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Byeon HJ, Ko J, Kikkawa DO, Yoon JS. Preoperative Risk Factors for Proptosis Recurrence After Rehabilitative Orbital Decompression in Graves' Orbitopathy Patients. Am J Ophthalmol 2024; 258:110-118. [PMID: 37544496 DOI: 10.1016/j.ajo.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/08/2023] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE Rehabilitative orbital decompression treats disfiguring exophthalmos in patients with Graves' orbitopathy (GO). This study aimed to identify risk factors associated with the postoperative recurrence of proptosis after orbital decompression. DESIGN Retrospective, case-control study. METHODS This retrospective review included patients with GO who underwent rehabilitative orbital decompression for disfiguring proptosis in an inactive state with a low clinical activity score (0-2) between January 2017 and December 2020 by a single surgeon. Exophthalmos was measured using a Hertel exophthalmometer, and recurrence was defined as an increase of 2 mm or more after decompression during the follow-up period. The association between preoperative variables and proptosis recurrence was analyzed using multivariable logistic regression. RESULTS Of the total 217 patients, 11 (5.1%) developed recurrence of proptosis during the follow-up period (range, 3-30; mean, 15.6 months). Univariate logistic regression analysis identified thyroid-stimulating hormone receptor antibody (TRAb) and thyroid-stimulating immunoglobulin (TSI) as significant factors for recurrence, with age, sex, smoking, disease duration, orbital radiotherapy, and total thyroidectomy history being nonsignificant. TRAb remained significant in a multivariate logistic regression analysis (odds ratio, 1.06; P = .014). Receiver operating characteristic curve analysis revealed an area under the curve of 0.86 with a sensitivity of 90.9% and specificity of 82.0% at a TRAb level of 7.96 IU/L. CONCLUSION Preoperative TRAb and TSI are valuable markers to predict proptosis recurrence after orbital decompression. These results may help surgeons to decide the optimal timing for orbital decompression to lessen the risk of postoperative recurrence of proptosis.
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Affiliation(s)
- Hyeong Ju Byeon
- From the Department of Ophthalmology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (H.J.B., J.K., J.S.Y.)
| | - JaeSang Ko
- From the Department of Ophthalmology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (H.J.B., J.K., J.S.Y.)
| | - Don O Kikkawa
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego, San Diego, California, USA (D.O.K.)
| | - Jin Sook Yoon
- From the Department of Ophthalmology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (H.J.B., J.K., J.S.Y.).
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Yuksel N, Saritas O, Yuksel E. Effect of thyroid hormone status on complete blood cell count-derived inflammatory biomarkers in patients with moderate-to-severe Graves' ophthalmopathy. Int Ophthalmol 2023:10.1007/s10792-023-02742-x. [PMID: 37209204 DOI: 10.1007/s10792-023-02742-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/06/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE To evaluate the systemic inflammation in moderate-to-severe Graves' ophthalmopathy patients with abnormal thyroid function by using complete blood cell count-derived inflammatory biomarkers and compare to moderate-to-severe GO patients with regulated thyroid function and healthy controls. The second aim is to evaluate the relationship of complete blood cell count-derived inflammatory biomarkers with clinical findings in moderate-to-severe GO. METHODS In this retrospective study, 90 GO patients with abnormal thyroid function composed Group 1, 58 patients who had normal thyroid function for at least 3 months composed Group 2, and 50 healthy individuals composed Group 3. Demographic data, neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), mean platelet volume (MPV), and systemic immune-inflammatory index (SII) were evaluated. RESULTS There was no statistically significant difference between groups in terms of age, sex, and smoking habits (p > 0.05). There was a statistically significant difference in NLR (p = 0.011), MLR (p = 0.013), MPV (p < 0.001), and SII (p < 0.001) values among 3 groups. For NLR, MLR, and SII the highest values were detected in Group 1. MPV levels were higher in Group 3 than Groups 1 and 2 (p < 0.001). None of the hematological parameters were found to be a risk factor for any clinical severity findings of GO. CONCLUSION The higher levels of NLR, MLR, and SII levels may show systemic inflammation in GO patients with abnormal thyroid function, and this may have an impact on the clinical course of ophthalmopathy. These findings may suggest that cautious control of thyroid hormone levels is important in the management of GO.
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Affiliation(s)
- Nilay Yuksel
- Department of Ophthalmology, Ophthalmic Plastic Surgery Service, Ankara Bilkent City Hospital, Universiteler Mah 1604. Cadde No:9 Bilkent, Çankaya, 06800, Ankara, Turkey.
| | - Ozge Saritas
- Department of Ophthalmology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Erdem Yuksel
- Department of Ophthalmology, Medical Faculty, Kastamonu University, Kastamonu, Turkey
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Zhang X, Han C, Wang H, Sun X, Dou X, He X, Wu D, Shen S, Zhu D, Zhang X, Bi Y. The correlation of the neutrophil-lymphocyte ratio to clinical and imaging parameters in patients with thyroid eye disease. Endocr Connect 2022; 11:e220260. [PMID: 36099552 PMCID: PMC9578078 DOI: 10.1530/ec-22-0260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022]
Abstract
Thyroid eye disease (TED) is the major extrathyroidal manifestation of Graves' disease (GD). Treatment choice is based on clinical activity and severity of TED, as evaluated with clinical activity score (CAS) and magnetic resonance (MR) imaging. We aimed to determine the relationship between neutrophil-to-lymphocyte ratio (NLR), a readily available indicator of systemic inflammation, and clinical and MR imaging parameters in TED patients. Eighty-seven consecutive TED patients were included. The average signal intensity ratio (SIR), average extraocular muscle (EOM) diameter, and proptosis of the study eye were extracted from MR images. A baseline NLR ≥ 2.0 was recorded in 37 (42.5%) patients and NLR < 2.0 in 50 (57.5%) patients. TED patients with NLR ≥ 2.0 were older, had a higher CAS, average SIR, average EOM diameter and proptosis, and a lower serum thyrotrophin receptor antibody level than patients with NLR < 2.0 (all P < 0.05). All MR parameters showed significant correlation with CAS (P < 0.05). NLR correlated significantly with CAS (P = 0.001), average SIR (P = 0.004), average EOM diameter (P = 0.007), and proptosis (P = 0.007). Multiple regression revealed a significant correlation between NLR and CAS (P = 0.001), average SIR (P = 0.029), and proptosis (P = 0.037). Cox regression analysis showed that a high NLR at baseline was associated with a worse clinical outcome of TED (hazard ratio 3.7, 95% CI 1.22-11.2, P = 0.02), at a median follow-up of 25 months. In conclusion, NLR was correlated with CAS and MR imaging parameters and was associated with a worse clinical outcome of TED at follow-up in patients with TED. Additional prospective studies are needed to validate our findings.
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Affiliation(s)
- Xiaowen Zhang
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, Nanjing, China
| | - Chen Han
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, Nanjing, China
- Department of Endocrinology and Metabolism, Drum Tower Clinical Medical College, Southeast University, Nanjing, China
| | - Hongwei Wang
- State Key Laboratory of Analytical Chemistry for Life Science & Jiangsu Key Laboratory of Molecular Medicine, Nanjing University School of Medicine, Nanjing, China
| | - Xinghong Sun
- Department of Ophthalmology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Xin Dou
- Department of Radiology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Xueying He
- Department of Radiology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Di Wu
- Department of Radiology, Southeast University Medical School Affiliated Zhongda Hospital, Nanjing, China
| | - Shanmei Shen
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, Nanjing, China
| | - Dalong Zhu
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, Nanjing, China
| | - Xinlin Zhang
- Department of Cardiology, Nanjing University Medical School Affiliated Drum Tower Hospital, Nanjing, China
| | - Yan Bi
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, Nanjing, China
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Zhu X, Zhang Y, Zhao X, Zhang X, Ru Z, Wu Y, Yang X, Hou B, Qiao H. The relationship between atherosclerotic disease and relapse during ATD treatment. Front Cardiovasc Med 2022; 9:1039829. [DOI: 10.3389/fcvm.2022.1039829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundClinical relapse is a potential risk for traditional antithyroid drug (ATD) treatment in hyperthyroid patients. Evidence suggests that atherosclerotic disease is closely associated with hyperthyroidism, while the relationship between atherosclerosis and relapse remains unclear.MethodsTwo hundred and twenty-five patients with GD who underwent ATD as their first treatment were studied; 88 and 137 patients were categorized as drug reduction relapse and drug reduction remission, respectively. Logistic regression was used to analyze risk factors of drug reduction relapse in patients with GD.ResultsDuring a median of 48 months followed up 88 patients who relapsed. According to multivariate analyses, atherosclerosis related diseases, FT4, goiter, and anxiety rating scores are independent risk factors for drug reduction. According to K-M survival analysis, patients with atherosclerosis related diseases, FT4 > 18.82 pmol/L, anxiety rating scores > 23, and gradation of goiter ≥ Grade II had a higher risk of relapse than those with lower levels. ROC analysis shown atherosclerosis related diseases significantly improved the predictive accuracy of relapse.ConclusionsAtherosclerotic disease is closely related to the relapse of hyperthyroidism, ATD treatment in hyperthyroid patients with atherosclerosis should be given more attention.
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Duan L, Zhang HY, Lv M, Zhang H, Chen Y, Wang T, Li Y, Wu Y, Li J, Li K. Machine learning identifies baseline clinical features that predict early hypothyroidism in patients with Graves' disease after radioiodine therapy. Endocr Connect 2022; 11:e220119. [PMID: 35521803 PMCID: PMC9175589 DOI: 10.1530/ec-22-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 04/22/2022] [Indexed: 11/08/2022]
Abstract
Background and objective Radioiodine therapy (RAI) is one of the most common treatment solutions for Graves' disease (GD). However, many patients will develop hypothyroidism as early as 6 months after RAI. This study aimed to implement machine learning (ML) algorithms for the early prediction of post-RAI hypothyroidism. Methods Four hundred and seventy-one GD patients who underwent RAI between January 2016 and June 2019 were retrospectively recruited and randomly split into the training set (310 patients) and the validation set (161 patients). These patients were followed for 6 months after RAI. A set of 138 clinical and lab test features from the electronic medical record (EMR) were extracted, and multiple ML algorithms were conducted to identify the features associated with the occurrence of hypothyroidism 6 months after RAI. Results An integrated multivariate model containing patients' age, thyroid mass, 24-h radioactive iodine uptake, serum concentrations of aspartate aminotransferase, thyrotropin-receptor antibodies, thyroid microsomal antibodies, and blood neutrophil count demonstrated an area under the receiver operating curve (AUROC) of 0.72 (95% CI: 0.61-0.85), an F1 score of 0.74, and an MCC score of 0.63 in the training set. The model also performed well in the validation set with an AUROC of 0.74 (95% CI: 0.65-0.83), an F1 score of 0.74, and a MCC of 0.63. A user-friendly nomogram was then established to facilitate the clinical utility. Conclusion The developed multivariate model based on EMR data could be a valuable tool for predicting post-RAI hypothyroidism, allowing them to be treated differently before the therapy. Further study is needed to validate the developed prognostic model at independent sites.
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Affiliation(s)
- Lian Duan
- Department of Nuclear Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Han-Yu Zhang
- Changzhi Medical College, Changzhi, Shanxi, China
| | - Min Lv
- Department of Nuclear Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Han Zhang
- Changzhi Medical College, Changzhi, Shanxi, China
| | - Yao Chen
- Changzhi Medical College, Changzhi, Shanxi, China
| | - Ting Wang
- Department of Nuclear Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Yan Li
- Department of Nuclear Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Yan Wu
- Department of Clinical Laboratory, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Junfeng Li
- Department of Radiology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Kefeng Li
- School of Medicine, University of California, San Diego, California, USA
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Zhao H, Ruan Y. Relative Adrenocortical Insufficiency Following Radioactive Iodine Therapy for Graves' Disease: A Report of Two Cases. Int J Gen Med 2021; 14:1641-1646. [PMID: 33976564 PMCID: PMC8104983 DOI: 10.2147/ijgm.s305454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction In recent years, radioactive iodine (RAI) therapy has become a main choice for Graves' disease. The rapid release of thyroid hormones following RAI may on occasion trigger severe events, such as thyroid storm or heart block. This study presents two cases of possible acute adrenocortical insufficiency precipitated by radioiodine therapy. Case Presentation Two females aged 65 and 19 years with long-standing Graves' disease underwent radioiodine treatment at our clinical center. Both patients suffered nausea, fatigue, aggravated palpitation, and relative hypotension thereafter. Laboratory data showed severe thyrotoxicosis with free thyroxine higher than three times the upper limit, while basal serum cortisol (8 AM) was below the lower limit (5.08 μg/dL and 2.08 μg/dL respectively) under stress, indicating a potential relative adrenocortical insufficiency. There was then full recovery after adequate hydrocortisone therapy. As thyrotoxicosis resolved, the levels of basal cortisol were subsequently raised to normal. Conclusion Post-RAI adrenocortical insufficiency might occur in patients with severe Graves' disease. Basal serum cortisol might be a cost-effective parameter for the identification of potential patients.
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Affiliation(s)
- Hanxin Zhao
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, People's Republic of China
| | - Yu Ruan
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, People's Republic of China
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ÇETİN E, KAMIŞ F, KARAKILIÇ E, ARSLAN M, BEYAZIT Y. Evaluation of the hematologic indices in patients with thyrotoxicosis with distinct etiologies: a case-control study. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.857780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Riguetto CM, Barreto IS, Maia FFR, da Assumpção LVM, Zantut-Wittmann DE. Usefulness of pre-thyroidectomy neutrophil-lymphocyte, platelet-lymphocyte, and monocyte-lymphocyte ratios for discriminating lymph node and distant metastases in differentiated thyroid cancer. Clinics (Sao Paulo) 2021; 76:e3022. [PMID: 34406270 PMCID: PMC8341041 DOI: 10.6061/clinics/2021/e3022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/11/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This study aimed to analyze the relationship of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) with clinicopathological characteristics of patients with differentiated thyroid cancer (DTC). METHODS This retrospective study included 390 patients with DTC who had complete blood cell counts available at the time of surgery. NLR, PLR, and MLR were calculated, and the risk of cancer-related death, structural recurrence, and response to therapy were assessed using the eighth edition of the tumor-node-metastasis classification, American Thyroid Association (ATA) Risk Stratification System, and ATA Response to Therapy Reclassification, respectively. RESULTS PLR was higher in patients with distant metastasis than in those without (133.15±43.95 versus 119.24±45.69, p=0.0345) and lower in patients with disease-free status (117.72±44.70 versus 131.07±47.85, p=0.0089) than in those who experienced persistent disease or death. Patients aged ≥55 years had a higher MLR than those aged <55 years (0.26±0.10 versus 0.24±0.12, p=0.0379). Higher MLR (odds ratio [OR]: 8.775, 95% confidence interval [CI]: 1.532-50.273, p=0.0147), intermediate ATA risk (OR: 4.892, 95% CI: 2.492-9.605, p≤0.0001), and high ATA risk (OR: 5.998, 95% CI: 3.126-11.505, p≤0.0001) were risk factors associated with active disease. NLR was not significantly different among the studied variables. Receiver operating characteristic curve cut-off values for NLR, PLR, and MLR were able to differentiate distant metastasis from lymph node metastasis (NLR>1.93: 73.3% sensitivity and 58.7% specificity, PLR>124.34: 86.7% sensitivity and 69.2% specificity, MLR>0.21: 80% sensitivity and 45.2% specificity). CONCLUSION Cut-off values of NLR, PLR, and MLR differentiated distant metastasis from lymph node metastasis with good sensitivity and accuracy. PLR was associated with disease-free status and it was higher in DTC patients with distant metastasis, persistent disease, and disease-related death. MLR was a risk factor for active disease.
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Affiliation(s)
- Cínthia Minatel Riguetto
- Divisao de Endocrinologia, Departamento de Medicina Interna, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SP, BR
| | - Icléia Siqueira Barreto
- Departamento de Patologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SP, BR
| | - Frederico Fernandes Ribeiro Maia
- Divisao de Endocrinologia, Departamento de Medicina Interna, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SP, BR
| | - Lígia Vera Montali da Assumpção
- Divisao de Endocrinologia, Departamento de Medicina Interna, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SP, BR
| | - Denise Engelbrecht Zantut-Wittmann
- Divisao de Endocrinologia, Departamento de Medicina Interna, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SP, BR
- Corresponding author. E-mail:
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Szydełko J, Litwińczuk M, Szydełko M, Matyjaszek-Matuszek B. Neutrophil-to-Lymphocyte, Monocyte-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Relation to Clinical Parameters and Smoking Status in Patients with Graves' Orbitopathy-Novel Insight into Old Tests. J Clin Med 2020; 9:jcm9103111. [PMID: 32993174 PMCID: PMC7600876 DOI: 10.3390/jcm9103111] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
Graves' orbitopathy (GO) is an autoimmune disease with a chronic inflammatory background. Smoking behavior is the main environmental factor responsible for the transition of this major extra thyroidal manifestation of Graves' disease (GD) from the subclinical to the overt form. Complete blood count-derived parameters are suggested to be novel inflammatory indices. The aim of this retrospective study was to investigate the association between neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), and platelet-to-lymphocyte ratios (PLR) with selected clinical parameters and smoking status in 406 GD patients with (n = 168) and without GO (n = 238). The control group consisted of 100 healthy individuals. The activity of GO was graded according to Clinical Activity Score. Significantly higher white blood cells (WBC), neutrophil, and NLR (p < 0.05) values were observed in GD patients with GO compared with those without GO. PLR values were significantly higher in GO patients than in the controls. WBC (6.81 ± 1.56 vs. 5.70 ± 1.23) and neutrophils (3.89 ± 1.06 vs. 3.15 ± 0.95) count was higher in active GO patients than in those with inactive GO. Positive correlation (p < 0.05) between CAS score and WBC, neutrophil and monocyte count, and NLR was found. Smoking was associated with higher WBC (p = 0.040), neutrophil (p = 0.049), PLR (p = 0.032) values. Multivariate analysis revealed that WBC, NLR may be risk factors for GO development. WBC, neutrophil, NLR and PLR values seem to be useful tools in the assessment of inflammation in GD.
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Affiliation(s)
- Joanna Szydełko
- Department of Endocrinology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland;
- Correspondence: ; Tel.: +48-81-724-4668; Fax: +81-724-4669
| | - Michał Litwińczuk
- Department of Endocrinology, Independent Public Clinical Hospital No. 4 in Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (M.L.); (M.S.)
| | - Magdalena Szydełko
- Department of Endocrinology, Independent Public Clinical Hospital No. 4 in Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (M.L.); (M.S.)
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