Eliana Piantanida

Diagnosis and management of amiodarone‐induced thyrotoxicosis in Europe: results of an international survey among members of the European Thyroid Association

objective  To determine how expert European thyroidologists assess and treat amiodarone‐induced thyrotoxicosis (AIT).

Body mass index is associated with the development of the post-thrombotic syndrome.

Post-thrombotic syndrome (PTS) is a chronic complication of deep vein thrombosis (DVT). Little is known about prognostic factors that might identify patients at high risk for the development of PTS. Body mass index (BMI) has been previously reported to be associated to the development of PTS. The aim of this study was to assess the association between BMI and other anthropometric parameters and PTS in a general population of DVT patients. In a prospective cohort study, 83 consecutive patients with objective diagnosis of DVT underwent physical examination. BMI was recorded at baseline and at 12 months, and waist circumference was recorded at 12 months to assess individual patterns of body fat distribution. The presence of PTS at 12 months was ascertained using a validated clinical scale. Sixty-three patients (75.9%) were overweight or obese at 12 months, 60 (72.3%) had a weight gain over 1 year. Twenty patients developed PTS (24.1%). Mean BMI was significantly higher in patients who developed PTS than in patients who did not (29.6 and 27.2 Kg/m(2), respectively, p = 0.022). A BMI of > 28 Kg/m(2) predicted early onset of PTS (OR 3.54, 95% CI 1.07-12.08, p = 0.017). Neither patterns of fat distribution nor weight gain in 1 year were correlated with PTS (p = 0.918 and p = 0.775, respectively). BMI is significantly correlated with the development of PTS. Patients with DVT should be encouraged to avoid weight gain. Reducing patient weight might be an important strategy to prevent PTS.

Diagnosis and management of amiodarone-induced thyrotoxicosis : similarities and differences between North American and European thyroidologists

Objective  To investigate how North American thyroidologists assess and treat amiodarone‐induced thyrotoxicosis (AIT) and to compare the results with those of the same questionnaire‐based survey previously carried out among European thyroidologists.

Prevalence and natural history of Graves’ orbitopathy in the XXI century

Graves’ orbitopathy (GO) is an autoimmune disorder and the main extrathyroidal expression of Graves’ disease. There is a spectrum of ocular involvement in Graves’ disease, from complete absence of symptoms and signs to sight-threatening conditions. The prevalence of GO varies in different published series of Graves’ patients, due to confounding factors (new diagnosis vs long-lasting disease, way of defining and assessing ocular involvement, treatment of hyperthyroidism with potentially GO-modifying treatments, such as radioiodine). Recent studies, however, suggest that most Graves’ patients have mild or no GO at presentation, while moderate-to-severe GO is rare, and sight-threatening GO (mostly due to dysthyroid optic neuropathy) is exceptional in non-tertiary referral centers. The natural course of GO is incompletely defined, particularly in patients with moderate-to-severe GO, because these patients require prompt and disease-modifying therapies for orbital disease. In patients with mild GO at presentation, progression to severe forms is rare, while partial or complete remission is frequent. Progression of pre-existing GO or de novo occurrence of GO is more likely in smokers. There seems to be a trend towards a decline in progression of GO, possibly due to a better control of risk factors (cigarette smoking, thyroid dysfunction, etc.) and a closer interaction between endocrinologists and ophthalmologists allowing an improved integrated management of thyroid and orbital disease.

An update on medical management of Graves' ophthalmopathy.

Graves’ ophthalmopathy (GO), the most frequent extrathyroidal manifestation of Graves’ disease, is a disorder of autoimmune origin, the pathogenic mechanisms of which are still incompletely understood. Although GO is severe in only 3–5% of affected individuals, quality of life is severely impaired even in patients with mild GO. Management of severe GO can be either medical or surgical (orbital decompression, eye muscle or lid surgery). Medical management relies on the use of highdose systemic glucocorticoids or orbital radiotherapy, either alone or in combination. Studies carried out in the last 5 yr have shown that glucocorticoids are more effective through the iv route than through the oral route. However, particular attention should be paid to possible liver toxicity of iv glucocorticoids. Recent randomized clinical trials have, with one exception, confirmed that orbital radiotherapy is an effective and safe therapeutic procedure for GO. At variance with previous encouraging data, recent randomized clinical trials have shown that currently available SS analogs are not very effective in the management of GO. Antioxidants might have a role, at least in mild forms of GO. Particular attention should be paid to correction of risk factors (cigarette smoking, thyroid dysfunction, radioiodine therapy) involved in GO progression.

Relationship between management of hyperthyroidism and course of the ophthalmopathy

The relationship between treatment for hyperthyroidism and course of Graves’ ophthalmopathy (GO) has been and still is a matter of debate. Literature often presents conflicting data, due to several influencing factors, such as selection bias, nonrandomized and uncontrolled or retrospective features of many studies, non-standardized evaluation of ocular changes. However, it seems clear that neither antithyroid drug treatment nor thyroidectomy affect the natural course of GO, while radioiodine therapy may cause, in about 15% of cases, GO progression. The latter is more likely in patients who smoke, have pre-existing GO and more severe hyperthyroidism, or whose post-radioiodine hypothyroidism is not promptly corrected by L-thyroxine. GO progression after radioiodine therapy can be prevented by concomitantly treating patients with glucocorticoids, thus making radioiodine therapy a safe procedure also in GO patients. The presence of GO should not, therefore, influence the choice of treatment for hyperthyroidism. Should antithyroid drug treatment or thyroidectomy be selected for patients with mild ophthalmopathy, no treatment for GO is necessary, while a short course of moderate doses of glucocorticoids is advised if radioiodine therapy is chosen. In patients with severe GO, treatment of hyperthyroidism and management of GO proceed independently of each other, and either definitive (radioiodine or thyroidectomy) or conservative (antithyroid drugs) treatment for hyperthyroidism can be selected while treating GO. The authors’ preference goes to the former, because it depletes intrathyroidal autoreactive T lymphocytes and removes thyroid antigens, which are likely to be involved in the pathogenesis of autoimmune reactions of the ophthalmopathy.

Natriuretic peptides as markers of preclinical cardiac disease in obesity

Background  Aim of the study was to evaluate the role of atrial (ANP) and brain natriuretic peptides (BNP) as markers of preclinical cardiac disease in obesity.

Safety of neural monitoring in thyroid surgery

During thyroid surgery, the functional integrity of the recurrent laryngeal nerve (RLN) is not only threatened by direct nerve injury resulting from accidental transection, clipping or ligation. In fact, indirect trauma, e.g. traction and compression occurring repeatedly throughout gland dissection, contribute to long-term nerve impairment. In order to avoid RLN lesions and preserve nerve function the surgeon must adhere to and comply with a strict standardized intraoperative neuromonitoring (IONM) technique to preserve results, quality and safety. IONM should be a team work between the surgeon and the anesthesiologist.

Subclinical hypothyroidism and deep venous thrombosis - A pilot cross-sectional study

Several in-vivo studies have shown a procoagulant state in both overt and subclinical hyperthyroidism and in subclinical hypothyroidism. Insofar, no clinical studies have ever evaluated the relationship between thyroid dysfunction and clinically deep venous thrombosis (DVT). A pilot cross-sectional study aimed at assessing the frequency of overt and subclinical thyroid dysfunction patients with DVT was carried out. Fifty consecutive adult outpatients with a previous diagnosis of provoked DVT (pDVT), and 50 consecutive adult outpatients with a previous diagnosis unprovoked DVT (unDVT), both of the lower legs, who were followed at the Thrombosis Unit of the University Hospital of Varese, Italy, were enrolled after written informed consent. Fifty subjects, in whom such a diagnosis could be ruled out, served as controls. In each patient serum free thyroxine (FT4), free triiodothyronine (FT3), thyrotropin (TSH), anti-thyroid peroxidase (AbTPO), and anti-thyroglobulin (AbTg) antibodies were assayed. Previously unrecognised subclinical hypothyroidism was diagnosed in seven (14.0%) unDVT patients, one (2%) pDVT patient, and one (2%) control (odds ratio at multivariate analysis, 5.54; 95% confidence interval, 0.6-52.6); one new case of subclinical hyperthyroidism was diagnosed in each group; only one case (in the control group) of clinical overt hyperthyroidism was observed. The prevalence of thyroid autoantibodies, including both euthyroid and subclinical hypothyroid patients, did not differ in the three groups. The results of this pilot study suggest an increased prevalence of subclinical hypothyroidism in patients with unDVT. The clinical relevance of these preliminary findings needs to be addressed in larger prospective studies.

Influence of new technologies on thyroid surgery: state of the art

The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between 1873 and 1910. In general, the essential objectives for thyroidectomy are conservation of the parathyroid glands, avoidance of injury to the recurrent laryngeal nerve, an accurate hemostasis and an excellent cosmesis. In the last 20 years, major improvements and new technologies have been proposed and applied in thyroid surgery; among these are mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, regional anesthesia and intraoperative neuromonitoring.