651
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Bell L, Hunter AL, Kyriacou A, Mukherjee A, Syed AA. Clinical diagnosis of Graves' or non-Graves' hyperthyroidism compared to TSH receptor antibody test. Endocr Connect 2018; 7. [PMID: 29531156 PMCID: PMC5881005 DOI: 10.1530/ec-18-0082] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND TSH receptor antibody (TRAb) is considered the gold standard diagnostic test for the autoimmunity of Graves' disease (GD), which is commonly diagnosed clinically. AIM To evaluate the true positive (sensitivity) and true negative (specificity) rates of clinical diagnosis of GD or non-GD hyperthyroidism compared to the TRAb test. SETTING University teaching hospital in North West England. PARTICIPANTS Patients in the Endocrinology service who had a TRAb measurement between December 2009 and October 2015. METHODS Electronic patient records were studied retrospectively for a pre-TRAb clinical diagnosis of GD or non-GD hyperthyroidism. We examined descriptive statistics and binary classification tests; Fisher exact test was used to analyse contingency tables. RESULTS We identified 316 patients with a mean age of 45 (range, 17-89) years; 247 (78%) were women. Compared to the TRAb result, clinical diagnosis had a sensitivity of 88%, specificity 66%, positive predictive value 72%, negative predictive value 84%, false negative rate 12%, false positive rate 34%, positive likelihood ratio 2.6 and negative likelihood ratio 0.2 (P < 0.0001). CONCLUSIONS Clinicians were liable to both over- and under-diagnose GD. The TRAb test can help reduce the number of incorrect or unknown diagnoses in the initial clinical assessment of patients presenting with hyperthyroidism.
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Affiliation(s)
- Lauren Bell
- Faculty of BiologyMedicine and Health, University of Manchester, Manchester, UK
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
| | - Ann Louise Hunter
- Faculty of BiologyMedicine and Health, University of Manchester, Manchester, UK
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
| | - Angelos Kyriacou
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
- CEDM Centre of EndocrinologyDiabetes & Metabolism, Limassol, Cyprus
| | - Annice Mukherjee
- Faculty of BiologyMedicine and Health, University of Manchester, Manchester, UK
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
| | - Akheel A Syed
- Faculty of BiologyMedicine and Health, University of Manchester, Manchester, UK
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
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652
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Lee JE, Lee DH, Oh TJ, Kim KM, Choi SH, Lim S, Park YJ, Park DJ, Jang HC, Moon JH. Validity and Reliability of the Korean Version of the Hyperthyroidism Symptom Scale. Endocrinol Metab (Seoul) 2018; 33:70-78. [PMID: 29589389 PMCID: PMC5874198 DOI: 10.3803/enm.2018.33.1.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 11/15/2017] [Accepted: 12/26/2017] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Thyrotoxicosis is a common disease resulting from an excess of thyroid hormones, which affects many organ systems. The clinical symptoms and signs are relatively nonspecific and can vary depending on age, sex, comorbidities, and the duration and cause of the disease. Several symptom rating scales have been developed in an attempt to assess these symptoms objectively and have been applied to diagnosis or to evaluation of the response to treatment. The aim of this study was to assess the reliability and validity of the Korean version of the hyperthyroidism symptom scale (K-HSS). METHODS Twenty-eight thyrotoxic patients and 10 healthy subjects completed the K-HSS at baseline and after follow-up at Seoul National University Bundang Hospital. The correlation between K-HSS scores and thyroid function was analyzed. K-HSS scores were compared between baseline and follow-up in patient and control groups. Cronbach's α coefficient was calculated to demonstrate the internal consistency of K-HSS. RESULTS The mean age of the participants was 34.7±9.8 years and 13 (34.2%) were men. K-HSS scores demonstrated a significant positive correlation with serum free thyroxine concentration and decreased significantly with improved thyroid function. K-HSS scores were highest in subclinically thyrotoxic subjects, lower in patients who were euthyroid after treatment, and lowest in the control group at follow-up, but these differences were not significant. Cronbach's α coefficient for the K-HSS was 0.86. CONCLUSION The K-HSS is a reliable and valid instrument for evaluating symptoms of thyrotoxicosis in Korean patients.
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Affiliation(s)
- Jie Eun Lee
- Department of Internal Medicine, Seoul National University Healthcare System Gangnam Center, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hwa Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tae Jung Oh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyoung Min Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung Hee Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Young Joo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Do Joon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hak Chul Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Hoon Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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653
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Lee JE, Lee DH, Oh TJ, Kim KM, Choi SH, Lim S, Park YJ, Park DJ, Jang HC, Moon JH. Clinical Feasibility of Continuously Monitored Data for Heart Rate, Physical Activity, and Sleeping by Wearable Activity Trackers in Patients with Thyrotoxicosis: Protocol for a Prospective Longitudinal Observational Study. JMIR Res Protoc 2018; 7:e49. [PMID: 29467121 PMCID: PMC5842324 DOI: 10.2196/resprot.8119] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 11/22/2017] [Accepted: 12/16/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Thyrotoxicosis is a common disease caused by an excess of thyroid hormones. The prevalence of thyrotoxicosis about 2% and 70-90% of thyrotoxicosis cases are caused by Graves' disease, an autoimmune disease, which has a high recurrence rate when treated with antithyroid drugs such as methimazole or propylthiouracil. The clinical symptoms and signs of thyrotoxicosis include palpitation, weight loss, restlessness, and difficulty sleeping. Although these clinical changes in thyrotoxicosis can be detected by currently available wearable activity trackers, there have been few trials of the clinical application of wearable devices in patients with thyrotoxicosis. OBJECTIVE The aim of this study is to investigate the clinical applicability of wearable device-generated data to the management of thyrotoxicosis. We are analyzing continuously monitored data for heart rate, physical activity, and sleep in patients with thyrotoxicosis during their clinical course after treatment. METHODS Thirty thyrotoxic patients and 10 control subjects were enrolled in this study at Seoul National University Bundang Hospital. Heart rate, physical activity, and sleep are being monitored using a Fitbit Charge HR or Fitbit Charge 2. Clinical data including anthropometric measures, thyroid function test, and hyperthyroidism symptom scale are recorded. RESULTS Study enrollment began in December 2016, and the intervention and follow-up phases are ongoing. The results of the data analysis are expected to be available by September 2017. CONCLUSIONS This study will provide a foundational feasibility trial of the clinical applications of biosignal measurements to the differential diagnosis, prediction of clinical course, early detection of recurrence, and treatment in patients with thyrotoxicosis. TRIAL REGISTRATION ClinicalTrials.gov NCT03009357; https://clinicaltrials.gov/ct2/show/NCT03009357 (Archived by WebCite at http://www.webcitation.org/6wh4MWPm2).
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Affiliation(s)
- Jie-Eun Lee
- Department of Internal Medicine, Seoul National University Healthcare System Gangnam Center, Seoul, Republic Of Korea
| | - Dong Hwa Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic Of Korea
| | - Tae Jung Oh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic Of Korea
| | - Kyoung Min Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic Of Korea
| | - Sung Hee Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic Of Korea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic Of Korea
| | - Young Joo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic Of Korea
| | - Do Joon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic Of Korea
| | - Hak Chul Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic Of Korea
| | - Jae Hoon Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic Of Korea
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654
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No evidence of a causal relationship between hypothyroidism and glaucoma: A Danish nationwide register-based cohort study. PLoS One 2018; 13:e0192311. [PMID: 29444121 PMCID: PMC5812610 DOI: 10.1371/journal.pone.0192311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 01/22/2018] [Indexed: 02/06/2023] Open
Abstract
Background An interrelationship between hypothyroidism and glaucoma, due to a shared autoimmune background or based on deposition of mucopolysaccharides in the trabecular meshwork in the eye, has been suggested but is at present unsubstantiated. Therefore, our objective was to investigate, at a nationwide and population-based level, whether there is such an association. Subjects and methods Observational cohort study using record-linkage data from nationwide Danish health registers. 121,799 individuals diagnosed with a first episode of hypothyroidism were identified and were matched with 4 non-hypothyroid controls according to age and sex. Prevalence of glaucoma was recorded and cases and controls were followed over a mean of 7.1 years (range 0–17). Logistic and Cox regression models were used to assess the risk of glaucoma before and after the diagnosis of hypothyroidism, respectively. Results Overall, we found a higher prevalence of glaucoma in subjects with hypothyroidism as compared to controls (4.6% vs. 4.3%, p < 0.001). Prior to the diagnosis of hypothyroidism, the odds ratio (OR) was significantly increased for glaucoma [1.09; 95% confidence interval (CI): 1.04–1.13]. Based on the Cox regression model, there was no increased risk of glaucoma after the diagnosis of hypothyroidism [hazard ratio (HR) 1.00; 95% CI: 0.96–1.06], and the HR decreased further after adjusting for pre-existing co-morbidity (0.88; 95% CI: 0.84–0.93). Conclusions There was an increased risk of glaucoma before but not after the diagnosis of hypothyroidism, suggesting that screening for glaucoma in hypothyroid individuals is unwarranted.
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655
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Abad S, Héran F, Terrada C, Bielefeld P, Sène D, Trad S, Saadoun D, Sève P. [Management of orbital inflammation in internal medicine. Proposal for a diagnostic work-up]. Rev Med Interne 2018; 39:746-754. [PMID: 29398045 DOI: 10.1016/j.revmed.2017.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 12/28/2017] [Indexed: 12/17/2022]
Abstract
Inflammatory orbitopathies relate to an inflammatory state originating within the orbit and its adnexes, except the inner ocular globe. Orbital inflammation (OI) may be either localized manifestation of a proven or like autoimmune disease, or local response from immune system against infectious, structural or tumoral antigens. We review the clinical manifestations of OI, which provide helpful clues to the diagnosis and describe the inflammatory, infectious and neoplastic conditions classically associated with OI. Autoimmune diseases are probably the most common causes of OI associated with a bilateral dacryoadenitis (e.g., sarcoidosis, granulomatosis with polyangiitis, IgG4-related disease). We focused on a major part of the IgG4-RD spectrum, the IgG4-related orbital disease which has been recently described and the idiopathic orbital inflammation syndrome that one should consider in patients 40 years of age or older with non specific inflammation OI on biopsy but without underlying local or systemic disease. An algorithm for the diagnostic approach of OI was proposed. If systemic explorations fail to diagnose an underlying disease, histopathologic control is required for distinguishing non-specific OI from other differential diagnosis, especially lymphoma. In the cases of pure myositic locations and posteriorly located tumours where biopsy could damage to the optic nerve, analysis of orbital lesions in T2W IRM sequence may be helpful to distinguish idiopathic OI (IOI) from lymphoma. When the diagnostic work-up fails, a corticosteroid trial could be used, but its beneficial effect has to be cautiously interpretated before definitively diagnosing IOI. Finally, treatments used in main infllammatory orbitopathies were also reviewed.
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Affiliation(s)
- S Abad
- UMR1125, LI2P, service de médecine interne, hôpital Avicenne, faculté de médecine SMBH, université Paris 13, Sorbonne Paris Cité, Assistance publique-hôpitaux de Paris (AP-HP), 125, route de Stalingrad, 93000 Bobigny cedex 09, France.
| | - F Héran
- Service d'imagerie, Fondation Adolphe-de-Rothschild, 25, rue Manin, 75019 Paris, France.
| | - C Terrada
- Service d'ophtalmologie, hôpital Pitié-Salpêtrière, groupe hospitalier (GH) Pitié-Salpêtrière, université Paris 6, AP-HP, 47-83, boulevard de l'hôpital, 75013 Paris, France; Centre Roule-Péretti, 169, avenue Achille-Péretti, 92200 Neuilly-sur-Seine, France.
| | - P Bielefeld
- Service de médecine interne et maladies systémiques, médecine interne 2, hôpital du Bocage, 2, boulevard Maréchal-de-Lattre-de-Tassigny, BP 77908, 21079 Dijon cedex, France.
| | - D Sène
- Service de médecine interne B, hôpital Lariboisière, groupe hospitalier Saint-Louis-Lariboisière-Fernand-Widal, université Sorbonne Paris Cité- Paris Diderot, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France.
| | - S Trad
- Service de médecine interne, hôpital Ambroise-Paré, AP-HP, 9, avenue du Général-de-Gaulle, 92100 Boulogne-Billancourt, France; Université de Versailles-Saint-Quentin-en-Yvelines (UVSQ), 55, avenue de Paris, 78000 Versailles, France.
| | - D Saadoun
- Department of internal medicine and clinical immunology, groupe hospitalier Pitié-Salpêtrière, université Pierre-et-Marie Curie, AP-HP, Paris 6, 75013 Paris, France; DHU I2B, inflammation, immunopathology, biotherapy, UPMC, Paris 6, 75013 Paris, France; Centre national de référence des maladies auto-immunes et systémiques rares, 75013 Paris, France.
| | - P Sève
- Service de médecine interne, hôpital de la Croix-Rousse, hospices Civils de Lyon, université de Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France.
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656
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Smith TJ. New advances in understanding thyroid-associated ophthalmopathy and the potential role for insulin-like growth factor-I receptor. F1000Res 2018; 7:134. [PMID: 29744034 PMCID: PMC5795270 DOI: 10.12688/f1000research.12787.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 01/15/2023] Open
Abstract
Thyroid-associated ophthalmopathy (TAO), a localized periocular manifestation of the autoimmune syndrome known as Graves’ disease, remains incompletely understood. Discussions of its pathogenesis are generally focused on the thyrotropin receptor, the proposed role for which is supported by substantial evidence. Considerations of any involvement of the insulin-like growth factor-I receptor (IGF-IR) in the disease are frequently contentious. In this brief, topically focused review, I have attempted to provide a balanced perspective based entirely on experimental results that either favor or refute involvement of IGF-IR in TAO. Discussion in this matter seems particularly timely since the currently available treatments of this disfiguring and potentially sight-threatening disease remain inadequate. Importantly, no medical therapy has thus far received approval from the US Food and Drug Administration. Results from a very recently published clinical trial assessing the safety and efficacy of teprotumumab, an inhibitory human anti–IGF-IR monoclonal antibody, in active, moderate to severe TAO are extremely encouraging. That double-masked, placebo-controlled study involved 88 patients and revealed unprecedented clinical responses in the improvement of proptosis and clinical activity as well as a favorable safety profile. Should those results prove reproducible in an ongoing phase III trial, therapeutic inhibition of IGF-IR could become the basis for paradigm-shifting treatment of this vexing disease.
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Affiliation(s)
- Terry J Smith
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center and Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA
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657
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Modulation of hyaluronan polymer size regulates proliferation of perimysial fibroblasts in thyroid eye disease. Biochem Biophys Res Commun 2018; 496:1376-1381. [DOI: 10.1016/j.bbrc.2018.02.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/04/2018] [Indexed: 11/22/2022]
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658
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Moayerifar M, Koohmanaee S, Moayerifar M, Nakhochari AM, Rad AH, Dalili S. Malignant struma ovarii in an 11-year-old girl. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2017.09.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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659
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Suwansaksri N, Preechasuk L, Kunavisarut T. Nonthionamide Drugs for the Treatment of Hyperthyroidism: From Present to Future. Int J Endocrinol 2018; 2018:5794054. [PMID: 29849619 PMCID: PMC5937426 DOI: 10.1155/2018/5794054] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 03/11/2018] [Indexed: 12/20/2022] Open
Abstract
Hyperthyroidism is a common endocrine disease. Although thionamide antithyroid drugs are the cornerstone of hyperthyroidism treatment, some patients cannot tolerate this drug class because of its serious side effects including agranulocytosis, hepatotoxicity, and vasculitis. Therefore, nonthionamide antithyroid drugs (NTADs) still have an important role in controlling hyperthyroidism in clinical practice. Furthermore, some situations such as thyroid storm or preoperative preparation require a rapid decrease in thyroid hormone by combination treatment with multiple classes of antithyroid drugs. NTADs include iodine-containing compounds, lithium carbonate, perchlorate, glucocorticoid, and cholestyramine. In this narrative review, we summarize the mechanisms of action, indications, dosages, and side effects of currently used NTADs for the treatment of hyperthyroidism. In addition, we also describe the state-of-the-art in future drugs under development including rituximab, small-molecule ligands (SMLs), and monoclonal antibodies with a thyroid-stimulating hormone receptor (TSHR) antagonist effect.
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Affiliation(s)
| | - Lukana Preechasuk
- Siriraj Diabetes Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tada Kunavisarut
- Division of Endocrine and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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660
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Yao QM, Li L, Song ZY, Wang B, Qin Q, An XF, Zhang JA. Elevated Interleukin-36α And CD4 +IL-36α +T Cells Are Involved in the Pathogenesis of Graves' Disease. Front Endocrinol (Lausanne) 2018; 9:591. [PMID: 30356900 PMCID: PMC6190875 DOI: 10.3389/fendo.2018.00591] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/18/2018] [Indexed: 11/13/2022] Open
Abstract
Background: IL-36α is involved in the pathogenesis of a variety of autoimmune diseases, but the relationship between IL-36α and Graves' disease (GD) has rarely investigated. In the present study, we aimed to explore the expression of IL-36α and elucidate the potential role of IL-36α in GD. Methods: The expression of IL-36α mRNA in peripheral blood mononuclear cells (PBMCs) from 32 newly diagnosed GD patients, 15 refractory GD patients and 30 normal controls (NC) was examined using quantitative real-time polymerase chain reaction (qRT-PCR). The level of IL-36α in serum from 46 newly diagnosed GD patients, 10 refractory GD patients and 24 NC was measured using enzyme linked immunosorbent assay (ELISA). The percentage of CD4+IL-36α+T cells was detected by flow cytometry. PBMCs from newly diagnosed GD patients and NC group were cultured in the presence or absence of recombinant human IL-36α, and the expression levels of IFN-γ, TNF-α, IL-6, and IL-17A in culture supernatant were detected by cytokine array. Results: The expression of IL-36α mRNA in newly diagnosed GD patients was significantly higher than that in NC group (P = 0.019). IL-36α mRNA expression was positively associated with thyrotropin receptor antibody (TRAb) (P = 0.004, r = 0.498) in newly diagnosed GD patients. The level of IL-36α in serum from newly diagnosed GD patients was significantly higher than that in refractory GD patients and NC group (P = 0.01; P = 0.007). The percentage of CD4+IL-36α+T cells in newly diagnosed GD patients was significantly higher than that in NC group (P = 0.030). In GD group, recombinant human IL-36α stimulation resulted in the increase of INF-γ, TNF-α, IL-6 and IL-17A (P = 0.015; P = 0.016; P = 0.039; P = 0.017). Conclusion: IL-36α and CD4+IL-36α+T cells may be involved in the pathogenesis of GD by promoting the production of Th1, Th2, and Th17 cytokines.
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Affiliation(s)
- Qiu-ming Yao
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Ling Li
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Zhen-Yu Song
- Department of Urology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Bin Wang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Qiu Qin
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Xiao-fei An
- Department of Endocrinology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Jin-an Zhang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
- *Correspondence: Jin-an Zhang
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661
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Jia X, Wang B, Yao Q, Li Q, Zhang J. Variations in CD14 Gene Are Associated With Autoimmune Thyroid Diseases in the Chinese Population. Front Endocrinol (Lausanne) 2018; 9:811. [PMID: 30700980 PMCID: PMC6343429 DOI: 10.3389/fendo.2018.00811] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 12/24/2018] [Indexed: 12/12/2022] Open
Abstract
Autoimmune thyroid diseases (AITDs) are chronic organ-specific autoimmune diseases and mainly include Graves' disease (GD) and Hashimoto's thyroiditis (HT). CD14 is an important component of the immune system as a receptor for gram-negative lipopolysaccharide (LPS). The genetic polymorphisms of CD14 have been confirmed to be associated with a variety of autoimmune diseases. However, its relationship with AITDs is still unclear. The study was aimed to determine whether four single nucleotide polymorphisms (rs2915863, rs2569190, rs2569192, and rs2563298) of CD14 are associated with AITDs and its subgroups of GD and HT. The results showed significant association of rs2915863 and rs2569190 with GD. The frequencies of rs2915863 genotypes and T allele in patients with GD differed significantly from their controls (P = 0.007 and P = 0.021, respectively). For rs2569190, frequencies of genotypes and G allele in GD patients also showed positive P-values (P = 0.038 and P = 0.027, respectively). The correlations between these two loci and GD are more pronounced in female GD patients and patients with a family history. In genetic model analysis, the allele model, recessive model, and homozygous model of rs2569190 and rs2915863 embodied strong correlations with GD after the adjusting of age and gender (P = 0.014, P = 0.015, P = 0.009, and P = 0.014, P = 0.001, P = 0.006, respectively). However, these four sites are not related to HT. We firstly discovered the relationship between CD14 gene polymorphism and GD, and the results indicate that CD14 is an important risk locus for AITD and its SNPs may contribute to host's genetic predisposition to GD.
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Affiliation(s)
- Xi Jia
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Bing Wang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Qiuming Yao
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Qian Li
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Jinan Zhang
- Department of Endocrinology, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
- *Correspondence: Jinan Zhang
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662
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Salvi M. Graves’ Orbitopathy. ENCYCLOPEDIA OF ENDOCRINE DISEASES 2018:711-718. [DOI: 10.1016/b978-0-12-801238-3.98497-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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663
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Yoon JH, Kang HC. Interpretation of puzzling thyroid function tests. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2018. [DOI: 10.5124/jkma.2018.61.4.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jee Hee Yoon
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Ho-Cheol Kang
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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664
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Brandt F, Thvilum M, Hegedüs L, Brix TH. Hyperthyroid patients without Graves' orbitopathy are not at increased risk of developing glaucoma: a nationwide Danish register-based case-control study. Endocrine 2018; 59:137-142. [PMID: 29198022 DOI: 10.1007/s12020-017-1485-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 11/24/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Graves' disease (GD) and toxic nodular goiter (TNG) are associated with various comorbidities. However, it is unclarified whether TNG and GD without orbitopathy are associated with glaucoma. METHODS This was a case-control study using record-linkage data from nationwide Danish health registers. 28,461 patients with GD and 17,283 with TNG were included. Each case was age and sex matched with four non-hyperthyroid controls and followed over a mean period of 8 years. Data on glaucoma was obtained by record linkage within the National Danish Patient Register and/or the Danish National Prescription Registry. Logistic and Cox regression models were used to assess the risk of glaucoma before and after the diagnosis of GD and TNG. RESULTS Compared to controls, there was a significantly increased frequency of glaucoma in patients with GD (4.6 vs. 4.2%, P = 0.006) and in patients with TNG (6.2 vs. 5.7%, P = 0.003). Prior to the diagnosis of hyperthyroidism, the odds ratio (OR) for glaucoma was non-significant in GD (1.09, 95% CI: 1.00-1.18) but slightly increased in TNG (1.13, 95% CI: 1.02-1.24). However, in TNG the OR attenuated completely when only including patients without co-morbidity in the analysis (1.03, 95% CI: 0.93-1.14). After adjustment for pre-existing co-morbidity, the hazard ratio (HR) for glaucoma following GD and TNG was not significantly increased (HR 1.08, 95% CI: 0.98-1.18 and HR 1.10, 95% CI: 0.99-1.21, respectively). CONCLUSIONS Neither prior to nor following the diagnosis of GD and TNG had any significant association with glaucoma.
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Affiliation(s)
- F Brandt
- Department of Internal Medicine, Hospital of Southern Jutland, Sydvang 1, 6400, Sønderborg, Denmark.
- Department of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000, Odense, Denmark.
| | - M Thvilum
- Department of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000, Odense, Denmark
| | - L Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000, Odense, Denmark
| | - T H Brix
- Department of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000, Odense, Denmark
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665
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Conversion of standard retrospective patient-reported outcomes to momentary versions: cognitive interviewing reveals varying degrees of momentary compatibility. Qual Life Res 2017; 27:1065-1076. [DOI: 10.1007/s11136-017-1762-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2017] [Indexed: 01/23/2023]
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666
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Yang J, Yao LP, Dong MJ, Xu Q, Zhang J, Weng WW, Chen F. Clinical Characteristics and Outcomes of Propylthiouracil-Induced Antineutrophil Cytoplasmic Antibody-Associated Vasculitis in Patients with Graves' Disease: A Median 38-Month Retrospective Cohort Study from a Single Institution in China. Thyroid 2017; 27:1469-1474. [PMID: 29088997 DOI: 10.1089/thy.2017.0468] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND This study sought to investigate the clinical characteristics and outcomes of propylthiouracil (PTU)-induced antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis in patients with Graves' disease. METHODS Sixteen patients diagnosed with PTU-induced ANCA-associated vasculitis at the authors' hospital from January 2010 to June 2017 were analyzed retrospectively. RESULTS All 16 patients with PTU-induced ANCA-associated vasculitis were female. The mean age ± standard deviation of the patients was 39.4 ± 15.3 years (range 19-69 years), and the median time of onset was 36 months (range 1-193 months) post-PTU initiation. The median dose at the onset of PTU-induced ANCA-associated vasculitis was 150 mg/day (range 50-300 mg/day). All patients had a positive serum perinuclear staining pattern (p-ANCA) and antibodies directed against myeloperoxidase (anti-MPO). Six patients tested positive for both anti-MPO antibodies and antibodies directed against proteinase-3. Seven (43.8%) patients presented with involvement of a single organ. The kidney was the organ most commonly affected, as 12 (75%) patients were found to have disease involving this organ. PTU was stopped in all patients, corticosteroids were administered to two patients, and immunosuppressive agents and corticosteroids were administered to five patients. Three patients were lost to follow-up. However, the remaining patients achieved remission after a median follow-up period of 38 months (range 6-76 months). Patients who were positive for pANCA and displayed cytoplasmic staining showed negative findings at rates of approximately 53.8% (7/13) and 100% (6/6), respectively, following treatment. CONCLUSIONS PTU-induced ANCA-positive vasculitis occurs at varying times and after exposure to various doses of PTU. The condition has a milder course and has a better prognosis after PTU cessation.
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Affiliation(s)
- Jun Yang
- 1 Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, P.R. China
| | - Lin-Peng Yao
- 2 Department of Radiology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, P.R. China
| | - Meng-Jie Dong
- 1 Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, P.R. China
| | - Qin Xu
- 1 Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, P.R. China
| | - Jun Zhang
- 1 Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, P.R. China
| | - Wan-Wen Weng
- 1 Department of Nuclear Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, P.R. China
| | - Feng Chen
- 2 Department of Radiology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, P.R. China
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667
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Thvilum M, Brandt F, Brix TH, Hegedüs L. The interrelation between hypothyroidism and glaucoma: a critical review and meta-analyses. Acta Ophthalmol 2017; 95:759-767. [PMID: 28211200 DOI: 10.1111/aos.13412] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 01/07/2017] [Indexed: 01/12/2023]
Abstract
Data on the association between hypothyroidism and glaucoma are conflicting. We sought to shed light on this by conducting a critical review and meta-analyses. The meta-analyses were conducted in adherence with the widely accepted MOOSE guidelines. Using the Medical Subject Heading (MeSH) terms: hypothyroidism, myxoedema and glaucoma or intraocular pressure, case-control studies, cohort studies and cross-sectional studies were identified (PubMed) and reviewed. Using meta-analysis, the relative risk (RR) of coexistence of glaucoma and hypothyroidism was calculated. Based on the literature search, thirteen studies fulfilled the inclusion criteria and could be categorized into two groups based on the exposure. The designs of the studies varied considerably, and there was heterogeneity related to lack of power, weak phenotype classifications and length of follow-up. Eight studies had glaucoma (5757 patients) as exposure and hypothyroidism as outcome. Among these, we found a non-significantly increased risk of hypothyroidism associated with glaucoma (RR 1.65; 95% confidence interval [CI]: 0.97-2.82). Based on five studies (168 006 patients) with hypothyroidism as exposure and glaucoma as outcome, we found the risk of glaucoma to be significantly increased (RR 1.33; 95% CI: 1.13-1.58). Based on these meta-analyses, there seems to be an association between hypothyroidism and glaucoma, which does not seem to be the case between glaucoma and hypothyroidism. However, larger scale studies with better phenotype classification, longer follow-up and taking comorbidity and other biases into consideration are needed to address a potential causal relationship.
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Affiliation(s)
- Marianne Thvilum
- Department of Endocrinology and Metabolism; Odense University Hospital; Odense C Denmark
| | - Frans Brandt
- Department of Internal Medicine; Hospital of Southern Denmark; Sonderborg Denmark
| | - Thomas Heiberg Brix
- Department of Endocrinology and Metabolism; Odense University Hospital; Odense C Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism; Odense University Hospital; Odense C Denmark
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668
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Ferløv-Schwensen C, Brix TH, Hegedüs L. Death by Suicide in Graves' Disease and Graves' Orbitopathy: A Nationwide Danish Register Study. Thyroid 2017; 27:1475-1480. [PMID: 29084476 DOI: 10.1089/thy.2017.0365] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Graves' disease (GD) is associated with excess morbidity and mortality, but little is known about unnatural manners of death and the potential relation with Graves' orbitopathy (GO). This study investigated the risk of unnatural death in Graves' patients with and without orbitopathy compared to matched control populations. METHODS This was a cohort study covering all adult Danes (≥18 years) diagnosed with GD or GO during 1995-2012. Median follow-up time was 7.9 years (range 0-17.5 years). Utilizing the Danish Register of Causes of Death and the Danish National Patient Registry, 28,461 subjects with GD and 3965 with GO were identified and matched for age and sex with four subjects from the background population. The manner of death was identified, and hazard ratios (HR) for mortality due to unnatural deaths (accident, suicide, violence/homicide, and unknown) were calculated using Cox regression analyses, adjusted for pre-existing somatic and psychiatric morbidity. RESULTS In Graves' disease overall (GD + GO), there was an increased risk of death from unknown unnatural manners (HR = 2.01 [confidence interval (CI) 1.17-3.45], p = 0.012) and of suicide, although the latter difference was not with certainty statistically significant (HR = 1.43 [CI 1.00-2.04], p = 0.053). There was no significant difference in risk of death from suicide in GD subjects compared to their controls (HR = 1.27 [CI 0.85-1.89], p = 0.253). However, GO patients had a significantly higher risk of death from suicide (HR = 2.71 [CI 1.16-6.32], p = 0.022). CONCLUSIONS Mortality by suicide was increased in Graves' disease overall, most significantly in patients with GO, also after adjustment for pre-existing somatic and psychiatric disease. These findings indicate that GD and GO may have a significant role in the pathophysiological mechanisms of suicidal behavior. Beyond independent confirmation, reasons for this need to be explored in order to introduce preventive measures.
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Affiliation(s)
| | - Thomas Heiberg Brix
- Department of Endocrinology and Metabolism, Odense University Hospital , Odense, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital , Odense, Denmark
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669
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Thvilum M, Brandt F, Brix TH, Hegedüs L. Month of birth is associated with the subsequent diagnosis of autoimmune hypothyroidism. A nationwide Danish register-based study. Clin Endocrinol (Oxf) 2017; 87:832-837. [PMID: 28727153 DOI: 10.1111/cen.13425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 06/28/2017] [Accepted: 07/15/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The triggering of thyroid autoimmunity in the genetically susceptible remains a conundrum. Environmental exposures during gestation and/or early postnatally have proponents, as suggested in diabetes mellitus, with a higher incidence of births during spring and summer. Whether the development of autoimmune hypothyroidism (AIT) is influenced by month or season of birth is less clear. METHOD Nationwide cohort study of 111 565 individuals diagnosed with AIT and four euthyroid controls per case, matched according to age and sex, were identified from Danish health registers. Differences in month of birth across the year were evaluated by the Walter-Elwood test. The risk of patients with AIT being born in a certain month or season of the year was calculated using a Cox regression model. RESULTS There was a significant difference in birth month between cases and controls, P<.001. Individuals with AIT had a significantly increased risk of being born in June (Hazard ratio 1.04; 95% Confidence interval (CI): 1.02-1.08) and in the summer (June-August; HR 1.02; 95%CI: 1.01-1.04). CONCLUSION In this large-scale nationwide cohort study, we found a higher risk of AIT when born in the summer season or more specifically in June, supporting the hypothesis that seasonal variations in exposures-gestationally and/or early postnatally-may contribute to the development of AIT.
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Affiliation(s)
- Marianne Thvilum
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense C, Denmark
| | - Frans Brandt
- Department of Internal Medicine, Hospital of Southern Denmark, Sonderborg, Denmark
| | - Thomas Heiberg Brix
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense C, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense C, Denmark
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670
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Orbital flourine-18-fluorodeoxyglucose positron emission tomography in patients with Graves’ disease for evaluation of active inflammation. Nucl Med Commun 2017; 38:964-970. [DOI: 10.1097/mnm.0000000000000737] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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671
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Abstract
PURPOSE OF REVIEW This review provides an appraisal of recent evidence for or against selenium supplementation in patients with autoimmune thyroid diseases, and discusses possible effect mechanisms. RECENT FINDINGS Epidemiological data suggest an increased prevalence of autoimmune thyroid diseases under conditions of low dietary selenium intake. Two systematic reviews have evaluated controlled trials among patients with autoimmune thyroiditis and report that selenium supplementation decreases circulating thyroid autoantibodies. The immunomodulatory effects of selenium might involve reducing proinflammatory cytokine release. However, clinically relevant effects of selenium supplementation, including improvement in quality of life, are more elusive. In Graves' disease, some, but not all, trials indicate that adjuvant selenium supplementation enhances the restoration of biochemical euthyroidism, and might benefit patients with mild Graves' orbitopathy. SUMMARY The use of selenium supplementation as adjuvant therapy to standard thyroid medication may be widespread, but a growing body of evidence yields equivocal results. The available evidence from trials does not support routine selenium supplementation in the standard treatment of patients with autoimmune thyroiditis or Graves' disease. However, correction of moderate to severe selenium deficiency may offer benefits in preventing, as well as treating, these disorders. Molecular mechanisms have been proposed, but further studies are needed.
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Affiliation(s)
- Kristian H Winther
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
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672
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Abstract
PURPOSE OF REVIEW Hyperthyroidism in pregnant women should be adequately treated to prevent maternal and fetal complications. The treatment of choice in pregnancy is antithyroidal medications (ATDs). The risk of embryopathies associated with the use of Methimazole (MMI) and Propylthiouracil (PTU) in early pregnancy is a matter of clinical attention and concern. This review describes current evidence and how scientific findings are reflected in current clinical guidelines. RECENT FINDINGS Embryopathies after the use of ATDs were previously mainly described in case reports and considered rare. Recent large observational studies, including nonexposed control groups, have quantified an increased risk of embryopathies associated with use of ATDs during pregnancy. Findings suggest a risk of embryopathies with the use of both MMI and PTU, but the pattern of embryopathies differs, and embryopathies with the use of PTU appear less severe. SUMMARY Current guidelines highlight the need for clinical attention on the use of ATDs in early pregnancy. Patients managed on ATDs for the treatment of hyperthyroidism should be counseled to report a pregnancy as early as possible. PTU is the recommended treatment in early pregnancy, but if the risk of relapse or worsening of hyperthyroidism is considered low, it is suggested that ATD treatment can be withdrawn followed by frequent monitoring of thyroid function.
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Affiliation(s)
- Stine L Andersen
- aDepartment of Endocrinology bDepartment of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
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673
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Abstract
Graves' disease is the most frequent cause of hyperthyroidism in iodine-sufficient geographical areas and is characterized by the presence in patients' serum of autoantibodies directed against the thyrotropin receptor (TRAb) that cause overproduction and release of thyroid hormones. Clinical presentation results from both hyperthyroidism and underlying autoimmunity. The diagnosis is based on characteristic clinical features and biochemical abnormalities. If serum thyrotropin (TSH) is low, serum free thyroxine (FT4) and free triiodothyronine (FT3) concentrations should be measured to distinguish between subclinical (with normal circulating thyroid hormones) and overt hyperthyroidism (with increased circulating thyroid hormones). Graves' disease is treated with any of three effective and relatively safe initial treatment options: antithyroid drugs (ATDs), radioactive iodine ablation (RAIU), and surgery. Total thyroidectomy is favored in several clinical situations, such as intolerance, ineffectiveness or recurrence after ATD treatment, radioiodine therapy contraindicated, documented or suspected thyroid malignancy, one or more large thyroid nodules, coexisting moderate-to-severe active Graves' orbitopathy, women planning a pregnancy within 6 months. Whenever surgery is selected as treatment, selection of an expert high-volume thyroid surgeons is fundamental and careful preoperative management is essential to optimize surgical outcomes. Pretreatment with ATDs in order to promptly achieve the euthyroid state is recommended to avoid the risk of precipitating thyroid storm during surgery. For the majority of patients, euthyroidism is achieved after few weeks of ATD treatment. Beta-blockers, such as propranolol, are often added effectively to control hyperthyroid symptoms. Saturated solution of potassium iodide (SSKI) or potassium iodine (Lugol's solution), given for a short period prior to surgery, in order to reduce both thyroid hormone release and thyroid gland vascularity, is beneficial to decrease intra-operative blood loss.
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Affiliation(s)
- Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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674
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Kamboj A, Lause M, Kumar P. Ophthalmic manifestations of endocrine disorders-endocrinology and the eye. Transl Pediatr 2017; 6:286-299. [PMID: 29184810 PMCID: PMC5682375 DOI: 10.21037/tp.2017.09.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Disorders of the endocrine system usually manifest in a multi-organ fashion. More specifically, many endocrinopathies become apparent in the eye first through a variety of distinct pathophysiologic disturbances. The eye provides physicians with valuable clues for the recognition and management of numerous systemic diseases, including many disorders of the endocrine pathway. Recognizing ophthalmic manifestations of endocrine disorders is critical not only for rapid diagnosis and treatment, but also to prevent significant morbidity and mortality. In this review, we discuss relevant ophthalmic findings associated with key disorders of the pancreas, thyroid gland, and hypothalamic-pituitary axis, as well as with multiple hereditary endocrine syndromes. We have chosen to focus on diabetes mellitus (DM), Graves' ophthalmopathy, pituitary tumors, and some less common disorders that underscore the unique relationship between the eye and the endocrine system.
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Affiliation(s)
- Alisha Kamboj
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Michael Lause
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Priyanka Kumar
- Department of Ophthalmology, the Children's Hospital of Philadelphia, Philadelphia, PA, USA
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675
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Andersen SL, Lönn S, Vestergaard P, Törring O. Birth defects after use of antithyroid drugs in early pregnancy: a Swedish nationwide study. Eur J Endocrinol 2017; 177:369-378. [PMID: 28780518 DOI: 10.1530/eje-17-0314] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/02/2017] [Accepted: 07/31/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Antithyroid drugs (ATDs) may have teratogenic effects, but more evidence is needed on the risk and types of birth defects after the use of methimazole (MMI) and propylthiouracil (PTU). This study aimed to evaluate the association between the use of ATDs in early pregnancy and birth defects. DESIGN Swedish nationwide register-based cohort study. METHODS The study included 684 340 children live-born in Sweden from 2006 to 2012. Exposure groups defined by maternal ATD use in early pregnancy were MMI (n = 162); PTU (n = 218); MMI and PTU (n = 66); ATD before or after, but not in pregnancy (n = 1551) and non-exposed (never ATD (n = 682 343)). Outcome was cumulative incidence of birth defects diagnosed before two years of age. RESULTS The cumulative incidence of birth defects was not significantly different in children exposed to MMI (6.8%, P = 0.6) or PTU (6.4%, P = 0.4) vs non-exposed (8.0%). For subtypes of birth defects, MMI was associated with an increased incidence of septal heart defects (P = 0.02). PTU was associated with ear (P = 0.005) and obstructive urinary system malformations (P = 0.006). A case of choanal atresia was observed after exposure to both MMI and PTU. The incidence of birth defects in children born to mothers who received ATD before or after, but not in pregnancy, was 8.8% and not significantly different from non-exposed (P = 0.3), MMI exposed (P = 0.4) or PTU exposed (P = 0.2). CONCLUSIONS MMI and PTU were associated with subtypes of birth defects previously reported, but the frequency of ATD exposure in early pregnancy was low and severe malformations described in the MMI embryopathy were rarely observed.
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Affiliation(s)
- Stine Linding Andersen
- Departments of Endocrinology
- Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Stefan Lönn
- Department of Research and Development, Region Halland, Halmstad, Sweden
| | - Peter Vestergaard
- Departments of Endocrinology
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ove Törring
- Department of Clinical Research and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Division of Endocrinology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
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676
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Bliddal S, Nielsen CH, Feldt-Rasmussen U. Recent advances in understanding autoimmune thyroid disease: the tallest tree in the forest of polyautoimmunity. F1000Res 2017; 6:1776. [PMID: 29043075 PMCID: PMC5621109 DOI: 10.12688/f1000research.11535.1] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2017] [Indexed: 12/17/2022] Open
Abstract
Autoimmune thyroid disease (AITD) is often observed together with other autoimmune diseases. The coexistence of two or more autoimmune diseases in the same patient is referred to as polyautoimmunity, and AITD is the autoimmune disease most frequently involved. The occurrence of polyautoimmunity has led to the hypothesis that the affected patients suffer from a generalized dysregulation of their immune system. The present review summarizes recent discoveries unravelling the immunological mechanisms involved in autoimmunity, ranging from natural autoimmunity to disease-specific autoimmunity. Furthermore, the clinical grounds for considering AITD in a setting of polyautoimmunity are explored. A better understanding of these may pave the way for designing new treatment modalities targeting the underlying immune dysregulation when AITD appears in the context of polyautoimmunity.
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Affiliation(s)
- Sofie Bliddal
- Department of Medical Endocrinology, Section 2132, Copenhagen University Hospital (Rigshospitalet), Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Claus Henrik Nielsen
- Institute for Inflammation Research, Center for Rheumatology and Spine Diseases, section 7521, Copenhagen University Hospital (Rigshospitalet), Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology, Section 2132, Copenhagen University Hospital (Rigshospitalet), Blegdamsvej 9, 2100 Copenhagen, Denmark
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677
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[A novel method for quantitative measurement of orbital fat volume based on magnetic resonance images]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017. [PMID: 28951370 PMCID: PMC6765498 DOI: 10.3969/j.issn.1673-4254.2017.09.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To establish a new method for rapid and quantitative measurement of orbital fat volume based on magnetic resonance imaging (MRI) data. METHODS We collected MRI data from normalized mold and patients with the diagnosis of thyroid-associated ophthalmopathy (TAO). The cross-sectional areas of the orbital fat on each MR image slice were measured to calculate the fat volume on each slice and then the total orbital fat volume. We recorded the time for completing the measurement and assessed the precision, reliability, repeatability and interoperator variations of the results. RESULTS This MRI data-based method allowed precise measurement of the orbital fat volumes with an absolute value of the mean percentage difference <1%. This method was fast and the results showed a good repeatability (with CVs <1%), a high reliability (ICC=0.996, 95%CI: 0.985-0.999) and a high interoperator concordance (95%CI of the Bland-Altman: -0.54-0.90). CONCLUSION The novel method we established for orbital fat volume measurement is rapid, accurate, reliable and reproducible with a low learning cost for clinical use.
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678
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Zhang R, Zhang G, Wang R, Tan J, He Y, Meng Z. Prediction of thyroidal 131I effective half-life in patients with Graves' disease. Oncotarget 2017; 8:80934-80940. [PMID: 29113356 PMCID: PMC5655251 DOI: 10.18632/oncotarget.20849] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/07/2017] [Indexed: 11/25/2022] Open
Abstract
Purpose Calculation of effective thyroidal half-life (Teff) of iodine-131(131I) is cumbersome and tedious. The aim of this study was to investigate factors that could be used to predict Teff and to develop a Teff prediction model in Graves' disease patients. Methods A total of 256 patients with GD were involved in this study. We investigated the influences of age, gender, disease duration, thyroid weight, antithyroid drugs, antithyroid drugs discontinuation period (ADP), thyroid function indexes, thyroid autoantibodies, thyroid-stimulating hormone receptor antibody (TRAb) level and radioactive iodine uptake (RAIU) values before 131I therapy on Teff, applying univariate and multivariate analyses. Results Teff correlated negatively with thyroid peroxidase antibody, TRAb and thyroid weight, as well as positively with 24-hour, 48-hour, and 72-hour RAIU. Additionally, a longer ADP (especially≥ 14d) or without antithyroid drugs before 131I therapy led to a longer Teff. Stepwise multiple linear regression analysis showed that 24-hour and 72-hour RAIU were statistically significant predictors of Teff (P<0.001). The relationship was: predictive Teff=5.277+0.295×72-hour RAIU-0.217×24-hour RAIU (r =0.865, P < 0.001). Conclusion The present results indicate that prediction of Teff from 24-hour and 72-hour RAIU is feasible in patients with Graves' disease, with high prediction accuracy.
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Affiliation(s)
- Ruiguo Zhang
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Guizhi Zhang
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Renfei Wang
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Jian Tan
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yajing He
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhaowei Meng
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, China
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679
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Sorensen JR, Watt T, Cramon P, Døssing H, Hegedüs L, Bonnema SJ, Godballe C. Quality of life after thyroidectomy in patients with nontoxic nodular goiter: A prospective cohort study. Head Neck 2017; 39:2232-2240. [PMID: 28872214 DOI: 10.1002/hed.24886] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 04/18/2017] [Accepted: 06/15/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Using the thoroughly validated Thyroid-Related Quality-of-Life Patient-Reported Outcome (ThyPRO) questionnaire, the purpose of this study was to investigate changes in disease-specific quality of life (QOL) after surgical treatment in patients with benign nontoxic multinodular goiters. METHOD Patients with goiters scheduled for thyroid surgery (n = 106) and individuals from the general population (n = 739) were studied. The ThyPRO data before, 3 months, and 6 months after surgery were compared with normative scores from the general population using a linear mixed model and t tests. RESULTS Before surgery, patients with goiters experienced poorer scores on all scales compared to the general population. After surgery, moderate to large improvements were seen in goiter symptoms, tiredness, anxiety, and overall QOL. After surgery, all scales returned to values equal to the general population. The degree of anxiety was, in fact, lower than in the general population. CONCLUSION Thyroid surgery leads to significant benefit among patients with benign nontoxic goiters by restoring QOL equal to that in the general population.
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Affiliation(s)
- Jesper Roed Sorensen
- Department of ORL Head & Neck Surgery, Odense University Hospital, Odense, Denmark
| | - Torquil Watt
- Department of Medical Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Per Cramon
- Department of Medical Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Helle Døssing
- Department of ORL Head & Neck Surgery, Odense University Hospital, Odense, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Christian Godballe
- Department of ORL Head & Neck Surgery, Odense University Hospital, Odense, Denmark.,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
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680
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Diana T, Wüster C, Olivo PD, Unterrainer A, König J, Kanitz M, Bossowski A, Decallonne B, Kahaly GJ. Performance and Specificity of 6 Immunoassays for TSH Receptor Antibodies: A Multicenter Study. Eur Thyroid J 2017; 6:243-249. [PMID: 29071236 PMCID: PMC5649260 DOI: 10.1159/000478522] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/09/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The measurement of TSH receptor (TSHR) antibodies is warranted for diagnosis of Graves' disease (GD). OBJECTIVE The performance, detection sensitivity, and specificity of 6 TSHR immunoassays were compared. METHODS Two bioassays and 4 binding assays (Kronus, Immulite, Kryptor, Dynex) were compared in a dilution study performed in patients with autoimmune thyroid disease. Both bioassays were compared to 2 binding assays using stimulatory (M22) and blocking (K1-70) monoclonal antibody (MAb) mixtures. RESULTS Thirty samples from stimulatory (TSAb)-positive/blocking (TBAb)-negative patients with GD were diluted serially and measured in all assays. Samples were positive until dilution 1:2,187 in the TSAb bioassay, 1:81 in the Immulite (p < 0.002 vs. bioassay) and Kronus ELISA (p = 0.039) assays, and 1:27 in the Kryptor and Dynex ELISA (p < 0.001 vs. bioassay). Ten samples from TBAb-positive/TSAb-negative patients with GD or Hashimoto's thyroiditis were positive in all binding assays. None of the binding assays differentiated between TSAb and TBAb. Mixtures of 100% K1-70 (200 ng/mL), 80% K1-70 + 20% M22, 60% K1-70 + 40% M22, 40% K1-70 + 60% M22, 20% K1-70 + 80% M22, and 100% M22 (20 ng/mL) tested positive in both Immulite (26.4, 20.2, 15.2, 10.5, 6.3, 2.00 IU/L) and Kronus assays (27.1, 23.3, 19.3, 12.0, 5.7, 2.2 IU/L). These MAb mixtures were tested in the TBAb bioassay and showed 82, 61, 24 (negative), -26 (negative), -77 (negative), and -95% (negative) inhibition, respectively. CONCLUSIONS The sample dilution study showed higher detection sensitivity for the TSAb bioassay, and the antibody mixture study demonstrated exclusive specificity of the bioassays over all automated and ELISA binding assays.
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Affiliation(s)
- Tanja Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | | | - Paul D. Olivo
- Department of Microbiology, Washington University, St. Louis, Missouri, USA
| | - Angelica Unterrainer
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Michael Kanitz
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Artur Bossowski
- Department of Pediatrics, Endocrinology, and Diabetology, Medical University of Byalistok, Bialystok, Poland
| | - Brigitte Decallonne
- Division of Clinical and Experimental Endocrinology, UZ Leuven, Leuven, Belgium
| | - George J. Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- *Prof. George J. Kahaly, JGU Medical Center, Langenbeckstrasse 1, DE–55131 Mainz (Germany), E-Mail
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681
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Folkestad L, Brandt F, Brix T, Vogsen M, Bastholt L, Grupe P, Krogh Petersen J, Hegedüs L. Total Thyroidectomy for Thyroid Cancer Followed by Thyroid Storm due to Thyrotropin Receptor Antibody Stimulation of Metastatic Thyroid Tissue. Eur Thyroid J 2017; 6:276-280. [PMID: 29071241 PMCID: PMC5649237 DOI: 10.1159/000479061] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/27/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Graves disease (GD) is an autoimmune condition characterized by the presence of antibodies against the thyrotropin receptor (TRAB), which stimulate the thyroid gland to produce excess thyroid hormone. Theoretically, TRAB could stimulate highly differentiated thyroid cancer tissue and/or metastases to produce thyroid hormone. CASE A 68-year-old male, with weight loss and palpitations, was diagnosed with thyrotoxicosis. A later MRI, due to persistent shoulder pain, revealed multiple bone metastases. A biopsy was diagnostic for follicular variant of papillary thyroid carcinoma, and total thyroidectomy was performed. One week after thyroidectomy the patient was admitted with severe hyperthyroidism. TRAB was >40 IU/mL (normal <0.7 IU/mL). High-dose antithyroid drug treatment was followed by high-dose radioactive iodine-131 (RAI) and local radiotherapy covering the right shoulder. Antithyroid drug treatment continued until after the fourth RAI dose. Hypothyroidism did not occur until following the fifth RAI treatment. SUMMARY AND CONCLUSIONS We present a patient initially diagnosed with thyrotoxicosis and subsequently with metastatic follicular variant of papillary thyroid cancer. It is suggested that TRAB stimulated the highly differentiated extrathyroidal metastatic thyroid tissue to produce excessive amounts of thyroid hormone, delayed diagnosis, and potential aggravation of the course of thyroid cancer.
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Affiliation(s)
- Lars Folkestad
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- *Lars Folkestad, MD, PhD, Endocrine Elite Research Center, Odense University Hospital, Kløvervænget 10, 6. sal, DK–5000 Odense C (Denmark), E-Mail
| | - Frans Brandt
- Department of Internal Medicine, Hospital of Southern Jutland, Sønderborg, Denmark
| | - Thomas Brix
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Marianne Vogsen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Lars Bastholt
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Peter Grupe
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | | | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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682
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Rhodes DA, Isenberg DA. TRIM21 and the Function of Antibodies inside Cells. Trends Immunol 2017; 38:916-926. [PMID: 28807517 DOI: 10.1016/j.it.2017.07.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/28/2017] [Accepted: 07/18/2017] [Indexed: 11/26/2022]
Abstract
Therapeutic antibodies targeting disease-associated antigens are key tools in the treatment of cancer and autoimmunity. So far, therapeutic antibodies have targeted antigens that are, or are presumed to be, extracellular. A largely overlooked property of antibodies is their functional activity inside cells. The diverse literature dealing with intracellular antibodies emerged historically from studies of the properties of some autoantibodies. The identification of tripartite motif (TRIM) 21 as an intracellular Fc receptor linking cytosolic antibody recognition to the ubiquitin proteasome system brings this research into sharper focus. We review critically the research related to intracellular antibodies, link this to the TRIM21 effector mechanism, and highlight how this work is exposing the previously restricted intracellular space to the potential of therapeutic antibodies.
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Affiliation(s)
- David A Rhodes
- Department of Pathology, Immunology Division, University of Cambridge, Cambridge, UK.
| | - David A Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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683
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Tu Y, Fan G, Zeng T, Cai X, Kong W. Association between polymorphism within interleukin related genes and Graves' disease: a meta-analysis of 22 case-control studies. Oncotarget 2017; 8:98993-99002. [PMID: 29228744 PMCID: PMC5716784 DOI: 10.18632/oncotarget.20114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/25/2017] [Indexed: 01/27/2023] Open
Abstract
Graves' disease (GD) is a common autoimmune disorder with a genetic predisposition. There is strong evidence to suggest that both Th1 and Th2 circulating cytokines are involved in the development of GD. In this study, we conducted a meta-analysis to assess the impact of seven variations of five IL-related genes on the susceptibility to GD. A total of 22 case-control studies involving 5338 GD patients and 6446 healthy controls were included. The results showed that only one SNP rs1800795 in IL-6 was significantly associated with GD in homozygous model (CC vs. GG: OR = 2.714, 95% CI = 1.047-7.039, p = 0.04), heterozygous model (CG vs. GG: OR = 1.295, 95% CI = 1.013-1.655, p = 0.039), dominant model (CC+CG vs. GG: OR = 1.418, 95% CI = 1.122-1.793, p = 0.003) and additive model (C vs. G: OR = 1.432, 95% CI = 1.087-1.886, p = 0.011).To explain the heterogeneity, we performed the subgroup analysis by ethnicity. The ethnicity stratification revealed that the association between rs1800795 and GD tended to be much stronger for Asian than European population in homozygous, dominant, recessive, and additive models. The remaining 6 SNPs in 4 genes did not show any significant association with GD in any genetic models. Together, our data support that rs1800795 within the IL-6 gene confers genetic susceptibility for GD. Future large-scale studies are required to validate the associations between IL-6 and others IL-related genes and GD.
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Affiliation(s)
- Yaqin Tu
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Guorun Fan
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Tianshu Zeng
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xiong Cai
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Wen Kong
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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684
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Piantanida E, Bartalena L. Teprotumumab: a new avenue for the management of moderate-to-severe and active Graves' orbitopathy? J Endocrinol Invest 2017. [PMID: 28634704 DOI: 10.1007/s40618-017-0717-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- E Piantanida
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Ospedale di Circolo, Viale Borri, 57, Varese, Italy
| | - L Bartalena
- Department of Medicine and Surgery, Endocrine Unit, University of Insubria, ASST dei Sette Laghi, Ospedale di Circolo, Viale Borri, 57, Varese, Italy.
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685
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Citterio CE, Veluswamy B, Morgan SJ, Galton VA, Banga JP, Atkins S, Morishita Y, Neumann S, Latif R, Gershengorn MC, Smith TJ, Arvan P. De novo triiodothyronine formation from thyrocytes activated by thyroid-stimulating hormone. J Biol Chem 2017; 292:15434-15444. [PMID: 28743746 DOI: 10.1074/jbc.m117.784447] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 07/24/2017] [Indexed: 01/01/2023] Open
Abstract
The thyroid gland secretes primarily tetraiodothyronine (T4), and some triiodothyronine (T3). Under normal physiological circumstances, only one-fifth of circulating T3 is directly released by the thyroid, but in states of hyperactivation of thyroid-stimulating hormone receptors (TSHRs), patients develop a syndrome of relative T3 toxicosis. Thyroidal T4 production results from iodination of thyroglobulin (TG) at residues Tyr5 and Tyr130, whereas thyroidal T3 production may originate in several different ways. In this study, the data demonstrate that within the carboxyl-terminal portion of mouse TG, T3 is formed de novo independently of deiodination from T4 We found that upon iodination in vitro, de novo T3 formation in TG was decreased in mice lacking TSHRs. Conversely, de novo T3 that can be formed upon iodination of TG secreted from PCCL3 (rat thyrocyte) cells was augmented from cells previously exposed to increased TSH, a TSHR agonist, a cAMP analog, or a TSHR-stimulating antibody. We present data suggesting that TSH-stimulated TG phosphorylation contributes to enhanced de novo T3 formation. These effects were reversed within a few days after removal of the hyperstimulating conditions. Indeed, direct exposure of PCCL3 cells to human serum from two patients with Graves' disease, but not control sera, led to secretion of TG with an increased intrinsic ability to form T3 upon in vitro iodination. Furthermore, TG secreted from human thyrocyte cultures hyperstimulated with TSH also showed an increased intrinsic ability to form T3 Our data support the hypothesis that TG processing in the secretory pathway of TSHR-hyperstimulated thyrocytes alters the structure of the iodination substrate in a way that enhances de novo T3 formation, contributing to the relative T3 toxicosis of Graves' disease.
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Affiliation(s)
- Cintia E Citterio
- From the Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, Michigan 48105.,the Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Microbiología, Inmunología y Biotecnología/Cátedra de Genética, C1113AAD Buenos Aires, Argentina.,the CONICET-Universidad de Buenos Aires, Instituto de Inmunología, Genética y Metabolismo (INIGEM), C1120AAR Buenos Aires, Argentina
| | - Balaji Veluswamy
- From the Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, Michigan 48105
| | - Sarah J Morgan
- the National Institutes of Health, NIDDK, Laboratory of Endocrinology and Receptor Biology (LERB), Bethesda, Maryland 20892
| | - Valerie A Galton
- the Department of Physiology and Neurobiology, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire 03756
| | - J Paul Banga
- the Department of Molecular Ophthalmology, University of Duisburg-Essen, 45147 Essen, Germany
| | - Stephen Atkins
- the Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan 48105, and
| | - Yoshiaki Morishita
- From the Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, Michigan 48105
| | - Susanne Neumann
- the National Institutes of Health, NIDDK, Laboratory of Endocrinology and Receptor Biology (LERB), Bethesda, Maryland 20892
| | - Rauf Latif
- the Thyroid Research Unit, James J. Peters Veterans Affairs Medical Center, The Icahn School of Medicine at Mount Sinai, New York, New York 10468
| | - Marvin C Gershengorn
- the National Institutes of Health, NIDDK, Laboratory of Endocrinology and Receptor Biology (LERB), Bethesda, Maryland 20892
| | - Terry J Smith
- From the Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, Michigan 48105.,the Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan 48105, and
| | - Peter Arvan
- From the Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, Michigan 48105,
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686
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Doroudian S, Pedersen IB, Knudsen CS, Handberg A, Andersen SL. Comparison of three competitive immunoassays for measurement of TSH receptor antibodies in patients with Graves’ disease. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:535-540. [DOI: 10.1080/00365513.2017.1354257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Sara Doroudian
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Aase Handberg
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Stine Linding Andersen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
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687
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DNA methylation in ELOVL2 and C1orf132 correctly predicted chronological age of individuals from three disease groups. Int J Legal Med 2017; 132:1-11. [PMID: 28725932 PMCID: PMC5748441 DOI: 10.1007/s00414-017-1636-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 07/04/2017] [Indexed: 12/21/2022]
Abstract
Improving accuracy of the available predictive DNA methods is important for their wider use in routine forensic work. Information on age in the process of identification of an unknown individual may provide important hints that can speed up the process of investigation. DNA methylation markers have been demonstrated to provide accurate age estimation in forensics, but there is growing evidence that DNA methylation can be modified by various factors including diseases. We analyzed DNA methylation profile in five markers from five different genes (ELOVL2, C1orf132, KLF14, FHL2, and TRIM59) used for forensic age prediction in three groups of individuals with diagnosed medical conditions. The obtained results showed that the selected age-related CpG sites have unchanged age prediction capacity in the group of late onset Alzheimer’s disease patients. Aberrant hypermethylation and decreased prediction accuracy were found for TRIM59 and KLF14 markers in the group of early onset Alzheimer’s disease suggesting accelerated aging of patients. In the Graves’ disease patients, altered DNA methylation profile and modified age prediction accuracy were noted for TRIM59 and FHL2 with aberrant hypermethylation observed for the former and aberrant hypomethylation for the latter. Our work emphasizes high utility of the ELOVL2 and C1orf132 markers for prediction of chronological age in forensics by showing unchanged prediction accuracy in individuals affected by three diseases. The study also demonstrates that artificial neural networks could be a convenient alternative for the forensic predictive DNA analyses.
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688
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Bakon S, Craft J, Christensen M. Hypocalcaemia-induced tetany secondary to total thyroidectomy: a nursing case review. Nurs Crit Care 2017; 24:349-354. [PMID: 28677878 DOI: 10.1111/nicc.12309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/27/2017] [Accepted: 06/01/2017] [Indexed: 11/29/2022]
Abstract
Presentations to the emergency department with a diagnosis of hypocalcaemia-induced tetany secondary to total thyroidectomy are rare. A patient presented to the emergency department of a regional Australian hospital with hypocalcaemia-induced tetany. A case study was employed to reflect on the care provided and identify knowledge practice deficits within this unusual patient presentation. Calcium plays a central role within the nervous system and is vital for both cardiac and muscular contraction. The clinical manifestations of electrolyte disturbances such as hypocalcaemia can be life threatening, and therefore, appropriate assessment, monitoring and management are essential to ensure positive patient outcomes. Understanding the importance of calcium imbalance for the emergency and critical care nurse is paramount in preventing complications associated with cardiac conduction and muscle tone, especially the potential for airway compromise. Education is central to this and may include clinical case reviews, the application of pathophysiological presentations of electrolyte imbalance and a review of electrolyte administration guidelines. Understanding the role of calcium within the body will assist emergency and critical care nurses to assess, monitor and intervene appropriately, thereby preventing the life-threatening manifestations of hypocalcaemia.
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Affiliation(s)
- Shannon Bakon
- Queensland University of Technology, Caboolture Campus, Cnr Manley and Tallon Street, Caboolture, Queensland, 4510, Australia.,Emergency Department, Queensland Health, Queensland, 4510, Australia
| | - Judy Craft
- Queensland University of Technology, Caboolture Campus, Cnr Manley and Tallon Street, Caboolture, Queensland, 4510, Australia
| | - Martin Christensen
- Academic Lead for Nursing, Queensland University of Technology, Caboolture Campus, Cnr Manley and Tallon Street, Caboolture, Queensland, 4510, Australia
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689
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Lillevang-Johansen M, Abrahamsen B, Jørgensen HL, Brix TH, Hegedüs L. Excess Mortality in Treated and Untreated Hyperthyroidism Is Related to Cumulative Periods of Low Serum TSH. J Clin Endocrinol Metab 2017; 102:2301-2309. [PMID: 28368540 DOI: 10.1210/jc.2017-00166] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/23/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION AND AIM Cumulative time-dependent excess mortality in hyperthyroid patients has been suggested. However, the effect of antithyroid treatment on mortality, especially in subclinical hyperthyroidism, remains unclarified. We investigated the association between hyperthyroidism and mortality in both treated and untreated hyperthyroid individuals. PATIENTS AND METHODS Register-based cohort study of 235,547 individuals who had at least one serum thyroid-stimulating hormone (TSH) measurement in the period 1995 to 2011 (7.3 years median follow-up). Hyperthyroidism was defined as at least two measurements of low serum TSH. Mortality rates for treated and untreated hyperthyroid subjects compared with euthyroid controls were calculated using multivariate Cox regression analyses, controlling for age, sex, and comorbidities. Cumulative periods of decreased serum TSH were analyzed as a time-dependent covariate. RESULTS Hazard ratio (HR) for mortality was increased in untreated [1.23; 95% confidence interval (CI), 1.12 to 1.37; P < 0.001], but not in treated, hyperthyroid patients. When including cumulative periods of TSH in the Cox regression analyses, HR for mortality per every 6 months of decreased TSH was 1.11 (95% CI, 1.09 to 1.13; P < 0.0001) in untreated hyperthyroid patients (n = 1137) and 1.13 (95% CI, 1.11 to 1.15; P < 0.0001) in treated patients (n = 1656). This corresponds to a 184% and 239% increase in mortality after 5 years of decreased TSH in untreated and treated hyperthyroidism, respectively. CONCLUSIONS Mortality is increased in hyperthyroidism. Cumulative periods of decreased TSH increased mortality in both treated and untreated hyperthyroidism, implying that excess mortality may not be driven by lack of therapy, but rather inability to keep patients euthyroid. Meticulous follow-up during treatment to maintain biochemical euthyroidism may be warranted.
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Affiliation(s)
- Mads Lillevang-Johansen
- Department of Endocrinology and Metabolism, Odense University Hospital, 5000 Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Bo Abrahamsen
- Institute of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Odense Patient Data Explorative Network OPEN, University of Southern Denmark, 5000 Odense, Denmark
- Department of Medicine, Holbæk Hospital, 4300 Holbæk, Denmark
| | | | - Thomas Heiberg Brix
- Department of Endocrinology and Metabolism, Odense University Hospital, 5000 Odense, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, 5000 Odense, Denmark
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690
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Schwensen CF, Brandt F, Hegedüs L, Brix TH. Mortality in Graves' orbitopathy is increased and influenced by gender, age and pre-existing morbidity: a nationwide Danish register study. Eur J Endocrinol 2017; 176:669-676. [PMID: 28258132 DOI: 10.1530/eje-16-0954] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/25/2017] [Accepted: 03/03/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION It is unclear whether the excess mortality associated with Graves' disease differs between individuals with Graves' orbitopathy (GO) or without (GD). SUBJECTS AND METHODS A nationwide, register-based cohort study in which all adult Danes diagnosed with GD (n = 28 461) and GO (n = 3965) between 1995 and 2012 were matched for age and gender with four control subjects. Median follow-up time was 7.9 years (range 0-17.5). Mortality risk in GO patients compared to the control population and compared to GD patients was calculated using Cox regression analyses, adjusting for pre-existing morbidity using the Charlson score. RESULTS Adjusted mortality in Graves' disease overall (GD + GO) was significantly increased compared to that in the background population (HR = 1.18 (95% confidence interval: 1.15-1.21)). In GD and GO separately, adjusted mortality was also significantly higher than that in their respective control populations (HR: 1.19 (1.16-1.22) and HR: 1.23 (1.12-1.35) respectively). However, mortality in GO compared to that in GD was decreased (HR: 0.64 (0.59-0.69)), although this difference attenuated after adjustment for pre-existing morbidity, age and gender. Both GD and GO males had a significantly higher mortality than those in females. For GO, but not for GD, mortality risk was the highest in the youngest and decreased with increasing age. CONCLUSIONS GD and GO were associated with increased mortality, especially in males. In GO, but not in GD patients, there was an inverse relationship between age and mortality. Surprisingly, and in need of further study, mortality was not higher in GO than that in GD individuals.
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Affiliation(s)
- Charlotte F Schwensen
- Department of Endocrinology and MetabolismOdense University Hospital, Odense, Denmark
| | - Frans Brandt
- Department of Internal MedicineHospital of Southern Jutland, Sønderborg, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and MetabolismOdense University Hospital, Odense, Denmark
| | - Thomas H Brix
- Department of Endocrinology and MetabolismOdense University Hospital, Odense, Denmark
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Nik N, Fong A, Derdzakyan M, Adamopoulou C, Sise A, Khanifar A, Sanders R. Changes in Choroidal Perfusion after Orbital Decompression Surgery for Graves' Ophthalmopathy. J Ophthalmic Vis Res 2017; 12:183-186. [PMID: 28540010 PMCID: PMC5423372 DOI: 10.4103/jovr.jovr_165_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: To assess choroidal perfusion before and after orbital decompression surgery in patients with Graves' ophthalmopathy. Methods: In this interventional case series, surgical decompression for optic nerve compromise was performed on four eyes of three patients with Graves' disease. Complete ophthalmic examination including visual acuity, color vision, and intraocular pressure assessment were done pre- and postoperatively. High-speed indocyanine green angiography was performed prior to surgery and was repeated one year after surgery. Results: In all three patients, choroidal perfusion defects were noted pre-operatively in the eyes with the compressive optic neuropathy. At 1 year after orbital decompression surgery, the defects improved or completely resolved. Improved visual acuity and color perception, as well as decreased intraocular pressure, were also noted postoperatively. Conclusion: Patients with Graves' orbitopathy may have abnormal choroidal perfusion even in the absence of optic neuropathy. Orbital decompression may improve choroidal circulation in these patients.
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Affiliation(s)
- Narieman Nik
- Department of Ophthalmology and Visual Sciences, Georgetown University/MedStar Washington Hospital Center, Washington, DC, USA
| | - Amelia Fong
- Department of Ophthalmology and Visual Sciences, Georgetown University/MedStar Washington Hospital Center, Washington, DC, USA
| | | | | | - Adam Sise
- Private Practice, Eyecare Medical Group, Portland, Maine, USA
| | - Aziz Khanifar
- Private Practice, Retina Group of Washington, Chevy Chase, Maryland, USA
| | - Reginald Sanders
- Private Practice, Retina Group of Washington, Chevy Chase, Maryland, USA
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Smith TJ, Kahaly GJ, Ezra DG, Fleming JC, Dailey RA, Tang RA, Harris GJ, Antonelli A, Salvi M, Goldberg RA, Gigantelli JW, Couch SM, Shriver EM, Hayek BR, Hink EM, Woodward RM, Gabriel K, Magni G, Douglas RS. Teprotumumab for Thyroid-Associated Ophthalmopathy. N Engl J Med 2017; 376:1748-1761. [PMID: 28467880 PMCID: PMC5718164 DOI: 10.1056/nejmoa1614949] [Citation(s) in RCA: 426] [Impact Index Per Article: 60.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Thyroid-associated ophthalmopathy, a condition commonly associated with Graves' disease, remains inadequately treated. Current medical therapies, which primarily consist of glucocorticoids, have limited efficacy and present safety concerns. Inhibition of the insulin-like growth factor I receptor (IGF-IR) is a new therapeutic strategy to attenuate the underlying autoimmune pathogenesis of ophthalmopathy. METHODS We conducted a multicenter, double-masked, randomized, placebo-controlled trial to determine the efficacy and safety of teprotumumab, a human monoclonal antibody inhibitor of IGF-IR, in patients with active, moderate-to-severe ophthalmopathy. A total of 88 patients were randomly assigned to receive placebo or active drug administered intravenously once every 3 weeks for a total of eight infusions. The primary end point was the response in the study eye. This response was defined as a reduction of 2 points or more in the Clinical Activity Score (scores range from 0 to 7, with a score of ≥3 indicating active thyroid-associated ophthalmopathy) and a reduction of 2 mm or more in proptosis at week 24. Secondary end points, measured as continuous variables, included proptosis, the Clinical Activity Score, and results on the Graves' ophthalmopathy-specific quality-of-life questionnaire. Adverse events were assessed. RESULTS In the intention-to-treat population, 29 of 42 patients who received teprotumumab (69%), as compared with 9 of 45 patients who received placebo (20%), had a response at week 24 (P<0.001). Therapeutic effects were rapid; at week 6, a total of 18 of 42 patients in the teprotumumab group (43%) and 2 of 45 patients in the placebo group (4%) had a response (P<0.001). Differences between the groups increased at subsequent time points. The only drug-related adverse event was hyperglycemia in patients with diabetes; this event was controlled by adjusting medication for diabetes. CONCLUSIONS In patients with active ophthalmopathy, teprotumumab was more effective than placebo in reducing proptosis and the Clinical Activity Score. (Funded by River Vision Development and others; ClinicalTrials.gov number, NCT01868997 .).
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Affiliation(s)
- Terry J Smith
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - George J Kahaly
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Daniel G Ezra
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - James C Fleming
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Roger A Dailey
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Rosa A Tang
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Gerald J Harris
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Alessandro Antonelli
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Mario Salvi
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Robert A Goldberg
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - James W Gigantelli
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Steven M Couch
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Erin M Shriver
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Brent R Hayek
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Eric M Hink
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Richard M Woodward
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Kathleen Gabriel
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Guido Magni
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
| | - Raymond S Douglas
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center (T.J.S., R.S.D.), and the Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine (T.J.S.), University of Michigan Medical School, Ann Arbor; the Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.); Moorfields Eye Hospital, London (D.G.E.); the University of Tennessee Health Science Center, Memphis (J.C.F.); the Oculofacial Plastic Surgery Division, Oregon Health and Science University, Portland (R.A.D.); Eye Wellness Center, Neuro-Ophthalmology of Texas, Houston (R.A.T.); the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee (G.J.H.); the Department of Clinical and Experimental Medicine, University of Pisa, Pisa (A.A.), and the Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda, University of Milan, Milan (M.S.) - both in Italy; the Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles (R.A.G.); the University of Nebraska Medical Center, Omaha (J.W.G.); Barnes-Jewish Hospital, Washington University, St. Louis (S.M.C.); the Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City (E.M.S.); the Department of Ophthalmology, Emory University, Atlanta (B.R.H.); the Department of Ophthalmology, University of Colorado, Aurora (E.M.H.); and River Vision Development, New York (R.M.W., K.G., G.M.)
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693
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Sharif K, Watad A, Bragazzi NL, Adawi M, Amital H, Shoenfeld Y. Coffee and autoimmunity: More than a mere hot beverage! Autoimmun Rev 2017; 16:712-721. [PMID: 28479483 DOI: 10.1016/j.autrev.2017.05.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 04/05/2017] [Indexed: 12/20/2022]
Abstract
Coffee is one of the world's most consumed beverage. In the last decades, coffee consumption has attracted a huge body of research due to its impact on health. Recent scientific evidences showed that coffee intake could be associated with decreased mortality from cardiovascular and neurological diseases, diabetes type II, as well as from endometrial and liver cancer, among others. In this review, on the basis of available data in the literature, we aimed to investigate the association between coffee intake and its influence on the immune system and the insurgence of the most relevant autoimmune diseases. While some studies reported conflicting results, general trends have been identified. Coffee consumption seems to increase the risk of developing rheumatoid arthritis (RA) and type 1 diabetes mellitus (T1DM). By contrast, coffee consumption may exert a protective role against multiple sclerosis, primary sclerosing cholangitis, and ulcerative colitis. Concerning other autoimmune diseases such as systemic lupus erythematosus, psoriasis, primary biliary cholangitis and Crohn's disease, no significant association was found. In other studies, coffee consumption was shown to influence disease course and management options. Coffee intake led to a decrease in insulin sensitivity in T1DM, in methotrexate efficacy in RA, and in levothyroxine absorption in Hashimoto's disease. Further, coffee consumption was associated with cross reactivity with gliadin antibodies in celiac patients. Data on certain autoimmune diseases like systemic sclerosis, Sjögren's syndrome, and Behçet's disease, among others, are lacking in the existent literature. As such, further research is warranted.
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Affiliation(s)
- Kassem Sharif
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Abdulla Watad
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nicola Luigi Bragazzi
- School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Mohammad Adawi
- Padeh and Ziv hospitals, Bar-Ilan Faculty of Medicine, Israel
| | - Howard Amital
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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694
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Amann BL, Radua J, Wunsch C, König B, Simhandl C. Psychiatric and physical comorbidities and their impact on the course of bipolar disorder: A prospective, naturalistic 4-year follow-up study. Bipolar Disord 2017; 19:225-234. [PMID: 28544558 DOI: 10.1111/bdi.12495] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/01/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aim of the present study was to increase the available evidence on how physical and psychiatric comorbidities influence the long-term outcome in bipolar I and II disorder. METHODS We examined the prevalence of comorbid physical (metabolic, cardiovascular, thyroid, and neurological) diseases and psychiatric (neurotic, stress-related, somatoform, and personality) disorders and their impact on the risk of relapse in bipolar disorder. A total of 284 consecutively admitted patients with ICD-10 bipolar I (n=161) and II (n=123) disorder were followed up naturalistically over a period of 4 years. RESULTS Globally, 22.0% patients had metabolic, 18.8% cardiovascular, 18.8% thyroid, and 7.6% neurological diseases; 15.5% had neurotic, stress-related, and somatoform disorders; 12.0% had personality disorders; and 52.9% had nicotine dependence. We did not find any effect of comorbid metabolic, cardiovascular or neurological diseases or psychiatric disorders on the relapse risk. However, the presence of thyroid diseases, and especially hypothyroidism, was associated with an increased risk of manic relapse in bipolar disorder I (thyroid disease: hazard ratio [HR]=2.7; P=.003; hypothyroidism: HR=3.7;, P<.001). Among patients with hypothyroidism, higher blood levels of baseline thyroid-stimulating hormone (bTSH) were also associated with an increased risk of manic relapse (HR=1.07 per milli-international units per liter; P=.011), whereas blood levels of free triiodothyronine (fT3 ) or free thyroxine (fT4 ) were not found to have an influence. CONCLUSIONS Our data underline the negative long-term impact of thyroid diseases, and especially hypothyroidism with high blood levels of bTSH, on bipolar disorder with more manic episodes, and the importance of its detection and treatment.
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Affiliation(s)
- Benedikt L Amann
- Institut de Neuropsiquiatria i Addicions, Centre Fòrum Research Unit, Parc de Salut Mar, Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Department of Psychiatry, Autonomous University of Barcelona, Barcelona, Spain.,CIBERSAM, Madrid, Spain
| | - Joaquim Radua
- CIBERSAM, Madrid, Spain.,FIDMAG Research Foundation Germanes Hospitalàries, Barcelona, Spain.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Christian Wunsch
- Bipolar Center Wiener Neustadt, Wiener Neustadt, Vienna, Austria
| | - Barbara König
- Bipolar Center Wiener Neustadt, Wiener Neustadt, Vienna, Austria
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695
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Perros P, Hegedüs L, Bartalena L, Marcocci C, Kahaly GJ, Baldeschi L, Salvi M, Lazarus JH, Eckstein A, Pitz S, Boboridis K, Anagnostis P, Ayvaz G, Boschi A, Brix TH, Currò N, Konuk O, Marinò M, Mitchell AL, Stankovic B, Törüner FB, von Arx G, Zarković M, Wiersinga WM. Graves' orbitopathy as a rare disease in Europe: a European Group on Graves' Orbitopathy (EUGOGO) position statement. Orphanet J Rare Dis 2017; 12:72. [PMID: 28427469 PMCID: PMC5397790 DOI: 10.1186/s13023-017-0625-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/05/2017] [Indexed: 01/09/2023] Open
Abstract
Background Graves’ orbitopathy (GO) is an autoimmune condition, which is associated with poor clinical outcomes including impaired quality of life and socio-economic status. Current evidence suggests that the incidence of GO in Europe may be declining, however data on the prevalence of this disease are sparse. Several clinical variants of GO exist, including euthyroid GO, recently listed as a rare disease in Europe (ORPHA466682). The objective was to estimate the prevalence of GO and its clinical variants in Europe, based on available literature, and to consider whether they may potentially qualify as rare. Recent published data on the incidence of GO and Graves’ hyperthyroidism in Europe were used to estimate the prevalence of GO. The position statement was developed by a series of reviews of drafts and electronic discussions by members of the European Group on Graves’ Orbitopathy. The prevalence of GO in Europe is about 10/10,000 persons. The prevalence of other clinical variants is also low: hypothyroid GO 0.02–1.10/10,000; GO associated with dermopathy 0.15/10,000; GO associated with acropachy 0.03/10,000; asymmetrical GO 1.00–5.00/10,000; unilateral GO 0.50–1.50/10,000. Conclusion GO has a prevalence that is clearly above the threshold for rarity in Europe. However, each of its clinical variants have a low prevalence and could potentially qualify for being considered as a rare condition, providing that future research establishes that they have a distinct pathophysiology. EUGOGO considers this area of academic activity a priority.
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Affiliation(s)
- P Perros
- Institute of Genetic Medicine, Newcastle University, Central Parkway, Newcastle upon Tyne, Tyne, NE1 3BZ, UK. .,Department of Endocrinology, Level 6, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK.
| | - L Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, 5000, Denmark
| | - L Bartalena
- Endocrine Unit, University of Insubria, Ospedale di Circolo, Viale Borri, 57 21100, Varese, Italy
| | - C Marcocci
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, 55101, Germany
| | - L Baldeschi
- Department of Ophthalmology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - M Salvi
- Graves' Orbitopathy Center, Endocrinology, Fondazione Ca' Granda IRCCS, Department of Medical and Community Sciences, University of Milan, Milan, Italy
| | - J H Lazarus
- Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - A Eckstein
- Department of Ophthalmology, D-45122 University of Duisburg-Essen, Essen, Germany
| | - S Pitz
- Department of Ophthalmology, Johannes Gutenberg University Medical Center, Mainz, 551331, Germany
| | - K Boboridis
- 3rd University Department of Ophthalmology, Aristotle University of Thessaloniki, 1 Kyriakidi Street, 546 36, Thessaloniki, Greece
| | - P Anagnostis
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Thessaloniki, Greece
| | - G Ayvaz
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Besevler, Ankara, 06500, Turkey
| | - A Boschi
- Department of Ophthalmology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - T H Brix
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, 5000, Denmark
| | - N Currò
- Department of Ophthalmology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - O Konuk
- Department of Ophthalmology, Gazi University Faculty of Medicine, Besevler, Ankara, 06500, Turkey
| | - M Marinò
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - A L Mitchell
- Institute of Genetic Medicine, Newcastle University, Central Parkway, Newcastle upon Tyne, Tyne, NE1 3BZ, UK
| | - B Stankovic
- Faculty of Medicine University of Belgrade, Institute of Ophthalmology Clinical Centre of Serbia, Belgrade, Serbia
| | - F B Törüner
- Department of Endocrinology and Metabolism, Gazi University, Faculty of Medicine, Besevler, Ankara, 06500, Turkey
| | - G von Arx
- Basedow.ch Interdisciplinary Centre for Graves' Orbitopathy, Fährweg 10, 4600, Olten, Switzerland
| | - M Zarković
- School of Medicine, University of Belgrade, Clinic of Endocrinology, Clinical Centre of Serbia, Belgrade, Serbia
| | - W M Wiersinga
- Academic Medical Center, 22660 1100 DD, Amsterdam, Netherlands
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696
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Wang B, Shao X, Song R, Xu D, Zhang JA. The Emerging Role of Epigenetics in Autoimmune Thyroid Diseases. Front Immunol 2017; 8:396. [PMID: 28439272 PMCID: PMC5383710 DOI: 10.3389/fimmu.2017.00396] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/21/2017] [Indexed: 12/15/2022] Open
Abstract
Autoimmune thyroid diseases (AITD) are a group of both B cell- and T cell-mediated organ-specific autoimmune diseases. Graves’ disease and Hashimoto thyroiditis are the two main clinical presentations of AITD. Both genetic and environmental factors have important roles in the development of AITD. Epigenetics have been considered to exert key roles in integrating those genetic and environmental factors, and epigenetic modifications caused by environmental factors may drive genetically susceptibility individuals to develop AITD. Recent studies on the epigenetics of AITD have provided some novel insights into the pathogenesis of AITD. The aim of this review is to provide an overview of recent advances in the epigenetic mechanisms of AITD, such as DNA methylation, histone modifications, and non-coding RNAs. This review highlights the key roles of epigenetics in the pathogenesis of AITD and potential clinical utility. However, the epigenetic roles in AITD are still not fully elucidated, and more researches are needed to provide further deeper insights into the roles of epigenetics in AITD and to uncover new therapeutic targets. Although there are many studies assessing the epigenetic modifications in AITD patients, the clinical utility of epigenetics in AITD remains poorly defined. More studies are needed to identify the underlying epigenetic modifications that can contribute to accurate diagnosis of AITD, adequate choice of treatment approach, and precise prediction of treatment outcomes.
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Affiliation(s)
- Bin Wang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China.,Department of Rheumatology and Immunology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Xiaoqing Shao
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China.,Department of Rheumatology and Immunology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Ronghua Song
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China.,Department of Rheumatology and Immunology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Donghua Xu
- Department of Rheumatology and Immunology, The Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Jin-An Zhang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China.,Department of Rheumatology and Immunology, Jinshan Hospital of Fudan University, Shanghai, China
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697
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Hegedüs L, Bonnema SJ. Calculating the incalculable. Optimal radioiodine dose in Graves' hyperthyroidism. Endocrine 2017; 56:222-223. [PMID: 28188478 DOI: 10.1007/s12020-017-1253-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/30/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, DK, 5000, Denmark.
| | - Steen J Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, DK, 5000, Denmark
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698
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Struja T, Kaeslin M, Boesiger F, Jutzi R, Imahorn N, Kutz A, Bernasconi L, Mundwiler E, Mueller B, Christ-Crain M, Meienberg F, Ebrahimi F, Henzen C, Fischli S, Kraenzlin M, Meier C, Schuetz P. External validation of the GREAT score to predict relapse risk in Graves' disease: results from a multicenter, retrospective study with 741 patients. Eur J Endocrinol 2017; 176:413-419. [PMID: 28100628 DOI: 10.1530/eje-16-0986] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/11/2017] [Accepted: 01/17/2017] [Indexed: 11/08/2022]
Abstract
CONTEXT First-line treatment in Graves' disease is often done with antithyroid agents (ATD), but relapse rates remain high making definite treatment necessary. Predictors for relapse risk help guiding initial treatment decisions. OBJECTIVE We aimed to externally validate the prognostic accuracy of the recently proposed Graves' Recurrent Events After Therapy (GREAT) score to predict relapse risk in Graves' disease. DESIGN, SETTING AND PARTICIPANTS We retrospectively analyzed data (2004-2014) of patients with a first episode of Graves' hyperthyroidism from four Swiss endocrine outpatient clinics. MAIN OUTCOME MEASURES Relapse of hyperthyroidism analyzed by multivariate Cox regression. RESULTS Of the 741 included patients, 371 experienced a relapse (50.1%) after a mean follow-up of 25.6 months after ATD start. In univariate regression analysis, higher serum free T4, higher thyrotropin-binding inhibitor immunoglobulin (TBII), younger age and larger goiter were associated with higher relapse risk. We found a strong increase in relapse risk with more points in the GREAT score from 33.8% in patients with GREAT class I (0-1 points), 59.4% in class II (2-3 points) with a hazard ratio of 1.79 (95% CI: 1.42-2.27, P < 0.001) and 73.6% in class III (4-6 points) with a hazard ratio of 2.24 (95% CI: 1.64-3.06, P < 0.001). CONCLUSIONS Based on this retrospective analysis within a large patient population from a multicenter study, the GREAT score shows good external validity and can be used for assessing the risk for relapse in Graves' disease, which influence the initial treatment decisions.
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Affiliation(s)
- Tristan Struja
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Marina Kaeslin
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Fabienne Boesiger
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Rebecca Jutzi
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Noemi Imahorn
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Alexander Kutz
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Luca Bernasconi
- Department of Laboratory MedicineKantonsspital Aarau, Aarau, Switzerland
| | - Esther Mundwiler
- Department of Laboratory MedicineKantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
- Medical Faculty of the University of BaselBasel, Switzerland
| | - Mirjam Christ-Crain
- Medical Faculty of the University of BaselBasel, Switzerland
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Fabian Meienberg
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Fahim Ebrahimi
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Christoph Henzen
- Medical Faculty of the University of BaselBasel, Switzerland
- Clinic for EndocrinologyDiabetes & Metabolism, Kantonsspital Luzern, Luzern, Switzerland
| | - Stefan Fischli
- Clinic for EndocrinologyDiabetes & Metabolism, Kantonsspital Luzern, Luzern, Switzerland
| | - Marius Kraenzlin
- Medical Faculty of the University of BaselBasel, Switzerland
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Christian Meier
- Medical Faculty of the University of BaselBasel, Switzerland
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
- Medical Faculty of the University of BaselBasel, Switzerland
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699
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Bidot S, Biousse V. [Diplopia: An important symptom in internal medicine!]. Rev Med Interne 2017; 38:806-816. [PMID: 28325621 DOI: 10.1016/j.revmed.2017.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 01/21/2017] [Indexed: 11/25/2022]
Abstract
Diplopia is defined as "double vision" when looking at a single object. Monocular diplopia is related to an ocular disorder and must be differentiated from binocular diplopia which is secondary to ocular misalignment. The examination of the patient with binocular diplopia is often challenging for non-specialists. However, a careful and systematic clinical examination followed by targeted ancillary testing allows the clinician to localize the lesion along the oculomotor pathways. The lesion may involve the brainstem, the ocular motor nerves III, IV or VI, the neuromuscular junction, the extraocular ocular muscles, or the orbit. Causes of binocular diplopia are numerous and often include disorders typically managed by internal medicine such as inflammatory, infectious, neoplastic, endocrine, and metabolic disorders. In addition to treating the underlying disease, it is important not to leave diplopia uncorrected. Temporary occlusion of one eye by applying tape on one lens or patching one eye relieves the diplopia until more specific treatments are offered should the diplopia not fully resolve.
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Affiliation(s)
- S Bidot
- Fondation ophtalmologique Adolphe-de-Rothschild, 75019 Paris, France; Centre hospitalier national d'ophtalmologie des Quinze-Vingts, 75571 Paris, France
| | - V Biousse
- Services d'ophtalmologie et de neurologie, Emory university school of medicine, Atlanta, GA, États-Unis.
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700
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Ferreira C, Meireles C, Marques O, Antunes A. Therapeutic challenge of a paediatric case of Graves' disease with severe ophthalmopathy. BMJ Case Rep 2017; 2017:bcr-2017-219269. [PMID: 28302662 DOI: 10.1136/bcr-2017-219269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Carla Ferreira
- Department of Pediatrics, Hospital Sra da Oliveira Guimarães, Guimarães, Portugal
| | - Carla Meireles
- Department of Pediatrics, Hospital Sra da Oliveira Guimarães, Guimarães, Portugal
| | - Olinda Marques
- Department of Endocrinology, Hospital de Braga, Braga, Portugal.,Pediatric Endocrinology Unit, Hospital de Braga, Braga, Portugal
| | - Ana Antunes
- Pediatric Endocrinology Unit, Hospital de Braga, Braga, Portugal.,Pediatric Department, Hospital de Braga, Braga, Portugal
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