Does a three-degree hypoechogenicity grading improve ultrasound thyroid nodule risk stratification and affect the TI-RADS 4 category? A retrospective observational study

ABSTRACT Objective: The aim of this study was to determine whether classifying hypoechogenicity in three degrees (mild, moderate, and marked) could improve the distinction between benign and malignant nodules and whether such an approach could influence Category 4 of the Thyroid Imaging Reporting and Data System (TI-RADS). Materials and methods: In total, 2,574 nodules submitted to fine needle aspiration, classified by the Bethesda System, were retrospectively assessed. Further, a subanalysis considering solid nodules without any additional suspicious findings (n = 565) was performed with the purpose of evaluating mainly TI-RADS 4 nodules. Results: Mild hypoechogenicity was significantly less related to malignancy (odds ratio [OR]: 1.409; CI: 1.086-1.829; p = 0.01), compared to moderate (OR: 4.775; CI: 3.700-6.163; p < 0.001) and marked hypoechogenicity (OR: 8.540; CI: 6.355-11.445; p < 0.001). In addition, mild hypoechogenicity (20.7%) and iso-hyperechogenicity (20.5%) presented a similar rate in the malignant sample. Regarding the subanalysis, no significant association was found between mildly hypoechoic solid nodules and cancer. Conclusion: Stratifying hypoechogenicity into three degrees influences the confidence in the assessment of the rate of malignancy, indicating that mild hypoechogenicity has a unique low-risk biological behavior that resembles iso-hyperechogenicity, but with minor malignant potential when compared to moderate and marked hypoechogenicity, with special influence on the TI-RADS 4 category.

Screening, diagnosis and management of hypothyroidism in pregnancy: Number 10 - October 2022

Key points Pregnancy places a metabolic overload on the maternal thyroid, especially in the first trimester, mainly because of the demand imposed by the conceptus. The fetal thyroid becomes functionally mature only around pregnancy week 20. Until then, the fetus depends on the transfer of maternal thyroid hormones (THs). Thyroid hormones are essential for the adequate fetal neurofunctional and cognitive development. Hypothyroidism brings higher risks of obstetric and fetal complications, namely, first-trimester miscarriage, preeclampsia and gestational hypertension, placental abruption, prematurity, low birth weight, and higher perinatal morbidity and mortality. Primary hypothyroidism (involvement of the gland with difficulty in producing and/or releasing TH) is the most common form of disease presentation, with the main etiology of Hashimoto's thyroiditis of autoimmune origin. In about 85%-90% of cases of Hashimoto's thyroiditis, antithyroid antibodies are present; the antithyroperoxidase (ATPO) is the most frequent. Positivity for ATPO is determined when circulating values exceed the upper limit of the laboratory reference. It implies greater risks of adverse maternal-fetal outcomes. Such a correlation occurs even in ranges of maternal euthyroidism. The critical point for the diagnosis of hypothyroidism during pregnancy is an elevation of thyroid-stimulating hormone (TSH). The measurement of free thyroxine (FT4) differentiates between subclinical and overt hypothyroidism. In subclinical hypothyroidism, FT4 is within the normal range, whereas in overt hypothyroidism, FT4 values are below the lower limit of the laboratory reference. Treatment of hypothyroidism is performed with levothyroxine (LT4) replacement with the aim of achieving adequate TSH levels for pregnancy. Some women have a previous diagnosis of hypothyroidism, and may or may not be compensated at the beginning of pregnancy. Even in compensated cases, the increase in LT4 dose is necessary as soon as possible. In the postpartum period, adjustment of the LT4 dose depends on the condition of previous disease, on the positivity for ATPO, and also on the value of LT4 in use at the end of pregnancy. Recommendations In places with full technical and financial conditions, TSH testing should be performed for all pregnant women (universal screening) as early as possible, ideally at the beginning of the first trimester or even in preconception planning. In places with less access to laboratory tests, screening is reserved for cases with greater risk factors for decompensation, namely: previous thyroidectomy or radioiodine therapy, type 1 diabetes mellitus or other autoimmune diseases, presence of goiter, previous history of hypo or hyperthyroidism or previous ATPO positivity. The TSH dosage should be repeated throughout pregnancy only in these cases. The diagnosis of hypothyroidism is made from the TSH value > 4.0 mIU/L. Pregnant women with previous hypothyroidism, overt hypothyroidism diagnosed during pregnancy or those with the above-mentioned higher risk factors for decompensation should be referred for risk antenatal care, preferably in conjunction with the endocrinologist. Overt hypothyroidism in pregnancy is identified when TSH > 10 mIU/L, and treatment with LT4 is readily recommended at an initial dose of 2 mcg/kg/day. TSH values > 4.0 mUI/L and ≤ 10.0 mUI/L require FT4 measurement with two diagnostic possibilities: overt hypothyroidism when FT4 levels are below the lower limit of the laboratory reference, or subclinical hypothyroidism when FT4 levels are normal. The treatment for subclinical hypothyroidism is LT4 at an initial dose of 1 mcg/kg/day, and the dose should be doubled upon diagnosis of overt hypothyroidism. In cases of TSH > 2.5 and ≤ 4.0 mIU/L, if there are complete conditions, ATPO should be measured. If positive (above the upper limit of normal), treatment with LT4 at a dose of 50 mcg/day is indicated. If conditions are not complete, the repetition of the TSH dosage should be done only for cases at higher risk. In these cases, treatment with LT4 will be established when TSH > 4.0 mIU/L at a dose of 1 mcg/kg/day; if needed, the dose can be adjusted after FT4 evaluation. Women with previous hypothyroidism should have their LT4 dose adjusted to achieve TSH < 2.5 mIU/L at preconception. As soon as they become pregnant, they need a 30% increase in LT4 as early as possible. In practice, they should double the usual dose on two days a week. Levothyroxine should be given 30-60 minutes before breakfast or three hours or more after the last meal. Concomitant intake with ferrous sulfate, calcium carbonate, aluminum hydroxide and sucralfate should be avoided. The target of LT4 therapy during pregnancy is to achieve a TSH value < 2.5 mIU/L. Once the therapy is started, monthly control must be performed until the mentioned goal is reached. In the postpartum period, women with previous disease should resume the preconception dose. Cases diagnosed during pregnancy in use of LT4 ≤ 50 mcg/day may have the medication suspended. The others should reduce the current dose by 25% to 50% and repeat the TSH measurement in six weeks. Cases of ATPO positivity are at higher risk of developing postpartum thyroiditis and de-escalation of LT4 should be performed as explained.

Choosing Wisely for Thyroid Conditions: Recommendations of the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism

ABSTRACT Objective: Choosing Wisely (CW) is an initiative that aims to advance the dialogue between physicians and patients about low-value health interventions. Given that thyroid conditions are frequent in clinical practice, we aimed to develop an evidence-based list of thyroid CW recommendations. Materials and methods: The Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) named a Task Force to conduct the initiative. The Task Force work was based on an electronic Delphi approach. The 10 recommendations that received the highest scores by the Task Force were submitted for voting by all SBEM associates. The 5 recommendations that received the highest scores by SBEM associates are presented herein. Results: The Task Force was composed of 14 thyroidologists from 10 tertiary-care, teaching-based Brazilian institutions. The brainstorming/ideation phase resulted in 69 recommendations. After the removal of duplicates and recommendations that did not adhere to the initiative's scope, 35 remained. Then the Task Force voted to attribute a grade (0 [lowest agreement] to 10 [highest agreement]) for each recommendation. The 10 recommendations that received the highest scores by the Task Force were submitted to all SBEM associates. A total of 683 associates voted electronically, attributing a grade (0 to 10) for each recommendation. The 5 recommendations that received the highest scores by the SBEM associates compose our final list. Conclusion: A set of recommendations to avoid unnecessary medical tests, treatments, or procedures for thyroid conditions are offered with a transparent methodology. This initiative aims to foster productive interactions between physicians and patients, stimulating shared decision-making.

Heart rate response to graded exercise test of elderly subjects in different ranges of TSH levels

ABSTRACT Objective: Life expectancy is increasing worldwide and studies have been demonstrating that elevated serum thyroid stimulating hormone (TSH) concentration in elderly is associated with some better health outcomes. This elevation is somewhat physiological as aging. The aim of this study was to investigate the heart rate (HR) response during a graded exercise test and its recovery in healthy elderly, comparing subjects within serum TSH in the lower limit of reference range to those within the TSH in the upper limit. Subjects and methods: A cross-sectional study was conducted with 86 healthy elderly aged 71.5 ± 5.1 years, with serum TSH between 0.4 - 4.0 mUl/mL. The participants were divided into two groups according to TSH level: < 1.0 mUl/mL (n = 13) and ≥ 1.0 µUI/mL (n = 73). All participants performed an ergometric test on a treadmill. The HR was recorded and analyzed at rest, during exercise and during the three minutes immediately after exercise. Results: No differences were observed in relation to HR at peak of exercise (TSH < 1.0 µUI/mL: 133.9 ± 22.5 bpm vs. TSH ≥ 1.0 µUI/mL: 132.4 ± 21.3 bpm; p = 0.70) and during the first minute of recovery phase (TSH < 1.0 µUI/mL: 122.3 ± 23.1 bpm vs. TSH ≥ 1.0 µUI/mL: 115.7 ± 18.4 bpm p = 0.33). The groups also presented similar chronotropic index (TSH < 1.0 µUI/mL: 78.1 ± 30.6 vs. TSH ≥ 1.0 µUI/mL: 79.5 ± 26.4; p = 0.74). Conclusion: In this sample studied, there were no difference between lower and upper TSH level concerning HR response during rest, peak of exercise and exercise recovery.

Exercise training improves quality of life in women with subclinical hypothyroidism: a randomized clinical trial

ABSTRACT Objective: The aim was to evaluate the quality of life (HRQoL) in women with subclinical hypothyroidism (sHT) after 16 weeks of endurance training. Subjects and methods: In the first phase, a cross-sectional study was conducted in which 22 women with sHT (median age: 41.5 (interquartile range: 175) years, body mass index: 26.2 (8.7) kg/m2, thyroid stimulating hormone > 4.94 mIU/L and free thyroxine between 0.8 and 1.3 ng/dL were compared to a group of 33 euthyroid women concerned to HRQoL. In the second phase, a randomized clinical trial was conducted where only women with sHT were randomly divided into two groups: sHT-Tr (n = 10) - participants that performed an exercise program - and sHT-Sed (n = 10) - controls. Exercise training consisted of 60 minutes of aerobic activities (bike and treadmill), three times a week, for 16 weeks. The HRQoL was assessed by the SF-36 questionnaire in the early and at the end of four months. Results: Women with sHT had lower scores on functional capacity domain in relation to the euthyroid ones (770 ± 23.0 vs. 88.8 ± 14.6; p = 0.020). The sHT-Tr group improved functional capacity, general health, emotional aspects, mental and physical component of HRQoL after training period, while the sHT-Sed group showed no significant changes. Conclusion: After 16 weeks of aerobic exercise training, there were remarkable improvements in HRQoL in women with sHT.

Recent recommendations from ATA guidelines to define the upper reference range for serum TSH in the first trimester match reference ranges for pregnant women in Rio de Janeiro

ABSTRACT Objectives: American Thyroid Association (ATA)'s new guidelines recommend use of population-based trimester-specific reference range (RR) for thyrotropin (TSH) in pregnancy. The aim of this study was to determine first trimester TSH RR for a population of pregnant women in Rio de Janeiro State. Subjects and methods: Two hundred and seventy pregnant women without thyroid illness, defined by National Academy of Clinical Biochemistry, and normal iodine status were included in this sectional study. This reference group (RG) had normal median urinary iodine concentration (UIC = 219 μg/L) and negative anti-thyroperoxidase antibodies (TPOAb). Twin pregnancy, trophoblastic disease and use of drugs or supplements that influence thyroid function were excluded. In a second step, we defined a more selective reference group (SRG, n = 170) by excluding patients with thyroiditis pattern on thyroid ultrasound and positive anti-thyroglobulin antibodies. This group also had normal median UIC. At a final step, a more selective reference group (MSRG, n = 130) was defined by excluding any pregnant women with UIC < 150 μg/L. Results: In the RG, median, 2.5th and 97.5th percentiles of TSH were 1.3, 0.1, and 4.4 mIU/L, respectively. The mean age was 270 ± 5.0 and the mean body mass index was 25.6 ± 5.2 kg/m2. In the SRG and MSRG, 2.5th and 975th percentiles were 0.06 and 4.0 (SRG) and 0.1 and 3.6 mIU/L (MSRG), respectively. Conclusions: In the population studied,TSH upper limit in the first trimester of pregnancy was above 2.5 mIU/L. The value of 3.6 mIU/L, found when iodine deficiency and thyroiditis (defined by antibodies and ultrasound characteristics) were excluded, matches recent ATA guidelines.

Likelihood of malignancy in thyroid nodules according to a proposed Thyroid Imaging Reporting and Data System (TI-RADS) classification merging suspicious and benign ultrasound features

ABSTRACT Objective The aim of this study was to describe the ultrasound features of benign and malignant thyroid nodules and evaluate the likelihood of malignancy associated with each feature according to the Bethesda System for Reporting Thyroid Cytopathology and histopathology. With this analysis, we propose a new TI-RADS classification system. Materials and methods The likelihood of malignancy from ultrasound features were assessed in 1413 thyroid nodules according to the Bethesda System for Reporting Thyroid Cytopathology and histopathological findings. A score was established by attributing different weights to each ultrasound feature evaluated. Results Features positively associated with malignancy in bivariate analysis received a score weight of +1. We attributed a weight of +2 to features which were independently associated with malignancy in a multivariate analysis and +3 for those associated with the highest odds ratio for malignancy (> 10.0). Hence, hypoechogenicity (graded as mild, moderate or marked, according to a comparison with the overlying strap muscle), microcalcification and irregular/microlobulated margin received the highest weights in our scoring system. Features that were negatively associated with malignancy received weights of -2 or -1. In the proposed system a cutoff score of 2 (sensitivity 97.4% and specificity 51.6%) was adopted as a transition between probably benign (TI-RADS 3) and TI-RADS 4a nodules. Overall, the frequency of malignancy in thyroid nodules according to the categories was 1.0% for TI-RADS 3, 7.8% for TI-RADS 4a, 35.3% for TI-RADS 4b, and 84.7% for TI-RADS 5. Conclusion A newly proposed TI-RADS classification adequately assessed the likelihood of malignancy in thyroid nodules.

Does low serum TSH within the normal range have negative impact on physical exercise capacity and quality of life of healthy elderly people?

Objective Investigate the differences in cardiopulmonary (CP) capacity and Quality of Life (QOL) between healthy elderly (≥ 65 years) with different TSH levels (< 1.0 and ≥ 1.0 μIU/mL) both within the normal range. Also, evaluate the effects of TSH elevation on CP test and QOL, by administering methimazole to subjects with initial lower-normal TSH, in order to elevate it to superior-normal limit. Materials and methods Initially, a cross-sectional study was performed to compare CP capacity at peak exercise and QOL (using WHOQOL-OLD questionnaire) between healthy seniors (age ≥ 65 years) with TSH < 1.0 μIU/mL vs. TSH ≥1.0 μIU/mL. In the second phase, participants with TSH < 1.0 μIU/mL were included in a non-controlled-prospective-interventional study to investigate the effect of TSH elevation, using methimazole, on QOL and CP capacity at peak exercise. Results From 89 elderly evaluated, 75 had TSH ≥ 1 μIU/mL and 14 TSH < 1 μIU/mL. The two groups had similar basal clinical characteristics. No difference in WHOQOL-OLD scores was observed between groups and they did not differ in terms of CP function at peak exercise. QOL and CP variables were not correlated with TSH levels. Twelve of 14 participants with TSH < 1.0 μIU/mL entered in the prospective study. After one year, no significant differences in clinical caracteristics, QOL, and CP variables were detected in paired analysis before and after methimazole intervention. Conclusions We found no differences in CP capacity and QOL between health elderly with different TSH levels within normal range and no impact after one year of methimazole treatment. More prospective-controlled-randomized studies are necessary to confirm or not the possible harm effect in normal low TSH.

Tratamento do hipotireoidismo no idoso / Treatment of hypothyroidism in the elderly

A população mundial está envelhecendo, e o interesse pelo estudo da associação entre disfunções tireoidianas e o processo de envelhecimento também. Existem evidências de que os níveis de TSH são mais elevados na população idosa, com uma relação positiva entre os aumentos da faixa etária e do TSH. A elevação do TSH pode chegar a mais de 20%, sendo que a grande maioria apresenta hipotireoidismo subclínico (HSC). Essa elevação ocorre também na população idosa sem doença autoimune tireoidiana, sugerindo que faça parte do processo fisiológico relacionado ao envelhecimento...

The world population is aging and the interest in the study of association between thyroid dysfunctions and aging process is also increasing. There are evidences that serum TSH levels are higher in the elderly population, with a positive relationship between age and TSH. The prevalence of TSH elevations can reach over 20%, and the vast majority has subclinical hypothyroidism (SCH). This elevation of TSH occurs also in the elderly population without autoimmune thyroid disease, suggesting that it could be part of a physiological process related to aging...

Exercise is associated with better quality of life in patients on TSH-suppressive therapy with levothyroxine for differentiated thyroid carcinoma / O exercício está associado com melhor qualidade de vida em pacientes em terapia de supressão de TSH com levotiroxina para o carcinoma diferenciado de tireoide

Objective : To evaluate if a supervised exercise training program improves the quality of life (QoL) of differentiated thyroid carcinoma (DTC) patients on TSH-suppressive therapy with levothyroxine (L-T4).Subjects and methods : Initially, a cross-sectional study was performed to compare the QoL and the health-related quality of life (HRQoL) between subclinical hyperthyroidism (SCH) patients (n = 33) and euthyroid subjects (EU; n = 49). In the prospective phase of the study, SCH patients were randomized in a non-blinded fashion to either participate (SCH-Tr = trained patients; n = 16) or not (SCH-Sed = untrained patients; n = 17) in a supervised exercise training program. The exercise program consisted of 60 minutes of aerobic and stretching exercises, twice a week, during twelve weeks. The QoL was assessed by the application of the WHOQOL-Bref, and the SF-36 was used to assess the HRQoL.Results : SCH patients had statistically lower scores than EU on the “physical” domain of WHOQOL-Bref, besides “physical function”, “role-physical”, “bodily pain”, “general health”, “vitality”, “role-emotional”, and “mental-health” domains of SF-36. After three months, SCH-Tr patients showed improvement in the “physical” and “psychological” domains of WHOQOL-Bref (p < 0.05), and in the “physical function”, “role-physical”, “bodily pain”, “vitality” and “mental health” domains of SF-36.Conclusion : Patients on TSH-suppressive therapy with L-T4 for DTC had impaired QoL and HRQoL compared to EU, but it was improved after 3-months of an exercise training program. Exercise seems to play an important role in the follow-up of DTC patients, since it seems to minimize the adverse effects of the treatment on QoL and HRQoL. Arq Bras Endocrinol Metab. 2014;58(3):274-81.

Objetivo : Avaliar se um programa de exercícios supervisionado melhora a qualidade de vida (QV) de pacientes com carcinoma diferenciado de tireoide (CDT) em tratamento de supressão de TSH com levotirotoxina (L-T4).Sujeitos e métodos : Inicialmente, foi feito um estudo cruzado para se comparar a QV e a qualidade de vida relacionada à saúde (QVRS) em pacientes com hipertireoidismo subclínico (HSC, n = 33) e indivíduos eutiroides (EU; n = 49). Na fase prospectiva do estudo, os pacientes com HSC foram randomizados de forma não cega para participar (HSC-Tr = pacientes treinados; n = 16) ou não (HSC-Sed = pacientes não treinados; n = 17) de um programa de exercícios supervisionado. O programa de exercícios consistiu de 60 minutos de atividade aeróbica e alongamento, duas vezes por semana, por 12 semanas. A qualidade de vida foi avaliada pelos questionários WHOQOL-Bref, e a QVRS pelo SF-36.Resultados : Os pacientes com HSC apresentaram escores estatisticamente mais baixos do que os EU no domínio “físico” do WHOQOL-Bref, além dos domínios “função física”, “papel físico”, “dor corporal”, “saúde geral”, “vitalidade”, “papel emocional” e “saúde mental” do SF-36. Após três meses, os pacientes HSC-Tr mostraram melhora nos domínios “físico” e “psicológico” do WHOQOL-Bref (p < 0,05) e nos domínios “função física”, “papel físico”, “dor corporal”, “vitalidade” e “saúde mental” do SF-36.Conclusão : Os pacientes em terapia de supressão de TSH com L-T4 para CDT apresentaram QV e QVRS afetados negativamente quando comparados com sujeitos EU, mas essas avaliações melhoraram após ...

Evaluation of thyroid function and autoimmunity in HIV-infected women / Avaliação da função tiroidiana e autoimunidade em mulheres infectadas pelo HIV

Autoimmune thyroid diseases (AITD) are the main causes of thyroid dysfunction and the most common autoimmune diseases in the world. An association between AITD and infections with the human immunodeficiency virus (HIV), in combination with the effects of highly active anti-retroviral therapy (HAART), has been suggested by several research groups. The aim of the present study was to evaluate the frequency of thyroid dysfunction and AITD in women > 35 years of age infected with HIV, and to identify factors associated with the emergence of these thyroid abnormalities. HIV-infected women (n = 153) selected from the infectious disease outpatient clinic at a University Hospital in Rio de Janeiro were characterized based on their circulating CD4+ lymphocytes levels, viral loads, serum TSH levels, and the presence of FT4 and anti-thyroperoxidase antibodies (TPO-Ab). A total of 129 participants were on HAART and 24 were not. The frequency of thyroid disorders was 7.8% (12/153 patients) and all were on HAART at the time of diagnosis, yielding a prevalence of 9.3% in patients receiving HAART compared with 0% in patients not on HAART. AITD, hyper, and hypothyroidism were detected in 4.6%, 3.1%, and 4.1% of HAART patients. It was not detected any thyroid dysfunction or autoimmunity in HIV-infected women not on HAART. This study demonstrated an association between HAART and the development of AITD. In addition AITD only developed in HAART patients also presenting with undetectable viral loads and slightly elevated CD4+ T cell counts.

Doenças tiroidianas autoimunes (DTAI) são a maior causa de disfunção tiroidiana e são as doenças autoimunes mais comuns no mundo. A associação entre DTAI e infecções com o vírus da imunodeficiência humana (HIV), em combinação com a terapia antirretroviral altamente ativa (HAART), foi sugerida por vários grupos de pesquisadores. O objetivo do presente estudo foi avaliar a fre-quência de disfunção tiroidiana e DTAI em mulheres com mais 35 anos de idade infectadas com o HIV e identificar fatores associados com a emergência dessas anormalidades tiroidianas. As mulheres infectadas com HIV (n = 153), selecionadas do ambulatório de doenças infecciosas de um hospital universitário do Rio de Janeiro, foram caracterizadas com base no nível de linfócitos CD4+ circulantes, carga viral, níveis de TSH sérico e presença de anticorpos FT4 e antitiroperoxidase (TPO-Ab). Um total de 129 participantes se tratava com HAART e 24 não. A frequência de desordens da tiroide foi 7,8% (12/153 pacientes) e todas estavam em tratamento com HAART no momento do diagnóstico, levando a uma prevalência 9,3% em pacientes recebendo HAART, em comparação com 0% em pacientes não tratadas com HAART. DTAI, hipertireoidismo e hipotireoidismo foram detectados em 4,6%, 3,1% e 4,1% das pacientes tratadas com HAART. Não foram detectadas disfunção tiroidiana ou autoimunidade em mulheres infectadas com HIV e não tratadas com HAART. Este estudo demonstrou uma associação entre a HAART e o desenvolvimento de DTAI. Além disso, a DTAI apenas se desenvolveu em pacientes tratadas com HAART e que apresentavam cargas virais indetectáveis e contagens de células CD4+ T levemente elevadas.

Prevalence of goiter and thyroid nodular disease in patients with class III obesity / Prevalência de bócio e doença nodular tireoidiana em pacientes com obesidade grau III

OBJECTIVES: To evaluate the prevalence of goiter and nodular disease in patients with class III obesity, and to correlate results with serum leptin levels and insulin resistance (IR) parameters. SUBJECTS AND METHODS: A cross-sectional study was performed to assess thyroid ultrasound (US) patterns, HOMA-IR, serum leptin, and TSH levels in obese patients and controls. RESULTS: Thyroid volume was positively correlated with body mass index (BMI) (r = 0.240, p = 0.039) and with HOMA-IR (r = 0.329; p < 0.01). Thyroid US patterns were similar between groups. However, when data from the male group was considered, greater thyroid volume was detected in the obese group compared with controls (10.8 vs. 8.5 cm³; p = 0.04). Also, nodules were more frequently detected (67% vs. 18%), as were nodules requiring FNAB (33.3% vs. 0%, p ≥ 0.05-0.09), in this group. CONCLUSION: Although IR did not correlate directly with the presence of nodules, the results support the hypothesis of a direct association between insulin resistance and thyroid volume.

OBJETIVOS: Avaliar a prevalência de bócio e doença nodular tireoidiana em pacientes com obesidade grau III e correlacionar os resultados com os níveis de leptina e parâmetros de resistência à ação da insulina (RI). SUJEITOS E MÉTODOS: Estudo seccional foi desenvolvido realizando ultrassonografia (US) tireoidiana e níveis séricos de HOMA-IR e TSH nos pacien­tes obesos e nos controles. RESULTADOS: Volume tireoidiano foi positivamente correlacionado com índice de massa corporal (IMC) (r = 0,240, p = 0,039) e com HOMA (r = 0,329; p < 0,01). Volume tireoidiano e prevalência de doença nodular tireoidiana foram similares entre os grupos. Quando avaliado o subgrupo masculino, maiores volumes tireoidianos foram detectados no grupo dos obesos comparados aos controles (10,8 vs. 8,5 cm³; p = 0,04), nódulos foram mais frequentes (67% vs. 18%), assim como nódulos com indicação de punção (33,3% vs. 0%, p ≥ 0,05-0,09). CONCLUSÃO: Embora RI não se correlacione diretamente com a presença de nódulos, os resultados suportam a hipótese da direta associação entre resistência à ação da insulina e volume tireoidiano.

Effects of subclinical hypothyroidism treatment on psychiatric symptoms, muscular complaints, and quality of life / Efeitos do tratamento do hipotiroidismo subclínico sobre sintomas psiquiátricos, queixas musculares e qualidade de vida

OBJECTIVES: To evaluate the impact of subclinical hypothyroidism (sHT) treatment on health-related quality of life (QoL), psychiatric symptoms, clinical score, and muscle function. MATERIALS AND METHODS: In this randomized double-blind study, patients were assigned either to treatment (n = 35) or placebo (n = 36). Clinical and psychiatric symptoms were assessed by the Zulewski, Hamilton and Beck scales. QoL was assessed by the SF-36 questionnaire. Assessments of quadriceps (QS) and inspiratory muscle (IS) strength were performed by a chair dynamometer and a manuvacuometer. RESULTS: Treatment improved IS (+11.5 ± 17.2; p = 0.041), as did QoL domains "Pain" and "Role Physical" (+19.7 ± 15.2, 0.039 and +22.1 ± 47.5, p = 0.054; respectively). Clinical and psychiatric symptoms showed similar responses to both interventions. CONCLUSIONS: sHT treatment improved IS and physical aspects of QoL, despite no impact in other muscle parameters. Clinical score, psychiatric symptoms, and SF-36 domains, based on mental dimensions of QoL may be more susceptible to "placebo effect" in patients with sHT.

OBJETIVOS: Avaliar o impacto do tratamento do hipotireoidismo subclínico (sHT) na qualidade de vida relacionada à saúde (QoL), aos sintomas psiquiátricos, ao escore clínico e à função muscular. MATERIAIS E MÉTODOS: Em um ensaio randomizado duplo-cego, pacientes foram randomizados para tratamento (n = 35) ou uso de placebo (n = 36). Sintomas clínicos e psiquiátricos foram acessados por meio das escalas de Zulewski, Hamilton e Beck. A QoL foi avaliada pelo questionário SF-36. Medidas da força de quadríceps (QS) e inspiratória (IS) foram obtidas por um dinamômetro de cadeira e um manovacuômetro. RESULTADOS: O tratamento melhorou a IS (+11,5 ± 17,2; p = 0,041), assim como os domínios "Dor" e "Aspectos Físicos" da QoL (+19,7 ± 15,2, 0,039 e +22,1 ± 47,5, p = 0,054, respectivamente). Sintomas clínicos e psiquiátricos demonstraram respostas similares a ambas as formas de intervenção. CONCLUSÕES: Tratamento do sHT melhorou IS e aspectos físicos da QoL, apesar de não ter impacto em outros parâmetros musculares. Escore clínico, sintomas psiquiátricos e domínios do SF-36 que focam em dimensões mentais podem ser mais suscetíveis ao "efeito placebo" em pacientes com sHT.

Impact of subclinical hypothyroidism treatment in systolic and diastolic cardiac function / Impacto do tratamento do hipotireoidismo subclínico na função cardíaca sistólica e diastólica

OBJECTIVE: To evaluate the effects of levothyroxine (L-T4) replacement in echocardiographic parameters of middle-aged women with subclinical hypothyroidism (SH). SUBJECTS AND METHODS: This was a randomized, double-blind, placebo-controlled study. Echocardiographic evaluation was carried out at baseline and one year after restoration of euthyroidism. Thirty-three women with SH were assigned to one of two groups (L-T4 or placebo). RESULTS: The two groups had similar basal characteristics. There was a significant deterioration of left ventricular Tei index after one year of placebo use, which differed from the effect of L-T4 replacement (+0.086 ± 0.092 vs. -0.014 ± 0.012; p = 0.047). There was also a slight reduction in cardiac output and cardiac index with placebo use, which was not different from L-T4 effect. CONCLUSION: Results suggest a positive impact of L-T4 replacement in cardiac function of middle-aged women with SH.

OBJETIVO: Avaliar os efeitos da reposição de levotiroxina (L-T4) nos parâmetros ecocardiográficos em mulheres de meia-idade com hipotireoidismo subclínico (HS). SUJEITOS E MÉTODOS: Realizado estudo duplo-cego, controlado com placebo com avaliação dos parâmetros ecocardiográficos no início e um ano após o restabelecimento do eutireoidismo. Trinta e três mulheres foram incluídas em dois grupos (uso de L-T4 ou placebo). RESULTADOS: Os dois grupos tinham características basais similares. Houve uma significativa piora do índice TEI do ventrículo esquerdo no grupo que usou placebo por um ano. Já no grupo em reposição com L-T4 observou-se uma leve melhora desse índice (+0,086 ± 0,092 vs. -0,014 ± 0,012; p = 0,047). Ocorreu também uma leve redução no débito cardíaco e no índice cardíaco com placebo, os quais não diferiram do efeito da reposição de L-T4. CONCLUSÃO: Os resultados sugerem um impacto positivo com a reposição de L-T4, na função cardíaca de mulheres de meia-idade, com HS.

Frequency of thyroid carcinoma and thyroid autoimmunity in first-degree relatives of patients with papillary thyroid carcinoma: A single center experience / Frequência de carcinoma de tireoide e autoimunidade tireoidiana em parentes de primeiro grau de portadores de carcinoma de tireoide: Experiência de um único centro

OBJECTIVE: To evaluate the frequency of thyroid cancer and thyroid dysfunction in first-degree relatives of thyroid cancer patients, and to determine if there is a difference between familial and sporadic thyroid cancer. SUBJECTS AND METHODS: Fifteen first-degree relatives of seven families with at least two family members with thyroid cancer (TC) were compared with 128 first-degree relatives of 45 families with only one family member affected. Laboratory and ultrasound evaluation, fine-needle aspiration biopsy and thyroid surgery were used as normally done in clinical practice. RESULTS: Thyroid dysfunction was similar between the two groups. The frequency of TC and autoimmunity in the group that had two relatives with known thyroid cancer was higher, compared with the families that had sporadic thyroid cancer among their family members (40 percent vs. 2 percent, p = 0.0001). CONCLUSION: Frequency of TC increases when more than one member of the family is affected. These findings suggest that these relatives should be screened more frequently than individuals in families in which only one case of TC is observed.

OBJETIVO: Avaliar a frequência de carcinoma de tireoide e disfunção tireoidiana em parentes de pacientes com câncer da tireoide e determinar se há diferença entre aqueles com mais de um familiar acometido e os casos esporádicos. SUJEITO E MÉTODOS: Quinze familiares de sete famílias com dois membros sabidamente acometidos foram submetidos à avaliação ultrassonográfica e laboratorial. Cento e vinte e oito familiares de pacientes com carcinoma de tireoide, porém sem outros casos na família, foram utilizados como grupo comparador. RESULTADOS: Em relação à disfunção tireoidiana, não houve diferença entre os grupos. A frequência de carcinoma da tireoide e autoimunidade foi maior nos parentes que tinham dois membros da família afetados (40 por cento vs. 2 por cento, p = 0.0001). A apresentação clínica foi semelhante nos dois grupos. CONCLUSÃO: Devido à maior frequência de carcinoma de tireoide em parentes que possuem mais de um familiar afetado, o rastreamento desses indivíduos talvez deva ser mais intenso do que nos casos em que há apenas um caso na família.

Impaired functional and hemodynamic response to graded exercise testing and its recovery in patients with subclinical hyperthyroidism / Capacidade funcional e hemodinâmica em esforço e na recuperação de pacientes com hipertireoidismo subclínico

OBJECTIVE: To evaluate the functional and hemodynamic responses during exercise and its recovery in patients with subclinical hyperthyroidism (SCH). SUBJECTS AND METHODS: A cross-sectional study was carried out with 29 patients on TSH-suppressive therapy with levothyroxine for thyroid carcinoma and 35 euthyroid subjects. All volunteers underwent a cardiopulmonary exercise testing on a treadmill and functional and hemodynamic variables were measured during exercise and its recovery. RESULTS: SCH patients showed impaired functional response to exercise, marked by lower values for oxygen consumption and exercise duration in addition to premature achievement of the anaerobic threshold. Heart-rate and blood pressure recovery immediately after exercise were slower among SCH patients when compared to euthyroid subjects. CONCLUSION: SCH is associated with impaired functional and hemodynamic responses during exercise and its recovery.

OBJETIVO: Avaliar a capacidade funcional e hemodinâmica em esforço e durante a recuperação em pacientes com hipertireoidismo subclínico (SCH). SUJEITOS E MÉTODOS: Foi realizado um estudo seccional em que participaram 29 pacientes em terapia supressiva de TSH com levotiroxina para carcinoma diferenciado de tireoide e 35 indivíduos sem doença tireoidiana. Todos foram submetidos a um teste cardiopulmonar de esforço em esteira, no qual foram medidas variáveis funcionais e hemodinâmicas durante o exercício e a recuperação. RESULTADOS: Os pacientes apresentaram um comprometimento na capacidade funcional, evidenciado por menores valores de consumo de oxigênio e duração de exercício, além do alcance prematuro do limiar anaeróbio. Imediatamente após o exercício, os pacientes apresentaram uma curva mais lenta de recuperação da frequência cardíaca e da pressão arterial. CONCLUSÃO: O SCH está associado ao comprometimento na capacidade funcional e hemodinâmica em esforço e na recuperação.