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Zhou Y, Zhou M, Qi Y, Wang W, Chen X, Wang S. The prognostic value of thyroid-stimulating immunoglobulin in the management of Graves' disease. Ther Adv Endocrinol Metab 2021; 12:20420188211044943. [PMID: 34603682 PMCID: PMC8481717 DOI: 10.1177/20420188211044943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/06/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The bioassay of thyroid-stimulating immunoglobulin was reported to have a similar performance to the commonly used thyroid-stimulating hormone binding inhibition assay, also known as thyroid receptor antibody assay. The normal reference range of thyroid receptor antibody levels indicates the withdrawal of anti-thyroid drugs in the recent clinical guidelines. METHODS A prospective, longitudinal observational study was conducted to evaluate the prognostic value of thyroid-stimulating immunoglobulin in patients with Graves' disease. RESULTS A total of 77 patients with Graves' disease treated with anti-thyroid drugs were in a continuous follow-up until 1 year after anti-thyroid drugs discontinuation. Commercial kits of thyroid-stimulating immunoglobulin and M22-thyroid-stimulating hormone binding inhibition assay were used and compared. Thyroid-stimulating immunoglobulin was all negative in healthy controls, Hashimoto thyroiditis, and subacute thyroiditis. Thyroid-stimulating immunoglobulin value was highest in untreated patients with Graves' disease (p < 0.001). Under anti-thyroid drugs treatment, thyroid-stimulating immunoglobulin value decreased gradually. A total of 21 patients had positive thyroid-stimulating immunoglobulin at the end of treatment. According to clinical fate of patients with Graves' disease after withdrawal of anti-thyroid drugs, thyroid-stimulating immunoglobulin value and positivity in patients with relapse were significantly higher than that reported in patients with remission (p = 0.001, p < 0.001). After adjustment for age, gender, initial thyroid receptor antibody, initial thyroid-stimulating immunoglobulin, and thyroid receptor antibody at the end of treatment, the odds ratio of positive thyroid-stimulating immunoglobulin for the risk of relapse was 33.271 (95% confidence interval: 4.741-233.458, p < 0.001) and odds ratio of quantitative thyroid-stimulating immunoglobulin was 1.009 (95% confidence interval: 1.002-1.015, p < 0.001). CONCLUSION Thyroid-stimulating immunoglobulin is a good predictor of relapse in patients with Graves' disease treated with anti-thyroid drugs. It might be safer to discontinue anti-thyroid drugs when thyroid-stimulating immunoglobulin and thyroid receptor antibody were both negative.
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Affiliation(s)
- Yulin Zhou
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, Shanghai, P.R. China
| | - Mengxi Zhou
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, Shanghai, P.R. China
| | - Yicheng Qi
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, Shanghai, P.R. China
| | | | | | - Shu Wang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, 197 Ruijin 2nd Road, Shanghai 200025, P.R. China
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Seo S, Sánchez Robledo M. Usefulness of TSH receptor antibodies as biomarkers for Graves' ophthalmopathy: a systematic review. J Endocrinol Invest 2018; 41:1457-1468. [PMID: 30194634 DOI: 10.1007/s40618-018-0945-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/10/2018] [Indexed: 01/24/2023]
Abstract
PURPOSE Over the past several decades, many papers have been published about the usefulness of thyrotropin receptor antibodies (TRAbs) as biomarkers of Graves' ophthalmopathy (GO). However, results have been inconsistent. The purpose of this analysis is to determine a possible cause of these discrepancies and to examine the usefulness of TRAbs as biomarkers for GO, especially 'thyrotropin-binding inhibiting immunoglobulin (TBII)' and 'thyroid-stimulating antibody (TSAb)'. METHOD 26 articles discussing the association between TRAbs and GO were selected which were then divided into three groups based on the study method and whether or not the patients had been treated for hyperthyroidism. From the results of the papers reviewed, a provisional conclusion was made and a theoretical model on the TBII-TSAb coordinate plane was developed to confirm that conclusion. RESULTS TSAb is reported to be significantly or strongly associated with GO in the studies of pre- and post-treated patients for hyperthyroidism. TBII is positively correlated, negatively correlated or uncorrelated with GO in studies of pre-treated patients. However, it is generally agreed upon that TBII and GO are closely correlated in studies of post-treated patients. CONCLUSION We conclude that the level of TBII may not be a reliable indicator of the current state of GO in pre-treated patients. Whereas, in post-treated patients, due to changes in the correlation between TBII and TSAb due to the effect of hyperthyroidism treatment, the level of TBII can be a more reliable indicator of GO. Furthermore, the current level of TBII is closely associated with the onset and severity of GO in the future and it can be a valid predictor of GO. However, the TSAb level appears to be more reliable.
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Affiliation(s)
- S Seo
- Department of Medicine, School of Clinical Science, Universidad de Santiago de Compostela, Rúa da Choupana, s/n, 15706, Santiago de Compostela, A Coruña, Spain.
| | - M Sánchez Robledo
- Department of Internal Medicine, Hospital Universitario del Henares, Madrid, Spain
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Chen X, Zhou Y, Zhou M, Yin Q, Wang S. Diagnostic Values of Free Triiodothyronine and Free Thyroxine and the Ratio of Free Triiodothyronine to Free Thyroxine in Thyrotoxicosis. Int J Endocrinol 2018; 2018:4836736. [PMID: 29971103 PMCID: PMC6008621 DOI: 10.1155/2018/4836736] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 04/16/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The results of previous studies on the usefulness of free triiodothyronine (FT3) to free thyroxine (FT4) are controversial. We investigated the usefulness of FT3, FT4, and FT3/FT4 ratio in differentiating Graves' disease (GD) from destructive thyroiditis. METHODS A total of 126 patients with untreated GD, 36 with painless thyroiditis, 18 with painful subacute thyroiditis, and 63 healthy controls, were recruited. The levels of FT3 and FT4 and the FT3/FT4 ratios for the different etiologies of thyrotoxicosis were evaluated separately by receiver operating characteristic (ROC) curve analysis. The expression levels of type 1 and type 2 deiodinase (DIO1 and DIO2) in thyroid tissues were also investigated. RESULTS The optimal cut-off values were 7.215 pmol/L for FT3, 21.71 pmol/L for FT4, and 0.4056 for the FT3/FT4 ratio. The specificity and positive predictive value of the FT3/FT4 ratio were highest for values > 0.4056. DIO1 mRNA expression was significantly higher in the thyroid tissue of patients with GD (P = 0.013). CONCLUSIONS We demonstrated that the FT3/FT4 ratio was useful in differentiating GD from destructive thyroiditis. In addition, a relatively high expression of type 1 deiodinase in the thyroid might be responsible for the high FT3/FT4 ratio in patients with GD.
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Affiliation(s)
- Xinxin Chen
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai 200025, China
| | - Yulin Zhou
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai 200025, China
| | - Mengxi Zhou
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai 200025, China
| | - Qinglei Yin
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai 200025, China
| | - Shu Wang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai 200025, China
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Bell L, Hunter AL, Kyriacou A, Mukherjee A, Syed AA. Clinical diagnosis of Graves' or non-Graves' hyperthyroidism compared to TSH receptor antibody test. Endocr Connect 2018; 7. [PMID: 29531156 PMCID: PMC5881005 DOI: 10.1530/ec-18-0082] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND TSH receptor antibody (TRAb) is considered the gold standard diagnostic test for the autoimmunity of Graves' disease (GD), which is commonly diagnosed clinically. AIM To evaluate the true positive (sensitivity) and true negative (specificity) rates of clinical diagnosis of GD or non-GD hyperthyroidism compared to the TRAb test. SETTING University teaching hospital in North West England. PARTICIPANTS Patients in the Endocrinology service who had a TRAb measurement between December 2009 and October 2015. METHODS Electronic patient records were studied retrospectively for a pre-TRAb clinical diagnosis of GD or non-GD hyperthyroidism. We examined descriptive statistics and binary classification tests; Fisher exact test was used to analyse contingency tables. RESULTS We identified 316 patients with a mean age of 45 (range, 17-89) years; 247 (78%) were women. Compared to the TRAb result, clinical diagnosis had a sensitivity of 88%, specificity 66%, positive predictive value 72%, negative predictive value 84%, false negative rate 12%, false positive rate 34%, positive likelihood ratio 2.6 and negative likelihood ratio 0.2 (P < 0.0001). CONCLUSIONS Clinicians were liable to both over- and under-diagnose GD. The TRAb test can help reduce the number of incorrect or unknown diagnoses in the initial clinical assessment of patients presenting with hyperthyroidism.
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Affiliation(s)
- Lauren Bell
- Faculty of BiologyMedicine and Health, University of Manchester, Manchester, UK
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
| | - Ann Louise Hunter
- Faculty of BiologyMedicine and Health, University of Manchester, Manchester, UK
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
| | - Angelos Kyriacou
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
- CEDM Centre of EndocrinologyDiabetes & Metabolism, Limassol, Cyprus
| | - Annice Mukherjee
- Faculty of BiologyMedicine and Health, University of Manchester, Manchester, UK
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
| | - Akheel A Syed
- Faculty of BiologyMedicine and Health, University of Manchester, Manchester, UK
- Endocrinology & DiabetesSalford Royal NHS Foundation Trust, Salford, UK
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Ansakorpi H, Sumelahti ML, Kaasila R. Medical students' experience of emotions and success in neurological studies - What do they tell us? BMC MEDICAL EDUCATION 2017; 17:68. [PMID: 28376787 PMCID: PMC5379665 DOI: 10.1186/s12909-017-0905-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 03/25/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND There is a need to develop effective educational experience in neurology to improve the students' skills in diagnosing and managing patients with neurological symptoms or disease. The aim of this study was to investigate the medical students' attitudes and emotions towards neurology before and after the four week clinical course at two Finnish Universities in order to find elements to improve effective learning by decreasing the emotional stress in medical studies. METHODS In this two-stage study, 58 medical students participated in an internet survey with open-ended questions after completing a clinical neurology course. In the content analysis of this survey 20 students (35%) were identified with negative anticipation towards neurology before undertaking the clinical neurology course. In the second phase of the study, the narrative analysis method was used to analyse the face-to-face interviews. Two of these interviews are described in this paper and represent cases who expressed negative emotions in both online survey and narrative interview. RESULTS According to the content analysis, the principal emotions that were experienced at the beginning of the clinical neurology course were insecurity about personal performance (n = 19, 95%) anxiety (n = 9, 45%) and fear (n = 6, 30%). During the course the combined negative emotions (insecurity, anxiety, and fear) decreased in 80% of students (16/20 cases), remained unchanged in 15% (3/20) and could not be evaluated in 1 (5%) case. The main reasons for the observed negative anticipation were the complexity of neurology and challenges in the interpretation of clinical findings. Based on content analysis and narratives, elements that were evaluated as the most significant contributors in reducing this included small group teaching with real patients, teachers' expertise and the increase in self-confidence. CONCLUSION Teaching with appropriate didactic methodology and feedback, and plenty of practical training can improve effective learning in neurology. We suggest that the pedagogic competence of the clinical teacher influences a student's motivation and proficiency and reduce stress in neurology-related learning tasks.
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Affiliation(s)
- Hanna Ansakorpi
- Research Unit of Clinical Neuroscience, University of Oulu, B.O.X. 5000, 90014 Oulu, Finland
- Oulu University Hospital, B.O.X. 5000, 90014 Oulu, Finland
| | | | - Raimo Kaasila
- Faculty of Education, University of Oulu, B.O.X. 2000, 90014 Oulu, Finland
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Bartalena L, Burch HB, Burman KD, Kahaly GJ. A 2013 European survey of clinical practice patterns in the management of Graves' disease. Clin Endocrinol (Oxf) 2016; 84:115-20. [PMID: 25581877 DOI: 10.1111/cen.12688] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 11/13/2014] [Accepted: 12/02/2014] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Management of Graves' disease (GD) in Europe was published in 1987. Aim of this survey was to provide an update on clinical practice in Europe, and to compare it with a 2011 American survey. DESIGN Members of the European Thyroid Association (ETA) were asked to participate in a survey on management of GD, using the same questionnaire of a recent American survey. RESULTS A total of 147 ETA members participated. In addition to serum TSH and free T4 assays, most respondents would request TSH-receptor autoantibody (TRAb) measurement (85·6%) and thyroid ultrasound (70·6%) to confirm aetiology, while isotopic studies were selected by 37·7%. Antithyroid drug (ATD) therapy was the preferred first-line treatment (83·8%). Compared to the previous European survey, Europeans currently more frequently use TRAb measurement and thyroid ultrasound for diagnosis and evaluation, but first-line treatment remains ATDs in a similar percentage of respondents. Current clinical practice patterns differ from those in North America, where isotopic studies are more frequently used, and radioiodine (RAI) still is first-line treatment. When RAI treatment is selected in the presence of mild Graves' orbitopathy and/or associated risk factors for its occurrence/exacerbation, steroid prophylaxis is frequently used. The preferred ATD in pregnancy is propylthiouracil in the first trimester and methimazole in the second and third trimesters, similar to North America. CONCLUSIONS Significant changes in clinical practice patterns in Europe were noted compared to the previous European survey, as well as persisting differences in diagnosis and therapy between Europe and North America.
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Affiliation(s)
- L Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - H B Burch
- Endocrinology, Diabetes, and Metabolism Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - K D Burman
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC, USA
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
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Abstract
In the developed world, all routine clinical laboratories should be able to perform tests for the assessment of the pituitary-thyroid axis. Testing strategies usually involve the measurement of thyroid-stimulating hormone (TSH), either alone or in combination with free thyroxine (FT4), which itself should also be measured when TSH is abnormal or if there is a suspicion of pituitary disease. Based on these findings, clinical history and medications such as amiodarone, free tri-iodothyronine (FT3), thyroid-binding globulin (TBG), and/or autoantibodies may then be measured. All these assays have their individual challenges. For example, sensitivity of a TSH assay is of crucial importance for improving distinction between eu- and hyperthyroidism. In the measurement of free hormones, there is the potential disturbance of the equilibrium between free and bound moieties by separating systems. There are a number of commercial diagnostic kits available for each of these tests. This chapter presents various representative assays and their principles. With the exception of FT4 determination by equilibrium dialysis, those that employ a 96-well plate format and use non-isotopic techniques have been described. Attention has been paid to limitations of the assays, standardization of assay kits, imprecision, recovery, detection limit, and ease of use. The assays described have been given as typical and reliable examples, but it is the responsibility of assayists to choose methods that are best suited to their needs.
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Flannery T, Gormley G. Evaluation of the contribution of theatre attendance to medical undergraduate neuroscience teaching – A pilot study. Br J Neurosurg 2014; 28:680-4. [DOI: 10.3109/02688697.2014.896873] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Estrada JM, Soldin D, Buckey TM, Burman KD, Soldin OP. Thyrotropin isoforms: implications for thyrotropin analysis and clinical practice. Thyroid 2014; 24:411-23. [PMID: 24073798 PMCID: PMC3949435 DOI: 10.1089/thy.2013.0119] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Serum thyrotropin (TSH) is considered the single most sensitive and specific measure of thyroid function in the general population owing to its negative logarithmic association with free triiodothyronine and free thyroxine concentrations. It is therefore often the test of choice for screening, diagnosis, and monitoring of primary hypothyroidism. Serum TSH concentrations can be analyzed quantitatively using third-generation immunoassays, whereas its bioactivity can be measured by TSH activity assays in cell culture. Theoretically, if serum TSH concentrations are directly related to TSH activity, the two tests should yield comparable results. However, on occasion, the results are discordant, with serum concentrations being higher than TSH biological activity. This review focuses on the dissociation between the clinical state and serum TSH concentrations and addresses clinically important aspects of TSH analysis.
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Affiliation(s)
- Joshua M. Estrada
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Danielle Soldin
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Timothy M. Buckey
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Kenneth D. Burman
- Endocrine Section, Medstar Washington Hospital Center, Washington, District of Columbia
| | - Offie P. Soldin
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
- Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia
- Department of Obstetrics and Gynecology, Georgetown University Medical Center, Washington, District of Columbia
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Olooto WE, Adeleye AO, Amballi AA, Mosuro AO, Banjo TA. Thyroid stimulating hormone assay as the first line biochemical parameter to determine thyroid gland abnormalities. Pak J Biol Sci 2014; 17:118-121. [PMID: 24783789 DOI: 10.3923/pjbs.2014.118.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Increased cellular catabolic activities observed in hyperthyroid state had been established. This is consequent to excessive hormones secreted by the thyroid gland during this condition. A total of 60 subjects comprising of 45 females mean age 43.02 +/- 1.90 (range 22-70 years) and 15 males mean age 50.40 +/- 3.59 (range 25-68) and 60 controls comprising of 45 females mean age 41.18 +/- 1.68 (range 22-68 years) and 15 males mean age 40.53 +/- 2.88 (range 25-65) were recruited for the study. The plasma level of T4, T3 and TSH were determined in both the experiment group and the controls. A significant increase (p < 0.05) in plasma T4, T3 and a significant decrease (p < 0.05) in plasma TSH were observed in the experiment group in comparison to the controls. Also, an inverse relationship was noted to exist between the plasma T4 and T3; and TSH in primary hyperthyroid state.
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Abstract
Graves disease is an autoimmune disorder characterized by goitre, hyperthyroidism and, in 25% of patients, Graves ophthalmopathy. The hyperthyroidism is caused by thyroid hypertrophy and stimulation of function, resulting from interaction of anti-TSH-receptor antibodies (TRAb) with the TSH receptor on thyroid follicular cells. Measurements of serum levels of TRAb and thyroid ultrasonography represent the most important diagnostic tests for Graves disease. Management of the condition currently relies on antithyroid drugs, which mainly inhibit thyroid hormone synthesis, or ablative treatments ((131)I-radiotherapy or thyroidectomy) that remove or decrease thyroid tissue. None of these treatments targets the disease process, and patients with treated Graves disease consequently experience either a high rate of recurrence, if receiving antithyroid drugs, or lifelong hypothyroidism, after ablative therapy. Geographical differences in the use of these therapies exist, partially owing to the availability of skilled thyroid surgeons and suitable nuclear medicine units. Novel agents that might act on the disease process are currently under evaluation in preclinical or clinical studies, but evidence of their efficacy and safety is lacking.
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Affiliation(s)
- Luigi Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Viale Borri, 57, 21100 Varese, Italy
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Hargreaves CE, Grasso M, Hampe CS, Stenkova A, Atkinson S, Joshua GWP, Wren BW, Buckle AM, Dunn-Walters D, Banga JP. Yersinia enterocolitica provides the link between thyroid-stimulating antibodies and their germline counterparts in Graves' disease. THE JOURNAL OF IMMUNOLOGY 2013; 190:5373-81. [PMID: 23630351 DOI: 10.4049/jimmunol.1203412] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Graves' disease results from thyroid-stimulating Abs (TSAbs) activating the thyrotropin receptor (TSHR). How TSAbs arise from early precursor B cells has not been established. Genetic and environmental factors may contribute to pathogenesis, including the bacterium Yersinia enterocolitica. We developed two pathogenic monoclonal TSAbs from a single experimental mouse undergoing Graves' disease, which shared the same H and L chain germline gene rearrangements and then diversified by numerous somatic hypermutations. To address the Ag specificity of the shared germline precursor of the monoclonal TSAbs, we prepared rFab germline, which showed negligible binding to TSHR, indicating importance of somatic hypermutation in acquiring TSAb activity. Using rFab chimeras, we demonstrate the dominant role of the H chain V region in TSHR recognition. The role of microbial Ags was tested with Y. enterocolitica proteins. The monoclonal TSAbs recognize 37-kDa envelope proteins, also recognized by rFab germline. MALDI-TOF identified the proteins as outer membrane porin (Omp) A and OmpC. Using recombinant OmpA, OmpC, and related OmpF, we demonstrate cross-reactivity of monoclonal TSAbs with the heterogeneous porins. Importantly, rFab germline binds recombinant OmpA, OmpC, and OmpF confirming reactivity with Y. enterocolitica. A human monoclonal TSAb, M22 with similar properties to murine TSAbs, also binds recombinant porins, showing cross-reactivity of a spontaneously arising pathogenic Ab with Y. enterocolitica. The data provide a mechanistic framework for molecular mimicry in Graves' disease, where early precursor B cells are expanded by Y. enterocolitica porins to undergo somatic hypermutation to acquire a cross-reactive pathogenic response to TSHR.
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Affiliation(s)
- Chantal E Hargreaves
- Division of Diabetes and Nutritional Sciences, King's College London School of Medicine, London SE5 9NU, United Kingdom
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Kamath C, Young S, Kabelis K, Sanders J, Adlan MA, Furmaniak J, Rees Smith B, Premawardhana LD. Thyrotrophin receptor antibody characteristics in a woman with long-standing Hashimoto's who developed Graves' disease and pretibial myxoedema. Clin Endocrinol (Oxf) 2012; 77:465-70. [PMID: 22891608 DOI: 10.1111/j.1365-2265.2012.04397.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
CONTEXT Sequential conversion of Hashimoto's thyroiditis (HT) to Graves' disease (GD) is uncommon. Distinct immune paradigms, paucity of functioning tissue in long-standing HT, and infrequent conversion of blocking (TBAb) to stimulating (TSAb) thyrotrophin receptor antibody (TRAb) may account for this. Molecular and crystal structure analysis helps delineate TSH receptor (TSHR)/TRAb interactions in detail. Such 'fingerprinting' helps determine the behaviour and characteristics of TRAb in longitudinal studies. PATIENT An 80-year-old woman taking thyroxine for long-standing HT became hyperthyroid. This persisted despite thyroxine withdrawal - free T3 was 7·3 pmol/l (2·6-5·7) and TSH < 0·01 mU/l (0·2-4·5) and TRAb highly positive. She had a goitre (ultrasound - HT), pretibial myxoedema, with mild inactive Graves' orbitopathy. She had RAI treatment and is on thyroxine replacement. MEASUREMENTS AND RESULTS Blood samples at presentation (A) and 1 year (B) showed high TSAb and TPOAb activity but no TBAb. Experiments involving TSHR mutations confirmed that (i) TRAb had stable characteristics over 1 year; (ii) TSHR mutation R255D caused complete inhibition and (iii) R109A caused marked reduction of cAMP production by M22 (TSHR-stimulating human monoclonal antibody) and A and B; (iv) mutations R80A, E107A and K129A while affecting M22 had little effect on A and B. CONCLUSIONS The reasons for an immunological paradigm shift in this elderly woman remain speculative. We believe that de-novo TSAb synthesis occurred converting her long-standing HT to GD although the mechanisms responsible remain unexplained. TRAb analysis confirmed stable autoantibody characteristics over 1 year and variable effects of TSHR mutations on TRAb and M22 function.
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Affiliation(s)
- C Kamath
- Section of Diabetes and Endocrinology, Department of Medicine, Caerphilly Miners' Hospital, Caerphilly, UK
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Tozzoli R, Bagnasco M, Giavarina D, Bizzaro N. TSH receptor autoantibody immunoassay in patients with Graves' disease: improvement of diagnostic accuracy over different generations of methods. Systematic review and meta-analysis. Autoimmun Rev 2012; 12:107-13. [PMID: 22776786 DOI: 10.1016/j.autrev.2012.07.003] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND TSH receptor antibodies (TRAb) are the diagnostic hallmark of Graves' disease (GD) and immunoassays for their detection have been available for more than 30 years over three generations of laboratory methods. Despite a growing body of data produced by clinical and laboratory research which demonstrates its elevated sensitivity and specificity, TRAb testing is poorly used for diagnosing GD. The aim of our systematic review and meta-analysis is to verify the diagnostic performance of TRAb detected with 2nd and 3rd generation immunoassay methods. METHODS We searched for English articles using MEDLINE with the search terms "TSH receptor antibody assay", "TSH Receptor antibody tests" and "Graves' disease". We analyzed studies reporting on TSH receptor antibody tests performed by quantitative immunoassays, on untreated patients with GD as the index disease (sensitivity) and on a control group of either healthy subjects or patients affected by other thyroid diseases (specificity). A total of 681 titles were initially identified with the search strategy described. 560 publications were excluded based on abstract and title. Full-text review was undertaken as the next step on 111 publications providing data on TRAb testing; 58 articles were subsequently excluded because they did not include untreated GD patients, or used either bioassays or 1st generation immunoassays. 32 were also excluded because they included data only on sensitivity or only on specificity of the assay, or were duplicates. Finally, 21 articles were selected for meta-analysis. Extraction of data from selected articles was performed by two authors independently, using predefined criteria: the number of patients with GD and the number of healthy or diseased controls; specification of the analytical method used to detect TRAb; sensitivity and specificity of the assay. RESULTS The meta-analysis showed that the overall pooled sensitivity and specificity of the 2nd and 3rd generation TRAb assays are 97.1% and 97.4%, and 98.3% and 99.2%, respectively, with little difference between the types of immunoassay methods employed (human or porcine receptor, manual or automated procedure). The likelihood of a TRAb-positive individual to have GD is 1367- to 3420-fold greater (depending upon the type of assay) compared to a TRAb-negative person. CONCLUSIONS Data from the meta-analysis showed that TRAb measured with 2nd and 3rd generation immunoassay methods have very high sensitivity and specificity in the diagnosis of GD. The difference between 2nd and 3rd generation methods is small and is equally useful. In contrast with recommendations made by clinical endocrinologists who are not familiar with the state of the art in diagnostic technologies of autoimmunology laboratories, we propose a wide application of these tests in clinical practice to screen all hyperthyroid patients.
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Affiliation(s)
- R Tozzoli
- Laboratory of Clinical Pathology, Dept. of Laboratory Medicine, S. Maria degli Angeli Hospital, Pordenone, Italy.
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The role of thyrotrophin receptor antibody assays in graves' disease. J Thyroid Res 2012; 2012:525936. [PMID: 22577596 PMCID: PMC3345237 DOI: 10.1155/2012/525936] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 01/27/2012] [Indexed: 11/17/2022] Open
Abstract
Thyrotrophin receptor antibodies (TRAb) exist as stimulating or blocking antibodies in the serum (neutral TRAb have been identified recently). The clinical features of GD occur when stimulating TRAb predominate. But the relationship of TRAb to clinical phenotype and outcome is not clear when current assay methods are used. Therefore no consensus exists about its utility in diagnosing and predicting outcome in GD. The most commonly used TRAb assays, measure thyroid binding inhibiting immunoglobulins (TBII or “receptor assays”) and don't differentiate between stimulating and blocking antibodies. However, the more expensive, technically demanding and less freely available “biological assays” differentiate between them by their ability to stimulate cyclic AMP or failure to do so. Failure to differentiate between TRAb types and its heterogeneous molecular and functional properties has limited TBII use to GD diagnosis and differentiating from other forms of thyrotoxicosis. The current 2nd-3rd generation receptor assays are highly sensitive and specific when used for this purpose. TRAb assays should also be done in appropriate pregnant women. Current data do not support its use in outcome prediction as there is a significant variability of assay methodology, population characteristics and study design in published data, resulting in a lack of consensus.
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Xia Y, Kellems RE. Receptor-activating autoantibodies and disease: preeclampsia and beyond. Expert Rev Clin Immunol 2011; 7:659-74. [PMID: 21895478 DOI: 10.1586/eci.11.56] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The research reviewed in this article provides examples of autoantibody-mediated receptor activation that likely contributes to disease. The classic example is Graves' hyperthyroidism, in which autoantibodies activate the thyroid-stimulating hormone receptor resulting in overproduction of thyroid hormones. Other compelling examples come from the cardiovascular literature and include agonistic autoantibodies targeting the cardiac β(1)-adrenergic receptor, which are associated with dilated cardiomyopathy. Autoantibodies capable of activating α(1)-adrenergic receptors are associated with refractory hypertension and cardiomyopathy. A prominent example is preeclampsia, a hypertensive disease of pregnancy, characterized by the presence of autoantibodies that activate the major angiotensin receptor, AT(1). AT(1) receptor-activating autoantibodies are also observed in kidney transplant recipients suffering from severe vascular rejection and malignant hypertension. AT(1) receptor-activating autoantibodies and antibodies that activate the endothelin-1 receptor, ET(A), are prevalent in individuals diagnosed with systemic sclerosis. Thus, the presence of agonistic autoantibodies directed to G protein-coupled receptors has been observed in numerous cardiovascular disease states. Rapidly emerging evidence indicates that receptor-activating autoantibodies contribute to disease, and that efforts to detect and remove these pathogenic autoantibodies or block their actions will provide promising therapeutic possibilities.
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Affiliation(s)
- Yang Xia
- Department of Biochemistry and Molecular Biology, The University of Texas Medical School, Houston, TX 77030, USA.
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Theodoraki A, Jones G, Parker J, Woolman E, Martin N, Perera S, Thomas M, Bunn C, Khoo B, Bouloux PM, Vanderpump MPJ. Performance of a third-generation TSH-receptor antibody in a UK clinic. Clin Endocrinol (Oxf) 2011; 75:127-33. [PMID: 21521291 DOI: 10.1111/j.1365-2265.2011.04022.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND UK national guidelines recommend the measurement of TSH receptor antibodies (TRAb) in certain clinical scenarios. A commercial third-generation TRAb autoantibody M22-biotin ELISA assay was introduced in May 2008 in our centre. OBJECTIVE To evaluate the diagnostic performance of a TRAb assay in a retrospective and subsequently a prospective cohort in a UK centre. DESIGN A retrospective review of patients with thyroid disease followed by a prospective observational study in consecutive patients with newly found suppressed serum thyrotrophin (TSH). PATIENTS AND MEASUREMENTS Medical records of 200 consecutive patients with thyroid disorders who had TRAb measured since the introduction of the assay. In a prospective study 44 patients with newly identified hyperthyroidism (TSH < 0·02 mIU/l) had sera assayed for TRAb prior to their clinic appointment at which a final diagnosis was sought. RESULTS In the retrospective cohort, the manufacturer's cut-off point of TRAb ≥0·4 U/l resulted in a positive predictive value (PPV) of 95%, sensitivity 85%, specificity 94% and negative predictive value (NVP) 79% to diagnose Graves' disease using defined criteria. Receiver operating characteristic (ROC) analysis determined an optimal cut-off point of TRAb ≥3·5 U/l with a 100% specificity to exclude patients without Graves' disease at the cost though of a lower sensitivity (43%). In the prospective study, the sensitivity, PPV, specificity and NPV were all 96% using the ≥0·4 U/l cut-off. When combining hyperthyroid patients from both cohorts the assay sensitivity and specificity at ≥0·4 U/l cut-off were 95% and 92% respectively. A positive TRAb result increased the probability of Graves' disease for a particular patient by 25-35% and only six (2·5%) patients had a diagnosis of hyperthyroidism of uncertain aetiology after TRAb testing. CONCLUSIONS The assay studied specifically identifies patients with Graves' disease. It is a reliable tool in the initial clinical assessment to determine the aetiology of hyperthyroidism and has the potential for cost-savings.
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Affiliation(s)
- A Theodoraki
- Departments of EndocrinologyClinical ImmunologyClinical Biochemistry, Royal Free Hampstead NHS Trust, London, UK
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Matthews DC, Syed AA. The role of TSH receptor antibodies in the management of Graves' disease. Eur J Intern Med 2011; 22:213-6. [PMID: 21570635 DOI: 10.1016/j.ejim.2011.02.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 02/05/2011] [Accepted: 02/08/2011] [Indexed: 11/23/2022]
Abstract
The central role of thyrotropin receptor antibodies (TRAbs) in the pathogenesis of Graves' disease has been recognised for several decades. However, the practical application of testing for TRAbs in clinical decision making remains the subject of controversy. The diagnosis of Graves' disease can be made in most cases simply based on a patient's clinical presentation. The TRAb test is therefore of most value in ambiguous clinical scenarios such as in the differential diagnosis of unilateral exophthalmos, euthyroid Graves' ophthalmopathy, subclinical hyperthyroidism, thyrotoxicosis associated with hyperemesis gravidarum, amiodarone-induced thyrotoxicosis and painless thyroiditis. It may also have a role in predicting the risk of a recurrence of Graves' disease following a course of antithyroid drug treatment. One further clinical utility of the TRAb test is in pregnancy where antibody titre measured during the third trimester is used to predict the risk of neonatal thyroid dysfunction. The TRAb titre not only aids in clinching a difficult diagnosis but can also help guide treatment in some patients. Although the TRAb assay has become more affordable in recent years, cost remains an important factor when considering its use routinely. Nonetheless, this is an underutilised blood test that could augment standard endocrine investigations in the differential diagnosis of hyperthyroidism.
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Affiliation(s)
- David C Matthews
- The University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom.
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Lee JI, Jang HW, Kim SK, Choi JY, Kim JY, Hur KY, Kim JH, Min YK, Chung JH, Kim SW. Diagnostic value of a chimeric TSH receptor (Mc4)-based bioassay for Graves' disease. Korean J Intern Med 2011; 26:179-86. [PMID: 21716594 PMCID: PMC3110850 DOI: 10.3904/kjim.2011.26.2.179] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 02/17/2011] [Accepted: 03/28/2011] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Graves' disease (GD) is caused by thyroid-stimulating hormone receptor (TSHR) and thyroid-stimulating immunoglobulin (TSI). We used a recently introduced, technically enhanced TSI bioassay to assess its diagnostic value and determine the cut-off in patients in high iodine intake area. METHODS In a cross-sectional setting, we collected serum from 67 patients with untreated GD, 130 with GD under treatment, 22 with GD in remission, 42 with Hashimoto's thyroiditis, 12 with subacute thyroiditis, 20 with postpartum thyroiditis, and 93 euthyroid controls. TSI was measured using the Thyretain™ bioassay, which is based on Chinese hamster ovary cells transfected with chimeric TSHR (Mc4). TSI levels are reported as a specimen-to-reference ratio percentage (SRR%). RESULTS The TSI levels in patients with GD (either treated or not) were significantly higher than those of the remaining patients (p < 0.05). The new bioassay showed a sensitivity of 97.0% and a specificity of 95.9% with a cut-off value of 123.0 SRR% for GD. A weak correlation was found between TSI and thyrotropin-binding inhibiting immunoglobulin (TBII) (r(s) = 0.259, p = 0.03), but no correlation was found between TSI and tri-iodothyronine or free thyroxine. CONCLUSIONS The Mc4-CHO bioassay showed comparable diagnostic value for GD with the conventional TBII assay. We propose a cut-off of 123.0 SRR% in areas where iodine intake is high.
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Affiliation(s)
- Ji In Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Won Jang
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Kyoung Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Young Kim
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Ki Min
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Bauer AJ. Approach to the pediatric patient with Graves' disease: when is definitive therapy warranted? J Clin Endocrinol Metab 2011; 96:580-8. [PMID: 21378220 DOI: 10.1210/jc.2010-0898] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Pediatric Graves' disease accounts for 10-15% of thyroid disorders in patients less than 18 yr of age. The onset of symptoms may be insidious and subsequently associated with a delay in diagnosis. Decreased concentration and poor school performance are frequent complaints and can be quite frustrating for the patient and family. Severe ophthalmopathy is uncommon. The diagnosis is established by the findings of an increased heart rate and goiter in the setting of a suppressed TSH and elevated T(3) and/or T(4). The majority of pediatric patients are initially placed on antithyroid medications and maintained on these medications for prolonged periods of time in hopes of achieving remission. Unfortunately, for many children and adolescents remission is unattainable, ultimately occurring in only 15-30% of patients. Several recent studies have suggested that the age of the patient, the degree of thyrotoxicosis at diagnosis, the initial response to therapy, and the level of TSH receptor antibodies serve as reasonable predictors of remission and relapse. However, a consensus on the utility of these markers has not been reached. The present clinical case describes an adolescent with Graves' disease and highlights the negative impact that prolonged medical therapy can have on quality of life and school performance; it reviews pertinent data on the diagnosis, comorbidities, and treatment options; and it identifies gaps in knowledge for when definitive therapy should be pursued. The case serves as a reminder that earlier discussion and decision for definitive therapy should be more commonplace in caring for our pediatric patients with Graves' disease.
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Affiliation(s)
- Andrew J Bauer
- Department of Pediatrics, Walter Reed Army Medical Center, Washington, D.C. 20307, USA.
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Wang Z, Zhang Q, Lu J, Jiang F, Zhang H, Gao L, Zhao J. Identification of outer membrane porin f protein of Yersinia enterocolitica recognized by antithyrotopin receptor antibodies in Graves' disease and determination of its epitope using mass spectrometry and bioinformatics tools. J Clin Endocrinol Metab 2010; 95:4012-20. [PMID: 20484489 DOI: 10.1210/jc.2009-2184] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT In addition to genetic susceptibility, Yersinia enterocolitica (YE) infection played an important causative role in the pathogenesis of Graves' disease (GD) through molecular mimicry. However, the specific YE proteins and epitopes recognized by anti-TSH receptor (TSHR) autoantibodies (TRAb) have not been fully clarified, resulting in conflicting results from clinical research. OBJECTIVE Our aim was to explore the roles of YE in the pathogenesis of GD and identify the YE proteins and epitopes that are similar to the TSHR and are recognized by TRAb. DESIGN Assays of YE antibodies, TRAb, thyroglobulin antibodies, and thyroid microsomal antibodies as well as cross-absorption and two-way immunodiffusion were performed in patients with GD. Using mass spectrometry and the bioinformatics tools of protein structure modeling and epitope prediction, we identified the YE protein and its epitope, which was recognized by TRAb and was similar to TSHR. RESULTS Our study demonstrated for the first time that the YE protein outer membrane porin F protein (ompF) shared cross-immunogenicity with a leucine-rich domain of TSHR. The epitope recognized by antihuman TSHR antibody is located within the ompF region of amino acids 190-197, and the polyantibody against ompF protein showed TSAb activity. CONCLUSIONS Our results suggest that YE ompF is involved in the production of TRAb and the pathogenesis of GD through molecular mimicry. These findings are potentially important for understanding the role molecular mimicry plays in the disturbance of immune tolerance and the induction of autoimmunity to the TSHR.
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Affiliation(s)
- Zhe Wang
- Division of Endocrinology and Metabolism, Provincial Hospital, Shandong University, 324 Jing Wu Road, Jinan 250021, China
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Zinchuk AV, Flanagan EP, Tubridy NJ, Miller WA, McCullough LD. Attitudes of US medical trainees towards neurology education: "Neurophobia" - a global issue. BMC MEDICAL EDUCATION 2010; 10:49. [PMID: 20573257 PMCID: PMC2900283 DOI: 10.1186/1472-6920-10-49] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 06/23/2010] [Indexed: 05/09/2023]
Abstract
BACKGROUND Several studies in the United Kingdom and Asia have suggested that medical students and residents have particular difficulty in diagnosing and managing patients with neurological problems. Little recent information is available for US trainees. We examined whether students and residents at a US university have difficulty in dealing with patients with neurological problems, identified the perceived sources of these difficulties and provide suggestions for the development of an effective educational experience in neurology. METHODS A questionnaire was administered to third and fourth year medical students at a US school of medicine and to residents of an internal medicine residency program affiliated with that school. Perceived difficulties with eight medical specialties, including neurology, were examined. Methods considered to be most useful for learning medicine were documented. Reasons why neurology is perceived as difficult and ways to improve neurological teaching were assessed. RESULTS 152 surveys were completed. Participation rates varied, with medical students having higher response rates (> 50%) than medical residents (27%-48%). Respondents felt that neurology was the medical specialty they had least knowledge in (p < 0.001) and was most difficult (p < 0.001). Trainees also felt they had the least confidence when dealing with patients with neurological complaints (p < 0.001). Residents felt more competent in neurology than students (p < 0.001). The paramount reasons for perceived difficulties with neurology were the complexity of neuroanatomy, limited patient exposure and insufficient teaching. Transition from pre-clinical to clinical medicine led to a doubling of "poor" ratings for neurological teaching. Over 80% of the respondents felt that neurology teaching could be improved through greater exposure to patients and more bedside tutorials. CONCLUSIONS Medical students and residents at this US medical university found neurology difficult. Although this is consistent with prior reports from Europe and Asia, studies in other universities are needed to confirm generalizability of these findings. The optimal opportunity for improvement is during the transition from preclinical to clinical years. Enhanced integration of basic neurosciences and clinical neurology with emphasis on increased bedside tutorials and patient exposure should improve teaching. Studies are needed to quantify the effect of these interventions on confidence of trainees when dealing with patients presenting with neurological complaints.
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Affiliation(s)
- Andrey V Zinchuk
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston MA, 02215 USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, 200 First St. S.W., Rochester MN 55905 USA
| | - Niall J Tubridy
- Department of Neurology, St. Vincent's University Hospital, Elm Park 4. 01 2695005 Dublin, Ireland
| | - Wendy A Miller
- Department of Medicine, University of Connecticut Health Center, 263 Farmington Avenue, Farmington CT, 06030 USA
| | - Louise D McCullough
- Department of Neurology, University of Connecticut Health Center 263 Farmington Avenue, Farmington CT, 06030 USA
- The Stroke Center at Hartford Hospital, Hartford, CT, USA
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Inaba H, Martin W, Ardito M, De Groot AS, De Groot LJ. The role of glutamic or aspartic acid in position four of the epitope binding motif and thyrotropin receptor-extracellular domain epitope selection in Graves' disease. J Clin Endocrinol Metab 2010; 95:2909-16. [PMID: 20392871 PMCID: PMC2902065 DOI: 10.1210/jc.2009-2393] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Development of Graves' disease (GD) is related to HLA-DRB1*0301 (DR3),and more specifically to arginine at position 74 of the DRB1 molecule. The extracellular domain (ECD) of human TSH receptor (hTSH-R) contains the target antigen. OBJECTIVE AND DESIGN We analyzed the relation between hTSH-R-ECD peptides and DR molecules to determine whether aspartic acid (D) or glutamic acid (E) at position four in the binding motif influenced selection of functional epitopes. RESULTS Peptide epitopes from TSH-R-ECD with D or E in position four (D/E+) had higher affinity for binding to DR3 than peptides without D/E (D/E-) (IC(50) 29.3 vs. 61.4, P = 0.0024). HLA-DR7, negatively correlated with GD, and DRB1*0302 (HLA-DR18), not associated with GD, had different profiles of epitope binding. Toxic GD patients who are DR3+ had higher responses to D/E+ peptides than D/E- peptides (stimulation index 1.42 vs. 1.22, P = 0.028). All DR3+ GD patients (toxic + euthyroid) had higher responses, with borderline significance (Sl; 1.32 vs. 1.18, P = 0.051). Splenocytes of DR3 transgenic mice immunized to TSH-R-ECD responded to D/E+ peptides more than D/E- peptides (stimulation index 1.95 vs. 1.69, P = 0.036). Seven of nine hTSH-R-ECD peptide epitopes reported to be reactive with GD patients' peripheral blood mononuclear cells contain binding motifs with D/E at position four. CONCLUSIONS TSH-R-ECD epitopes with D/E in position four of the binding motif bind more strongly to DRB1*0301 than epitopes that are D/E- and are more stimulatory to GD patients' peripheral blood mononuclear cells and to splenocytes from mice immunized to hTSH-R. These epitopes appear important in immunogenicity to TSH-R due to their favored binding to HLA-DR3, thus increasing presentation to T cells.
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Affiliation(s)
- Hidefumi Inaba
- Department of Cellular and Molecular Biology, University of Rhode Island, 80 Washington Street, Providence, Rhode Island 02903, USA
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Tran HA, Reeves GE. The influence of hepatitis C infection and interferon-alpha therapy on thyrotropin blocking and stimulating autoantibodies in Graves' ophthalmopathy: a case report. Thyroid Res 2009; 2:12. [PMID: 19954547 PMCID: PMC2791747 DOI: 10.1186/1756-6614-2-12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 12/02/2009] [Indexed: 11/16/2022] Open
Abstract
Background Hepatitis C virus is a highly immunogenic pathogen often inducing autoimmune activation changes and this can often be further exacerbated by Interferon therapy. As HCV is lymphocytotropic, it can modulate T cell and B cell antibody responses, affecting many endocrine organs, most commonly the thyroid. Case presentation We hereby describe a case of fluctuating and wavering thyrotropin autoantibodies of both stimulating and blocking nature in the setting of Graves's ophthalmopathy, hepatitis C infection and interferon-α, causing hypo- and subsequently hyper-thyroidism. The autoantibody profile was clearly modified during interferon therapy and settled into a new equilibrium at the completion of treatment. Conclusion The case highlights the possible existence of a dual thyroid autoantibody population associated with hepatitis C, and its modulation by interferon therapy, which further compounds the difficulties in the assessment thyroid disease in this setting.
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Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry and University of Newcastle, Locked Bag 1, Hunter Region Mail Centre, Newcastle, New South Wales 2310, Australia.
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Padoa CJ, Larsen SL, Hampe CS, Gilbert JA, Dagdan E, Hegedus L, Dunn-Walters D, Banga JP. Clonal relationships between thyroid-stimulating hormone receptor-stimulating antibodies illustrate the effect of hypermutation on antibody function. Immunology 2009; 129:300-8. [PMID: 19845794 DOI: 10.1111/j.1365-2567.2009.03184.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Graves' disease is characterized by production of agonist antibodies to the thyroid-stimulating hormone receptor (TSHR), but knowledge of the genetic and somatic events leading to their aberrant production is limited. We describe the genetic analysis of two monoclonal antibodies (mAbs) with thyroid-stimulating activity (TSAb) obtained from a single mouse with experimental Graves' disease. The mAbs were class switched, but used the same rearrangement of immunoglobulin heavy chain, variable region (IGHV) and immunoglobulin light chain, variable region (IGLV) germline genes, implying a clonal relationship and derivation from a single precursor B-cell clone. The IGHV-region genes of the two mAbs underwent high degrees of somatic hypermutation by sharing numerous mutations before diverging, while the IGLV genes evolved separately. Interestingly, the mutations were present in both the complementarity-determining regions (CDRs) and the framework regions. The cloned IGHV and IGLV genes were confirmed to have TSAb properties in experiments in which they were expressed as recombinant Fabs (rFabs). In other experiments, we swapped the IGLV genes with IGHV genes by constructing chimeric rFabs and showed that the chimeras retained TSAb activities, confirming the close functional relatedness of the V-region genes. Importantly, the IGLV genes in chimeric rFabs had a dominant stimulatory effect at low concentrations, while the IGHV genes had a dominant effect at higher concentrations. Our findings demonstrate that, in experimentally immunized mice, multiple pathogenic antibodies to TSHR can arise from a single clone by a series of somatic mutations in the V-region genes and may give an insight into how such antibodies develop spontaneously in autoimmune Graves' disease.
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Affiliation(s)
- Carolyn J Padoa
- Division of Gene and Cell Based Therapy, King's College London School of Medicine, London, UK
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Massart C, Gibassier J, d'Herbomez M. Clinical value of M22-based assays for TSH-receptor antibody (TRAb) in the follow-up of antithyroid drug treated Graves' disease: comparison with the second generation human TRAb assay. Clin Chim Acta 2009; 407:62-6. [PMID: 19576193 DOI: 10.1016/j.cca.2009.06.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 06/23/2009] [Accepted: 06/23/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND We compared the clinical performances of two new M22-based assays for TSH-receptor antibody (TRAb) with those of the human TRAb assay (hTRAK) in Graves' disease patients at the end of treatment. PATIENTS AND METHODS Sera were obtained from 128 Graves' patients treated for 18 months with antithyroid drugs. Sixty-six remained in remission and sixty-two had relapse of hyperthyroidism in a 3-year follow-up after discontinuing treatment. TRAbs were measured using two M22-based methods (electrochemiluminescence using the Cobas or ELISA using the Medizym TRAb clone) and with the hTRAK. RESULTS At T18, the results were significantly higher by the Cobas assay (median: 2.7 IU/L, range: 1.1-18.5 IU/L) or lower by ELISA (median: 0.56 IU/L, range: 0.22-14.8 IU/L) than those obtained for the hTRAK (median: 1.5 IU/L, range: 0.9-9.8 IU/L). The use of cut-off limits at 1.9 IU/L, 3.2 IU/L and 0.94 IU/L gave similar and higher prevalences of TRAb-positive patients in the group of relapse as compared to the remission group. However, some patients remained misclassified in each remission or relapse group. CONCLUSIONS The M22-based TRAb assays did not improve the predictive value of relapse obtained with the hTRAK measured at the end of treatment. High inter-method variability requires assay harmonization for correct interpretation of results.
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Affiliation(s)
- C Massart
- Unité Fonctionnelle d'Hormonologie, CHU de Rennes, France.
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