Transcript
Page 1: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Grand Round 06/10/2009

Martin O. Weickertand colleagues

Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism

Neck & Hormones

Page 2: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

• thyroid– thyrotoxicosis (2% of UK population)

– hypothyroidism (9.3% (w), >60 yrs up to 16%; 1.35% (m))

• parathyroid glands– hyperparathyroidism

(prim HPT < 0.1 – 3.4%, ↑ with age;

sec HPT i.e. 80% in chronic haemodialysispatients )

– hypoparathyroidism(most common post-surgery;

otherwise rare)

Endocrine active organs in the neck

Yu et al. Clin Endocrinol 2009; Franklyn ESE abstracts 2009

Page 3: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

An interesting case….

Steph Horne

House Officer

Page 4: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Demographics

• 35 year old Caucasian Female

• self admission to A&E

Page 5: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Presenting complaint

• upper abdominal pain

• epigastric area: burning/sharp in nature

• bloody diarrhoea

• vomited 15 times, diarrhoea for 5 days

• not able to tolerate any oral food/fluids

• similar episode 6 months ago

• OP endoscopy booked but DNA

Page 6: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

And the rest…

• PMHX:– appendix removed 6

years ago– hyperthyroidism– anxiety

• SHX:– smoker 4-5 per day– mild alcohol intake– on methadone treatment

Page 7: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

On examination:

Temperature: 36.3

BP: 174/112

PR: 99

RR: 24

O2 Sats: 99% OA

Mews: 2

Pain score: 3 (0-3)

Chest clear

HS I + II + 0

CNS intact

Epigastric pain

No Organomegaly

BS +

Unable to demonstrate guarding

PR: Empty Rectum

Page 8: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Impression…..

• perforated ulcer• gallstones• GORD• pancreatitis• gastroenteritis

Page 9: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

The blood results…

• electrolytes: NAD• WCC: 14.42, Hb: 11.8, Plts: 417• alk Phos: 227, ALT: 36, Amylase: 33

Page 10: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

TIMELINE

Surgical team referral

Admitted to SAU

OGD and Colonoscopy

Discussions re; Laparotomy

A&E: Abdo pain and diarrhoea

Impression: Acute

abdomen

AXR/CXR:

NAD Gastro referral

Page 11: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Then along came….

• TSH < 0.02 mU/L (0.35 – 6 mU/L)• free T3 – 36.3 pmol/L (2.8 – 7.1 pmol/L)• free T4 – > 100 pmol/L (9 – 26 pmol/L)

Page 12: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Treatment…

• symptomatic relief : beta blockers

• carbimazole• USS thyroid gland• thyroid autoantibodies

Page 13: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

The result…

• diarrhoea resolved

• tremor/anxiety improved

• discharged with endocrine follow up

Page 14: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Common causes of thyrotoxicosis

• Graves` disease

• toxic adenomas

• toxic multinodular goitre

• thyroiditis

• ingestion of excessive exogenous thyroid hormone– iatrogenic, inadvertent, or surreptitious

Page 15: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Some rarer causes

• TSH-secreting pituitary adenoma

• struma ovarii– ectopic production in ovarian teratomas

• extremly high levels of hCG– choriocarcinomas, germ cell tumours

Page 16: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

“Classical” symptoms of thyrotoxicosis

• hyperactivity, irritability, altered mood

• sleep disturbances

• sweating, heat intolerance

• palpitations

• weight loss, occasionally weight gain (polyphagia)

• oligo-/amenorrhoea, loss of libido

Page 17: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

unspecific in aged patients...

• tiredness, apathy, depression

• „dementia“, confusion, psychosis

• GI symptoms

• AF, worsening of angina pectoris, or congestive heart failure

Page 18: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Thyrotoxic periodic paralysis (TPP)

• 2% in Asians, rare in Caucasians (0.15%)

• hyperthyroidism-related hypokalaemia

• sudden shift of K+ into cells– associated with exercise– inducible by carbohydrate + insulin challenge

• presentation in ED with – acute muscle weakness – systolic hypertension, tachycardia, high QRS

voltage, first degree AV block

McFadzean BMJ 1967, Lin Mayo Clin Proc 2005

Page 19: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Biochemical findings in thyrotoxicosis

• low TSH

Page 20: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Other states with low TSH

• secondary hypothyroidism– low normal or normal TSH– low fT4– usually associated with deficiencies of other pituitary

hormones

• thyroid sick syndrome– ? aquired transient central hypothyroidism (Chopra JCEM

1997)

– low TSH (but not completely suppressed)– low fT4 and fT3

Page 21: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Biochemical findings in thyrotoxicosis

• low or suppressed TSH

• increased fT4 and/or fT3 in overt thyrotoxicosis– check for isolated fT3 thyrotoxicosis

• normal fT4 and/or fT3 in „subclinical“ thyrotoxicosis– increased risk of osteoporosis; evtl symptomatic

• frequently increased auto-Abs level in AIT

Page 22: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Further changes...

• normocytic anaemia

• increased LFTs

• increased bone AP

• hypercalcaemia, hyperphosphataemia

• low albumin

• mild leukopenia

• low cholesterol

Page 23: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

24-hour variation of TSH

Hormone Circadian Sleep-wake homeostasis

Cortisol +++ +Testosterone +++ -GH + +++PRL ++ +++

adapted from McDermott: Sleep and Endocrinology 2009

Page 24: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

24-hour variation of TSH

Hormone Circadian Sleep-wake homeostasis

Cortisol +++ +Testosterone +++ -GH + +++PRL ++ +++TSH +++ ++

adapted from McDermott: Sleep and Endocrinology 2009; Patel Clin Sci 1972

Page 25: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Circadian rhythm of TSH

• ? less bioactive and differently glycosylated TSH molecules secreted during the night(Persani et al JCEM 1995)

Russell et al. JCEM 2009

Page 26: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Circadian rhythm of TSH and fT3

• circadian rhythm of fT3

• delayed by 90 min

• clinical relevance?• drug induced

increase of TSH, e.g. metoclopramide (Scanlon JCEM 1980))

Russell et al. JCEM 2009

Page 27: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Interaction with SHBG

• oral contraceptives may not be fully protective in thyrotoxicosis – ↑ SHBG (Ford Clin End 1992)

– ↑ clearance of contraceptives

• caution in fertile female patients after radioiodine therapy

Page 28: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

An orthopaedic outlier !

Noushad

Page 29: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

History

• 59 year old lady• attended A&E at

01.42 am, 16/7/09• fell down in the toilet• injury to left arm• deformity of left arm

No orthopaedic intervention

needed!

W20

Page 30: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

History

• increasing confusion- 16 weeks

• weight loss and bilateral leg pains for the same period

• was not mobilising, just stayed in bed!

• no medical help sought until the fall

• fracture of right olecranon in 2006 after a trivial fall

Page 31: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Further story

• left humerus was painful and deformed

• X-ray showed• referred to ortho• ‘no ortho intervention

needed, can go home with fracture clinic appointment’

Page 32: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Further story

• patient’s daughters mentioned the poor physical and mental state, refuses to take her home

• 04.45- patient c/o of right thigh pain

• X-ray ordered

Page 33: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Blood investigations

• urea 9.0, creatinine 64, Na 143, K 4.0

• adjusted Ca 3.68, ALP 606, Alb 41

• Hb 11.0, WCC 17.36, Neuts 15.29

• TSH 2.71

• CRP <3

Page 34: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Further investigations

• myeloma screen negative• PTH 114.2 (NR1.1-4.2), Vitamin D 11.0

(NR 10-60)• in the meanwhile patient was reviewed by

T&O team• ‘pathological fractures due to likely

malignancy’, • admitted to medical ward (20), for joint

care

Page 35: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Management

• final diagnosis- primary hyperparathyroidism with pathological fractures

• patient transferred to orthopaedic ward

• close input from endocrine team

• MIBI scan and USS neck- Left inferior parathyroid adenoma

Page 36: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Management

• IV N.Saline 4L/day

• IV pamidronate

• pain relief

• traction for fracture femur

• cast for fracture humerus

Page 37: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Other x-rays

Page 38: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Management

• left inferior parathyroidectomy 17/8/09

• severe hypocalcaemia expected

• ergocalciferol (Vitamin D2) 300,000 units i.m. given after parathyroidectomy

• sandocal 1gram TDS started

Page 39: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Date Calcium(2.1-2.58)

PTH(1.1-4.2)

ALP(30-120)

16/7/09 3.68 114.2 606

16/8/09 2.76 450

17/8/09 2.61

18/8/09 2.41

18/8/09 2.35 0.8 437

18/8/09 2.26 0.6 405

19/8/09 2.28 452

21/8/09 1.99 5.6

26/8/09 1.93 16.5 711

30/8/09 1.92 36.4 658

1/9/09 1.87 45.4 574

18/9/09 2.13 24.9 325

3/10/09 2.18 223

Ca2+ and PTH trends post op

Page 40: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Current management

• sandocal 1gram TDS

• alfacalcidol 1microgram/day

• traction down

• still an inpatient

• not yet weight bearing

Page 41: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Follow up x-rays- 30/9/09

Page 42: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Hungry bone syndrome

• excessive skeletal remineralization once skeleton released from PTH excess

• ongoing ↑ALP, ↓Ca, ↓Ph, ↓Mg

• hypocalcaemia in pre-existing VitD deficiency

• may require large doses of VitD/derivates and calcium for weeks to month

Page 43: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Primary hyperparathyroidism (pHPT)

• „stones, bones, abdominal groans …“

• depression

• „stones, bones, abdominal groans, and psychic moans …“

Page 44: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Modern vs classical pHPT

• abrupt increase in annual incidence since the early 1970s – 0.15 (1965 – 1974) to 1.12 (1975) per 1000

persons (Wermers Ann Int Med 1997)

– introduction of screening

• > 85% of modern pHPT patients are asymptomatic or have unspecific symptoms

Page 45: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Modern vs classical pHPT

• kidney stones only in 15-20% of patients with „modern“ pHPT

• reduced BMD

• far subtler abnormalities in bone

• often radiographics NAD • routine skeletal x-rays are no longer

recommended (Bilezikian et al. JCEM 2002)

Page 46: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Biochemical findings in pHPT

• increased PTH

• increased (or normal) calcium

• low normal fasting serum phosphate

• other associated findings may include– increased chloride, Cl/phosphate ratio ≥ 33,

elevated urinary pH (> 6), increased alkaline phosphatase

Page 47: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Band keratopathy

• calcium-phosphate precipitation in medial and limbic margins of cornea

Page 48: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Parathyroid bone disease

• thin cortices

• contrasting maintenance of trabecular bone

patient with pHPT control

Biopsy specimens from iliac crest

Parisien et al. JCEM 1990

Page 49: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Osteitis fibrosa cystica

• striking and generalised increase in osteoclastic bone resorption

• osteoclastomas (brown tumours) with osteous expansion and lucency

• fibrovascular marrow replacement

• increased osteoblastic activity

Page 50: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

salt-and-pepper appearance of the calvarium

trabecular bone resorption with loss of definition of cortices

Page 51: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

subperiostal bone resorption

along the radial aspects of themiddle phalanges

distal clavicular resorption

radiological disappearance of some bones

Page 52: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

pHPT and vitamin D deficiency

• modern pHPT: bone disease mainly in patients with severe vitamin D deficiency

• however• co-existing pHPT and vitamin D deficiency is

very common! (Mossgaard Clin End 2005, Eastell JCEM 2009)

– association with ↑ PTH, Ca, ALP, accelerated bone turnover, larger parathyroid glands/tumours, greater likelihood of abnormal bones (Tucci Eur J Endocrinol 2009)

– calcium levels can also be normal

Page 53: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Grey et al. JCEM 2005

Page 54: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Grey et al. JCEM 2005

Cholecalciferol tablets 1.25 mg (50000 units) weekly for 4 weeks,thereafter 1 tablet per month for 12 month

Page 55: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

„…suggest that vitamin D repletion in patients with PHPT does not exacerbate hypercalcemia and may decrease levels of PTH and bone turnover“.

Grey et al. JCEM 2005

Page 56: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

? Mechanisms

• PTH-induced increase in 1-alpha hydroxylase

• ↑ 1,25(OH)2D (calcitriol)

• inhibition of PTH gene transcription, protein production and parathyroid gland proliferation (Beckermann Am J Med Sci 1999)

• no association between change in 1,25(OH)2D

and PTH levels (Grey JCEM 2005)

• no decrease of PTH with active Vit D metabolites (Lind Acta Endocrinol 1989)

• no relation 25(OH)D with 1,25(OH)2D in cross-sectional studies (Silverberg Am J Med 1999, Rao JCEM 2000)

Page 57: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Mechanisms

• ? non-1,25(OH)2D induced effects of 25(OH)D and other metabolites on PTH production

• ? stimulation of VitD receptor in parathyroid tissue by VitD deficiency

• ? intracrine action of parathyroid-derived 1,25(OH)2D to reduce PTH

Page 58: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

low magnesium levels blunt the stimulation of parathyroid glandsinduced by low Vit D levels

often normal PTH levels even when 25-OH VitD below 20 ng/mL

unknown effects of hypomagnesia in patients with pHPT

Interactions with magnesium

Sahota et al. Osteoporos Int 2006

Page 59: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Further secrets parathyroid

• PTH levels normally decrease with age

• association pHPT with metabolic syndrome– increased body weight in patients with pHPT

(Bolland JCEM 2005, Meta-analysis)

– increased leptin and decreased adiponectin (Delfini et al Metabolism 2007)

• consider co-existing disorders in patients with pHPT– drugs (thiazides, lithium), malabsorption, renal

failure, tumours

Page 60: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Familiar hypocalciuric hypercalcaemia (FHH)

• 2% of all asymptomatic hypercalcaemia

• dominantly inherited

• usually heterozygous loss of function mutation in the CaSR

• PTH inappropriately normal or high, lifelong Ca++ ↑ and Mg++ ↑, both of variable degree

• enlarged glands and mild parathyroid hyperplasia can occur

Page 61: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

FHH

• usually benign and asymptomatic

• family history? • urinary

calcium/creatinine clearance < 0.01

• surgery in FHH patients without benefit!

Page 62: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones
Page 63: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Patient with adynamia and dizziness

• bradycardia

• first degree AV block

• low voltage in all leads

• flat or negative T-waves

• ↑ QT interval

Page 64: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

after starting treatment with L-Thyroxine

untreated

ECG in severe hypothyroidism

Page 65: Grand Round 06/10/2009 Martin O. Weickert and colleagues Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Neck & Hormones

Conclusions

• patients with neck hormonal derangements may primarily present in other Specialties– e.g. Gastroenterology, Orthopaedics, ED, Cardiology,

Psychiatry

• being unaware of hormonal derangements can expose the patient to unnessecary procedures– e.g. EGD, coloscopy, intracardiac catheter, surgery…


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