Changes in TSH levels in athyreotic patients with differentiated thyroid cancer during levothyroxine therapy: influence on dose adjustments

PURPOSE

The aim of the study was to describe the spontaneous TSH level variations and levothyroxine dose adjustments in athyreotic patients with differentiated thyroid cancer (DTC) in real-life practice.

METHODS

Patients with DTC were retrospectively evaluated at a tertiary referral center between October 2006 and November 2013. Hormone measurements (TSH and FT4 serum levels), L-T4 prescription information (dose per kg per day) and other medications were recorded at 1 month and 3, 12, 24, 36 and 48 months after primary treatment (surgery ± radioiodine therapy).

RESULTS

The cohort was composed of 452 patients; about 20% of patients with stable levothyroxine dose have clinically meaningful spontaneous TSH variations (defined as ΔTSH > 2 mcUI/mL) at yearly follow-up visit. Furthermore, about 25% of athyreotic DTC patients with stable dose have a ΔTSH > 1.5 mcUI/mL and about 40% a ΔTSH > 1 mcUI/mL during each follow-up visit. We further investigated whether this TSH variation would lead to subsequent dose changes. About 19.9-37.7% of DTC patients on stable LT4 dose on the previous visit had their levothyroxine dose reduced, while 7.8-14.9% increased due to TSH variations. We further evaluated the decision to change the dose in relation with the age-specific TSH range. Up to 77.2% of patients had their dose adjusted due to TSH falling below the age-specific range.

CONCLUSIONS

Spontaneous serum TSH variations determine levothyroxine replacement therapy in athyreotic patients with DTC, requiring multiple dose changes.

Education to legality and doping

When planning actions to prevent doping in the general population, public health operators may collide against the interests of criminal organizations involved in illicit trafficking of drugs. In addition to technical and professional expertise, or clinical and pharmacological skills, also a deep knowledge of legal and social issues is strongly required to face the problem and assure the effectiveness of the preventive actions. Sports competitions, athletes training or adapted physical activity may all represent conditions and environments at risk for misusing or abusing drugs and dietary supplements. A correct approach to sport and physical activity implies respect of competition rules, attention to own body limits and knowledge of risk factors. Health education campaigns and preventive actions should also consider education to legality in the different settings. The comprehension of the complex net that is available to access doping, locally or globally through online Internet sites, is essential as well as the awareness of the huge economic burden of crime interests behind the illicit trafficking of drugs. A modern whole rounded approach needs to consider doping not only as a violation of sport rules but also of the own body health, representing almost a form of addiction involving individuals and communities, and being supported by crime. Within this frame, doping is considered not just as a sport violation or a risk factor for individual's health, but as a disease of the society, in the society, against the society. A peculiar equilibrium seems to prevail between crime external pressures and resigned internal acceptance, according to the 'mafia hypothesis' model, where hosts accept parasitism to avoid retaliation. Here, main contributes and topics from the Erice 53rd Course are summarized and reviewed, providing links and references for further studies in the field. Health education and education to legality represent two sides of a same question, concerning both the general population and the health authorities. In conclusion, education to legality is a key component for prevention of doping and a priority for public health operators involved in protecting population health.

[The PiCCO system with brachial-axillary artery access in hemodynamic monitoring during surgery of abdominal aortic aneurysm]

BACKGROUND

The haemodynamic monitor PiCCO System, based on transpulmonary arterial thermodilution, has been used with a brachial-axillary access instead of the femoral arterial access during abdominal aortic aneurysm surgical repair. Accuracy and limitations of pulse contour continuous cardiac output (PCCO) were evaluated on the basis of arterial thermodilution cardiac output. The patterns of cardiac index, preload, afterload and cardiac function parameters were also studied in the different phases of the surgical procedure.

METHODS

Twenty consecutive patients were studied. Mean differences (bias) between PCCO and arterial thermodilution cardiac output were calculated by the Bland-Altman test. Analysis of variance with multiple comparison test of haemodynamic variables in the different phases were performed. The correlation coefficients between cardiac index and the volumetric preload variables were also obtained.

RESULTS

Brachial artery catheterization was achieved without any major complication. Pulse contour continuous cardiac index (CI) and arterial thermodilution CI values showed overall mean differences (bias) of -0.04 Lámin-1. m-2 (SD 0.8) but after aortic cross-clamping and aortic unclamping they were 0.64 Lámin-1. m-2 (SD 0.57) e -0.57 Lámin-1. m-2 (SD 0.85), respectively (p<0.05). CI, global end-diastolic volume (GEDV) and intrathoracic blood volume (ITBVI) were significantly lower during aortic cross-clamping. CI was not correlated to central venous pressure (r=0.18) but instead, to GEDV (r=0.57) and ITBVI (r=0.65).

CONCLUSIONS

PiCCO System with brachial-axillary arterial access was suitable for haemodynamic monitoring of the abdominal aortic aneurysm surgical repair procedures. PCCO must be recalibrated with arterial thermodilution after aortic cross-clamping and unclamping to avoid an over-estimation and an under-estimation respectively. During aortic cross-clamping GEDV and ITBVI indicated a decreased preload. Other haemodynamic variables were less valuable but EVLWI showed an interesting steady increase during the whole procedure.