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Keen F, Williams DM, Essame J, Udiawar M, Nagarajah K, Witczak J, Mitchem K, Kalhan A. Isolated central hypothyroidism: Underlying pathophysiology and relation to antidepressant and antipsychotic medications-A multi-centre South Wales study. Clin Endocrinol (Oxf) 2024; 100:245-250. [PMID: 37749919 DOI: 10.1111/cen.14977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE Isolated biochemical central hypothyroidism is a presentation we are experiencing more frequently as endocrinologists, with variation in levels of investigation between physicians. We therefore conducted research to investigate the final diagnosis and clinical outcome of patients across multiple hospitals in South Wales with biochemical isolated central hypothyroidism; namely to establish whether this isolated biochemical picture was clinically significant. We also analysed whether there is an association between this biochemical picture and treatment with antidepressant and antipsychotic medications, and how common this is. DESIGN We performed a retrospective observational study of patients across nine different hospitals in South Wales. We analysed patients referred to endocrinology at each site over a 6-year period with unexplained isolated biochemical central hypothyroidism. MATERIALS AND METHODOLOGY 1022 individual patients' thyroid function test results were identified from our biochemical database using our inclusion criteria. After exclusion criteria were applied, 71 patients' results were analysed as to the final pathophysiology of their central hypothyroidism. RESULT Of the 71 patients included in the study, none were found to have any clinically significant pathology on pituitary imaging. On reviewing their medications, 46/71 (65%) were found to be taking psychotropic medications. CONCLUSIONS Our study strongly suggests isolated central hypothyroidism, in the absence of other pituitary hormone dysfunction or visual field defect, does not require further investigation, saving resources as well as sparing patients unnecessary anxiety. It also strongly supports a relationship between patients taking psychotropic medications and biochemical isolated central hypothyroidism, an association only described in a very limited amount of literature before this, and further supporting our previous single-centre study findings. The mechanism behind this is likely to be the suppression of thyrotropin secretion via antagonism of the dopamine-serotoninergic pathway. In our opinion, patients found to have isolated biochemical central hypothyroidism who are taking psychotropic medications can therefore be regarded to have a recognised cause for this biochemical finding and do not require further radiological investigation.
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Affiliation(s)
- Frederick Keen
- Department of Diabetes and Endocrinology, Nevill Hall Hospital, Brecon Road, Abergavenny, Wales, UK
| | - David M Williams
- Department of Diabetes and Endocrinology, Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, Wales, UK
| | - Jenna Essame
- Department of Diabetes and Endocrinology, Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, Wales, UK
| | - Maneesh Udiawar
- Department of Diabetes and Endocrinology, Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, Wales, UK
| | - Kalyani Nagarajah
- Department of Diabetes and Endocrinology, University Hospital of Wales, Heath Park Way, Cardiff, Wales, UK
| | - Justyna Witczak
- Department of Diabetes and Endocrinology, University Hospital of Wales, Heath Park Way, Cardiff, Wales, UK
| | - Kelly Mitchem
- Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun, Wales, UK
| | - Atul Kalhan
- Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun, Wales, UK
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Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial. Lancet Diabetes Endocrinol 2024; 12:39-50. [PMID: 38061371 PMCID: PMC7615591 DOI: 10.1016/s2213-8587(23)00321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001). INTERPRETATION Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor. FUNDING Boehringer Ingelheim and Eli Lilly.
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Shimano H, Shimizu Y, Shimoda H, Shin K, Shivashankar G, Shojima N, Silva R, Sim CSB, Simmons K, Sinha S, Sitter T, Sivanandam S, Skipper M, Sloan K, Sloan L, Smith R, Smyth J, Sobande T, Sobata M, Somalanka S, Song X, Sonntag F, Sood B, Sor SY, Soufer J, Sparks H, Spatoliatore G, Spinola T, Squyres S, Srivastava A, Stanfield J, Staplin N, Staylor K, Steele A, Steen O, Steffl D, Stegbauer J, Stellbrink C, Stellbrink E, Stevens W, Stevenson A, Stewart-Ray V, Stickley J, Stoffler D, Stratmann B, Streitenberger S, Strutz F, Stubbs J, Stumpf J, Suazo N, Suchinda P, Suckling R, Sudin A, Sugamori K, Sugawara H, Sugawara K, Sugimoto D, Sugiyama H, Sugiyama H, Sugiyama T, Sullivan M, Sumi M, Suresh N, Sutton D, Suzuki H, Suzuki R, Suzuki Y, Suzuki Y, Suzuki Y, Swanson E, Swift P, Syed S, Szerlip H, Taal M, Taddeo M, Tailor C, Tajima K, Takagi M, Takahashi K, Takahashi K, Takahashi M, Takahashi T, Takahira E, Takai T, Takaoka M, Takeoka J, Takesada A, Takezawa M, Talbot M, Taliercio J, Talsania T, Tamori Y, Tamura R, Tamura Y, Tan CHH, Tan EZZ, Tanabe A, Tanabe K, Tanaka A, Tanaka A, Tanaka N, Tang S, Tang Z, Tanigaki K, Tarlac M, Tatsuzawa A, Tay JF, Tay LL, Taylor J, Taylor K, Taylor K, Te A, Tenbusch L, Teng KS, Terakawa A, Terry J, Tham ZD, Tholl S, Thomas G, Thong KM, Tietjen D, Timadjer A, Tindall H, Tipper S, Tobin K, Toda N, Tokuyama A, Tolibas M, Tomita A, Tomita T, Tomlinson J, Tonks L, Topf J, Topping S, Torp A, Torres A, Totaro F, Toth P, Toyonaga Y, Tripodi F, Trivedi K, Tropman E, Tschope D, Tse J, Tsuji K, Tsunekawa S, Tsunoda R, Tucky B, Tufail S, Tuffaha A, Turan E, Turner H, Turner J, Turner M, Tuttle KR, Tye YL, Tyler A, Tyler J, Uchi H, Uchida H, Uchida T, Uchida T, Udagawa T, Ueda S, Ueda Y, Ueki K, Ugni S, Ugwu E, Umeno R, Unekawa C, Uozumi K, Urquia K, Valleteau A, Valletta C, van Erp R, Vanhoy C, Varad V, Varma R, Varughese A, Vasquez P, Vasseur A, Veelken R, Velagapudi C, Verdel K, Vettoretti S, Vezzoli G, Vielhauer V, Viera R, Vilar E, Villaruel S, Vinall L, Vinathan J, Visnjic M, Voigt E, von-Eynatten M, Vourvou M, Wada J, Wada J, Wada T, Wada Y, Wakayama K, Wakita Y, Wallendszus K, Walters T, Wan Mohamad WH, Wang L, Wang W, Wang X, Wang X, Wang Y, Wanner C, Wanninayake S, Watada H, Watanabe K, Watanabe K, Watanabe M, Waterfall H, Watkins D, Watson S, Weaving L, Weber B, Webley Y, Webster A, Webster M, Weetman M, Wei W, Weihprecht H, Weiland L, Weinmann-Menke J, Weinreich T, Wendt R, Weng Y, Whalen M, Whalley G, Wheatley R, Wheeler A, Wheeler J, Whelton P, White K, Whitmore B, Whittaker S, Wiebel J, Wiley J, Wilkinson L, Willett M, Williams A, Williams E, Williams K, Williams T, Wilson A, Wilson P, Wincott L, Wines E, Winkelmann B, Winkler M, Winter-Goodwin B, Witczak J, Wittes J, Wittmann M, Wolf G, Wolf L, Wolfling R, Wong C, Wong E, Wong HS, Wong LW, Wong YH, Wonnacott A, Wood A, Wood L, Woodhouse H, Wooding N, Woodman A, Wren K, Wu J, Wu P, Xia S, Xiao H, Xiao X, Xie Y, Xu C, Xu Y, Xue H, Yahaya H, Yalamanchili H, Yamada A, Yamada N, Yamagata K, Yamaguchi M, Yamaji Y, Yamamoto A, Yamamoto S, Yamamoto S, Yamamoto T, Yamanaka A, Yamano T, Yamanouchi Y, Yamasaki N, Yamasaki Y, Yamasaki Y, Yamashita C, Yamauchi T, Yan Q, Yanagisawa E, Yang F, Yang L, Yano S, Yao S, Yao Y, Yarlagadda S, Yasuda Y, Yiu V, Yokoyama T, Yoshida S, Yoshidome E, Yoshikawa H, Young A, Young T, Yousif V, Yu H, Yu Y, Yuasa K, Yusof N, Zalunardo N, Zander B, Zani R, Zappulo F, Zayed M, Zemann B, Zettergren P, Zhang H, Zhang L, Zhang L, Zhang N, Zhang X, Zhao J, Zhao L, Zhao S, Zhao Z, Zhong H, Zhou N, Zhou S, Zhu D, Zhu L, Zhu S, Zietz M, Zippo M, Zirino F, Zulkipli FH. Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial. Lancet Diabetes Endocrinol 2024; 12:51-60. [PMID: 38061372 DOI: 10.1016/s2213-8587(23)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). INTERPRETATION In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. FUNDING Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.
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Taylor PN, Lansdown A, Witczak J, Khan R, Rees A, Dayan CM, Okosieme O. Correction to: Age-related variation in thyroid function - a narrative review highlighting important implications for research and clinical practice. Thyroid Res 2023; 16:20. [PMID: 37254130 DOI: 10.1186/s13044-023-00163-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Affiliation(s)
- Peter N Taylor
- Thyroid Research Group Institute of Molecular and Experimental Medicine, UHW, Cardiff University School of Medicine, C2 link corridor, Heath Park, Cardiff, UK.
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK.
| | - Andrew Lansdown
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Justyna Witczak
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Rahim Khan
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Aled Rees
- Thyroid Research Group Institute of Molecular and Experimental Medicine, UHW, Cardiff University School of Medicine, C2 link corridor, Heath Park, Cardiff, UK
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
- Neuroscience and Mental Health Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Colin M Dayan
- Thyroid Research Group Institute of Molecular and Experimental Medicine, UHW, Cardiff University School of Medicine, C2 link corridor, Heath Park, Cardiff, UK
| | - Onyebuchi Okosieme
- Thyroid Research Group Institute of Molecular and Experimental Medicine, UHW, Cardiff University School of Medicine, C2 link corridor, Heath Park, Cardiff, UK
- Diabetes Department, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Merthyr Tydfil, UK
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Taylor PN, Lansdown A, Witczak J, Khan R, Rees A, Dayan CM, Okosieme O. Age-related variation in thyroid function - a narrative review highlighting important implications for research and clinical practice. Thyroid Res 2023; 16:7. [PMID: 37009883 PMCID: PMC10069079 DOI: 10.1186/s13044-023-00149-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/05/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Thyroid hormones are key determinants of health and well-being. Normal thyroid function is defined according to the standard 95% confidence interval of the disease-free population. Such standard laboratory reference intervals are widely applied in research and clinical practice, irrespective of age. However, thyroid hormones vary with age and current reference intervals may not be appropriate across all age groups. In this review, we summarize the recent literature on age-related variation in thyroid function and discuss important implications of such variation for research and clinical practice. MAIN TEXT There is now substantial evidence that normal thyroid status changes with age throughout the course of life. Thyroid stimulating hormone (TSH) concentrations are higher at the extremes of life and show a U-shaped longitudinal trend in iodine sufficient Caucasian populations. Free triiodothyronine (FT3) levels fall with age and appear to play a role in pubertal development, during which it shows a strong relationship with fat mass. Furthermore, the aging process exerts differential effects on the health consequences of thyroid hormone variations. Older individuals with declining thyroid function appear to have survival advantages compared to individuals with normal or high-normal thyroid function. In contrast younger or middle-aged individuals with low-normal thyroid function suffer an increased risk of adverse cardiovascular and metabolic outcomes while those with high-normal function have adverse bone outcomes including osteoporosis and fractures. CONCLUSION Thyroid hormone reference intervals have differential effects across age groups. Current reference ranges could potentially lead to inappropriate treatment in older individuals but on the other hand could result in missed opportunities for risk factor modification in the younger and middle-aged groups. Further studies are now needed to determine the validity of age-appropriate reference intervals and to understand the impact of thyroid hormone variations in younger individuals.
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Affiliation(s)
- Peter N Taylor
- Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff, UK.
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK.
| | - Andrew Lansdown
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Justyna Witczak
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Rahim Khan
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Aled Rees
- Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff, UK
- Department of Endocrinology, University Hospital of Wales, Cardiff, UK
- Neuroscience and Mental Health Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Colin M Dayan
- Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | - Onyebuchi Okosieme
- Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff, UK
- Diabetes Department, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Merthyr Tydfil, UK
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Ravindran R, Witczak J, Bahl S, Premawardhana LDKE, Adlan M. Myositis, rhabdomyolysis and severe hypercalcaemia in a body builder. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200032. [PMID: 32698126 PMCID: PMC7354728 DOI: 10.1530/edm-20-0032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/15/2020] [Indexed: 12/27/2022] Open
Abstract
SUMMARY A 53-year-old man who used growth hormone (GH), anabolic steroids and testosterone (T) for over 20 years presented with severe constipation and hypercalcaemia. He had benign prostatic hyperplasia and renal stones but no significant family history. Investigations showed - (1) corrected calcium (reference range) 3.66 mmol/L (2.2-2.6), phosphate 1.39 mmol/L (0.80-1.50), and PTH 2 pmol/L (1.6-7.2); (2) urea 21.9 mmol/L (2.5-7.8), creatinine 319 mmol/L (58-110), eGFR 18 mL/min (>90), and urine analysis (protein 4+, glucose 4+, red cells 2+); (3) creatine kinase 7952 U/L (40-320), positive anti Jo-1, and Ro-52 antibodies; (4) vitamin D 46 nmol/L (30-50), vitamin D3 29 pmol/L (55-139), vitamin A 4.65 mmol/L (1.10-2.60), and normal protein electrophoresis; (5) normal CT thorax, abdomen and pelvis and MRI of muscles showed 'inflammation', myositis and calcification; (6) biopsy of thigh muscles showed active myositis, chronic myopathic changes and mineral deposition and of the kidneys showed positive CD3 and CD45, focal segmental glomerulosclerosis and hypercalcaemic tubular changes; and (7) echocardiography showed left ventricular hypertrophy (likely medications and myositis contributing), aortic stenosis and an ejection fraction of 44%, and MRI confirmed these with possible right coronary artery disease. Hypercalcaemia was possibly multifactorial - (1) calcium release following myositis, rhabdomyolysis and acute kidney injury; (2) possible primary hyperparathyroidism (a low but detectable PTH); and (3) hypervitaminosis A. He was hydrated and given pamidronate, mycophenolate and prednisolone. Following initial biochemical and clinical improvement, he had multiple subsequent admissions for hypercalcaemia and renal deterioration. He continued taking GH and T despite counselling but died suddenly of a myocardial infarction. LEARNING POINTS The differential diagnosis of hypercalcaemia is sometimes a challenge. Diagnosis may require multidisciplinary expertise and multiple and invasive investigations. There may be several disparate causes for hypercalcaemia, although one usually predominates. Maintaining 'body image' even with the use of harmful drugs may be an overpowering emotion despite counselling about their dangers.
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Affiliation(s)
| | - Justyna Witczak
- Section of Endocrinology, YYF Hospital, Ystrad Fawr Way, Caerphilly, UK
| | - Suhani Bahl
- Section of Endocrinology, YYF Hospital, Ystrad Fawr Way, Caerphilly, UK
| | - Lakdasa D K E Premawardhana
- Section of Endocrinology, YYF Hospital, Ystrad Fawr Way, Caerphilly, UK
- Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Cardiff, UK
| | - Mohamed Adlan
- Section of Endocrinology, YYF Hospital, Ystrad Fawr Way, Caerphilly, UK
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Hammad M, Albaqami M, Pooam M, Kernevez E, Witczak J, Ritz T, Martino C, Ahmad M. Cryptochrome mediated magnetic sensitivity in Arabidopsis occurs independently of light-induced electron transfer to the flavin. Photochem Photobiol Sci 2020; 19:341-352. [DOI: 10.1039/c9pp00469f] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Arabidopsis cryptochrome-dependent magnetosensitivity occurs via a reaction that does not require light. This excludes radical pairs formed during light-triggered electron transfer to the flavin.
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Affiliation(s)
- M. Hammad
- Sorbonne Universités – UPMC Paris 6 – CNRS
- UMR8256 - IBPS
- Photobiology Research Group
- 75005 Paris
- France
| | - M. Albaqami
- Sorbonne Universités – UPMC Paris 6 – CNRS
- UMR8256 - IBPS
- Photobiology Research Group
- 75005 Paris
- France
| | - M. Pooam
- Sorbonne Universités – UPMC Paris 6 – CNRS
- UMR8256 - IBPS
- Photobiology Research Group
- 75005 Paris
- France
| | - E. Kernevez
- Sorbonne Universités – UPMC Paris 6 – CNRS
- UMR8256 - IBPS
- Photobiology Research Group
- 75005 Paris
- France
| | - J. Witczak
- Sorbonne Universités – UPMC Paris 6 – CNRS
- UMR8256 - IBPS
- Photobiology Research Group
- 75005 Paris
- France
| | - T. Ritz
- Department of Physics and Astronomy
- University of California at Irvine
- USA
| | - C. Martino
- Department of Biomedical and Chemical Engineering and Science
- Florida Institute of Technology
- Melbourne
- USA
| | - M. Ahmad
- Sorbonne Universités – UPMC Paris 6 – CNRS
- UMR8256 - IBPS
- Photobiology Research Group
- 75005 Paris
- France
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Kamath C, Witczak J, Adlan MA, Premawardhana LD. Managing thymic enlargement in Graves' disease. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180119. [PMID: 30703065 PMCID: PMC6365683 DOI: 10.1530/edm-18-0119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/09/2019] [Indexed: 11/13/2022] Open
Abstract
Thymic enlargement (TE) in Graves' disease (GD) is often diagnosed incidentally when chest imaging is done for unrelated reasons. This is becoming more common as the frequency of chest imaging increases. There are currently no clear guidelines for managing TE in GD. Subject 1 is a 36-year-old female who presented with weight loss, increased thirst and passage of urine and postural symptoms. Investigations confirmed GD, non-PTH-dependent hypercalcaemia and Addison's disease (AD). CT scans to exclude underlying malignancy showed TE but normal viscera. A diagnosis of hypercalcaemia due to GD and AD was made. Subject 2, a 52-year-old female, was investigated for recurrent chest infections, haemoptysis and weight loss. CT thorax to exclude chest malignancy, showed TE. Planned thoracotomy was postponed when investigations confirmed GD. Subject 3 is a 47-year-old female who presented with breathlessness, chest pain and shakiness. Investigations confirmed T3 toxicosis due to GD. A CT pulmonary angiogram to exclude pulmonary embolism showed TE. The CT appearances in all three subjects were consistent with benign TE. These subjects were given appropriate endocrine treatment only (without biopsy or thymectomy) as CT appearances showed the following appearances of benign TE - arrowhead shape, straight regular margins, absence of calcification and cyst formation and radiodensity equal to surrounding muscle. Furthermore, interval scans confirmed thymic regression of over 60% in 6 months after endocrine control. In subjects with CT appearances consistent with benign TE, a conservative policy with interval CT scans at 6 months after endocrine control will prevent inappropriate surgical intervention. Learning points: Chest imaging is common in modern clinical practice and incidental anterior mediastinal abnormalities are therefore diagnosed frequently. Thymic enlargement (TE) associated with Graves' disease (GD) is occasionally seen in view of the above. There is no validated strategy to manage TE in GD at present. However, CT (or MRI) scan features of the thymus may help characterise benign TE, and such subjects do not require thymic biopsy or surgery at presentation. In them, an expectant 'wait and see' policy is recommended with GD treatment only, as the thymus will show significant regression 6 months after endocrine control.
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Affiliation(s)
- C Kamath
- Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Cardiff, UK
| | - J Witczak
- Section of Endocrinology, Department of Medicine, Ysbyty Ystrad Fawr, Caerphilly, UK
| | - M A Adlan
- Section of Endocrinology, Department of Medicine, Ysbyty Ystrad Fawr, Caerphilly, UK
| | - L D Premawardhana
- Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Cardiff, UK
- Section of Endocrinology, Department of Medicine, Ysbyty Ystrad Fawr, Caerphilly, UK
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Witczak J, Taylor P, Chai J, Amphlett B, Soukias JM, Das G, Tennant BP, Geen J, Okosieme OE. Predicting malignancy in thyroid nodules: feasibility of a predictive model integrating clinical, biochemical, and ultrasound characteristics. Thyroid Res 2016; 9:4. [PMID: 27313663 PMCID: PMC4910190 DOI: 10.1186/s13044-016-0033-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/19/2016] [Indexed: 11/10/2022] Open
Abstract
Background Although the majority of thyroid nodules are benign the process of excluding malignancy is challenging and sometimes involves unnecessary surgical procedures. We explored the development of a predictive model for malignancy in thyroid nodules by integrating a combination of simple demographic, biochemical, and ultrasound characteristics. Methods Retrospective case-record review. We reviewed records of patients with thyroid nodules referred to our institution from 2004 to 2011 (n = 536; female 84 %, mean age 51 years). All malignancy was proven histologically while benign disease was either confirmed histologically, or on cytology with minimum 36-month observation period. We focused on the following predictors: age, sex, smoking status, thyroid hormones (FT4 and TSH) and nodule characteristics on ultrasound. Variables were included in a multivariate logistic regression and bootstrap analyses were used to confirm results. Results Independent predictors of malignancy in the fully adjusted model were TSH (OR 1.53, 95 % CI 1.10, 2.12, p = 0.01), male gender (OR 3.45, 95 % CI 1.33, 8.92, p = 0.01), microcalcifications (OR 6.32, 95 % CI 2.82, 14.1, p < 0.001), and irregular nodule margins (OR 5.45, 95 % CI 1.61, 18.6, p = 0.006) Bootstrap analyses strengthened these associations and a parsimonious analysis consisting of these variables and age-group demonstrated an area under the curve of 0.77. A predictive score was sensitive (86.9 %) at low scores and highly specific (94.87 %) at higher scores for distinguishing benign from malignant disease. Conclusions A predictive model for malignancy using a combination of clinical, biochemical, and radiological characteristics may support clinicians in reducing unnecessary invasive procedures in patients with thyroid nodules. Electronic supplementary material The online version of this article (doi:10.1186/s13044-016-0033-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Justyna Witczak
- Centre for Endocrine and Diabetes Science, Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, University Hospital Wales, Cardiff, CF14 4XN UK.,Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf Health Board, Gurnos Estate Merthyr Tydfil, CF47 9DT UK
| | - Peter Taylor
- Centre for Endocrine and Diabetes Science, Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, University Hospital Wales, Cardiff, CF14 4XN UK.,Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf Health Board, Gurnos Estate Merthyr Tydfil, CF47 9DT UK
| | - Jason Chai
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf Health Board, Gurnos Estate Merthyr Tydfil, CF47 9DT UK
| | - Bethan Amphlett
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf Health Board, Gurnos Estate Merthyr Tydfil, CF47 9DT UK
| | - Jean-Marc Soukias
- Radiology Department, Prince Charles Hospital, Cwm Taf Health Board, Gurnos Estate Merthyr Tydfil, CF47 9DT UK
| | - Gautam Das
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf Health Board, Gurnos Estate Merthyr Tydfil, CF47 9DT UK
| | - Brian P Tennant
- Clinical Biochemistry Department, Prince Charles Hospital, Cwm Taf Health Board, Gurnos Estate Merthyr Tydfil, CF47 9DT UK
| | - John Geen
- Clinical Biochemistry Department, Prince Charles Hospital, Cwm Taf Health Board, Gurnos Estate Merthyr Tydfil, CF47 9DT UK.,Faculty of Life Sciences and Education, University of South Wales, Glyntaff Campus, Pontypridd, CF37 1DL UK
| | - Onyebuchi E Okosieme
- Centre for Endocrine and Diabetes Science, Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, University Hospital Wales, Cardiff, CF14 4XN UK.,Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf Health Board, Gurnos Estate Merthyr Tydfil, CF47 9DT UK
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Witczak J, Obuobie K. Reply: Reversible cerebral vasoconstriction syndrome might account for the headaches simulating subarachnoid haemorrhage. QJM 2016. [PMID: 26224053 DOI: 10.1093/qjmed/hcv140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J Witczak
- From the Royal Gwent Hospital, Aneurin Bevan Health Board, Gwent, NP20 2UB, UK
| | - K Obuobie
- From the Royal Gwent Hospital, Aneurin Bevan Health Board, Gwent, NP20 2UB, UK
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Witczak J, Obuobie K. Reply: A unique manifestation of primary adrenal insufficiency or a miss after all? QJM 2016. [PMID: 26224054 DOI: 10.1093/qjmed/hcv139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- J Witczak
- From Diabetes and Endocrinology Department, Royal Gwent Hospital, Aneurin Bevan Health Board, Newport, Gwent NP20 2UB, UK.
| | - K Obuobie
- From Diabetes and Endocrinology Department, Royal Gwent Hospital, Aneurin Bevan Health Board, Newport, Gwent NP20 2UB, UK
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Witczak J, Rees A, James P. Gender-related differences in circulating microparticles characteristics: implications for cardiovascular risk? ACTA ACUST UNITED AC 2015. [DOI: 10.1530/endoabs.38.p183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Affiliation(s)
- J Witczak
- From the Aneurin Bevan Health Board, Department of Diabetes and Endocrinology, Royal Gwent Hospital, Cardiff Road, Newport, Gwent, NP20 2UB, UK
| | - O Williams
- From the Aneurin Bevan Health Board, Department of Diabetes and Endocrinology, Royal Gwent Hospital, Cardiff Road, Newport, Gwent, NP20 2UB, UK
| | - T Shekaraiah
- From the Aneurin Bevan Health Board, Department of Diabetes and Endocrinology, Royal Gwent Hospital, Cardiff Road, Newport, Gwent, NP20 2UB, UK
| | - K Obuobie
- From the Aneurin Bevan Health Board, Department of Diabetes and Endocrinology, Royal Gwent Hospital, Cardiff Road, Newport, Gwent, NP20 2UB, UK
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