Tumour length as an independent prognostic factor in resectable oesophageal carcinoma.

INTRODUCTION: Oesophageal longitudinal tumour length has been investigated as a prognostic indicator for disease recurrence and overall survival in resectable oesophageal carcinoma. However, there is conflicting evidence regarding its use in clinical practice. This study aims to assess the prognostic significance of histological tumour length in potentially curative oesophageal resections for cancer. MATERIALS AND METHODS: Patients with locally advanced oesophageal carcinoma (squamous or adenocarcinoma) were identified in a single centre between July 2000 and December 2016. Patient demographics, tumour characteristics and survival outcomes were assimilated. Unifactorial and multifactorial analysis was performed to assess tumour length correlation with oncological outcomes. RESULTS: A total of 281 patients were included; 226 (80.4%) male and 55 (19.6%) female, with a median age of 66 years; 39 patients (13.9%) developed local recurrence and 104 (37%) distant metastases. Disease progression rate was 44.8% with a median progression-free survival of 21 months and median overall survival of 30 months. Median tumour length was 3cm (interquartile range 2-4.5cm). Multivariate analysis demonstrated longer tumours to be significantly associated with a higher rate of local recurrence (p=0.028), metastases (p=0.016), disease progression (p=0.001) and shorter progression-free survival (p=0.001). DISCUSSION: This study demonstrates histological tumour length as an independent prognostic factor for local recurrence, metastases, disease progression and progression-free survival. Further larger multicentre studies are required to define the role of longitudinal tumour length as a marker to identify patients who are at higher risk of poor oncological outcomes following surgery.

Serious toxicity associated with continuous nevirapine-based HAART in pregnancy.

OBJECTIVE: This study was designed to determine the safety of nevirapine (NVP)-based highly active antiretroviral therapy (HAART) in a cohort of HIV-positive pregnant women. DESIGN: This was a prospective cohort study of HIV-positive pregnant women. POPULATION AND SETTING: All HIV-positive women treated with HAART during pregnancy from January 1997 to February 2004 at the British Columbia (BC) Women's Hospital in Vancouver, BC, Canada. METHODS: Demographic and clinical data were collected to compare antiretroviral drug toxicities in women treated antenatally with NVP-based or non-NVP-based HAART. Multivariate analyses were then used to investigate determinants of toxicity. RESULTS: From 1997 to 2004, 103 HIV-positive pregnant women received HAART. Equivalent numbers of women were initially treated with NVP-based (54%) and non-NVP-based (46%) HAART. The groups did not differ by clinical or demographic parameters and duration of HAART exposure was similar between groups. Toxicities necessitating treatment discontinuation were observed in 6 of 56 NVP-exposed women (2 cases each of grade 2, 3, and 4 toxicity) compared with 1 of 47 in the non-NVP-exposed women. First time use of NVP approached significance as a predictor for toxicity, with a toxicity rate of 12.5% (6/48) observed among those taking NVP for the first time (adjusted OR 2.68, 95% CI 0.49-14.6). CONCLUSION: Continuous NVP use in pregnancy resulted in a relatively higher rate of toxicity, and all cases of NVP toxicity occurred in women exposed to NVP for the first time during pregnancy.

Acid-related oesophageal sensitivity, not dysmotility, differentiates subgroups of patients with non-erosive reflux disease.

BACKGROUND: Patients with non-erosive reflux disease can experience reflux symptoms with similar frequency and severity as those with erosive reflux disease. Oesophageal motility and acid sensitivity are thought to influence symptom occurrence. AIM: To compare the effect of infused hydrochloric acid on oesophageal physiology in patients with non-erosive reflux disease and erosive reflux disease. METHODS: Twelve healthy controls and 39 patients with reflux disease [14 erosive reflux disease, 11 non-erosive reflux disease with normal (functional heartburn) and 14 non-erosive reflux disease with excess acid exposure] had hydrochloric acid and saline infused into distal and then proximal oesophagus. Oesophageal contraction amplitude, lower oesophageal sphincter pressure and pain intensity were documented at baseline and during each infusion. RESULTS: Patients with non-erosive reflux disease had higher pain sensitivity to acid than those with erosive reflux disease and controls. Proximal acid infusion caused greater pain than distal in patients with non-erosive reflux disease. Acid and saline sensitivity were more pronounced in patients with functional heartburn. Lower oesophageal sphincter pressure and oesophageal contraction amplitudes were lower in the erosive reflux disease and non-erosive reflux disease groups, but did not change during infusions. CONCLUSIONS: Patients with non-erosive reflux disease and, to a lesser extent, patients with erosive reflux disease, are sensitive to acid in the oesophagus, being more sensitive to proximal acid. Hypersensitivity is most marked in functional heartburn patients. This acid sensitivity is not associated with motility change.

Thyroid autoantibody profiles in ophthalmic dominant and thyroid dominant Graves' disease differ and suggest ophthalmopathy is a multiantigenic disease.

BACKGROUND: Thyroid-associated ophthalmopathy (TAO) occurs in 25-50% of patients with Graves' disease (GD) and is occasionally seen in hypothyroid Hashimoto's disease or euthyroid individuals. The link between TAO and hyperthyroidism remains unclear. We hypothesized that qualitative or quantitative differences in thyroid antibodies might determine individual predisposition to these features. METHODS: In a prospective study over 3 years, thyroid antibody levels were measured in all patients diagnosed at the Singapore National Eye Centre to have GD. These patients had no known history of thyroid disease, presented with eye complaints and diagnosis was made by an ophthalmologist. A total of 31 patients were identified. Antibody levels were compared against 71 consecutive patients referred to a thyroid clinic (TC) for thyrotoxic symptoms in whom the diagnosis of GD was confirmed by a thyroidologist. FINDINGS: Thyroid autoantibody profiles of patients diagnosed at the ophthalmology centre (OC) and TC differed markedly. OC patients had significantly higher TSI (P = 0.003) but lower TPOAb (P = 0.008) and TgAb levels (P < 0.001). In contrast, TC patients had higher free T4 (P = 0.048) and higher TBII levels (P < 0.001). Antibody levels were correlated with four parameters of ophthalmopathy--chronic lid retraction, lid swelling, proptosis and extraocular myopathy (EOM). On univariate logistic regression analysis, TSI was a positive predictor and TPOAb and TgAb negative predictors of all four features. In the absence of TgAb, the odds ratios for individual TAO features ranged from 2.8 to 7.9, with corresponding values of 3.9-10.2 when TPOAb was absent. In stepwise logistic regression analysis, TSI was the strongest independent predictor of all aspects studied: lid fullness P = 0.001, proptosis P = 0.001, lid retraction P = 0.008, EOM P = 0.009. Among smokers, TPOAb were significantly lower (P = 0.044) but no association between smoking and the other antibodies was observed. INTERPRETATION: The study demonstrates markedly different thyroid autoantibody profiles in newly diagnosed GD patients with ophthalmic dominant as opposed to thyroid dominant features. It suggests differing antibody patterns are associated with predisposition to hyperthyroidism and orbitopathy. In addition, an association between smoking and low TPOAb levels was noted.

Restless legs symptoms in thyroid disorders.

Dopaminergic dysfunction is associated with thyroid disorders and restless legs syndrome (RLS). In a 'face-to-face' interview, we evaluated for RLS using the diagnostic criteria of the International Restless Legs Syndrome Study Group (IRLSSG) in patients diagnosed biochemically with either hyper- or hypothyroidism, and in controls without thyroid disorders. Amongst 146 consecutive patients with biochemically confirmed thyroid disorders, none satisfied all the IRLSSG criteria of RLS, similar to the control population (0.2%, 1/434). However, we found 8.2% (12/146) with RLS-like symptoms (satisfied the first 3 IRLSSG criteria) compared to 0.9% (4/434) in the controls (p < 0.0001). Four (33.3%) of these patients reported complete resolution of these symptoms after treatment for their thyroid condition. In conclusion, while RLS-like symptoms were observed in some patients with thyroid disorders, our study demonstrates no significant difference of RLS prevalence between patients with thyroid disorders and euthyroid controls.

Heterodigital arterialized flaps for large finger wounds: results and indications.

Deep defects of the hand and fingers with an unhealthy bed exposing denuded tendon, bone, joint, or neurovascular structures require flap coverage. However, the location and size of the defects often preclude the use of local flap coverage. Free-flap coverage is often not desirable either, because the recipient vessels may be unhealthy from surrounding infection or trauma. In such situations, a regional pedicled flap is preferable. A solution to this is the heterodigital arterialized flap. This flap is supplied by the digital artery and a dorsal vein of the finger for venous drainage. Unlike the neurovascular island flap, the digital nerve is left in situ in the donor finger, thus avoiding many of the neurologic complications associated with the Littler flap. The digital artery island flap is centered on the midlateral line of the donor finger. It extends from the middorsal line to the midpalmar line. The maximal length of the flap is from the base of the finger to the distal interphalangeal joint. By preserving the pulp and the digital nerve, a sensate pulp on the donor finger remains that reduces donor-finger morbidity and also preserves fingertip cosmesis. Twenty-nine flaps were performed in 29 patients and the outcomes in the donor finger and the reconstructed finger were reviewed. The flap survival was 100 percent. There were no cases of flap ischemia or flap congestion. Good venous drainage of the flap through the additional dorsal vein was helpful in preventing the occurrence of early postoperative venous congestion, which is common in island flaps of the fingers, which depend on only the venae comitantes for drainage. Donor-finger morbidity, measured in terms of range of motion and two-point discrimination in the pulp, was minimal. Ninety-seven percent of the donor fingers achieved excellent or good total active motion according to the criteria of Strickland and Glogovac. Pulp sensation in the donor fingers was normal in 28 of the 29 donor fingers. No cold intolerance of the donor finger or the adjacent finger is reported in this series.

EMG myokymia as a cause of ptosis in hypothyroidism.

Ptosis is known to be associated with thyroid disorders. We describe two biochemically corrected hypothyroid patients presenting with isolated bilateral ptosis. EMG of the orbicularis oculi showed continuous grouped motor unit potentials. In the absence of obvious aetiology, it is hypothesised that focal demyelination of terminal branches to the orbicularis oculi may play a role in the generation of the discharges.

Thyroid diseases in pregnancy.

INTRODUCTION: Changes in thyroid function in pregnancy encompass both hyper- and hypothyroidism. Failure to maintain euthyroidism may place both mother and foetus at higher risk of adverse obstetrical outcomes. This review examines the differences between physiological and pathological thyroid dysfunction during pregnancy and their management. METHODS: Data were obtained from relevant clinical studies and review articles listed in MEDLINE. Additional cross-references from selected articles were identified. RESULTS: In hyperthyroidism, the challenge lies in differentiating gestational transient thyrotoxicosis (GTT) from actual pathological states during the first trimester. GTT is thought to be due to elevation of isoforms of human chorionic gonadotropin (hCG) which may exert potent thyrotrophic effects. While thionamides are safe, the lowest possible dose should be used together with close monitoring of maternal thyroid function in order to avoid over-treatment. Surgery for thyroid nodules may be safely performed during the second trimester. Conversely, diagnosing hypothyroid states, particularly subclinical hypothyroidism and postpartum thyroiditis (PPT), require a high index of suspicion. High levels of thyroid peroxidase antibodies (TPOAb) and thyroid stimulating hormone (TSH) in early pregnancy may be predictive of PPT and subsequent permanent hypothyroidism. Clinicians must recognise the need to increase thyroxine replacement as maternal hypothyroidism may adversely affect the IQ scores of children. The association between thyroid autoimmunity and recurrent abortions remain unclear. CONCLUSION: Regardless of the aetiology of thyroid dysfunction, the key to management lies in individualized therapy in close collaboration with the obstetrician.

Prevalence of gestational thyrotoxicosis in Asian women evaluated in the 8th to 14th weeks of pregnancy: correlations with total and free beta human chorionic gonadotrophin.

OBJECTIVES: The prevalence of gestational transient thyrotoxicosis (GTT) in Europeans evaluated during the 8th to 14th weeks of pregnancy is 2-3%. However, there is evidence that GTT may be more common in some Asian populations. The aims of this study were to evaluate the prevalence of thyroid hormone abnormalities in Asian women in their 8th to 14th weeks of pregnancy using highly sensitive free T4 and TSH assays and to correlate these with total and free beta-hCG levels. DESIGN AND PATIENTS: One hundred and eighty-four consecutive unselected Asian (Singaporean) pregnant women seen at ante-natal clinics for the first time and who were in their 8th to 14th weeks of pregnancy were tested. MEASUREMENTS: Serum free T4, free T3, TSH, total beta-hCG and free beta-HCG levels were measured on the Vitros ECi system (Johnson & Johnson Ortho-Clinical Diagnostics, Amersham, UK) which employs chemiluminescent immunochemical technology. This free T4 assay is free of biases related to serum binding capacity. The TSH assay used was a third generation assay. Thyrotrophin-receptor antibody (TRAb) levels were measured using LUMItest TRAK (BRAHMS Diagnostica, Berlin, Germany). RESULTS: Two subjects (1.1%) were found to have Graves' disease. Elevated free T4, free T3, total T3 and suppressed TSH were seen in 14.8%, 3.3%, 26.4% and 33.0% of the remaining 182 pregnant women, respectively. Total and free beta-hCG correlated negatively with TSH (r = -0.30, P < 0.0001 and r = -0.29, P < 0.0001, respectively), positively with fT4 (r = 0.283, P < 0.001 and r = 0.253, P < 0.001) and fT3 (r = 0.273, P < 0.001 and r = 0.204, P < 0.01). 11.0% of cases had gestational thyrotoxicosis (GT) defined as elevated free T4 (> 19.1 pmol/l), suppressed TSH (< 0.36 mIU/l) and TRAb levels within the reference interval (0-0.9 U/l). The prevalence of GT was significantly higher in patients tested at 8-11 weeks compared to those evaluated at 12-14 weeks (14.4% vs. 4.7%, P < 0.05). Total beta-hCG (P = 0.0002), free beta-hCG (P < 0.0001) and free T4 (P = 0.02) levels were higher and TSH levels (P = 0.01) lower in patients tested at 8-11 weeks. Significant positive correlations between both total and free beta-hCG with free T4 were seen at 8-11 weeks but not in patients tested at 12 weeks or later. TT3 levels were similar in the two groups. CONCLUSIONS: Using sensitive assays, the prevalence of gestational thyrotoxicosis in Asian women was found to be 11.0% and was significantly higher in subjects at 8-11 weeks of gestation than at 12-14 weeks. The positive correlation between hCG and free T4 seen in patients tested at 8-11 weeks was absent in patients tested at later stages of the first trimester. Future studies investigating the entity of gestational thyrotoxicosis, at least in Asian patients, should focus on patients at earlier stages of gestation than currently practised.

Rigorous surveillance protocol increases detection of curable cancers associated with Barrett's esophagus.

Esophageal adenocarcinoma is increasing in incidence and has a high mortality unless detected early. Barrett's esophagus is the only known risk factor for this cancer; however, whether endoscopic surveillance reduces morbidity and mortality is controversial. Endoscopic cancer surveillance programes for Barrett's esophagus are not routinely practiced in the UK, and this is the first study to examine whether a rigorous surveillance protocol increases the detection rate of early oesophageal cancer. All patients with a diagnosis of Barrett's esophagus or associated adenocarcinoma attending Havering Hospitals NHS Trust between 1992 and 1998 were included. A retrospective analysis was made of patients undergoing informal surveillance (96 patients, 1992-1997) and a prospective analysis was conducted following the implementation of a rigorous protocol (108 patients, 1997-1998). Over the same time periods Barrett's associated cancers diagnosed in patients not undergoing surveillance were analyzed (262 patients 1992-1997, 98 patients 1997-1998). From 1992 to 1997, one case of high-grade dysplasia was detected (N = 96, 1%). From 1997 to 1998, two cancers and three high-grade dysplasias were detected during rigorous surveillance (N = 108, 4.6%). Three of these patients have had curative esophagectomies (one high-grade dysplasia and two T1,N0,M0 tumors). In 1992-1997, 10 patients were found to have cancer in previously undiagnosed Barrett's esophagus (N = 262, 3.8%). Of 3/10 cancers treated surgically, one patient had a curative procedure (T1,N0,M0). In 1997-1998, nine patients were found to have de novo Barrett's esophagus cancer (N = 88, 10.2%) and three had curative resections (T1,N0,M0). Two of the patients with T1 lesions had no endoscopic evidence of cancer but were detected as a result of the multiple biopsy protocol. In conclusion, a rigorous biopsy protocol increases the detection of early cancer in Barrett's esophagus.

Two Chinese families with Pendred's syndrome--radiological imaging of the ear and molecular analysis of the pendrin gene.

We report two families in whom the index cases satisfied the classical diagnostic criteria of Pendred's syndrome. In family I, two siblings were deaf, and one was normal. In family II, both parents and two offspring were deaf. Computed tomography scans performed in five of six of these deaf individuals showed enlarged vestibular aqueducts in all cases, and Mondini cochlea only in family II. Affected members in family I were compound heterozygotes inheriting the paternal allele with a novel mutation S398del in exon 10 and a maternal allele with two mutations IVS13+9C-->G in intron 13, in addition to H723R. In family II, the mother and one child carried both the novel intronic IVS8-2A-->G and H723R mutations, whereas the father and index case were homozygous for the IVS8-2A-->G mutation. A perchlorate discharge test was positive in 50% of cases tested. In conclusion, we concur that radiological and molecular studies should be performed for confirmation of Pendred's syndrome. We report, for the first time, a Pendred's syndrome family in which affected members had three mutations, as well as a second family in whom the intermarriage of two Pendred's syndrome patients resulted in Pendred's syndrome offspring.

A multiobjective evolutionary algorithm toolbox for computer-aided multiobjective optimization.

This paper presents an interactive graphical user interface (GUI) based multiobjective evolutionary algorithm (MOEA) toolbox for effective computer-aided multiobjective (MO) optimization. Without the need of aggregating multiple criteria into a compromise function, it incorporates the concept of Pareto's optimality to evolve a family of nondominated solutions distributing along the tradeoffs uniformly. The toolbox is also designed with many useful features such as the goal and priority settings to provide better support for decision-making in MO optimization, dynamic population size that is computed adaptively according to the online discovered Pareto-front, soft/hard goal settings for constraint handlings, multiple goals specification for logical "AND"/"OR" operation, adaptive niching scheme for uniform population distribution, and a useful convergence representation for MO optimization. The MOEA toolbox is freely available for download at http://vlab.ee.nus.edu.sg/-kctan/moea.htm which is ready for immediate use with minimal knowledge needed in evolutionary computing. To use the toolbox, the user merely needs to provide a simple "model" file that specifies the objective function corresponding to his/her particular optimization problem. Other aspects like decision variable settings, optimization process monitoring and graphical results analysis can be performed easily through the embedded GUIs in the toolbox. The effectiveness and applications of the toolbox are illustrated via the design optimization problem of a practical ill-conditioned distillation system. Performance of the algorithm in MOEA toolbox is also compared with other well-known evolutionary MO optimization methods upon a benchmark problem.

Inhibition of PKR activation by the proline-rich RNA binding domain of the herpes simplex virus type 1 Us11 protein.

Upon activation by double-stranded RNA in virus-infected cells, the cellular PKR kinase phosphorylates the translation initiation factor eukaryotic initiation factor 2 (eIF2) and thereby inhibits protein synthesis. The gamma 34.5 and Us11 gene products encoded by herpes simplex virus type 1 (HSV-1) are dedicated to preventing the accumulation of phosphorylated eIF2. While the gamma 34.5 gene specifies a regulatory subunit for protein phosphatase 1 alpha, the Us11 gene encodes an RNA binding protein that also prevents PKR activation. gamma 34.5 mutants fail to grow on a variety of human cells as phosphorylated eIF2 accumulates and protein synthesis ceases prior to the completion of the viral life cycle. We demonstrate that expression of a 68-amino-acid fragment of Us11 containing a novel proline-rich basic RNA binding domain allows for sustained protein synthesis and enhanced growth of gamma 34.5 mutants. Furthermore, this fragment is sufficient to inhibit activation of the cellular PKR kinase in a cell-free system, suggesting that the intrinsic activities of this small fragment, notably RNA binding and ribosome association, may be required to prevent PKR activation.

A man with osteoblastic metastasis and hypocalcaemia.

We report a case of an 80-year-old man with osteoblastic metastases from advanced carcinoma of the prostate presenting with a grand mal seizure resulting from severe hypocalcaemia. He had low serum phosphate and ionised calcium levels, elevated serum skeletal alkaline phosphatase and intact parathormone levels. 99mTc radioisotope bone scan revealed a "super bone scan" suggestive of osteomalacia. The serum 1, 25-dihydroxycholecalciferol level was unexpectedly elevated. The biochemical abnormalities persisted despite high dose calcium replacement, but improved with supraphysiological doses of 1,25 (OH)2 vitamin D3 (Rocaltrol) therapy. We hypothesise that the hypocalcaemia in this patient was due to vitamin D resistance secondary to a humoral factor secreted by the tumour.

Vancomycin pharmacokinetics and Bayesian estimation in pediatric patients.

The vancomycin pharmacokinetic profile was characterized in six pediatric patients and the potential of nonlinear mixed effects modeling and Bayesian forecasting for vancomycin monitoring was explored using NONMEM V (1.1). Based on steady state serial vancomycin concentrations, the estimates of mean t1/2, Vd, and Cl derived by the Sawchuk and Zaske method (1) were 3.52 hours, 0.57 L/kg, and 0.12 L/h per kg, respectively. NONMEM analysis demonstrated that a weight-adjusted two-compartment model described individual patients' data better than a comparable one-compartment model. The two-compartment estimates of mean t1/2alpha, t1/2beta, Vss, and Cl were 0.80 hour, 5.63 hours, 0.63 L/kg, and 0.11 L/h per kg, respectively. The relatively long mean t1/2alpha suggests that peak vancomycin concentrations measured earlier than 4 hours postdose do not reflect postdistributional serum concentrations. NONMEM population modeling revealed that a weight-adjusted two-compartment model provided a better fit than a comparable one-compartment model. The resulting population parameters and variances were fixed in NONMEM to obtain Bayesian predictions of individual vancomycin serum concentrations. Bayesian estimation with either a single midinterval or trough sample has the potential to provide accurate and precise predictions of vancomycin concentrations. This should be evaluated using a vancomycin population pharmacokinetic model based on a larger sample of pediatric patients.

Graves' ophthalmopathy in the absence of elevated free thyroxine and triiodothyronine levels: prevalence, natural history, and thyrotropin receptor antibody levels.

The aims of this study were to (a) determine the prevalence of patients without elevated thyroid hormone levels in Graves' ophthalmopathy (GO) using current generation free thyroid hormone assays, (b) measure the prevalence of thyrotropin receptor antibodies (TRAb) in these cases, and (c) identify possible predictors of hyperthyroidism. Over a 30-month period, 1020 cases of thyroid eye disease were evaluated, of which only 19 (1.9%) met the diagnostic criteria. Ten (1%) had subclinical thyrotoxicosis, 7 (0.7%) were euthyroid, and 2 (0.2%) were hypothyroid as determined by a third-generation thyrotropin (TSH) assay. TRAb levels were measured in 16 of these 19 patients. The prevalence of TRAb varied according to the assay used. Polyethylene glycol-extracted thyroid-stimulating immunoglobulin (PEG-TSI), unfractionated thyroid-stimulating immunoglobulin (uTSI), first-generation porcine TSH-binding inhibitory immunoglobulin (pTBII), and second-generation human TSH-binding inhibitory immunoglobulin (hTBII) assays were positive in 93.8%, 50%, 18.8%, and 81.3% of patients, respectively. TRAb was detected by at least one method in all patients. Patients were followed up for 15 to 45 months. Hyperthyroidism developed in 4 patients (25%). Suppressed TSH levels and elevated TBII were predictors of hyperthyroidism. When sensitive assays are used, the prevalence of GO patients without elevated thyroid hormone levels is extremely low. The sensitivities of assays for TRAb detection differ substantially in these cases. PEG extraction improves the detection rate of TSI (p = 0.02), and hTBII assays improve the detection of TBII in these patients (p = 0.002). The high prevalence of TRAb in such cases supports a role for these antibodies in the pathogenesis of thyroid-associated eye disease.

Thyrotoxicosis due to the simultaneous occurrence of silent thyroiditis and Graves' disease.

Silent thyroiditis (ST) and Graves' disease (GD) are two clinical entities belonging to the wide spectrum of autoimmune thyroid diseases (AITD). The two diseases are closely linked because sequential development of GD followed by ST, or the reverse course of events, ie, ST followed by GD, have been documented. However, the pathogenetic basis of the above association remains unknown. Some authors have suggested that the concomitant existence of ST and activation of GD can occur in thyrotoxic postpartum women with normal radioiodoine uptake. The simultaneous occurrence of the two diseases in different parts of the same thyroid gland has, however, to our knowledge, not been documented. We report the case of a 40-year-old thyrotoxic female with atypical presentation of GD. The titers of the antithyrotropin receptor antibodies were elevated and her initial 99mTc-pertechnetate thyroid scan showed the coexistence of ST and GD in different parts of the thyroid gland. Through serial thyroid scans, we document the recovery from ST in parts of the gland and demonstrate the progression to Graves' hyperthyroidism in the entire gland.