Faculty Bibliography

A 54-year-old woman was referred by her rheumatologist for evaluation of an elevated serum alkaline phosphatase (ALP) in the setting of polyarthritis. The metabolic work-up was significant for an elevated bone fraction of alkaline phosphatase isoenzymes, and high bone turnover markers, including fasting C- telopeptide (CTX). A diagnosis of Paget's disease of bone (PDB) was considered. A whole-body nuclear bone scan showed diffuse increased uptake in the calvarium, suggestive of PDB, with no other localizing areas of increased uptake. Skull X-rays show mild sclerosis and medullary expansion of the posterior parietal bones and occiput, interpreted by the radiologist as unlikely to be PDB with a high level of uncertainty. Bone density testing with dual-energy X-ray absorptiometry showed low bone mass (osteopenia) with fracture probability that was below the treatment threshold. The case was presented and discussed on Bone Health ECHO, a virtual community of practice with the aim of enhancing global capacity to deliver best practice skeletal health care. The results of the discussion are presented here.

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/CONCLUSIONS: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.

INTRODUCTION: Body mass index (BMI) has commonly been used as a parameter to assess obesity in trauma patients. However, the variability of height and weight data in trauma patients limits the use of BMI as an accurate assessment tool in the trauma population. Quantitative radiologic measurements of visceral adiposity is an accurate method for assessing obesity in patients but requires further analysis before it can be accepted as a measurement tool for trauma patients. METHODS: A retrospective review of trauma cases with pre-operative CT scan from 2008 to 2015 produced 57 patients for evaluation. Preoperative BMI was calculated using measured height (m2) and weight (kg). Radiologic measurements of adiposity were obtained from preoperative CT scans using OsiriX DICOM viewer software. Visceral fat areas (VFA) and subcutaneous fat areas (SFA) were measured from a single axial slice at the level of L4-L5 intervertebral space. RESULTS: No statistically significant results were found relating visceral fat:subcutaneous fat ratios to length of stay or post-operative complications. Initial clinical observations noting an increased incidence of complications among patients with a V/S >/= 0.4 demonstrates a possible link between obesity and poor outcomes in trauma patients. A statistically significant correlation was noted between length of stay, peri-nephric fat and injury severity score. DISCUSSION AND CONCLUSION: Our pilot study should be viewed as the foundation for a larger prospective study, utilizing quantitative measurements of visceral adiposity to assess outcomes in trauma patients.