What an endocrinologist should know for patients receiving lithium therapy

Lithium is an efficient treatment of bipolar disorder. Besides renal insufficiency, many endocrine side effects are described such as the occurrence of thyroid disorders, hypercalcaemia and nephrogenic diabetes insipidus. Lithium inhibits the secretion of thyroid hormones. The prevalence of goiter is 4 times more common in Lithium-treated patients compared as to the general population. Hypothyroidism (8–20%) is more frequent in women and in case of pre-existing thyroid autoimmunity. Grave's disease and other hyperthyroidisms are sometimes reported. Lithium stimulates the proliferation of parathyroid cells by activating the Wnt pathway. An increase in serum calcium and PTH is described in patients treated with Lithium with a 4 to 6-fold higher risk of primary hyperparathyroidism than in the general population. Nevertheless, 24-hour urine calcium is not often increased, and the phenotype can mimic a hypercalcemia-hypocalciuria syndrome that may regress with Lithium discontinuation. Surgery should be cautious since parathyroid hyperplasia is more common than parathyroid adenoma. Nephrogenic diabetes insipidus is frequently reported and may be debilitating, sometimes intricated with severe dehydration, hypernatremia, and acute renal insufficiency. Nephrogenic diabetes insipidus is not generally reversible after Lithium discontinuation, especially in patients who have chronic kidney disease due to interstitial tubule nephritis. In conclusion, clinical assessment (goiter, diuresis) and biological monitoring of serum calcium, sodium creatinine, TSH and lithium are recommended in patients receiving Lithium therapy. The risk of Lithium discontinuation in case of side effects should be weighed against the psychological risk, and must be discussed with the psychiatrist.     

Gray scale ultrasonography in the diagnosis of thyroid swellings

Thyroid masses which fail to concentrate radioactive iodine may be benign or malignant cysts or solid tumors. A-scan examination through any thyroid mass permits the differentation of a solid from a cystic consistency. The nature of solid masses is difficult to determine using the conventional B-scan ultrasound equipment. Our experience to date suggests that the difficulty can be resolved by the use of high quality gray-scale techniques which display the structure of normal glandular tissue, while malignant replacement is apparent as defects in this normal anatomy. The size and site of the thyroid implies that greatly improved resolution could be obtained by scanners dedicated to the examination of small superficial organs.     

基于“肺胃主瘿”理论辨治甲状腺功能亢进症

甲状腺功能亢进症的临床表现主要有易激动、烦躁失眠、乏力、多汗、消瘦、食欲亢进等,并伴有不同程度的甲状腺肿大,属于中医学中瘿病范畴。《太平圣惠方》载:"咽门者,胃气之道路;喉咙者,肺气之往来。今两经为邪气所乘,致经络否涩,气不宣通,结聚成瘿。"邪气侵犯肺胃二经,致经络气血运行不畅,瘀滞于颈部而成瘿。故从肺胃去讨论甲状腺功能亢进症之病因病机,以期获得更为精准的治疗。     

Unilateral thyroidectomy for the treatment of benign multinodular goiter

Background

Benign multinodular goiter (MNG) is one of the most commonly treated thyroid disorders. Although bilateral resection is the accepted surgical treatment for bilateral MNG, the appropriate surgical resection for unilateral MNG continues to be debated. Bilateral resection generally has lower recurrence rates but higher complication rates than unilateral resection. Therefore, the purpose of this study was to define the recurrence and complication rates of unilateral and bilateral resections to determine the appropriate intervention for patients with unilateral, benign MNG.

Methods

We reviewed a prospectively maintained database of all patients who underwent a thyroidectomy for treatment of benign MNG at a single institution between May 1994 and December 2011. All patients with bilateral MNG were treated with bilateral resection. Surgical treatment for unilateral MNG was determined by surgeon preference, with all but one surgeon opting for unilateral resection to treat unilateral MNG. Data were reported as means ± standard error of the mean. Chi-squared analysis was used to determine statistical significance at a level of P < 0.05.

Results

A total of 683 patients underwent thyroidectomy for MNG. Of these patients, 420 (61%) underwent unilateral resection and 263 patients (39%) underwent total thyroidectomy. The mean age was 52 ± 17 y, and 542 patients (79%) were female. The mean follow-up time was 46.1 ± 1.9 mo. The rate of recurrent disease was similar between unilateral (2%, n = 10) and bilateral (1%, n = 3) resections (P = 0.248). Unilateral resection patients had a lower total complication rate than patients with bilateral resections (8% versus 26%, P < 0.001); however, there was no difference in the rate of permanent complications (0.2% versus 1%, P = 0.133). Thyroid hormone replacement was rare in unilateral resection patients but necessary in all patients with bilateral resection (19% versus 100%, P < 0.001).

Conclusions

Patients that had unilateral resections endured less overall morbidities than those who had bilateral resections, and their risk of recurrent disease was similar. They were also significantly less likely to require lifelong hormone replacement therapy postoperatively. Although bilateral resection remains the recommended treatment for bilateral MNG, these data strongly support the use of unilateral thyroidectomy for the treatment of unilateral, benign MNG.     

结节性甲状腺肿中微小癌的诊断与治疗

目的探讨结节性甲状腺肿中甲状腺微小癌的诊断与治疗。方法对结节性甲状腺肿中甲状腺微小癌46例临床资料进行总结，主要分析其易误诊原因及探讨其手术治疗原则。结果本组48例中，术前可疑甲状腺微小癌诊断6例，诊断率为12．5％，其余则诊断为结节性甲状腺肿40例，甲状腺腺瘤2例；术中诊断37例，诊断率为77．1％。冰冻漏诊率为6．3％（3／48）。双侧病变时手术方式为患侧全切除＋对侧次全切，一侧病变时采用患侧甲状腺及峡部全切除术式。结论术中对可疑结节进行仔细解剖研究及快速冰冻检查是诊断该病的主要方法。患侧全切除＋对侧次全切或患侧甲状腺及峡部全切除是该病的主要术式。     

成安县部分高碘乡镇停供碘盐前后甲状腺肿流行病学调查

目的研究高碘地区居民停止食用碘盐对甲状腺肿的影响。方法随机抽取2个高碘乡8～10岁儿童用B超法诊断地方性甲状腺肿,同时检测居民的食用碘盐情况。结果停供碘盐前儿童甲状腺肿大率为10.57%,停供碘盐后1年时儿童甲状腺肿大率为5.36%,差异有统计学意义(χ2=4.84,P0.05)。停供碘盐前与停供碘盐后1年时,碘盐覆盖率差异有统计学意义(χ2=104.53,P0.01)。结论该县属水源性高碘地区,居民应食用无碘盐。     

福建省闽清县超声波水平的地方性甲状腺肿病情现状

用５ＭＨｚ探头ＰｈｉｌｉｐｓＳＤＲ１２００型超声仪器测量了福建省闽清县２９８名１０岁儿童的甲状腺体积与身高。结果表明，随着甲状腺触诊分度的增大，身高甲状腺体积指数也越大。全部儿童的甲状腺实质回声均匀。以对照点儿童的身高甲状腺体积指数正常值的９７％上限值５．０为标准，闽清县１０岁儿童的甲状腺肿大率为３３．６％。     

重庆市碘缺乏病现状调查分析

目的了解碘缺乏病现状，为制定防治对策提供依据。方法用随机抽样的方法检查8～12岁儿童甲状腺肿、智商、尿碘和居民食用盐。结果检查儿童1200人，甲状腺肿大率触诊和B超法分别为13．50％和14．18％，较1994年(触诊法41．80％)下降了67．70％，较1999年分别下降了43．18％和39．86％；尿碘360人，中位数为238．75μg／L；居民食用盐3200户，其碘盐覆盖率、合格率、合格碘盐食用率分别为95．83％、86．77％和83．44％。结论病情逐渐减轻，防治效果显著。     

某大学新生体检甲状腺异常临床分析

目的探讨大学新生入学体检触诊甲状腺异常，进一步行彩色超声检查及结合临床分析的必要性。方法触诊甲状腺肿大或结节161例，对其进行彩色多普勒超声（CDFI）检查，部分结合甲状腺功能五项化验。结果161例甲状腺异常彩超显示甲状腺声像图正常77例，异常84例，其中仅2例男性，余82例均为女性。甲状腺弥漫性病变52例，有14例合并甲状腺结节，诊断桥本炎26例，其中合并甲减及甲亢各2例，12例单纯性甲状腺肿。甲状腺结节45例，其中3例手术证实为甲状腺乳头状癌，1例高度怀疑甲状腺癌未手术。余41例无明显恶性倾向，建议定期复查。结论在新生体检颈部触诊异常时进行CDFI筛查，是非常重要的检查手段，结合甲状腺血生化，对甲状腺疾病能早发现，早治疗。     

足量碘营养状况下甲状腺肿大原因分析

目的 研究足量碘营养状况下甲状腺肿大原因.方法 完全随机选取2008年6月至2009年6月在山西省地方病防治研究所附属医院甲状腺专科门诊就诊的362例甲状腺肿大的初诊患者,进行甲状腺功能、甲状腺自身抗体测定以及甲状腺体积测量.结果 362例甲状腺肿大患者中,130例诊断为毒性弥漫性甲状腺肿(Graves病),90例诊断为慢性淋巴细胞性甲状腺炎(桥本病),43例诊断为结节性甲状腺肿,41例诊断为原发性甲状腺功能减退症,17例诊断为亚急性甲状腺炎,18例诊断为产后甲状腺炎,23例诊断为单纯性甲状腺肿.各种病患者均表现为女性占优势.结节性甲状腺肿大和原发性甲状腺功能减退症患者平均年龄高于其他患者(P<0.05).甲状腺微粒体抗体(TMAb)和(或)甲状腺球蛋白抗体(TGAb)的l辋性率为65.7%(238例),TMAb的阳性率为60.8%(220例),TGAb的阳性率为58.6%(212例).桥本病和Graves病患者的TMAb、TGAb水平明显高于其他病患者(P<0.05).结论 在目前足量碘营养条件下,各种甲状腺疾病特别是自身免疫性甲状腺疾病成为甲状腺肿大的主要原因.

Abstract：

Objective To study the cause of goiter with non-deficiency iodine. Methods Thyroid hormones and thyroid autoantibodys were determined and thyroid volumes were measured on 362 newly diagnosed outpatients with goiter. Results Among 362 cases of patients, 130 were diagnosed of Graves, 90 of hashimotos, 43 of thyroid nodules, 41 of primary hypothyroidism, 17 of subacute thyroiditis, 18 of postpartum thyroiditis and 23 of simple goiter. There were more females (P < 0.05). Patients with the thyroid nodules and the primary hypothyroidism were more elderly than other patients ( P < 0. 05 ). The positive rate of thyroid autoantibodys was 65. 7% , 60. 8% of TMAb and 58.6% of TGAb. The levels of TMAb and TGAb in both Graves and Hashimoto were higher than those in other groups (P <0.05). The levels of autoantibodys in the simple goiter were the lowest. The volume of thyroid in both Graves and Hashimoto were higher than that in other groups ( P < 0.05 ). The volumes of thyroid were correlated to the level of thyroid autoantibodys (P <0.05). Conclusion The thyroidism, especially the autoimmune thyroid diseases ( AFTD) is the prime reason for goiter with non-deficiency iodine.