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Restructuring an internal medicine residency program to meet regional and national needs for general internists
Education Primary care
Triiodothyronine
Hormone resistance
Hypotension, idiopathic orthostatic Syncope Autonomic dysfunction
Virilization Hepatic calcification
Cushing’s syndrome Adrenal rest
We report a case of a calcified liver tumor in a 23 year old female patient who presented with virilization and a mild degree of Cushing’s syndrome. Androgen levels were elevated; there was loss of cortisol circadian rhythm and marked increase in urinary 17ketogenic and 17ketosteroids which failed to suppress with administration of dexamethasone. Venous sampling by inferior vena cava catheterization showed that the highest steroid hormone levels were in blood from the right hepatic vein. After death, in vitro studies revealed that the tumcr contained testosterone and cortisol, as determined by immunofluorescence techniques. The adrenals and ovaries were atrophic. Results of metyrapone testing indicated dyshormonogenesis. To our knowledge, this is the first case of an adrenal rest tumor of the liver proved to be functionally active.
Wallace EZ, Leonidas J-R, Stanek AE, Avramides A: Endocrine studies in a patient with functioning adrenal rest tumor of the liver. Am J Med 1981; 70: 1122-1126.
Dyshormonogenesls
Adrenocorticat carcinoma
Classic cases of idiopathic autonomic dysfunction are easily recognized, but certain presentations may not immediately suggest the diagnosis. Among 297 cases in the experience of our institutions,eight have been selected as illustrative of the difficulties which may be encountered. The disorder may present as angina pectoris, Parkinsonism, night blindness, nasal stuffiness, malignant hypertension, postprandial fainting, intracerebral hemorrhage and respiratory arrest. Almost half of the patients with ktiopathic orthostatic hypotension manifest supine hypertension. These subjects are extremely sensitive to pressor and depressor agents; those who have angina pectoris complicating their disease are characteristically worsened by nitroglycerin.
Hines S, Houston M, Robertson D: The clinical spectrum of autonomic dysfunction. Am J Med 1981; 70: 1091-1096.
Parkinson’s disease
Shy-Drager syndrome
Continued on page A61
A partially thyroidectomized woman was euthyroid while ingesting 500 pg L-triiodothyronine (Ts) daily and was hypothyroid while taking 50 or 100 pg Ts daily. Her oxygen consumption rate was markedly subnormal at 50 and 100 pg Ts daily and did not increase greatly above predicted normal values at higher doses despite serum Ts concentrations greater than 3,000 ng/dl. Her cardiac performance changed minimally during this Ts dose range. In contrast, indices of muscle and skeletal protein catabolism and secretion of prolactin from the pituitary gland responded normally to changes in serum Ts. Thyrotropin secretion was never detectable. Ts absorption, serum protein binding and metabolic clearance rates were within normal limits. The findings in this case are compared to those in the previously reported cases of peripheral resistance to thyroid hormone. The molecular basis of this patient’s abnormality remains undefined.
Kaplan MM, Swartz SL, Larsen PR: Partial peripheral resistance to thyroid hormone: case reportand literature review. Am J Med 1981; 70: 11151121.
Thyroid hormone
The Department of Medicine at the University of Washington has reorganized its residency program to increase the emphasis on general internal medicine and primary care. New teaching services in community hospitals have been established, clinical training sites in Montana, Idaho and Eastern Washington opened, and primary care residency tracks begun. Whereas a decade ago approximately two thirds of the residents were becoming subspecialists. almost two thirds of the 1979 and 1980 program graduates are headed toward careers as general internists. The program serves as a model for the development of a regional program for graduate training in internal medicine.
Dale DC, Wallace JF, Clark H, Rockey PH, Featherstone H, Petersdorf RG: Restructuring an internal medicine residency program to meet regional and national needs for general internists. Am J Med 1981; 70: 1085-1090.
Teaching services
Internal medicine residency training
Residency program
Triiodothyronine
Hormone resistance
Hypotension, idiopathic orthostatic Syncope Autonomic dysfunction
Virilization Hepatic calcification
Cushing’s syndrome Adrenal rest
We report a case of a calcified liver tumor in a 23 year old female patient who presented with virilization and a mild degree of Cushing’s syndrome. Androgen levels were elevated; there was loss of cortisol circadian rhythm and marked increase in urinary 17ketogenic and 17ketosteroids which failed to suppress with administration of dexamethasone. Venous sampling by inferior vena cava catheterization showed that the highest steroid hormone levels were in blood from the right hepatic vein. After death, in vitro studies revealed that the tumcr contained testosterone and cortisol, as determined by immunofluorescence techniques. The adrenals and ovaries were atrophic. Results of metyrapone testing indicated dyshormonogenesis. To our knowledge, this is the first case of an adrenal rest tumor of the liver proved to be functionally active.
Wallace EZ, Leonidas J-R, Stanek AE, Avramides A: Endocrine studies in a patient with functioning adrenal rest tumor of the liver. Am J Med 1981; 70: 1122-1126.
Dyshormonogenesls
Adrenocorticat carcinoma
Classic cases of idiopathic autonomic dysfunction are easily recognized, but certain presentations may not immediately suggest the diagnosis. Among 297 cases in the experience of our institutions,eight have been selected as illustrative of the difficulties which may be encountered. The disorder may present as angina pectoris, Parkinsonism, night blindness, nasal stuffiness, malignant hypertension, postprandial fainting, intracerebral hemorrhage and respiratory arrest. Almost half of the patients with ktiopathic orthostatic hypotension manifest supine hypertension. These subjects are extremely sensitive to pressor and depressor agents; those who have angina pectoris complicating their disease are characteristically worsened by nitroglycerin.
Hines S, Houston M, Robertson D: The clinical spectrum of autonomic dysfunction. Am J Med 1981; 70: 1091-1096.
Parkinson’s disease
Shy-Drager syndrome
Continued on page A61
A partially thyroidectomized woman was euthyroid while ingesting 500 pg L-triiodothyronine (Ts) daily and was hypothyroid while taking 50 or 100 pg Ts daily. Her oxygen consumption rate was markedly subnormal at 50 and 100 pg Ts daily and did not increase greatly above predicted normal values at higher doses despite serum Ts concentrations greater than 3,000 ng/dl. Her cardiac performance changed minimally during this Ts dose range. In contrast, indices of muscle and skeletal protein catabolism and secretion of prolactin from the pituitary gland responded normally to changes in serum Ts. Thyrotropin secretion was never detectable. Ts absorption, serum protein binding and metabolic clearance rates were within normal limits. The findings in this case are compared to those in the previously reported cases of peripheral resistance to thyroid hormone. The molecular basis of this patient’s abnormality remains undefined.
Kaplan MM, Swartz SL, Larsen PR: Partial peripheral resistance to thyroid hormone: case reportand literature review. Am J Med 1981; 70: 11151121.
Thyroid hormone
The Department of Medicine at the University of Washington has reorganized its residency program to increase the emphasis on general internal medicine and primary care. New teaching services in community hospitals have been established, clinical training sites in Montana, Idaho and Eastern Washington opened, and primary care residency tracks begun. Whereas a decade ago approximately two thirds of the residents were becoming subspecialists. almost two thirds of the 1979 and 1980 program graduates are headed toward careers as general internists. The program serves as a model for the development of a regional program for graduate training in internal medicine.
Dale DC, Wallace JF, Clark H, Rockey PH, Featherstone H, Petersdorf RG: Restructuring an internal medicine residency program to meet regional and national needs for general internists. Am J Med 1981; 70: 1085-1090.
Teaching services
Internal medicine residency training
Residency program