Sarah D. Corathers
- Division of Endocrinology, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David M. Hartley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Levon Utidjian
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Adam C. Carle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Psychology, College of Arts and Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Erinn T. Rhodes
- Division of Endocrinology, Boston Children’s Hospital, Boston, Mass
- Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - G. Todd Alonso
- University of Colorado Anschutz Medical Campus, Barbara Davis Center, Aurora, Colo
| | | | | | - Justin A. Indyk
- Section of Endocrinology, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ana Maria Arbeláez
- Washington University in St. Louis, St. Louis, Mo
- St. Louis Children’s Hospital, St. Louis, Mo
| | - Elizabeth Shenkman
- University of Florida, College of Medicine, Department of Health Outcomes and Biomedical Informatics, Gainesville, Fla
| | | | | | | | - Sara Deakyne Davies
- University of Colorado Anschutz Medical Campus, Barbara Davis Center, Aurora, Colo
| | - Kathleen E. Walsh
- Department of Pediatrics, Harvard Medical School, Boston, Mass
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Mass
| |
Collapse
|
2
|
Hu TY, Price J, Pierce JS, Gannon AW. The association between pediatric mental health disorders and type 1 diabetes-related outcomes. Pediatr Diabetes 2022; 23:507-515. [PMID: 35249249 DOI: 10.1111/pedi.13330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 01/31/2022] [Accepted: 03/03/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Transition from pediatric to adult healthcare systems is a difficult process for young adults with Type 1 Diabetes (T1D) and most patients experience a deterioration in disease control. Mental health (MH) disorders are common in individuals with T1D and are believed to play a role in disease control and transition of care. We evaluated the association between the presence of pediatric MH disorder and measures of success in diabetes care in young adults who recently transitioned to adult care. RESEARCH DESIGN AND METHODS Retrospective cohort study of young adults in a large adult endocrinology system who transitioned from a pediatric hospital system after 2009. MH disorders were diagnosed by clinical pediatric psychologists during routine care at the pediatric hospital. Measurements of Hemoglobin A1c, diabetes-related emergencies, clinic attendance and intervals in transition were assessed and compared between the pediatric and adult hospital systems. RESULTS 237 young adults were identified and 100 (42%) of these were diagnosed with a MH disorder during pediatric care. Presence of a MH disorder was associated with higher Hemoglobin A1c levels prior to transition and increased rates of diabetes-related hospitalizations during the transition interval. Patients with a MH disorder were less likely to establish a pattern of consistent follow up after transition (p = 0.021). CONCLUSIONS MH disorders are common and predict greater challenges with diabetes management and less effective transition into the adult endocrinology system. Early recognition of MH disorders may allow for allocation of more proactive and intensive support for affected patients.
Collapse
Affiliation(s)
- Tina Y Hu
- Department of Pediatrics, Nemours Children's Hospital, Delaware, Wilmington, Delaware, USA.,Department of Internal Medicine, ChristianaCare Health System, Newark, Delaware, USA.,Departments of Internal Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Julia Price
- Departments of Internal Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Center for Healthcare Delivery Science, Nemours Children's Health System, Wilmington, Delaware, USA
| | - Jessica S Pierce
- Center for Healthcare Delivery Science, Nemours Children's Health System, Orlando, Florida, USA.,Department of Pediatrics, University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Anthony W Gannon
- Department of Pediatrics, Nemours Children's Hospital, Delaware, Wilmington, Delaware, USA.,Department of Internal Medicine, ChristianaCare Health System, Newark, Delaware, USA.,Departments of Internal Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Yuen KCJ, Alter CA, Miller BS, Gannon AW, Tritos NA, Samson SL, Dobri G, Kurtz K, Strobl F, Kelepouris N. Adult growth hormone deficiency: Optimizing transition of care from pediatric to adult services. Growth Horm IGF Res 2021; 56:101375. [PMID: 33341524 DOI: 10.1016/j.ghir.2020.101375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/23/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Most patients with childhood-onset growth hormone deficiency (CO-GHD) receive treatment with exogenous growth hormone (GH) to facilitate the attainment of their full potential adult height. Recent evidence suggests that continuing GH administration during the transition period between the end of linear growth and full adult maturity is necessary for proper body composition and bone and muscle health, and may also have beneficial effects on metabolic parameters, bone mineral density, and quality of life. The timing of this transition period coincides with the transfer of care from a pediatric to an adult endocrinologist, creating the potential for a care gap as a consequence of losing the patient to follow-up. DESIGN An advisory board comprising both pediatric and adult endocrinologists was assembled to address current clinical unmet needs and to collaborate on a structured transitional plan for optimal management of patients with CO-GHD. INSIGHTS/CONCLUSION The advisors suggest collaborative, multidisciplinary approaches to ensure continuity of care; ongoing testing and monitoring of GHD status into adulthood; and a clearly structured protocol that includes practical guidance for clinicians to establish best practices for transitioning older adolescents with persistent CO-GHD to adult care.
Collapse
Affiliation(s)
- Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine, Creighton School of Medicine, Phoenix, AZ, United States of America
| | - Craig A Alter
- Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Bradley S Miller
- Pediatric Endocrinology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States of America
| | - Anthony W Gannon
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, United States of America
| | - Nicholas A Tritos
- Massachusetts General Hospital, Neuroendocrine Unit, Harvard Medical School, Boston, MA, United States of America
| | - Susan L Samson
- Pituitary Center, Baylor St. Luke's Medical Center, Baylor College of Medicine, Houston, TX, United States of America
| | - Georgiana Dobri
- Neurological Surgery and Endocrinology Departments, Weill Cornell Medicine, New York, NY, United States of America
| | - Kristine Kurtz
- Novo Nordisk Inc., Plainsboro, NJ, United States of America
| | - Frank Strobl
- Novo Nordisk Inc., Plainsboro, NJ, United States of America
| | | |
Collapse
|
4
|
Abstract
BACKGROUND: Parathyroid carcinoma (PC) is exceptionally rare in children and its clinical features are poorly understood. Available reports have identified that very high serum calcium and parathyroid hormone levels would be expected in this disease. Definitive therapy for PC requires en bloc resection of the parathyroid tumor to reduce the risk of disease recurrence. Unfortunately, there are very few treatment options for metastatic PC and patients with recurrent PC have a high risk of mortality related to their disease. Because of the rarity of the condition, there are very limited data including pediatric patients. Case: A previously healthy 13-year-old girl initially presented to primary care with bilateral foot and ankle pain in the context of acute and progressive genu valgum, referred to the orthopedic clinic. Lab evaluation prompted by imaging demonstrated severe hypercalcemia (15.6 mg/dL) and hyperphosphatasia (Alkaline phosphatase 2056 units/L). She was urgently referred to our clinic where we found her to have a firm right sided neck mass within the thyroid. Lab testing at that time confirmed profound hyperparathyroidism (PTH 2970 pg/mL). Neck ultrasound confirmed the presence of a 5.8 cm hypoechoic lesion adjacent to the right lower lobe of the thyroid. The patient received IV fluid resuscitation before undergoing urgent parathyroid surgery. The parathyroid lesion was grossly adherent to the thyroid gland and she received en bloc resection of the tumor and right lobe of the thyroid. Post-operatively, PTH rapidly declined to <3.4 and she developed a prolonged hypocalcemic phase. PTH function improved, but she continued to require high doses of calcium carbonate to address hungry bone syndrome over subsequent weeks. Comprehensive evaluation included testing for genetic mutations, deletions, and duplications in CASR, CDC73, CDKN1B, MEN1 and RET, all of which were negative. Extensive genetic testing of the parathyroid tumor did not identify any specific mutations which have been previously associated with PC. Six months post-operatively, her labs have vastly improved, although she has clinical evidence of PTH resistance and her alkaline phosphatase has not yet normalized. Neck ultrasound, F-18 FDG PET/MRI imaging and Sestamibi scans show no evidence of persistent disease. Conclusions: While parathyroid carcinoma is extremely rare in pediatric patients, the diagnosis must be considered in cases of hypercalcemia with marked elevations in PTH and palpable neck mass. Although rarely described, bone changes related to PC may be dramatic and may result in lasting morbidity - including genu valgum requiring surgical intervention as well as prolonged hungry bone syndrome and metabolic bone disease. Genu valgum is a unique pediatric feature of this disease because this may only evolve in individuals whose physes are open.
Collapse
Affiliation(s)
- Tina Y Hu
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Loren Berman
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - William J Parkes
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | | | - Tejal Mody
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Katrina Conard
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Anthony W Gannon
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| |
Collapse
|
5
|
Yuen KCJ, Alter CA, Miller BS, Gannon AW, Tritos NA, Samson SL, Dobri GA, Kurtz K, Strobl F, Kelepouris N. SAT-LB11 Adult Growth Hormone Deficiency Transition Care From Pediatric to Adult Services: Insights From a US Advisory Board. J Endocr Soc 2020. [PMCID: PMC7208818 DOI: 10.1210/jendso/bvaa046.2083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: Transition care of patients with childhood-onset GH deficiency (CO-GHD) who were treated with GH during childhood remains an ongoing challenge with substantial variation in coordination of care, clinical assessment, and management among pediatric and adult services. Despite the availability of clinical guidelines providing a framework for transition care of adolescents with CO-GHD, many patients discontinue therapy during the transition phase. Methods: A panel of pediatric and adult US endocrinologists with extensive experience in treating transition patients convened in October 2019 as part of an advisory board to address current clinical unmet needs and to share learnings based on a structured transitional plan to strive for optimal management of these patients. Results: It is acknowledged that pediatric endocrinologists play a crucial role in initiating the transition process, which involves close communication and direct collaboration between pediatric and adult services to reduce delays in identifying patients and resuming GH therapy in adulthood; adult endocrinologists need to increase their awareness of the importance of potential benefits and extent of long-term safety of GH therapy in adult patients. There is also a need for consensus guidelines or a white paper that focuses on transition care and endorsed by pediatric and adult organizations. Because not all patients with CO-GHD will have persistent GHD as adults, there is a need to improve the identification and timely retesting of those who will require continuity of GH therapy into adulthood. An increase in accessibility for retesting and guidance on appropriate GH dosing once persistent GHD is confirmed are other important factors. Certain subpopulations of pediatric patients (e.g., cancer survivors; patients with congenital hypopituitarism, optic nerve hypoplasia, treated sellar masses, and traumatic brain injury) should be prioritized in determinations of when and how retesting should be performed. The viewpoints of both pediatric and adult endocrinologists were presented at this meeting, and comprehensive considerations and suggestions were discussed. Conclusion: Transition care of patients with CO-GHD requires a collaborative multidisciplinary approach to ensure continuity of care between pediatric and adult services and to improve bone health and reduce long-term cardiometabolic risks. The major challenge is to effectively ensure that transition patients are retested and offered adult GH therapy without delay. Current guidelines should be more focused on transition patients, addressing key areas of uncertainty as evidenced by variable clinical practices. A clearly structured transition protocol is vital, and these insights provide useful, practical guidance to clinicians to establish best practices when transitioning adolescents with persistent CO-GHD to adult services.
Collapse
Affiliation(s)
- Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ, USA
| | - Craig A Alter
- Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bradley Scott Miller
- Pediatric Endocrinology, University of Minnesota Masonic Children’s Hospital, Lino Lakes, MN, USA
| | - Anthony W Gannon
- Nemours / AIfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Nicholas A Tritos
- Massachusetts General Hospital, Neuroendocrine Unit & Harvard Medical School, Boston, MA, USA
| | - Susan Leanne Samson
- Pituitary Center, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Georgiana Alina Dobri
- Neurological Surgery and Endocrinology departments, Weill Cornell Medicine, New York, NY, USA
| | | | | | | |
Collapse
|
6
|
Bick SL, Steinkrauss LJ, Thacker MM, Berman L, Gannon AW. SUN-476 Risk of Thyroid Cancer in McCune-Albright Syndrome. J Endocr Soc 2020. [PMCID: PMC7209415 DOI: 10.1210/jendso/bvaa046.1489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: McCune-Albright syndrome (MAS) is a well described genetic syndrome characterized by café-au-lait spots, polyostotic fibrous dysplasia, and hyperfunctioning endocrinopathies. Hyperthyroidism is a common endocrine manifestation of MAS, but thyroid nodules are less frequently observed. Thyroid cancer is generally considered uncommon in patients affected by MAS.
Clinical Case: A 15-year-old male was referred to endocrinology for evaluation of polyostotic fibrous dysplasia with onset at 6 years old. He had no café-au-lait spots and initial labwork revealed no endocrine abnormalities. Subsequent labwork revealed non-autoimmune hyperthyroidism, leading to a diagnosis of MAS. Repeat clinical assessment revealed a goiter. 123-I uptake and scan revealed diffusely increased uptake throughout the gland with increased intensity in two regions of the right lobe separated by a region of photopenia. Ultrasound demonstrated three right-sided thyroid nodules – two correlating with the areas of increased iodine uptake and one with the area of photopenia. The left lobe of the thyroid was normal. FNA biopsy was performed and cytopathology was consistent with Bethesda II and III for the hyperfunctioning nodules and Bethesda VI for the cold nodule.
The patient received total thyroidectomy with right-sided central neck dissection, and he was found to have multiple foci of papillary thyroid carcinoma with central neck metastases. The largest hyperfunctioning thyroid nodule was benign. He received radioactive iodine ablation which demonstrated no distant metastases and has had no evidence of recurrent disease.
Conclusions: Hyperthyroidism is a common manifestation of MAS, but thyroid nodules are much less frequently observed, and thyroid cancer is considered quite rare. This patient developed TSH-independent hyperthyroidism in normal thyroid cells as well as in two hyperfunctioning thyroid nodules. He developed two contemporaneous classical papillary thyroid cancers – one manifesting as a nonfunctioning thyroid nodule and one manifesting as a thyrotoxic nodule with lymphatic invasion.
We conclude that individuals with MAS may be at an increased risk for thyroid nodules and thyroid cancer, although the data are not well established. Clinicians should have a low threshold for thyroid ultrasound in patients with MAS and goiter.
Reference: (1) Collins, M. T., Sarlis, N. J., Merino, M. J., Monroe, J., Crawford, S. E., Krakoff, J. A., Guthrie, L. C., Bonat, S., Robey, P. G., & Shenker, A. (2003). Thyroid carcinoma in the McCune-Albright syndrome: contributory role of activating Gsα mutations. The Journal of Clinical Endocrinology & Metabolism, 88(9), 4413-4417.
(2) Hannon, T. S., Noonan, K., Steinmetz, R., Eugster, E. A., Levine, M. A., & Pescovitz, O. H. (2003). Is McCune-Albright syndrome overlooked in subjects with fibrous dysplasia of bone?. The Journal of pediatrics, 142(5), 532-538.
Collapse
Affiliation(s)
- Sarah L Bick
- Nemours / AI DuPont Hospital for Children, Wilmington, DE, USA
| | | | - Mihir M Thacker
- Nemours / AI DuPont Hospital for Children, Wilmington, DE, USA
| | - Loren Berman
- Nemours / AI DuPont Hospital for Children, Wilmington, DE, USA
| | | |
Collapse
|
7
|
Gannon AW, Langer JE, Bellah R, Ratcliffe S, Pizza J, Mostoufi-Moab S, Cappola AR, Bauer AJ. Diagnostic Accuracy of Ultrasound With Color Flow Doppler in Children With Thyroid Nodules. J Clin Endocrinol Metab 2018; 103:1958-1965. [PMID: 29546281 PMCID: PMC6456954 DOI: 10.1210/jc.2017-02464] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/07/2018] [Indexed: 01/27/2023]
Abstract
CONTEXT Thyroid nodules are increasingly recognized in children and are associated with a greater risk for thyroid cancer compared with adults. Thyroid ultrasound is the favored tool for evaluation of thyroid nodules; however, there are limited data regarding the accuracy of thyroid ultrasound to confirm features associated with a low risk of thyroid cancer in children. OBJECTIVES We examined whether thyroid ultrasound is capable of accurately identifying thyroid nodules at a low risk of malignancy in children. DESIGN AND SETTING Using a retrospective cohort study design, we identified children age ≤18 years with thyroid nodules and adequate follow-up. Ultrasound images were reviewed independently by two blinded expert radiologists, and ultrasound characteristics were analyzed to determine optimal predictive value and reliability. PATIENTS AND RESULTS A total of 417 subjects were found to have thyroid nodules, and 152 subjects had adequate follow-up; 59 (38.8%) of these were diagnosed with thyroid cancer. We evaluated 236 individual nodules. Features most consistent with benign nodules included small size, isoechoic echogenicity, partially cystic structure, sharp or noninfiltrative margins, absent Doppler flow, and absent calcifications. Significant variability was found between expert interpretations of ultrasound features. Thyroid nodule composition appears to be the most sensitive and reliable feature for stratifying the risk of thyroid cancer. Ultrasound accurately identified benign thyroid nodules in 80.9% of subjects (95% confidence interval, 74-86.6). CONCLUSIONS Ultrasonography is useful for the evaluation of thyroid nodules, but we found no combination of ultrasound features sufficient to exclude thyroid cancer without a biopsy.
Collapse
Affiliation(s)
- Anthony W Gannon
- Division of Pediatric Endocrinology, Nemours/Alfred I DuPont Hospital for Children, Wilmington, Delaware
- Correspondence and Reprint Requests: Anthony W. Gannon, MD, MSCE, Alfred I DuPont Hospital for Children, 1600 Rockland Road, Wilmington, Delaware 19801. E-mail:
| | - Jill E Langer
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Bellah
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sarah Ratcliffe
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Pizza
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sogol Mostoufi-Moab
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anne R Cappola
- Division of Endocrinology, Diabetes, and Metabolism, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew J Bauer
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
8
|
Abstract
CONTEXT Neonatal severe hyperparathyroidism (NSHPT) is a severe form of familial hypocalciuric hypercalcemia characterized by severe hypercalcemia and skeletal demineralization. In most cases, NSHPT is due to biallelic loss-of-function mutations in the CASR gene encoding the calcium-sensing receptor (CaSR), but some patients have heterozygous mutations. Conventional treatment consists of iv saline, bisphosphonates, and parathyroidectomy. OBJECTIVE The aim of this project was to characterize the molecular basis for NSHPT in an affected newborn and to describe the response to monotherapy with cinacalcet. METHODS Clinical and biochemical features were monitored as cinacalcet therapy was initiated and maintained. Genomic DNA was obtained from the proband and parents. The CASR gene was amplified by PCR and sequenced directly. RESULTS The patient was a full-term male who developed hypotonia and respiratory failure soon after birth. He was found to have multiple fractures and diffuse bone demineralization, with a marked elevation in serum ionized calcium (1.99 mmol/L) and elevated serum levels of intact PTH (1154 pg/mL); serum 25-hydroxyvitamin D was low, and fractional excretion of calcium was reduced. The serum calcium level was not reduced by iv saline infusion. Based on an extensive family history of autosomal dominant hypercalcemia, a diagnosis of NSHPT was made, and cinacalcet therapy was initiated with a robust and durable effect. Molecular studies revealed a heterozygous R185Q missense mutation in the CASR in the patient and his father, whereas normal sequences for the CASR gene were present in the patient's mother. CONCLUSIONS We describe the first use of cinacalcet as monotherapy for severe hypercalcemia in a newborn with NSHPT. The rapid and durable response to cinacalcet suggests that a trial of calcimimetic therapy should be considered early in the course of NSHPT.
Collapse
Affiliation(s)
- Anthony W Gannon
- Division of Endocrinology and Diabetes (A.W.G., M.A.L.), and Department of Pharmacy Services (H.M.M.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; and Department of Pediatrics (A.W.G., M.A.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104
| | | | | |
Collapse
|
9
|
Melcescu E, Gannon AW, Parent AD, Fratkin JF, Nicholas WC, Koch CA, Galhom A. Silent or Subclinical Corticotroph Pituitary Macroadenoma Transforming Into Cushing Disease. Neurosurgery 2013; 72:E144-6. [DOI: 10.1227/neu.0b013e3182750850] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
10
|
Abstract
The role of oxidative stress in the long-term regulation of arterial pressure, renal hemodynamics, and renal damage was studied in Dahl salt-sensitive rats. Twenty-eight Dahl S/Rapp strain rats, equipped with indwelling arterial and venous catheters, were subjected to a 3-week intravenous infusion of either low Na (0.9 mmol/d) or high Na (20.6 mmol/d) or the superoxide dismutase mimetic, 4-hydroxyl-2,2,6,6-tetramethylpiperidine-1-oxyl (Tempol), at 125 micromol x kg(-1) x h(-1) plus low Na or high Na. After 21 days, mean arterial pressure was 140+/-3 mm Hg in the high-Na group, 118+/-1 mm Hg (P<0.05) in the high-Na/Tempol group, and unchanged in the low-Na/Tempol and low-Na groups. Tempol did not change renal blood flow, glomerular filtration rate, or glomerular cross-sectional area in rats subjected to the high-Na intake but did decrease urinary protein excretion, the percentage of sclerotic glomeruli, and the kidney weight to body weight ratio. In 15 additional Dahl S rats subjected to high or low Na intake for 3 weeks, renal cortical and medullary O2*- release increased significantly in the high-Na group when compared with the low-Na group. Tempol decreased both renal cortical and medullary O2*- release in the high- and low-Na rats, but the decrease in O2*- release was greater in high-Na rats. The data suggest that oxidative stress contributes to Dahl salt-sensitive hypertension and the accompanying renal damage.
Collapse
Affiliation(s)
- Shumei Meng
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, USA
| | | | | | | | | |
Collapse
|
11
|
Tian N, Gannon AW, Khalil RA, Manning RD. Mechanisms of salt-sensitive hypertension: role of renal medullary inducible nitric oxide synthase. Am J Physiol Regul Integr Comp Physiol 2003; 284:R372-9. [PMID: 12399250 DOI: 10.1152/ajpregu.00509.2002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The goal of this study was to determine the role of renal medullary inducible nitric oxide synthase (iNOS) in the arterial pressure, renal hemodynamic, and renal excretory changes that occur in Dahl/Rapp salt-resistant (R) and salt-sensitive (S) rats during high Na intake. Forty R and S rats, equipped with indwelling arterial, venous, and renal medullary catheters, were subjected to high (8%) Na intake, and selective iNOS inhibition was achieved with continuous intravenous or renal medullary interstitial infusion of aminoguanidine (AG; 3.075 mg. kg(-1). h(-1)). After 5 days of AG, mean arterial pressure increased to 132 +/- 2% control in the S rats with high Na intake and intramedullary AG compared with 121 +/- 4% control (P < 0.05) in the S rats with high Na intake alone and 121 +/- 2% control (P < 0.05) in the S rats with high Na intake and intravenous AG. AG did not change arterial pressure in R rats. AG also caused little change in renal hemodynamics, urinary Na, or H(2)O excretion or ACh-induced aortic vasorelaxation in R or S rats. The data suggest that during high Na intake, nitric oxide produced by renal medullary iNOS helps to prevent excessive increases in arterial pressure in the Dahl S rat but not the R rat.
Collapse
Affiliation(s)
- Niu Tian
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA
| | | | | | | |
Collapse
|