Two-week low iodine diet is necessary for adequate outpatient preparation for radioiodine rhTSH scanning in patients taking levothyroxine.

We evaluated a self-managed, outpatient, low iodine diet (LID) (<50 microg/day) designed to decrease total body iodine (TBI) in preparation for radioiodine (131I) scans. However, levothyroxine (LT4) ingestion is a significant source of dietary iodine in recombinant human TSH (rhTSH)-stimulated studies. Measuring urine iodine to creatinine ratios (I/Cr), a reflection of TBI, we evaluated the LID for 7-day and 14-day periods to determine the efficacy of our LID to deplete TBI, with and without LT4. Patients following the LID for 14 days (n = 28) without LT4 attained the goal of an iodine deficient state (I/Cr <50 microg/g) in 78% of cases, establishing the diet's efficacy in significantly reducing TBI. In patients taking LT4, 7 days of the LID was insufficient to attain this goal of true iodine deficiency. However, a 14 day LID while taking LT4 resulted in 21% of patients being iodine deficient. For diagnostic purposes, a 7 day LID period (n = 21) suboptimally but adequately (I/Cr <100 microg/g) prepared 41% of the patients, whereas 14 days on the diet (n = 24) adequately prepared 71% of the patients taking LT4. Our simple, self-managed, outpatient, LID effectively makes patients iodine deficient. Though less efficacious when taking LT4, this LID adequately reduces TBI for rhTSH-stimulated 131I uptake scans when followed for 14 days.     

Reevaluation of the impact of a stringent low-iodine diet on ablation rates in radioiodine treatment of thyroid carcinoma.

Prior analyses of the impact of stringent, preablative low-iodine diets (LIDs) on ablation in patients with differentiated thyroid cancer postthyroidectomy are dated. We retrospectively reviewed first-time, short-term ablation rates for 44 LID patients and 50 patients following a regular diet (RD) who were verbally instructed to avoid salt, seafood, and multivitamins containing iodine. Patients who had undergone ablation were given between 100 and 200 mCi of 131I, depending on the presence of metastases. We found a 68.2% ablation rate for LID patients, compared to a 62.0% rate for RD patients, a nonsignificant difference (p = 0.53). We observed a dose-response relationship for both patient groups, with higher ablation rates corresponding to higher doses of radioiodine administered. We also measured iodine levels in spot urine samples from 7 matched LID patients and 7 matched RD adherents (healthy volunteers) prediet and postdiet as well as 39 healthy volunteers. LID patients had a lower mean urinary iodine level postdiet (173.9 microg/L; range, 45-1,217 microg/L; standard deviation [SD] = 127.7) than the RD patients (mean, 381.4 microg/L; range, 140-630 microg/L; SD = 196.3) or the 39 normal controls (444.0 microg/L; range, 50-1,690 microg/L; SD = 413.4). Whereas the LID lowered urinary iodine levels by 69.4% from prediet values, the RD reduced urinary iodine by 23.6%. Although differences in the reduction of urinary iodine levels between the LID and the RD were substantial, both groups experienced equivalent outcomes. The level of iodine in the American diet has progressively decreased, and may be much lower now than when prior LID studies were conducted. We suggest that prescribing a refined, less stringent diet that avoids high-iodine-containing foods would offer equivalent outcomes with increased patient convenience.     

Usefulness of iodine/creatinine ratio from spot‐urine samples to evaluate the effectiveness of low‐iodine diet preparation for radioiodine therapy

Objective The success of a low‐iodine diet (LID) is best determined by measurement of 24‐h urine iodine (U‐I) excretion. The aim of this study was to determine reliable estimates for 24‐h U‐I based on spot‐urine samples and to provide cut‐offs to determine the effectiveness of LID preparation. Design We prospectively measured iodine levels in 193 patients based on 24‐h‐ and spot‐urine samples before radioactive iodine therapy. The iodine was expressed as the 24‐h U‐I excretion (μg/day) and as two different indices from spot urine, simple iodine concentration (simple I) and the iodine/creatinine (I/Cr) ratio. Poor LID preparation was defined as I excretion of >150 μg/day according to the 24‐h U‐I measurement. Results The measured 24‐h U‐I was significantly higher than the two indices from spot urine (P < 0·001). However, there were statistically significant correlations between the 24‐h U‐I values and the two spot‐urine‐based indices; the correlation coefficient was 0·539 for simple I and 0·773 for I/Cr ratio (P < 0·001). The cut‐off of I/Cr ratio for poor LID preparation was >66·2 μg/g Cr (sensitivity 96·4%, specificity 83·6%, positive predictive value 50·0% and negative predictive value 99·3%). Conclusions We demonstrated that the I/Cr ratio from spot urine could serve as a useful and reliable alternative to 24‐h urine collection as it has acceptable diagnostic values for detecting poor LID preparation.     

Daily urine iodine excretion while consuming a low-iodine diet in preparation for radioactive iodine therapy in a high iodine intake area

Objective Recommended durations of low‐iodine diet (LID) in preparation for radioactive iodine therapy (RAIT) vary among major guidelines and are important for patients in areas where iodine intake is high. The aim of this study was to investigate daily changes in urine iodine excretion after starting a LID. Design The daily iodine/creatinine (I/Cr) ratios and simple iodine concentration (simple I) of morning spot urine from 19 patients with differentiated thyroid carcinoma were measured for 2 weeks from the start of LID for RAIT preparation. We set the cut‐off of I/Cr and simple I for poor LID preparation at >66·2 μg/gCr and >150 μg/l, respectively. The day when daily I/Cr or simple I became equal to or below the cut‐off both by 95% CI and 90th percentile was defined as the end‐point for the appropriate duration of LID for RAIT. Results On day 6 of LID, the I/Cr ratio decreased below the cut‐off (≤66·2 μg/gCr) both by 95% CI (0–60·8) and by 90th percentile (51·9). Simple I reached the cut‐off (≤150 μg/l) on day 3 by both parameters (95%CI: 2·3–90·5; 90th percentile: 126·5). The morning spot‐urine I/Cr and simple I on day 7 and day 14 were significantly lower than on day 0 (P < 0·05). Conclusions One week of a strict LID is enough to decrease the level of urine iodine excretion in preparation for RAIT even in high iodine intake areas. These results provide essential data for future outcome studies regarding LID preparation for RAIT.     

T-2 mycotoxin intensifies iodine deficiency in mice fed low iodine diet

Mice were depleted of iodine and fed a 125I-labeled low iodine diet. After they developed isotopic equilibrium they were given T-2 mycotoxin, in doses 34% to 14% of LD50/day for 4 to 12 days. In all cases T-2 toxin caused loss of thyroid iodine from which the animals recovered when the T-2 toxin was stopped. When iodine intake was adequate, the T-2 toxin had no statistically significant effect on the thyroid iodine content. Since T-2 toxin is known to block the initiation of some protein synthesis, it may block thyroglobulin synthesis, and, in stimulated thyroids, limited hydrolysis may continue. Therefore, when the thyroids were stimulated and thyroglobulin was depleted, a blockade of thyroglobulin synthesis may have caused further depletion of thyroidal iodine.     

Thiocyanate feeding with low iodine diet causes chronic iodine retention in thyroids of mice

Effects of KSCN on thyroidal iodine metabolism were studied in weanling mice fed a low iodide diet (LID) labeled continuously with 125I as iodide. The addition of KSCN (0.3 and 0.6 mg/g diet) resulted in the accumulation of an unusual iodinated protein within the follicles of the mouse thyroids. After 60 days, total thyroidal iodine was 4 times greater than in controls without thiocyanate. The iodinated protein was essentially insoluble at pH 8.0 and was very slowly released from the thyroids; it contained more MIT than DIT and little thyroid hormone. By use of three isotopes (125I, 127I, and 131I) and auto-radiographs, there were shown different iodinated proteins synthesized during high and low iodine intakes and coexistent but segregated in the colloid. Low doses of perchlorate or iodide inhibited or prevented accumulation of the essentially insoluble iodinated protein. It is suggested that when mouse thyroids are iodine depleted, thiocyanate increases the formation of an essentially insoluble iodinated thyroglobulin within the thyroid. Only a small fraction of the iodination may have occurred by this route, but the rate of formation exceeded the rate of release, so the product continuously accumulated.     

Reevaluation of the thyroidal radioactive iodine uptake test, with special reference to reversible primary hypothyroidism with elevated thyroid radioiodine uptake

The clinical significance of the thyroidal radioactive iodine uptake (RAIU) test was reevaluated in patients with various thyroid disorders. Compared with 262 normal subjects or 194 patients with euthyroid diffuse goiter with normal serum TSH levels, RAIU values were significantly higher in 100 patients with latent primary hypothyroidism (serum TSH, 5-40 mU/L). In 126 patients with overt primary hypothyroidism (serum TSH, greater than 40 mU/L), RAIU values were either extremely high (49 patients with reversible hypothyroidism and 10 patients with postpartum hypothyroidism) or low (67 patients with irreversible hypothyroidism). The increase in RAIU values in latent, or reversible overt hypothyroidism was TSH dependent, and there was a good correlation between RAIU values and serum TSH levels (r = 0.6203; P less than 0.001). In overt primary hypothyroidism, spontaneous recovery of thyroid function during iodide restriction alone occurred in 52 of 53 patients with RAIU values above 35%, in only 7 of 23 patients with RAIU values between 10-35%, and in none of 50 patients with RAIU below 10%. Thus, recovery was predicted by high RAIU values (P less than 0.001; prediction rate, 91.4%). Goiter was found in about 80% of the patients with reversible hypothyroidism, compared with only 34% of the patients with irreversible hypothyroidism. Recovery of thyroid function during iodide restriction also occurred in 71% of the patients with latent hypothyroidism. However, RAIU measurements did not predict the prognosis of patients with latent hypothyroidism. We conclude that iodine-induced reversible hypothyroidism is common in our patient population, and RAIU measurements may be helpful in determining the prognosis of patients with overt primary hypothyroidism.     

Psychological aspects of low protein diet therapy

One of the main problems in low protein diet is patient's noncompliance and the risk of both depression and reduced quality of life. A pilot study investigated the life-style and the state of mood before and during low protein diet. The results show a deterioration in the life-style and the state of mood. Conclusions are concentrated on the necessity of a systematic psychological well-founded low protein diet educational program.     

Uninhibited thyroidal uptake of radioiodine despite iodine excess in amiodarone-induced hypothyroidism

Iodine excess is associated with a low thyroidal radioiodine uptake due to dilution of the radioisotope by the increased stable iodide pool. We studied thyroidal uptake of radioisotopes in cardiac patients with iodine excess due to amiodarone treatment. 99mTc-pertechnetate scintigraphy was performed in 13 patients receiving long term amiodarone therapy. Five patients had a clearly visible thyroid gland, and 8 patients had no or a very faint thyroid image. All patients with positive scans had an increased plasma TSH level, whereas all patients with negative scans had a normal or absent TSH response to TRH. Thyroidal uptake and discharge of 123I were studied in 30 other patients. Group I (n = 11) had normal plasma TSH responses to TRH and no iodine excess, group II (n = 7) had normal TSH responses to TRH and excess iodine from metrizoate angiography in the previous month, group III (n = 7) had normal or decreased TSH responses to TRH while receiving long term amiodarone therapy, and group IV (n = 5) had increased TSH responses to TRH while receiving long term amiodarone therapy. The mean radioiodine uptake value in group I [5.4 +/- 0.8% (+/- SE) at 60 min] was higher than those in group II (2.3 +/- 0.7%; P = 0.009) and group III (0.8 +/- 0.3%; P = 0.0005), but not different from that in group IV (5.3 +/- 1.2%; P = NS). Radioiodine discharge after perchlorate (expressed as a percentage of the 60 min uptake) in group I (10.1 +/- 2.2%) was lower than those in group II (24.9 +/- 10.6%; P = 0.05) and group III (28.8 +/- 5.3%; P less than 0.005), whereas discharge in group IV (58.0 +/- 6.1%) was greater than those in group II (P less than 0.05) and group III (P less than 0.01). In conclusion, 1) thyroid visualization by 99mTc-pertechnetate and thyroid radioiodine uptake during iodine excess are decreased in euthyroid and hyperthyroid patients, but preserved in hypothyroid patients. 2) The organification defect induced by iodine excess is greater in iodide-induced hypothyroidism than in eu- or hyperthyroidism. These findings may be explained by the increased TSH secretion in hypothyroidism and/or by decreased thyroidal concentration of an unknown specific iodinated compound (whose concentration and action vary with the total organic iodine content of the thyroid) that mediates the inhibition of iodide transport.     

Management of paediatric thyroid carcinoma: recent experience with recombinant human thyroid stimulating hormone in preparation for radioiodine therapy

Background: Thyroid carcinoma in children is rare and raises unique management issues. Although metastatic disease is more common in this age group, prognosis remains good with appropriate treatment. The aim of the study was to report recent experience in the management of differentiated thyroid carcinoma in children, especially in the use of radioiodine after recombinant human thyroid stimulating hormone (rhTSH) stimulation. Methods: Eight patients, aged 5–17 years (five were boys) presented following total thyroidectomy for thyroid carcinoma between May 2003 and June 2005. Seven had papillary carcinoma and one had follicular carcinoma. Five had known lymph node metastases and one had pulmonary metastases at presentation. Four patients had previously received therapeutic irradiation for malignancy. All eight underwent diagnostic iodine scans, seven with rhTSH stimulation. Seven went on to receive radioiodine treatment as hospital inpatients, comanaged by the paediatric and nuclear medicine units. The dosage of ¹³¹I ranged from 1.5 to 3.7 × 10⁹ Bq. All except one were prepared by rhTSH stimulation. Results: Seven of eight patients had significant uptake in the neck on diagnostic scan and two had pulmonary abnormalities. Six of seven evaluable patients achieved complete thyroid ablation. Both patients with pulmonary abnormalities had scan resolution, although one of them only after a second radioiodine treatment. All patients had thyroxine replacement in doses to suppress TSH and all remain alive and well at time of carrying out this study. Conclusion: Optimal management of paediatric thyroid carcinoma necessitates a multidisciplinary approach. Radioiodine therapy under rhTSH is an effective and safe adjuvant treatment in this special subgroup.     

Extended outpatient therapy with low molecular weight heparin for the treatment of recurrent venous thromboembolism despite warfarin therapy

PURPOSE: The optimal management of patients who have recurrent thromboembolism while being treated with oral anticoagulation therapy is unknown. This study reports managing such patients with extended duration low molecular weight heparin therapy. SUBJECTS AND METHODS: This study was a retrospective review of the prospective databases of three tertiary care teaching hospitals over a 27-month period. All patients who had recurrent symptomatic thromboembolism while being treated with warfarin were identified. All patients were treated with low molecular weight heparin (dalteparin), 200 U/kg daily. Data were collected for recurrent venous thromboembolism, bleeding, and survival. RESULTS: Eight hundred eighty-seven patients were managed for acute thromboembolism. In 32 patients, symptomatic, objectively documented thromboembolism recurred while they were taking warfarin; 63% of the patients with recurrence had cancer, compared with 30% of patients without recurrence. All recurrences were treated with dalteparin. In 3 patients (9% [95% confidence interval: 2% to 25%]), symptomatic recurrence developed while they were being treated with low molecular weight heparin. Nineteen patients (59%) died while receiving anticoagulation therapy; all deaths but 1 were due to malignancy, and none was due to pulmonary embolism or bleeding. CONCLUSIONS: These results suggest that recurrent venous thromboembolism is more likely to develop in cancer patients while being treated with warfarin and that long-term therapy with low molecular weight heparin may be effective in managing warfarin-failure thromboembolic disease.     

Recommendations for outpatient parenteral antimicrobial therapy in Brazil

A panel of national experts was convened by the Brazilian Infectious Diseases Society in order to determine the recommendations for outpatient parenteral antimicrobial therapy (OPAT) in Brazil. The following aspects are covered in the document: organization of OPAT programs; patient evaluation and eligibility criteria, including clinical and sociocultural factors; diagnosis of eligibility; venous access and antimicrobial infusion devices; protocols for antimicrobial use and monitoring and cost-effectiveness.