Current diagnosis and treatment of cardiac arrhythmias of thyroid origin

Cardiac arrhythmias may often be of the thyroid origin. It is so-called thyroid-cardiac syndrome which may also be manifested by the circulatory failure and angina pectoris. The authors have been observed 54 cases of such arrhythmias; they have frequently been manifested by the paroxysmal tachycardia, extrasystolic beats, and paroxysmal or stable atrial fibrillation. Diagnosis of such arrhythmias may be difficult in case of the masked hyperthyroidism being its only clinical symptom. In order to establish a proper diagnosis the following tests of thyroid gland functioning have been carried out: TRH-TSH, scintigraphy and ultrasound examination of the thyroid gland. TRH-TSH test enables to detect disorders of hypophyseal-thyroidal regulation characteristic for both overt and masked hyperthyroidism. Scintigraphic examination reveals autonomic nodules of the thyroid glands being frequently a cause of cardiac arrhythmias. Ultrasound examination enables confirmation of the diagnosed autonomic thyroid nodules without TSH test. In the majority of cases of cardiac arrhythmias therapy with radioactive iodine isotope was introduced. Some patients with appropriate indications have been treated surgically after proper preparation. Pharmacological treatment in thyroid-cardiac syndrome produces transient and instable result.     

The Problem of Diagnosing the Mental Development of Schoolchildren

The specificity of diagnostic tests depends on the tasks posed by their authors, on the nature of the object diagnosed, and on the principles of construction of such tests, which stem from the [authors'] initial theoretical positions. Experimental verification of tests requires a correct orientation toward the object of diagnosis and observance of the conditions of the diagnostic experiment itself as defined by its authors.     

Deep vein thrombosis: Current status and nanotechnology advances

Deep vein thrombosis (DVT) affects up to 2 million people in the United States, and worldwide incidence is 70 to 113 cases per 100,000 per year. Mortality from DVT is often due to subsequent pulmonary embolism (PE). Precise diagnosis and treatment is thereby essential for the management of DVT. DVT is diagnosed by a thorough history and physical examination followed by laboratory and diagnostic tests. The choice of laboratory and diagnostic test is dependent on clinical pretest probability. Available laboratory and diagnostic techniques mainly involve D-dimer test, ultrasound, venography, and magnetic resonance imaging. The latter two diagnostic tools require high doses of contrast agents including either radioactive or toxic materials. The available treatment options include lifestyle modifications, mechanical compression, anticoagulant therapy, inferior vena cava filter, and thrombolysis/thrombolectomy. All of these medical and surgical treatments have serious side effects including improper clot clearance and increased risk of hemorrhage occurrence. Therefore, research in this field has recently focused on the development of non-invasive and accurate diagnostics, such as ultrasound enhanced techniques and molecular imaging methods, to assess thrombus location and its treatment course. The frontier of nanomedicine also shows high prospects in tackling DVT with efficient targeted drug delivery. This review describes the pathology of DVT along with successive medical problems such as PE and features a detailed listing of various diagnostic and therapeutic modalities that have been in use and are under development.     

A Stepwise Approach to the Evaluation and Treatment of Subclinicalhyperthyroidism

ObjectivesTo review a stepwise approach to the evaluation and treatment of subclinical hyperthyroidism.MethodsEnglish-language articles regarding clinical management of subclinical hyperthyroidism published between 2007 and 2012 were reviewed.ResultsSubclinical hyperthyroidism is encountered on a daily basis in clinical practice. When evaluating patients with a suppressed serum thyrotropin value, it is important to exclude other potential etiologies such as overt triiodothyronine toxicosis, drug effect, nonthyroidal illness, and central hypothyroidism. In younger patients with mild thyrotropin suppression, it is acceptable to perform testing again in 3 to 6 months to assess for persistence before performing further diagnostic testing. In older patients or patients with thyrotropin values less than 0.1 mIU/L, diagnostic testing should proceed without delay. Persistence of thyrotropin suppression is more typical of nodular thyroid autonomy, whereas thyroiditis and mild Graves disease frequently resolve spontaneously. The clinical consequences of subclinical hyperthyroidism, such as atrial dysrhythmia, accelerated bone loss, increased fracture rate, and higher rates of cardiovascular mortality, are dependent on age and severity. The decision to treat subclinical hyperthyroidism is directly tied to an assessment of the potential for clinical consequences in untreated disease. Definitive therapy is generally selected for patients with nodular autonomous function, whereas antithyroid drug therapy is more appropriate for mild, persistent Graves disease.ConclusionThe presented stepwise approach to the care of patients presenting with an isolated suppression of serum thyrotropin focuses on the differential diagnosis, a prediction of the likelihood of persistence, an assessment of potential risks posed to the patient, and, finally, a personalized choice of therapy. (Endocr Pract. 2012;18: 772-780)     

Fungal Thyroiditis: An Overview

The authors review the epidemiology, clinical manifestations, diagnosis, and treatment of fungal thyroiditis cases previously reported in the medical literature. Aspergillus was by far the most common cause of fungal thyroiditis. Immunocompromised patients, such as those with leukemia, lymphoma, autoimmune diseases, and organ-transplant patients on pharmacological immunosuppression were particularly at risk. Fungal thyroiditis was diagnosed at autopsy as part of disseminated infection in a substantial number of patients without clinical manifestations and laboratory evidence of thyroid dysfunction. Local signs and symptoms of infection were indistinguishable from other infectious thyroiditis and included fever, anterior cervical pain, thyroid enlargement sometimes associated with dysphagia and dysphonia, and clinical and laboratory features of transient hyperthyroidism due to the release of thyroid hormone from follicular cell damage, followed by residual hypothyroidism. Antemortem diagnosis of fungal thyroiditis was made by direct microscopy and culture of a fine-needle aspirate, or/and biopsy in most cases. Since most patients with fungal thyroiditis had disseminated fungal infection with delay in diagnosis and treatment, the overall mortality was high.     

甲亢性肝损害116例临床分析

目的探讨甲状腺功能亢进症（甲亢）肝损害的临床特点。方法收集228例甲亢患者的临床资料,分为肝损害组及无肝损害组,对两组患者的年龄、性别、甲亢病程、肝功能及甲状腺功能等指标进行分析比较。结果 228例甲亢患者中发生肝损害116例,发生率为50.72%。甲亢患者的性别与甲亢性肝损害的发生率无相关性;而年龄越大甲亢性肝损害发生率越高,病程越长甲亢性肝损害发生率也越高。甲亢性肝损害患者甲状腺功能指标TT4、FT3明显高于甲亢肝功能正常的患者,差异有统计学意义（P〈0.05）;肝功能测定以ALT、ALP升高多见。结论甲亢性肝损害的发病率较高,病情的严重程度与年龄、病程、甲状腺激素水平有密切关系;建议临床医生对初诊及复诊甲亢患者进行肝功能常规测定,以便合理选用治疗方案,使甲亢性肝损害得以及早治疗。     

Pseudoreplication, chatter, and the international nature of science: a response to D.V. Tatarnikov

The commentary by Tatarnikov (2005) on the design and analysis of manipulative experiments in ecology represents an obvious danger to readers with poor knowledge of modern statistics due to its erroneous interpretation of pseudoreplication and statistical independence. Here we offer clarification of those concepts--and related ones such as experimental unit and evaluation unit--by reference to studies cited by Tatarnikov (2005). We stress the necessity of learning from the accumulated experience of the international scientific community in order not to repeat the errors found in earlier publications that have already been analyzed and widely written about. (An Englisch translation of the full article is available as a pdf-file from either or the authors.)     

Kyste de la vésicule séminale associé à une agénésie rénale homolatérale: à propos de trois observations

The combination of seminal vesicle cyst and homolateral renal agenesis is a rare congenital anomaly. However, this anomaly is diagnosed more frequently due to progress in medical imaging. The authors report three cases of seminal vesicle cyst associated with ipsilateral renal agenesis in two cases and ectopic ureter in one case. All cases presented nonspecific clinical symptoms. The diagnosis was suspected on imaging (ultrasound and computed tomography). Treatment was surgical in two cases and endoscopie in one case. The authors review the literature on the aetiology and pathogenesis of seminal vesicle cyst, its association with homolateral renal agenesis and diagnostic and therapeutic methods.     

The management of hyperthyroidism due to Graves' disease in Japan in 1988. The Japan Thyroid Association

The management of hyperthyroidism due to Graves' disease in Japan was the subject of a survey of the members of the Japan Thyroid Association (JTA), and the results were compared to those of the European Thyroid Association (ETA). In the questionnaire, in vivo and in vitro diagnostic procedures, the choice of treatment and the details of the treatment for a patient with typical, moderate and uncomplicated hyperthyroidism due to Graves' disease was at first asked, and eight variations with a single alternative were proposed to evaluate how each alternative would affect the choice of treatment. For the diagnostic procedures, thyroid uptake/scintigraphy was carried out by approximately 60% of the respondents and the isotope mainly used was 123I. The number of in vitro tests used for diagnosis averaged 8.1 +/- 1.8 tests. Measurements of basal TSH and free T4 were the most frequent tests performed to confirm the diagnosis of hyperthyroidism (94 and 80%, respectively). Determinations of microsomal, thyroglobulin and TSH-receptor autoantibodies were also employed by many respondents (96, 96 and 77%, respectively). On the other hand, the free T4 index and TRH test were less frequently employed. In the treatment of these patients, antithyroid drug treatment was the first choice, and surgery was not, in general, regarded as a primary therapy except in a patient with a large goiter. The frequency of the respondents who advocated radioiodine therapy was considerably higher for patients with recurrences and old age. No respondents proposed radioiodine therapy for young patients. Specialists tended to favor their own specialist treatment regimens. The initial dose of antithyroid drugs was reduced according to thyroid function, and withdrawal of antithyroid drug treatment was determined by some specific criteria (basal TSH in supersensitive assays, TSH-receptor autoantibodies, T3 suppression test, etc.). The aim of radioiodine therapy and surgery was to restore euthyroidism. The significant differences between the results from the JTA and those from the ETA were as follows; radionuclide used for thyroid uptake/scintigraphy was mainly 123I in Japan, but 131I in Europe, the number of diagnostic studies in Japan was more than that in Europe, and the dosage of antithyroid drugs was reduced according to thyroid function and discontinued based on certain specific criteria in Japan, but after fixed periods in Europe. These results may represent actual trends in how hyperthyroidism due to Graves' disease is managed in specialist clinics in Japan today and the differences between the JTA and the ETA.     

A strategy for thyroid function tests.

The concept of decision-aiding ranges were introduced to improve diagnostic efficiency. The clinical uncertainty in distinguishing borderline cases of hyperthyroidism and hypothyroidism among 1559 consecutive requests for thyroid function tests was 47%. This was reduced to 22% by using the free thyroxine index and to under 2% by using specific tests determined by the decision-aiding ranges.     

Wasting syndrome with deep bradycardia as presenting manifestation of long-standing severe male hypogonadotropic hypogonadism: a case series

Background

Non-thyroidal illness (NTI) refers to changes in thyroid hormone levels in critically ill patients in the absence of primary hypothalamic-pituitary-thyroid dysfunction, and these abnormalities usually resolve after clinical recovery. However, NTI can be accompanied by primary thyroid dysfunction. We report herein a case of a woman with NTI accompanied by primary hyperthyroidism.

Case presentation

A 52-year-old female was admitted to the intensive care unit with heart failure and atrial fibrillation. She had a longstanding thyroid nodule, and a thyroid function test revealed low levels of triiodothyronine and free thyroxine as well as undetectable thyroid stimulating hormone (TSH). She was diagnosed with NTI, and her TSH level began to recover but not completely at discharge. The thyroid function test was repeated after 42 months to reveal primary hyperthyroidism, and a thyroid scan confirmed a toxic nodule.

Conclusion

This case suggests that although NTI was diagnosed, primary hyperthyroidism should be considered as another possible diagnosis if TSH is undetectable. Thyroid function tests should be repeated after clinical recovery from acute illness.     

Homeostatic Problems in General Surgery

For electrolyte problems that arise during surgical procedures, the surgeon must be versed in the physiologic function of the organs that play vital roles in homeostasis. Pulmonary and renal evaluation before operation can give forewarning of potential dangers. Hyperaldosteronism, a disease entity influencing electrolytic changes and causing other pathophysiological effects, should be understood by the surgeon. Not only should he understand the causes of dehydration, hyperhydration, metabolic and respiratory acidosis and metabolic and respiratory alkalosis, he should also be able to recognize their deleterious effects clinically, know how to make use of adequate laboratory procedures to substantiate a diagnosis and determine the effect of treatment.The effect of water deficit and water excess, and of deficits and excesses of such ions as sodium, potassium, calcium, carbon dioxide and bicarbonate on the renal, cardiac, pulmonary and neuromuscular systems must be considered.Tetany before or after operation challenges a surgeon''s diagnostic acuity. Relying on laboratory tests only, without correlating the results with history and clinical features, may lead to errors in the administration of electrolytic fluids.     

Graves Hyperthyroidism and Pregnancy: A Clinical Update

ObjectiveTo provide a clinical update on Graves’ hyperthyroidism and pregnancy with a focus on treatment with antithyroid drugs.MethodsWe searched the English-language literature for studies published between 1929 and 2009 related to management of hyperthyroidism in pregnancy. In this review, we discuss differential diagnosis of hyperthyroidism, management, importance of early diagnosis, and importance of achieving proper control to avoid maternal and fetal complications.ResultsDiagnosing hyperthyroidism during pregnancy can be challenging because many of the signs and symptoms are similar to normal physiologic changes that occur in pregnancy. Patients with Graves disease require prompt treatment with antithyroid drugs and should undergo frequent monitoring for signs of fetal and maternal hyperthyroidism and hypothyroidism. Rates of maternal and perinatal complications are directly related to control of hyperthyroidism in the mother. Thyroid receptor antibodies should be assessed in all women with hyperthyroidism to help predict and reduce the risk of fetal or neonatal hyperthyroidism or hypothyroidism. The maternal thyroxine level should be kept in the upper third of the reference range or just above normal, using the lowest possible antithyroid drug dosage. Hyperthyroidism may recurin the postpartum period as Graves disease or postpartum thyroiditis; thus, it is prudent to evaluate thyroid function 6 weeks after delivery. Preconception counseling, a multidisciplinary approach to care, and patient education regarding potential maternal and fetal complications that can occur with different types of treatment are important.ConclusionPreconception counseling and a multifaceted approach to care by the endocrinologist and the obstetric team are imperative for a successful pregnancy in women with Graves hyperthyroidism. (Endocr Pract. 2010;16:118-129)     

病毒性肝炎肝硬化并脾功能亢进的治疗进展

病毒性肝炎肝硬化合并脾功能亢进是临床上常见的肝脏疾病,其产生的脾脏肿大占位效应和血细胞过度消耗及伴随骨髓移植等临床综合症状,严重影响了针对病毒性肝炎肝硬化的抗病毒治疗。目前通过非手术治疗难以控制脾脏肿大,且无特异性药物有效遏制,极易造成重度贫血和血小板减少症导致的出血现象,此时外科和介入治疗手段则为首选方式,一般包括脾脏切除、脾脏部分切除、介入治疗(目前以脾动脉栓塞为主)等,其中又以脾脏切除术疗效最直接和确切。然而脾切除对人体免疫功能的损害使人们认识到保脾的重要性,但如何最大限度的保留脾组织和脾功能,至今争议仍然存在。因此,本文综述了肝硬化脾功能亢进的发病原因及机制,脾亢的诊断标准以及脾功能亢进的外科和介入治疗方法,为脾功能亢进的研究提供一定的理论基础。     

McCune-Albright syndrome associated with non-autoimmune type of hyperthyroidism with development of thyrotoxic crisis

We report on a patient having McCune-Albright syndrome (MAS) associated with non-autoimmune hyperthyroidism associated with thyrotoxic crisis. Polyostotic fibrous dysplasia developed at age 8, and café-au-lait pigmentation was noted on the skin. At age 18, he developed hyperthyroidism with multiple adenomatous changes. The hyperthyroidism had been controlled with an antithyroid drug, but the antithyroid medication was discontinued by the patient at age 23. One year later, thyrotoxic crisis developed with fever, convulsions and loss of consciousness. Thyroid function tests showed serum concentrations of free T(4) of 5.1 ng/dl, and serum TSH of <0.1 microU/ml. Serum thyroglobulin concentrations were markedly increased (1,280 ng/ml). Three major thyroid-related autoantibodies (TSH receptor antibody, antithyroglobulin, and antimicrosomal antibodies) were not detected in serum. Serum GH concentrations were increased, and not suppressed by the glucose tolerance test, but increased paradoxically by TRH. The thyrotoxic crisis was ameliorated by treatment with a beta-adrenergic receptor-blocking agent, glucocoroticoid, iodine, antithyroid drug, and antibiotics. The cause of thyroidal defect in our patient is not considered to be autoimmune hyperthyroidism, but hyperthyroidism due to constitutive activation of G(s)alpha by inhibition of its GTPase. This paper describes, as far as we know, the first case of MAS associated with thyrotoxic crisis. Because hyperthyroidism in this patient recurred quickly after discontinuation of the antithyroid drug, the mode of treatment for MAS-associated hyperthyroidism appears to be total surgical ablation or repetitive radioiodine therapy.     

Screening of geriatric patients for thyroid dysfunction with thyrotropin-releasing-hormone test, sensitive thyrotropin and free thyroxine estimation

Hospitalized geriatric patients (N = 354) from an iodine-deficient area were screened with sensitive thyrotropin (TSH), free and total thyroxine (FT4, T4) and total triiodothyronine (T3) to determine the occurrence rate of clinical and subclinical thyroid dysfunction. The diagnostic value of the tests was compared to each other and to that of the thyrotropin-releasing-hormone test (TRH-test) in order to find the optimal first line screening test in geriatric patients. Clinical hyperthyroidism was found in 13, subclinical hyperthyroidism in 10, overt hypothyroidism in 6 and subclinical hypothyroidism in 8 cases. 20.6% of the patients were euthyroid but had subnormal TSH response to TRH, as a sign of possible thyroid autonomy. The low occurrence rate of clinical thyroid disorders (4.8%) does not justify the screening of geriatric patients in general, but the high probability of thyroid autonomy makes reasonable the investigation of every geriatric patient before iodine administration. Suppressed basal TSH and high FT4 were found to be both sensitive and specific in diagnosing clinical hyperthyroidism, but the predictive value was insufficient; elevated T4 and T3 are specific, but not sensitive. Basal TSH is sensitive, specific and has a good predictive value in diagnosing euthyroidism, whereas normal T4, FT4 or T3 are not specific enough for euthyroidism. Basal TSH is better as a first line test of thyroid function than FT4. A normal basal TSH confirms euthyroidism by itself. Other tests (TRH test, T4, FT4, T3) are necessary to elucidate the clinical importance of a subnormal or suppressed basal TSH.     

Thyroxine “Addicts”

Four patients are described who were surreptitiously taking thyroxine-containing tablets. In two cases this caused considerable diagnostic problems. The diagnosis should be considered in patients with clinical features of hyperthyroidism (but without goitres or proptosis), who appear psychiatrically abnormal and whose thyroid function tests show conflicting results.     

手术治疗老年上消化道穿孔的临床效果分析

目的：探讨并分析治疗老年上消化道穿孔的手术方法及其影响因素。方法：收集整理我院2012年1月至2013年1月收治的35例老年上消化道穿孔患者的临床资料,根据患者病情,选择合适的术式对全部患者给予手术治疗,对合并症患者给予积极的对应处理。结果：本组患者术中可见穿孔平均直径（1．7±0．2）cm,腹腔平均积液（2100±200）mL,积液均为混浊或脓性液。术后1例患者死亡,8例患者出现并发症。根据患者的临床因素对术后并发症的发生情况进行比对,我们发现：患者的年龄较大、合并症越复杂、接受手术的时间越迟,那么术后患者发生并发症的机率则越高。结论：采取手术治疗老年上消化道穿孔应充分考虑老年患者特殊的临床因素对其疗效及预后的影响,以安全、简单、有效为基本原则,选择适合病患实际病情的最佳术式,进一步提高手术成功率和临床疗效。     

Hyperthyroidism due to Coexistence of Graves’ Disease and Struma Ovarii

ObjectiveTo report an unusual case of persistent thyrotoxicosis after treatment of Graves’ disease, because of coexistence of struma ovarii.MethodsWe report the clinical history, imaging studies, laboratory and pathologic data, and treatment in a patient with persistent hyperthyroidism after surgical treatment of Graves’ disease. In addition, we discuss some aspects of the pathogenesis of hyperthyroidism due to functioning struma ovarii.ResultsA 42-year-old woman underwent near-total thyroidectomy for treatment of Graves’ disease. Post-operatively, hyperthyroidism was still present. Methimazole was administered again, and performance of a ¹³¹I whole-body scan demonstrated a focus of intense uptake in the pelvis. Pelvic ultrasonography revealed a mass (11 by 8 by 7.1 cm) arising from the right ovary, with both solid and cystic components. Abdominal surgical exploration was performed, and the final histologic diagnosis was struma ovarii. The symptoms of hyperthyroidism diminished, and 3 weeks postoperatively, the thyroid hormone levels were in the hypothyroid range.ConclusionIn patients with refractory hyperthyroidism after thyroid surgical treatment, radioiodine scanning should be performed to diagnose or exclude the functioning profile of ovarian masses. (Endocr Pract. 2007;13:274-276)