Programa nacional de bocio nodular (PRONBONO): Estudio multicéntrico de bocio nodular único palpable / National Program for Nodular Goiter (PRONBONO): Multicenter study of single palpable thyroid nodules

Introducción: La presencia de nódulos tiroideos palpables en la población general, es uno de los signos clínicos tiroideos más frecuentes en la práctica diaria. Objetivos: 1) establecer la prevalencia de las distintas patologías en bocio nodular único palpable y analizar sus características y su relación con los resultados citológicos. 2) analizar la existencia de diferencias regionales en Argentina. Pacientes y Métodos: Estudio prospectivo de 739 pacientes con bocio nodular único palpable evaluados entre el 1/1/2000 y el 31/12/2001 en Centros de Buenos Aires, Bahía Blanca, Mendoza y La Pampa. Se recabaron datos de examen clínico, ecografía tiroidea, TSH, ATPO y citología por punción con aguja fina. (PAAF). Fue utilizado para el análisis estadístico Correlación de Pearson, X2 y Test de Fisher. Resultados: la edad (X ± DS) fue 46,3 ± 14 años, 93,1 % eran de sexo femenino. El 1,6 % tenía historia de radiación en cuello y el 29,9 % antecedentes familiares de patología tiroidea. Hallazgos clínicos: disfagia en el 7,9 %, disfonía 3,5 %, crecimiento nodular en los últimos 6 meses 19,2 %, consistencia dura el 24,7 %, fijeza a estructuras adyacentes 1,5 % y adenopatías en el 3 %. Hallazgos bioquímicos: TSH normal en el 81,2 % y ATPO positivos en el 30,3 % de los casos. Características Ecográficas: nódulos sólidos: 53,1 %, hipoecoicos: 63,8 %, microcalcificaciones 10,3 %, halo incompleto: 15 %, multinodular: 30,5 %, tiroides heterogénea: 60,2 % y adenopatías: 3,8 %. Hallazgos citológicos: En el 86,8 % de los casos fue necesario solo una punción para llegar al diagnóstico. Insatisfactorio (excluyendo quiste): 3,2 %: benignos: 77,3 %; sospechosos: 12,6 % y cáncer: 7 % (42 papilar, 2 medular y 3 sin especificar). Una correlación significativa (p<0,02) fue observada entre citología maligna y crecimiento rápido, dureza, fijeza a estructuras vecinas, nódulo sólido, halo incompleto y adenopatías aunque estos parámetros son más frecuentes en números absolutos en nódulos benignos. La mayoría de las cirugías fueron indicadas en base al hallazgo citológico. El diagnóstico histológico de los 96 pacientes que fueron operados mostró 51 carcinomas, de los cuales solo dos tenían citología benigna y 31 adenomas. Conclusión: Los nódulos palpables únicos fueron más frecuentes en mujeres eutiroideas en la edad media de la vida. Un tercio tenía historia familiar de patología tiroidea, similar al porcentaje hallado de ATPO positivos. Por ecografía los nódulos fueron predominantemente sólidos, hipoecoicos, únicos con resto de la glándula tiroides heterogénea. La PAAF fue predominantemente benigna. El crecimiento rápido, la dureza, la fijeza a estructuras adyacentes, el halo incompleto y la presencia de adenopatías fueron relacionados con malignidad, pero la benignidad fue más frecuente. En la mayoría de los pacientes la cirugía fue recomendada por los hallazgos citológicos. Nuestros resultados son similares a los reportados en otras áreas geográficas.

Introduction: the presence of palpable thyroid nodules in the general population is one of the most common clinical signs of thyroid disease in daily practice. Objectives: 1) To assess the prevalence of pathologies, clinical and cytological findings of single palpable thyroid nodules (SPTN) in Argentina. 2) Analyze the regional differences in Argentina. Methods: Prospective study of 739 patients with STPN were evaluated at centres in Buenos Aires, Bahía Blanca, Mendoza, and La Pampa between 1/1/00 and 12/31/01. Clinical examination, thyroid ultrasound scan (US), TSH, TPOAb and fine needle aspirations (FNA) were performed. Statistics: Pearson Correlation, X2 & Fisher Tests. Results: Age (X ± SD) 46 ± 14ys: 93.1 % were women. Previous history of neck radiation & familial thyroid disease were found in 1.6 and 29.9 % respectively. Clinical findings: dysphagia: 7.9 %; dysphonia: 3.5%; nodule growth: 19.2 %; hard consistence: 24.7 %; fixation to adjacent structure: 1.5 % and lymphadenopathies (ADP): 3 %. Biochemical findings: TSH was normal in 81.2 % & TPOAb+ in 30.3 %. US features: solid: 53.1 %; hypoechoic: 63.8 %; microcalcifications: 10.3 %; incomplete halo: 15 %; more than 1 nodule: 30.5 %; thyroid heterogeneity: 60.2 % and ADP: 3.8 %. Cytology: Only 1 FNA was needed in 86.8%. Unsatisfactory (excluding cysts): 3.2 %; benign: 77.2%; suspicious: 12.6 % and cancer: 7 % (42 papillary, 2 medullary and 3 non specified). A significant correlation (p<0.02) was established between malignant nodules and rapid growth, hard, fixed, solid nodule, incomplete halo and ADP, though these parameters were more frequent (in absolute number) in benign nodules. Surgery was mainly indicated based on FNA results. Histological diagnosis of 96 patients who underwent surgery showed 51 carcinomas, of which only 2 were cytologically benign and 31 adenomas. Conclusion: Palpable single nodules were more frequent in middle aged euthyroid women. One third had familial thyroid pathology, similar to the presence of TPOAb. On US, nodules were predominantly solid, hypoechoic, single with heterogeneous thyroid gland. FNA was predominantly benign. Rapid growth, hard, fixed, solid nodule, incomplete halo and ADP were associated with malignancy, but benignity was more common. In most of the patients surgery was recommended based on cytological findings. Our results are similar to those reported in other geographic areas.

TSH Normal Alta: Su relación con bajo HDL-Colesterol en mujeres con resistencia a la insulina con independencia de otros posibles factores concurrentes / High Normal TSH: Its relationship with low HDL-Cholesterol in women with insulin resistance regardless of other possible concurrent factors

Objetivo: En el hipotiroidismo tanto clínico como subclínico se han descripto alteraciones en el metabolismo lipídico, entre ellas la disminución de colesterol de lipoproteínas de alta densidad (HDL-C). Considerando el rango normal de TSH entre 0.4-3.0 μUI/ml y valores normales altos entre 2.0 y 3.0 μUI/ml, nosotros investigamos la hipótesis de que niveles normales altos de TSH e insulinorresistencia (IR) se encuentran relacionados con HDL-C bajo en mujeres, en ausencia de otros factores concurrentes. Materiales y métodos: Estudiamos en un estudio transversal a 200 mujeres sanas, edad 18-50 años, eutiroideas, normotensas, con anticuerpos antiperoxidasa (ATPO) negativos, no diabéticas, premenopáusicas, IMC 18.0-25.0 Kg/m2, perímetro de cintura ≤ 88 cm; perímetro de cuello ≤ a 35 cm. Se las dividió en 4 grupos, cada uno compuesto por 50 mujeres: Grupo 1 (G1) TSH ≥ 2μU/ml, IR; grupo 2 (G2) TSH ≥ 2μU/ml, no IR; grupo 3 (G3): TSH 0,40 a 1,99 μU/ml, IR; Grupo 4 (G4) TSH 0,40 a 1,99 μU/ml, no IR. Se les midió lípidos, TSH, T4 total y libre (T4L), glucosa e insulina basal y posprandial, índices HOMA y QUICKI y volumen tiroideo (VT). Resultados: Observamos que en el G1 el nivel de HDL-C (46,7± 8,1 mg/dl) fue significativamente menor que en los restantes grupos. (vs G2: 56,8 ± 8,6 mg/dl; vs G3: 51,2 ± 7,6 mg/dl y vs G4: 56,5 ± 9,1 mg/dl. (p<0,01). La frecuencia de pacientes con HDL-C bajo en G1 fue significativamente mayor que en los restantes grupos (vs G2: OR 1,83, IC: 1,23-2,70; vs G3: OR 1,49, IC: 1,04-2,31; vs G4: OR 1,90, IC: 1,29-2,81) . No encontramos diferencias significativas en los niveles de HDL-C entre los restantes grupos. Conclusiones: Observamos en mujeres eutiroideas con TSH normal alta insulinorresistentes, sin otros factores concurrentes, niveles de HDL-C significativamente más bajos que en mujeres no insulinorresistentes y que en mujeres insulinorresistentes con TSH normal baja.

It has been described abnormalities in lipid metabolism in clinical and subclinical hypothyroidism, including the reduction of high-density lipoprotein cholesterol (HDL-C). Considering the normal range for TSH between 0.4-3.0 uUI / ml and high-normal values between 2.0 and 3.0 uUI / ml, we investigated the hypothesis that in euthyroid women, high-normal TSH levels and insulin resistance (IR) are associated with low HDL-C. We observed in euthyroid women with high-normal TSH and insulin resistance, without other factors, a significantly lower level of HDL-C than in non-insulin or insulin resistance women with low-normal TSH.

Management of overt and subclinical hypothyroidism. Factors influencing L-thyroxine dosage.

With the aim of establishing optimal dosage schedules, 171 women with either overt (OH, n = 80) or subclinical (SCH, n = 91) hypothyroidism were assessed before and 6 months after starting L-thyroxine (LT4) replacement therapy. Each group was further classified into four subgroups according to post-therapy serum TSH level, as follows: A) complete suppression; B) partial suppression; C) normal range and D) above normal range (insufficient response). In all subgroups, LT4 doses were higher for OH than for SCH, whether expressed as total daily dose (micrograms) or as a function of either actual or ideal body weight (micrograms/kg BW). In OH, LT4 dose was higher for subgroups A or B as compared with either C or D. In SCH, subgroup A received a larger dose than the other subgroups. Post-treatment serum thyroxine levels showed the same pattern for both OH and SCH. Mean LT4 dose was similar in patients with high and normal antithyroid antibodies and in patients with goiter and in those without it. In goitrous patients thyroid volume decreased in subgroup B, particularly in those patients that had elevated antithyroid antibodies, but not in subgroup C. In OH patients a significant negative correlation was found between daily LT4 dose per kg actual BW and actual BW, especially in subgroup C for patients with a body mass index > 27 kg/cm2 (r = -0.90, p < 0.001). In subgroup C of the SCH group, a negative correlation between LT4 dose and age was noticed. Both in OH and in SCH, LT4 dose per kg actual BW required to obtain a serum TSH within the normal range was lower in women with a body mass index (BMI) > 27 kg/m2 than in those with a BMI < or = 27 kg/m2. LT4 doses for subgroup C did not differ from those needed in hypothyroid patients with previous Graves' disease, in either OH or SCH patients.

Management of overt and subclinical hypothyroidism. Factors influencing L-thyroxine dosage.

With the aim of establishing optimal dosage schedules, 171 women with either overt (OH, n = 80) or subclinical (SCH, n = 91) hypothyroidism were assessed before and 6 months after starting L-thyroxine (LT4) replacement therapy. Each group was further classified into four subgroups according to post-therapy serum TSH level, as follows: A) complete suppression; B) partial suppression; C) normal range and D) above normal range (insufficient response). In all subgroups, LT4 doses were higher for OH than for SCH, whether expressed as total daily dose (micrograms) or as a function of either actual or ideal body weight (micrograms/kg BW). In OH, LT4 dose was higher for subgroups A or B as compared with either C or D. In SCH, subgroup A received a larger dose than the other subgroups. Post-treatment serum thyroxine levels showed the same pattern for both OH and SCH. Mean LT4 dose was similar in patients with high and normal antithyroid antibodies and in patients with goiter and in those without it. In goitrous patients thyroid volume decreased in subgroup B, particularly in those patients that had elevated antithyroid antibodies, but not in subgroup C. In OH patients a significant negative correlation was found between daily LT4 dose per kg actual BW and actual BW, especially in subgroup C for patients with a body mass index > 27 kg/cm2 (r = -0.90, p < 0.001). In subgroup C of the SCH group, a negative correlation between LT4 dose and age was noticed. Both in OH and in SCH, LT4 dose per kg actual BW required to obtain a serum TSH within the normal range was lower in women with a body mass index (BMI) > 27 kg/m2 than in those with a BMI < or = 27 kg/m2. LT4 doses for subgroup C did not differ from those needed in hypothyroid patients with previous Graves disease, in either OH or SCH patients.

[Iodine in school children. Relationship with incidence of goiter, socioeconomic group and salt intake]. / Ioduria en escolares. Relación con incidencia de bocio, nivel socioeconómico e ingesta de sal.

In order to evaluate iodine daily intake in 5-14 year-old school children urinary iodine excretion was measured in morning urinary samples of 134 school children. This value was corrected to microgram/ 24 h according to Jolin and Escobar del Rey's formula. Thyroid size was evaluated by two expert examiners following WHO criteria. Coincidence between both examiners was indispensable to establish goiter diagnosis. We evaluated urinary samples of 134 school children (117 normal and 17 goitrous). Urinary iodine excretion mean values were significantly different between Normal: 140.04 +/- 86.28 micrograms/24 h and Goitrous: 98.24 +/- 47.91 micrograms 24 h; p < 0.005). Goiter prevalence was found to diminish significantly when urinary iodine excretion was greater than 150 micrograms/24 h (p < 0.05). Similar mean urinary iodine excretion was observed in different socioeconomic groups. No significant differences were detected in the evaluation of two most common salt trademark consumer groups. In conclusion 1) iodoprophylaxis efficacy was assessed by urinary iodine excretion, a valid means to estimate iodine intake. Acceptable mean levels of iodine intake were found in the group under study, but the individual variability was important; 2) goitrous schoolchildren showed an iodine intake lower than normal and 3) the important variability observed in the evaluated data, the assessed relation between goiter and lower iodine intake, and the high frequency of insufficient iodine intake should justify a better control of iodoprophylaxis and a more widespread information dissemination among the population and perhaps iodine supplements in specific groups.