1
|
Løhre A. Brain fog in hypothyroidism: recovery or dementia? BMJ 2024; 386:q1426. [PMID: 38960619 DOI: 10.1136/bmj.q1426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Affiliation(s)
- Audhild Løhre
- Department of Teacher Education, Norwegian University of Science and Technology, Trondheim, Norway
- Patient author
| |
Collapse
|
2
|
Salas-Lucia F. Mapping Thyroid Hormone Action in the Human Brain. Thyroid 2024; 34:815-826. [PMID: 38757586 PMCID: PMC11295854 DOI: 10.1089/thy.2024.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Background: Normal brain development, mood, and cognitive functions depend on thyroid hormone (TH) action. However, little is known about how TH mediates its actions in the human brain. This is due to limited access to human brains deprived of TH during fetal and early postnatal life, as well as from adults with altered thyroid status. One way to partially bypass these limitations is by using magnetic resonance imaging and spectroscopy, two neuroimaging techniques that provide detailed, noninvasive information on human brain structure and function. Another way is using human-induced pluripotent stem cell (hiPSCs)-derived three-dimensional in vitro systems, known as brain organoids, which allow for the study of fundamental aspects of the early stages of human brain development. Summary: This narrative review focuses on neuroimaging and brain organoid studies. Neuroimaging of human brains performed in individuals with different thyroid conditions provides information on the volume, myelination, blood flow, neural activity, and connectivity of different areas. Such studies show that suboptimal thyroid status can impact human brain development and its normal function throughout life. This is true not only for patients with sporadic congenital hypothyroidism, during pregnancy or early after birth, but also for adult patients with hypo- or hyperthyroidism, patients carrying mutations that manifest as impaired sensitivity to TH, and even for normal individuals during aging. Studies using brain organoids generated from hiPSCs of healthy individuals or patients with thyroid genetic conditions provide insights into how TH can impact the early development of the human cerebral cortex. Conclusions: The developmental alterations in children born to mothers with different degrees of gestational hypothyroidism or who developed hypothyroidism early in life are remarkable, affecting multiple brain regions and pathways, including the cerebral cortex, hippocampus, cerebellum, interhemispheric and corticospinal tracts, and associative nuclei. The data connecting such changes to poor neurological outcomes in adult patients with hypothyroidism represent an objective link between thyroid-specific functional brain alterations and behavior. Growing brain organoids require TH, which is critical for human neurogenesis and oligodendrogenesis. These models have proven useful in screening drugs with potential therapeutic effects for patients with genetic thyroid diseases.
Collapse
|
3
|
Bas M, Kahriman M, Gencalp C, Koseoglu SK, Hajhamidiasl L. Adaptation and Validation of the Turkish Version of the Brain Fog Scale. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:774. [PMID: 38929020 PMCID: PMC11203739 DOI: 10.3390/ijerph21060774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024]
Abstract
Brain fog is a condition that is characterized by poor concentration, memory loss, decreased cognitive function, and mental fatigue. Although it is generally known as a long-term COVID-19 symptom, brain fog has also been reported to be caused by many other diseases. Thus, it is necessary to assess this condition in certain populations. This study aimed to evaluate the reliability and validity of the Brain Fog Scale in a Turkish population. We conducted the study in two phases. In a pilot study including 125 participants, we confirmed the suitability of the scale for validity analyses and then conducted exploratory (n = 230) and confirmatory factor analyses (n = 343). The Cronbach's alpha value of the 23-item Brain Fog Scale was 0.966. In addition, the 23-item and three-factor structure was confirmed as a result of the analyses. These three factors are mental fatigue, impaired cognitive acuity, and confusion. We also found that participants previously diagnosed with COVID-19 had higher brain fog scores. This finding indicates that brain fog is an important condition that can accompany COVID-19. Furthermore, this validated construct has an acceptable fit and is a valid and useful tool for the Turkish population.
Collapse
Affiliation(s)
- Murat Bas
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Acibadem Mehmet Ali Aydinlar University, Istanbul 34752, Türkiye; (M.K.); (C.G.); (S.K.K.); (L.H.)
| | | | | | | | | |
Collapse
|
4
|
Riis KR, Bonnema SJ, Dreyer AF, Glintborg D, Bilenberg N, Bleses D, Trecca F, Andersen MS. Thyroid autoimmunity in euthyroid pregnant women is associated with slower productive language acquisition: the Odense child cohort study. Eur Thyroid J 2024; 13:e230233. [PMID: 38688317 PMCID: PMC11227095 DOI: 10.1530/etj-23-0233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/29/2024] [Indexed: 05/02/2024] Open
Abstract
Objective Maternal thyroid autoimmunity and thyroid function in early pregnancy may impact fetal neurodevelopment. We aimed to investigate how thyroid autoimmunity and thyroid function in early pregnancy were associated with language acquisition in offspring at 12-36 months of age. Methods This study was embedded in the prospective Odense child cohort. Mother-child dyads were excluded in case of maternal intake of thyroid medication during pregnancy. The parents completed MacArthur-Bates Communicative Development Inventories (MB-CDI) every third month to assess their offspring's productive vocabulary. All completed reports for each child were included in the analyses. Logistic growth curve models evaluated associations between MB-CDI scores and levels of maternal thyroid peroxidase antibodies (TPOAb), free thyroxine (FT4), and thyrotropin, respectively, measured in early pregnancy (median gestational week 12). All models were stratified by offspring sex and adjusted for maternal age, education, pre-pregnancy body mass index, parity, breastfeeding, and offspring age. Results The study included 735 mother-child dyads. Children born to mothers with TPOAb ≥11 kIU/L, opposed to TPOAb <11 kIU/L, had a lower probability of producing words at age 18-36 months for girls (OR = 0.78, P < 0.001) and 33-36 months for boys (OR = 0.83, P < 0.001). The probability of producing words was higher in girls at 30-36 months of age with low-normal maternal FT4 vs high-normal FT4 (OR = 0.60, P < 0.001), and a similar trend was seen in boys. Results were ambiguous for thyrotropin. Conclusion In women without known thyroid disease, TPOAb positivity in early pregnancy was negatively associated with productive vocabulary acquisition in girls and boys. This association was not mediated by a decreased thyroid function, as low-normal maternal FT4, unexpectedly, indicated better vocabulary acquisition. Our results support that maternal thyroid autoimmunity per se may affect fetal neurodevelopment.
Collapse
Affiliation(s)
- Kamilla R Riis
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Steen J Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Anja F Dreyer
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Dorte Glintborg
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Niels Bilenberg
- Department of Child and Adolescent Mental Health, Mental Health Services in the Region of Southern Denmark, University of Southern Denmark Odense, Odense, Denmark
| | - Dorthe Bleses
- TrygFonden’s Centre for Child Research and School of Communication and Culture, Aarhus University, Aarhus, Denmark
| | - Fabio Trecca
- TrygFonden’s Centre for Child Research and School of Communication and Culture, Aarhus University, Aarhus, Denmark
| | - Marianne S Andersen
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
5
|
Bazika-Gerasch B, Kumowski N, Enax-Krumova E, Kaisler M, Eitner LB, Maier C, Dietrich JW. Impaired autonomic function and somatosensory disturbance in patients with treated autoimmune thyroiditis. Sci Rep 2024; 14:12358. [PMID: 38811750 PMCID: PMC11137073 DOI: 10.1038/s41598-024-63158-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 05/26/2024] [Indexed: 05/31/2024] Open
Abstract
Despite treatment with levothyroxine, hypothyroidism and autoimmune thyroiditis (AIT) may be associated with reduced quality of life (QoL), an enigmatic condition referred to as "syndrome T". Peripheral neuropathy, described in untreated thyroid disease, could be a contributing mechanism. We analysed autonomic and somatosensory function in 29 patients with AIT and treated hypothyroidism and 27 healthy volunteers. They underwent heart rate variability (HRV) analysis and quantitative sensory testing (n = 28), comprising 13 parameters of small and large nerve fibre function and pain thresholds. Autonomic cardiovascular function was assessed in rest, deep respiration and orthostasis. Additionally, biomarkers for autoimmunity and thyroid function were measured. Anxiety, depression and QoL were assessed using validated questionnaires. 36% of the patients showed at least one sign of somatosensory small or large fibre dysfunction. 57% presented with mild hyperalgesia to at least one stimulus. Several markers of autonomic function and some detection thresholds were related to the antibody titres. Anxiety, depression scores and QoL correlated to antibody titres and HRV measures. Autonomic and somatosensory dysfunction indicate that in treated hypothyroidism and AIT a subgroup of patients suffers from neuropathic symptoms leading to impaired QoL. Additionally, mild hyperalgesia as a possible sensitisation phenomenon should be considered a target for symptomatic treatment.
Collapse
Affiliation(s)
- Bojana Bazika-Gerasch
- Diabetes, Endocrinology and Metabolism Section, Department of Internal Medicine I, St. Josef Hospital, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, NRW, Germany
- Diabetes Centre Bochum/Hattingen, St. Elisabeth-Hospital Blankenstein, Im Vogelsang 5-11, 45527, Hattingen, NRW, Germany
- Centre for Diabetes Technology, Catholic Hospitals Bochum, Ruhr University Bochum, NRW, Gudrunstr. 56, 44791, Bochum, Germany
- Centre for Rare Endocrine Diseases, Ruhr Centre for Rare Diseases (CeSER), Ruhr University Bochum and Witten/Herdecke University, Alexandrinenstr. 5, 44791, Bochum, NRW, Germany
- Centre for Thyroid Medicine KKB, Catholic Hospitals Bochum, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, NRW, Germany
| | - Nina Kumowski
- Department of Internal Medicine 1, University Hospital Aachen, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Pauwelsstraße 30, 52074, Aachen, NRW, Germany
| | - Elena Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil gGmbH, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, NRW, Germany
| | - Miriam Kaisler
- Department of Neurology, BG University Hospital Bergmannsheil gGmbH, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, NRW, Germany
| | - Lynn Bernadette Eitner
- Pediatrics Department, Catholic Hospitals Bochum, Ruhr University Bochum, Alexandrinenstraße 5, 44791, Bochum, NRW, Germany
- Centre for Thyroid Medicine KKB, Catholic Hospitals Bochum, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, NRW, Germany
| | - Christoph Maier
- Pediatrics Department, Catholic Hospitals Bochum, Ruhr University Bochum, Alexandrinenstraße 5, 44791, Bochum, NRW, Germany
| | - Johannes W Dietrich
- Diabetes, Endocrinology and Metabolism Section, Department of Internal Medicine I, St. Josef Hospital, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, NRW, Germany.
- Diabetes Centre Bochum/Hattingen, St. Elisabeth-Hospital Blankenstein, Im Vogelsang 5-11, 45527, Hattingen, NRW, Germany.
- Centre for Diabetes Technology, Catholic Hospitals Bochum, Ruhr University Bochum, NRW, Gudrunstr. 56, 44791, Bochum, Germany.
- Centre for Rare Endocrine Diseases, Ruhr Centre for Rare Diseases (CeSER), Ruhr University Bochum and Witten/Herdecke University, Alexandrinenstr. 5, 44791, Bochum, NRW, Germany.
- Centre for Thyroid Medicine KKB, Catholic Hospitals Bochum, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, NRW, Germany.
| |
Collapse
|
6
|
Zhou H, Zhu H, Wang J, Gao X, Jiang C. Association between hypothyroidism subtypes and major depression: A two-sample Mendelian randomization study. J Affect Disord 2024; 351:843-852. [PMID: 38341154 DOI: 10.1016/j.jad.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/28/2024] [Accepted: 02/06/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND The causal relationship between different hypothyroidism subtypes and the risk of major depression (MD) is yet to be fully elucidated. This study aimed to determine if there's a causal relationship between various hypothyroidism subtypes (and related factors) and the risk of MD. METHODS This genetic association study utilized a two-sample Mendelian Randomization (MR) approach to explore the causal relationships between various hypothyroidism subtypes and MD risk. Genome-Wide Association Study (GWAS) summary statistics were obtained from the FinnGen and the UK Biobank. Instrumental variables (IVs) were chosen based on single nucleotide polymorphisms (SNPs). RESULTS Among the analyzed hypothyroidism subtypes and related factors, "Hypothyroidism, strict autoimmune" (HTCBSA) and "Hypothyroidism, levothyroxin purchases" (HT/LP) demonstrated a statistically significant positive causal relationship with MD, with odds ratios of 1.020 (95 % CI: 1.004-1.037) and 1.022 (95 % CI: 1.005-1.040), respectively. The sensitivity analysis supported the robustness of these findings, showing no significant horizontal pleiotropy and confirming the stability of results when individual SNPs were removed. "Congenital iodine-deficiency syndrome/hypothyroidism" (CIDS/HT), "Postinfectious hypothyroidism" (PHT), "Hypothyroidism due to medicaments and other exogenous substances" (HDTDM and OES), "Thyroid Stimulating Hormone" (TSH), "Thyrotropin-releasing hormone" (THRH), and "Hypothyroidism, strict autoimmune, 3 medication purchases required" (HTCBSA/3MPR) showed no significant causal relationship with MD. LIMITATIONS The study population was limited to individuals of European ancestry, and there may be certain genetic differences between different ethnic groups. CONCLUSIONS This MR study suggests a potential causal relationship between certain hypothyroidism subtypes (specifically HTCBSA and HT/LP) and an increased risk of MD.
Collapse
Affiliation(s)
- Hongliang Zhou
- Department of Medical Psychology, The Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China.
| | - Haohao Zhu
- Department of Psychiatry, Wuxi Mental Health Center, Nanjing Medical University, Wuxi, Jiangsu, China
| | - Jun Wang
- Department of Psychiatry, Wuxi Mental Health Center, Nanjing Medical University, Wuxi, Jiangsu, China
| | - Xuezheng Gao
- Department of Psychiatry, Wuxi Mental Health Center, Nanjing Medical University, Wuxi, Jiangsu, China
| | - Chenguang Jiang
- Department of Psychosomatics and Psychiatry, ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China
| |
Collapse
|
7
|
Rosenberg R, Thorpy MJ, Doghramji K, Morse AM. Brain fog in central disorders of hypersomnolence: a review. J Clin Sleep Med 2024; 20:643-651. [PMID: 38217475 PMCID: PMC10985301 DOI: 10.5664/jcsm.11014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 01/04/2024] [Accepted: 01/04/2024] [Indexed: 01/15/2024]
Abstract
Brain fog is an undefined term describing a cluster of symptoms related to fatigue and impaired memory, attention, and concentration. Brain fog or brain fog-like symptoms have been reported in central disorders of hypersomnolence and in a range of seemingly unrelated disorders, including coronavirus disease 2019, major depressive disorder, multiple sclerosis, lupus, and celiac disease. This narrative review summarizes current evidence and proposes a consensus definition for brain fog. Brain fog is prevalent in narcolepsy and idiopathic hypersomnia, with more than three-quarters of patients with either disorder reporting this symptom in a registry study; it has also been reported as particularly difficult to treat in idiopathic hypersomnia. Studies directly evaluating brain fog are rare; tools for evaluating this symptom cluster typically are patient reports, with few objective measures validated in any disorder. Evaluating brain fog is further complicated by confounding symptoms, such as excessive daytime sleepiness, which is a hallmark of hypersomnolence disorders. No treatments specifically address brain fog. The paucity of literature, assessment tools, and medications for brain fog highlights the need for research leading to better disambiguation and treatment. Until a clear consensus definition is established, we propose brain fog in hypersomnia disorders be defined as a cognitive dysfunction that may or may not be linked with excessive sleepiness, related to an underlying neuronal dysfunction, which reduces concentration and impairs information processing, leading to a complaint of lack of clarity of mental thinking and awareness. CITATION Rosenberg R, Thorpy MJ, Doghramji K, Morse AM. Brain fog in central disorders of hypersomnolence: a review. J Clin Sleep Med. 2024;20(4):643-651.
Collapse
Affiliation(s)
| | | | - Karl Doghramji
- Jefferson Sleep Disorders Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Anne Marie Morse
- Department of Child Neurology and Sleep Medicine, Geisinger Medical Center, Janet Weis Children’s Hospital, Danville, Pennsylvania
| |
Collapse
|
8
|
Ettleson MD, Ibarra S, Wan W, Peterson S, Laiteerapong N, Bianco AC. Demographic, Healthcare Access, and Dietary Factors Associated With Thyroid Hormone Treatments for Hypothyroidism. J Clin Endocrinol Metab 2023; 108:e1614-e1623. [PMID: 37327351 PMCID: PMC10655529 DOI: 10.1210/clinem/dgad331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/18/2023]
Abstract
CONTEXT Clinical guidelines have recommended a trial of liothyronine (LT3) with levothyroxine (LT4) in select patients with hypothyroidism. However, little is known about the real-world use of LT3 and desiccated thyroid extract (DTE) and the characteristics of patients treated with LT3 and DTE. OBJECTIVES (1) Determine national trends of new LT4, LT3, and DTE prescriptions in the United States; (2) determine whether sociodemographic, healthcare access, and dietary factors are associated with different thyroid hormone (TH) therapies. METHODS Parallel cross-sectional studies were conducted using 2 datasets: (1) a national patient claims dataset (2010-2020) and (2) the National Health and Nutrition Examination Study (NHANES) dataset (1999-2016). Included participants had a diagnosis of primary or subclinical hypothyroidism. Study outcomes included the impact of demographics and healthcare access on differences in the proportion of TH therapies consisting of LT4, LT3, and DTE (patient claims) and differences in dietary behaviors between DTE-treated participants and LT4-treated matched controls (NHANES). RESULTS On an average annual basis, 47 711 adults received at least 1 new TH prescription, with 88.3% receiving LT4 monotherapy, 2.0% receiving LT3 therapy, and 9.4% receiving DTE therapy. The proportion receiving DTE therapy increased from 5.4% in 2010 to 10.2% in 2020. In the analysis between states, high primary care and endocrinology physician densities were associated with increased use of LT4 monotherapy (odds ratio 2.51, P < .001 and odds ratio 2.71, P < .001). DTE-treated NHANES participants (n = 73) consumed more dietary supplements compared to LT4-treated participants (n = 146) (4.7 vs 2.1, P < .001). CONCLUSIONS The proportion of new TH therapies containing DTE for hypothyroidism doubled since 2010 while LT3 therapies remained stable. DTE treatment was associated with decreased physician density and increased dietary supplement use.
Collapse
Affiliation(s)
- Matthew D Ettleson
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
| | - Sabrina Ibarra
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
| | - Wen Wan
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Sarah Peterson
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, IL 60612, USA
| | - Neda Laiteerapong
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Antonio C Bianco
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
| |
Collapse
|
9
|
Delgado-Alonso C, Díez-Cirarda M, Pagán J, Pérez-Izquierdo C, Oliver-Mas S, Fernández-Romero L, Martínez-Petit Á, Valles-Salgado M, Gil-Moreno MJ, Yus M, Matías-Guiu J, Ayala JL, Matias-Guiu JA. Unraveling brain fog in post-COVID syndrome: Relationship between subjective cognitive complaints and cognitive function, fatigue, and neuropsychiatric symptoms. Eur J Neurol 2023. [PMID: 37797297 DOI: 10.1111/ene.16084] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 09/10/2023] [Accepted: 09/17/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND PURPOSE "Brain fog" is a frequent and disabling symptom that can occur after SARS-CoV-2 infection. However, its clinical characteristics and the relationships among brain fog and objective cognitive function, fatigue, and neuropsychiatric symptoms (depression, anxiety) are still unclear. In this study, we aimed to examine the characteristics of brain fog and to understand how fatigue, cognitive performance, and neuropsychiatric symptoms and the mutual relationships among these variables influence subjective cognitive complaints. METHODS A total of 170 patients with cognitive complaints in the context of post-COVID syndrome were evaluated using a comprehensive neuropsychological protocol. The FLEI scale was used to characterize subjective cognitive complaints. Correlation analysis, regression machine-learning algorithms, and mediation analysis were calculated. RESULTS Cognitive complaints were mainly attention and episodic memory symptoms, while executive functions (planning) issues were less often reported. The FLEI scale, a mental ability questionnaire, showed high correlations with a fatigue scale and moderate correlations with the Stroop test, and anxiety and depressive symptoms. Random forest algorithms showed an R2 value of 0.409 for the prediction of FLEI score, with several cognitive tests, fatigue and depression being the best variables used in the prediction. Mediation analysis showed that fatigue was the main mediator between objective and subjective cognition, while the effect of depression was indirect and mediated through fatigue. CONCLUSIONS Brain fog associated with COVID-19 is mainly characterized by attention and episodic memory, and fatigue, which is the main mediator between objective and subjective cognition. Our findings contribute to understanding the pathophysiology of brain fog and emphasize the need to unravel the main mechanisms underlying brain fog, considering several aspects.
Collapse
Affiliation(s)
- Cristina Delgado-Alonso
- Department of Neurology, Hospital Clínico San Carlos, Health Research Institute "San Carlos" (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| | - María Díez-Cirarda
- Department of Neurology, Hospital Clínico San Carlos, Health Research Institute "San Carlos" (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| | - Josué Pagán
- Department of Electronic Engineering, Universidad Politécnica de Madrid, Madrid, Spain
- Center for Computational Simulation, Universidad Politécnica de Madrid, Madrid, Spain
| | - Carlos Pérez-Izquierdo
- Department of Agricultural and Forestry Engineering, University Center of Plasencia, University of Extremadura, Plasencia, Spain
| | - Silvia Oliver-Mas
- Department of Neurology, Hospital Clínico San Carlos, Health Research Institute "San Carlos" (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| | - Lucía Fernández-Romero
- Department of Neurology, Hospital Clínico San Carlos, Health Research Institute "San Carlos" (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| | - Álvaro Martínez-Petit
- Department of Electronic Engineering, Universidad Politécnica de Madrid, Madrid, Spain
- Center for Computational Simulation, Universidad Politécnica de Madrid, Madrid, Spain
| | - María Valles-Salgado
- Department of Neurology, Hospital Clínico San Carlos, Health Research Institute "San Carlos" (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| | - María José Gil-Moreno
- Department of Neurology, Hospital Clínico San Carlos, Health Research Institute "San Carlos" (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| | - Miguel Yus
- Department of Radiology, Hospital Clinico San Carlos, Health Research Institute "San Carlos" (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| | - Jorge Matías-Guiu
- Department of Neurology, Hospital Clínico San Carlos, Health Research Institute "San Carlos" (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| | - José Luis Ayala
- Department of Automatic Architecture and Automation, Universidad Complutense, Madrid, Spain
| | - Jordi A Matias-Guiu
- Department of Neurology, Hospital Clínico San Carlos, Health Research Institute "San Carlos" (IdISCC), Universidad Complutense de Madrid, Madrid, Spain
| |
Collapse
|
10
|
Biondi B, Celi FS, McAninch EA. Critical Approach to Hypothyroid Patients With Persistent Symptoms. J Clin Endocrinol Metab 2023; 108:2708-2716. [PMID: 37071856 PMCID: PMC10686697 DOI: 10.1210/clinem/dgad224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/07/2023] [Accepted: 04/13/2023] [Indexed: 04/20/2023]
Abstract
Hypothyroidism is a common condition, and numerous studies have been published over the last decade to assess the potential risks associated with this disorder when inappropriately treated. The standard of care for treatment of hypothyroidism remains levothyroxine (LT4) at doses to achieve biochemical and clinical euthyroidism. However, about 15% of hypothyroid patients experience residual hypothyroid symptoms. Some population-based studies and international population-based surveys have confirmed dissatisfaction with LT4 treatment in some hypothyroid patients. It is well established that hypothyroid patients treated with LT4 exhibit higher serum thyroxine:triiodothyronine ratios and can have a persistent increase in cardiovascular risk factors. Moreover, variants in deiodinases and thyroid hormone transporter genes have been associated with subnormal T3 concentrations, persistent symptoms in LT4-treated patients, and improvement in response to the addition of liothyronine to LT4 therapy. The American (ATA) and European Thyroid Association (ETA) guidelines have recently evolved in their recognition of the potential limitations of LT4. This shift is reflected in prescribing patterns: Physicians' use of combination therapy is prevalent and possibly increasing. Randomized clinical trials have recently been published and, while they have found no improvement in treating hypothyroid patients, a number of important limitations did not allow generalizability. Meta-analyses have reported a preference rate for combination therapy in 46.2% hypothyroid patients treated with LT4. To promote discussions about an optimal study design, the ATA, ETA, and British Thyroid Association have recently published a consensus document. Our study provides a useful counterpoint on the controversial benefits of treating hypothyroid patients with combination therapy.
Collapse
Affiliation(s)
- Bernadette Biondi
- Division of Internal Medicine and Cardiovascular Endocrinology, Department of Clinical Medicine and Surgery, University Federico II of Naples, 80131 Naples, Italy
| | - Francesco S Celi
- Division of Endocrinology and Metabolism, Department of Medicine UConn Health, Farmington, CT 06030-8075, USA
| | - Elizabeth A McAninch
- Division of Endocrinology, Metabolism and Gerontology, Stanford University Medical Center, Stanford, CA 94305, USA
| |
Collapse
|
11
|
Jonklaas J. Is euthyroidism within reach for all? Expert Rev Endocrinol Metab 2023; 18:455-458. [PMID: 37811647 DOI: 10.1080/17446651.2023.2267120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, DC, United States
| |
Collapse
|
12
|
Mohammed RA, Baqais OA, Basalib SG, Owaidah AZ, Mirza AT, Sultan I. Hypothyroidism Among College Students and Its Association With Academic Performance: A Cross-Sectional Study. Cureus 2023; 15:e42588. [PMID: 37641777 PMCID: PMC10460479 DOI: 10.7759/cureus.42588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Little is known about the impact of hypothyroidism and its contribution to learning difficulties and academic performance in college-age students. OBJECTIVE The objective is toassess the frequency of hypothyroidism and its associations with academic performance in college-age students. METHODS A cross-sectional study included 395 students studying across various Jeddah universities and selected by non-probability convenient sampling. Students self-answered the survey using Google Forms. The survey included demographic data, thyroid data, academic achievement as measured by overall grade point average (GPA), and student persistence as measured by academic failure and delay. RESULTS Three hundred ninety-five students were included, their median age was 23 years (17-33), 96 were males (24.3%) and 299 were females (75.7%). Their median GPA was 4 (2.76-4). Thirty-two students (8.1%) had been treated for hypothyroidism and eight students (25.8%) were non-compliant with therapy. Odds of hypothyroidism increased among females (OR 3.33, 95% CI: 0.99-10.78, p=0.048), older age (OR 2.60, 95% CI: 1.33-5.77, p=0.009), those with a positive family history of thyroid illnesses (OR 5.49, 95% CI: 2.30-13.07, p<0.001), and those with academic failure (OR 3.31, 95% CI: 1.43-7.30, p=0.003) and academic delay (OR 2.83, 95% CI: 1.14-7.05, p=0.020). There was no significant association between hypothyroidism and GPA (OR 2.42, 95% CI: 0.83-7.77, P=0.092). CONCLUSION Hypothyroidism was prevalent among college students (8%), especially among older females. Hypothyroidism was associated with difficult student persistence, but this association did not reflect on their overall academic achievement. Incompliance with thyroid replacement therapy may be a common issue among hypothyroid patients. Further studies should focus on specific tests of the cognitive function of different learning domains and the role of treatment.
Collapse
Affiliation(s)
- Rehab A Mohammed
- Department of Internal Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, EGY
| | - Omar A Baqais
- Department of Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Samaher G Basalib
- Department of Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Abdulaziz Z Owaidah
- Department of Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Abdulrahman T Mirza
- Department of Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Intessar Sultan
- Department of Internal Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| |
Collapse
|
13
|
Casula S, Ettleson MD, Bianco AC. Are We Restoring Thyroid Hormone Signaling in Levothyroxine-Treated Patients With Residual Symptoms of Hypothyroidism? Endocr Pract 2023; 29:581-588. [PMID: 37419565 PMCID: PMC11221272 DOI: 10.1016/j.eprac.2023.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 07/09/2023]
Abstract
INTRODUCTION Levothyroxine (LT4) at doses that maintain the serum thyroid-stimulating hormone levels within the normal range constitutes the standard of care for the treatment of hypothyroidism. After a few months, this eliminates the signs and symptoms of overt hypothyroidism in the majority of patients, owing to the endogenous activation of thyroxine to triiodothyronine, the biologically active thyroid hormone. Still, a small percentage of the patients (10%-20%) exhibit residual symptoms, despite having normal serum thyroid-stimulating hormone levels. These symptoms include cognitive, mood, and metabolic deficits, with a significant impairment in psychological well-being and quality of life. OBJECTIVE To provide a summary of progress in the approach of patients with hypothyroidism that exhibit residual symptoms despite treatment. METHODS We reviewed the current literature and here we focused on the mechanisms leading to a deficiency of T3 in some LT4-treated patients, the role of residual thyroid tissue and the rationale for combination therapy with LT4 + liothyronine (LT3). RESULTS A score of clinical trials comparing therapy with LT4 versus LT4 + LT3 concluded that both are safe and equally effective (neither is superior); however, these trials failed to recruit a sufficiently large number of patients with residual symptoms. New clinical trials that considered LT4-treated symptomatic patients revealed that such patients benefit from and prefer therapy containing LT4 + LT3; desiccated thyroid extract has also been used with similar results. A practical approach to patients with residual symptoms and on initiation of combination therapy with LT4 + LT3 is provided. CONCLUSION A recent joint statement of the American, British, and European Thyroid Associations recommends that a trial with combination therapy be offered to patients with hypothyroidism that do not fully benefit from therapy with LT4.
Collapse
Affiliation(s)
- Sabina Casula
- Department of Endocrinology, Miami Veterans Affairs Healthcare System, Miami, Florida
| | - Matthew D Ettleson
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois.
| |
Collapse
|
14
|
Lindo A, Breikert A, Lakwijk P, Lundberg C, Lunner K, Johansson B, Filipsson Nyström H. Patient needs and care: moves toward person-centered care for Graves' disease in Sweden. Eur Thyroid J 2023; 12:e230010. [PMID: 36912797 PMCID: PMC10160562 DOI: 10.1530/etj-23-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/14/2023] Open
Abstract
Patients with Graves' disease (GD) not only need appropriate medical care, but they also need to be cared for. The aim of this review is to examine the literature on GD patient needs, expectations, perceptions, and quality of life. We will also present methods for patient care, define gaps in knowledge, and suggest factors that can be introduced into the regular care of GD patients. Patient information, teamwork with thyroid/contact nurses, education of personnel and patients, quality of life measurements, and the formation of a rehabilitation program have enough evidence to be implemented into regular care. However, visualizing patient needs through person-centered care requires further evaluation in GD patients before being implemented in routine care. We conclude that considerable improvement in nursing can be achieved in relation to GD.
Collapse
Affiliation(s)
- Agneta Lindo
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- The National Task Force in Hyperthyroidism, Swedish National System for Knowledge-Driven Management, Umeå, Sweden
| | - Anne Breikert
- The National Task Force in Hyperthyroidism, Swedish National System for Knowledge-Driven Management, Umeå, Sweden
- Department of Endocrinology and Diabetes, Örebro University Hospital, Örebro, Sweden
| | - Peter Lakwijk
- The National Task Force in Hyperthyroidism, Swedish National System for Knowledge-Driven Management, Umeå, Sweden
- Thyroid Federation International, Kungsbacka, Sweden
| | - Christin Lundberg
- The National Task Force in Hyperthyroidism, Swedish National System for Knowledge-Driven Management, Umeå, Sweden
- Swedish Thyroid Association, Stockholm, Sweden
| | - Katarina Lunner
- The National Task Force in Hyperthyroidism, Swedish National System for Knowledge-Driven Management, Umeå, Sweden
- Swedish Thyroid Association, Stockholm, Sweden
| | - Birgitta Johansson
- Institute of Neuroscience and Physiology Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Helena Filipsson Nyström
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- The National Task Force in Hyperthyroidism, Swedish National System for Knowledge-Driven Management, Umeå, Sweden
- Sweden and Wallenberg Center for Molecular and Translational Medicine, Västra Götaland Region, Göteborg, Sweden
| |
Collapse
|
15
|
Jansen HI, Boelen A, Heijboer AC, Bruinstroop E, Fliers E. Hypothyroidism: The difficulty in attributing symptoms to their underlying cause. Front Endocrinol (Lausanne) 2023; 14:1130661. [PMID: 36814580 PMCID: PMC9939761 DOI: 10.3389/fendo.2023.1130661] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/26/2023] [Indexed: 02/08/2023] Open
Abstract
Common symptoms of overt hypothyroidism are non-specific and include fatigue, lethargy, and dry skin. Although the diagnosis is considered to be straightforward, no single symptom can be used to identify patients with overt hypothyroidism, while many patients with subclinical hypothyroidism are asymptomatic. A large population-based study on the spectrum of symptoms in subclinical hypothyroidism showed similar rates of thyroid disease-related symptoms compared with euthyroid subjects, while the TSH concentration had no impact on symptom score. Together, these findings make it challenging to attribute symptoms to their underlying cause. This is also true in the case of unexplained persistent symptoms in levothyroxine-treated patients. Although generally considered a life-long replacement therapy, successful thyroid hormone discontinuation resulting in euthyroidism has been reported in approximately one third of patients. Thus, we overtreat patients with (subclinical) hypothyroidism, highlighting the importance of reliable diagnostic criteria. The diagnostic process, including the implementation of robust TSH and FT4 reference intervals, is especially challenging in specific situations including aging, pregnancy, non-thyroidal illness, and central hypothyroidism. There is a clear need for improved adherence to current guidelines from scientific societies and for willingness to manage symptoms without a clear pathological correlate, especially in the case of mild TSH elevations. This review will highlight recent literature on this topic and offers some practice points.
Collapse
Affiliation(s)
- Heleen I. Jansen
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam University Medical Centers (UMC) Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam University Medical Centers (UMC), Amsterdam, Netherlands
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam University Medical (UMC) Centers, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Heleen I. Jansen,
| | - Anita Boelen
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam University Medical Centers (UMC), Amsterdam, Netherlands
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam University Medical (UMC) Centers, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam University Medical Centers (UMC), Amsterdam, Netherlands
| | - Annemieke C. Heijboer
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam University Medical Centers (UMC) Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam University Medical Centers (UMC), Amsterdam, Netherlands
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam University Medical (UMC) Centers, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam University Medical Centers (UMC), Amsterdam, Netherlands
| | - Eveline Bruinstroop
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam University Medical Centers (UMC), Amsterdam, Netherlands
- Department of Endocrinology & Metabolism, Amsterdam University Medical Centers (UMC), University of Amsterdam, Amsterdam, Netherlands
| | - Eric Fliers
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam University Medical Centers (UMC), Amsterdam, Netherlands
- Department of Endocrinology & Metabolism, Amsterdam University Medical Centers (UMC), University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
16
|
Iron: Not Just a Passive Bystander in AITD. Nutrients 2022; 14:nu14214682. [PMID: 36364944 PMCID: PMC9658435 DOI: 10.3390/nu14214682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/27/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
Autoimmune thyroid disease (AITD) is the most prevalent autoimmune disease all over the world and the most frequent cause of hypothyroidism in areas of iodine sufficiency. The pathogenesis of AITD is multifactorial and depends on complex interactions between genetic and environmental factors, with epigenetics being the crucial link. Iron deficiency (ID) can reduce the activities of thyroid peroxidase and 5′-deiodinase, inhibit binding of triiodothyronine to its nuclear receptor, and cause slower utilization of T3 from the serum pool. Moreover, ID can disturb the functioning of the immune system, increasing the risk of autoimmune disorders. ID can be responsible for residual symptoms that may persist in patients with AITD, even if their thyrometabolic status has been controlled. The human lifestyle in the 21st century is inevitably associated with exposure to chemical compounds, pathogens, and stress, which implies an increased risk of autoimmune disorders and thyroid dysfunction. To summarize, in our paper we discuss how iron deficiency can impair the functions of the immune system, cause epigenetic changes in human DNA, and potentiate tissue damage by chemicals acting as thyroid disruptors.
Collapse
|
17
|
Jonklaas J, Bianco AC. Enhancing the Patient Voice: Quality of Life, Satisfaction, and Preference During Treatment of Hypothyroidism. Thyroid 2022; 32:1139-1141. [PMID: 36136911 PMCID: PMC9836669 DOI: 10.1089/thy.2022.0483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, District of Columbia, USA
| | - Antonio Carlos Bianco
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
18
|
Jonklaas J. Restoration of euthyroidism with levothyroxine: implications of etiology of hypothyroidism and the degree of residual endogenous thyroid function. Front Endocrinol (Lausanne) 2022; 13:934003. [PMID: 35966075 PMCID: PMC9363917 DOI: 10.3389/fendo.2022.934003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/27/2022] [Indexed: 01/13/2023] Open
Abstract
There are many thyroid-related factors that combine with non-thyroid-related factors in order to affect the patient response to treatment of hypothyroidism, in terms of their satisfaction with therapy. Some of the thyroid-derived factors include the etiology of the hypothyroidism and the amount of residual thyroid function that the patient retains. These two factors may be intertwined and affected by a third influence, the presence of thyroid peroxidase antibodies. The downstream consequences of the interactions between these three factors may influence both free thyroxine and free triiodothyronine levels, TSH concentrations, and various thyroid biomarkers. Evidence of the widespread importance of thyroid hormones can be inferred from the multiple genes that are regulated, with their regulation affecting multiple serum biomarkers. Thyroid biomarkers may extend from various well-known serum markers such as lipids and sex hormone-binding globulin to serum levels of thyroid hormone metabolites. Moreover, the interplay between thyroid hormones and biomarkers and their relative ratios may be different depending on the hypothyroidism etiology and degree of residual thyroid function. The ultimate significance of these relationships and their effect on determining patient-reported outcomes, quality of life, and patient satisfaction is, as yet, poorly understood. However, identification of better biomarkers of thyroid function would advance the field. These biomarkers could be studied and correlated with patient-reported outcomes in future prospective studies comparing the impact of various thyroid hormone therapies.
Collapse
Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, DC, United States
| |
Collapse
|
19
|
Abstract
Background: Some levothyroxine (LT4)-treated hypothyroid patients report a constellation of persistent and distressing cognitive symptoms that has been termed brain fog. This narrative review focuses on attempts to define and measure hypothyroid-associated brain fog, summarize possible etiologies and contributing factors, present treatment options, and propose avenues for future research. Methods: Published literature was reviewed to summarize available information on patient-reported symptoms associated with brain fog in hypothyroidism, as well as objective evidence of impairment based on neurocognitive testing and functional imaging studies. Given the limited information specific for hypothyroid-associated brain fog, relevant data from other medical conditions associated with brain fog were also reviewed and incorporated into recommendations for clinical care and future research areas. Results: Hypothyroid-associated brain fog has not been well defined or quantitated, and the underlying pathophysiology is unclear. Symptoms vary among patients but commonly include fatigue, depressed mood, and cognitive difficulties in the areas of memory and executive function. Symptoms often predate the diagnosis of hypothyroidism, and the magnitude of cognitive impairment can range from mild to severe. Regardless of severity, these symptoms are associated with impaired quality of life and cause dissatisfaction with treatment, so often lead to requests for alternate therapies. Disease-specific and psychological factors impact the experience of brain fog in complex ways, including potential limitations in LT4 monotherapy, self-knowledge of a disease state, and expectations for therapeutic effects. Conclusions: Brain fog is a variable symptom complex in people with hypothyroidism, causing significant distress and diminished quality of life. In the absence of proven therapies, individualized treatment plans are recommended, which incorporate thyroid-specific, general medical, and psychosocial approaches. In particular, cognitive rehabilitation is an underutilized technique that is beneficial in other medical conditions associated with brain fog and could improve symptoms in hypothyroid people. The limitations in our current knowledge and questions presented throughout this review highlight a major need for clinical research in this understudied area. Future research should include attention to standardization of survey instruments to quantitate brain fog in hypothyroid people, as well as rigorously designed intervention studies.
Collapse
Affiliation(s)
- Mary H. Samuels
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, Oregon, USA
| | - Lori J. Bernstein
- Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
20
|
Chen DW, Papaleontiou M. Clearing Up the Fog: Insights Into Brain Fog Experienced by Patients With Hypothyroidism. Endocr Pract 2022; 28:349-350. [PMID: 35077905 PMCID: PMC10080712 DOI: 10.1016/j.eprac.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Debbie W Chen
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Institute of Gerontology, University of Michigan, Ann Arbor, Michigan.
| |
Collapse
|
21
|
Cramon PK, Bjorner JB, Groenvold M, Boesen VB, Bonnema SJ, Hegedüs L, Feldt-Rasmussen U, Rasmussen ÅK, Watt T. Implementation of thyroid-related patient-reported outcomes in routine clinical practice. Front Endocrinol (Lausanne) 2022; 13:1000682. [PMID: 36246917 PMCID: PMC9554589 DOI: 10.3389/fendo.2022.1000682] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/09/2022] [Indexed: 11/26/2022] Open
Abstract
Patient-reported outcomes (PROs) are increasingly used in clinical practice to improve clinical care. Multiple studies show that systematic use of PROs can enhance communication with patients and improve patient satisfaction, symptom management and quality of life. Further, such data can be aggregated to examine health levels for patient groups, improve quality of care, and compare patient outcomes at the institutional, regional or national level. However, there are barriers and challenges that should be handled appropriately to achieve successful implementation of PROs in routine clinical practice. This paper briefly overviews thyroid-related PROs, describes unsolved quality of life issues in benign thyroid diseases, provides examples of routine collection of PROs, and summarizes key points facilitating successful implementation of thyroid-related PROs in routine clinical practice. Finally, the paper touches upon future directions of PRO research.
Collapse
Affiliation(s)
- Per Karkov Cramon
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Bue Bjorner
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- QualityMetric Incorporated, LLC, Johnston, RI, United States
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Palliative Care Research Unit, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Victor Brun Boesen
- Department of Internal Medicine, Copenhagen University Hospital Herlev Gentofte, Copenhagen, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Åse Krogh Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Torquil Watt
- Department of Internal Medicine, Copenhagen University Hospital Herlev Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Torquil Watt,
| |
Collapse
|
22
|
Ettleson MD, Papaleontiou M. Evaluating health outcomes in the treatment of hypothyroidism. Front Endocrinol (Lausanne) 2022; 13:1026262. [PMID: 36329885 PMCID: PMC9623066 DOI: 10.3389/fendo.2022.1026262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Clinical hypothyroidism is defined by the inadequate production of thyroid hormone from the thyroid gland to maintain normal organ system functions. For nearly all patients with clinical hypothyroidism, lifelong treatment with thyroid hormone replacement is required. The primary goal of treatment is to provide the appropriate daily dose of thyroid hormone to restore normal thyroid function for each individual patient. In current clinical practice, normalization of thyrotropin (TSH) level is the primary measure of effectiveness of treatment, however the use of a single biomarker to define adequate thyroid hormone replacement is being reevaluated. The assessment of clinical health outcomes and patient-reported outcomes (PROs), often within the context of intensity of treatment as defined by thyroid function tests (i.e., undertreatment, appropriate treatment, or overtreatment), may play a role in evaluating the effectiveness of treatment. The purpose of this narrative review is to summarize the prominent health outcomes literature in patients with treated hypothyroidism. To date, overall mortality, cardiovascular morbidity and mortality, bone health and cognitive function have been evaluated as endpoints in clinical outcomes studies in patients with treated hypothyroidism. More recent investigations have sought to establish the relationships between these end results and thyroid function during the treatment course. In addition to clinical event outcomes, patient-reported quality of life (QoL) has also been considered in the assessment of adequacy of hypothyroidism treatment. From a health care quality perspective, treatment of hypothyroidism should be evaluated not just on its effectiveness for the individual patients but also to the extent to which patients of different sociodemographic groups are treated equally. Ultimately, more research is needed to explore differences in health outcomes between different sociodemographic groups with hypothyroidism. Future prospective studies of treated hypothyroidism that integrate biochemical testing, PROs, and end result clinical outcomes could provide a more complete picture into the effectiveness of treatment of hypothyroidism.
Collapse
Affiliation(s)
- Matthew D. Ettleson
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, United States
- *Correspondence: Matthew D. Ettleson,
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes and Institute of Gerontology, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|