Low serum thyrotropin (thyroid-stimulating hormone) in older persons without hyperthyroidism

We studied a large population (n = 2575) of unselected ambulatory persons older than 60 years to determine the prevalence of a low serum thyroid-stimulating hormone (TSH) level, ie, of less than 0.1 mU/L using a sensitive assay, a level suggestive of hyperthyroidism in younger adults. One hundred one persons (3.9%) had a low serum TSH level. About half of them (51/101) were taking thyroid hormone. Of the remainder, 44 were not hyperthyroid did not become so during up to 4 years of follow-up. Forty-one of the 44 euthyroid persons had a serum thyroxine level of less than 129 nmol/L; repeated testing showed a serum TSH level of more than 0.1 mU/L in the three euthyroid persons with a serum thyroxine level of more than 129 nmol/L. Only six were hyperthyroid or became so during the follow-up period; all had a serum thyroxine level of more than 129 nmol/L. Routine clinical examination was not a sensitive indicator of hyperthyroidism and did not permit discrimination from euthyroidism. A low value of serum TSH alone, while it had high sensitivity and specificity for hyperthyroidism, had a low positive predictive value (12%) for this diagnosis; addition of the thyroxine assay raised the predictive value fivefold to 67%. A low value of serum TSH is far more common in older persons than is hyperthyroidism. Low values in euthyroid persons are accompanied by a clearly normal serum T4 concentration (less than 129 nmol/L) or by a serum TSH level of more than 0.1 mU/L on repeated testing. We recommend measurement of the serum TSH thyroid concentration, using a sensitive assay, as the initial step in testing any older person for possible hyperthyroidism. Measurement of the serum T4 concentration or the free T4 index on the same sample would be needed only in the approximately 2% with a serum TSH level of less than 0.1 mU/L; alternatively, the TSH assay in these could be repeated at a later time.

Ablative radioactive iodine therapy for apparently localized thyroid carcinoma. A decision analytic perspective

Adjuvant therapy with ablative radioiodine after surgical resection of apparently localized thyroid carcinoma remains controversial because of the favorable prognosis of thyroid carcinoma and the risk of leukemia from the radioiodine. No controlled trials have been performed to examine this issue. We constructed a decision analytic model to examine whether patients with apparently localized thyroid carcinoma should receive radioiodine. Our analysis suggests that radioiodine modestly improves life expectancy by 2 to 15 months, depending on the patient's age and sex. This model predicts that the benefit of a reduction in the likelihood of recurrence outweighs the risk of leukemia from radioiodine.

Progress in thyroid cancer

The last decade has seen significant advances in our understanding of thyroid cancers, in the areas of the molecular genetics and biology of these tumors, in effective use of preoperative diagnostic tools, and in appropriate long-term follow-up care. Studies of the roles of oncogenes, growth factors, and familial susceptibility factors offer the potential for further improvement in making early, accurate diagnoses. Objective prognostic scoring systems, now under development, can accurately separate the minority of papillary and follicular thyroid cancer patients at high risk for recurrence and mortality from the majority who do not need aggressive treatment. These systems will permit effective design of future studies of the impact on disease outcome of radioactive iodine treatment and follow-up testing by new imaging methods on disease outcome.

Thyroid nodularity and chromosome aberrations among women in areas of high background radiation in China

Thyroid nodularity following continuous low-dose radiation exposure in China was determined in 1,001 women aged 50-65 years who resided in areas of high background radiation (330 mR/yr) their entire lives, and in 1,005 comparison subjects exposed to normal levels of radiation (114 mR/yr). Cumulative doses to the thyroid were estimated to be of the order of 14 cGy and 5 cGy, respectively. Personal interviews and physical examinations were conducted, and measurements were made of serum thyroid hormone levels, urinary iodine concentrations, and chromosome aberrations in circulating lymphocytes. For all nodular disease, the prevalences in the high background and control areas were 9.5% and 9.3%, respectively. For single nodules, the prevalences were 7.4% in the high background area and 6.6% in the control area (prevalence ratio = 1.13; 95% confidence interval = 0.82-1.55). There were no differences found in serum levels of thyroid hormones. Women in the high background region, however, had significantly lower concentrations of urinary iodine and significantly higher frequencies of stable and unstable chromosome aberrations. Increased intake of allium vegetables such as garlic and onions was associated with a decreased risk of nodular disease, which seems consistent with experimental studies suggesting that allium compounds can inhibit tumor growth and proliferation. The prevalence of mild diffuse goiter was higher in the high background radiation region, perhaps related to a low dietary intake of iodine. These data suggest that continuous exposure to low-level radiation throughout life is unlikely to appreciably increase the risk of thyroid cancer. However, such exposure may cause chromosomal damage.

Thyroid nodularity after childhood irradiation for lymphoid hyperplasia: a comparison of questionnaire and clinical findings

Ionizing radiation is a well-established cause of thyroid cancer and nodularity, however, important questions relating to the magnitude of the risk following low-dose medical exposures remain unresolved. To address these issues, we conducted a follow-up study of 1590 individuals treated between 1938 and 1969 with X-rays for childhood lymphoid hyperplasia (av. thyroid dose = 24 cGy) and 1499 individuals treated with surgery only. Thyroid nodularity was determined from self-administered questionnaires completed by 1195 irradiated and 1063 surgically-treated subjects and from clinical examinations of 602 irradiated and 457 non-irradiated subjects. A much higher relative risk (RR) for radiation-induced thyroid nodules was estimated from the questionnaire than from the clinical examination data, 15.8 and 2.7, respectively. (The corresponding estimates of excess RR per cGy were 64 and 7%). Analysis of the examination data revealed a strong dose-response relationship, similar excess RR/cGy for males and females, and an inverse relationship with age at exposure. Although the thyroid gland is one of the most sensitive organs to the neoplastic effects of radiation, the radiation-induced risk of thyroid nodularity reported from questionnaire studies may over-estimate the true risk.

Phenolic and tyrosyl ring iodothyronine deiodination by the Caco-2 human colon carcinoma cell line

Thyroid hormone metabolism was studied in the human Caco-2 colon carcinoma cell line, which at confluence exhibits several functions of differentiated enterocytes. Cells were harvested two to 17 days after reaching confluence. Intact cells and homogenates were tested for deiodination of [125I]-labeled substrates. Small amounts of thyroxine (T4) were converted by homogenates to 3,3',5'-triiodothyronine (rT3), 3,3'-diiodothyronine (3,3'-T2), and 1-, with no detectable production of 3,5,3'-triiodothyronine (T3) by homogenates or cells. rT3 was converted to 3,3'-T2 and 1- with an apparent Michaelis constant (Km) for rT3 of 24 nmol/L; 6-n-propyl-2-thiouracil (PTU) had a 50% inhibitory concentration of 30 nmol/L and abolished rT3 5'-deiodination at 1 mmol/L in the presence of 20 mmol/L dithiothreitol (DTT). T3 was deiodinated to 3,3'-T2 and 3'-monoiodothyronine (3'-T1) with an apparent Michaelis constant (Km) for T3 of 5.7 nmol/L; this reaction was not inhibited by 1 mmol/L PTU. Phenolic and tyrosyl ring deiodinating activities were maximal four and six days, respectively, after the cells reached confluence. Homogenates of cells grown in standard medium containing fetal calf serum had fivefold higher rT3 5'-deiodinating activity than cells grown in a serum-free defined culture medium, reflecting a fivefold difference in the apparent Vmax with no difference in the apparent Km for rT3. There was no difference in T3 5-deiodination rates in homogenates of Caco-2 cells grown in the two media until 12 days postconfluence, when cells grown in standard medium had higher activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypothyroidism. Don't treat patients who don't have it

An erroneous diagnosis of hypothyroidism causes unnecessary expense and inconvenience for patients, may result in needless and possibly unsafe treatment, and could delay the correct diagnosis. The erroneous diagnosis is often reversed by a second opinion, thereby causing loss of patient confidence and damage to pride and self-esteem in the initial physician. To avoid these problems, the physician should look for the cause of the hypothyroidism, which is easily and reliably established in about 95% of patients. In the rare instance that one is not evident, it may be prudent for the primary care physician to seek consultation before prescribing lifelong thyroid hormone replacement therapy.

Effect of age on tests of intestinal and hepatic function in healthy humans

We studied intestinal function and hepatic microsomal phase I monooxygenase function in healthy, free-living subjects, aged 19-91 yr. In subjects (n = 114) given a diet including 100 g/day of fat, fecal fat in a 72-h collection did not increase with advancing age. D-Xylose excretion (n = 54) following a 25-g oral load significantly declined with increasing age, but a concomitant decline in creatinine clearance suggested a decrease in renal function rather than an absorptive defect. Furthermore, there was no evidence for an age-associated increase in bile salt deconjugation by intestinal bacteria as shown by the glycocholate breath test (n = 60). Finally, there was no evidence for a decrease in hepatic microsomal function with advancing age as measured by the aminopyrine breath test (n = 60). We conclude that digestive/absorptive and hepatic microsomal phase I monooxygenase function are well preserved in healthy humans throughout life.

Lymphadenopathy in primary biliary cirrhosis: CT observations

The authors retrospectively evaluated computed tomographic (CT) scans obtained in 21 patients with primary biliary cirrhosis, 13 of whom subsequently underwent liver transplantation. Evidence of enlarged lymph nodes, primarily in the gastrohepatic ligament and porta hepatis, was seen on CT scans in 17 patients (81%). Lymphadenopathy also occurred in unusual sites for benign adenopathy, including the paracardiac (24%) and mesenteric (19%) lymph nodes. Surgical or autopsy confirmation of enlarged lymph nodes was made in 13 patients, and histologic analysis of the specimens revealed reactive hyperplasia, sinus hyperplasia, sinus histiocytosis, fibrosis, or normal architecture in these enlarged nodes. The authors conclude that lymphadenopathy is a frequent CT finding in primary biliary cirrhosis and that recognition can help prevent misdiagnosis of lymphoma or metastatic disease.

Arthralgias as a presenting manifestation of primary biliary cirrhosis

Two patients presenting with arthralgias had associated minor elevations in liver enzymes. Each patient's serum had a cytoplasmic pattern of fluorescence on HEp-2 cells which led to the detection of antimitochondrial antibodies. Liver biopsy in both patients revealed primary biliary cirrhosis. Awareness of this limited, articular presentation of primary biliary cirrhosis may result in early treatment and the potential to arrest liver damage in some patients.

Management of biliary obstruction. A comparison of percutaneous, endoscopic, and operative techniques

Surgery for obstructive jaundice is being challenged by endoscopic and percutaneous techniques. To compare their safety and efficacy, the courses of 157 patients treated for biliary obstruction were examined. Outcome was judged by mortality, complications, and need for further intervention. Forty-eight patients underwent endoscopic papillotomy (43 [90%] had stone disease) with two deaths and 11 cases of (23% incidence) of cholangitis. Pancreatitis developed in 9 (19%). Twenty-seven patients (56%) required further endoscopic, percutaneous, or surgical intervention. Sixty-five patients underwent transhepatic drainage (58 [89%] had malignant neoplasms) with a 28% (n = 18) mortality rate. Cholangitis developed in 26 (40%), and 50 (77%) required further transhepatic or surgical intervention. Forty-four patients underwent surgery (22 [50%] had stone disease and 12 [27%] had malignant neoplasms) with a 4.5% (n = 2) mortality rate. Cholangitis developed in 3 (7%), pancreatitis developed in 2 (4.5%), and bleeding developed in 1 (2%). Eight (18%) required further intervention. While endoscopic papillotomy provides efficacious treatment for stone disease, surgery provides a more expeditious, less morbid relief for malignant obstruction.

Clinical use of serum enzymes in liver disease

Some of the many enzymes found in hepatocytes can be measured in the serum and are used as tests of liver function. We now review the current knowledge of their physiology and pathophysiology and outline their clinical usefulness. We divide them into two categories: enzymes that primarily reflect cholestasis, such as the alkaline phosphatase, the 5'-nucleotidase, and the gamma-glutamyl transpeptidase, and those that primarily reflect hepatocellular necrosis, such as the aminotransferases. We also briefly discuss several enzymes of more limited usefulness.

Inhibition of human neutrophil and Pseudomonas elastases by the amyloid P-component: a constituent of elastic fibers and amyloid deposits

The amyloid P-component (AP), a ubiquitous component of amyloid fibrils, is also a plasma protein and a connective tissue constituent. Its proximity to elastin, in particular, suggested that AP might serve to protect elastic tissue from hydrolytic enzymes. The inhibition of pancreatic elastase by AP has been reported. In the present study, the effects of AP on human neutrophil elastase and Pseudomonas elastase were investigated, and AP was shown to interfere with the cleavage of soluble elastin. As indicated by Michaelis-Menten analysis, AP is acting as a noncompetitive inhibitor. C-reactive protein, which is structurally similar to AP, had no effect on either elastase. AP was also found to inhibit the degradation of secondary amyloid fibrils by neutrophil elastase when these structures were first partially purified and then reexposed to AP. AP's ability to inhibit elastase was compared with alpha-1 antitrypsin in the presence and absence of oxidizing agents. These substances, which are released by inflammatory cells, are known to abrogate alpha-1 antitrypsin's anti-protease capacity. This contributes to elevated levels of free proteases in the circulation and extravascular spaces during severe inflammation. AP is not susceptible to oxidation and remains a functional inhibitor under these conditions. The potential role of AP as an elastase inhibitor is discussed.

Triiodothyronine exerts direct cell-specific regulation of thyrotropin-releasing hormone gene expression in the hypothalamic paraventricular nucleus

Thyroid hormone administered systemically exerts negative feedback control of biosynthesis of the TRH pro-hormone in the hypothalamic paraventricular nucleus (PVN), the origin of neurons that regulate anterior pituitary TSH secretion, but not in any other group of TRH-synthesizing neurons in the brain. To determine whether this response is mediated by direct effects on PVN neurons, we studied the effect of unilateral stereotaxic implants of L-T3 into the anterior hypothalamus on the concentration of pro-TRH mRNA and pro-TRH in the PVN of hypothyroid rats. Because hypothalamic-pituitary-thyroid function is also regulated by central catecholamines, we also determined the effect of unilateral ablation of ascending catecholaminergic fibers to one side of the PVN by stereotaxic injection of 6-hydroxydopamine or transection of ascending catecholaminergic pathways. T3-implanted hypothyroid animals showed a marked reduction in pro-TRH mRNA and immunoreactive pro-TRH in medial parvocellular neurons of the PVN on the same side as the implant, but not in contralateral PVN neurons or TRH-synthesizing neurons in other hypothalamic regions. In contrast, hypothyroid animals implanted with pellets of hormonally inactive 3,5-diiodo-L-thyronine showed intense symmetric hybridization and immunoreaction product in both wings of the PVN. Despite marked unilateral reduction in the catecholamine innervation to the PVN, no reduction in pro-TRH mRNA or immunoreactive pro-TRH was observed in the PVN on the affected side compared to that on the unaffected side. These studies demonstrate that negative feedback regulation of thyroid hormone occurs directly on TRH neurons and is restricted only to those in the PVN tuberoinfundibular system.

Fat-soluble vitamin nutriture in primary biliary cirrhosis

We measured serum levels of vitamins A, E, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D, as well as levels of abnormal (des-gamma-carboxy) prothrombin, in 52 patients with primary biliary cirrhosis. Decreased serum levels of retinol (vitamin A) and 25-hydroxyvitamin D and elevated levels of abnormal prothrombin were common in these patients and correlated with the histologic stage of the disease and with the clinical severity of disease as judged by elevated serum bilirubin levels and decreased serum albumin levels. The increased levels of abnormal prothrombin were due primarily to vitamin K deficiency but also, in part, to the severity of the liver disease itself. Vitamin E deficiency was rare. Only 1 patient had clinical manifestations of fat-soluble vitamin deficiency, night blindness, and gastrointestinal bleeding related to a marked prolongation of the prothrombin time. Deficiencies of fat-soluble vitamins are most likely to be present in jaundiced patients with long-standing, severe cholestasis. We suggest that fat-soluble vitamin status be determined in all patients with primary biliary cirrhosis by appropriate blood tests and that vitamin supplements be given only to those patients who require them.

Inhibition of thyroxine 5'-deiodination type II in cultured human placental cells by cortisol, insulin, 3', 5'-cyclic adenosine monophosphate, and butyrate

The regulation of conversion of thyroxine (T4) to 3,5,3'-triiodothyronine (T3) by the type II iodothyronine deiodinating pathway was studied in normal human placental cells cultured from the chorionic membrane. T4 5'-deiodination was measured in cell sonicates after intact cells were incubated with test agents for 24 to 48 hours. Stimulation of T4 5'-deiodination occurred to a similar degree after depriving cells of thyroid hormone in serum-free medium and in medium containing 10% calf serum. Cortisol at 10 to 100 nmol/L in serum-free medium inhibited T4 5'-deiodination up to 36%, and 1 to 100 nmol/L of insulin inhibited deiodination up to 50%. Dibutyryl-cyclic AMP (dbcAMP) inhibited deiodination, but this appeared to result from the inhibitory effects of butyrate. Addition to the culture media of 8-bromo-cAMP, cholera toxin, and theophylline each caused partial inhibition of T4 5'-deiodination, strongly suggesting an inhibitory effect of raised intracellular cAMP. Neither alpha- nor beta-adrenergic agonists had any effect when added to the culture medium, nor did glucagon or cysteamine. These results demonstrate a complex, multihormonal control of human placental type II iodothyronine deiodination, and suggest that changes in the activity of this pathway may result in altered intracellular, and conceivably circulating, T3 concentrations in states of cortisol excess and marked hyperinsulinism. The factor that regulates type II deiodination via cAMP remains to be identified.