Comparative screening for thyroid disorders in old age in areas of iodine deficiency, long-term iodine prophylaxis and abundant iodine intake.

OBJECTIVE: To investigate the effect of varying amounts of iodine intake on the prevalence of thyroid dysfunction, autoimmunity and goitre in old age. DESIGN: The first screening study where elderly subjects with varying amounts of iodine supply but from the same geographical and ethnographical region (Carpathian basin) were compared, and all hormone measurements and ultrasonography were performed by the same laboratory or person. PATIENTS: Nursing home residents were screened for thyroid disorders from: (A) an iodine-deficient area, Northern Hungary (n = 119; median age 81 years; median iodine excretion (MIE) 0.065 mumol/mmol creatinine (equivalent to 72 micrograms/g creatinine); (B) an area of obligatory iodinated salt prophylaxis since the 1950s, Slovakia (n = 135; median age 81 years, MIE 0.090 mumol/mmol creatinine (equivalent to 100 micrograms/g creatinine)) and (C) an abundant iodine intake area, Eastern Hungary (n = 92; median age 78 years; MIE 0.462 mumol/mmol creatinine (equivalent to 513 micrograms/g creatinine)). MEASUREMENTS: TSH, T4, free T4, T3, thyroglobulin (Tg), antibodies to Tg (AbTg) and to thyroid peroxidase (AbTPO), iodine excretion, ultrasonography of the thyroid gland. RESULTS: In regions A, B, and C, the prevalence of unsuspected clinical hypothyroidism was 0.8%, 1.5% and 7.6% (P = 0.006), with all cases except one being antibody positive (Ab+). The occurrence of subclinical hypothyroidism was 4.2% in region A, 10.4% in region B and 23.9% in region C (P < 0.001), but only 3 of 22 cases with subclinical hypothyroidism from region C were Ab+. The overall prevalence of Ab positivity (either antiTg+ or antiTPO+) was similar in the three regions (A, 19.3%; B, 24.4%; C, 22.8%). The occurrence of hyperthyroidism (clinical plus subclinical) was 3.4% in region A, 3.0% in region B and 0% in region C (not significant). The rate of elevated Tg levels was similar in the three regions. The prevalence of goitre was 39.4%, 16.4% and 12.2% (P < 0.001), respectively in regions A, B and C. In euthyroid subjects the mean ultrasonographically determined thyroid volume was 21.9 ml in region A, 13.6 ml in region B and 15.1 ml in region C (ANOVA F = 5.76; P = 0.0038). There was no significant difference in the occurrence of cases with hypoechogenic echotexture of the thyroid gland. CONCLUSIONS: The screening for hypothyroidism in nursing home residents living in iodine-rich regions is justified by the high prevalence of unsuspected clinical hypothyroidism. The high prevalence of antibody positivity in old age is independent of the iodine supply, but iodine supply has a determining role in the development of autoimmune hypothyroidism in the aged. Most cases of subclinical hypothyroidism in iodine-rich regions are not of autoimmune origin. In old age, hypoechogenic texture of the thyroid gland is not predictive of thyroid dysfunction.

Adrenal incidentalomas--analysis of 23 cases discovered by ultrasound.

Frequent use of abdominal ultrasonography (USG) increases discovery of incidental adrenal tumors. Our experience and concise review of recent opinions on management of adrenal incidentalomas is presented. In four out of 23 patients with adrenal incidentalomas false positivity of USG was found (all on the left side), 4 cases were identified as pseudoadrenal masses. Hormonal activity was proved in 4 out of 15 true adrenal masses (2 pheochromocytomass, 2 aldosteronomas). Five out of 11 hormonally inactive tumors were benign adenomass, 2 myelolipomas, 2 simple cysts, 1 metastasis of bronchogenic carcinoma and 1 tuberculotic involvement. The smallest tumor was aldosteronoma (2 cm in diameter), the largest was myelolipoma (more than 10 cm). Size of benign adenomas ranged between 2.5-4.8 cm. Three main ultrasonic patterns of adrenal tumors were recognized: (1) anechogenic cysts, (2) complex but predominantly hyperechogenic myelolipomas, (3) hypoechogenic all other masses.

[Octreotide in the treatment of thyrotropin-secreting pituitary adenomas]. / Oktreotid v liecbe tyreotropín secernujúcich adenómov hypofýzy.

The authors detected in a 30-year-old patient a very rare type of hyperthyroidism caused by a thyrotropin secreting pituitary adenoma. Scintigraphic examination of the pituitary by means of 111In radiolabelled octreotide revealed an increased accumulation of the radiopharmaceutical preparation in the tumour, which confirmed the high density of somatostatin receptors. After onset of octreotide treatment (Sandostatin, Sandoz, Switzerland) 3 x 100 ug/day by the s.c. route a brisk decline and normalization of thyrotropin already after the first dose was recorded. The thyroxine concentration declined slowly to the upper range of normal values. After 5 months treatment despite the positive response to receptor scintigraphy diminution of the adenoma was not recorded. Again an increase of thyrotropin above the upper limit of the reference range and a marked rise of thyroxinaemia were observed. Six months after radical selective trans-sphenoidal adenomectomy normal pituitary function was confirmed.

[Thyrotropin-secreting adenomas of the hypophysis]. / Tyreotropín secernujúce adenómy hypofýzy.

Thyrotropin secreting pituitary adenomas are scarce. They may cause an extremely rare form of hyperthyroidism. The diagnosis is often delayed because the clinical symptoms are attributed to common types of hyperthyroidism. The diagnosis involves detection of elevated or normal (unsuppressed) thyrotropin levels in hyperthyroid patients and evidence of a pituitary adenoma by computed tomography or magnetic resonance imaging. The thyrotropin response in the thyrotropin-releasing hormone test is either absent or insufficient. When the pituitary microadenoma appears to be undetectable, the familiar syndrome of selective pituitary resistance to thyroid hormones has to be excluded. Treatment involves extirpation of the tumour. If the macroadenoma is not removed completely, external radiotherapy of the pituitary follows. If this conventional treatment does not produce an adequate effect, treatment with long-acting somatostatin analogues is recommended.

[Therapeutic approach in patients in hypertensive crisis]. / Terapeutický prístup k pacientovi s hypertenznou krízou.

The clinical picture of a hypertensive crisis is not determined only by the blood pressure reading but mainly by the associated symptoms of acute organ damage: neurological, cardiovascular and renal symptoms. The approach to the patient depends on the fact whether an emergency or urgent condition is involved. The authors review at first general principles of treatment of hypertensive crises. The analyze the therapeutic approach to different clinical conditions.

[Thin-needle aspiration biopsy in the preoperative diagnosis of non-toxic nodular goiter]. / Aspiracná tenkoihlová biopsia v predoperacnej diagnostike netoxickej uzlovej strumy.

The ascertainment of diagnostic reliability of fine needle aspiration biopsy in preoperative examination of non-toxic goitres is performed by comparing its results with the findings of the definitive histologic examination. The set of patients did not include those with the cytological finding of Hürtle tumour for the impossibility to distinguish between adenomas and carcinomas from oxyphilic cells by means of cytologic examination. Aspirates were stained by May, Grunwald and Giemsa method. Histologic results were gained from 185 patients. Cytologic findings were considered as benign in 95 cases (however 3 cases of cancer were revealed by the histologist--false negativity). In 90 cases, atypia, findings of suspectivity, or diagnosis of malignity were described, however the histologist evaluated 49 cases of goitres as being benign (false positivity). Totally 44 cases of malignant tumours were histologically diagnosed. Diagnostic sensitivity in our set of patients was 0.97 and diagnostic specificity was 0.46. In accordance with the available literature, fine needle cytodiagnosis is considered to represent an appropriate screening method in the process of decision as to whether conservative or surgical therapy with histologic verification in patients with non-toxic nodular goitres is to be indicated. (Tab. 1, Ref. 6.).

[The effectiveness of iodine prophylaxis of endemic goiter in Slovakia from the viewpoint of physical and ultrasonographic examinations of the thyroid gland]. / Ucinnost jódovej profylaxie endemickej strumy na Slovensku z hl'adiska fyzikálneho a ultrasonografického vysetrenia stítnej zl'azy.

Being aimed at the effectivity of iodine prophylaxis of endemic goitre the authors examined 2946 children and adolescents at the age of 6-18 years during the period from 1989 to 1995 in 6 regions of Slovakia. The thyroid glands were examined physically and ultrasonographically. The authors have found out that the occurrence rate of diffuse goitre is acceptable and it is not meeting the criteria of endemic goitre. No case of nodular goitre was revealed. Similarly to the relative frequency of diffuse goitre, neither the ultrasonographically measured volumes of thyroid glands differed among various areas. They are comparable with the volumes detected in countries with a sufficient iodine supply. The use of criteria for iodine deficiency evaluation recommended by WHO (goitre occurrence, thyroid gland volume, ioduria) leads the authors to consider the current prophylaxis of endemic goitre as being effective and successful. (Tab. 5, Ref. 20.).

[Surgical treatment of hyperparathyroidism]. / Chirurgická liecba hyperparatyreoidizmu.

The authors present their experience with the diagnosis and treatment of hyperparathyroidism in a group of eight patients operated between June 1993 and November 1993 at the Surgical Clinic of Dérer's Hospital in Bratislava-Kramáre. They summarize the findings on the disease from the literature and compare them with their own clinical observations, which confirm the indication of surgical revision as a useful localizing method, and the necessity of perioperative histological diagnosis to determine the extent of surgery.

Compliance with antihypertensive treatment in consultation rooms for hypertensive patients.

Compliance with antihypertensive therapy was examined by a questionnaire in 124 essential hypertension patients in an outpatient hypertension clinic. It was found that antihypertensive drugs were used regularly by only 62% of patients, with forgetting and feeling of well-being without therapy the principal reasons given for irregular drug taking. Treatment of hypertension is reported to have a deleterious effect on physical and mental activity, routine activities, sexual activity, memory, athletics and family life in only 2% of patients. Patients who were aware that increased BP reduces life span used the prescribed drugs more regularly and came regularly for checkups compared with patients lacking the relevant information. Patients over 60 years of age and smokers exhibited the worst compliance. No significant differences were found for sex or duration of treatment. With regard to nonpharmacological measures, most patients were willing to begin a programme of regular physical exercise, reduce weight, learn relaxation techniques and reduce alcohol intake: smokers, however were unable to stop the habit.

Incidence of thyroid hormone autoantibodies in patients with thyroid diseases with respect to diagnosis, other types of autoantibodies, duration of disease and treatment.

Thyroid hormone autoantibodies (THAA] were estimated in a total of 149 patients (139 women and 10 men) with various thyroid diseases. THAA were found in a total of 22 patients (all women), i.e. 14.7%. In 8 of them both T4Ab and T3Ab were found, while T4Ab only were found in 4 patients and T3Ab only in 10 patients. The highest incidence of THAA was found in patients with diffuse lymphocytic thyroiditis (i.e. 11 cases out of a total of 64 patients) and similarly high incidence was in patients with suspected autoimmune goiter but without thin needle biopsy (i.e. 5 cases out of a total of 21 patients). If only the patients with manifested or silent hypothyroidism were selected, T4Ab were found exclusively in this group, while the incidence of T3Ab was 3 times higher as that in patients without hypothyroidism. Though the incidence of T4Ab in patients with positive antithyroglobulin and antimicrosomal antibodies was 3 times higher than in negative ones, the difference was not significant. No correlation was found between the incidence of THAA on one hand and the duration of disease, the duration of treatment and the drug used for treatment on the other. However, a significant correlation was found between the incidence of THAA and the presence of goiter (P less than 0.05).

[Comparison of the results of radioimmunologic and hemagglutination methods in the determination of antibodies against thyroglobulin and the effect of these antibodies on thyroglobulin serum levels]. / Porovnanie výsledkov rádioimunologickej a hemaglutinacnej metódy na urcenie protilátok proti tyreoglobulínu a ovplyvnenie jeho hladiny v sére prítomnost'ou týchto látok.

The following methods have been introduced at our institute: labeling of human thyroglobulin (H-Tg) with the radioiodine 125I by the lactoperoxidase method, radioimmunologic method for serum H-Tg determination by means of rabbit antiserum to H-Tg prepared at our institute, and radioimmunologic method for the determination of antibodies to thyroglobulin. Sera from 15 patients with different thyropathies were examined by the given methods. In the first part of the work the quality of 125I labeled H-Tg was studied. The maximum binding by antiserum was found to be substantially decreased as early as two weeks following labeling, The second part of the study presents our first experience with comparing our RIA method and the hemagglutination method for TgAb determination. The results yielded by the two methods did not differ significantly. The level of serum H-Tg is falsely affected by the competition of TgAb autoantibodies with the first rabbit antibody to H-Tg at recipitation by means of the second antibody. It is therefore important to establish the titer of autoantibodies before actual serum H-Tg determination. This approach is of importance e.g. in following up patients with malignant goiter. The introduced methods are a contribution to diagnosis and management of patients with thyropathies.

Plasma cells in aspirates of goitre and overt permanent hypothyroidism following subacute thyroiditis. Preliminary report.

The occurrence of permanent overt hypothyroidism (POH) following subacute thyroiditis (SAT) was studied in 103 patients during 11-142 months (mean 52.8 months). Increased amount of plasma cells in cytological pictures of goitre aspirates was found at the time of diagnosis of SAT in 25 cases (24.3%). POH developed in 11 patients (10.7%). Eight patients with high titres of circulating thyroid antibodies demonstrated also cytological characteristics of autoimmune thyroiditis (increased amount of plasma cells inclusively) at the time of the diagnosis of SAT. Early developing POH in these patients was found. The association with HLA-Bw35 in this subgroup was not striking. In another subgroup of 3 patients POH developed after an interval of several years of euthyroidism following SAT. In such cases the autoimmune thyroiditis was not conspicuous and HLA-Bw35 was found in all 3 cases. Increased amount of plasma cells in aspirates of goitre at the time of symptomatology of SAT was observed only in one patient. It is concluded that increased amount of plasma cells (in addition to usual cytological picture of SAT) in aspirates of goitre at the time of clinical manifestation of SAT may be a warning of increased risk of development of permanent hypothyroidism following SAT. Some speculations on possible heterogeneity of subacute thyroiditis are presented.

The frequency of HLA-Dw1 determinant in subacute (de Quervain's) thyroiditis.

Investigation of a group of 23 patients suffering from subacute (de Quervain's) thyroiditis for the frequency of the HLA-Dw1 determinant showed this determinatant to be more frequent--30.4%--compared to its frequency in a healthy population--19.1%. The finding is not statistically significant.

Subacute (de Quervain's) thyroiditis: association with HLA-Bw35 antigen and abnormalities of the complement system, immunoglobulins and other serum proteins.

The HLA antigens in 40 patients with subacute thyroiditis were investigated. An association between subacute thyroiditis and HLA-Bw35 antigen as previously reported, was confirmed. Further immunological observations included a decrease in Serum Clq, C4 and C3 activator levels; conversely, there was an increase in serum C3, IgM, alpha1-acid glycoprotein and alpha1-antitrypsin levels. Serum IgA levels were decreased in those patients who were Bw35 negative, but were normal in the patients who were Bw-35 positive, with serum alpha2-macroglobulin levels the opposite was found. These studies support the view that a genetic factor(s), viz., the major histocompatibility system, plays a role in the pathogenesis of subacute thyroiditis. A "nosological clustering" around the Bw35 antigen as a marker for viral susceptibility is suggested.