Thyroid disease in women

The hypothalamus-pituitary-thyroid axis is disrupted by exposure to a mix of tributyltin and bisphenol S

Tributyltin is a biocide and bisphenol S is a plasticizer. The effects of the TBT + BPS mix on thyroid axis function are unknown. This study evaluated the effects of subacute exposure to TBT and BPS, both in mix and alone, in female young Wistar rats. Thyroid morphophysiology, gene expression, oxidative stress and collagen deposition were evaluated. TBT and BPS exposure resulted in a decrease in thyroid hormone levels, whereas TBT alone resulted in a decrease in TSH levels. The TBT + BPS group exhibited an increase in T4 levels, a decrease in T3 levels, a decrease in TPO activity, and an increase in TSHr mRNA expression. Deiodinase 1 (D1) and 2 (D2) were increased in the hypothalamus-pituitary-thyroid (HPT) axis (except for D2 in the pituitary gland) and in the liver of the TBT + BPS group, beside increases in the pituitary TRHr and thyroid ER mRNAs. The thyroid morphology of the TBT + BPS group revealed significant expansion of both the thyroid follicle and its surrounding tissue. In contrast, the TBT and BPS groups displayed numerous thyroid follicles undergoing fusion, a decrease in epithelial height and the epithelial/colloid ratio. The BPS group was the only group that exhibited increased collagen deposition. The TBT + BPS group demonstrated significant increases in the transcript levels of nrf2 and keap1. In all groups, the number of thiol groups decreased. There was an increase in SOD activity in the TBT + BPS group. Overall, subacute exposure to a mix deregulates the HPT axis, which correspondingly affects gene expression and causes enzymatic and morphological changes in the thyroid gland.

Exploring the Association Between Hypothyroidism, Mean Platelet Volume, and Red Cell Distribution Width: A Case-Control Study

BACKGROUND

Thyroid hormones are important in regulating hematopoiesis. Recent research has suggested that red cell distribution width (RDW) and mean platelet volume (MPV) may be useful inflammatory markers in various disorders, including thyroid disorders. Hence, the study aimed to evaluate the association between hypothyroidism, RDW, and MPV.

METHODS

We used data from King Abdulaziz Medical City, Jeddah (KAMC-J) from May 2016 to June 2022. One hundred ninety-eight adults, 99 patients with hypothyroidism and 99 healthy controls, were assessed for thyroid function tests and a complete blood count (CBC). The association between hypothyroidism, RDW, and MPV was assessed using the Wilcoxon rank sum test. The sensitivity and specificity of RDW and MPV were plotted using the ROC curve.

RESULTS

The median RDW levels of the hypothyroid and control groups were 14 (13-14.8)% and 13 (12.6-14)%, respectively (p<0.001). The median MPV levels of the hypothyroid and control groups were 10.43 (9.46-11.1) fL and 8.9 (8.47-10.1) fL, respectively (p<0.001). MPV levels greater than 9.40 have 77% sensitivity and 70% specificity in predicting hypothyroidism (AUC: 0.796 [95% CI: 0.735-0.858]; p<0.001). RDW levels greater than 13 have a sensitivity value of 75% and a specificity value of 51.5% in predicting hypothyroidism (AUC: 0.683 [95% CI: 0.608-0.758]; p<0.001).

CONCLUSION

Elevated mean platelet volume (MPV) and RDW levels were observed in individuals with hypothyroidism, suggesting that these parameters may serve as potential indicators of the condition. While this study identifies a significant association between MPV, RDW, and hypothyroidism, it does not conclude causality. Further investigation is warranted to determine the clinical utility of MPV and RDW as screening tools for hypothyroidism. These findings have potential implications for future research on the early detection and management of hypothyroidism.

Advancing thyroid disease research: The role and potential of zebrafish model

Thyroid disorders significantly affect human metabolism, cardiovascular function, skeletal health, and reproductive systems, presenting a complex challenge due to their multifactorial nature. Understanding the underlying mechanisms and developing novel therapeutic approaches require appropriate models. Zebrafish, with their genetic tractability, short life cycle, and physiological relevance, have emerged as a valuable model for investigating thyroid diseases. This review provides a comprehensive analysis of the zebrafish thyroid gland's structure and function, explores its application in modeling thyroid pathologies such as hypothyroidism, hyperthyroidism, and thyroid cancer, and discusses current limitations and possible improvements. Furthermore, it outlines future directions for zebrafish-based research, focusing on enhancing the model's relevance to human thyroid disease and its potential to expedite the development of clinical therapies.

Effect of hypothyroidism on short-term outcomes after autologous and implant-based breast reconstruction

Hypothyroidism has high prevalence in elderly women, which overlaps with the patient population who opt for post-mastectomy breast reconstruction. While hypothyroidism was shown to impact outcomes in other surgeries, its effect on breast reconstruction has not been established. This study aimed to compare the short-term outcomes of patients with and without hypothyroidism who underwent autologous (ABR) and implant-based breast reconstruction (IBR), respectively. Patients having ABR or IBR were identified in the National Inpatient Sample from Q4 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without hypothyroidism, adjusted for demographics, socioeconomic status, comorbidities, and hospital characteristics. There were 12,765 patients underwent ABR, where 1591 (12.46%) of them had hypothyroidism, while 17,670 patients had IBR with 1,984 (11.23%) having hypothyroidism. Hypothyroid patients had a higher risk of hemorrhage/hematoma (aOR = 1.254, 95 CI 1.079-1.457, p < 0.01) after ABR. However, there were no differences in terms of mortality and organ system complications, nor wound dehiscence, superficial/deep wound complications, seroma, flap revision, excessive scarring, venous thromboembolism, pulmonary embolism, vascular complications, infection, sepsis, transfer out, length of stay (LOS), nor hospital charge between patients with and without hypothyroidism after ABR. All postoperative outcomes were comparable between hypothyroid patients and controls after IBR. While breast reconstruction is generally safe for hypothyroid patients, preoperative screening for hypothyroidism may be beneficial for those undergoing ABR. In ABR, hypothyroidism correction and blood management may help prevent bleeding complications in hypothyroid patients. Future studies should explore the long-term prognosis of hypothyroid patients after breast reconstruction.

Unusual Presentations of Thyrotoxic Tricuspid and Mitral Regurgitations in 62 Adults: A Systematic Review of Case Reports with In-depth Pathophysiological Review

Background

Thyrotoxicosis is related to cardiovascular mortality. This can be caused by several clinical manifestations involving the rare provocation of tricuspid regurgitation (TR) and mitral regurgitation (MR). However, there are still no clear data on thyrotoxic TR and/or MR. This study examines the progression of TR, MR, heart failure (HF) and pulmonary hypertension (PH) in response to the thyrotoxic heart manifestations, clinical characteristics and treatment approaches.

Methods

A PRISMA-based systematic search was conducted using PubMed and other databases up to 17 June 2023. The outcomes of this study were TR, MR, HF and PH with their progression on follow-up, clinical characteristics and treatment approaches.

Results

A total of 57 case reports involving 62 patients (45.77 ± 13.41 years) were included in this study. They were predominantly women (n=50; 80.65%) and diagnosed with Graves' disease (n=41; 75.81%). All patients were diagnosed with thyrotoxicosis, and this included 23 (37.10%) cases of thyroid storm. From echocardiographic studies, several patients improved clinically within the first 6 months of follow-up, including 20 TR patients (83.33%) in 6 months, nine MR patients (69.23%) in 3 months, eight HF patients (66.67%) in 2 months and 16 PH patients (76.19%) in 6 months.

Conclusion

Several mechanisms are involved in thyrotoxic TR and/or MR, including the direct thyroid hormone effect and the indirect effect of other hyperthyroidism-associated factors. Patients with thyrotoxic TR and/or MR, including those with HF and PH, can experience clinical and structural improvements following hyperthyroidism treatment in the first 6 months.

Trends in thyrotoxicosis-related mortality in the United States from 1999 to 2020

PURPOSE

Thyrotoxicosis is defined as a condition caused by excessive thyroid hormone concentrations, with the main cause being inappropriately increased thyroid hormone production. Existing literature indicates a correlation between thyrotoxicosis and mortality. Thus, this descriptive analysis was conducted to assess the demographic and regional trends of thyrotoxicosis-related mortality in the United States.

METHODS

Death certificates from the Center of Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC-WONDER) from 1999 to 2020 were retrieved for thyrotoxicosis-related mortality in the United States. The crude and age-adjusted mortality rates (AAMRs) per 1,000,000 population and annual percentage change (APCs) were calculated.

RESULTS

There were 33,253 thyrotoxicosis-related deaths from 1999 to 2020. Initially, the AAMR increased from 1999 to 2003 (APC: 3.09; 95% CI 0.83 to 8.16), followed by a steep decline from 2003 to 2008 (APC: -4.28; 95% CI -7.46 to -2.47), followed by a marginal decline from 2008 to 2018 (APC: -0.71; 95% CI -1.70 to 0.95), and concluded by a significant increase from 2018 to 2020 (APC: 11.72; 95% CI 5.06 to 15.32). Non-Hispanic (NH) Black or African American, Hispanic or Latino, and NH White populations demonstrated a significant rise in thyrotoxicosis-related mortality during 2018 to 2020. In contrast, the NH Asian or Pacific Islander population did not denote any significant variations within the included study timeframe. States including West Virginia, the District of Columbia, Vermont, California, and Montana were in the top 10th percentile of thyrotoxicosis-related mortality.

CONCLUSION

After an extended period of decline, the recent increments in thyrotoxicosis-related mortality rates are concerning. Further consideration is urged with respect to thyroid screening, especially among females, in order to reduce the overall thyrotoxicosis-related mortality.

Post-thyroidectomy Depression and Associated Factors in Saudi Arabia

Background Thyroidectomy is a common surgical procedure used to treat thyroid gland illnesses. The surgery has many outcomes, and one of them may show an association with depression. This study aims to assess the factors associated with depression after thyroidectomy in Saudi Arabia. Methodology A cross-sectional study was conducted among 414 Saudi participants. The target population included patients more than 18 years old and who had undergone thyroidectomy, whereas patients 18 years or younger were excluded. The data were collected between December 2023 and January 2024 using an electronic self-administered questionnaire that included demographics, clinical characteristics, and the nine-item Patient Health Questionnaire. The questionnaire was distributed randomly throughout social media, and patient consent was obtained. The descriptive and inferential analyses were performed using SPSS software version 27 (IBM Corp., Armonk, NY, USA). Results The study showed that of the 414 participants, 306 were females and 108 were males. Depression affected 335 (80.92%) participants and was mostly mild (120, 28.99%), followed by moderate (109, 26.33%), moderately severe (55, 13.29%), and severe (51, 12.32%). Depression symptoms were more common in females than males. The participants who underwent total thyroidectomy (217, 52.41%) were more than those who underwent partial thyroidectomy (197, 47.58%). Temporary complications were more prevalent in the participants exhibiting symptoms of depression. Both educational level and surgery time were significant factors. Conclusions The study revealed a significant prevalence of post-thyroidectomy depression. The associated factors in post-thyroidectomy depression included educational level, with more depression symptoms noted with high education. In addition, surgery time showed an increased risk of developing depression that still existed two years postoperatively.

Associations Between Hypothyroidism and Subclinical Atherosclerosis Among Male and Female Patients Without Clinical Disease Referred to Computed Tomography

OBJECTIVES

Hypothyroidism is recognized as a risk factor for coronary artery disease (CAD). However, reports are conflicting when the results are stratified by sex and the underlying risk of CAD. We examine the sex-specific associations of hypothyroidism with coronary calcification and plaques.

METHODS

Retrospective cross-sectional study was conducted among adult patients referred to (64 multidetector spiral) computed tomography. Those with pre-existing CAD were excluded. Hypothyroidism was defined as thyroid-stimulating hormone ≥ 4.5 mU/L. Plaques were determined based on quantification of coronary calcium and coronary computed tomography angiography.

RESULTS

A total of 2499 patients (1544 male and 955 female) were included. The prevalence of hypothyroidism was significantly higher in female than in male patients (18.0% vs 12.9%, P < .001), in all patients and those <65 years. Hypothyroidism in male patients was significantly associated with higher coronary calcium score > 0, higher coronary calcium score groups, and both soft and calcified plaques (P = .027, P = .032, P = .005, and P = .017, respectively). After adjusting for traditional coronary risk factors, the higher risk in male patients remained significant for coronary plaque but not for coronary calcium score >0 (odds ratios and CIs were 1.77, 1.08-2.90, P = .023 and .98, 0.63-1.52, P = .925, respectively). On the other hand, hypothyroidism in female patients was not significantly associated with coronary calcification nor plaques in both univariate and multivariate analyses.

CONCLUSIONS

There are sex-specific differences in the association of hypothyroidism with subclinical atherosclerosis. The higher risk of coronary plaques but not calcification in male patients was independent of traditional coronary risk factors. The lack of associations in female patients may be related to lower underlying risk of CAD.

Evaluation of optimal methods and ancestries for calculating polygenic risk scores in East Asian population

Polygenic risk scores (PRSs) have been studied for predicting human diseases, and various methods for PRS calculation have been developed. Most PRS studies to date have focused on European ancestry, and the performance of PRS has not been sufficiently assessed in East Asia. Herein, we evaluated the predictive performance of PRSs for East Asian populations under various conditions. Simulation studies using data from the Korean cohort, Health Examinees (HEXA), demonstrated that SBayesRC and PRS-CS outperformed other PRS methods (lassosum, LDpred-funct, and PRSice) in high fixed heritability (0.3 and 0.7). In addition, we generated PRSs using real-world data from HEXA for ten diseases: asthma, breast cancer, cataract, coronary artery disease, gastric cancer, glaucoma, hyperthyroidism, hypothyroidism, osteoporosis, and type 2 diabetes (T2D). We utilized the five previous PRS methods and genome-wide association study (GWAS) data from two biobank-scale datasets [European (UK Biobank) and East Asian (BioBank Japan) ancestry]. Additionally, we employed PRS-CSx, a PRS method that combines GWAS data from both ancestries, to generate a total of 110 PRS for ten diseases. Similar to the simulation results, SBayesRC showed better predictive performance for disease risk than the other methods. Furthermore, the East Asian GWAS data outperformed those from European ancestry for breast cancer, cataract, gastric cancer, and T2D, but neither of the two GWAS ancestries showed a significant advantage on PRS performance for the remaining six diseases. Based on simulation data and real data studies, it is expected that SBayesRC will offer superior performance for East Asian populations, and PRS generated using GWAS from non-East Asian may also yield good results.

Cerebral Venous Thrombosis during Thyrotoxicosis: Case Report and Literature Update

Cerebral venous thrombosis (CVT) is a rare cause of stroke, particularly in young adults. Several known thrombophilic conditions may lead to an increased CVT risk. Interestingly, few cases in the literature have reported an association between CVT and thyrotoxicosis. Here, we describe the case of a young woman with CVT and concomitant thyrotoxicosis, without any other known prothrombotic conditions. We also performed a literature review of CVT cases and hyperthyroidism, searching for all articles published in peer-reviewed journals. We identified 39 case reports/case series concerning patients with CVT associated with thyrotoxicosis, highlighting, in most cases, the association with additional known prothrombotic factors. We then discussed the possible mechanisms by which hyperthyroidism could underlie a pro-coagulative state resulting in CVT. Thyroid disease might be a more common prothrombotic risk factor than expected in determining CVT. However, in most cases, a coexistence of multiple risk factors was observed, suggesting a multifactorial genesis of the disorder. We hope that this work may alert clinicians to consider thyrotoxicosis as a potential risk factor for CVT, even in patients who apparently have no other pro-coagulative conditions.

Morphometric and volumetric analysis of lacrimal glands in patients with thyroid eye disease

Assessment of morphometric and volumetric changes in lacrimal glands in thyroid eye disease, its clinical manifestations in relation of disease progression. Retrospective volumetric analysis included both genders and was performed on total of 183 patients - 91 patients with diagnosed Grave's disease and thyroid eye disease and 92 patients without Grave's disease and thyroid eye disease who underwent multidetector computed tomography (MDCT) examination in routine daily work according to other medical indications. In the group of females, there was statistical significance between patients with thyroid eye disease and controls who were smoking and had body weight gain. We found statistical significance in volumetric enlargements for both orbits in both genders for the patients group when compared to controls. There was also statistical significance in morphometric characteristics for the lacrimal gland diameters measured. Determination planimetric morphometric parameters of importance were coronary height of lacrimal gland of the right eye, coronary height of lacrimal gland of the left eye and coronary width of lacrimal gland of the left eye for the group of males. In a group of females the established determination parameters of importance were the coronary height of lacrimal gland of the left eye, the axial width of lacrimal gland of the left eye, volume of lacrimal gland of the right eye and the volume of lacrimal gland of the left eye. When we compared the displaced lacrimal gland coming forward (proptosis) in time progressing disease between group of patients and controls, we also found statistical significant connection. Evaluation of lacrimal gland volumetric and morphometric data may increase validity of defining this anatomical substrate and its morphology disruption as liable tool for thyroid eye disease progression follow up and treatment planning and outcome.

Gender-based research underscores sex differences in biological processes, clinical disorders and pharmacological interventions

Earlier research has presumed that the male and female biology is similar in most organs except the reproductive system, leading to major misconceptions in research interpretations and clinical implications, with serious disorders being overlooked or misdiagnosed. Careful research has now identified sex differences in the cardiovascular, renal, endocrine, gastrointestinal, immune, nervous, and musculoskeletal systems. Also, several cardiovascular, immunological, and neurological disorders have shown differences in prevalence and severity between males and females. Genetic variations in the sex chromosomes have been implicated in several disorders at young age and before puberty. The levels of the gonadal hormones estrogen, progesterone and testosterone and their receptors play a role in the sex differences between adult males and premenopausal women. Hormonal deficiencies and cell senescence have been implicated in differences between postmenopausal and premenopausal women. Specifically, cardiovascular disorders are more common in adult men vs premenopausal women, but the trend is reversed with age with the incidence being greater in postmenopausal women than age-matched men. Gender-specific disorders in females such as polycystic ovary syndrome, hypertension-in-pregnancy and gestational diabetes have attained further research recognition. Other gender-related research areas include menopausal hormone therapy, the "Estrogen Paradox" in pulmonary arterial hypertension being more predominant but less severe in young females, and how testosterone may cause deleterious effects in the kidney while having vasodilator effects in the coronary circulation. This has prompted the National Institutes of Health (NIH) initiative to consider sex as a biological variable in research. The NIH and other funding agencies have provided resources to establish state-of-the-art centers for women health and sex differences in biology and disease in several academic institutions. Scientific societies and journals have taken similar steps to organize specialized conferences and publish special issues on gender-based research. These combined efforts should promote research to enhance our understanding of the sex differences in biological systems beyond just the reproductive system, and provide better guidance and pharmacological tools for the management of various clinical disorders in a gender-specific manner.

The association between cytology and histopathology in thyroid nodules over a 6-year period in an urban hospital in South Africa

BACKGROUND

Thyroid cancer is prevalent both internationally and locally, and is the most common cause of endocrine malignancies in Africa. The prognosis of thyroid cancer in general is quite good, but to achieve good outcomes, appropriate methods for diagnosis are important. A cytology result obtained from a fine needle aspiration and biopsy (FNAB) is one such method, and is less invasive and has less risk compared with obtaining a histological result via open surgery. However, there are accuracy differences that have been reported in different literature findings.

OBJECTIVES

To determine the diagnostic accuracy rate of thyroid FNAB compared with histopathological samples at an urban hospital in South Africa (SA), and compare this with international standards.

METHODS

A retrospective observational study was conducted of patients who had undergone both FNAB and thyroidectomies at Helen Joseph Hospital, Gauteng Province, SA, a public tertiary hospital, between 1  January 2016 and 31  December 2021. Various analytical methods were used, including Poisson generalised linear model, binomial generalised linear model, a two-proportion z-test, McNemar's test and the F1 score.

RESULTS

There were 164 participants in this study who were between the ages of 21 and 82 years old. Thirty-six records were excluded for use as a comparison between cytology and histology, as they were in Bethesda categories 1, 3 and 4. Out of the 128 records that were compared, there was statistically significant agreement v. non-agreement between cytology and histology findings for thyroid nodules (109  v. 19, p<0.001, respectively). A comparison between our sample population and internationally published standards in terms of rate of malignancy noted that our rate of malignancy was slightly higher in Bethesda 2 patients (5.88%) v. internationally published standards (0 - 3%), and slightly lower in Bethesda 4 (23.52%) and 6 (77.77%) v. internationally published standards (25 - 40% and 97 - 99%, respectively.

CONCLUSION

There was good correlation between cytology and histology for thyroid nodules. Differences were noted between the percentage of malignant cases in the different Bethesda categories compared with international standards as noted above. We recommend that further studies are conducted locally to improve knowledge on this topic.

An Assessment of Thyroid Dysfunction and Related Parameters in Patients With Systemic Autoimmune Disorders

Background and objective Systemic autoimmune disorders involve abnormal immune responses leading to tissue damage. Dysfunction of the thyroid gland due to autoimmune mechanisms is common in such disorders, which can cause either hypofunctioning or hyperfunctioning of the gland. This study aimed to investigate the prevalence of thyroid dysfunction among patients with various systemic autoimmune disorders. Material and methods This cross-sectional observational study included 110 adult patients either diagnosed with or having clinical/biological features of systemic autoimmune diseases. The patients underwent a detailed clinical history assessment, physical examination, and necessary investigations. Data were analyzed using IBM SPSS Statistics for Windows, Version 26.0. (IBM Corp., Armonk, NY). Results Among the 110 autoimmune disorder patients, 22.7% had thyroid dysfunction, specifically hypothyroidism, while 77.3% were euthyroid. Hypothyroidism was prevalent among patients with rheumatoid arthritis (RA, 20.3%), systemic sclerosis (SSc, 20%), ankylosing spondylitis (AS, 15.8%), and systemic lupus erythematosus (SLE, 54.5%). Moreover, 60% of patients were anemic, and the prevalence of anemia was higher among female patients and younger individuals. Conclusions This study showed a higher prevalence of thyroid dysfunction, particularly hypothyroidism, in patients with systemic autoimmune disorders. Female patients and younger individuals were more susceptible to autoimmune disorders, thyroid dysfunction, and anemia. These findings highlight the need for simultaneous screening and evaluation for thyroid dysfunction and anemia in systemic autoimmune disease patients, particularly in female patients and those of younger age groups.

Phytochemical profiling of polyphenols and thyroid stimulatory activity of Ficus religiosa leaf extract in 6-propyl-thiouracil-induced hypothyroid rats

ETHNOPHARMACOLOGICAL RELEVANCE

The plant, Ficus religiosa (L.) from the family Moraceae, has been extensively used in Ayurveda and Unani. Traditionally this plant is known for the treatment of constipation, liver diseases and neurological disorders that are related to hypothyroidism.

AIM OF THE STUDY

This study was primarily designed to evaluate the effect of Ficus religiosa leaf (FL) extract in ameliorating hypothyroidism in rats and to identify the major bioactive compounds in the test extract that might be responsible for the thyroid-altering activity. In addition, the probable mechanism underlying the thyroid regulation of the main FL constituents were analyzed by molecular docking.

MATERIALS AND METHODS

Adult female Wistar rats were used. LC-ESI-MS/MS was performed to identify the compounds present in the extract. HPLC analysis of FL extract was also performed. A pilot study was made using 3 doses of FL extract. Out of 50, 100, and 200 mg/kg, 100 mg/kg appeared to be the most effective one as it could increase thyroid hormones and decreased TSH levels. In the final experiment, propyl-thiouracil (PTU)-induced hypothyroid rats were orally treated with FL extract (100 mg/kg) or L-thyroxine (100 μg/kg, i.p.) daily for 28 consecutive days. On 29th day, all rats were sacrificed and the serum levels of triiodothyronine (T₃), thyroxine (T₄), thyrotropin (TSH), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and hepatic 5' deiodinase-1(5'D1) were estimated by ELISA. Liver marker enzymes (alanine aminotransferase, ALT and aspartate aminotransferase, AST); total cholesterol (TC) and triglycerides (TG); hepatic lipid peroxidation (LPO) and the activities of antioxidants such as superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and glutathione (GSH) content were estimated in liver tissues.

RESULTS

LC-MS-MS analyses of the leaf extract identified 11 compounds including the three major compounds, betulinic acid (BA), chlorogenic acid (CGA), and quinic acid (QA). While the PTU treatment decreased the levels of thyroid hormones and 5'D1 activity, it increased the TSH, ALT, AST, TNF-α, IL-6, TC, and TG levels. Furthermore, hepatic LPO significantly increased with a decrease in reduced GSH, SOD, CAT, and GPx. However, FL treatment in PTU-induced animals nearly reversed these adverse effects and improved liver function by decreasing ALT, AST, hepatic LPO and increasing the levels of antioxidants. FL not only improved the liver histology, but also suppressed the inflammatory cytokines, TNF-α and IL-6 in PTU-induced animals. A molecular docking study towards the understanding of the thyroid stimulatory mechanism of action revealed that BA, CGA, and QA might have augmented thyroid hormones by interacting with the thyroid hormone receptor (TRβ1) and TSH receptor (TSHR).

CONCLUSION

For the first time, we report the pro-thyroidal potential of Ficus religiosa leaf extract. We postulate that its main bioactive compounds, BA, CGA, and QA involved in this action may serve as novel thyroid agonists in ameliorating hypothyroidism.

Correlation of Maternal Thyroid Stimulating Hormone Levels With Lipid Profile in Pregnant Women With Hypothyroidism

Introduction Pregnancy leads to changes in hormonal levels and lipid profile. Thyroid hormones play a crucial role in embryonic growth and fetal development. Untreated thyroid disease during pregnancy can lead to a high risk of complications. Aim The aim of the study is to examine the correlation between thyroid stimulating hormone (TSH) and lipid profile in pregnant women with hypothyroidism. Materials and methods This cross-sectional case-control study was conducted at the Biochemistry Department, Alfalah School of Medical Science & Research Centre, Dhauj, Faridabad, Haryana, India. The study consisted of 500 patients (250 cases and 250 controls) who fulfilled the inclusion and exclusion criteria. Of the 250 cases recruited, 23 cases were in the 2nd trimester and 209 cases were in the 3rd trimester. Blood samples were collected from the participants to assess their lipid profile and TSH levels.  Results The study showed a statistically significant difference between the mean TSH levels of hypothyroid pregnant females in the 2nd trimester (3.85 ± 0.59) and the 3rd trimester (4.71 ± 0.54). There was a significant positive correlation observed between TSH and Total Cholesterol, Triglycerides, and LDL-C in both the 2nd and 3rd trimesters. In the second trimester, there was a significant positive correlation observed between TSH & TC (r = 0.6634, p<0.0005), TSH & TG (r= 0.7346, p=0.00006), TSH & LDL (r= 0.5322, p= 0.008). In the third trimester, there was a significant positive correlation observed between TSH & TC (r = 0.8929, p<0.00001), TSH & TG (r= 0.430, p<0.00001), TSH & LDL (r= 0.168, p= 0.015). However, no significant correlation was found between TSH levels and HDL-C in either trimester. The correlation coefficient and p-value for TSH & HDL were r = 0.2083, p=0.340 in the second trimester, and r = 0.0189, p=0.2384 in the third trimester. Conclusion A significant increase in TSH levels in hypothyroid pregnant women was observed in the 3rd trimester compared to the second trimester. Moreover, a significant positive correlation was found between TSH and lipid profile (total cholesterol, triglycerides, and LDL) in both trimesters, but not with HDL. These findings highlight the importance of monitoring thyroid hormone levels in the later stages of pregnancy to avoid potential maternal & fetal complications.

Pediatric Thyroid Nodules: Ultrasound Characteristics as Indicators of Malignancy

Objective

Pediatric thyroid nodules are uncommon but carry a 25% malignancy risk. Adult patients have well-established ultrasound characteristics that are predictive of malignancy, but these are not clearly defined in pediatric patients. We reviewed a case series of pediatric thyroid nodules.

Study Design

Retrospective chart review.

Setting

Tertiary children’s hospital.

Method

Institutional review board approval was obtained. This case series with chart review includes all pediatric thyroid nodules with ultrasounds from 2006 to 2016 at 2 pediatric tertiary care centers.

Results

An overall 112 pediatric thyroid nodules were analyzed. The mean patient age was 14.3 years; there was a female:male ratio of 4:1; and 94% were Caucasian. Seventeen percent (20/112) of nodules were malignant. In patients with malignant nodules, the average presenting age was 15.5 years, with a female:male ratio of 5.6:1. Seventy percent of malignant nodules had accompanying microcalcifications, 55% had abnormal lymph nodes, and 45% had irregular margins. In the benign nodules, 11% had microcalcifications, 12% had abnormal lymph nodes, and 26% had irregular margins. The presence of microcalcifications (odds ratio, 19.1 [95% CI, 6.0-61.0]; P < .0001), abnormal lymph nodes (odds ratio, 9.0 [95% CI, 3.0-26.6]; P = .0001), and size >3.5 cm (odds ratio, 5.8 [95% CI, 1.5-22.5]; P = .01) was associated with thyroid cancer. Irregular margins were not statistically significant (odds ratio, 2.3 [95% CI, 0.86-6.3]; P = .9).

Conclusions

Our data suggest that abnormal lymph nodes, microcalcifications, and size >3.5 cm could be predictors of malignancy in the pediatric population and influence clinical decision making.

Thyrotoxic Periodic Paralysis: An Incidental Diagnosis!

Thyrotoxic periodic paralysis is a rare presentation of thyrotoxicosis where the patient develops a transient motor deficit secondary to acute hypokalemia. The thyroid hormone augments gene transcription and post-transcriptional modification of Na-K ATPase, a cell membrane protein that regulates the electrical potential of the cell. Na-K ATPase increases active transport of potassium (K+) ions into the intracellular compartment causing hypokalemia without total body potassium deficit. Severe hypokalemia affects depolarization of the muscle cell membrane, clinically evidenced as paralysis. Other factors that may trigger hypokalemia and paralysis in the setting of hyperthyroidism include diet intake high in carbohydrates and salt, alcohol ingestion, trauma, infections, certain medication, and strenuous exercise. This rare but possible clinical presentation of thyrotoxicosis is significantly more predominant in males of Asian descent. We are reporting a case of a 44-year-old Asian-American male who presented to the emergency department with complaints of acute onset of bilateral lower extremity weakness. He had severe hypokalemia and was diagnosed with primary hyperthyroidism due to Graves' disease.

Thyrotoxic periodic paralysis: case report and review of the literature

Introduction

Thyrotoxic periodic paralysis (TPP) is a rare and potentially lethal complication of hyperthyroidism. It is characterized by sudden onset paralysis associated with hypokalemia. Management includes prompt normalization of potassium, which results in resolution of the paralysis. Definitive treatment of hyperthyroidism resolves TPP completely.

Case presentation

A 23-year-old African American male patient presented to the emergency room at the University of Mississippi Medical Center, USA in November 2016 with sudden onset quadriplegia. He also endorsed a history of weight loss, palpitations, heat intolerance and tremors. The patient reported similar episodes of quadriplegia in the past, which were associated with hypokalemia and resolved with normalization of potassium levels. Physical examination was significant for exophthalmos, smooth goiter with bruit consistent with the diagnosis of Graves’ disease. Laboratory assessment showed severe hypokalemia, hypomagnesemia, suppressed thyroid stimulating hormone (TSH) and high free thyroxine (T4). Urine potassium creatinine ratio was less than one, indicating transcellular shift as the cause of hypokalemia. After normalization of potassium and magnesium, the paralysis resolved in 12 hours. He was started on methimazole. On follow up, the patient was clinically and biochemically euthyroid with no further episodes of paralysis.

Take-away lesson

TPP is a rare and reversible cause of paralysis. Physicians need to be aware of the diagnostic and treatment modalities as delayed recognition in treatment could result in potential harm or unnecessary interventions.

Temporal Changes of PBDE Levels in California House Cats and a Link to Cat Hyperthyroidism

In this study, we measured serum PBDE levels in California (CA) house cats during two time periods: 2008-2010 and 2012-2013 to assess the impacts of the decline in use of these materials after the bans. The median ∑19PBDE level in CA household cats (age ≥10 yr) was 3479 ng/g lipid in 2008-2010 (1st time period, n = 21) and 1518 ng/g lipid in 2012-2013 (2nd time period, n = 22), about 2 times lower than in the first time period (p = 0.006). In contrast, PCB and OCP levels showed no statistically significant changes. With better matched group size and age (HT = 11 vs non-HT = 11, age ≥10 yr) in the second time period, we found that ∑19PBDE level (mean ± SE ng/g lipid) was significantly higher in the HT group (3906 ± 1442) than those in the non-HT group (1125 ± 244) (p = 0.0030). Higher levels of PCBs and OCPs were also found in HT group. Despite the declines of PBDE levels, our findings indicate that the current levels of PBDEs, as well as PCBs and OCPs, may still pose health effects for house cats and, possibly, humans.

What are the characteristics of phenotypic type 2 diabetic patients with low-titer GAD65 antibodies?

Type 2 diabetes results from combined insulin resistance and β-cell deficiency. Type 1 diabetes results from β-cell destruction associated with islet autoantibodies, including those directed against glutamate decarboxylase (GAD65 antibodies [GADA]). Clinical impact of low GADA positivity (<60 U/ml) in type 2 diabetes is debated, being rarely performed in routine care. The aim of our study was to determine the prevalence and cardiometabolic/autoimmune phenotype of GADA[+] patients. 524 type 2 diabetes consecutive outpatients were assessed for glucose homeostasis using homeostasis model assessment (HOMA): insulin sensitivity (HOMA S); β-cell function (HOMA B) and annualized loss in [BXS]. GADA prevalence was 6% (n = 30). There were no differences between groups for age, diabetes duration and family history of diabetes. There were proportionately more women (33 vs. 53%) in GADA[+]. There were no differences in body mass index, waist circumference or visceral fat. HOMA S was lower than normal, with no difference between groups, as was HOMA B. Annualized rate of [BXS] loss was 1.26%/year (GADA[+]) versus 1.34%/year (GADA[-]; NS). HbA1c was 7.8% (GADA[+]) versus 7.6% (GADA[-]; NS). Among all patients, prevalence of autoimmune thyroid disease was 10%. In GADA[+], this prevalence was significantly increased and equally affected both sexes: 29% (men) versus 25% (women), while for GADA[-] the prevalence was 5% (men) versus 18% (women; p < 0.0001). Low-titer GADA autoimmunity among type 2 diabetes patients was not associated with accelerated β-cell function, nor with any distinctive cardiometabolic phenotype, but for a markedly increased prevalence of autoimmune thyroid disease, especially among men.

Thyrotoxic periodic paralysis: diversity in America

BACKGROUND

Thyrotoxic periodic paralysis (TPP) is a potentially life-threatening complication of thyrotoxicosis, characterized by hypokalemia and muscle paralysis.

OBJECTIVE

TPP, although becoming more prevalent in western countries, is still often not recognized due to lack of familiarity and the subtlety of the thyrotoxic symptoms. Early recognition by emergency physicians can prevent potential mortality.

CASE REPORT

A 23-year-old Vietnamese male presented with a 2-h history of complete flaccid quadriplegia and chest tightness. Electrolyte studies revealed a critical potassium level of 1.4 mmol/L. The patient was admitted to the intensive care unit where further workup revealed thyrotoxicosis and the patient was subsequently diagnosed with TPP.

CONCLUSIONS

TPP should always be considered as a differential in patients, especially in young males of Asian descent with lower-limb paralysis or weakness. We present this case, followed by a review of the literature.

Thyrotoxic periodic paralysis: clinical and molecular aspects

Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism that most often affects young East Asian males but increasingly also in other ethnic groups. The typical presentation is acute attacks varying from mild weakness to total paralysis starting at night or in the early morning a few hours after a heavy meal, alcohol abuse or strenuous exercise with complete recovery within 72 h. Signs and symptoms of hyperthyroidism may not be obvious. The hallmark is hypokalemia from increased cellular sodium/potassium-ATPase pump activity with transport of potassium from the extracellular to the intracellular space in combination with reduced potassium output. Recently, KCNJ18 gene mutations which alter the function of an inwardly rectifying potassium channel named Kir2.6 have been detected in 0-33 % of cases. Hence, the pathophysiology in TPP includes a genetic predisposition, thyrotoxicosis and environmental influences and the relative impact from each of these factors may vary. The initial treatment, which is potassium supplementation, should be given with caution due to a high risk of hyperkalemia. Propranolol is an alternative first-line therapeutic option based on the assumption that hyperadrenergic activity is involved in the pathogenesis. If thyroid function tests are unobtainable in the acute situation the diagnosis is supported by the findings of hypokalemia, low spot urine potassium excretion, hypophosphatemia with hypophosphaturia, high spot urine calcium/phosphate ratio, and electrocardiographic abnormalities as tachycardia, atrial fibrillation, high QRS voltage, and atrioventricular block. Definitive treatment is cure of the hyperthyroidism. The underlying mechanisms of TPP remain, however, incompletely understood awaiting further studies.

Thyroid hormones status during pregnancy in normal Iranian women

Pregnancy is associated with significant, but reversible changes in thyroid function studies, which are among the most profound seen as a result of a normal physiologic state. The present study was carried out to find out alterations in thyroid function tests in each trimester in normal pregnant women as compared to non-pregnant women in Tabriz-Iran. A case-control study designed with 229 normal pregnant women that randomly selected from the first (64 samples), the second (92 samples), and the third (73 samples) trimesters and 250 randomly selected non-pregnant healthy female controls. Age range in both groups was 16-40 years. Thyroid function tests carried out by measuring serum levels of thyroid stimulating hormone (TSH), free and total thyroxin (FT(4), TT(4)), and free and total triiodothyronine (FT(3), TT(3)) by commercially available radio immunoassay kits. We found that mean TT(4) increased progressively during pregnancy. Our study showed increasing in serum levels of TT(3) in the second trimester and then declining during the third trimester compared with non-pregnant women. We showed that FT(4) strongly decreased during the third trimester. Free T(3) showed declining in the second and third trimesters. Mean TSH did not show significant difference in each trimester compared with non-pregnant women. The thyroid function tests in pregnancy should be interpreted against gestational age-related reference intervals to avoid mis-interpretation of thyroid function during pregnancy.

Arg16Gly polymorphism in beta2-adrenergic receptor gene is not associated with thyrotoxic periodic paralysis in Korean male patients with Graves' disease

BACKGROUND

Thyrotoxic periodic paralysis (TPP) occurs most frequently in Asian males and present with an acute episode of proximal muscle weakness in the setting of thyrotoxicosis. Despite the fact that mutations were described in genes encoding ion channels in familial hypokalaemic periodic paralysis, no definite genetic variants were found in TPP. beta2-adrenergic receptors (ADRB2s) are expressed in skeletal muscle and stimulate the sodium pump. Single nucleotide polymorphisms in ADRB2 gene were identified and may act as disease modifiers in various diseases.

OBJECTIVE

We were to demonstrate that ADRB2 gene might be a susceptibility gene for TPP in Korean male patients with Graves' disease.

DESIGN AND PATIENTS

In a series of 28 male TPP patients and 31 control patients, three polymorphisms in ADRB2 gene have been studied: a T to C substitution at -47 (-47T/C), Arg16Gly and Gln27Glu. Control patients were male Graves' patients without history of paralysis.

RESULTS

The distributions of the -47C, Gly16 and Glu27 alleles in all patients were 0.02, 0.34 and 0.02, respectively. The genotype Arg16/Arg16 was not significantly associated with TPP (odds ratio 0.53; 95% confidence interval, 0.19-1.50; corrected P = 0.897). Also, the frequency of genotype Gly16/Gly16 was not significantly different in TPP patients than in controls (0.07 vs. 0.23; odds ratio, 0.26; 95% confidence interval, 0.05-1.40; corrected P = 0.45). Allele frequencies of ADRB2 in patients with TPP did not differ from controls.

CONCLUSIONS

The polymorphism of the ADRB2 gene may not confer genetic susceptibility to TPP in Korean male patients with Graves' disease.

Myxedematous coma in a laboring woman suggested a pre-eclamptic coma: a case report

Myxedematous coma in pregnancy is a rare incident. We present a case of Myxedematous coma in a laboring woman that suggested a pre-eclamptic coma and finalized with a healthy baby.

The pitfalls of potassium replacement in thyrotoxic periodic paralysis: a case report and review of the literature

Thyrotoxic Periodic Paralysis is an uncommon disorder seen primarily in Asian males and caused by excessive thyroid hormones. This is an endocrine emergency that can lead to respiratory failure, dysrhythmia, and death. The mainstay of therapy has been potassium replacement, however, recent evidence suggests propranolol is a more effective therapy. We present a severe case of TPP in a 22-year-old Latino male with rapidly progressive ascending paralysis and hypokalemia severe enough to lead to cardiac arrest.

Maternal issues affecting the fetus

Maternal disorders and exposures that affect fetal cardiac structure and function are reviewed, emphasizing fetal echocardiographic diagnosis and monitoring, and approaches for in utero therapy. Maternal diabetes, hyperthyroidism, lupus erythematosis, epilepsy, congenital heart disease, infections, and drug exposures are considered.

Thyroid Function during Pregnancy

Background: This Case Conference reviews the normal changes in thyroid activity that occur during pregnancy and the proper use of laboratory tests for the diagnosis of thyroid dysfunction in the pregnant patient.

Case: A woman in the 18th week of pregnancy presented with tachycardia, increased blood pressure, severe vomiting, increased total and free thyroid hormone concentrations, a thyroid-stimulating hormone (TSH) concentration within the reference interval, and an increased human chorionic gonadotropin (hCG) β-subunit concentration.

Issues: During pregnancy, normal thyroid activity undergoes significant changes, including a two- to threefold increase in thyroxine-binding globulin concentrations, a 30–100% increase in total triiodothyronine and thyroxine concentrations, increased serum thyroglobulin, and increased renal iodide clearance. Furthermore, hCG has mild thyroid stimulating activity. Pregnancy produces an overall increase in thyroid activity, which allows the healthy individual to remain in a net euthyroid state. However, both hyper- and hypothyroidism can occur in pregnant patients. In addition, two pregnancy-specific conditions, hyperemesis gravidarum and gestational trophoblastic disease, can lead to clinical hyperthyroidism. The normal changes in thyroid activity and the association of pregnancy with conditions that can cause hyperthyroidism necessitates careful interpretation of thyroid function tests during pregnancy.

Conclusion: Assessment of thyroid function during pregnancy should be done with a careful clinical evaluation of the patient’s symptoms as well as measurement of TSH and free, not total, thyroid hormones. Measurement of thyroid autoantibodies may also be useful in selected cases to detect maternal Graves disease or Hashimoto thyroiditis and to assess risk of fetal or neonatal consequences of maternal thyroid dysfunction.

Successful outcome of pregnancy in a thyroidectomized-parathyroidectomized young woman affected by severe hypothyroidism

Severe hypothyroidism was discovered in a young woman in her 29th week of pregnancy. Previously, at the age of 12 years, she had undergone thyroid surgery for Graves' disease that resulted in persistent hypothyroidism and hypoparathyroidism. After surgical excision, the patient started levothyroxine replacement therapy and had regular control of thyroid function with normal findings throughout the years. The dose of levothyroxine had not been adjusted when the pregnancy started, and at the 29th week of gestation the patient had a thyrotropin (TSH) of 72.4 microU/mL. Ultrasound studies were performed in order to monitor fetal development. The fetal parameters analyzed before the adjustment of levothyroxine therapy showed growth retardation of various degrees. All analyzed fetal parameters (biparietal diameter, cranial and abdominal circumference, humerus and femur length) improved during the last 6 weeks of gestation, showing a good correlation with the newly achieved euthyroid state of the mother. The infant was clinically euthyroid at birth and was found normal at all evaluations of the neonatal hypothyroidism screening program (1, 5, 30 days).

Relationship of thyroid blood flow to reproductive events in normal Chinese females

The purpose of this study was to investigate the blood flow characteristics in the superior thyroid artery (STA) in normal females of prepubertal, reproductive, and postmenopausal age. The study was performed in 29 prepubertal girls, 27 females of reproductive age, and 26 postmenopausal women. The peak systolic velocity (PSV) and the pulsatility index (PI) of the STA were measured repeatedly during one menstrual cycle in females of reproductive age, and measured once in each prepubertal and postmenopausal subject. Different waveforms were observed in females of prepubertal, reproductive, and postmenopausal age. The PSV of the STA increased progressively in females from prepubertal to postmenopausal phases. The PI of the STA in all of the prepubertal girls was lower than that of adult females in different phases of the menstrual cycle. In adult females, the PI in the follicular phase was significantly higher than those in the ovulatory and luteal phases. In all of the postmenopausal women, the PI was comparable to that in older prepubertal subjects and in adult females during the ovulatory and luteal phases. The results suggest that oestrogen may affect thyroid blood flow during the normal menstrual cycle. Growth and progressive change of arterial structure are suggested to affect the thyroid blood flow in prepubertal and postmenopausal states.

Certainty, leaps of faith, and tradition: rethinking clinical interventions

Clinical decision making requires that clinicians think quickly and in ways that will foster optimal, safe client care. Tradition influences clinical decision making, enhancing efficiency of resulting nursing action; however, since many decisions must be based on data that are either uncertain, incomplete, or indirect, clinicians are readily ensnared in processes involving potentially faulty logic associated with tradition. The author addresses the tenacity of tradition and then focuses on three processes--consensus formation, the grounding of certainty in inductive reasoning, and affirming the consequent--that have affected clinical decision making. For some recipients of care, tradition has had a substantial and invalid influence on their ability to access care.