Predictive factors for intraoperative excessive bleeding in Grave’s disease

Background: Grave’s disease frequently results in and is the most common cause of hyperthyroidism. It also often results in an enlarged thyroid. It also known as toxic diffuse goiter, is an autoimmune disease that affects the thyroid. This study evaluates all the factors that cause intra-operative blood loss and how it affects the grave’s disease.Methods: This study was conducted on 100 patients with Grave’s disease, who underwent thyroidectomy during the period from May 2010 to April 2016.Results: The majority of patients were females which constitute about 76.3% with a median age of 33 years. The median period between the onset of the disease and operation was 15 months. Weight of thyroid in grams was 40. Post-operative hospital stay was 3 days. Univariate analysis revealed that the strongest correlation of amount of intraoperative blood loss (AIOBL) was noted with the weight of thyroid (p<0.001). Additionally, AIOBL was correlated positively with the period be- tween disease onset and surgery (p<0.001) and negatively with preoperative free T4 (p<0.01). Occurrences of postoperative complications, such as recurrent laryngeal nerve palsy or hypoparathyroidism, and postoperative hospital stay were not correlated with AIOBL.Conclusions: For Grave’s disease, for excessive bleeding during surgery, a large goiter presented as a predictive factor, and transfusion of blood should be considered in cases in which goiter weighs more than 200 g.

Graves hyperthyroidism in pregnancy: a rare presentation

Hyperthyroidism in pregnancy is much less common occurring in 0.1-0.2% of women with Grave’s disease being the most common cause accounting for 90% of the cases. It is important to diagnose hyperthyroidism in pregnancy because fetal loss in untreated patients is high and may even be life threatening for the mother. We are presenting a case of 29 years old G3P2L1 who presented to our emergency with amenorrhea of 7 months and history of loose stools for the last 20 days. It was associated with generalized weakness. She also had history of palpitations, weight loss and sleep disturbances. She was a known case of hyperthyroidism for the past 1-2 years and was already taking anti-thyroid drugs. B/L exophthalmos was apparently present. Patient was severly anaemic with haemoglobin of 5.5gms/dl. Ultrasound showed fetal demise at 28weeks. Patient was given 3 units of blood transfusion and was induced with prostaglandins. She delivered a dead male baby weighing 1.2kgs. Her postpartum period was uneventful. Timely diagnosis of graves hyperthyroidism and its optimal treatment throughout pregnancy is vital in reducing maternal, fetal and neonatal complications.

Hijos de madres con enfermedad de Basedow Graves / Newborn of mothers with Graves' disease

Resumen: Introducción: La causa más frecuente de hipertiroidismo congénito es la enfermedad de Basedow Graves (EG) materna, en la que anticuerpos anti receptor de hormona tiroestimulante (TSH) (TRAb) atraviesan la placenta estimulando al receptor de TSH fetal y/o neonatal para producir hormonas ti roideas. La disfunción tiroidea en estos pacientes se confirma con el aumento de las concentraciones de tiroxina (T4) y triyodotironina (T3) acompañado de niveles de TSH suprimida. Objetivos: Carac terizar la evolución clínica y bioquímica de los recién nacidos (RN) hijos de madres con EG, y sugerir recomendaciones respecto al tratamiento y seguimiento. Material y Método: Se realizó una revisión de la literatura usando la base de datos MEDLINE, identificando artículos que incluyeran más de 30 RN de madres con EG y describieran su evolución. Se agregaron además revisiones del tema enfati zando la evaluación y manejo de los hijos de madres con EG. Resultados: Se incluyeron 9 estudios de cohorte que incorporaron 790 embarazadas. Hubo heterogeneidad entre los trabajos; un porcentaje variable de los hijos desarrolló tirotoxicosis neonatal, la que fue más frecuente cuando las madres presentaron concentraciones elevadas de TRAb. El tratamiento de los RN se inició según diferentes criterios. La literatura recomienda tratar los casos de hipertiroidismo clínico y considerarlo en casos de hipertiroidismo bioquímico. Conclusión: Los hijos de madres con EG y TRAb elevados deben ser evaluados por la probabilidad de desarrollar tirotoxicosis neonatal. Se sugiere controlar función tiroidea periódicamente durante el primer mes de vida y tratar los pacientes con hipertiroidismo clínico y bioquímico.

Abstract: Introduction: The most frequent cause of congenital hyperthyroidism is maternal Graves' disease (GD), in which thyroid stimulating hormone (TSH) receptor antibodies (TRAb) cross the placenta and stimulate the fetal and/or neonatal TSH receptor to produce thyroid hormones. Thyroid dys function in these patients is confirmed by increased thyroxine (T4) and triiodothyronine (T3) levels accompanied by suppressed TSH levels. Objective: To characterize the clinical and biochemical evo lution of newborns of mothers with GD and to suggest recommendations regarding treatment and follow-up. Material and Method: A literature review using the MEDLINE database was made, iden tifying scientific articles that included more than 30 neonates of mothers with GD and described their evolution. In addition, a review of the topic with an emphasis on the evaluation and management of these patients was included. Results: Nine cohort studies were included, with a total of 790 pregnant women. There was high heterogeneity among the studies. A variable percentage of newborns deve loped neonatal thyrotoxicosis, which was more frequent in those patients whose mothers had high levels of TRAb. The treatment of newborns was initiated according to different criteria. The literature recommends treating cases of clinical hyperthyroidism and considers it in cases of biochemical hy perthyroidism. Conclusion: Children of mothers with GD and high TRAb should be evaluated due to the likelihood of developing neonatal thyrotoxicosis. It is suggested to monitor thyroid function periodically during the first month of life and treat patients with clinical and biochemical hyper thyroidism.

Lipoprotein associated phospholipase A2 enzyme; possible new roles and inhibition for therapeutic intervention.

Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) is a 45-kDa protein of 441 amino acids encoded by the pla2g7 gene in the humans. In the blood it is associated mainly with Low Density Lipoprotein (LDL) and less than 20% is associated with High Density Lipoprotein (HDL). This enzyme is characterized by its ability to specifically hydrolyze PAF as well as glycerophospholipids containing short, truncated, and/or oxidized fatty acyl groups at the sn-2 position of the glycerol backbone. Genetic studies conducted in humans harboring an inactivating mutation at this locus suggest that loss of Lp-PLA2 function is a risk factor for inflammatory and vascular conditions. Consistently, overexpression of Lp-PLA2 has anti-inflammatory or pro-inflammatory actions and anti-atherogenic properties in animal models. This article discusses two simple techniques to estimate Lp-PLA2 activity. New therapeutic agents inhibiting the activity of Lp-PLA2 are being investigated for curative purpose.

The sickness impact and the quality of life in Grave's disease patients after treatment with 131I / 中华行为医学与脑科学杂志

Objective To evaluate the sickness impact and the quality of life in patients who received 131 I treatment for Grave's disease with one year of follow-up.Methods 376 patients with Grave's disease(GD) who voluntarily received 131I treatment were recruited.The follow-up archives were established.The Sickness Impact and the Quality of life in patient' s with GD were measured using the Sickness Impact Profile (SIP),Self-Rating Anxiety Scale (SAS),Self-Rating Depression Scale(SAS) and Social Disability Screening Schedule (SDSS) and Quality of life scale(QLS,SF-36) before and after treatment with 131I for 6 months and 12 months.Results 57 out of 376 cases were lost.319 cases finished follow-up studies.There was significant difference of SAS,SDS,SDSS,SIP and SF-36 and their agent score among three groups:before and 6months and 12months after 131I treatment in the 319 patients(F=8.561-1080.317,P＜0.001).After treatment with 131I,SAS,SDS,SDSS and SIP score were lower(P＜0.05),SF-36 total and agent score were higher(P＜0.05).There was no significant difference between the score of SAS,SDS,SDSS,SIP total score and it' s agent score of SD-Ⅱ,SR,W,SF-36 agent score of RP,BP,VT,SF at the end of 12 months compared to the score at the end of 6 months(P＞0.05).But there was significant difference between the score of SIP agent score of SD-Ⅰ,HM,RP,SF-36 total score and it' s agent score of PF,GH,RE,M H at the end of 12 months compared to the score at the end of 6 months (P＜0.05).At the end of 6 months and 12 months after treatment the subjects were divided five groups according to different clinical outcome.Not only at the end of 6 months,but also at the end of 12 months,there was significant difference of SAS,SDS,SDSS,SIP total score,and it' s agent score of SD-Ⅰ,SD-Ⅱ,SR,W,RP,SF-36 total score,and it's agent score PF,RP,BP,GH,VT,SF,RE,MH among the five groups(F6 =6.870-143.790,F12 =13.956-837.184,P＜0.001).There was no significant difference of HM among five groups (F6 =1.733,P6 =0.142; F12 =2.015,P12 =0.092).The score of SF-36 and its agent score PF,RP,VT,SF,RE,MH in three subgroup (healthy control,the patient group at end of 6 months and 12 months with normal thyroid function) was significant different,respectively(F=8.320-82.791,P＜0.001).There was no significant different for agent score of BP and GH(F=2.990,2.652,P=0.051,0.072).Conclusion Quality of life of patients with GD is decrease.131I treatment can improve it,but socialpsycho function can not be improved satisfactorily.It is necessary for GD patients to pay attention to the quality of life and provide effective mental intervention to improve the recovery completely.

Hipertireoidismo congênito / Congenital hyperthyroidism

Objetivo: Relatar a importância de suspeitar e reconhecer o quadro clínico do hipertireoidismo congênito, dado sua infrequência. Descrição: Os autores relatam um caso de hipertireoidismo congênito diagnosticado em recém-nascido de parto normal com 32 semanas, o qual permaneceu internado por prematuridade, baixo peso de nascimento (sem necessidade de suporte ventilatório), vômitos e dificuldade para ganhar peso. A criança se apresentava taquicárdica, com aspecto de desnutrido e exoftalmia. Foi diagnosticada doença de Graves materna com aproximadamente 29 semanas de gestação, sendo iniciado seu tratamento com propiltiouracil e cloridrato de propranolol. Comentários: Concluímos que a suspeita clínica e o diagnóstico pré-natal de doença de Graves materna evitam danos ao feto e possibilitam adequado tratamento e acompanhamento ainda durante a gestação. O tratamento com propiltiouracil ainda é o melhor para a gestante e para reduzir complicações.

The clinical value of serum IL-6 detection in patients with Graves / 中国综合临床

Objective To study the clinical value of serum FL-6 detection in patients with Graves. Methods The level of IL-6 was detected in 75 Graves patients and controls with ELISA, the correlation between IL-6, other function parameter (T3, T4, etc.) and immune indicators (TRAb) were analyzed. Results The level of IL-6 in Graves patients was(1. 84 ±1. 58) ng/L, which was significantly higher than the healthy controls(l. 28 ±0.46)ng/L (t=2.55,P<0.05).IL-6 was positive correlation with T3(r =0. 55) ,T4(r =0. 40) ,FT4(r =0. 36) , FT3(r = 0. 35)and TRAb(r = 0. 47) (P <0. 05)and was negative correlation with TSH(r= -0. 58, P < 0. 05). Conclusions IL-6 can be used as a good index of immune derangement and thyroid function disorders in Grave patients.

Análise morfométrica da fenda palpebral de pacientes com oftalmopatia distireóidea antes e após aplicação de toxina botulínica tipo A / Morphometric analysis of the palpebral fissure in patients with thyroid-related disfunction before and after application of botulinum toxin / Morphometric analysis of the palpebral fissure in patients with thyroid-related disfunction before and after application of botulinum toxin

INTRODUÇÃO: A toxina botulínica tem sido usada como opção terapêutica para retração palpebral em pacientes com oftalmopatia distireóidea. Os objetivos deste trabalho foram apresentar dados morfométricos da fenda palpebral, avaliar o efeito da medicação sobre a função do músculo elevador da pálpebra superior e em relação à exposição ocular. MÉTODOS: Foram incluídos 7 pacientes com retração palpebral. A propedêutica foi realizada com o registro de imagens através de câmera filmadora digital. Foram utilizados programas para edição dos vídeos e para análise da fenda palpebral. Também foi realizada a medida da função do tendão do músculo elevador da pálpebra superior e a propedêutica do filme lacrimal. RESULTADOS: Os dados morfométricos mostraram uma diminuição da fenda palpebral e da distância entre a margem da pálpebra superior e o reflexo luminoso no centro da córnea, a função do músculo elevador da pálpebra superior apresentou uma diminuição de seu valor e a propedêutica do filme lacrimal evidenciou uma maior estabilidade do filme lacrimal após o uso da medicação. DISCUSSÃO: A toxina pode ser uma opção de tratamento para pacientes com retração palpebral, amenizando o problema estético e os sinais de exposição corneana.

INTRODUCTION: Botulinum toxin is an alternative treatment for retraction of ocular thyroid related dysfunction. The aim of this study was to evaluate the effects of this medication on upper lid position, levator palpebrae superioris muscle function and corneal exposure. METHODS: Seven patients were enrolled into the study. The palpebral fissure images were acquired by a digital camera and transferred to a computer video edition program in order to be processed and analyzed. The levator palpebrae superioris muscle function and lacrimal film tests were also studied. RESULTS: The distance between upper eyelid superior margin and light reflection on the center of the cornea had a significantly reduction in its measurements after toxin injection. The muscle function was diminished and there were improvement in corneal exposure after treatment. DISCUSSION: Botulinum toxin injection could be an alternative treatment for upper eyelid retraction; it may relieve symptoms and improve eye appearance.

A Case of Polyglandular Autoimmune Syndrome

When dysfunction of two or more endocrine glands occurs in association with circulating organ specific antibodies directed against the involved glands, the term polyglandular autoimmune (PGA) syndrome is applied. This syndrome is usually classified into three groups. The autoimmune nature of this disease has been based on the presence of lymphocytic infiltration of the affected glands, organ specific autoantibody in serum, cellular immune defects and association with HLA DR/DQ genes. A 12-year-old girl developed PGA syndrome, type III manifesting Grave's disease and insulin-dependent diabetes mellitus. The thyroid microsomal Ab, TSH receptor Ab and pancreatic islet cell Ab were positive. She should be observed for the possible development of adrenal insufficiency and/or other autoimmune disease.

Diagnostic approach to thyroid carcinoma in Graves' disease

Among 545 surgically treated Graves' disease patients, 17 were found to have coexisting thyroid neoplasms. Of these 17 patients, 11 turned out to have thyroid carcinomas. These patients could be divided into 2 groups; Group I with a diffusely enlarged gland with a clinically palpable nodule (n = 6) and Group II without a palpable nodule (n = 5). In Group I, 4 patients were diagnosed by preoperative fine needle aspiration cytology, and the remaining 2 by intraoperative frozen-section examination. In Group II, none of the patients were suspected of any concurrent thyroid carcinoma preoperatively, and only 2 were identified by intraoperative frozen-section examination. Thus, 8 of the 11 patients were diagnosed preoperatively or intraoperatively. These observations suggest that in all patients with Graves' disease and concurrent thyroid nodules, the suspicion of associated malignancy may be raised. And also, fine needle aspiration cytology in every case of Graves' disease with a palpable nodule and intraoperative frozen-section examination of the suspicious lobe in the cases of non-palpable nodules appear worthwhile in detecting a concurrent thyroid carcinoma.