Thyroiditis: Evaluation and Treatment.

Thyroiditis is a general term for inflammation of the thyroid gland. The most common forms of thyroiditis encountered by family physicians include Hashimoto, postpartum, and subacute. Most forms of thyroiditis result in a triphasic disease pattern of thyroid dysfunction. Patients will have an initial phase of hyperthyroidism (thyrotoxicosis) attributed to the release of preformed thyroid hormone from damaged thyroid cells. This is followed by hypothyroidism, when the thyroid stores are depleted, and then eventual restoration of normal thyroid function. Some patients may develop permanent hypothyroidism. Hashimoto thyroiditis is an autoimmune disorder that presents with or without signs or symptoms of hypothyroidism, often with a painless goiter, and is associated with elevated thyroid peroxidase antibodies. Patients with Hashimoto thyroiditis and overt hypothyroidism are generally treated with lifelong thyroid hormone therapy. Postpartum thyroiditis occurs within one year of delivery, miscarriage, or medical abortion. Subacute thyroiditis is a self-limited inflammatory disease characterized by anterior neck pain. Treatment of subacute thyroiditis should focus on symptoms. In the hyperthyroid phase, beta blockers can treat adrenergic symptoms. In the hypothyroid phase, treatment is generally not necessary but may be used in patients with signs and symptoms of hypothyroidism or permanent hypothyroidism. Nonsteroidal anti-inflammatory drugs and corticosteroids are indicated for the treatment of thyroid pain. Certain drugs may induce thyroiditis, such as amiodarone, immune checkpoint inhibitors, interleukin-2, interferon-alfa, lithium, and tyrosine kinase inhibitors. In all cases of thyroiditis, surveillance and clinical follow-up are recommended to monitor for changes in thyroid function.

Maternal Health in the Transgender Population.

Social acceptance and legal protections for transgender and gender nonconforming patients have increased over the past decade, but significant health care disparities still remain. Such an area of disparity is discussion with and interventions for fertility, contraception, pregnancy, and lactation in TGNC patients. Providing optimal care starts with creating a welcoming and safe environment. Appropriate preconception education includes the effects of gender-affirming therapies (both surgical and nonsurgical) on fertility as well the fertility preservation techniques that are available. However, as gamete retrieval requires natal hormone stimulation, gender dysphoria may be worsened. Thus, these patients should be carefully monitored not only medically, but also with regard to their mental health. In addition to assisted reproductive technologies, protocols exist to aid with induction of lactation as well as discontinuation if desired. As this is a growing field of medicine with limited data available on safety and long-term outcomes, recommendations are for a multidisciplinary team approach to ensure patients' safety and well-being.

Mobile health applications enhance weight loss efficacy following bariatric surgery.

INTRODUCTION: With the epidemic of obesity numerous mobile health (mHealth) applications have been designed with the goal of facilitating weight loss. This technology has the potential to focus behavioral modification in a manner that's effective for weight loss. We examined the use of this mHealth technology in our bariatric surgery population to evaluate effects on weight loss following surgery. METHODS: Single institution prospective randomized control trial performed at an academic center. 56 patients who recently underwent a laparoscopic sleeve gastrectomy (LSG) were enrolled into a control group with standard post-operative monitoring and a mHealth application group provided with iPad© minis with the MyFitnessPal© mHealth application. Participants were followed for 24 months. The primary outcomes were effect on weight loss as determined by excess body weight loss (%EWL) and excess BMI loss (%EBL). RESULTS: Statistically significant differences in weight loss outcomes between the groups were present throughout the duration of the study. At 12 months, %EWL was 74.41% (control) vs 81.41% (mHealth) p value 0.047 and at 24 months, it was 59.10% (control) vs 71.47% (mHealth) p value 0.0078. %EBL findings at 12 months was 28.02% (control) vs 32.15% (mHealth) p value 0.0007 and at 24 months, it was 25.39% (control) vs 27.87% (mHealth) p value 0.048. CONCLUSION: Our results demonstrate mHealth applications are a useful adjunct to improve and maintain weight loss following bariatric surgery. We suggest mHealth applications should be utilized following bariatric surgery for improved outcomes.

A retrospective review of the medical management of hypertension and diabetes mellitus following sleeve gastrectomy.

BACKGROUND: Bariatric surgery is being performed with increasing frequency in the USA as a definitive treatment for morbid obesity and associated comorbidities. Management strategies of type 2 diabetes mellitus (T2DM) and hypertension (HTN) medications in sleeve gastrectomy (SG) patients postoperatively are unclear, specifically in the immediate postoperative period and 6 months following surgery. METHODS: From 01 June 2010 to 30 June 2011, at a single military medical facility, a retrospective review of 88 consecutive SG patients was conducted to examine the postoperative medical management of HTN and T2DM. Patient's HTN and T2DM medication regimens were evaluated for 6 months postoperatively. Categorical data was analyzed using chi-square, and continuous data was compared using the Student t test. Statistical analyses were completed with Stata, version 12. RESULTS: Fifty patients were prescribed an average of 2.21 HTN medications at baseline which was reduced to an average of 1.23 (p < 0.01) medications per patient at 1 month. Twenty-four patients received an average of 1.41 oral T2DM medications with a reduction to 0.70 (p < 0.01) on average at 1 month postoperatively. Medication changes persisted throughout the 6-month follow-up. Among T2DM patients requiring insulin therapy, the mean insulin dose was 42.1 units reduced to 16.8 units immediately postoperatively (p < 0.01) which persisted at 1 month. At 6 months, the mean insulin dose was 13.3 units. CONCLUSIONS: Medication adjustments for HTN and T2DM made immediately in the postoperative period following SG persisted throughout the 6-month follow-up period and in some patients, required further adjustments.

Thyroiditis: an integrated approach.

Thyroiditis is a general term that encompasses several clinical disorders characterized by inflammation of the thyroid gland. The most common is Hashimoto thyroiditis; patients typically present with a nontender goiter, hypothyroidism, and an elevated thyroid peroxidase antibody level. Treatment with levothyroxine ameliorates the hypothyroidism and may reduce goiter size. Postpartum thyroiditis is transient or persistent thyroid dysfunction that occurs within one year of childbirth, miscarriage, or medical abortion. Release of preformed thyroid hormone into the bloodstream may result in hyperthyroidism. This may be followed by transient or permanent hypothyroidism as a result of depletion of thyroid hormone stores and destruction of thyroid hormone-producing cells. Patients should be monitored for changes in thyroid function. Beta blockers can treat symptoms in the initial hyperthyroid phase; in the subsequent hypothyroid phase, levothyroxine should be considered in women with a serum thyroid-stimulating hormone level greater than 10 mIU per L, or in women with a thyroid-stimulating hormone level of 4 to 10 mIU per L who are symptomatic or desire fertility. Subacute thyroiditis is a transient thyrotoxic state characterized by anterior neck pain, suppressed thyroid-stimulating hormone, and low radioactive iodine uptake on thyroid scanning. Many cases of subacute thyroiditis follow an upper respiratory viral illness, which is thought to trigger an inflammatory destruction of thyroid follicles. In most cases, the thyroid gland spontaneously resumes normal thyroid hormone production after several months. Treatment with high-dose acetylsalicylic acid or nonsteroidal anti-inflammatory drugs is directed toward relief of thyroid pain.

Hypothyroidism: an update.

Hypothyroidism is a clinical disorder commonly encountered by the primary care physician. Untreated hypothyroidism can contribute to hypertension, dyslipidemia, infertility, cognitive impairment, and neuromuscular dysfunction. Data derived from the National Health and Nutrition Examination Survey suggest that about one in 300 persons in the United States has hypothyroidism. The prevalence increases with age, and is higher in females than in males. Hypothyroidism may occur as a result of primary gland failure or insufficient thyroid gland stimulation by the hypothalamus or pituitary gland. Autoimmune thyroid disease is the most common etiology of hypothyroidism in the United States. Clinical symptoms of hypothyroidism are nonspecific and may be subtle, especially in older persons. The best laboratory assessment of thyroid function is a serum thyroid-stimulating hormone test. There is no evidence that screening asymptomatic adults improves outcomes. In the majority of patients, alleviation of symptoms can be accomplished through oral administration of synthetic levothyroxine, and most patients will require lifelong therapy. Combination triiodothyronine/thyroxine therapy has no advantages over thyroxine monotherapy and is not recommended. Among patients with subclinical hypothyroidism, those at greater risk of progressing to clinical disease, and who may be considered for therapy, include patients with thyroid-stimulating hormone levels greater than 10 mIU per L and those who have elevated thyroid peroxidase antibody titers.

Relationship between alcohol use disorders, cortisol concentrations, and cytokine levels in patients with sepsis.

INTRODUCTION: Patients with alcohol use disorders (AUD) are at increased risk of developing sepsis and have higher mortality. AUD are associated with higher cortisol and anti-inflammatory cytokine profile. Higher cortisol increases risk of death in septic patients. The relationship between AUD and cortisol in septic patients is unknown. We aimed to study this relationship and postulated that AUD would be associated with higher cortisol and anti-inflammatory cytokine profile. METHODS: This was a prospective cohort study of 40 medical intensive care unit (ICU) patients admitted with sepsis. Cortisol, anti-inflammatory interleukin (IL) 10, and pro-inflammatory IL1ß, IL6, tumor necrosis factor (TNF) α were measured. RESULTS: Thirteen (32%) out of 40 patients had AUD. AUD patients had higher cortisol by univariate (39 microg/dl versus 24, P = 0.04) and multivariable analyses (44 microg/dl versus 23, P = 0.004). By univariate analyses, AUD patients had higher IL10 (198 picog/dl versus 47, P = 0.02) and IL6 (527 picog/ml versus 156, P = 0.048), but similar IL1ß and TNFα. By multivariable analyses, AUD patients had higher IL10 (182 picog/dl versus 23, P = 0.049) but similar IL1ß, IL6, and TNFα. AUD patients had lower IL1ß/IL10 (univariate 0.01 versus 0.10, P = 0.04; multivariable 0.01 versus 0.03, P = 0.04), lower TNFα/IL10 (univariate 0.15 versus 0.52, P = 0.03; multivariable 0.11 versus 0.63, P = 0.01), but similar IL6/IL10. CONCLUSIONS: AUD are common diagnoses among medical ICU patients with sepsis. Patients with AUD have higher cortisol concentrations and have differences in cytokine expression. Future studies should seek to determine if these differences may explain the higher severity of illness seen in patients with sepsis and AUD. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00615862.