The epidemiology of thyroid disease and implications for screening

From Bench-to-Bedside: How Artificial Intelligence is Changing Thyroid Nodule Diagnostics, a Systematic Review

CONTEXT

Use of artificial intelligence (AI) to predict clinical outcomes in thyroid nodule diagnostics has grown exponentially over the past decade. The greatest challenge is in understanding the best model to apply to one's own patient population, and how to operationalize such a model in practice.

EVIDENCE ACQUISITION

A literature search of PubMed and IEEE Xplore was conducted for English-language publications between January 1, 2015 and January 1, 2023, studying diagnostic tests on suspected thyroid nodules that used AI. We excluded articles without prospective or external validation, nonprimary literature, duplicates, focused on nonnodular thyroid conditions, not using AI, and those incidentally using AI in support of an experimental diagnostic outside standard clinical practice. Quality was graded by Oxford level of evidence.

EVIDENCE SYNTHESIS

A total of 61 studies were identified; all performed external validation, 16 studies were prospective, and 33 compared a model to physician prediction of ground truth. Statistical validation was reported in 50 papers. A diagnostic pipeline was abstracted, yielding 5 high-level outcomes: (1) nodule localization, (2) ultrasound (US) risk score, (3) molecular status, (4) malignancy, and (5) long-term prognosis. Seven prospective studies validated a single commercial AI; strengths included automating nodule feature assessment from US and assisting the physician in predicting malignancy risk, while weaknesses included automated margin prediction and interobserver variability.

CONCLUSION

Models predominantly used US images to predict malignancy. Of 4 Food and Drug Administration-approved products, only S-Detect was extensively validated. Implementing an AI model locally requires data sanitization and revalidation to ensure appropriate clinical performance.

Autoimmune Thyroid Diseases

Autoimmune thyroid diseases (AITDs) include a wide spectrum of thyroid diseases affecting more commonly women than men. The most frequent forms are Graves' Disease (GD) and Hashimoto's thyroiditis / Autoimmune Thyroiditis (AIT), but there are also other immunogenic destructive forms of thyroiditis, that is, silent and postpartum thyroiditis. In the last decade, AITDs and other inflammatory thyroid diseases related to anti-tumor molecular drugs are more frequently seen due to the widespread use of tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICPIs). Autoimmune thyroiditis related to SARS-CoV-2 infection has been a novel entity in recent years. Graves' Disease and AIT may shift from hyperthyroidism to hypothyroidism, which may complicate the differential diagnosis and further treatment strategy. Moreover, all AITDs may manifest with thyrotoxicosis (a clinical condition marked with high serum levels of thyroid hormones) which has to be distinguished from hyperthyroidism (increased thyroid hormone production and secretion as a result of hyperfunctioning thyroid gland) due to different therapeutic approaches. Nuclear medicine techniques, such as radioiodine uptake (RAIU) and thyroid scintigraphy, using 99mTc- pertechnetate (Na[99mTc]TcO4) or 123-Iodine (Na[123I]I), have a crucial role in the differential diagnosis. Measurement of thyroid antibodies, e.g. thyroid peroxidase antibodies (TPO) and thyrotropin receptor antibodies (TRAb), as well as thyroid ultrasound, are complementary methods in the evaluation of thyroid disorders.

Effects of short- and long-term TSH suppression on lumbar bone mineral density in both genders using PET/CT

Iatrogenic subclinical hyperthyroidism is induced intentionally in patients with differentiated thyroid cancer to reduce the risk of tumor recurrence. This retrospective study aimed to investigate the effect of thyroid-stimulating hormone (TSH) suppressive therapy on bone mineral density in men and women. Two cohorts of endocrine cancer patients were compared. In cohort A, 42 patients with long-lasting suppressed serum TSH were assessed. Cohort B consisted of 41 euthyroid patients. Bone density was measured in the L1-L4 lumbar vertebrae of all patients using PET/CT scans performed for cancer staging. In 17 patients of cohort A who received a second PET/CT scan, bone density was measured again to provide longitudinal analysis. A non-significant difference in age (p = .572) and equal distribution of sex (p = .916) was determined when comparing both cohorts. A significant difference (p = .011) with a moderate effect (η2 = .08; 20.4%) was observed regarding higher bone mineral density (BMD^HU) in cohort B with normal TSH levels (M 160.63 ± 54.7 HU) versus cohort A under TSH suppression therapy (M 127.9 ± 59.5 HU) for a mean duration of 4.45 ± 2.64 years. Furthermore, no significant change in BMD^HU (p = .786) was found in those patients who received a second PET/CT scan after a mean observation time of 2.3 ± 1.2 years. In conclusion, long-lasting TSH suppression therapy caused a statistically significant decrease in BMD^HU while short-lasting therapy didn't. Therefore, we can assume a higher likelihood of osteoporosis in those patients under prolonged TSH suppression.

Cardiovascular Health by Graves' Disease Management Modality - Surgery Versus Radioactive Iodine Versus Antithyroid Medications: A Network Meta-Analysis

INTRODUCTION

Graves' disease is an autoimmune disorder of the thyroid gland associated with the overproduction of thyroid hormones. Excess secretion of thyroid hormones leads to cardiovascular consequences. Treatment options include antithyroid medications (ATM), radioactive iodine (RAI) ablation, and total thyroidectomy. We examined the cardiovascular outcomes following Graves' disease management modality.

METHODS

A systematic search was performed up to September 22nd, 2021, using PubMed, EMBASE, and Web of Science databases. We conducted a network meta-analysis analyzing cardiovascular outcomes of interest, including congestive heart failure (CHF), arrhythmia, atrial fibrillation (AF), and hypertension.

RESULTS

Three studies were included in this analysis totaling 6700 patients with Graves' disease, of which 74% were female. The mean age was 44.34 y. When compared to pretreatment, management options lowered the risk of maintaining arrhythmia 81% with surgery (relative risk [RR] = 0.19; 95% confidence interval [CI] = 0.12 to 0.31), 67% with ATM (RR = 0.33; 95% CI = 0.23 to 0.49), and 50% with RAI (RR = 0.50; 95% CI = 0.13 to 1.95). Risk of maintaining CHF was reduced 80% with surgery (RR = 0.20; 95% CI = 0.08 to 0.49), 41% with ATM (RR = 0.59; 95%CI = 0.52 to 0.67), and only 7% with RAI (RR = 0.93; 95%CI = 0.68 to 1.26). Treatment-ranking analysis found all parameters, including CHF, arrhythmia, AF, and hypertension, to be in favor of surgical treatment over medical treatment and RAI ablation.

CONCLUSIONS

This is the first network meta-analysis analyzing the cardiovascular outcomes in Graves' disease patients by treatment option. Our study demonstrated that surgery is superior to RAI and medical treatment.

The Spectrum of Thyroid Nodules at Kinshasa University Hospital, Democratic Republic of Congo: A Cross-Sectional Study

We analyzed the spectrum of thyroid nodules in patients attending the endocrinology unit care of the Kinshasa University Hospital and assessed their associated factors. We conducted a cross-sectional study, performing descriptive statistics and logistic regression. From the 888 enrolled patients, thyroid nodules were detected in 658 patients (74.1%), as mononodules in 22.5% and multiple nodules in 77.5%. Thyroid function was normal in 71.3% cases, while hyperthyroidism and hypothyroidism were found in 26.1% and 2.6% of cases, respectively. Women were more affected than men (75.1% vs. 63.6%; p = 0.03). Patients with thyroid nodules were older (44 ± 12 vs. 38 ± 12 years; p < 0.001), with a family history of goiter (38.3% vs. 27.4%; p = 0.003) and residence in the iodine-deficient region (51.7% vs. 38.8%; p = 0.012); they had a higher proportion of longer delays to consultation (47% vs. 20%; p < 0.001), but a higher rate of normal thyroid function (85.5% vs. 3 1.3%; p < 0.001). Thyroid nodules were associated with the delay to consultation (for duration ≥ three years, OR: 6.560 [95% CI: 3.525−12.208)], multiparity (present vs. absent: 2.863 [1.475−5.557]) and family history of goiter (present vs. absent: 2.086 [95% CI:1.231−3.534]) in female patients alone. The high frequency of thyroid nodules observed requires measures aimed at early detection in the population, the training of doctors involved in the management and the strengthening of technical platforms in our hospitals.

Evaluating thyroid function in pregnant women

Thyroid hormones are primarily responsible for regulating the basal metabolic rate but also make important contributions to reproductive function and fetal development. Both hyper- and hypothyroidism in pregnancy have been associated with increased risks of complications that include preeclampsia and low birth weight, among others. Furthermore, thyroid hormone deficiency in the developing fetus results in neurodevelopmental delay. As the fetus is exclusively reliant on maternal thyroid hormone for most of the first trimester and requires continued maternal supply until birth, identifying maternal thyroid dysfunction is critically important. However, evaluating thyroid function in pregnancy is challenging because of the many physiological changes that affect concentrations of thyroid-related analytes. Increasing plasma human chorionic gonadotropin (hCG) concentrations in the second half of the first trimester elicit a corresponding transient decrease in thyroid-stimulating hormone (TSH), and continually increasing estradiol concentrations throughout pregnancy cause substantial increases in thyroxine-binding globulin (TBG) and total thyroxine (T4) relative to the nonpregnant state. Lastly, free T4 concentrations gradually decrease with increasing gestational age. For these reasons, it is essential to interpret thyroid function test results in the context of trimester-specific reference intervals to avoid misclassification of thyroid status. This review summarizes the effects of thyroid dysfunction prior to conception and during pregnancy and describes considerations for the laboratory assessment of thyroid function in pregnant women.

Biomarkers and Disease Trajectories Influencing Women's Health: Results from the UK Biobank Cohort

Women's health is important for society. Despite the known biological and sex-related factors influencing the risk of diseases among women, the network of the full spectrum of diseases in women is underexplored. This study aimed to systematically examine the women-specific temporal pattern (trajectory) of the disease network, including the role of baseline physical examination indexes, and blood and urine biomarkers. In the UK Biobank study, 502,650 participants entered the cohort from 2006 to 2010, and were followed up until 2019 to identify disease incidence via linkage to the patient registers. For those diseases with increased risk among women, conditional logistic regression models were used to estimate odds ratios (ORs), and the binomial test of direction was further used to build disease trajectories. Among 301 diseases, 82 diseases in women had ORs > 1.2 and p < 0.00017 when compared to men, involving mainly diseases in the endocrine, skeletal and digestive systems. Diseases with the highest ORs included breast diseases, osteoporosis, hyperthyroidism, and deformity of the toes. The biomarker and disease trajectories suggested estradiol as a risk predictor for breast cancer, while a high percentage of reticulocyte, body mass index and waist circumference were associated with an increased risk of upper-limb neuropathy. In addition, the risk of cholelithiasis was increased in women diagnosed with dyspepsia and diaphragmatic hernia. In conclusion, women are at an increased risk of endocrine, skeletal and digestive diseases. The biomarker and disease trajectories in women suggested key pathways to a range of adverse outcomes downstream, which may shed light on promising targets for early detection and prevention of these diseases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43657-022-00054-1.

Observational Study on Outcomes after Radioiodine Ablation in Hyperthyroid Patients

INTRODUCTION

Radio-active Iodine (RAI) is a safe, definitive, and cost-effective modality of treatment that is used as the first line of treatment for Graves' hyperthyroidism by most endocrinologists. Very few reports are available from India, observational follow-up data is needed to determine the meaningful prognostic outcomes of RAI ablation in the Indian population.

AIMS

To study the outcomes in hyperthyroid patients undergoing RAI ablation.

MATERIALS AND METHODS

This observational cohort study was conducted at Department of Endocrinology at Indraprastha Apollo Hospital, New Delhi. A total of 82 hyperthyroid patients who underwent RAI ablation between June 2014 to June 2018 were enrolled. RAI dose was calculated arbitrarily in most cases; often by an empirical fixed dose based on the goiter size and RAIU. The patients were reviewed at 1, 3 and 6 months post-RAI ablation. During follow-up, along with a detailed clinical examination, free T4, free T3 and TSH were checked.

RESULTS

The dose of I-131 varied from 6 mCi to 14 mCi. Most of the patients were given RAI in the dose of 7.1-10 mci. About 63.4% of patients achieved hypothyroidism in 6 months, 6.1% in 1 month, 37.8% in 3 months, and 19.5% in 6 months. Gender, age, etiology of hyperthyroidism, baseline thyroid function, goiter, and ophthalmopathy did not affect outcomes after RAI ablation. Those who were not treated with antithyroid drugs prior to RAI therapy were found to have higher rates of conversion to a hypothyroid state.

CONCLUSION

RAI can be given safely as the first line of treatment in Graves' disease and antithyroid drug naïve patients respond better to therapy.

Vitamin D improves oxidative stress and histopathological damage in rat ovaries caused by hyperthyroidism

OBJECTIVE

The aim of this study is to investigate the histopathological and biochemical efficacy of vitamin D on oxidative damage and fibrosis in rat ovaries induced by experimental hyperthyroidism.

METHODS

This study is a comparative, prospective experimental rat study. Sprague-Dawley female rats were divided into four groups. Only distilled water was given to the rats in group 1 for 25 days. In group 2, 100 μg/day L-thyroxine was given to rats for 25 days. In Group 3, 100 μg/day L-thyroxine and 200 IU/day vitamin D were given to rats for 25 days. In group 4, only 200 IU/day vitamin D was administered for 25 days.

RESULTS

This study is the first to demonstrate the protective effect of vitamin D against ovarian damage caused by experimental hyperthyroidism. Hyperthyroidism caused fibrotic degenerative changes in the ovaries and an increase in the fibrillin 1 score. It caused serum follicle-stimulating hormone (FSH) levels to increase and serum E2 levels to decrease. In addition, malondialdehyde (MDA) and total oxidant status (TOS) levels increased in rats with hyperthyroidism. Vitamin D decreased MDA and TOS values and increased total antioxidant status (TAS) values in rats with hyperthyroidism. It also increased TSH values by causing a decrease in TT3 and TT4 values. It decreased fibrosis, follicle degeneration, stromal degeneration, and fibrillin 1 score in ovarian tissue.

CONCLUSION

Vitamin D has positive histopathological and biochemical effects on the oxidative stress and follicle damage caused by hyperthyroidism in ovarian tissue. Human studies with larger case populations should be conducted to evaluate the effects and clinical applications of vitamin D.

Etiological Association Between Psoriasis and Thyroid Diseases

Psoriasis is a chronic relapsing/remitting autoimmune disease affecting skin and fingernails. It is associated with many other autoimmune diseases such as rheumatoid arthritis, celiac disease, Crohn's disease, and thyroid diseases. Two important autoimmune thyroid diseases - Hashimoto's thyroiditis (hypothyroidism) and Grave's disease (hyperthyroidism) - affect the body's significant organs such as the brain, muscles, digestive function, and the skin. Although some studies have established the connection between psoriasis and thyroid diseases with autoimmunity, our article provides an in-depth analysis of the connection between these two diseases and other common etiological factors associated with them, along with autoimmunity.

We reviewed articles from PubMed using regular keywords and Medical Subject Headings (MeSH) keywords and finalized 45 articles to find an association between these two diseases. These articles showed that this association is more prevalent in obese patients and late-onset psoriasis. Most of the articles showed a positive association, but few articles showed no connection between them. However, there is no concrete explanation to prove the association due to limited research; additional studies are necessary. It requires the attention of both clinicians and researchers to develop a universal drug that will work on both diseases, and also thyroid evaluation could be included in psoriatic patient care so that there is a possibility to decrease cost and efforts while treating these diseases. 

Clinical and pathologic features for predicting malignancy in thyroid follicular neoplasms

Background

The cytologic findings of follicular neoplasm do not distinguish between benign follicular adenoma and follicular thyroid carcinoma (FTC). The objective of this retrospective study was to identify clinical and cytologic/pathologic features to predict malignancy in patients preoperatively diagnosed with follicular neoplasms.

Methods

In total, 416 patients with follicular neoplasms who underwent thyroidectomy were reviewed at Seoul St. Mary's Hospital (Seoul, Korea) from January 2010 to June 2018. Clinicopathological features were analyzed retrospectively by complete medical chart review and pathologic slide review.

Results

Thyroid malignancy/noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was diagnosed in 209 patients (50.2%). In total, 59 patients (14.2%) were diagnosed with FTC, 55 patients (13.3%) were diagnosed with follicular variant papillary thyroid carcinoma (fvPTC). The number of patients with PTC-related nuclear changes was higher in the malignancy/NIFTP group than in the benign group (16.3% vs. 1.9%, P<0.001). Multivariate analysis indicated that the significant risk factors for the diagnosis of malignancy/NIFTP include cytologic or pathologic diagnosis with PTC-related nuclear changes, NRAS mutation, and male sex.

Conclusions

The prevalence of malignancy in patients with a preoperative diagnosis of follicular neoplasm was much higher in our study than in previous reports. Cytologic or pathologic PTC-related nuclear changes is a useful predictor of the presence of malignancy. Further studies must be conducted to support our results.

Immunoinformatic Analysis of Human Thyroglobulin

The AutoImmune ThyroiDitis (AITD), known as Hashimoto’s disease, is a chronic autoimmune thyroid disease progressively developed to hypothyroidism. The AITD is characterized by the formation of autoantibodies targeting two specific thyroid antigens, Thyroglobulin (Tg) and Thyroid PerOxidase (TPO). Tg is a precursor of the thyroid hormones while TPO catalyses their synthesis. The AITD has a strong genetic predisposition. During the last years, it was found that the susceptibility to AITD is associated with certain Human Leukocyte Antigens (HLA) class II genes of loci DR and DQ. In the present study, we applied in-house immunoinformatic tools to identify peptides originating from Tg and binding to AITD susceptible alleles: HLA-DR3, HLA-DR4, HLA-DR5, HLA-DQ2 and HLA-DQ8. Five peptide fragments containing promiscuous overlapping binders were selected. These were p470, p949, p1948, p2348 and p2583. Only one of them contains a known epitope (p1948). The rest have not been reported yet. The selected peptide fragments will be coupled to monoclonal antibodies specific to inhibitory B cell receptors designed to suppress the production of Tg autoantibodies.

Human immunodeficiency virus, diabetes mellitus and thyroid abnormalities: Should we be screening?

Background

Diabetes mellitus (DM) and human immunodeficiency virus (HIV) are associated with thyroid abnormalities. Scarce literature exists on the prevalence of thyroid abnormalities in people living with HIV (PLWH) and DM (PLWHD). Guidelines vary regarding thyroid-stimulating hormone (TSH) screening in PLWH and/or DM.

Objectives

This study describes thyroid abnormalities in PLWHD and HIV-uninfected people living with DM (PLWD).

Method

This was a cross-sectional analysis of demographic, clinical and biochemical data including TSH results of first-visit patients to the Edendale Hospital diabetes clinic between January 2016 and December 2017.

Results

A total of 915 patients were enrolled: 165 PLWHD and 750 PLWD. Overall prevalence of thyroid disorders in PLWD was 8.53% (64/750). The occurrence of ‘total’ thyroid disorders and of ‘subclinical-hypothyroidism’ (SCH) was higher in PLWHD than PLWD (23.03% vs. 8.53% and 20.61% vs. 4%, p < 0.001; respectively). People living with HIV and diabetes with thyroid disorders had lower CD4 counts than PLWHD without thyroid disorders (376.08 ± 333.30 vs. 509 ± 341.7 cells/mm³; p = 0.004). Subclinical-hypothyroidism was more common in patients on antiretroviral therapy [ART] (27/136 [19.85%] vs. 4/27 [14.81%], p < 0.001). A significant number of PLWHD acquired HIV before the onset of DM (107/165 [64.85%] vs. 58/165 [35.15%], p < 0.001). Patients on ART were more likely to develop DM, OR 2.66 (95% CI 1.11–6.38).

Conclusion

Our study showed an increased prevalence of thyroid disorders (especially SCH) in PLWD and a higher prevalence in PLWHD. Young, overweight, female PLWHD were at risk of SCH. People living with HIV and DM on ART demonstrated an increased prevalence of thyroid dysfunction and poor lipaemic control. The introduction of combined communicable–non-communicable disease clinics might provide an integrated patient screening option.

Identifying benign and malignant thyroid nodules based on blood serum surface-enhanced Raman spectroscopy

The aim of this study is to evaluate the feasibility of using blood serum surface-enhanced Raman spectroscopy (SERS) to identify benign and malignant thyroid nodules. Blood serum samples collected from three different groups including healthy volunteers (n = 22), patients with benign nodules (n = 19) and malignant nodules (n = 22) were measured by SERS. The spectral analysis results demonstrate that biomolecules in serum, such as amino acids, adenine and nucleic acid bases, change differently due to the different progression of nodules. By further combining with partial least square analysis and linear discriminant analysis (PLS-LDA) method, diagnostic accuracies of 93.65% and 82.93%, sensitivities of 92.68% and 81.82% and specificities of 95.45% and 84.21% can be achieved for differentiating healthy versus thyroid nodular groups and benign versus malignant groups, respectively. The above results have suggested that the blood serum SERS technique is helpful for precise diagnosis and timely treatment for patients with thyroid nodules.

Parity and Incidence of Thyroid Autoimmunity: A Population-Based Tehran Thyroid Study

Introduction: Autoimmune thyroid disease is the most common autoimmune disorder. Evidence regarding causes of the high prevalence and incidence of thyroid autoimmunity in women, and especially women of reproductive age, is still inconclusive and previous studies have suggested genetic, environmental, and existential factors to play a role in its pathogenesis. In this study, we aimed to investigate the effect of parity and other reproductive factors on the incidence of thyroid autoimmunity within the framework of the Tehran Thyroid Study (TTS). Materials and Methods: This study was conducted within the framework of the TTS and 1999 nonpregnant euthyroid thyroid peroxidase antibody (TPOAb) negative women were followed up for an average of 8.3 years. A pooled logistic regression model was used to assess the association (odds ratio) between time-dependent covariates parity, menopause, and abortion, and incidence of TPOAb positivity. Results: The total incidence rate of TPOAb positivity was 8.65 [7.35-10.18] per 1000 person-years. We found no significant association between changes in the number of parity and risk of developing TPOAb using multiple pooled logistic models both as crude effect and after adjustment for age, body mass index, and smoking. Similarly, there was no association between changes of parity, menopause, and abortion status, and incidence of TPOAb positivity. Conclusions: Parity does not seem to have an independent role in triggering thyroid autoimmunity, but vast immunological and physiological changes during pregnancy may act as a precipitating factor in the context of other genetic and environmental modifiers.

Discordance Between the American Thyroid Association and the American College of Radiology Guideline Systems for Thyroid Nodule Biopsy

BACKGROUND

Previously, fine-needle aspiration biopsy was recommended for any thyroid nodule >1.0 cm in size. In 2015, the American Thyroid Association (ATA) introduced a pattern-based approach for biopsy recommendations based on size and ultrasound (US) characteristics. In 2016, the American College of Radiology (ACR) published the Thyroid Imaging Reporting and Data System, using a point-based system that assesses risk of US characteristics.

METHODS

This study aims to compare recommendations for thyroid nodule biopsy between the ATA and ACR systems and identify outcomes of nodules with discordant recommendations (DRs). US characteristics, fine-needle aspiration biopsy, and surgical pathology results were evaluated for all patients with >1.0 cm thyroid nodules treated at a single tertiary-care institution from 2010 to 2018.

RESULTS

Inclusion criteria were met by 1100 nodules from 687 patients; 42.8% (n = 471) had DR between the ATA and ACR guidelines. All (100%) DR nodules were not recommended for biopsy by ACR, though 53% were recommended to have follow-up. A majority (79%) of DR nodules were recommended for biopsy by ATA, with the remaining 21% recommended for follow-up. Among surgically excised DR nodules (n = 292), 10.3% (n = 30) nodules were found to be malignant, with the vast majority (90.3%) being well-differentiated carcinoma. Among malignant nodules, the ACR would not have recommended biopsy or follow-up for 26.7% (n = 8).

CONCLUSIONS

The ACR classification system is more restrictive compared with the ATA system for recommending thyroid nodule biopsy. This discrepancy could result in confusion for clinicians and delay in diagnosis or therapy for patients with thyroid cancer.

Comorbidity burden in axial spondyloarthritis: a cluster analysis

OBJECTIVES

To examine how comorbidities cluster in axial spondyloarthritis (axSpA) and whether these clusters are associated with quality of life, global health and other outcome measures.

METHODS

We conducted a cross-sectional study of consecutive patients meeting ASAS criteria for axSpA in Liverpool, UK. Outcome measures included quality of life (EQ5D), global health and disease activity (BASDAI). We used hierarchical cluster analysis to group patients according to 38 pre-specified comorbidities. In multivariable linear models, the associations between distinct comorbidity clusters and each outcome measure were compared, using axSpA patients with no comorbidities as the reference group. Analyses were adjusted for age, gender, symptom duration, BMI, deprivation, NSAID-use and smoking.

RESULTS

We studied 419 patients (69% male, mean age 46 years). 255 patients (61%) had at least one comorbidity, among whom the median number was 1 (range 1-6). Common comorbidities were hypertension (19%) and depression (16%). Of 15 clusters identified, the most prevalent clusters were hypertension-coronary heart disease and depression-anxiety. Compared with patients with no comorbidities, the fibromyalgia-irritable bowel syndrome cluster was associated with adverse patient-reported outcome measures; these patients reported 1.5-unit poorer global health (95%CI 0.01, 2.9), reduced quality of life (0.25-unit lower EQ5D; 95%CI -0.37, -0.12) and 1.8-unit higher BASDAI (95% CI 0.4, 3.3). Similar effect estimates were found for patients in the depression-anxiety cluster.

CONCLUSION

Comorbidity is common among axSpA patients. The two most common comorbidities were hypertension and depression. Patients in the depression-anxiety and fibromyalgia-IBS clusters reported poorer health and increased axSpA severity.

The effects of powdered black cumin seeds on markers of oxidative stress, intracellular adhesion molecule (ICAM)-1 and vascular cell adhesion molecule (VCAM)-1 in patients with Hashimoto's thyroiditis

OBJECTIVE

Oxidative stress plays an important role in the pathogenesis of Hashimoto's thyroiditis. Because of the major anti-oxidant properties of black cumin, the current study aimed to evaluate the effect of powdered Nigella sativa seeds on markers of oxidative stress, endothelial dysfunction and serum lipids in patients with Hashimoto's thyroiditis.

METHODS

Forty patients with Hashimoto's thyroiditis, aged between 22 and 50 years old, participated in the trial and were randomly allocated into two groups of intervention and control receiving powdered N. sativa or placebo daily for 8 weeks. Changes in markers of oxidative stress, including total anti-oxidant capacity (TAC), malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPX), and biomarkers of endothelial dysfunction including Intracellular Adhesion Molecule (ICAM)-1, Vascular Cell Adhesion Molecule (VCAM)-1 and serum lipids were also evaluated.

RESULTS

Treatment with N. sativa, significantly increased serum TAC, SOD and reduced MDA concentrations with no significant change in GPX (P < 0.05). A significant reduction in VCAM-1 (P = 0.0012), body mass index (P = 0.002), serum concentrations of low density lipoprotein cholesterol (P = 0.002) and triglyceride (P = 0.02) were also reported in N. sativa-treated group after 8 weeks; while serum high density lipoprotein cholesterol (HDL) also significantly increased (P < 0.05). No change in other parameters were reported.

CONCLUSIONS

Giving attention to the potent beneficial effects of powdered black cumin seeds in improving oxidative stress, endothelial dysfunction, serum lipids and anthropometric features in patients with Hashimoto's thyroiditis, this medicinal plant can be considered as a therapeutic agent in management of Hashimoto-related metabolic abnormalities.

TRIAL REGISTRATION NUMBER

Iranian registry of clinical trials (registration number IRCT2015021719082N4).

Quantifying the differences in surgical management of patients with definitive and indeterminate thyroid nodule cytology

INTRODUCTION

Thyroid nodules are increasingly common. Despite being an essential pre-operative diagnostic tool, up to 30% of fine needle aspirate cytology (FNAC) yields a non-definitive diagnosis. This study aimed to quantify differences in surgical management of patients with definitive and indeterminate thyroid nodule cytology, and determine if clinical factors can improve cytological diagnosis.

MATERIALS AND METHODS

Patients who underwent thyroidectomy for nodules from 2001 to 2015 were recruited. Those with benign and malignant preoperative cytology were included in the "definitive diagnosis" (DC) group; patients with all other preoperative cytology results were included in the "indeterminate diagnosis" (IC) group. We compared demographics and procedures between these groups. Clinical factors and demographics were also compared between patients with benign and malignant histology in the IC group.

RESULTS

A total of 3821 cases were included. A significantly larger proportion of the IC patients had a hemithyroidectomy (IC 69% vs. DC 39%, p < 0.001) initially, and also had a significantly higher rate of two-stage surgery compared to the DC group (IC 17% vs. DC 11%, p < 0.001). Patients in the DC group were twice as likely to undergo concurrent central lymph node dissection for papillary and medullary cancers than the IC group (p < 0.001). Overall, up to 60% of IC patients had been over- or under-treated at initial surgery. The clinical factors examined were not significantly associated with higher risk of malignancy in IC patients.

CONCLUSION

This study highlights the potential for improved preoperative diagnosis to streamline decision making for surgical management of patients with thyroid nodules.

The prevalence and incidence of thyroid dysfunction in patients with diabetes - a longitudinal follow-up study

BACKGROUND

Thyroid dysfunction (TD) occurs in 13.4% of diabetic patients, which has prompted recommendations for annual thyroid screening in patients with diabetes. However, recommendations for annual screening should be based on disease incidence rather than prevalence.

METHODS

In 1997-1998, seven hundred and thirty patients (618 type 2 diabetes, 55% male; 112 type 1 diabetes, 47% male) were sequentially screened for TD. The 639 patients with normal thyroid function were followed from 1999 to 2006, with annual thyroid function tests.

RESULTS

A total of 21/112 (19%) with type 1 diabetes (T1DM) and 70/618 (11%) with type 2 diabetes (T2DM) had TD. TD was more frequent in females (p < 0.05) and T1DM (p = 0.04). The mean annual rate of conversion to abnormal tests was 2.1%. At 8 years, there were 100 new cases of TD representing 15.6% of the cohort (17 T1DM and 83 T2DM). TD was more frequent in females (p < 0.05), but there was no difference in the incidence of new TD between T1DM and T2DM (p = 0.39).

CONCLUSIONS

Our data confirms the high prevalence of TD in diabetic patients, in concordance with the results from other series. We found only 25 treatable cases of new thyroid disease from 639 patients in the 8-year follow-up, less than 0.5% per year. The low incidence of treatable thyroid disease challenges the need for annual screening for thyroid abnormalities in patients with type 2 diabetes.

The chance of a live birth after assisted reproduction in women with thyroid disorders

Purpose

Women with thyroid disorders may have increased infertility and poor reproductive outcomes, but it is unclear if assisted reproductive technology (ART) is effective in this population. The aim of this study was to examine the chance of a pregnancy (biochemical and clinical), and a live birth after ART, in women with thyroid disorders undergoing ART treatment, compared to women without thyroid disorders. Among live-born children, we assessed the risk of congenital malformations.

Patients and methods

In a nationwide cohort study of all women undergoing ART treatments in Denmark from 1 January 1994 throughout June 2017, we calculated the chance of a pregnancy and a live birth after embryo transfer. Women with thyroid disorders were stratified into two groups: those diagnosed with hypothyroid or hyperthyroid disorders. The adjusted OR (aOR) of a biochemical and a clinical pregnancy, a live born child and a congenital malformation was computed using multilevel logistic regression models.

Results

In total, 199,674 embryo transfers were included in 2,101 women with thyroid disorders and in 65,526 women without thyroid disorders. The chance of a biochemical pregnancy was significantly reduced in women with hyperthyroidism (aOR=0.80, 95% CI 0.69–0.93), and the aOR of a live birth was 0.86, 95% CI 0.76–0.98. The aOR for a live birth in women with hypothyroidism was 1.03 (95% CI 0.94–1.12). Children of women with hypothyroidism, who were conceived after ART treatment, had a significantly increased risk of any congenital malformation (aOR=1.46 [95% CI 1.07–2.00]).

Conclusion

Women with hyperthyroidism receiving ART treatment had a decreased chance of a live birth per embryo transfer compared to women without thyroid disorders. Women with hypothyroidism did not have a decreased chance of a live birth but their offspring had an increased risk of congenital malformation.

A Cross-Sectional Study to Assess the Prevalence of Adult Thyroid Dysfunction Disorders in Jordan

Background: Insufficient production of thyroid hormones results in hypothyroidism, while overproduction results in hyperthyroidism. These are common adult disorders, with hypothyroidism more common in the elderly. Jordan has had past problems with dietary iodine deficiency but there are no published studies assessing the population prevalence of these disorders in the Arab Middle East. Methods: A cross-sectional study was conducted in three representative areas of Jordan. There were 7085 participants with a mean age of 40.8 years. Participants completed a questionnaire and had blood taken for thyroid analysis. Results:Hypothyroidism: The prevalence of any hypothyroidism (already diagnosed and/or identified by blood testing) was 17.2% in females and 9.1% in males. Undiagnosed prevalence was 8% and 6.2% for females and males, respectively. The prevalence of subclinical hypothyroidism, defined as high serum thyrotropin (TSH) and normal serum-free thyroxine (fT4), was 5.98% among females and 4.40% among males. The prevalence of overt hypothyroidism, defined as high TSH and low fT4, was 2.00% among females and 1.80% among males. Only 53.5% (55.3% for females, 42.1% males) of those previously diagnosed with hypothyroidism had TSH levels within the appropriate range. Hyperthyroidism: The prevalence of any hyperthyroidism (already diagnosed and/or identified by blood testing) was 1.8% in females and 2.27% in males. The undiagnosed prevalence was 1.4% and 2.1% for females and males, respectively. The prevalence of subclinical hyperthyroidism (low TSH and normal fT4) was 1.20% and 1.80% among males and females accordingly. The prevalence of overt hyperthyroidism (low TSH and high fT4) was 0.2% among females and 0.3% among males. About 85.7% (83.3% for females, 100% males) of those previously diagnosed with hyperthyroidism had TSH levels within the appropriate range. Conclusions: The results of this study reveal that the total prevalence of thyroid dysfunction among adult females and males in Jordan is very high compared with international statistics, particularly in the rates of undiagnosed cases. This indicates the need for further assessment of the value of screening for adult hypothyroidism in Jordan.

Variation in the Quality of Thyroid Nodule Evaluations Before Surgical Referral

BACKGROUND

Thyroid nodules are highly prevalent, and owing to their malignant potential, proper evaluation is imperative. The objective of this study was to characterize variation in thyroid nodule evaluations.

MATERIALS AND METHODS

This retrospective review included all consecutive surgical referrals for thyroid nodules from October to December 2017 at a single institution. We determined the proportion of evaluations that contained a thyroid-stimulating hormone (TSH) level and a high-quality ultrasound because these components of thyroid nodule evaluations are common to several evidence-based guidelines.

RESULTS

The study cohort included 64 patients, with a median age of 51.5 y. Primary care providers referred most patients (51.6%), followed by endocrinologists (40.6%), and other specialists (7.8%). In total, 35.9% of evaluations did not include a TSH value, which is vital to any thyroid nodule evaluation. Most evaluations (95.3%) included a dedicated ultrasound, but only 12.3% of ultrasound reports commented on nodule size in three dimensions, structure, echogenicity, and lymph nodes, which we considered the minimum commentary indicative of a high-quality ultrasound. Only 51.5% of evaluations included both a TSH and a thyroid ultrasound. If patients receiving low-quality ultrasound reports were excluded, 9.4% of the entire cohort received a guideline-concordant, high-quality evaluation.

CONCLUSIONS

Great variation exists in the quality of thyroid nodule evaluations before surgical referral. Two necessary components of thyroid nodule evaluations that contribute most to the observed deviation from guidelines are obtaining a TSH value and obtaining an ultrasound with enough information to risk stratify the nodule.

Centrifuged supernatants from FNA provide a liquid biopsy option for clinical next-generation sequencing of thyroid nodules

BACKGROUND

Molecular testing is recommended as an adjunct to improve the preoperative diagnosis of fine-needle aspiration (FNA) of thyroid nodules. Centrifuged supernatants from FNA samples, which are typically discarded, have recently emerged as a novel liquid-based biopsy for molecular testing. This study evaluates the use of thyroid FNA supernatants for detecting clinically relevant mutations.

METHODS

Supernatants from thyroid FNA samples (n = 156) were evaluated. A 50-gene next-generation sequencing (NGS) assay was used, and mutation analysis results from a subset of samples were further compared with those of paired FNA smears and/or cell blocks.

RESULTS

All 156 samples yielded adequate DNA (median, 135 ng; range, 11-3180 ng), and 129 of these samples (83%) were successfully sequenced by NGS. The most frequently detected somatic mutations included BRAF and RAS mutations, which were followed by RET, TP53, PTEN, CDKN2A, and PIK3CA mutations. Eleven of 31 cases with an indeterminate cytologic diagnosis and 9 of 12 cases that were suspicious for malignancy had somatic mutations, including the BRAF V600E mutation, which is highly definitive for papillary thyroid carcinoma (PTC). Seven of the 9 indeterminate and suspicious cases with the BRAF V600E mutation had surgical follow-up, and they were all confirmed to be PTC. A comparison of the mutation profiles derived from supernatants with those of paired smears and/or cell blocks in a small subset of cases (n = 8) showed 100% concordance.

CONCLUSIONS

This study provides evidence that FNA supernatants can be used as a surrogate for thyroid molecular testing to improve diagnostic accuracy in indeterminate nodules, provide prognostic/predictive information, and improve overall patient management.

Vitamin D, autoimmunity and recurrent pregnancy loss: More than an association

Recurrent pregnancy loss (RPL) affects close to 1% of couples; however, the etiology is known in only about 50% of the cases. Recent studies show that autoimmune dysregulation is a probable cause of RPL, which in some cases may be overlooked. In order for a pregnancy to proceed to term, early modulation of immunologic response is required to induce tolerance to the semi-allogenic fetus. Certain subsets of both the innate and adaptive immune responses play a role in the induction of fetomaternal tolerance. A relatively predominant T-cell helper (Th) 2 and T regulatory (Treg) cell population seem to favor a better pregnancy outcome, whereas Th1 and Th17 cell populations appear to have an opposite effect. Lately, the role of vitamin D in the modulation of immune response was established. Vitamin D has been shown to promote a more favorable environment for pregnancy through various mechanisms, such as enhancement of the shift toward Th2 cells and regulation of immune cell differentiation and cytokine secretion. Therefore, it seems that vitamin D deficiency sways the balance toward a worse outcome and may play a part in recurrent pregnancy loss. This review sheds light on the immunologic changes, which occur in early pregnancy and the regulatory role vitamin D has in the maintenance of this delicate balance.

Comparison of Strain Elastography, Shear Wave Elastography, and Conventional Ultrasound in Diagnosing Thyroid Nodules

Objective:

The purpose of this study is to compare the diagnostic performances of strain elastography (SE), shear wave elastography (SWE), and traditional ultrasound (US) features in diagnosing thyroid nodules.

Subjects and Methods:

This study included 185 adult patients with thyroid nodules who underwent conventional gray-scale US, SE, and SWE. SE was scored using a four-pattern elastographic scoring (ES) system. SWE values were presented as mean SWE values and standard derivation using Young's modules. The optimal cutoff values of the mean SWE values for predicting malignancy were determined using receiver operating characteristic (ROC) curve analysis. We used logistic regression models to test elastography as a novel significant predictor for the diagnosis of malignant nodules. The diagnostic performance of elastography parameters was compared with a traditional trained model.

Results:

Malignant thyroid nodules were stiffer for SE (ES patterns 1 and 2/3 and 4) and mean SWE values (4/17; 51.0 ± 24.4 kPa) than for benign nodules (114/50; 33.1 ± 25.2 kPa) (P < 0.01). In ROC curve analyses, a mean SWE value of 32 kPa was the optimal cutoff point, with diagnostic performance measures of 81% sensitivity, 65% specificity, a 23% positive predictive value (PPV), and 96% negative predictive value (NPV). In multivariate logistic regression, the mean SWE value (≥32 kPa) was an independent predictor for malignancy (odds ratio: 16.8; 95% confidence interval [CI]: 3.6–78.3). However, after the addition of SE and SWE to traditional US features, the C-statistic was not significantly increased compared to the traditional model (0.88, 95% CI: 0.81–0.94 vs. 0.91, 0.85–0.97, P = 0.4).

Conclusion:

In this study, we confirmed SWE as an independent predictor for malignant thyroid nodules. However, in comparing the new extended elastography model to our previous prediction model, the new extended model showed no significant difference in the diagnostic performance.

THE CORRELATION BETWEEN INFLAMMATORY AND METABOLIC PARAMETERS WITH THYROID FUNCTION IN PATIENTS WITH HASHIMOTO'S THYROIDITIS: THE POTENTIAL ROLE OF INTERLEUKIN 23 (IL-23) AND VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) - 1

CONTEXT

Hashimoto's thyroiditis is the most common autoimmune disorder as cause of secondary hypothyroidism. The disease is associated with several metabolic disturbances and inflammatory disorders.

OBJECTIVES

The aim of the current report was to evaluate several inflammatory and metabolic predictors of Hashimoto's thyroiditis.

SUBJECTS AND METHODS

In the current study, forty patients with Hashimoto's thyroiditis participated in the current study. They were aged between 20 to 50 years old. Anthropometric and nutritional measurements were assessed and biochemical factors including serum VEGF, IL-23, Nesfatin-1 and serum lipids were measured.

RESULTS

Waist circumference was higher among patients with lower serum TSH concentrations. Serum HDL and T4 concentrations were lower and serum IL-23 was higher among patients with higher TSH concentrations. BMI, WC and serum HDL were negative predictors of serum TSH while IL-23 was positively associated with TSH concentrations. Serum lipids including TC, TG and LDL were also negatively associated with T3 and T4 concentrations.

CONCLUSIONS

According to our findings, VEGF and serum IL-23 were potent predictors of Hashimoto's thyroiditis. However, further studies are warranted to better clarify these associations and underlying pathologic mechanisms.

Powdered black cumin seeds strongly improves serum lipids, atherogenic index of plasma and modulates anthropometric features in patients with Hashimoto's thyroiditis

Background

Hashimoto’s thyroiditis is associated with serious alterations in serum lipids and glucose homeostasis. The aims of the current study were to evaluate the effect of powdered Nigella sativa on serum lipids, glucose homeostasis and anthropometric variables in patients with Hashimoto’s thyroiditis.

Methods

Forty patients with Hashimoto’s thyroiditis, aged between 22 and 50 years old, participated in the trial and were randomly allocated into two groups of intervention and control receiving powdered Nigella sativa or placebo daily for 8 weeks. Serum lipids, glucose homeostasis, and anthropometric variables were evaluated at baseline and after intervention.

Results

Treatment with Nigella sativa significantly reduced body weight and body mass index (BMI). Serum concentrations of low density lipoprotein cholesterol (LDL) and triglyceride (TG) also decreased in Nigella sativa-treated group after 8 weeks; while serum high density lipoprotein cholesterol (HDL) significantly increased after treatment with Nigella sativa (P < 0.05). None of these changes had been observed in placebo treated group. Serum Nesfatin-1 concentrations was in inverse relationship with serum triglyceride (TG) (r = − 0.31, P = 0.04).

Conclusions

Giving attention to the potent beneficial effects of powdered black cumin seeds in improving serum lipid profile and anthropometric features in patients with Hashimoto’s thyroiditis, this medicinal plant could be considered as a beneficial herbal supplement alongside with the disease- specific medications including Levothyroxine in management of Hashimoto’s thyroiditis- related metabolic abnormalities.

Trial registration

Iranian registry of clinical trials (registration number IRCT2014090819082N2- Registered 2014-09-29).

Assessment of clinical and pathological features of patients who underwent thyroid surgery: A retrospective clinical study

AIM

To evaluate whether there was any correlation between the clinical parameters and final pathological results among patients who underwent thyroid surgery.

METHODS

We retrospectively analyzed parameters, including age, sex, complete blood cell count parameters, nodule diameter, nodule localization, thyroid function testing, and pathology reports, in patients who underwent thyroid surgery. The patients were divided into malignant (n = 92) and benign (n = 413) groups depending on the final pathological results. Both groups were compared for demographic and clinical parameters. The Kolmogorov-Smirnov normality test was used to determine if the quantitative variables had a normal distribution. The nonparametric Mann-Whitney U test was used to compare quantitative data that were not normally distributed, and Pearson’s chi-squared test was used to compare the qualitative data. The correlation between the final pathological results and fine-needle aspiration biopsy findings was calculated using the cross-tabulation method.

RESULTS

This study included 406 women and 99 men aged between 15 and 85 years. No significant differences were found between the groups with respect to age, sex, white blood cell count, neutrophil count, lymphocyte count, thrombocyte count, red cell distribution width, platelet distribution width, mean platelet volume, platecrit, nodule localization, and thyroid function testing. On the other hand, there were significant differences between the groups with respect to nodule size (P = 0.001), cervical lymphadenopathy (P = 0.0001) and nodular calcification (P = 0.0001). Compared with the malignant group, the benign group had a significantly greater nodule size (35.4 mm vs 27.6 mm). The best cut-off point (≤ 28 mm) for nodule size, as determined by the receiver operating characteristic curve, had a sensitivity and specificity of 67.7% and 64.4%, respectively. The correlation between fine-needle aspiration biopsy and the final pathological results was assessed using the cross-table method. The sensitivity and specificity of fine-needle aspiration biopsy were 60% and 98%, respectively.

CONCLUSION

This study showed that significant differences existed between the malignant and benign groups with regard to nodule size, cervical lymphadenopathy, and nodular calcification.

Thyroid Disease and Surgery in CHEER: The Nation's Otolaryngology-Head and Neck Surgery Practice-Based Network

OBJECTIVES

(1) Describe thyroid-related diagnoses and procedures in Creating Healthcare Excellence through Education and Research (CHEER) across academic and community sites. (2) Compare management of malignant thyroid disease across these sites. (3) Provide practice-based data related to flexible laryngoscopy vocal fold assessment before and after thyroid surgery based on the American Academy of Otolaryngology-Head and Neck Surgery Foundation's clinical practice guidelines.

STUDY DESIGN

Review of retrospective data collection (RDC) database of the CHEER network using ICD-9 and CPT codes related to thyroid conditions.

SETTING

Multisite practice-based network.

SUBJECTS AND METHODS

There were 3807 thyroid patients (1392 malignant, 2415 benign) with 10,160 unique visits identified from 1 year of patient data in the RDC. Analysis was performed for identified cohort of patients using demographics, site characteristics, and diagnostic and procedural distribution.

RESULTS

Mean number of patients with thyroid disease per site was 238 (range, 23-715). In community practices, 19% of patients with thyroid disease had cancer versus 45% in the academic setting (P < .001). While academic sites manage more cancer patients, community sites are also surgically treating thyroid cancer and performed more procedures per cancer patient (4.2 vs 3.5, P < .001). Vocal fold function was assessed by flexible laryngoscopy in 34.0% of preoperative patients and in 3.7% postoperatively.

CONCLUSION

This is the first overview of malignant and benign thyroid disease through CHEER. It shows how the RDC can be used alone and with national guidelines to inform of clinical practice patterns in academic and community sites. This demonstrates the potential for future thyroid-related studies utilizing the otolaryngology-head and neck surgery practice-based research network.

Screening for thyroid cancer in survivors of childhood and young adult cancer treated with neck radiation

BACKGROUND

The optimal method of screening for thyroid cancer in survivors of childhood and young adult cancer exposed to neck radiation remains controversial. Outcome data for a physical exam-based screening approach are lacking.

METHODS

We conducted a retrospective review of adult survivors of childhood and young adult cancer with a history of neck radiation followed in the Adult Long-Term Follow-Up Clinic at Memorial Sloan Kettering between November 2005 and August 2014. Eligible patients underwent a physical exam of the thyroid and were followed for at least 1 year afterwards. Ineligible patients were those with prior diagnosis of benign or malignant thyroid nodules.

RESULTS

During a median follow-up of 3.1 years (range 0-9.4 years), 106 ultrasounds and 2277 physical exams were performed among 585 patients. Forty survivors had an abnormal thyroid physical exam median of 21 years from radiotherapy; 50% of those with an abnormal exam were survivors of Hodgkin lymphoma, 60% had radiation at ages 10-19, and 53% were female. Ultimately, 24 underwent fine needle aspiration (FNA). Surgery revealed papillary carcinoma in seven survivors; six are currently free of disease and one with active disease is undergoing watchful waiting. Among those with one or more annual visits, representing 1732 person-years of follow-up, no cases of thyroid cancer were diagnosed within a year of normal physical exam.

CONCLUSIONS

These findings support the application of annual physical exam without routine ultrasound for thyroid cancer screening among survivors with a history of neck radiation.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors with a history of neck radiation may not require routine thyroid ultrasound for thyroid cancer screening. Among adult survivors of childhood and young adult cancer with a history of radiation therapy to the neck, annual physical exam is an acceptable thyroid cancer screening strategy.

Endocrinological Evaluations of a Neurofibromatosis Type 1 Cohort: Is it Necessary to Evaluate Autoimmune Thyroiditis in Neurofibromatosis Type 1?

Background:

Neurofibromatosis type 1 is an autosomal dominant neurocutaneous disorder in which the coexistence of autoimmune thyroiditis and thyroid gland tumours has been reported previously.

Aims:

To determine the thyroid function and autoimmune thyroid diseases in neurofibromatosis type 1 patients in order to identify the possible association between neurofibromatosis type 1 and thyroid diseases.

Study Design:

Case-control study.

Methods:

The study includes 78 consecutive patients diagnosed with neurofibromatosis type 1 between June 2010 and June 2014 and 50 healthy controls. Baseline demographic data were generated from patient examination record forms, including age, sex, height, and weight, as well as levels of free triiodothyronine, free thyroxine, thyroid-stimulating hormone, anti-thyroid peroxidase and anti-thyroglobulin levels.

Results:

Mean age, sex, and body mass index were similar in both groups (p>0.05). The mean levels of free triiodothyronine, free thyroxine, and thyroid-stimulating hormone were not statistically different between the neurofibromatosis type 1 and control groups. Similarly, no statistically significant difference was observed between the neurofibromatosis type 1 and control groups for anti-thyroid peroxidase and anti-thyroglobulin positivity (2.5% vs 0%, p>0.05).

Conclusion:

Screening for autoimmune thyroid disease and thyroid function seems to be unnecessary in patients with neurofibromatosis type 1.

Demographic associations for autoantibodies in disease-free individuals of a European population

The presence of autoantibodies usually precedes autoimmune disease, but is sometimes considered an incidental finding with no clinical relevance. The prevalence of immune-mediated diseases was studied in a group of individuals from the Estonian Genome Project (n = 51,862), and 6 clinically significant autoantibodies were detected in a subgroup of 994 (auto)immune-mediated disease-free individuals. The overall prevalence of individuals with immune-mediated diseases in the primary cohort was 30.1%. Similarly, 23.6% of the participants in the disease-free subgroup were seropositive for at least one autoantibody. Several phenotypic parameters were associated with autoantibodies. The results suggest that (i) immune-mediated diseases are diagnosed in nearly one-third of a random European population, (ii) 6 common autoantibodies are detectable in almost one-third of individuals without diagnosed autoimmune diseases, (iii) tissue non-specific autoantibodies, especially at high levels, may reflect preclinical disease in symptom-free individuals, and (iv) the incidental positivity of anti-TPO in men with positive familial anamnesis of maternal autoimmune disease deserves further medical attention. These results encourage physicians to evaluate autoantibodies in addition to treating a variety of patient health complaints to detect autoimmune-mediated disease early.

Effects of nodule characteristics on sampling number and duration of thyroid fine-needle aspiration biopsy: size does not matter, but cystic degeneration ratio does

Background Ultrasound-guided fine needle aspiration biopsy (FNAB) of thyroid nodules, though the most accurate method to rule out malignancy, still has an inherent risk of yielding non-diagnostic specimens despite immediate assessment of specimen adequacy by an on-site cytopathologist. Purpose To evaluate the effects of nodule volume and extent of cystic degeneration on total biopsy time and number of aspirations required for obtaining an adequate specimen. Material and Methods A total of 510 patients underwent FNAB by a single radiologist accompanied by a cytopathologist who immediately assessed each sample for specimen adequacy. All sampled nodules were single and had one maximum diameter > 10 mm. Nodule volumes and cystic degeneration ratios were calculated prior to the intervention. Aspirations were repeated until the cytological material was deemed adequate by the cytopathologist; the number of aspirations and total biopsy time were then recorded. Results Nodule volumes did not have significant effect on neither number of aspirations necessary for achieving specimen adequacy ( P > 0.05) nor total biopsy time (r = -0.148 with P = 0.001). Predominantly cystic nodules, compared to predominantly solid nodules, required more sampling per nodule (4.58 ± 1.11 vs. 3.44 ± 1.19 aspirations, P = 0.001) and longer total biopsy time (16.40 ± 6.19 vs. 11.15 ± 6.18 min, P = 0.001). Conclusion Predominantly cystic nodules require allocation of more time for biopsy. To ensure specimen adequacy when immediate specimen evaluation by an on-site cytopathologist is not possible, four samples from predominantly solid nodules and five passes through predominantly cystic nodules are required.

Overt Primary Hypothyroidism in an Industrial Area in São Paulo, Brazil: The Impact of Public Disclosure

Background: Primary hypothyroidism (PH) is the most common thyroid pathology. Purpose: to evaluate the impact of public disclosure of an unexpected number of PH cases on the frequency of patients seeking medical evaluation for endocrinological diseases. Methods: data on 6306 subjects (3356 living in the surroundings of a petrochemical complex and 2950 in a control region) were collected over a 15-year time span. Thyroid function was determined by serum levels of triiodothyronine, thyroxine, free thyroxine and thyrotrophin. Antithyroglobulin and antithyroperoxidase antibodies and sonographic scans of the thyroid were performed in all patients. The data were analyzed via log-linear models to compute odds and odds ratios. Results: An increasing trend in the odds of PH was detected along the observation period with greater slope in the study region than in the control region. The odds of PH in the post-disclosure period (2002 to 2004) are greater than the corresponding ones in the pre-disclosure period (1989 to 2001). Conclusions: This study shows that living in the surroundings of a petrochemical complex may be an important risk factor for PH for both adults and children. Furthermore, public disclosure of such risk factor contributes to the awareness of the problem and to the possibility of an early diagnosis.

The effects of Nigella sativa on thyroid function, serum Vascular Endothelial Growth Factor (VEGF) - 1, Nesfatin-1 and anthropometric features in patients with Hashimoto's thyroiditis: a randomized controlled trial

Background

Hashimoto’s thyroiditis is an autoimmune disorder and the most common cause of hypothyroidism. The use of Nigella sativa, a potent herbal medicine, continues to increase worldwide as an alternative treatment of several chronic diseases including hyperlipidemia, hypertension and type 2 diabetes mellitus (T2DM). The aim of the current study was to evaluate the effects of Nigella sativa on thyroid function, serum Vascular Endothelial Growth Factor (VEGF) – 1, Nesfatin-1 and anthropometric features in patients with Hashimoto’s thyroiditis.

Methods

Forty patients with Hashimoto’s thyroiditis, aged between 22 and 50 years old, participated in the trial and were randomly allocated into two groups of intervention and control receiving powdered Nigella sativa or placebo daily for 8 weeks. Changes in anthropometric variables, dietary intakes, thyroid status, serum VEGF and Nesfatin-1 concentrations after 8 weeks were measured.

Results

Treatment with Nigella sativa significantly reduced body weight and body mass index (BMI). Serum concentrations of thyroid stimulating hormone (TSH) and anti-thyroid peroxidase (anti-TPO) antibodies decreased while serum T3 concentrations increased in Nigella sativa-treated group after 8 weeks. There was a significant reduction in serum VEGF concentrations in intervention group. None of these changes had been observed in placebo treated group. In stepwise multiple regression model, changes in waist to hip ratio (WHR) and thyroid hormones were significant predictors of changes in serum VEGF and Nesgfatin-1 values in Nigella sativa treated group (P < 0.05).

Conclusions

Our data showed a potent beneficial effect of powdered Nigella sativa in improving thyroid status and anthropometric variables in patients with Hashimoto’s thyroiditis. Moreover, Nigella sativa significantly reduced serum VEGF concentrations in these patients. Considering observed health- promoting effect of this medicinal plant in ameliorating the disease severity, it can be regarded as a useful therapeutic approach in management of Hashimoto’s thyroiditis.

Trial registration

Iranian registry of clinical trials (registration number IRCT2015021719082N4- Registered March-15-2015).

L-carnitine supplementation for the management of fatigue in patients with hypothyroidism on levothyroxine treatment: a randomized, double-blind, placebo-controlled trial

Hypothyroid patients experience fatigue-related symptoms despite adequate thyroid hormone replacement. Thyroid hormone plays an essential role in carnitine-dependent fatty acid import and oxidation. We investigated the effects of L-carnitine supplementation on fatigue in patients with hypothyroidism. In total, 60 patients (age 50.0 ± 9.2 years, 3 males, 57 females) who still experienced fatigue (fatigue severity scale [FSS] score ≥ 36) were given L-carnitine (n = 30, 990 mg L-carnitine twice daily) or placebo (n = 30) for 12 weeks. After 12 weeks, although neither the FSS score nor the physical fatigue score (PFS) changed significantly, the mental fatigue score (MFS) was significantly decreased by treatment with L-carnitine compared with placebo (from 4.5 ± 1.9 to 3.9 ± 1.5 vs. from 4.2 ± 1.8 to 4.6 ± 1.6, respectively; P < 0.01). In the L-carnitine group, 75.0%, 53.6%, and 50.0% of patients showed improvement in the FSS score, PFS, and MFS, respectively, but only 20.0%, 24.0%, and 24.0%, respectively, did so in the placebo group (all P < 0.05). Both the PFS and MFS were significantly improved in patients younger than 50 years and those with free T3 ≥ 4.0 pg/mL by treatment with L-carnitine compared with placebo. Additionally, the MFS was significantly improved in patients taking thyroid hormone after thyroid cancer surgery. These results suggest that L-carnitine supplementation may be useful in alleviating fatigue symptoms in hypothyroid patients, especially in those younger than 50 years and those who have hypothyroidism after thyroidectomy for thyroid cancer (ClinicalTrials.gov: NCT01769157).

Five-Year Prospective Evaluation of Thyroid Function Test Evolution in Children with Hashimoto's Thyroiditis Presenting with Either Euthyroidism or Subclinical Hypothyroidism

BACKGROUND

Whether the course of thyroid function in Hashimoto's thyroiditis (HT) differs in children who present with either euthyroidism or subclinical hypothyroidism (SH) has been incompletely investigated.

AIM

Using a five-year prospective evaluation of 234 children with HT and no prognostic risk factors, this study investigated whether the evolution of the thyroid status is influenced by the biochemical pattern at initial diagnosis.

RESULTS

In the entire series, thyrotropin values significantly increased during follow-up, while free thyroxine values decreased and the proportion of children with a thyroid dysfunction increased from 27.3% to 47.4% (p = 0.0001). An increasing proportion of cases with severe thyroid dysfunction was identified, especially among the 64 patients presenting with SH (group B), but also among the 170 children presenting with euthyroidism (group A) at initial diagnosis. At the end of follow-up, the prevalence of children with overt hypothyroidism was 12.3% in group A compared with 31.2% in group B (p = 0.0007). In the overall population, however, the majority of patients (52.6%) exhibited biochemical euthyroidism at the end of follow-up.

CONCLUSIONS

Children with HT may develop a deterioration of thyroid status during the first five years of disease. Such a trend may be observed, even in the patients who initially present with a mild biochemical picture (either SH or euthyroidism). A total of 57.1% of initially euthyroid children remain euthyroid, and 40.6% of patients with initial SH normalize thyroid function within five years after HT diagnosis. The patients presenting with SH are more prone to the risk of developing severe thyroid dysfunction over time.

Expression of Cytokeratin-19 and Thyroperoxidase in Relation to Morphological Features in Non-Neoplastic and Neoplastic Lesions of Thyroid

INTRODUCTION

Thyroperoxidase (TPO) is a protein involved in thyroid hormone synthesis. TPO gene suppression and mutation were involved in thyroid tumours. CK-19 plays important role in the structural integrity of epithelial cells. Reduced TPO expression with increased CK-19 immunoreactivity has been implicated as a marker for differentiating non neoplastic and neoplastic thyroid lesions.

AIM

To study the histopathological features of thyroid lesions and to evaluate the diagnostic role of thyroperoxidase and CK-19 in non-neoplastic and neoplastic thyroid lesions.

MATERIALS AND METHODS

Prospective observational study of 65 thyroid specimens was studied for detailed histopathological examination and Expression of Immunohistochemical Markers Cytokeratin-19 (CK-19) and Thyroperoxidase.

RESULTS

TPO IHC marker was expressed by non-neoplastic and benign lesions of thyroid but not in malignancy. CK-19 was expressed 100% in papillary carcinoma of thyroid and its variants, focal and weak staining noted in goitre and hyperplastic areas.

CONCLUSION

Most of the non-neoplastic and neoplastic lesions were diagnosed based on histopathological features. When the histopathological diagnosis are equivocal, immunohistochemical markers aids in diagnosing malignancy. Diffuse and strong TPO expression indicates non-neoplastic thyroid lesions whereas diffused and strong CK-19 expression indicates thyroid malignancy.

Signal peptide-CUB-EGF domain-containing protein 1 (SCUBE1) levels in patients with overt and subclinical hyperthyroidism: effects of treatment

BACKGROUND AND OBJECTIVES

Signal peptide-CUB-EGF domain-containing protein 1 (SCUBE1) has been shown to increase in parallel with platelet activation in acute ischaemic and thrombotic diseases. There has been no study evaluating SCUBE1 levels in patients with overt hyperthyroidism (OHyper) and subclinical hyperthyroidism (SHyper), conditions which are known to show impairment of both endothelial and platelet function. This study sought to evaluate SCUBE1 concentrations in patients with SHyper and OHyper, and assessed the effects of antithyroid drug (ATD) therapy on circulating SCUBE1 levels.

DESIGN AND METHODS

Forty-five untreated patients with OHyper, 20 untreated patients with SHyper and 30 age- and sex-matched healthy controls were prospectively included in the study. Biochemical and hormonal parameters were evaluated in all patients before and after treatment.

RESULTS

Compared with the control subjects, SCUBE1 levels were significantly increased in patients with SHyper and OHyper (P < 0·0001 and P = 0·002, respectively). SCUBE1 levels were not significantly different in patients with OHyper compared with patients with SHyper. There was no significant correlation between serum thyroid hormones and SCUBE1 levels. Plasma SCUBE1 levels decreased significantly in both OHyper and SHyper after ATD treatment (P < 0·05).

CONCLUSIONS

Increased SCUBE1 levels in both SHyper and OHyper patients may reflect increased platelet activation and possible endothelial dysfunction, which might augment the risk for atherosclerotic and atherothrombotic complications. SCUBE1 may be used as a reliable marker of endothelial damage in hyperthyroidism, especially in the subclinical period.

Encephalopathy Associated with Autoimmune Thyroid Disease: A Potentially Reversible Condition

Autoimmune thyroid disease may occasionally associate with unspecific neurological symptoms, which are more commonly insidious, include cognitive or behavioural symptoms, and may associate with tremor, myoclonus, or ataxia. We report a 61-year-old female patient who presented with chronic headache, insidious mood, and cognitive disturbance which evolved in a few months to dementia associated with exuberant limb myoclonus. Diagnostic workup revealed high anti-thyroid peroxidase antibody titers and an inflammatory CSF profile, and it was negative for other possible etiologies. Treatment with steroids induced significant improvement. The diagnosis of encephalopathy associated with autoimmune thyroid disease is still controversial given the fact that the clinical presentation and diagnostic workup are unspecific, the pathophysiology is still undetermined, and the diagnosis is mostly of exclusion. No direct correlation is found between anti-thyroid antibody titers and clinical presentation, and it is currently speculated that other still unrecognized antibodies may be responsible for this clinical entity. It is extremely important to recognize this entity because it is potentially treatable with immunotherapies. It is also increasingly recognized that clinical improvement with first-line treatment with steroids may be absent or incomplete, and other immunotherapies as immunosuppressants, intravenous immunoglobulin, or plasma exchange must be attempted in the clinical suspicion of EEAT.