• Thomas B. Repas, DO, FACP, FACE, CDE
  • Thomas B. Repas, DO, FACP, FACE, CDE, is an endocrinologist, lipidologist and physician nutrition specialist in clinical practice at the Regional Medical Clinic Endocrinology and Diabetes Education Center in Rapid City, SD. Dr. Repas is the former chairman of the professional diabetes advisory committees of the Wyoming and the Wisconsin Diabetes Prevention and Control Programs. He is board certified in the areas of endocrinology, diabetes and metabolism, clinical lipidology, internal medicine and nutrition, and is also a certified diabetes educator.

Thursday, January 23, 2014

Hot thyroid nodules can sometimes be cancer

Thomas B. Repas, DO, FACP, FACE, CDE

A woman presented with hyperthyroidism. Her TSH was <0.01.  Radioactive iodine uptake and scan revealed an area of increased uptake on the right with suppression of the surrounding thyroid tissue consistent with a hyperfunctioning nodule (see Figure #1).

Tuesday, October 22, 2013

The true heroes of clinical research

Thomas B. Repas, DO, FACP, FACE, CDE

One of my patients mentioned to me that he was taking an investigational drug as part of a clinical research study.

“Thank you for your participation,” I said.

He seemed a little puzzled.

I clarified: “Thank you for volunteering to be a participant in that research study.”

After a moment, the patient replied, “Oh thank you and … uh … you’re welcome.”

Wednesday, August 14, 2013

Examination of comet tail artifact and other echogenic foci on thyroid ultrasound

Thomas B. Repas, DO, FACP, FACE, CDE

Echogenic foci are commonly identified on thyroid ultrasound. Some echogenic foci such as microcalcifications are associated with increased risk for malignancy, while others such as comet tail artifact are associated with low risk. 

Microcalcifications are tiny and without posterior shadowing. They are often more readily seen while performing ultrasound in real-time and often less obvious on still images. As the ultrasound probe is moved back and forth, microcalcifications come in and out of view. Some have called this the “starry sky at night” because of this twinkling appearance. Macrocalcification can be distinguished from microcalcifications and comet tail artifact because they are larger and there is posterior shadowing.

Monday, May 20, 2013

Case 3 denied: Blood glucose test strips in type 1 diabetes

Thomas B. Repas, DO, FACP, FACE, CDE

Patient 3 is an elderly gentleman with type 1 diabetes. He has erratic, unpredictable glycemic control with frequent hypoglycemia and hypoglycemic unawareness.

After doing well for several months, his wife began having to use glucagon and to call EMTs every week or two because of severe hypoglycemia. One of these episodes resulted in him being hospitalized.

Thursday, March 21, 2013

Case 2 denied: Testosterone therapy in Klinefelter's syndrome

Thomas B. Repas, DO, FACP, FACE, CDE

Patient 2 is a 43-year-old-man with hypogonadism due to Klinefelter’s syndrome treated with transdermal testosterone gel. He had done well without adverse drug reactions or side effects of therapy. He had been on the same dose for years; thus, we had decreased the frequency of routine lab testing to annually.

He transitioned over to new insurance. Before agreeing to cover the testosterone therapy, they demanded that I provide copies of his pre-treatment testosterone levels proving that they were below the normal range.

Wednesday, February 20, 2013

Case 1 denied: Calcitriol is a vitamin

Thomas B. Repas, DO, FACP, FACE, CDE

One of the more frustrating aspects of medical practice is fighting with insurance companies to get our patients the care they need. As preventionists, endocrinologists struggle to keep our patients out of the hospital while also trying to minimize health care costs. We spend hours every day completing prior authorization forms, sending letters of appeal to insurance companies and explaining why our patients deserve the care we recommend.

At the same time, we see wasteful over-utilization of resources, unnecessary procedures or imaging studies, and hospitalizations that could possibly have been avoided. And yet, no one questions any of that.

Tuesday, January 15, 2013

Ultrasound in hyperthyroidism

Thomas B. Repas, DO, FACP, FACE, CDE

I saw a 32-year-old man in consultation for hyperthyroidism. His thyroid-stimulating hormone was <0.01 and both free T4 and free T3 were elevated. He had palpitations, tremor and insomnia but denied other symptoms.  On exam, his thyroid was non-tender and without nodules. More than likely his diagnosis is Graves’ disease, I thought.

After discussing the treatment options in detail, we both leaned towards methimazole (Tamazole, King). At first, I did not think that radioactive iodine uptake and scan would be needed as we were not planning on radioactive iodine therapy.

Tuesday, December 11, 2012

Beware: Nutritional supplements may be contaminated with anabolic steroids

Thomas B. Repas, DO, FACP, FACE, CDE

A young man was referred to me for evaluation of low testosterone and gynecomastia. The initial total testosterone was 57 ng/dL; results of a repeat testosterone assessment were even lower. Prolactin was normal, but follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were both undetectable. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were previously normal but were now both over 200. His total and LDL cholesterol levels were high; his HDL was low.

He was muscular, physically fit and an avid weight lifter. I questioned him about the use of anabolic steroids. He had not knowingly used any product that was marketed as an anabolic steroid for a few years. He seemed sincere and I believed him.

Wednesday, November 21, 2012

Gene-expression classifier: A new diagnostic test for indeterminate FNAs

Thomas B. Repas, DO, FACP, FACE, CDE

Cytologically indeterminate fine needle aspiration results are common. From 15% to 30% FNA biopsies of thyroid nodules are indeterminate or suspicious, including atypia or follicular lesions of undetermined significance (AUS/FLUS); follicular or Hürthle cell neoplasms; and FNA suspicious for malignancy. Because the risk for malignancy in an indeterminate FNA may be as high as 30%, most of these patients were traditionally advised to proceed with surgical resection, followed by completion thyroidectomy if malignancy was confirmed.

Friday, November 2, 2012

Which of these patients has acromegaly?

Thomas B. Repas, DO, FACP, FACE, CDE

In this blog post, I present three cases involving patients suspected of having possible acromegaly and discuss follow up. After reading, please share your thoughts.

Case #1

Case #1 is a 51-year-old man who was first referred to me for primary hypothyroidism. However, at our first visit, I was struck by his large hands. Upon further questioning, he reported a history of snoring, sleep apnea and excessive sweating. He no longer was able to wear his wedding ring.