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1.
J Thyroid Res ; 2014: 364146, 2014.
Article in English | MEDLINE | ID: mdl-24587936

ABSTRACT

Objective. To study histopathology of the thyroid and parathyroid glands in HIV-infected African Americans in the United States. Methods. A retrospective review of 102 autopsy cases done by the Department of Pathology at Howard University Hospital from 1980 through 2007 was conducted. The histopathological findings of the thyroid and parathyroid glands were reviewed, both macroscopically and microscopically. A control group of autopsy patients with chronic non-HIV diseases was examined. Results. There were 71 males (70%) and 31 females (30%) with an average age of 38 years (range: 20-71 y). Thirteen patients with abnormal thyroid findings were identified. Interstitial fibrosis was the most common histological finding (4.9%), followed by thyroid hyperplasia (1.9%). Infectious disease affecting the thyroid gland was limited to 2.9% and consisted of mycobacterium tuberculosis, Cryptococcus neoformans, and cytomegalovirus. Kaposi sarcoma of the thyroid gland was present in only one case (0.9%). Parathyroid hyperplasia was the most common histological change noted in the parathyroid glands. Comparing the histological findings of cases and controls, we found a similar involvement of the thyroid, with a greater prevalence of parathyroid hyperplasia in HIV patients. Conclusion. Thyroid and parathyroid abnormalities are uncommon findings in the HIV-infected African American population.

5.
Acta Cytol ; 53(5): 517-23, 2009.
Article in English | MEDLINE | ID: mdl-19798878

ABSTRACT

OBJECTIVE: To address the likelihood of thyroid malignancy for each cytologic interpretation, highly cellular and benign vs. follicular carcinoma, with particular attention to the indeterminate cytologic result, follicular neoplasm. STUDY DESIGN: We retrospectively reviewed thyroid nodule cytologic and histologic interpretations from 1994 to 2002 in a tertiary medical center setting. Patients were referred for evaluation of thyroid nodules found incidentally or on physical examination. RESULTS: A total of 886 thyroid nodules were aspirated in 802 patients (500 benign, 195 indeterminate, 129 inadequate, 62 malignant). Of 195 indeterminate lesions, 180 were classified as follicular neoplasm or "cannot rule out/possible" follicular neoplasm, with 144 of these ultimately removed and with malignant histologic findings in 28. Any mention of follicular neoplasm in the cytology report conferred a 19.4% risk of malignancy in patients who went on to surgery (including an unexpected 18.2% rate of malignancy in the subcategory in which a possible follicular neoplasm was a secondary listing in an otherwise-benign cytologic differential diagnosis). CONCLUSION: There was no difference in the likelihood of histologic malignancy between the cytologic subcategories of "definite "follicular neoplasm and "cannot rule out/possible" follicular neoplasm. We recommend that cytologic reports on fine needle aspiration of thyroid nodules with a diagnosis of follicular neoplasm reflect this fact.


Subject(s)
Adenoma/pathology , Biopsy, Fine-Needle , Carcinoma, Papillary/pathology , Thyroid Neoplasms/pathology , Thyroid Nodule/pathology , Adenoma/surgery , Adolescent , Adult , Aged , Aged, 80 and over , Carcinoma, Papillary/surgery , Child , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Retrospective Studies , Risk Assessment , Thyroid Neoplasms/surgery , Thyroid Nodule/surgery , Young Adult
6.
Thyroid ; 18(5): 571-3, 2008 May.
Article in English | MEDLINE | ID: mdl-18407755

ABSTRACT

OBJECTIVE: Surgery-induced thyroiditis can pose a significant clinical problem that is underappreciated. We present a case of new-onset atrial fibrillation as a consequence of palpation thyroiditis in a 70-year-old man who underwent radical right neck dissection for malignant melanoma and review the limited literature on this topic. DESIGN: Biochemical parameters including thyrotropin, free thyroxine, triiodothyronine, erythrocyte sedimentation rate, C-reactive protein, thyroglobulin, thyroid stimulating immunoglobulins, thyroid binding inhibitory immunoglobulins, thyroid peroxidase, thyroglobulin antibodies, and 24-hour urine iodine were measured. Thyroid ultrasound and technetium-99m pertechnetate scintigraphy with radioactive iodine 131 uptake were employed for diagnostic purposes. MAIN OUTCOME: Following right neck exploratory dissection, the patient developed hyperthyroidism and atrial fibrillation. Imaging studies were compatible with right lobar thyroiditis. Other etiologies of thyroiditis were excluded. Despite normalization of thyroid function after 2 weeks, atrial fibrillation persisted and required cardioversion. CONCLUSIONS: Manipulation of the thyroid gland during neck exploratory surgery can result in hyperthyroidism with atrial fibrillation as a consequence. To avoid this complication, careful attention should be paid during surgical procedures or other clinical situations in which the thyroid gland is manipulated.


Subject(s)
Atrial Fibrillation/etiology , Thyroiditis/complications , Aged , Atrial Fibrillation/diagnosis , Humans , Hyperthyroidism/etiology , Male , Thyroid Gland/surgery , Thyroiditis/diagnosis
7.
Endocr Pract ; 14(9): 1137-49, 2008 Dec.
Article in English | MEDLINE | ID: mdl-19158054

ABSTRACT

OBJECTIVE: To review the pathogenesis as well as the clinical and laboratory features of catecholamine-induced cardiomyopathy associated with pheochromocytoma and other disorders and discuss the various treatment options available. METHODS: Materials used for this article were identified through MEDLINE, PubMed, and Google Scholar searches of the relevant literature from 1955 to the present. RESULTS: Catecholamines and their oxidation products cause a direct toxic effect on the myocardium. Catecholamines also exert a receptor-mediated effect on the myocardium. Catecholamine-mediated myocardial stunning has been implicated in the pathogenesis of stress-induced cardiomyopathy. Biopsy of the myocardium in patients with pheochromocytoma or those with stress-induced cardiomyopathy shows similar pathologic findings. The clinical features in pheochromocytoma-related cardiomyopathy include hypertension, dilated or hypertrophic cardiomyopathy, pulmonary edema due to cardiogenic and noncardiogenic factors, cardiac arrhythmias, and even cardiac arrest. Stress-related cardiomyopathy such as takotsubo cardiomyopathy occurs primarily in postmenopausal women. These patients may present with clinical features suggestive of an acute myocardial infarction or a hemodynamically compromised state. The definitive management of cardiomyopathy associated with pheochromocytoma includes medical treatment with alpha-adrenergic blockade, possibly along with angiotensin converting enzyme blockers and beta1-adrenergic receptor blockers, followed by excision of the tumor. Stress-induced cardiomyopathy is usually self-limiting; patients may require support with nonadrenergic inotropes. CONCLUSION: Recognition of catecholamine-induced cardiomyopathy, especially in patients with pheochromocytoma, before surgical treatment is important to minimize morbidity and mortality.


Subject(s)
Adrenal Gland Neoplasms/complications , Cardiomyopathies/etiology , Catecholamines/adverse effects , Pheochromocytoma/complications , Adrenal Gland Neoplasms/epidemiology , Adrenal Gland Neoplasms/metabolism , Animals , Cardiomyopathies/diagnosis , Cardiomyopathies/epidemiology , Cardiomyopathies/therapy , Catecholamines/metabolism , Humans , Myocardium/pathology , Pheochromocytoma/epidemiology , Pheochromocytoma/metabolism , Prevalence , Prognosis
8.
Endocr Pract ; 13(7): 780-4, 2007.
Article in English | MEDLINE | ID: mdl-18194937

ABSTRACT

OBJECTIVE: To describe a patient with a histologically proven pancreatic glucagonoma, noted incidentally during a follow-up visit for high aminotransferase levels, and to evaluate its autonomy with a standard 75-g oral glucose tolerance test. METHODS: We present the results of a 2-hour oral glucose tolerance test, with plasma glucagon and blood glucose levels measured every 30 minutes after an oral glucose load. In addition, we provide a brief review of the literature on the diagnosis and management of glucagonomas and the importance of long-term surveillance. RESULTS: In our patient, who had a 1-year history of impaired fasting glucose, plasma glucagon levels were persistently suppressed to within the normal range after oral glucose challenge. Octreotide scintigraphy revealed abnormal uptake in the pancreatic tail, and a 2.8-cm mass was removed at laparoscopic distal pancreatectomy. Immunohistochemical staining of the tumor tissue showed intense reactivity for glucagon. Plasma glucagon levels were reduced to <50 pg/mL postoperatively, and scintigraphic study at 4-month follow-up showed no residual uptake at the previous tumor site or elsewhere. CONCLUSION: Glucagon-secreting pancreatic tumors are extremely rare. A substantially elevated plasma level of glucagon is usually seen in patients with metastatic tumors. In the early stage of a glucagonoma, however, the plasma glucagon level may be only modestly elevated and may still be susceptible to normal negative feedback inhibition. We demonstrated plasma glucagon complete suppressibility after oral glucose challenge in a patient with a glucagonoma, the first such report in the literature.


Subject(s)
Glucagon/blood , Glucagonoma/blood , Glucose Tolerance Test , Pancreatic Neoplasms/blood , Alanine Transaminase/blood , Aspartate Aminotransferases/blood , Gastrins/analysis , Glucagon/analysis , Glucagonoma/diagnostic imaging , Glucagonoma/surgery , Humans , Immunohistochemistry , Male , Middle Aged , Pancreatectomy , Pancreatic Neoplasms/diagnostic imaging , Pancreatic Neoplasms/surgery , Tomography, X-Ray Computed
9.
Thyroid ; 15(2): 170-5, 2005 Feb.
Article in English | MEDLINE | ID: mdl-15753678

ABSTRACT

Papillary thyroid carcinoma (PTC) commonly metastasizes to cervical lymph nodes. Distant metastases are unusual with the lungs most frequently involved. Well-differentiated thyroid carcinoma very rarely presents with metastases to the spleen. This is the case of a 25-year-old man with a history of PTC (1.4 cm primary; no capsular invasion and negative lymph node metastases). One year after initial surgery, recurrent disease was found in multiple neck nodes by central neck dissection. Whole body scan (WBS) following a therapeutic ablation dose of 150 mCi I(131) revealed mediastinal metastases. Computerized axial tomography (CT) of the chest one year later showed no gross mediastinal or pulmonary disease. However, multiple large splenic lesions were incidentally noted. Evaluation by ultrasound (US) showed lesions to be solid echogenic masses without remarkable Doppler characteristics to suggest vascular tumors. US-guided percutaneous fine-needle aspiration biopsy (FNAB) of one lesion was nondiagnostic. After withdrawal from Levothyroxine, serum TSH was >100 mU/L with a thyroglobulin of 9.4 ng/mL and negative anti-thyroglobulin antibodies. Diagnostic WBS revealed faint splenic uptake but was otherwise unremarkable. Following treatment with 192 mCi I(131), WBS demonstrated increased activity in the mediastinum as well as in the spleen suggesting mediastinal and splenic metastases. Contrast CT of the abdomen showed multiple low-attenuated heterogeneously enhancing splenic masses, normal liver and no intra-abdominal lymphadenopathy. The largest mass (4.5 x 3.5 cm) was exophytic and in close proximity to the splenic capsule. Despite the serum thyroglobulin of only 9.4 ng/mL, the finding of I(131) accumulation within solid splenic masses led to a preoperative diagnosis of thyroid carcinoma metastases. To establish the diagnosis and to remove the risk for splenic rupture, a laparoscopic splenectomy was performed. Histopathologic analysis showed large littoral cell angiomas (LCA). False-positive radioiodine scintigraphy in the setting of PTC involving a vertebral hemangioma has been reported. To our knowledge, this is the first case that describes multiple angiomas mimicking metastatic thyroid carcinoma to the spleen. In one-third of all cases reported, LCA co-exists with various visceral organ cancers or malignant lymphoma. This is the first report of an association between LCA and thyroid carcinoma.


Subject(s)
Carcinoma, Papillary/secondary , Hemangioma/pathology , Splenic Neoplasms/secondary , Thyroid Neoplasms/pathology , Adult , Carcinoma, Papillary/diagnostic imaging , Diagnosis, Differential , False Positive Reactions , Female , Hemangioma/diagnostic imaging , Humans , Iodine Radioisotopes , Radionuclide Imaging , Splenic Neoplasms/diagnostic imaging , Tomography, X-Ray Computed , Ultrasonography, Doppler
10.
Bone ; 34(6): 1037-43, 2004 Jun.
Article in English | MEDLINE | ID: mdl-15193551

ABSTRACT

One hundred sixty-four (164) healthy, young Caucasian women enrolled as midshipmen at the United States Naval Academy with no known disease or bone injury were followed for 3.6 years. Change in bone mineral density (BMD) of the hip, lumbar spine and distal tibia, and total body bone mineral content (TBMC) was measured by dual energy X-ray absorptiometry (DXA). Bone mineral density and TBMC of these women were measured within 2 months (60 +/- 4 days) of entering the Academy and annually. Over the study period, hip BMD increased 2.26% (P < 0.001), lumbar spine BMD increased 3.27% (P < 0.001) and distal tibia BMD increased 5.2% (P < 0.001). Total body bone mineral content showed a 5.25% (P < 0.001) increase during the study period. In this group of young women, gain in BMD and TBMC continued until age 22. These results suggest that bone mass may accrue in certain groups of women beyond age 22. The significance of this increase in bone mass during early adulthood on risk for osteoporotic fractures in later life and its impact on exercise-related bone injuries are unknown and warrant further examination.


Subject(s)
Bone Density/physiology , Adolescent , Adult , Age Factors , Analysis of Variance , Confidence Intervals , Female , Femur Neck/physiology , Humans , Longitudinal Studies , Lumbar Vertebrae/physiology , Tibia/physiology
12.
JAMA ; 290(22): 2952-8, 2003 Dec 10.
Article in English | MEDLINE | ID: mdl-14665656

ABSTRACT

CONTEXT: Standard therapy for patients with primary hypothyroidism is replacement with synthetic thyroxine, which undergoes peripheral conversion to triiodothyronine, the active form of thyroid hormone. Within the lay population and in some medical communities, there is a perception that adding synthetic triiodothyronine, or liothyronine, to levothyroxine improves the symptoms of hypothyroidism despite insufficient evidence to support this practice. OBJECTIVE: To evaluate the benefits of treating primary hypothyroidism with levothyroxine plus liothyronine combination therapy vs levothyroxine monotherapy. DESIGN, SETTING, AND PATIENTS: Randomized, double-blind, placebo-controlled trial conducted from May 2000 to February 2002 at a military treatment facility that serves active duty and retired military personnel and their family members. The trial included a total of 46 patients aged 24 to 65 years with at least a 6-month history of treatment with levothyroxine for primary hypothyroidism. INTERVENTION: Patients received either their usual dose of levothyroxine (n = 23) or combination therapy (n = 23), in which their usual levothyroxine dose was reduced by 50 micro g/d and substituted with liothyronine, 7.5 micro g, taken twice daily for 4 months. MAIN OUTCOME MEASURES: Scores on a hypothyroid-specific health-related quality-of-life (HRQL) questionnaire, body weight, serum lipid levels, and 13 neuropsychological tests measured before and after treatment. RESULTS: Serum thyrotropin levels remained similar and within the normal range in both treatment groups from baseline to 4 months. Body weight and serum lipid levels did not change. The HRQL questionnaire scores improved significantly in both the control group (23%; P<.001) and the combination therapy group (12%; P =.02), but these changes were statistically similar (P =.54). In 12 of 13 neuropsychological tests, outcomes between groups were not significantly different; the 1 remaining test (Grooved Peg Board) showed better performance in the control group. CONCLUSION: Compared with levothyroxine alone, treatment of primary hypothyroidism with combination levothyroxine plus liothyronine demonstrated no beneficial changes in body weight, serum lipid levels, hypothyroid symptoms as measured by a HRQL questionnaire, and standard measures of cognitive performance.


Subject(s)
Hormone Replacement Therapy , Hypothyroidism/drug therapy , Thyroxine/therapeutic use , Triiodothyronine/therapeutic use , Adult , Body Weight , Cognition , Double-Blind Method , Drug Therapy, Combination , Female , Humans , Hypothyroidism/physiopathology , Lipids/blood , Male , Middle Aged , Quality of Life , Thyroxine/administration & dosage , Treatment Outcome , Triiodothyronine/administration & dosage
13.
Endocr Pract ; 9(5): 353-62, 2003.
Article in English | MEDLINE | ID: mdl-14608992

ABSTRACT

OBJECTIVE: To compare the clinical and biochemical features, bone densitometry data, and results of diagnostic imaging to localize parathyroid tumors in patients with radiation-associated hyperparathyroidism (R-HPT) and patients with HPT who had no history of radiation exposure (NR-HPT). METHODS: We performed a retrospective analysis of 34 patients with HPT who underwent evaluation and subsequent neck exploration between 1990 and 1995. We recorded and compared the symptoms, biochemical findings, bone densitometry data, results of diagnostic imaging, and pathologic findings in R-HPT and NR-HPT groups. RESULTS: The R-HPT group (8 men and 4 women)generally was older than the NR-HPT group (14 men and 8 women), but the age difference was not statistically significant. Patients in the R-HPT group had received radiotherapy (6.9 to 21.7 Gy) between 2 and 9 years of age for various diagnoses. Eight patients (67%) in the R-HPT group and 13 (59%) in the NR-HPT group had no symptoms of HPT. The rest of the patients in both groups had nonspecific symptoms, such as fatigue and dyspepsia. Four patients (18%) in the NR-HPT group had nephrolithiasis, and 3 (14%) had skeletal manifestations at initial assessment. Serum calcium, phosphorus, and parathyroid hormone levels and 24-hour urine calcium excretion were similar in both groups. Mean lumbar spine bone mineral density was lower in women in the R-HPT group than in those in the NR-HPT group, but the prevalence of osteoporosis did not differ significantly in the two study groups. Sestamibi scintigraphy accurately localized adenomas in both groups equally well (sensitivity >90%). In the R-HPT group, 11 patients had a single parathyroid adenoma and 1 had hyperplasia of all four parathyroid glands. In the NR-HPT group, 21 patients had a single parathyroid adenoma and 1 had parathyroid hyperplasia. In nine patients in the R-HPT group, ultrasonography showed thyroid nodules >1 cm. Pathologic examination of surgical specimens in the R-HPT group confirmed thyroid carcinoma in 11 patients ( 10 papillary and 1 follicular can-cer); no patient in the NR-HPT group had thyroid cancer. Six weeks after thyroidectomy, patients with thyroid can-cer received 1311 (mean dose, 145 mCi), five of whom needed additional 1311 treatments. CONCLUSION: Patients with a history of childhood neck irradiation who have HPT have a high likelihood of coexisting thyroid cancer. This observation may justify surgical exploration rather than vigilant follow-up in asymptomatic patients with primary HPT and coexisting thyroid nodules who have a history of radiation exposure.


Subject(s)
Hyperparathyroidism/diagnostic imaging , Hyperparathyroidism/epidemiology , Radiotherapy/adverse effects , Thyroid Neoplasms/radiotherapy , Adult , Bone Density , Child , Female , Humans , Male , Middle Aged , Neck , Osteoporosis/epidemiology , Prevalence , Radiation Dosage , Radionuclide Imaging , Radiopharmaceuticals , Retrospective Studies , Technetium Tc 99m Sestamibi , Thyroid Neoplasms/epidemiology
15.
Endocr Pract ; 8(3): 177-83, 2002.
Article in English | MEDLINE | ID: mdl-12113629

ABSTRACT

OBJECTIVE: To improve glycemic control by substituting saturated fat for starch, to identify any adverse effect on lipids masked by the extensive use of metformin and lipid-lowering drugs, and to attempt to separate dietary effects from effects of multiple drugs. METHODS: We undertook a retrospective review of medical records of patients who completed 1 year of follow-up after dietary prescription. The study subjects included 151 patients in the diet group (whose dietary instructions included high saturated fat but starch avoidance) and 132 historical control subjects (who were allowed unlimited monounsaturated fat but had restriction of starch in their diets). RESULTS: Hemoglobin A1c (HbA1c) levels improved in both study groups (-1.4 +/- 0.2% [P<0.001]; 95% confidence interval [CI], -1.9 to -0.9). Use of metformin was associated with a decrease in HbA1c (-0.12 +/- 0.003%/mo [P<0.001]; 95% CI, -0.17 to -0.07). The diet group had an additional decrease of -0.7 +/- 0.2% (P<0.001; 95% CI, -1.1 to -0.3). Weight increase was associated with the use of insulin (+0.3 +/- 0.07 kg/mo [P<0.001]; 95% CI, 0.2 to 0.5), sulfonylurea (+0.18 +/- 0.06 kg/mo [P<0.01]; 95% CI, 0.05 to 0.30), and troglitazone (+0.7 +/- 0.2 kg/mo [P<0.005]; 95% CI, 0.3 to 1.2). Although not statistically significant, metformin therapy showed a trend for weight loss (-0.14 +/- 0.08 kg/mo; P = 0.07). An additional weight loss was noted in the diet group (-2.65 +/- 0.62 kg [P<0.001]; 95% CI, -3.87 to -1.44). Hydroxymethylglutaryl-coenzyme A reductase inhibitor use was associated with reduced total cholesterol level (-1.7 +/- 0.6 mg/dL per month [P<0.005]; 95% CI, -2.9 to -0.5). The diet group had an additional decrease of -13.0 +/- 4.5 mg/dL (P<0.001; 95% CI, -21.9 to -4.1). No significant effect of the diet on triglyceride, low-density lipoprotein, or high-density lipoprotein levels was detected. CONCLUSION: Addition of saturated fat and removal of starch from a high-monounsaturated fat and starch-restricted diet improved glycemic control and were associated with weight loss without detectable adverse effects on serum lipids.


Subject(s)
Diabetes Mellitus, Type 2/therapy , Dietary Fats/administration & dosage , Metformin/therapeutic use , Starch/administration & dosage , Thiazolidinediones , Cholesterol/blood , Cholesterol, LDL/blood , Chromans/therapeutic use , Diabetes Mellitus, Type 2/blood , Female , Gemfibrozil/therapeutic use , Glycated Hemoglobin/analysis , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Hypoglycemic Agents/therapeutic use , Lipids/blood , Male , Middle Aged , Retrospective Studies , Thiazoles/therapeutic use , Triglycerides/blood , Troglitazone , Weight Loss
17.
Bone ; 27(6): 835-9, 2000 Dec.
Article in English | MEDLINE | ID: mdl-11113395

ABSTRACT

Eighty-six healthy, young Caucasian 18-year-old men with no known disease or bone injury were recruited to this study at the United States Naval Academy. Change in bone mineral density (BMD) of the hip, lumbar spine, and distal tibia, and total body bone mineral content (TBMC) was measured by dual-energy X-ray absorptiometry (DXA). BMD and TBMC of these men were measured within 2 months (67 +/- 3 days) of entering the Academy, and, at the end of their first, second, and fourth years. Hip BMD was unchanged during the study period (p > 0.05). Lumbar spine BMD increased 3% (p < 0.001) and distal tibia BMD increased 5% (p < 0.001). TBMC showed a 7.5% increase over the study period. In this group of young men, gain in BMD and TBMC is greatest to age 21 years, with minimal further increase after age 21. The significance of this rise in bone mass during early adulthood on risk for osteoporotic fractures in later life or its impact on exercise-related bone injuries is unknown and warrants further examination.


Subject(s)
Absorptiometry, Photon/standards , Bone Density , Adolescent , Adult , Body Mass Index , Humans , Longitudinal Studies , Male , Military Personnel , Reference Values , White People
19.
Mayo Clin Proc ; 75(2): 189-92, 2000 Feb.
Article in English | MEDLINE | ID: mdl-10683660

ABSTRACT

Usual causes of intolerance to thyroxine sodium include coronary artery disease, advanced age, untreated adrenal insufficiency, and severe hypothyroidism. We describe 4 patients with iron deficiency anemia and primary hypothyroidism. After treatment with thyroxine sodium, these patients developed palpitations and feelings of restlessness, which necessitated discontinuation of the thyroid hormone. After the anemia was treated with ferrous sulfate for 4 to 7 weeks, they were able to tolerate thyroxine sodium therapy. Iron deficiency anemia coexisting with primary hypothyroidism results in a hyperadrenergic state. In such patients, we postulate that thyroid hormone administration causes palpitations, nervousness, and feelings of restlessness. Correction of any existing pronounced anemia in hypothyroid patients who are intolerant to thyroxine sodium therapy may result in tolerance to this agent.


Subject(s)
Anemia, Iron-Deficiency/complications , Anemia, Iron-Deficiency/drug therapy , Ferrous Compounds/therapeutic use , Hypothyroidism/complications , Hypothyroidism/drug therapy , Thyroxine/adverse effects , Adult , Anemia, Iron-Deficiency/metabolism , Anemia, Iron-Deficiency/physiopathology , Female , Humans , Hypothyroidism/metabolism , Hypothyroidism/physiopathology , Treatment Outcome
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