Fatal course of cyclic Cushing's disease - lessons from a case

We present a 56-year-old patient with cyclic Cushing's disease (CCD) observed for 28 months, who presented clinically and biochemically with alternating episodes of hyper-, normo- and hypocortisolemia. The course of the disease was fatal, the patient died due to severe hypokalemia.

Increased risk of thyroid pathology in patients with thyroid hemiagenesis: results of a large cohort case-control study

OBJECTIVE

Thyroid hemiagenesis (THA) is an anomaly resulting from the developmental failure of one thyroid lobe. Etiopathogenesis, clinical significance, and management of patients in whom THA is diagnosed are still a matter of debate. The aim of the study is to provide the first systematic analysis of a large cohort of subjects with THA.

DESIGN

Forty patients with THA are described in comparison to a control group of 80 subjects with fully developed thyroid gland.

METHODS

Serum concentrations of thyrotropin (TSH), free thyroxine (FT(4)), free triiodothyronine (FT(3)), and thyroid autoantibodies were measured. In 37 patients, thyroid ultrasonography and Tc-99m thyroid scintiscan were performed, followed by fine-needle aspiration biopsy if indicated. The remaining archival three cases were diagnosed with the use of I-131 scintiscan under basal conditions and after TSH stimulation.

RESULTS

Patients with THA, while usually clinically euthyroid, presented with significantly higher levels of TSH and FT(3) as well as with higher FT(3)/FT(4) concentration in comparison to the control group. Furthermore, a higher incidence of associated functional, morphological, and autoimmune thyroid disorders in patients with THA was observed when compared to subjects with bilobate thyroid (P<0.05).

CONCLUSIONS

Our results revealed that individuals with THA are more likely to develop thyroid pathology. The observed high incidence of associated pathologies is presumably due to long-lasting TSH overstimulation. Therefore, THA diagnosis should be followed by systematic observation and adequate levothyroxine treatment in patients with elevated TSH level.

[Influence of the endogene TSH stimulation of thyroid volume increase in the patients after total thyroidectomy due to differentiated thyroid cancer]

INTRODUCTION

The treatment-of-choice for differentiated thyroid carcinoma (DTC) is a total thyroidectomy with subsequent radioiodine therapy. In order to increase an iodine uptake in thyroid tissue remnants, the L-thyroxine withdrawal is required. It is recommended to achieve TSH levels higher than 25 mU/ml. As TSH is a known key factor in thyroid cell proliferation regulation, prolonged stimulation of the cells during L-thyroxine withdrawal can be a causative factor for a re-growth. Our aim was to assess the degree of thyroid re-growth in the patients after total thyroidectomy due to DTC and its possible clinical implications.

MATERIAL AND METHODS

23 patients operated due to papillary and follicular thyroid cancer were included into the study. Biochemical determinations and ultrasound thyroid imaging were performed (TSH, Tg) during suppressive L-thyroxine therapy as well as 4-5 weeks after the withdrawal.

RESULTS

The mean volume of thyroid tissue remnants increased after withdrawal for substantial 30.1%. The difference was extremely significant.

CONCLUSIONS

L-Thyroxine withdrawal in the patients after total thyroidectomy due to DTC can cause re-growth of the tissue remnants. The phenomenon may be of a clinical significance in the selected cases influencing therapeutic decisions.

Changes in thyroid morphology and function in children in western Poland as a result of intensified iodine prophylaxis

AIM

To determine the changes in thyroid pathology resulting from obligatory salt iodization in a group of children aged 8-12 years from the rural and urban areas of Wielkopolska Region, Poland.

POPULATION AND METHODS

The survey was conducted on 1215 children, of both sexes, 402 of whom were examined in 1992 (before salt iodization), 408 in 2000, and 405 in 2005 (after salt iodization beginning in 1996). Thyroid ultrasound, urinary iodine, FT4, FT3, TSH and antithyroid antibodies were measured.

RESULTS

A significant drop in goiter cases was observed (35.4% in 1992 vs 6.3% in 2005), coupled with a marked increase of urinary iodine. There were also changes in ultrasonography and elevated levels of antibodies.

CONCLUSIONS

The study proves the high efficacy of iodine prophylaxis. Despite a growing number of children with elevated antithyroid antibody titers, only a slight increase of autoimmune thyroid disorders was observed.

[Autoimmunization and multinodular large toxic goiter therapy using repeated doses of 131I]

The radioiodine therapy can favour and induces of autommunological reaction in thyroid gland. The aim of the study was evaluation of antithyroid autoantibodies in patients with multinodular large toxic goiter treated with repeated doses of 131I before and after therapy. Studies were conducted in 24 women (age range: 65-84 yrs) with multinodular large toxic goiters--goiter volume assessed by USG over 100 ml. Serum TSH, fT4, antithyroid antibodies (anti-TPO, anti-Tg, TSHR-Ab) levels were estimated in all patients parallel with radioiodine uptake test (after 5 and 24 hours), 131I thyroid scintigraphy and fine needle biopsy. These studies and therapy with 22 mCi 131I were repeated every 3 months. Before therapy median of thyroid volume was approximately 195 ml and during therapy gradually decreased to 110 ml after 12 months. After 12 months we found 11% of patients with hyperthyrodism, 62% of patients with euthyroidism and 27% of patients with hypothyroidism. Before radioiodine treatment aTg and aTPO presence were detected in the most of patients, but only in 5 cases above normal value. TSHRAb were detected (normal, very low values) in 16 patients. During therapy statistically significance increase of TSHRAb levels (median: from 0,27 to 0,65 after 6 months and to 0,71 IU/l after 9 months) was observed; aTPO and aTg antibodies levels showed marked tendency to rise, but without significant differences (aTPO median: from 40 IU/ml to 48 IU/ml; aTg - median: from 27 IU/ml to 46 IU/ml). During these observations we didn't find evident correlation between the levels of antithyroid antibodies, radioiodine uptake, proved reduction of goiter volume and TSH, FT4, FT3 values.

[Iodine prophylaxis in children population on the Wielkopolska Region area from year 1992 to 2005]

INTRODUCTION

The aim of the study was to evaluate of efficiency of iodine prophylaxis based on obligatory model of salt iodization.

MATERIAL AND METHODS

The study included 1444 children from the rural and urban area, with the proportional sex and age (8-12 years) distribution--432 children in 1992 (before salt iodization), 558 children in 2000 and 454 children in 2005 (during salt iodization from 1996).

RESULTS

The prevalence of goiter detected in children population in 1992 was 40% (recount by current criteria), in 2005 was reduced to 6% (p < 0.01). Parallel, median of urinary iodine concentration increased from 44 microg/l in 1992 to 107 microg/l (p < 0.01) in 2005. The increase of incidence of autoimmunological thyroid diseases is observed, especially chronic thyroiditis.

CONCLUSIONS

The study proves high efficiency of iodine prophylaxis in Wielkopolska Region, but it is still the area with mild iodine deficiency.

Implementing programs for chronic illness management: the case of hypertension services

BACKGROUND

This article describes the process by which HealthSystem Minnesota (a vertically integrated health care organization), functioning in a competitive managed care environment, has been implementing a hypertension services program. The program involves a team approach to care, with emphasis on patient participation in treatment; decentralized care delivery by nurse coordinators at primary care practice sites; ongoing training and education for patients and providers; and the continuous monitoring and evaluation of patient outcomes and satisfaction. JOB-LEVEL ISSUES: A variety of issues, such as the role and responsibilities of the nurse coordinator, became evident as the program moved towards operational status at four primary care practice sites, which prolonged the implementation period. PROCESS-LEVEL ISSUES: Issues relating to work process changes were more complicated to resolve and required, in some cases, changes in the proposed model. The most significant process-level issues related to educating physicians about the program to secure their participation and support. ORGANIZATION-LEVEL ISSUES: Such issues, which were the most difficult for program implementors to anticipate and resolve, included an organizational culture that emphasized decision making autonomy at primary practice sites. In part, the difficulty encountered in resolving organization-level issues reflected the implementors' lack of awareness of the strength or complexity of the environmental pressures facing the organization, as well as a lack of sensitivity to nuances relating to organizational culture.

MOVING AHEAD

Two groups of hypertensive patients--at the implementation and comparison sites--will be compared with respect to satisfaction with care, clinical outcomes, and costs. Expansion of the model to patients with other chronic conditions is under consideration.

[Primary hyperparathyroidism--diagnostic problems]

Parathyroid imaging with 99m Tc-MIBI, introduced at the beginning of the 90's seems to be a promising method for parathyroid adenomas localization. The aim of the study was to assess the efficacy of parathyroid imaging with 99m Tc-MIBI for preoperative localization of parathyroid adenomas and to compare that method with the high-resolution ultrasonography. Thirteen patients with primary hyperparathyroidism of duration from 2 to 25 years were included in the study. The presence of parathyroid adenomas was confirmed by histopathology in all patients. The sensitivity for scintigraphy and ultrasonography was 92.8% and 78.5%, the number of false positive results was 0 and 2 and false negative-0 and 1, respectively. Parathyroid imaging with 99m Tc-MIBI is a useful method for parathyroid adenomas localization, and in contrast to ultrasonography its sensitivity does not decrease if a parathyroid adenoma is located ectopically. Nevertheless, because of the greater accessibility, lower costs and its simplicity ultrasonography should be used as a screening modality for parathyroid adenoma localization.

Evaluation of a nurse-based hypertension management program: screening, management, and outcomes

This article reports the experience of patients with elevated blood pressure scheduled to be seen in a nurse-based hypertension management program in a large multispecialty group practice. The hypertension management program is a screening and follow-up program designed to improve the measurement and management of patients' blood pressure with standardized protocols. The cohort for this study of the effectiveness of the hypertension management program consisted of 200 patients with elevated blood pressure (140 referred directly for management and counseling, 60 entered through screening). At entry, only 17% of the patients had blood pressure within controlled limits (< 140/90 mm Hg). One year after entry in the management phase of the program, systolic pressure had decreased an average of 6.20 mm Hg (P < 0.01), and 44% of patients had blood pressure within controlled limits (P < 0.001). These results suggest that the use of standardized screening techniques using multiple measurements helps to ensure that patients will not be unnecessarily treated. Furthermore, patients who entered the program successfully lowered their blood pressure and maintained the reduction over time.