1
|
Ushakov AV. Ultrasound, Doppler and other signs during drug-free transition from subclinical hypothyroidism to euthyroidism: a case report. AME Case Rep 2025; 9:32. [PMID: 39866257 PMCID: PMC11759927 DOI: 10.21037/acr-24-59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 12/13/2024] [Indexed: 01/28/2025]
Abstract
Background It is known that subclinical hypothyroidism (SCH) often converts to euthyroidism. However, the mechanism of such changes is unclear and can only be speculated. This difficulty is likely due to limitations in diagnostic guidelines and their interpretation. Therefore, in the presented case, important diagnostic criteria that can improve understanding of the essence and pathogenesis of primary hypothyroidism are shown and explained. Case Description A 15-year-old female patient experienced a transition from SCH to euthyroidism against the background of highly normal values of thyroid hormones, the full state of the thyroid parenchyma and significantly increased blood flow in the Doppler mode. She did not take medications. Conditions likely to trigger SCH included acute respiratory illness, living in a cold climate, and mental stress due to prolonged preparation for exams. The transition to euthyroidism occurred after sufficient stay in the conditions of a southern resort in the summer and mental comfort. Conclusions As a result, it was revealed that the amount of thyroid-stimulating hormone (TSH) depends on the intensity of energy expenditure of the body in accordance with living conditions. The increased intensity of blood flow in the thyroid during SCH and euthyroidism shows the leading role of the autonomic nervous system and the auxiliary importance of TSH. The concentration of thyroid hormones at the maximum limit of normal in SCH, together with the significantly increased Doppler blood flow, suggests common elements of pathogenesis with Graves' disease through the autonomic nervous system. With many months of thyroid overstrain, ultrasound shows signs of corresponding depletion in the form of hypoechogenicity of the lobules, but the preservation of a sufficient amount of hormone-producing tissue.
Collapse
|
2
|
Bi WK, Xu H, Tian ZH, Teng W, Zheng GW, Yin QQ. Stimulated Thyrotropin (TSH) Levels Were Inversely Correlated with Age. Int J Gen Med 2024; 17:6479-6486. [PMID: 39742031 PMCID: PMC11687293 DOI: 10.2147/ijgm.s497208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2024] [Accepted: 12/21/2024] [Indexed: 01/03/2025] Open
Abstract
Purpose Serum Thyrotropin (TSH) levels in the elderly have been reported to be inconsistent in different studies. One of the difficulties in determining the effect of aging on TSH levels is that TSH levels are influenced by various factors, including thyroid-related factors. Therefore, this study aimed to assess the effect of aging on TSH levels while controlling for thyroid factors. Patients and Methods This study included a total of 343 subjects, who underwent thyroidectomy, levothyroxine (LT4) supplementation and withdraw. All participants were divided into young(18-44year old), middle(45-59year old), and old age(>60year old) groups based on their age. The clinical data of the subjects were reviewed, and analyzed based on their age. Results With LT4 supplementation, there was no difference in free triiodothyronine (FT3), free thyroxine (FT4), and TSH levels among the three age groups. However, after approximately 4 weeks of LT4 withdrawal, the TSH levels of the three groups showed significant differences. The median stimulated TSH levels were 100, 83.1, and 64.6 mIU/L in the young, middle, and old age groups, respectively (P<0.01). Moreover, the percentages of subjects, with TSH levels higher than 100 mIU/L, were 63.2%, 33.1%, and 12.9% (P<0.01) in the young, middle, and old age groups, respectively. Spearman correlation analysis (R=-0.42, P<0.01) and partial correlation analysis (R=-0.44, P<0.01) revealed an inverse correlation between age and TSH levels after LT4 withdrawal. Conclusion Aging plays an important role in TSH regulation. Age was inversely related to the stimulated TSH levels. The effect of senescence on TSH levels, as well as the underlying regulatory mechanisms, warrant further investigation.
Collapse
Affiliation(s)
- Wen-Kai Bi
- Department of Nuclear Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, People’s Republic of China
| | - Hua Xu
- Shizhong District Center for Disease Control and Prevention, Jinan, Shandong, People’s Republic of China
| | - Zhen-Hua Tian
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, People’s Republic of China
| | - Wei Teng
- Department of Nuclear Medicine, Laizhou People’s Hospital, Yantai, Shandong, People’s Republic of China
| | - Gui-Wen Zheng
- Department of Nuclear Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, People’s Republic of China
| | - Qing-Qing Yin
- Department of Geriatric Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, Shandong, People’s Republic of China
| |
Collapse
|
3
|
Feng Z, Dang C, Xu Z, Zhang Y. Genetic Causality of Hypothyroidism and Adverse Pregnancy Outcomes: A Combined Mendelian Randomisation Study and Bioinformatics Analysis. Int J Womens Health 2024; 16:2195-2202. [PMID: 39717392 PMCID: PMC11665139 DOI: 10.2147/ijwh.s474865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 12/05/2024] [Indexed: 12/25/2024] Open
Abstract
Background Observational studies have shown that hypothyroidism is strongly associated with adverse pregnancy outcomes, and that thyroxine during pregnancy comes mainly from the mother; therefore, thyroid defects in women may lead to problems such as miscarriage due to hormonal instability in early pregnancy, and foetal neurological deficits in mid- to late gestation, but whether there is a genetic causality between the two is still a matter of some controversy. Objective Goal to investigate the possible causal association between hypothyroidism and unfavorable pregnancy outcomes through the use of bioinformatics and Mendelian randomization (MR). Methods We used Mendelian randomization (MR) analyses using single nucleotide polymorphism (SNP) sites as instrumental variables to infer causal associations between exposures and outcomes. The inverse variance weighting method was primarily used in the analysis. Heterogeneity and horizontal multiplicity tests were also conducted to evaluate the results' robustness and the degree of causality. Lastly, preliminary bioinformatics analyses were conducted to investigate the underlying biological mechanisms. Results The resultant variance inverse weighting method found that hypothyroidism increased the risk of developing gestational hypertension (OR=1.054, 95% CI: 1.002-1.110 P=0.042) and poor foetal growth (OR=1.081, 95% CI:1.005-1.162 P=0.035). Heterogeneity tests, multiplicity tests and leave-one-out sensitivity analyses did not reveal any heterogeneity or multiplicity effects in the estimated effects of these three exposure factors on the risk of ovarian dysfunction. Conclusion Our research establishes genetically the causal relationship between pregnancy-related hypertension, hypothyroidism, and poor fetal growth-a relationship that could be linked to endosomal and cellular transport.
Collapse
Affiliation(s)
- Zichen Feng
- College of Acupuncture and Massage, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Chunxiao Dang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Zhiwei Xu
- College of Acupuncture and Massage, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Yongchen Zhang
- College of Acupuncture and Massage, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| |
Collapse
|
4
|
Otsuka E, Kitamura M, Funakoshi S, Mukae H, Nishino T. Roxadustat has risks of reversible central hypothyroidism in patients undergoing hemodialysis: a single-center retrospective cohort study. Ren Fail 2024; 46:2410375. [PMID: 39378117 PMCID: PMC11463015 DOI: 10.1080/0886022x.2024.2410375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 09/21/2024] [Accepted: 09/24/2024] [Indexed: 10/10/2024] Open
Abstract
Roxadustat, a hypoxia-inducible factor-prolyl hydroxylase inhibitor, has proven efficacy in the treatment of renal anemia; however, evidence indicates that it may cause central hypothyroidism. The prevalence and reversibility of roxadustat-induced central hypothyroidism in patients undergoing hemodialysis remain unclear. Here, we retrospectively analyzed thyroid-stimulating hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) levels in 51 patients (mean age: 72.3 ± 10.7 years; 58.8% male) undergoing hemodialysis before, during, and after halting roxadustat treatment. TSH levels were significantly decreased from a median of 2.46 (interquartile range:1.60-4.51) mU/L before roxadustat treatment to 1.36 (0.72-2.41) mU/L during treatment (p < 0.001), and improved to 2.56 (1.78-4.63) mU/L after halting roxadustat (p < 0.001). Similarly, FT4 levels decreased from 1.11 (0.97-1.24) ng/dL before roxadustat treatment to 0.92 (0.71-1.03) ng/dL during treatment (p < 0.001) and improved to 1.05 (0.93-1.17) ng/dL after halting roxadustat (p < 0.001). FT3 levels were 2.04 (1.78-2.31) pg/mL before starting roxadustat, 1.97 (1.69-2.27) pg/mL during treatment, and 1.90 (1.63-2.18) pg/mL after halting roxadustat, with no significant difference between each group. Moreover, 2.0% of patients exhibited extremely low TSH levels (≤0.1 mU/L) and low TSH levels (>0.1 mU/L to <0.4 mU/L) before starting roxadustat and that percentage increased to 5.9% and 7.8%, respectively, during treatment. After roxadustat cessation, extremely low or low TSH levels recovered in all patients. Taken together, the results indicate that roxadustat can cause reversible central hypothyroidism in patients undergoing hemodialysis.
Collapse
Affiliation(s)
- Emiko Otsuka
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Nagasaki Renal Center, Nagasaki, Japan
| | - Mineaki Kitamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Nagasaki Renal Center, Nagasaki, Japan
| | | | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| |
Collapse
|
5
|
Gottwald-Hostalek U, Tayrouz Y. A review of the safety of triiodothyronine in combination with levothyroxine for the management of hypothyroidism. Curr Med Res Opin 2024; 40:2109-2116. [PMID: 39625345 DOI: 10.1080/03007995.2024.2435460] [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: 10/28/2024] [Revised: 11/18/2024] [Accepted: 11/25/2024] [Indexed: 12/13/2024]
Abstract
There remains considerable interest in the therapeutic use of combinations of levothyroxine (LT4) and triiodothyronine (liothyronine, T3) in the management of hypothyroidism, especially where hypothyroid-like symptoms persist on optimised LT4 monotherapy. This interest appears to be increasing, despite the lack of consistent identification of clinical benefit in people with hypothyroidism in randomised trials going back two decades. Guidelines support an individualised trial of addition of T3 to LT4 for symptomatic patients on optimised LT4. A new generation of clinical trials seeks to address this issue, using thyroid-specific instruments to measure patient-reported outcomes, among other innovations. Safety is the other critical element of the therapeutic profile of a drug. In this article, we review the safety of treatment LT4 + T3, with an emphasis on side-effects suggestive of thyrotoxicosis (overtreatment with thyroid hormones). Randomised trials that evaluated LT4 + T3 did not raise clear or consistent safety issues with this treatment. This was despite the use of regimens with a lower ratio of LT4:T3 (usually 4-10:1) than recommended currently by clinical experts in the field. In addition, a real-world analysis of side-effects of a commercial LT4 + T3 treatment (LT4:T3 ratio 5:1) that were reported spontaneously to a pharmacovigilance database revealed a low rate of reports, both overall and with regard to symptoms possible reminiscent of thyrotoxicosis. Safety concerns regarding the possibility of iatrogenic thyrotoxicosis appear unlikely to limit the future guideline-driven therapeutic use of LT4:T3 combinations with a ratio of these ingredients of around 15:1.
Collapse
|
6
|
Hegedüs L, Van Der Feltz-Cornelis CM, Papini E, Nagy EV, Weetman AP, Perros P. Medically not yet explained symptoms in hypothyroidism. Nat Rev Endocrinol 2024; 20:685-693. [PMID: 39138377 DOI: 10.1038/s41574-024-01022-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 08/15/2024]
Abstract
Persistent symptoms are common in the general population and even more so in people with hypothyroidism. When symptoms are unexplained and brought to medical attention, they can be referred to as medically not yet explained symptoms (MNYES), a term preferred to other descriptors by patients, care-givers and experts. MNYES might be neglected by endocrinologists or misattributed to hypothyroidism. Awareness of MNYES could open up more effective and less harmful interventions for patients who present to endocrinologists with unexplained symptoms than costly over-investigations and over-treatment with thyroid hormones (such as levothyroxine and liothyronine). The role of the endocrinologist is to recognize and acknowledge that MNYES could be underlying a patient's presentation, to communicate effectively with the patient and others involved in the patient's care, to apply a 'two-track approach' in management by paying equal attention to physical and psychosocial contributors, and to collaborate with other relevant health professionals. Categorization of patients into levels of risk for symptom deterioration helps in selecting suitable therapies. Effective management of MNYES demands time, training, expertise and resources.
Collapse
Affiliation(s)
- Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark.
| | | | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano, Rome, Italy
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anthony P Weetman
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Petros Perros
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
7
|
Valea A, Costachescu M, Stanciu M, Nistor C, Sima OC, Carsote M, Nistor TVI, Tanasescu D, Popa FL, Ciobica ML. A Real-Life Study in Patients Newly Diagnosed with Autoimmune Hashimoto's Thyroiditis: Analysis of Asthenia as Admission Complaint. Life (Basel) 2024; 14:1380. [PMID: 39598179 PMCID: PMC11595665 DOI: 10.3390/life14111380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Revised: 10/23/2024] [Accepted: 10/24/2024] [Indexed: 11/29/2024] Open
Abstract
Background: Amid the large panel of autoimmune thyroid diseases, Hashimoto's thyroiditis (HT) represents a major point across multidisciplinary daily practice. When it comes to the clinical picture, particularly in regard to asthenia (also described as "fatigue" or "decreased energy"), the differential diagnosis is challenging, and a meticulous anamnesis should be backed up by focused lab investigations. Our objective was to analyze the thyroid panel in newly diagnosed patients with HT in relationship with the presence of asthenia as an admission complaint. Methods: This was a retrospective, multi-centric, real-life study conducted in secondary endocrine units (university hospitals) from July 2022 to July 2023. The exclusion criteria were COVID-19 infection; an active malignancy, etc. Results: The cohort (N = 120) included an asthenia group (AS, 49.2%) and a non-AS group of a similar age (49.3 ± 14.7 vs. 47.1 ± 14.8 y, p = 0.426). Headache was more frequent in the AS group (35.6% vs. 18%, p = 0.03). Thyroid function and HT-related antibodies assays were similar between the groups and show no correlation with serum total cholesterol and triglycerides, respectively. TSH levels did not vary among the age sub-groups (p = 0.701). One third of the studied population was affected by hypothyroidism (TSH > 4.5 μIU/mL), being seen at a higher rate in the AS (39%) vs. non-AS group (23%). Total cholesterol positively correlated with the patients' age (r = 0.180, p = 0.049) and triglycerides (N = 120; r = 0.324, p < 0.001), as found only in the non-AS group (r = 0.246, p = 0.006, respectively, r = 0.319, p < 0.001). Conclusions: The analysis of the AS vs. non-AS group pinpointed the fact that, in regard to daily practice, asthenia as an admission complaint seems less of an indicator of an underlying thyroid dysfunction or a higher level of serum antibodies against thyroid in patients without a full clinical picture of thyrotoxicosis or myxoedema.
Collapse
Affiliation(s)
- Ana Valea
- Department of Endocrinology, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Department of Endocrinology, County Emergency Clinical Hospital, 400347 Cluj-Napoca, Romania
| | - Mihai Costachescu
- PhD Doctoral School of “Carol Davila” University of Medicine and Pharmacy, 010825 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Emergency University Military Hospital, 010825 Bucharest, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, “Lucian Blaga” University of Sibiu, Victoriei Blvd., 550024 Sibiu, Romania;
- Department of Endocrinology, Clinical County Emergency Hospital, 550245 Sibiu, Romania
| | - Claudiu Nistor
- Thoracic Surgery Department, “Dr. Carol Davila” Central Emergency University Military Hospital, 010825 Bucharest, Romania
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Oana-Claudia Sima
- PhD Doctoral School of “Carol Davila” University of Medicine and Pharmacy, 010825 Bucharest, Romania;
| | - Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Clinical Endocrinology V, C.I. Parhon National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Tiberiu Vasile Ioan Nistor
- Medical Biochemistry Discipline, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania;
| | - Denisa Tanasescu
- Medical Clinical Department, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550169 Sibiu, Romania;
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania;
| | - Mihai-Lucian Ciobica
- Department of Internal Medicine and Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Internal Medicine I and Rheumatology, “Dr. Carol Davila” Central Military University Emergency Hospital, 010825 Bucharest, Romania
| |
Collapse
|
8
|
Kotak PS, Kadam A, Acharya S, Kumar S, Varma A. Beyond the Thyroid: A Narrative Review of Extra-thyroidal Manifestations in Hashimoto's Disease. Cureus 2024; 16:e71126. [PMID: 39525250 PMCID: PMC11544504 DOI: 10.7759/cureus.71126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2024] [Accepted: 10/08/2024] [Indexed: 11/16/2024] Open
Abstract
Hashimoto's disease, the most common cause of hypothyroidism in iodine-sufficient regions, is traditionally viewed as a thyroid-specific autoimmune disorder. However, emerging evidence indicates that Hashimoto's disease has far-reaching systemic effects, manifesting in multiple organ systems beyond the thyroid gland. This comprehensive review aims to elucidate the extra-thyroidal manifestations of Hashimoto's disease, highlighting their pathophysiology, clinical presentation, and management strategies. The review explores neurological, cardiovascular, dermatological, gastrointestinal, musculoskeletal, and hematological manifestations, which can significantly impact the quality of life and complicate the clinical course of the disease. Neurological symptoms such as cognitive impairment, depression, and peripheral neuropathy, as well as cardiovascular complications like dyslipidemia and atherosclerosis, are increasingly recognized as significant concerns in patients with Hashimoto's disease. Additionally, autoimmune skin disorders, gastrointestinal motility issues, and musculoskeletal pain are discussed in the context of their connection to thyroid dysfunction. The review emphasizes the importance of recognizing these systemic manifestations for comprehensive patient management and suggests that a holistic approach, rather than focusing solely on thyroid hormone replacement, is essential. This review aims to improve diagnostic accuracy, treatment outcomes, and overall patient care by broadening the understanding of Hashimoto's disease to include its extra-thyroidal effects. Further research is encouraged to explore novel therapeutic approaches targeting the autoimmune mechanisms underlying these systemic manifestations.
Collapse
Affiliation(s)
- Palash S Kotak
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Medical Research, Wardha, IND
| | - Abhinav Kadam
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Medical Research, Wardha, IND
| | - Sourya Acharya
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Medical Research, Wardha, IND
| | - Sunil Kumar
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Medical Research, Wardha, IND
| | - Anuj Varma
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Medical Research, Wardha, IND
| |
Collapse
|
9
|
Senat A, Erinc O, Yesilyurt S, Gok G, Erel O. Assessment of thiol-disulfide and glutathione homeostasis after levothyroxine replacement in individuals with autoimmune or nonautoimmune hypothyroidism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2024; 68:e230197. [PMID: 39420884 PMCID: PMC11326736 DOI: 10.20945/2359-4292-2023-0197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 03/18/2024] [Indexed: 08/08/2024]
Abstract
Objective Thyroid hormones are known to affect the biosynthesis and degradation of antioxidant compounds, suggesting a possible link between hypothyroidism and oxidative stress. However, there is no clear consensus in the literature regarding this association. The aim of this study was to evaluate oxidative stress markers (extracellular thiol-disulfide homeostasis and intracellular glutathione homeostasis) in patients with hypothyroidism due to autoimmune (Hashimoto's thyroiditis) or nonautoimmune thyroid disease rendered euthyroid after levothyroxine replacement. Subjects and methods The study included 116 patients admitted to the Taksim Training and Research Hospital (Istanbul, Türkiye). Of these, 50 had hypothyroidism due to Hashimoto's thyroiditis (HT group), 30 had nonautoimmune hypothyroidism (NAIH group), and 36 were healthy controls (control group). All participants were women. Extracellular thiol-disulfide homeostasis and intracellular glutathione homeostasis tests were assessed as oxidative stress markers. Results Thiol-disulfide homeostasis in both HT and NAIH groups was shifted toward the oxidative spectrum. Compared with the control group, the HT and NAIH groups had lower levels of native (p < 0.001 and p = 0.001, respectively) and total (p = 0.002 and p = 0.012, respectively) thiol, as well as a lower native thiol/total thiol ratio (p < 0.001 for both). The HT group also had higher disulfide levels than the control group (p = 0.027). Reduced glutathione (GSH) and oxidized glutathione (GSSG) values were comparable across all three groups, but the HT and NAIH groups had higher GSSG/GSH (p < 0.001 for both) and GSSG/(GSH+GSSG) ratios (p = 0.003 and p = 0.005, respectively), along with lower GSH/(GSH+GSSG) ratio (p = 0.001 and p = 0.002, respectively) than the control group. Conclusion Levothyroxine replacement was ineffective in ameliorating oxidative stress in patients with hypothyroidism due to Hashimoto's thyroiditis or nonautoimmune causes, as extracellular thiol-disulfide homeostasis was notably altered in these patients compared with healthy controls. The findings of this study suggest that oxidative stress remains a prevailing issue in patients with autoimmune or nonautoimmune hypothyroidism even after euthyroidism is restored.
Collapse
Affiliation(s)
- Almila Senat
- Taksim Training and Research HospitalIstanbulTürkiye Taksim Training and Research Hospital, Medical Biochemistry, Istanbul, Türkiye
| | - Osman Erinc
- Taksim Training and Research HospitalIstanbulTürkiyeTaksim Training and Research Hospital, Internal Medicine, Istanbul, Türkiye
| | - Soner Yesilyurt
- Taksim Training and Research HospitalIstanbulTürkiyeTaksim Training and Research Hospital, Internal Medicine, Istanbul, Türkiye
| | - Gamze Gok
- Ankara City HospitalAnkaraTürkiyeAnkara City Hospital, Medical Biochemistry, Ankara, Türkiye
| | - Ozcan Erel
- Ankara City HospitalAnkaraTürkiyeAnkara City Hospital, Medical Biochemistry, Ankara, Türkiye
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
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.
Collapse
Affiliation(s)
- Samer Shaja
- Family Medicine, JenCare Senior Medical Center, Glenwood, USA
| | | |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
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
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
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.
Collapse
Affiliation(s)
- Antonio C Bianco
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago School of Medicine, Chicago, Illinois, USA;
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Jonklaas J. Is euthyroidism within reach for all? Expert Rev Endocrinol Metab 2023; 18:455-458. [PMID: 37811647 DOI: 10.1080/17446651.2023.2267120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, DC, United States
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|