儿童亚临床甲状腺功能减退症

以往研究多关注成年人亚临床甲状腺功能减退症(SH),但因它对儿童神经心理发育有潜在影响,可能影响到儿童的认知水平和智力发育,从而影响其成年后生活质量,因而对儿童SH的研究受到关注.目前对其发病机制的研究较为清楚,然而关于如何进行治疗还存在争议,是否需要甲状腺素替代治疗尚无定论.     

糖尿病合并亚临床甲状腺功能减退症及其对动脉粥样硬化的影响

糖尿病大血管病变是糖尿病发病率最高、危害性最大、致死率最高的并发症。亚临床甲状腺功能减退症是以正常甲状腺素水平和升高的促甲状腺激素水平为特征的一种轻度或补偿型原发性甲状腺功能减退症。近年来国内研究显示升高的促甲状腺激素可作为动脉粥样硬化的独立危险因素,通过多种途径促进动脉粥样硬化的发展,从而参与糖尿病大血管病变的进展。文章通过参考总结相关文献将亚临床甲状腺功能减退与糖尿病患者动脉粥样硬化之间的相关性作一综述。     

亚临床甲状腺功能减退症

亚临床甲状腺功能减退症（简称亚临床甲减，subclinical hypothyroidism），以往也称轻度甲状腺功能减退症或临床前甲状腺功能减退症。一般是指血清游离甲状腺素（FT4）在正常范围，而血清促甲状腺激素（thyroid—stimulating hormone，TSH）水平升高，患者没有明显的甲状腺功能减退（甲减）的临床症状和体征，是甲状腺功能减退症的早期阶段，诊断必须依靠血清学检查。国内外对亚临床甲减的治疗和处理尚无统一的意见和观点，本文就有关亚临床甲减研究的现状进行复习，以供临床诊疗参考。     

亚临床甲状腺功能减退症患者血脂水平分析

目的 观察亚临床甲状腺功能减退症(亚临床甲减)患者的血脂水平,并与临床甲状腺功能减退症(临床甲减)患者和甲状腺功能正常者(对照组)相比较,探讨其机制.方法 160例患者被分为亚临床甲减组46例,临床甲减组40例,对照组74例,应用固相化学发光酶免疫分析法检测超敏促甲状腺素(s-TSH)、游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4),同时测定总胆固醇(代)、甘油三酯(TG)、低密度脂蛋白(LDL)、高密度脂蛋白(HDL)、载脂蛋白A Ⅰ(ApoA Ⅰ)、载脂蛋白B100(ApoB100)、脂蛋白(a)[LP(a)].结果 亚临床甲减组的代、LDL、LP(a)高于对照组(P＜0.05,P＜0.01,P＜0.01),其中LDL、LP(a)水平接近临床甲减组.结论 亚临床甲减可以引起血脂代谢异常,并且部分血脂指标接近临床甲减.     

亚临床甲状腺功能减退症的研究进展

亚临床甲状腺功能减退症（亚临床甲减，Subclinical hypothyroidism，SHT），以往也称轻度甲状腺功能减退症，甲状腺储备功能受损或临床前甲状腺功能减退症。是甲状腺功能减退症的早期阶段。随着测定血清促甲状腺激素放射免疫技术的不断改进，其诊断率越来越高。近年来，亚临床甲减对人类的潜在危害已被许多研究证实，因此它受到更多的关注，尤其在治疗与否的问题上引起了学术界的广泛争论。     

亚临床甲状腺功能减退症的治疗

亚临床甲状腺功能减退症(亚甲减)以基线促甲状腺激素(TSH)水平升高和血清游离甲状腺素水平正常为特征，亚临床或隐匿性甲减常常反映甲状腺激素分泌的缺陷。甲状腺破坏性治疗(甲状腺次全切除术或放射碘治疗)或颈部广泛放射治疗后的亚临床甲减应开始使用左甲状腺素(L-T4)治疗；妊娠和哺乳期的亚甲减也应使用L-T4治疗。其他早期使用甲状腺激素替代治疗的指征包括TSH水平升高以及抗甲状腺过氧化物酶(TPO)抗体阳性，因为这些患者的亚甲减很可能进展为临床甲减。提示存在甲状腺激素相对缺乏的I临床体征和症状的所有患者都应该试用L-T4替代治疗，这些患者包括亚临床甲减并发不孕、抑郁症或其他神经心理异常。单纯血清TSH水平升高或高胆固醇血症不是L-T4治疗的适应症，除非患者有甲状腺疾病史以及提示甲状腺激素缺乏的临床症状。     

亚临床甲状腺功能减退症

亚临床甲状腺功能减退症(甲减)是一种业临床甲状腺疾病.诊断标准是血清促甲状腺激素(TSH)水平高于正常上限而游离T4水平尚在正常范围.目前全世界业临床甲减的平均患病率为4%～10%,主要发生在女性和老年人群.桥本甲状腺炎是最常见的病因.其卡要的临床危害包括引起血脂异常、导致动脉粥样硬化和,冠心病、影响认知功能,还可导致不孕和流产.治疗主要针对血清TSH10 mIU/L的患者,应用左旋-T4替代治疗.对于血清TSH 4～10 mIU/L,特别是甲状腺自身抗体阳性者需密切监测.此外,对妊娠期亚临床甲减患者的治疗要求控制TSH<2.5 mlU/L.     

亚临床甲状腺功能减退症

亚临床甲状腺功能减退症（甲减）是一种亚临床甲状腺疾病。诊断标准是血清促甲状腺激素（TSH）水平高于正常上限而游离T4水平尚在正常范围。目前全世界亚临床甲减的平均患病率为4％-10％,主要发生在女性和老年人群。桥本甲状腺炎是最常见的病因。其主要的临床危害包括引起血脂异常、导致动脉粥样硬化和冠心病、影响认知功能,还可导致不孕和流产。治疗主要针对血清TSH〉10ml U／L的患者,应用左旋-T4替代治疗。对于血清TSH4～10ml U／L,特别是甲状腺自身抗体阳性者需密切监测。此外,对妊娠期亚临床甲减患者的治疗要求控制TSH〈2．5ml U／L。     

亚临床甲状腺功能减退症患者及甲状腺功能正常者甲状腺功能与血糖水平的关系

目的研究亚临床甲状腺功能减退症患者及甲状腺功能正常者甲状腺功能与血糖的关系。方法采用整群抽样法于2007年至2010年从沈阳市城市成年居民中招募2751名研究对象,行问卷调查,测量血压、身高、体重、腰围、促甲状腺激素、游离三碘甲状腺原氨酸、游离甲状腺素、空腹血糖、口服葡萄糖耐量试验2h血糖、甘油三酯、总胆固醇和高密度脂蛋白胆固醇。将受试者分为亚临床甲状腺功能减退症组（n=193）及甲状腺功能正常组（n=2146）,甲状腺功能正常组又进一步分为促甲状腺激素低水平组（n=352,促甲状腺激素／〉0．3-〈1．0mU／L）、促甲状腺激素中水平组（n=916,促甲状腺激素≥1．0-≤1．9mU／L）、促甲状腺激素高水平组（n=944,促甲状腺激素1．9〈-≤4．8mU／L）。受试者根据血糖水平进一步分为糖耐量正常组、糖调节异常组、糖尿病组,分析甲状腺功能指标与血糖的关系。采用t检验及方差分析进行数据统计。结果亚临床甲状腺功能减退症组口服葡萄糖耐量试验2h血糖明显高于甲状腺功能正常组[（8．34-4．4）vs（7．74-4．2）mmol／L,t=一2．163,P〈0．05],2组糖调节异常及糖尿病的患病率差异无统计学意义。糖尿病组游离甲状腺素水平高于糖调节异常组和糖耐量正常组[分别为（16．8±2．1）、（16．3±2．1）、（16．2±1．9μmol／L,F=10．515,P〈0．01],女性中糖尿病组[15．3％（26／188）]及糖调节异常组[15．0％（34／227）]亚临床甲状腺功能减退症的患病率明显高于糖耐量正常组[9．5％（86／903）]（）（2值分别为7．165、5．685,均P〈0．05）,女性亚临床甲状腺功能减退症的患病率明显高于男性[11．1％（146／1318）VS4．6％（47／1027）,x2=31．852,P〈0．01]。多元线性回归分析显示,校正体质指数、腰围、血压、血脂后,总体受试者空腹血糖与游离甲状腺素呈正相关（β=2．748,P〈0．01）,男性受试者空腹血糖与游离甲状腺素亦呈正相关（口=2．346,P〈0．01）,女性受试者口服葡萄糖耐量试验2h血糖与游离甲状腺素呈正相关（／3=2．748,P〈0．01）。在正常范围内,游离甲状腺素水平越高,糖尿病的患病危险越大[总体：比值比（OR）=1．142,95％可信区间（cl）1．064-1．225,P〈0．01;女性：OR=1．147,95％C11．024-1．284,P〈0．05：男性：OR：1．142,95％C11．035-1．261,P〈0．01]。促甲状腺激素及游离三碘甲状腺原氨酸与糖尿病无关。结论女性糖调节异常和糖尿病患者亚临床甲状腺功能减退症的患病率增高;游离甲状腺素与血糖水平呈正相关,游离甲状腺素越高,糖尿病的患病风险越大。     

减重手术对肥胖患者性功能和性激素水平的影响

肥胖给患者带来一系列并发症,如糖尿病、肾功能不全、性功能减退等.肥胖已被确认是男性性功能障碍的危险因素,一些研究表明,肥胖男性的睾酮和性激素结合球蛋白水平下降,但雌二醇水平升高.关于肥胖对女性性功能影响的研究相对较少,对于女性性功能和肥胖之间关系的认识不一致.最近一些研究报道减重手术可提高肥胖患者的性功能,并改变性激素水平.然而对于减重手术后肥胖患者性功能和性激素的变化情况,尚未达成共识.     

亚临床甲状腺功能减退症对糖尿病血管并发症的影响

糖尿病和甲状腺功能障碍是常见的内分泌代谢疾病,糖尿病患者中合并甲状腺功能异常者越来越多,其中以亚临床甲状腺功能减退症居多.目前大多数研究认为,亚临床甲状腺功能减退症可通过引起血脂紊乱、血流动力学异常及内皮功能紊乱等机制,参与并加重糖尿病微血管及大血管并发症.     

Staple-line leak after sleve gastrectomy in obese patients: A hot topic in bariatric surgery

Laparoscopic sleeve gastrectomy is a surgical procedure that is being increasingly performed on obese patients. Among its complications, leaks are the most serious and life threatening. The placement of esophageal, covered, self-expandable metal stents in these cases has been performed by many authors but reports on the outcome of this procedure are limited and the technical aspects are not well defined. Stent migration is the main complication of the procedure and poses a challenge to the surgeon, with a limited number of options. Here we evaluate the technical and clinical outcome of a new, dedicated, self-expanding metal stent, comparing the advantages of this stent to those traditionally used to treat staple-line leak after sleeve gastrectomy. While published data are limited, they seem support the use of this kind of new stent as the best option for the stenting treatment of a staple-line leak after sleeve gastrectomy, over other kinds of stents. Further studies based on larger series are needed to better evaluate patient outcome.     

93例亚临床甲状腺功能减退症的随访研究

目的 研究不同碘摄入量地区亚临床甲状腺功能减退症(甲减)的流行病学特点和影响转归的因素。方法 选择盘山、彰武和黄骅3个农村社区(分别为低碘、适碘和高碘地区)，在入户调查的基础上行采样调查。测定血清TSH、甲状腺过氧化物酶抗体(TPOAb)、甲状腺球蛋白抗体(TGAb)、尿碘浓度及进行甲状腺B超检查，TSH异常者测定FT3、FT4，筛选出118例亚临床甲减患者。盘山和彰武社区于2年后、黄骅社区于1年后进行随访，再次进行以上检查。结果 盘山、彰武和黄骅社区亚临床甲减的患病率分别为0．73％、2．90％和5．96％。亚临床甲减的病因33．1％是自身免疫性甲状腺疾病。在随访到的93例亚临床甲减患者中有4例女性进展为临床甲减。结论 随着碘摄入量的增加亚临床甲减的患病率增加，但无明显性别差异。随访研究证实女性、甲状腺自身抗体阳性是亚临床甲减患者进展至临床甲减的危险因素，碘摄入量与亚临床甲减的转归无关。     

Mean platelet volume in patients with subclinical hypothyroidism

Subclinical hypothyroidism (SCH) is frequently encountered in the general population. Since it is generally asymptomatic, these patients are mostly identified through routine screening or evaluation of non-specific symptoms. It has been suggested as a risk factor for cardiovascular disease. On the other hand, mean platelet volume (MPV), which is a determinant of platelet function, is an independent risk factor for cardiovascular disease. The aim of this study was to evaluate MPV values in subclinical hypothyroidic patients when they were subclinical hypothyroidic and became euthyroidic after 12 weeks of levothyroxine replacement therapy. Sixty patients with subclinical hypothyroidism and 78 euthyroid healthy subjects matched for age, gender and body mass index were enrolled in the study. None of the study subject had diabetes, hypertension or dyslipidemia. All the study subjects were evaluated by biochemical and platelet parameters. Subclinical hypothyroidic patients were then reevaluated with the same parameters when they became euthyroid after 12 weeks of levothyroxine treatment. Platelet counts and metabolic parameters, except serum triglyceride and high density lipoprotein cholesterol (HDLC) levels, were similar between the two groups. Serum triglyceride and MPV values were significantly higher (pTG?=?0.007 and pMPV?<?0.001) while HDLC levels were lower (pHDLC?=?0.008) in the subclinical hypothyroidic group. MPV was found to be correlated with only antithyroid peroxidase (anti-TPO) antibody levels (P?<?0.001). MPV values were decreased after subclinical hypothyroidic patients became eythyroid. However, post-treatment MPV values were still higher (p?=?0.035) in the patient group than in control group. These results suggest that subjects with SCH are susceptible to increased platelet activation and increased MPV values which contribute to increased risk of cardiovascular complications.     

Cardiovascular benefits of bariatric surgery in morbidly obese patients

Morbid obesity is associated with increased morbidity and represents a major healthcare problem with increasing incidence worldwide. Bariatric surgery is considered an effective option for the management of morbid obesity. We searched MEDLINE, Current Contents and the Cochrane Library for papers published on bariatric surgery in English from 1 January 1990 to 20 July 2010. We also manually checked the references of retrieved articles for any pertinent material. Bariatric surgery results in resolution of major comorbidities including type 2 diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome, non‐alcoholic fatty liver disease, nephropathy, left ventricular hypertrophy and obstructive sleep apnea in the majority of morbidly obese patients. Through these effects and possibly other independent mechanisms bariatric surgery appears to reduce cardiovascular morbidity and mortality. Laparoscopic Roux‐en‐Y gastric bypass (LRYGB) appears to be more effective than laparoscopic adjustable gastric banding (LAGB) in terms of weight loss and resolution of comorbidities. Operation‐associated mortality rates after bariatric surgery are low and LAGB is safer than LRYGB. In morbidly obese patients bariatric surgery is safe and appears to reduce cardiovascular morbidity and mortality.     

老年亚临床甲状腺功能减退症的诊治分析

目的分析老年亚临床甲状腺功能减退症（亚甲减）患者的临床表现及甲状腺激素替代治疗后疗效及不良反应,从而探讨老年亚甲减的治疗方案。方法选择华东医院2007年4月至2009年5月门诊诊断为亚甲减的老年患者87例,给予左旋甲状腺素钠（L—T4）替代治疗。初始替代剂量为12．5gg／日,逐渐增加剂量,至TSH恢复正常,维持原方案治疗3个月后,复查血清FT3、FT4及sTSH水平及血清总胆固醇（TC）、甘油三酯（TG）、低密度脂蛋白胆固醇（LDL）、高密度脂蛋白胆固醇（HDL）水平3观察甲状腺激素替代治疗前后临床症状、血脂的改善及不良反应。结果1．L—T4替代治疗后,51例有症状的患者38例有2种以上的症状明显改善。2．L—T4替代治疗后,TC、LDL明显下降（P〈0．05）。结论1．老年亚甲减患者的临床症状不明显,容易误诊、漏诊。2．左旋甲状腺素钠（L—T4）替代治疗能改善老年亚甲减患者的临床症状,降低TC、LDL水平。3．老年亚甲减患者的替代治疗,应从小剂量开始,注意个体化。     

Subclinical hypothyroidism and the risk of coronary heart disease: a meta-analysis

Purpose

Subclinical hypothyroidism has been associated with elevated cholesterol and increased risk for atherosclerosis, but data on the risk of coronary heart disease (CHD) are conflicting. We performed a systematic review to determine whether subclinical hypothyroidism is associated with CHD in adults.

Methods

We searched MEDLINE from 1966 to April 2005, and the bibliographies of key articles to identify studies that provided risk estimates for CHD or cardiovascular mortality associated with subclinical hypothyroidism. Two authors independently reviewed each potential study for eligibility, assessed methodologic quality, and extracted the data.

Results

We identified 14 observational studies that met eligibility criteria. Subclinical hypothyroidism increased the risk of CHD (summary odds ratio [OR]: 1.65, 95% confidence interval [CI], 1.28-2.12). The summary OR for CHD was 1.81 (CI, 1.38-2.39) in 9 studies adjusted or matched for demographic characteristics, and 2.38 (CI, 1.53-3.69) after pooling the studies that adjusted for most cardiovascular risk factors. Sensitivity analyses including only population-based studies and those with formal outcome adjudication procedures yielded similar results. Subgroup analyses by type of study design showed a similar trend, but lower risk, in the 5 prospective cohort studies (OR 1.42, CI, 0.91-2.21), compared with the case-control and cross-sectional studies (OR 1.72, CI, 1.25-2.38).

Conclusion

Our systematic review indicates that subclinical hypothyroidism is associated with an increased risk of CHD. Clinical trials are needed to assess whether thyroxine replacement reduces the risk of CHD in subjects with subclinical hypothyroidism.