Association of First-Trimester Thyroid Function Test Values with Thyroperoxidase Antibody Status,Smoking, and Multivitamin Use

ObjectiveTo determine first-trimester thyroid function values and associations with thyroperoxidase antibody (TPO-Ab) status, smoking, emesis, and iodine-containing multivitamin use.MethodsWe collected information by interview, questionnaire, and blood draw at the initial obstetric visit in 668 pregnant women without known thyroid disease. We compared thyroid-stimulating hormone (TSH), total thyroxine (T₄), and free T₄ index (FT₄I) values by TPO-Ab status. Multiple regression was used to identify characteristics associated with thyroid function values.ResultsThe following median (range containing 95% of the data points) thyroid function test values were obtained in 585 TPO-Ab–negative women: TSH, 1.1 mIU/L (0.04-3.6); FT₄I, 2.1 (1.5-2.9); and T₄, 9.9 μg/dL (7.0-14.0). The following median (range containing 95% of the data points) thyroid function test values were obtained in 83 TPO-Ab–positive women: TSH, 1.8 mIU/L (0.3-6.4) (P < .001); FT₄I, 2.0 (1.4-2.7) (P = .06); and T₄, 9.3 μg/dL (6.8-13.0) (P = .03) (P values denote statistically significant differences between TPO-Ab–positive and negative participants). Among TPO-Ab–negative participants, TSH level was not associated with use of iodine-containing multivitamins, smoking, or race. TSH increased 0.03 mIU/L for every year of maternal age (P = .03) and decreased by 0.3 mIU/L for every increase in parity (P < .001). T₄ decreased 0.04 μg/dL for every year of maternal age (P = .04). Mean FT₄I was 2.05 in smokers and 2.20 in nonsmokers (P < .01). There were no relationships between T₄ or FT₄I and parity, race, or iodine-containing multivitamin use.ConclusionTPO-Ab status of pregnant women should be considered when constructing trimester-specific reference ranges because elevated serum TPO-Ab levels are associated with higher TSH and lower T₄ values. (Endocr Pract. 2008;14:33-39)     

Percutaneous Laser Ablation in the Treatment of Toxic and Pretoxic Nodular Goiter

ObjectiveTo report data regarding treatment with use of percutaneous laser ablation (PLA) in autonomously functioning thyroid nodules (AFTN).MethodsWe treated 18 patients (10 women and 8 men, 31 to 80 years old) who presented with a single hyperfunctioning thyroid nodule (8 patients) or a multi-nodular goiter (10 patients) with clearly hyperfunctioning areas on a thyroid scintiscan. In 5 cases, free thyroxine (FT₄) and free triiodothyronine (FT₃) levels were high, and in these patients and a further 9 patients with cardiovascular symptoms, methimazole therapy was initiated to restore euthyroidism. The total number of PLA sessions ranged from 1 to 5 (median, 3). Thyroid-stimulating hormone, FT₄, FT₃, thyroglobulin, and antithyroglobulin and anti-thyroid peroxidase antibodies were measured by a commercial kit the day after PLA treatment, then weekly during the first month, and monthly thereafter. The Student t test was used for statistical analyses, and data are reported as mean values ± SE.ResultsAfter each PLA session, there was a transient and mild increase in FT₄ and FT₃—5.2% to 18.1% (mean, 11.1 ± 0.69%) (P < 0.001) in patients not treated with methimazole and 4.0% to 8.3% (mean, 5.9 ± 0.31%) (P < 0.001) in patients treated with methimazole—relative to values before treatment; however, these values never reached the range of hyperthyroidism. In addition, thyroglobulin showed a remarkable increase after 24 hours— 115% to 390% (mean, 266.0 ± 12.7%) (P < 0.001). Thyroid-stimulating hormone increased in all cases and reached normal values in all patients with single AFTN and in 5 patients (50%) with multinodular goiter within 3 months after PLA. At 1-year follow-up, the decrease in nodular volume was 24% to 72% (mean, 59.3 ± 8.2%; P < 0.001).ConclusionOur data show that PLA can be a useful treatment in AFTN and particularly in single toxic nodules. Possible elective indications are patients who refuse surgical or radioiodine treatment and patients with cardiovascular comorbidity who need rapid restoration of the euthyroid state and who cannot tolerate the discontinuation of antithyroid drugs for radioiodine treatment. (Endocr Pract. 2007;13:30-36)     

Utility of Ultrasound-Guided Fine-Needle Aspiration of Parathyroid Adenomas for Localization Before Minimally Invasive Parathyroidectomy

ObjectiveTo determine the sensitivity and specificity of ultrasound (US)-guided fine-needle aspiration (FNA) and measurement of parathyroid hormone (PTH) in the aspirate (FNA/PTH) as a preoperative localization procedure.MethodsThe study group consisted of 34 consecutive patients with primary hyperparathyroidism. The FNA/PTH estimations in these patients were compared with those from 13 proven thyroid nodules. All patients underwent US study of the neck, which suggested the presence of a solitary adenoma in 30 patients and of hyperplasia in 2; no adenoma or hyperplasia could be visualized in 2 patients. Thirty-two patients underwent FNA/PTH, which yielded a mean PTH level of 22,060.0 ± 6,653.0 pg/mL. This result was significantly different (P < 0.001) from the mean PTH level in 13 thyroid nodules (9.0 ± 1.0 pg/mL).ResultsOn the basis of the FNA/PTH results, 28 patients with suspected adenomas underwent minimally invasive parathyroidectomy (MIP), and 2 patients are awaiting a surgical procedure. Of these 28 patients, 27 had more than a 50% decline in intraoperative PTH level after removal of the suspected adenoma, confirming surgical success. In 1 patient, multigland hyperplasia was discovered during the operation. The 2 study subjects with US findings of suspected hyperplasia underwent 4-gland surgical procedures. All patients treated surgically continued to have normal serum calcium levels 6 to 18 months post-operatively.ConclusionPrimary hyperparathyroidism is caused most commonly by a solitary adenoma and less commonly by multigland hyperplasia of the parathyroid glands. Surgical resection is the only curative therapy. MIP has become a frequently used strategy, but there are limitations to current preoperative localization techniques. We conclude that US-guided FNA is a useful technique that facilitates MIP, with a high degree of specificity (95%) and sensitivity (91%). (Endocr Pract. 2007;13:333-337)     

Urinary iodine and thyroid function in a population of healthy pregnant women in the North of Spain

BackgroundIodine is an essential trace element for the synthesis of thyroid hormones, which are keys in maternal metabolism during pregnancy as well as in neurological development during fetal and postnatal life. This was a prospective study on iodine status and thyroid function in women during pregnancy in the Basque country to assess whether there was any relationship among maternal urinary iodine, maternal thyroid function and thyrotropin (TSH) in newborns, and to explore any difference in women experiencing miscarriages.MethodsWe analyzed TSH, free T₄ (FT₄), free T₃ (FT₃), thyroid peroxidase antibody (TPO-Ab) titers in serum and urinary iodine concentrations (UIC) in 2104 women in the first trimester of pregnancy and in 1322 of them in their second trimester. We obtained neonatal TSH levels in 1868 cases.ResultsIn the first (T1) and second trimesters (T2), the median UICs were 88.5 μg/L and 140 μg/L, respectively. No relationship was found between UIC and FT₄, or maternal and neonatal TSH. In T1 and T2, 9.7% and 7.5% of women were TPO-Ab positive, respectively. The total miscarriage rate was 10%. The percentage of miscarriages in healthy women was 8.9%, lower than in women with overt hypothyroidism (21.2%; p < 0.001) and than in women with subclinical hypothyroidism (15.6%; p < 0.025). The miscarriage rate was not higher in TPO-Ab-positive women.ConclusionsIn this study most women had iodine deficiency during pregnancy. Neonatal TSH is not correlated with maternal UIC during pregnancy. Pregnant women with hypothyroidism have a higher rate of miscarriages.     

Impacto asistencial tras la introducción de la ecografía tiroidea en una unidad monográfica de atención al nódulo tiroideo

IntroductionWorldwide incidence of thyroid cancer has increased in recent decades.ObjectiveTo provide evidence of the diagnostic and care efficiency of a monographic thyroid nodule clinic integrating clinical examination, ultrasound examination, and cytology with on site evaluation.Patients and methodsPatients attending the monographic thyroid nodule clinic from January 2004 to June 2010. Two periods may be distinguished based on availability of ultrasound equipment at the time of the visit: a first period (P1: 01/2004-09/2007) where no ultrasound equipment was available at the clinic and FNA by palpation was performed, and a second period (P2: 10/2007-06/2010) where this equipment was available and ultrasound-guided FNA was performed.ResultsA total of 1036 patients [P1: 537 (52%), P2: 499 (48%)] were seen and enrolled.Diagnostic efficiency (P1 vs P2): 143 vs 181 patients were seen annually, p < 0.001; FNA number/nodule: 1.68 vs 1.17, p < 0.001; percent FNAs with inadequate material: 26% vs 5.3%, p < 0.001; mean (SD) nodule size: 23.6 (12.4) vs 21.7 (11.7) mm, p 0.040; proportion of nodules examined less than 10 mm in size: 9.9% vs 13.7%, p 0.030.Care efficiency: mean time (range) from the first visit to surgery indication: 332 (0-2177) vs 108 (0-596) days, p < 0.001; proportion of patients referred for surgery due to suspect cytology/other reasons: 1.06 vs 2.21, p < 0.001; and operated benign neoplasm/pathology: 0.47 vs 0.93, p = 0.002.ConclusionA monographic thyroid nodule clinic integrating clinical examination, ultrasound, and cytology evaluated on site increases diagnostic and care efficiency in patients with thyroid nodules.     

Association Between Thyroid Function and Objective and Subjective Sleep Quality in Older Men: The Osteoporotic Fractures in Men (MrOS) Study

ObjectiveTo determine the association between thyroid hormone levels and sleep quality in community-dwelling men.MethodsAmong 5,994 men aged ≥ 65 years in the Osteoporotic Fractures in Men (MrOS) study, 682 had baseline thyroid function data, normal free thyroxine (FT₄) (0.70 ≤ FT₄ ≤ 1.85 ng/dL), actigraphy measurements, and were not using thyroid-related medications. Three categories of thyroid function were defined: subclinical hyperthyroid (thyroid-stimulating hormone [TSH] < 0.55 mIU/L), euthyroid (TSH, 0.55 to 4.78 mIU/L), and subclinical hypothyroid (TSH > 4.78 mIU/L). Objective (total hours of nighttime sleep [TST], sleep efficiency [SE], wake after sleep onset [WASO], sleep latency [SL], number of long wake episodes [LWEP]) and subjective (TST, Pittsburgh Sleep Quality Index score, Epworth Sleepiness Scale score) sleep quality parameters were measured. The association between TSH and sleep quality was examined using linear regression (continuous sleep outcomes) and log-binomial regression (categorical sleep outcomes).ResultsAmong the 682 men examined, 15 had subclinical hyperthyroidism and 38 had subclinical hypothyroidism. There was no difference in sleep quality between subclinical hypothyroid and euthyroid men. Compared to euthyroid men, subclinical hyperthyroid men had lower mean actigraphy TST (adjusted mean difference [95% confidence interval (CI)], − 27.4 [− 63.7 to 8.9] minutes), lower mean SE (− 4.5% [− 10.3% to 1.3%]), and higher mean WASO (13.5 [− 8.0 to 35.0] minutes]), whereas 41% had increased risk of actigraphy-measured TST < 6 hours (relative risk [RR], 1.41; 95% CI, 0.83 to 2.39), and 83% had increased risk of SL ≥ 60 minutes (RR, 1.83; 95% CI, 0.65 to 5.14) (all P > .05).ConclusionNeither subclinical hypothyroidism nor hyperthyroidism is significantly associated with decreased sleep quality. (Endocr Pract. 2014;20:576-586)     

Optimal Free Thyroxine Levels for Thyroid Hormone Replacement in Hypothyroidism

ObjectiveTo determine whether a difference exists in the free thyroxine level required to achieve a normal thyrotropin (thyroid-stimulating hormone or TSH) level between patients with primary hypothyroidism and euthyroid control subjects and compare the free thyroxine levels in patients with primary and secondary hypothyroidism receiving thyroid hormone replacement.MethodsWe retrospectively assessed TSH and free thyroxine values in 58 patients with primary hypothyroidism and 78 euthyroid control subjects for whom screening thyroid function tests had been performed. From the medical records, we also obtained free thyroxine values for 23 patients with central hypothyroidism receiving stable levothyroxine replacement therapy.ResultsThe mean free thyroxine level was significantly higher in patients with primary hypothyroidism than in euthyroid control subjects (1.36 ± 0.201 ng/dL versus 1.10 ± 0.155 ng/dL, respectively, P < .0001), whereas the corresponding mean TSH concentrations did not differ significantly (1.60 ± 1.183 mlU/L versus 1.73 ± 0.792 mlU/L, P = .46). The mean free thyroxine value was also significantly higher in the patients with central hypothyroidism in comparison with that in the euthyroid control subjects (1.31 ± 0.278 ng/dL versus 1.10 ± 0.155 ng/dL, respectively, P < .0001), and no significant difference was noted between the patients with primary and central hypothyroidism (1.36 ng/dL versus 1.31 ng/dL, P = .60).ConclusionPatients with hypothyroidism require a higher level of serum free thyroxine to achieve a normal TSH value in comparison with euthyroid control subjects. This finding suggests that patients with central hypothy-roidism should be treated to achieve free thyroxine levels in the upper part of the reference range. (Endocr Pract. 2008;14:550-555)     

Calcium,Parathyroid Hormone,and Vitamin D in Patients with Primary Hyperparathyroidism: Normograms Developed from 10000 Cases

ObjectiveTo better define the typical and atypical biochemical profiles of patients with surgically proven primary hyperparathyroidism.MethodsIn this single-center, prospectively conducted study of consecutive patients with surgically proven primary hyperparathyroidism over a 7-year period, we analyzed serum calcium, parathyroid hormone, and 25-hydroxyvitamin D concentrations.ResultsA total of 10 000 patients were included, and more than 210 000 calcium, parathyroid hormone, and 25-hydroxyvitamin D values were evaluated. Both calcium and parathyroid hormone levels demonstrated a Gaussian distribution with the average calcium concentration being 10.9 ± 0.6 mg/dL and the average parathyroid hormone concentration being 105.8 ± 48 pg/mL. The average highest calcium and parathyroid hormone concentrations were 11.4 ± 0.7 mg/dL and 115.3 ± 50 pg/mL, respectively. At least 1 calcium value of 11.0 mg/dL was seen in 87% of patients, but only 21% had 1 or more calcium value above 11.5 mg/dL. Only 7% had a single serum calcium level reaching 12.0 mg/dL. Normocalcemic hyperparathyroidism was seen in just under 3% of patients who had identical findings at surgery. An average parathyroid hormone concentration less than 65 pg/mL was seen in 16%, with 10% of patients who had no high parathyroid hormone values. The average 25-hydroxyvitamin D concentration was 22.4 ± 9 ng/mL, with levels decreasing as calcium levels increased (P < .001); 36% had 25-hydroxyvitamin D levels below 20 ng/mL.ConclusionsPatients with PHPT present with a number of distinct biochemical profiles, but as a group, they present with a near-normal Gaussian distribution of both calcium and parathyroid hormone levels. Either serum calcium or parathyroid hormone remained normal in 13% of patients, yet the findings at surgery are similar to those of patients with elevated calcium or parathyroid hormone. Low 25-hydroxyvitamin D is an expected finding in patients with PHPT, decreasing as serum calcium levels increase. (Endocr Pract. 2011;17:384-394)     

Fine-Needle Aspiration Biopsy of Thyroid Nodules: Comparison of Diagnostic Performance of Experienced and Inexperienced Physicians

ObjectiveTo determine whether a difference exists in terms of obtaining adequate cytologic samples from ultrasound-guided fine-needle aspiration cytology (US-FNAC) between experienced and inexperienced physicians in a tertiary referral center.MethodsIn a prospective design, all patients with thyroid nodules of at least 10 mm in diameter were referred for US-FNAC tissue sampling as a part of their diagnostic work-up. Between May 2006 and September 2009, 997 euthyroid patients with 1, 320 thyroid nodules were referred for US-FNAC by the attending endocrinologist (experienced physician) or 1 of 2 endocrinology fellows (inexperienced physicians).ResultsOf the 1, 320 nodules, 713 biopsy specimens were obtained by the experienced physician and 607 were obtained by the inexperienced physicians. Nodule size was significantly larger in the endocrinologist’s group of patients than in the fellows’ group of patients (17 mm versus 14 mm, respectively; P < .001). The inadequacy rate of the US-FNAC procedures performed by the experienced physician (22 of 713 thyroid nodules or 3.1%) was significantly lower than for those performed by the inexperienced physicians (102 of 607 thyroid nodules or 16.8%) (P < .001).ConclusionWe conclude that, with increasing operator experience, the number of inadequate cytologic specimens generated by US-FNAC procedures is substantially reduced. This limits both direct and indirect costs and also minimizes the risks of possibly unnecessary surgical procedures. (Endocr Pract. 2010;16:986-991)     

Substitution of Liothyronine at a 1:5 Ratio for a Portion of Levothyroxine: Effect on Fatigue,Symptoms of Depression,and Working Memory Versus Treatment With Levothyroxine Alone

ObjectiveTo attempt to confirm a previous report of superior effectiveness of using two thyroid hormones rather than one hormone to treat hypothyroidism.MethodsThis trial attempted to replicate prior findings, which suggested that substituting 12.5 μg of liothyronine (LT₃) for 50 μg of levothyroxine (LT₄) might improve mood, cognition, and physical symptoms in patients with primary hypothyroidism. Additionally, this trial aimed to extend the previous findings to fatigue and to assess for differential effects in subjects with low fatigue and high fatigue at baseline. A randomized, double-blind, two-period, crossover design was used. At an endocrinology and diabetes clinic, 30 adult subjects with primary hypothyroidism stabilized on LT₄ were recruited. Patients randomly assigned to treatment sequence 1 received their standard LT₄ dose in one capsule and placebo in another. Patients assigned to sequence 2 received their usual LT₄ dose minus 50 μg in one capsule and 10 μg of LT₃ in the other. At the end of the first 6 weeks, subjects were crossed over to receive the other treatment. Carryover and treatment effects were assessed by t tests.ResultsOf the 30 enrolled study subjects, 27 completed the trial. The mean LT₄ dose was 121 ± 26 μg/day at baseline. No significant differences in fatigue and symptoms of depression were found between treatments. Measures of working memory were unchanged. During substitution treatment, the free thyroxine index was reduced by 0.7 (P < 0.001), total serum thyroxine was reduced by 3.0 μg/dL (P < 0.001), and total serum triiodothyronine was increased by 20.5 ng/dL (P = 0.004).ConclusionWith regard to the outcomes measured, substitution of LT₃ at a 1:5 ratio for a portion of baseline LT₄ yielded no better results than did treatment with the original dose of LT₄ alone. (Endocr Pract. 2005;11:223-233)     

The Clinical Utility of Free Thyroxine in Oral Levothyroxine Absorption Testing

ObjectiveOriginal absorption studies for levothyroxine (LT₄) were validated using total thyroxine (TT₄) measurements. Free thyroxine (FT₄) has largely supplanted TT₄ in clinical practice. The objective of our study was to assess the clinical utility of FT₄ in oral LT₄ absorption testing.MethodsIn this retrospective electronic health record analysis, we recorded data of patients who underwent LT₄ oral absorption testing between November 2010 and January 2012 because of persistent hypothyroidism despite a greater than anticipated weight-based dose of LT₄. Patients included had primary hypothyroidism and an absorption test with assessment of both TT₄ and FT₄ measured at times 0, 30, 60, 90, 120, 180, 240, 300, and 360 minutes. The test was conducted with 1 mg (five 200-μg tablets) of Synthroid® after an overnight fast by a standard nonisotopic method.ResultsA total of 10 patients (3 men/7 women) underwent absorption testing. Prior to testing, the median daily LT₄ dose was 250 μg (range, 150 to 350 μg). Three patients were also on liothyronine (10, 20, or 50 μg daily). Based on the calculated amount absorbed, 1 patient demonstrated subnormal absorption, and 9 patients were normal. Median body mass index was 33 kg/m² (range, 21 to 50 kg/m²). Median calculated absorption was 105% (range, 3.7 to 195.6%). The correlation comparing FT₄ and TT₄ was 0.88 (95% confidence interval, 0.56 to 0.97, P < .001), a significant correlation.ConclusionFT₄ and TT₄ correlated highly, even in patients who were severely hypothyroid; FT₄ may be used interchangeably with TT₄ as a qualitative assessment of suspected malabsorption using an oral LT₄ absorption test. (Endocr Pract. 2014;20:925-929)     

Utility of Adrenocorticotropic Hormone in Assessing the Response to Transsphenoidal Surgery for Cushing’s Disease

ObjectivesTo compare adrenocorticotrophic hormone (ACTH) and cortisol dynamics in subjects with Cushing’s disease (CD) following transsphenoidal surgery (TSS) and to determine the value of early postoperative ACTH levels in predicting subsequent hypocortisolemia.MethodsFollowing TSS for CD, serum cortisol and plasma ACTH were measured every 6 hours in the absence of empiric glucocorticoid coverage.ResultsA total of 26 subjects (25 female) underwent 28 operations. Hypocortisolemia was achieved in 21 (81%) subjects after the initial TSS. Repeat TSS was performed in 2 subjects, resulting in hypocortisolemia in 1. Subjects who achieved hypocortisolemia had significantly lower ACTH levels by 19 hours postoperatively (P = .007). Plasma ACTH fell to < 30 pg/mL in 86% and < 20 pg/mL in 82% of subjects who subsequently achieved hypocorti- solemia. Plasma ACTH declined to < 30 pg/mL by a mean of 10 hours and to < 20 pg/mL by 13 hours prior to hypo- cortisolemia. Follow-up data were available on 25 patients for a median of 23 months. Three subjects who achieved initial surgical remission had disease recurrence at 19, 24, and 36 months; all of these subjects had a postoperative nadir serum cortisol levels < 3 μg/dL and plasma ACTH < 20 pg/mL.ConclusionFollowing TSS for CD, plasma ACTH declined prior to achievement of hypocortisolemia in most subjects. In the majority, the ACTH level reached a nadir of < 20 pg/mL. Low early postoperative ACTH levels predict early hypocortisolemia but may not accurately predict long-term remission. (Endocr Pract. 2014;20:1159-1164)     

Safe and Simple Emergency Department Discharge Therapy for Patients with Type 2 Diabetes Mellitus and Severe Hyperglycemia

ObjectiveTo investigate the safety and effectiveness of 2 simple discharge regimens for use in patients with type 2 diabetes mellitus (DM2) and severe hyperglycemia, who present to the emergency department (ED) and do not need to be admitted.MethodsWe conducted an 8-week, open-label, randomized controlled trial in 77 adult patients with DM2 and blood glucose levels of 300 to 700 mg/dL seen in a public hospital ED. Patients were randomly assigned to receive glipizide XL, 10 mg orally daily (G group), versus glipizide XL, 10 mg orally daily, plus insulin glargine, 10 U daily (G + G group). The primary outcome was to maintain safe fasting glucose and random glucose levels of < 350 and < 500 mg/dL up to 4 weeks and < 300 and < 400 mg/ dL, respectively, thereafter and to have no return ED visits (responders).ResultsBaseline characteristics were similar between the 2 treatment groups. The primary outcome was achieved in 87% of patients in both treatment groups. The enrollment mean blood glucose values of 440 and 467 mg/dL in the G and G + G groups, respectively, declined by the end of week 1 to 298 and 289 mg/dL and by week 8 to 140 and 135 mg/dL, respectively. Homeostasis model assessment of b-cell function and early insulin response improved 7-fold and 4-fold, respectively, in responders at the end of the 8-week study.ConclusionSulfonylurea with and without use of a small dose of insulin glargine rapidly improved blood glucose levels and b-cell function in patients with DM2. Use of sulfonylurea alone once daily can be considered a safe discharge regimen for such patients and an effective bridge between ED intervention and subsequent follow-up. (Endocr Pract. 2009;15:696-704)     

Improvement in Pancreatic β-Cell Function with Vitamin D and Calcium Supplementation in Vitamin D-Deficient Nondiabetic Subjects

ObjectiveThere are varied reports on the effect of vitamin D supplementation on β-cell function and plasma glucose levels. The objective of this study was to examine the effect of vitamin D and calcium supplementation on β-cell function and plasma glucose levels in subjects with vitamin D deficiency.MethodsNondiabetic subjects (N = 48) were screened for their serum 25-hydroxyvitamin D (25-OHD), albumin, creatinine, calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone (PTH) status. Subjects with 25-OHD deficiency underwent a 2-hour oral glucose tolerance test. Cholecalciferol (9,570 international units [IU]/day; tolerable upper intake level, 10,000 IU/day; according to the Endocrine Society guidelines for vitamin D supplementation) and calcium (1 g/day) were supplemented.ResultsThirty-seven patients with 25-OHD deficiency participated in the study. The baseline and postvitamin D/calcium supplementation and the difference (corrected) were: serum calcium, 9 ± 0.33 and 8.33 ± 1.09 mg/dL (− 0.66 ± 1.11 mg/dL); 25-OHD, 8.75 ± 4.75 and 36.83 ± 18.68 ng/mL (28.00 ± 18.33 ng/mL); PTH, 57.9 ± 29.3 and 36.33 ± 22.48 pg/mL (− 20.25 ± 22.45 pg/mL); fasting plasma glucose, 78.23 ± 7.60 and 73.47 ± 9.82 mg/dL (− 4.88 ± 10.65 mg/dL); and homeostasis model assessment-2–percent β-cell function C-peptide secretion (HOMA-2–%B C-PEP), 183.17 ± 88.74 and 194.67 ± 54.71 (11.38 ± 94.27). Significant differences were observed between baseline and post-vitamin D/calcium supplementation serum levels of corrected calcium (Z, − 3.751; P < .0001), 25-OHD (Z, − 4.9; P < .0001), intact PTH (Z, − 4.04; P < .0001), fasting plasma glucose (Z, − 2.7; P < .007), and HOMA-2–%B C-PEP (Z, − 1.923; P < .05) as determined by Wilcoxon signed rank test. Insulin resistance as measured by HOMA was unchanged.ConclusionOptimizing serum 25-OHD concentrations and supplementation with calcium improves fasting plasma glucose levels and β-cell secretory reserve. Larger randomized control studies are needed to determine if correction of 25-OHD deficiency will improve insulin secretion and prevent abnormalities of glucose homeostasis. (Endocr Pract. 2014;20:129-138)     

Nodule thyroïdien bénin fixant le 99mTc-MIBI

ObjectivesTo illustrate a case of intense uptake of ^99mTc-MIBI on benign thyroid nodule and to recall the mechanisms of this uptake.Case presentationA patient of 25 years old had a parathyroid scintigraphy for suspected right lower parathyroid adenoma. The exam showed intense uptake of ^99mTc-MIBI at the infero-lateral region of the right thyroid lobe. Low levels of PTH prompted to perform a thyroid scintigraphy for better diagnostic orientation. The scan revealed a large cold right basilobar thyroid nodule. The patient underwent a right loboisthmectomy. The histological analysis found a 3 cm diameter vesicular adenoma with oncocytic cells of the lower pole of right thyroid lobe.Discussion/conclusion^99mTc-MIBI is used in the imaging of hyperparathyroidism. Radiotracer uptake is correlated to the parathyroid adenoma content in oxyphil cells. These cells are rich in mitochondria and retain the ^99mTc-MIBI. This radiotracer can bind also on thyroid nodules. The specificity of this uptake for the diagnosis of malignancy is low. It is relevant to the nodule's wealth in oncocytic cells. These cells possess numerous mitochondria and can sequester ^99mTc-MIBI like parathyroid oxyphil cells.     

Serum Thyrotropin in Graves’ Disease: A More Reliable Index of Circulating Thyroid-Stimulating Immunoglobulin Level than Thyroid Function?

ObjectiveTo assess the relationship between serum thyrotropin (thyroid-stimulating hormone or TSH) on one hand and thyroid-stimulating immunoglobulin (TSI), free thyroxine (T₄), and triiodothyronine (T₃) levels on the other in Graves’ disease, inasmuch as TSH may be suppressed in the presence of TSI because TSI may bind to the TSH receptor on the thyroid gland membrane and thus eliminate the need for circulating TSH for stimulating the thyroid gland.MethodsWe determined serum TSI levels in 37 women and 13 men with Graves’ disease, stratified into 4 groups on the basis of serum TSH levels irrespective of serum free T₄ and T₃ levels. Our reference ranges were 0.72 to 1.74 ng/dL for free T₄, 80 to 200 ng/dL for T₃, and to 4.0 μU/mL for TSH.ResultsMean serum TSI concentrations were highest (215% ± 28%) in patients with undetectable TSH levels (< 0.03 μU/mL) and lowest (103% ± 9%) in those with supernormal TSH concentrations (> 4.0 μU/mL). TSI levels were intermediate in the other study groups: 157% ± 16% in patients with subnormal though detectable TSH levels (0.03 to 0.39 μU/mL) and 125% ± 12% in those with normal TSH levels (0.4 to 4.0 μU/mL). Moreover, a progressive decline in TSI levels with increasing serum TSH concentrations was noted, along with a significant negative correlation (r = -0.45; P < 0.01) between serum TSI and TSH concentrations. Finally, relationships between free T₄ and T₃ levels on one hand and TSI or TSH levels on the other were not significant, with a considerable variability in free T₄ and T₃ levels being noted in individual study groups.ConclusionSerum TSH is frequently suppressed after treatment with antithyroid drugs or radioiodine (¹³¹I), irrespective of clinical thyroid function as expressed by increased, normal, or decreased free T₄ and T₃ concentrations. In an individual patient with Graves’ disease, the serum TSH level may be more reflective of the circulating TSI concentration than is thyroid gland function as expressed by free T₄ and T₃ concentrations and therefore may be as reliable a predictor of remission as TSI. (Endocr Pract. 2007;13:615-619)     

Pretreatment hemoglobin level as a prognostic factor in patients with locally advanced head and neck squamous cell carcinoma

AimEvaluate pretreatment hemoglobin values as a prognostic factor in patients with locally advanced head and neck squamous cell carcinoma treated with concurrent chemoradiotherapy.BackgroundAnemia is one of the most prevalent laboratory abnormalities in oncological disease. It leads to a decrease in cellular oxygen supply, altering radiosensitivity of tumor cells and compromising therapeutic outcomes.Materials and MethodsRetrospective evaluation of patients with HNSCC treated with cCRT. Primary and secondary endpoint was to evaluate the correlation of Hb levels (≥12.5 g/dL or <12.5 g/dL) at the beginning of cCRT with overall survival (OS) and progression-free survival (PFS), respectively.ResultsA total of 108 patients were identified. With a median follow-up of 16.10 months median OS was 59.70 months for Hb ≥12.5 g/dL vs. 14.13 months for Hb <12.5 g/dL (p = 0.004). PFS was 12.29 months for Hb ≥12.5 g/dL and 1.68 months for Hb <12.5 g/dL (p = 0.016).ConclusionsIn this analysis, Hb ≥12.5 g/dL correlated with significantly better OS and PFS. Further studies are needed to validate these findings.     

Beneficial effects of oral chromium picolinate supplementation on glycemic control in patients with type 2 diabetes: A randomized clinical study

BackgroundChromium is an essential mineral that contributes to normal glucose function and lipid metabolism. This study evaluated the effect of chromium picolinate (CrPic) supplementation in patients with type 2 diabetes mellitus (T2DM).MethodsA four month controlled, single blind, randomized trial was performed with 71 patients with poorly controlled (hemoglobin A1c [HbA1c] > 7%) T2DM divided into 2 groups: Control (n = 39, using placebo), and supplemented (n = 32, using 600 μg/day CrPic). All patients received nutritional guidance according to the American Diabetes Association (ADA), and kept using prescribed medications. Fasting and postprandial glucose, HbA1c, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides and serum ferritin were evaluated.ResultsCrPic supplementation significantly reduced the fasting glucose concentration (−31.0 mg/dL supplemented group; −14.0 mg/dL control group; p < 0.05, post- vs. pre-treatment, in each group) and postprandial glucose concentration (−37.0 mg/dL in the supplemented group; −11.5 mg/dL in the control group; p < 0.05). HbA1c values were also significantly reduced in both groups (p < 0.001, comparing post- vs. pre-treatment groups). Post-treatment HbA1c values in supplemented patients were significantly lower than those of control patients. HbA1c lowering in the supplemented group (−1.90), and in the control group (−1.00), was also significant, comparing pre- and post-treatment values, for each group (p < 0.001 and p < 0.05, respectively). CrPic increased serum chromium concentrations (p < 0.001), when comparing the supplemented group before and after supplementation. No significant difference in lipid profile was observed in the supplemented group; however, total cholesterol, HDL-c and LDL-c were significantly lowered, comparing pre- and post-treatment period, in the control group (p < 0.05).ConclusionsCrPic supplementation had a beneficial effect on glycemic control in patients with poorly controlled T2DM, without affecting the lipid profile. Additional studies are necessary to investigate the effect of long-term CrPic supplementation.     

Glycemic Control and Outcomes of Hospitalization in Noncritically Ill Patients With Type 2 Diabetes Admitted With Cardiac Problems or Infections

ObjectiveAlthough the importance of glycemic control is well established for patients with diabetes hospitalized for surgical problems, it has not been supported by clinical studies for patients with diabetes hospitalized on the medical floors.MethodsWe conducted a retrospective study of 378 patients with type 2 diabetes admitted for cardiac or infectious disease (ID) diagnosis between September 1, 2011, and August 1, 2012. Exclusion criteria included type 1 diabetes, admission to the intensive care unit (ICU), hospital stay shorter than 3 days, and daily glucocorticoid dose > 20 mg of methylprednisolone. The primary composite outcome included death during hospitalization, ICU transfer, initiation of enteral or parenteral nutrition, line infection, deep vein thrombosis, pulmonary embolism, rise in plasma creatinine by 1 or > 2 mg/dL, new infection, an infection lasting for more than 20 days, and readmission within 30 days and between 1 and 10 months after discharge.ResultsPatients were stratified by mean blood glucose (BG) level: group 1 had mean BG of < 180 mg/dL (n = 286; mean BG, 142 ± 23 mg/dL), whereas group 2 had mean BG levels > 181 mg/dL (n = 92; mean BG, 218 ± 34 mg/dL; P < .0001). Group 2 had a 46% higher occurrence of the primary outcome (P < .0004). The rate of unfavorable events was greater in cardiac and ID patients with worse glycemic control (group 2).ConclusionOur data strongly support a positive influence of better glycemic control (average glycemia < 180 mg/dL or 10 mmol/L) on outcomes of hospitaliza-tion in patients with type 2 diabetes. (Endocr Pract. 2014; 20:1303-1308)     

Elevated Fructosamine Levelsin Acquired Immunodeficiency Syndrome

ObjectiveTo investigate whether the mechanism of increased glycation in acquired immunodeficiency syndrome (AIDS) is due to an alteration in a circulatory plasma enhancer.MethodsWe assessed glycation of serum protein and hemoglobin in patients with AIDS without altered carbohydrate metabolism. Fasting concentrations of glucose, ethanol, vitamin E, fructosamine, hemoglobin, hemoglobin A1c (A1C), and partial pressure of alveolar oxygen (Pao₂) were determined in 50 men with AIDS and in 25 age-matched healthy men in whom normal glucose tolerance was established by oral glucose tolerance tests.ResultsFasting serum glucose was not significantly different between the men with AIDS (87 ± 4 mg/dL) and the healthy male volunteers (84 ± 6 mg/dL); however, A1C (6.9 ± 0.2%) and serum fructosamine levels (288 ± 15 μmol/L) were significantly higher (P < .01) in the patients with AIDS than in the normal subjects (A1C, 5.6 ± 0.1%; fructosamine, 204 ± 14 μmol/L). Moreover, both A1C and fructosamine concentrations were significantly higher (P < .01) in the patients with AIDS than in the normal subjects divided into subgroups on the basis of fasting plasma glucose concentrations (70 to 79 mg/dL, 80 to 89 mg/dL, and 90 to 99 mg/dL). None of the study participants had anemia (hemoglobin < 12 g/dL) or hypoxia (Pao₂ < 95 mm Hg), and serum ethanol was undetectable. Furthermore, vitamin E concentrations were not significantly different between the patients with AIDS (25 ± 3 mg/L) and the normal subjects (22 ± 4 mg/L).ConclusionOn the basis of this study, glycation of some circulating proteins appears to be enhanced in AIDS and may be induced by an undetermined plasma enhancer, inasmuch as known circulating factors promoting glycation were absent. (Endocr Pract. 2008;14:686-690)