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Hoff G, Bernklev T, Johnsen L, Reitsma L, Sina D, Lauzike A, Gibbs C, Hoel Lende T, Narvestad JK, Kildahl R, Omdal R, Kvaløy JT, Søiland H. Thyroidectomy for Euthyroid Patients with Hashimoto Disease and Persistent Symptoms: An Observational, Postrandomization Study. J Thyroid Res 2024; 2024:5518720. [PMID: 38606313 PMCID: PMC11008973 DOI: 10.1155/2024/5518720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/06/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024] Open
Abstract
Background Despite adequate hormone substitution in Hashimoto disease, some patients may have persistent symptoms with a possible autoimmune pathophysiology. A recent randomized trial (RCT) using patient-reported outcome measures as the primary endpoint showed benefit in total thyroidectomy, but at a cost of high complication rates. Objective To verify results from the RCT in an observational study including a wider range of patients and explore means of predicting who may benefit from such surgery. Design A total of 154 patients with Hashimoto disease, euthyroid with or without thyroid hormone substitution, and persistent Hashimoto-related symptoms were subjected to total thyroidectomy and followed for 18 months after surgery. The primary outcome was the General Health (GH) dimensional score in the Short Form-36 Health Survey (SF-36). Results Eighteen months after surgery, a clinically significant improvement in GH was seen, similar to the findings in the previous RCT. Anti-TPO antibody titers were markedly reduced after surgery, but preoperative titers or other preoperative parameters could not predict the outcome of surgery. Three (1.9%) of 154 patients experienced permanent unilateral recurrent nerve palsy and six (3.9%) experienced hypoparathyroidism after surgery. Conclusions Thyroidectomy had a beneficial symptom-reducing effect in euthyroid patients with Hashimoto disease and persistent symptoms. The pathophysiology of residual symptoms remains unclear, and surgical complication rates are high. If thyroidectomy is considered as a treatment option, it should be performed in dedicated centers with experienced endocrine surgeons and as part of further studies on persistent symptoms. This trial is registered with NCT-02319538.
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Affiliation(s)
- Geir Hoff
- Department of Research, Telemark Hospital, Skien, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tomm Bernklev
- Department of Research, Vestfold Hospital, Tønsberg, Norway
| | - Lene Johnsen
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Laurens Reitsma
- Department of Breast and Endocrine Surgery, Akershus University Hospital, Campus Oslo, Lørenskog, Norway
| | - Dirk Sina
- Department of Breast and Endocrine Surgery, Telemark Hospital, Skien, Norway
| | - Andromeda Lauzike
- Department of Breast and Endocrine Surgery, Telemark Hospital, Skien, Norway
| | | | - Tone Hoel Lende
- Department of Breast and Endocrine Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Jon Kristian Narvestad
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | | | - Roald Omdal
- Department of Research, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Jan Terje Kvaløy
- Department of Research, Stavanger University Hospital, Stavanger, Norway
- Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
| | - Håvard Søiland
- Department of Research, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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Shaja S, Khaleeluddin MA. Hypothyroidism Presenting Atypically as an Isolated Pericardial and Pleural Effusion: A Case Report. Cureus 2024; 16:e59255. [PMID: 38813286 PMCID: PMC11134305 DOI: 10.7759/cureus.59255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2024] [Indexed: 05/31/2024] Open
Abstract
Hypothyroidism is an endocrine disorder characterized by low thyroid hormone levels, which commonly presents as fatigue, cold intolerance, constipation, poor memory and/or concentration, and weight gain. Common signs of hypothyroidism include bradycardia, electrocardiograph changes, a lower basal temperature, a slower relaxation phase of deep tendon reflexes, and swelling of the extremities. Hypothyroidism is diagnosed with labs showing high thyroid-stimulating hormone levels and low free thyroxine. Hypothyroidism may present as a pericardial or pleural effusion, with the incidence of each being unknown. The paucity of information regarding the incidence of pericardial and pleural effusions in hypothyroidism may be due to effusions being an atypical complication of a common endocrine disorder. Hypothyroidism, including in cases of pericardial or pleural effusions, is typically treated with thyroid hormone replacement therapy, usually in the form of levothyroxine. Hemodynamic compromise may necessitate pericardiocentesis or pleurocentesis. In this case report, we present an atypical presentation of hypothyroidism that is characterized by an isolated pericardial and pleural effusion in a patient with post-thyroidectomy hypothyroidism who was non-adherent to levothyroxine. We discuss the pathophysiology of pleural and pericardial effusions in thyroid disease, which is thought to involve increased capillary permeability and changes in oncotic pressure related to albumin. We also review treatment strategies regarding pericardial and pleural effusions in hypothyroidism.
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Affiliation(s)
- Samer Shaja
- Family Medicine, JenCare Senior Medical Center, Glenwood, USA
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Molewijk E, Fliers E, Dreijerink K, van Dooren A, Heerdink R. Quality of life, daily functioning, and symptoms in hypothyroid patients on thyroid replacement therapy: A Dutch survey. J Clin Transl Endocrinol 2024; 35:100330. [PMID: 38357535 PMCID: PMC10864335 DOI: 10.1016/j.jcte.2024.100330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
Objective To explore the nature and extent of possible residual complaints among Dutch hypothyroid patients using thyroid replacement therapy, we initiated a comprehensive study measuring health-related quality of life (QoL), daily functioning, and hypothyroidism-associated symptoms in patients and control persons. Methods An online survey measuring thyroid-specific QoL (ThyPRO), daily functioning, and hypothyroidism-associated symptoms (ThySHI) was distributed among treated hypothyroid patients and control individuals. The advertising text was formulated in an open-ended manner. Patients also provided their most recent thyroid blood values and their thyroid medication. Results There was a large-sized impairment of QoL (Cohen's d = 1.04, +93 % ThyPRO score) in hypothyroid patients on thyroid replacement therapy (n = 1195) as compared to controls (n = 236). Daily functioning was significantly reduced i.e., general health (-38 %), problems with vigorous- (+64 %) and moderate activities (+77 %). Almost 80 % of patients reported having complaints despite thyroid medication and in-range thyroid blood values, with 75 % expressing a desire for improved treatment options for hypothyroidism (total n = 1194). Hypothyroid patients experienced 2.8 times more intense hypothyroidism-associated symptoms than controls (n = 865, n = 203 resp). Patients' median reported serum concentrations were: TSH 0.90 mU/L, FT4 17.0 pmol/L, and FT3 2.67 pmol/L, with 52 % having low T3 levels (<3.1 pmol/L). The QoL was not found to be related to age, sex, BMI, menopausal status, stress, serum thyroid parameters, the origin and duration of hypothyroidism, the type of thyroid medication, or the LT4 dose used. Conclusions Our study revealed major reductions in quality of life and daily functioning, and nearly three times more intense hypothyroidism-associated symptoms in treated hypothyroid patients as compared to controls, despite treatment and largely in-range serum TSH/FT4 concentrations. The QoL was not associated with serum thyroid parameters. We recommend future research into the origin of persisting complaints and the development of improved treatment modalities for hypothyroidism.
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Affiliation(s)
- Ellen Molewijk
- University of Applied Sciences Utrecht, Utrecht, the Netherlands
| | - Eric Fliers
- Amsterdam University Medical Centers, Location Academic Medical Center Amsterdam, Department of Endocrinology and Metabolism, Amsterdam Gastroenterology, Endocrinology & Metabolism, the Netherlands
| | - Koen Dreijerink
- Amsterdam University Medical Centers, Location VU University, Department of Endocrinology and Metabolism, Amsterdam Gastroenterology, Endocrinology & Metabolism, the Netherlands
| | - Ad van Dooren
- University of Applied Sciences Utrecht, Utrecht, the Netherlands
| | - Rob Heerdink
- University of Applied Sciences Utrecht, Utrecht, the Netherlands
- Utrecht Institute for Pharmaceutical Sciences, Utrecht, the Netherlands
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Cusi K. Selective Agonists of Thyroid Hormone Receptor Beta for the Treatment of NASH. N Engl J Med 2024; 390:559-561. [PMID: 38324491 DOI: 10.1056/nejme2314365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Affiliation(s)
- Kenneth Cusi
- From the Division of Endocrinology, Diabetes, and Metabolism, University of Florida, Gainesville
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Kolanu ND, Awan NA, Butt AI, Reza T, Almadhoun MKIK, Janoowala T, Bokhari SFH, Zain Z, Sharif T, Chauhan L, Choudhari J. From Antibodies to Artificial Intelligence: A Comprehensive Review of Diagnostic Challenges in Hashimoto's Thyroiditis. Cureus 2024; 16:e54393. [PMID: 38505448 PMCID: PMC10949900 DOI: 10.7759/cureus.54393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 03/21/2024] Open
Abstract
Hashimoto's thyroiditis (HT) poses diagnostic challenges due to its diverse clinical presentation and the intricacies of autoimmune thyroid diseases. This comprehensive narrative review explores the evolving landscape of diagnostic challenges in HT, aiming to provide a thorough understanding of the complexities involved in its diagnosis. The diagnostic criteria for HT involve a multifaceted approach, including clinical features, laboratory findings, and imaging studies. Serum antibodies against thyroid antigens, primarily thyroperoxidase (TPO) and thyroglobulin, play a crucial role in confirming the autoimmune nature of the disease. However, seronegative HT adds complexity by presenting without detectable antibodies. The significance of addressing diagnostic challenges lies in potential delays and misdiagnoses, emphasizing the need for accurate and timely intervention. The review explores future directions, emphasizing molecular and cellular aspects, genetic factors, and the emerging field of thyroid regeneration. Standardized diagnostic criteria are essential, considering the subjective nature of the current process. The heterogeneity of disease manifestations complicates targeted treatments, necessitating a deeper understanding of clinical presentations and underlying pathophysiology. Future research directions and challenges outlined in this review contribute to advancing our understanding and improving diagnostic precision in HT.
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Affiliation(s)
| | | | | | - Taufiqa Reza
- Medicine, Avalon University School of Medicine, Youngstown, USA
| | | | | | | | - Zukhruf Zain
- Family Medicine, Aga Khan University Hospital, Karachi, PAK
| | - Tanzila Sharif
- General Practice, Fatima Jinnah Medical University, Lahore, PAK
| | | | - Jinal Choudhari
- Research & Academic Affairs, Larkin Community Hospital, Miami, USA
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Bianco AC. Emerging Therapies in Hypothyroidism. Annu Rev Med 2024; 75:307-319. [PMID: 37738506 PMCID: PMC10843736 DOI: 10.1146/annurev-med-060622-101007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
Levothyroxine (LT4) is effective for most patients with hypothyroidism. However, a minority of the patients remain symptomatic despite the normalization of serum thyrotropin levels. Randomized clinical trials including all types of patients with hypothyroidism revealed that combination levothyroxine and liothyronine (LT4+LT3) therapy is safe and is the preferred choice of patients versus LT4 alone. Many patients who do not fully benefit from LT4 experience improved quality of life and cognition after switching to LT4+LT3. For these patients, new slow-release LT3 formulations that provide stable serum T3 levels are being tested. In addition, progress in regenerative technology has led to the development of human thyroid organoids that restore euthyroidism after being transplanted into hypothyroid mice. Finally, there is a new understanding that, under certain conditions, T3 signaling may be compromised in a tissue-specific fashion while systemic thyroid function is preserved. This is seen, for example, in patients with metabolic (dysfunction)-associated fatty liver disease, for whom liver-selective T3-like molecules have been utilized successfully in clinical trials.
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Affiliation(s)
- Antonio C Bianco
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago School of Medicine, Chicago, Illinois, USA;
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Fenneman AC, Rampanelli E, van der Spek AH, Fliers E, Nieuwdorp M. Protocol for a double-blinded randomised controlled trial to assess the effect of faecal microbiota transplantations on thyroid reserve in patients with subclinical autoimmune hypothyroidism in the Netherlands: the IMITHOT trial. BMJ Open 2023; 13:e073971. [PMID: 37709342 PMCID: PMC10503357 DOI: 10.1136/bmjopen-2023-073971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/22/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Hashimoto's thyroiditis (HT) is a common endocrine autoimmune disease affecting roughly 5% of the general population and involves life-long treatment with levothyroxine, as no curative treatment yet exists. Over the past decade, the crosstalk between gut microbiota and the host immune system has been well-recognised, identifying the gut microbiome as an important factor in host health and disease, including susceptibility to autoimmune diseases. Previous observational studies yielded a link between disruption of the gut microbiome composition and HT. This is the first study that investigates the potential of restoring a disrupted gut microbiome with faecal microbiota transplantations (FMTs) to halt disease progression and dampen autoimmunity. METHODS AND ANALYSIS The IMITHOT trial is a randomised, double-blinded, placebo-controlled study evaluating either autologous or allogenic FMTs in medication-naïve patients with subclinical autoimmune hypothyroidism. In total, 34 patients will be enrolled to receive either three allogenic or autologous FMTs. FMT will be made of fresh stool and directly administered into the duodenum. Patients will be evaluated at baseline before the first FMT is administered and at 6, 12 and 24 months post-intervention to assess efficacy and adverse events. The primary outcome measure will be the net incremental increase (incremental area under the curve) on thyrotropin-stimulated free thyroxine and free triiodothyronine release at 6 and 12 months compared with baseline. Results will be disseminated via peer-reviewed journals and international conferences. The recruitment of the first patient and donor occurred on 18 December 2019. ETHICS AND DISSEMINATION Ethics approval was obtained from the hospital Ethics Committee (Medical Ethics Committee) at Amsterdam University Medical Center. The trial's outcomes offer high-quality evidence that aids in unveiling distinct patterns within the gut microbiota potentially associated with improved thyroid function. Consequently, this may open avenues for the future clinical applications of microbial-targeted therapy in individuals at risk of developing overt HT. TRIAL REGISTRATION NUMBER NL7931.
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Affiliation(s)
- Aline C Fenneman
- Department of (Experimental) Vascular Medicine, Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), AmsterdamUMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Elena Rampanelli
- Department of (Experimental) Vascular Medicine, Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne H van der Spek
- Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), AmsterdamUMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric Fliers
- Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), AmsterdamUMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Max Nieuwdorp
- Department of (Experimental) Vascular Medicine, Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Jonklaas J. Is euthyroidism within reach for all? Expert Rev Endocrinol Metab 2023; 18:455-458. [PMID: 37811647 DOI: 10.1080/17446651.2023.2267120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, DC, United States
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Lieber I, Van Der Feltz-Cornelis CM, Razvi S, Moriarty AS, Wilkes S, Ott M, Mannchen J, Eliasson M, Werneke U. Treating subclinical hypothyroidism in individuals with or without mental health problems -A Delphi based expert consensus study in two countries. Front Endocrinol (Lausanne) 2023; 14:1204842. [PMID: 37501790 PMCID: PMC10369346 DOI: 10.3389/fendo.2023.1204842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Background Subclinical hypothyroidism (SCH) is a common endocrine problem with prevalence estimates between 4% and 20%. Symptoms are often non-specific but can substantially affect well-being leading to repeated medical consultations. The effect of thyroid hormone replacement therapy (THRT) in patients with SCH remains uncertain. Current guidelines, limited by the lack of high-quality evidence, have been controversial with limited adherence in clinical practice. Methods Three-round modified Delphi method to establish consensus regarding diagnosis and treatment of individuals with SCH with and without affective disorder or anxiety, conducted with clinicians from three specialties, general practice, endocrinology and psychiatry, and two countries, Sweden and the United Kingdom. Results Sixty clinicians, 20 per specialty, were recruited. Fifty-three (88%) participants completed all three rounds. The participants reached consensus on five of the 26 practice statements that (a) repeated testing was required for the diagnosis of subclinical hypothyroidism, (b) antibody screening should usually occur, and (c and d) antibody screening would strengthen the indication for thyroid hormone replacement therapy in both individuals with or without affective disorder or anxiety. The participants disagreed with (e) a requirement of a TSH threshold ≥ 20 mIU/L for thyroid hormone replacement therapy start. Psychiatrists and GPs but not endocrinologists, agreed that there was a frequent discrepancy between laboratory results and clinical symptoms, and disagreed that testing for thyroid dysfunction was overused in patients presenting with depression or anxiety, or fatigue. Conclusions In many aspects, attitudes toward diagnosing and treating SCH remain diverse. The inability of our Delphi panel to achieve consensus on most items and the disagreement with a TSH ≥ 20 mIU/L threshold for treatment suggest that the concept of SCH may need rethinking with a better understanding of the hypothalamic-pituitary-thyroid physiology. Given that the scientific evidence is currently not conclusive, guidelines in this area should not be taken as definitive.
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Affiliation(s)
- Ingrid Lieber
- Department of Clinical Sciences, Division of Psychiatry, Sunderby Research Unit, Umeå University, Umeå, Sweden
| | - Christina Maria Van Der Feltz-Cornelis
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
- York Biomedical Research Institute, University of York, York, United Kingdom
- R&D Department, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, United Kingdom
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew S. Moriarty
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | - Scott Wilkes
- Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland, Sunderland, United Kingdom
| | - Michael Ott
- Department of Public Health and Clinical Medicine – Medicine, Umeå University, Umeå, Sweden
| | - Julie Mannchen
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | - Mats Eliasson
- Department of Public Health and Clinical Medicine, Sunderby Research Unit, Umeå University, Luleå, Sweden
| | - Ursula Werneke
- Department of Clinical Sciences, Division of Psychiatry, Sunderby Research Unit, Umeå University, Umeå, Sweden
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