Clinical and immunological studies on patients with Graves' disease preoperatively treated with corticosteroids and iodides

The purpose of this study was to evaluate the acute effects of corticosteroid and iodide preoperative therapy in patients with Graves' disease in terms of thyroid function and immunological parameters. The above combination was prescribed for 4 patients who had experienced severe side effects from antithyroid drugs (ATD) in order to reduce the possibility of post-thyroidectomy thyroid storm. Corticosteroids were employed daily for four days, and iodides were given daily for two weeks prior to thyroidectomy. The free T3 values decreased rapidly to euthyroid levels following the administration of both drugs, although the free T4 values were still much higher than normal in 3 of the 4 patients at the time of surgery. By comparison, 3 of 8 patients treated with ATD also had thyroid hormone levels above normal. Studies of lymphocyte subsets revealed that the percentage of helper T cells was significantly less in the corticosteroid-iodide treatment group than in the control and ATD groups. It is thus possible that postoperative thyroid storm might be prevented through corticosteroid-iodide therapy by virtue of the reduction of free T3 values to within the normal range by the time of surgery. The acute suppression of helper T cells was another results of this form of therapy observed.     

Lithium carbonate in the preoperative preparation of Graves' disease

Lithium carbonate was given in the preoperative preparation of 12 patients with Graves' disease, the reasons for its use being side effects of thionamide in 9 patients, insufficient control by thionamide in 1 and psychic symptoms in 2. Lithium carbonate was often used in combination with other drugs, namely; thionamide in 4 patients, beta-adrenergic blockades in 5, reserpine in 5 and glucocorticoid in 1. This preoperative control significantly decreased the mean serum T₂ and T₄ levels from 656±55 ng/dl to 180±16 ng/dl and from 25.9±2.1 μg/dl to 9.7±1.5 μg/dl, respectively. The only adverse effect of lithium carbonate was pollakisuria observed in one patient. All patients underwent subtotal thyroidectomy uneventfully. It is concluded that the administration of lithium carbonate alone or in combination with other durgs is an effective method of preoperatively controlling hyperthyroidism when conventional antithyroid drugs show adverse effects.     

Clinical significance of risedronate for osteoporosis in the initial treatment of male patients with Graves' disease

It has been well established that hyperthyroidism leads to diminished bone mineral density (BMD), and that a previous history of hyperthyroidism remains a risk factor for fractures. However, little is known about how to manage the reduction in BMD caused by hyperthyroidism. The purpose of this study was to evaluate the efficacy of risedronate for the treatment of osteoporosis/osteopenia in patients with Graves' disease (GD). Of 34 Japanese male patients with newly diagnosed GD, 27 with osteoporosis/osteopenia were included in this study. They were randomly divided into two groups by therapeutic regimen. Group A consisted of 14 patients treated with an antithyroid drug and risedronate. Group B consisted of 13 patients treated with the same antithyroid drug only. We used dual-energy X-ray absorptiometry to measure BMD at the lumber spine, femoral neck, and distal radius at baseline, and at 6 and 12 months after the trial. Bone-specific alkaline phosphatase and urinary N-terminal telopeptide of type I collagen normalized by creatinine were significantly more reduced in group A than in group B after both 6 and 12 months. The percentage increases in BMD at the lumbar spine and distal radius were significantly greater in group A than in group B. These beneficial effects of risedronate for patients with osteoporosis/osteopenia caused by GD may lead to a reduced risk of future fractures. We thus conclude that risedronate should be considered for the treatment of decreased bone mass associated with GD.     

The outcome of patients with thyroid carcinoma and graves' disease

A total 847 consecutive patients with Graves' disease who underwent thyroidectomy between 1965 and 1990 were found to have a 4.3% incidence of coincident carcinoma of the thyroid. In 68.2% of these cases the tumors were less than 1 cm in diameter and were detected in only 7 patients (19.4%) prior to surgery. Dissection of the regional lymph nodes was necessary in only 11 patients. A review of the patients in 1990 revealed no carcinoma-related deaths with metastases occurring most commonly in the patients with larger tumors and in those whose cancer had been detected prior to thyroidectomy. Although the detection of potential tumors occurring with Graves' disease using preoperative echogram may be of interest, our results suggest that occult micro-carcinoma occurring coincidentally with Graves' disease is not clinically significant as it did not cause any recurrence in this study. Moreover, there was no evidence to suggest that Graves' disease was associated with the increased or rapid growth of these tumors.     

Incidental thyroid carcinoma in patients with Graves' disease

BACKGROUND: The clinical significance of incidental thyroid carcinoma in patients with Graves' disease is uncertain. METHODS: The prevalence of incidental thyroid carcinoma was determined in patients with Graves' disease who underwent surgery from 1990 to 2007 and was compared with patients with nontoxic nodular goiter or toxic multinodular goiter who underwent surgery during the same time period. RESULTS: Of the 93 patients who underwent thyroidectomy for Graves' disease, 2 patients (2.2%) had an incidental papillary carcinoma: .4 and .5 cm in size. Neither patient developed recurrent disease after 3 and 13 years of follow-up evaluation. The prevalence of incidental thyroid cancer was 3.6% and 6.2% in patients with nontoxic nodular goiter and toxic multinodular goiter, respectively (P = not significant). CONCLUSIONS: The prevalence of incidental thyroid carcinoma in patients with Graves' disease is comparable with patients with nontoxic or toxic goiter. Incidental thyroid carcinomas in patients with Graves' disease were papillary microcarcinomas of no clinical consequence.     

Graves病患者骨代谢变化临床分析

目的 探讨Graves病患者骨代谢变化的特点及作用机制。方法 测定49例Graves病患者骨代谢指标，并与甲状腺激素进行相关分析。结果 Graves病患者血BGP、ICTP、Ca、AKP和U-HOP／Cr升高，BMD下降；并与T13、TT4正相关。结论 Graves病患者骨吸收和骨形成指标均异常升高，表现为高转化骨代谢紊乱；骨吸收大于骨形成。这一代谢紊乱与甲状腺激素有关。     

Clinical significance of serum levels of thyroid stimulating hormone receptor antibody in pregnant women with Graves′disease

<正>Objective:To investigate the clinical significance of serum thyroid stimulating hormone(TSH) receptor antibody (TRAb) levels and the antithyroid drug(ATDs) use in pregnant women with Graves' disease in their neonatal thyroid function. Methods:The serum TRAb and T3,T4,FT3,FT4,TSH levels in 68 pregnant women with Graves' disease and their newborns were detected by radio receptor assay(RRA) and electrical chemiluminescence immunoassay (ECLIA),respectively.Based on the maternal serum TRAb levels and the use of antithyroid drugs during pregancy, the newborns were divided into different groups.The incidence of neonatal thyroid dysfunction and its risk factors were analyzed. Results:The results showed the incidence of abnormal thyroid function of newborns was 29.4%(20/68).The proportion of neonatal thyroid dysfunction in women with high TRAb levels in the third trimester of pregnancy were significantly higher than these with normal TRAb(P0.01).In 23 newborns whose mothers were normal in serum TRAb levels and took no ATDs during pregnancy,only one case had thyroid dysfunction within two weeks after birth,while in other 45 newborns whose mothers had a high level of serum TRAb and/or took ATDs during pregnancy, 19 developed thyroid dysfunction within two weeks after birth. Conclusion:Neonatal thyroid function depends on the balance between the transplacental TRAb and ATDs. TRAb measurement in pregnant women with Graves' disease is of significance in evaluation of neonatal thyroid function. Elevated level of serum TRAb in the third trimester of pregnancy is a risk factor for neonatal thyroid dysfunction.     

检测Graves病孕妇血清促甲状腺激素受体抗体的临床意义

目的 探讨Graves病妊娠患者血清促甲状腺激素受体抗体（TRAb）水平和服用抗甲状腺药物（ATDs）对新生儿甲状腺功能异常的影响.方法 应用放射性受体法（RRA）和电化学发光免疫分析法（ECLIA）分别检测了68例Graves病孕妇及其新生儿血清TRAb和三碘甲状腺原氨酸（T3）、甲状腺素（T4）、游离三碘甲状腺原氨酸（FT3）、游离甲状腺素（FT4）、促甲状腺激素（TSH）水平,根据母亲孕期血清TRAb水平和服用ATDs的情况对新生儿甲状腺功能异常发生率及影响因素进行分析.结果 新生儿甲状腺功能异常发生率为29.4%（20/68）,母亲妊娠晚期TRAb增高组其新生儿甲状腺功能异常发生率显著高于TRAb正常组（P〈0.01）.新生儿出生后5～14 d取静脉血测定TRAb和甲状腺功能,23例血清TRAb正常且未服ATDs的孕妇,其新生儿1例发生甲状腺功能异常;45例血清TRAb增高和（或）妊娠期间ATDs治疗的孕妇,其新生儿中19例发生新生儿甲状腺功能异常.结论 新生儿甲状腺功能取决于通过胎盘屏障的TRAb与ATDs之间的平衡.Graves病妊娠妇女血清TRAb的测定对评估新生儿甲状腺功能具有重要意义,妊娠晚期血清TRAb水平增高是新生儿甲状腺功能异常的一个危险因素.     

Hemiaplasia of the thyroid associated with Graves' disease: Report of three cases and a review of the literature

We recently treated three additional patients with hemiaplasia of the thyroid associated with Graves' disease, making a total of eight such cases. All eight of these patients were women and their chief complaints were goiter in five cases, whereas exophthalmos or palpebral edema were noted in six cases. All eight patients underwent surgery for Graves' disease. The left lobe was absent in six cases and the right lobe in two, whereas the isthmus was absent in six cases and the pyramidal lobe in four. A total of 102 cases of hemiaplasia of the thyroid, including our present three cases, have been reported in the world literature since 1970, with 32 of them consisting of hemiaplasia associated with hyperthyroidism. Of these, the cause of hyperthyroidism was Graves' disease in 22 cases, an autonomously functioning thyroid nodule in 7, and thyrotoxic multinodular goiter in 3. The left lobe was absent in 19 cases while the right lobe was missing in 12, and laterality was unknown in 1 case.     

Clinical aspects of the evolution of dental caries and periodontal disease in patients treated with corticosteroids

Patients treated with adrenal glucocorticoids may run a higher risk of dental caries, both as a result of their medical condition and of the physical and physiological effects of their pharmacotherapy. Our clinical study reports about patients treated with glucocorticoids who were also having an odonto-periodontal condition. They were examined and we found rampant caries and periodontal diseases. The slow evolution of asymptomatic periodontal disease encouraged destruction of teeth in root caries. The rampant caries were correlated with immunodeficiency and treatment of these caries must take into account the general treatment.     

Increased incidence of medullary thyroid carcinoma in patients treated for Hirschsprung's disease

Background/Purpose

Mutations of the RET proto-oncogene are responsible for the development of inherited multiple endocrine neoplasia type 2 and familial medullary thyroid carcinoma (MTC). RET mutations are encountered in patients with Hirschsprung's disease (HD). We hypothesized that the incidence of MTC is increased in patients with HD.

Methods

Patients treated for HD at the Children's Hospital, University of Helsinki, during 1939 and 1986 were surveyed for cancer using the population-based countrywide Finnish Cancer Registry from 1967 to 2000. The number of observed cancer cases and that of person-years at risk were counted. The expected number of cancer cases was extrapolated from national cancer incidence rates. To calculate the standardized incidence ratios (SIRs), the observed number of cancer cases was divided by the expected number of cancer cases.

Results

One hundred fifty-six patients (132 males) with HD were identified. The mean length of patient follow-up was 30.9 years. Seven cases of cancer were observed (SIR, 3.5; 95% CI, 1.4-7.3). Two patients developed MTC (SIR, 550; 95% CI, 67-2000). The cases of MTC occurred in male patients at the ages of 34 and 37 years. No patient developed pheochromocytoma.

Conclusions

In this study, we report for the first time an increased risk of MTC occurring in patients treated for HD. The increased risk may be attributed to mutations of the RET proto-oncogene shared by MTC and HD. These findings warrant further studies concerning screening for MTC-type RET mutations in patients with HD.     

Long-Term follow up of patients with conservatively treated Kienböck's disease

Seventeen patients with unilateral conservatively treated Kienböck's disease who had been followed up for more than 10 years were studied. We examined pain, range of wrist motion, grip strength, radiological staging, Ståhl index, and clinical results. At the time of final follow up, none of the patients complained of pain severe enough to keep them from working. The flexion/extension arc was less than 60 degrees in only 1 patient. As for radiological changes, five wrists remained in the same category of the Lichtman's staging system⁴ throughout the follow-up period, while eight progressed to higher categories. The remaining four wrists showed radiological improvement. Clinical results were good in 10 patients, fair in 4, and poor in 3. The overall results were better than those reported in other studies of conservatively treated Kienböck's disease with shorter follow-up periods^1,3,7,9. These results strongly suggest that Kienböck's disease has the capacity to heal spontaneously in the long run. Surgical treatment that accelerates healing should be employed, rather than excision or excision/replacement of the lunate.     

Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery

Cardiovascular comorbidities are amongst the most important modifiable risk factors in patients undergoing non-cardiac surgery. Likewise, cardiac complications are a leading cause of all perioperative morbidity and mortality. Major adverse events include acute myocardial ischaemia, infarction, congestive cardiac failure, arrhythmias, and cardiac arrest. Preoperative assessment and planning aims to minimize these risks. Although testing is important, it must be rationalized lest resources are misused and undue delays ensue. Current thinking in preoperative therapy, intraoperative management and postoperative care is discussed. Although most patients with cardiac disease have ischaemic heart disease, other specific cardiac conditions and principles of their management are briefly considered.     

The patient with endocrine disease

Uncontrolled endocrine pathology can cause significant adverse complications during a patient’s perioperative journey. With the ageing population, increasing comorbidity and rising obesity rates, the incidence of endocrine disease in elective and emergency work is likely to increase. A thorough understanding of diagnosis and management perioperatively is essential to prevent any excess morbidity and mortality. The perioperative period may precipitate endocrine emergencies which require rapid diagnosis and life-saving treatments. This article will cover the management of diabetes, thyroid and adrenal disease in the perioperative period.     

Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery

One of the biggest challenges for anaesthetists today is the safe conduct of anaesthesia for patients who might be elderly, have pre-existing cardiac disease and are scheduled to undergo non-cardiac surgery. Within the financial constraints of today’s health services, the appropriate investigations need to be decided and performed for these patients in order to inform the anaesthetist, surgeon and the patient of the risk of surgery. These should be undertaken only if they will influence management of the patient. The preoperative assessment will help with the formation of a perioperative management plan, including preoperative optimization and postoperative care, in order to minimize the risk of an adverse outcome. The most recent guidelines for preoperative cardiovascular evaluation for non-cardiac surgery are discussed in detail, including assessment of risk factors and cardiac investigations. Current thinking in preoperative therapy, intraoperative management and postoperative management is discussed. Although most patients with cardiac disease have ischaemic heart disease, other specific cardiac conditions and the principles of their management are discussed briefly.     

老年胃癌合并心血管疾病的围手术期处理体会

目的探讨老年胃癌患者合并心血管疾病的围手术期处理。方法对116例合并心血管疾病的胃癌患者的临床资料进行回顾性分析。结果术后重度血压升高7例,严重低血压1例,充血性心力衰竭5例,心绞痛2例,心肌梗死1例,各类心律失常28例。并发切口裂开1例,切口感染1例,肺部感染2例,低血糖昏迷1例,吻合口瘘1例,吻合口出血1例。围手术期死亡3例。术后心血管并发症发生率、其他并发症发生率、围手术期死亡率分别为37．9％（44／116）、6．0％（7／116）、2．6％（3／116）。结论老年胃癌合并心血管疾病增加了手术的风险性,但加强围手术期处理可提高手术的安全性,降低围手术期死亡率和并发症发生率。     

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目的探讨合并心血管病高龄结直肠癌病人的围手术期处理。方法根据ACC/AHA制定的非心脏手术围手术期心血管评估指南标准,将2004年1月至2006年12月间在上海交通大学医学院附属新华医院手术的306例70岁以上合并心血管病结直肠癌病人分为高危、中危和低危3级后进行围手术期干预并做回顾性分析。结果高危20例,中危70例,低危216例。术后重度血压升高22例,充血性心力衰竭10例,心绞痛3例,心肌梗死1例,各类心律失常102例。切口裂开3例,肺部感染34例,糖尿病酮症酸中毒1例,肾功能不全4例,吻合口漏6例,应激性溃疡8例。围手术期死亡4例,其中评估为高危者2例,中危者2例。结论术前合并心血管疾病增加了手术的风险,但完善术前评估、加强围手术期的处理可提高手术的安全性,降低手术死亡率和并发症发生率。     

The patient with endocrine disease

Uncontrolled endocrine pathology can cause significant adverse complications during a patient's perioperative journey. With an ageing population, increasing comorbidity, and rising obesity rates, the incidence of endocrine disease in elective and emergency work is likely to increase. A thorough understanding of diagnosis and management perioperatively is essential to prevent any excess morbidity and mortality. The perioperative period may precipitate endocrine emergencies which require rapid diagnosis and life-saving treatments. This article will cover the management of diabetes, thyroid and adrenal disease in the perioperative period with reference to recently published national guidance.     

甲亢131I治疗前后骨密度测定的临床分析

目的 探讨甲亢患者131I治疗前及治疗后临床缓解持续时间的长短及其骨密度的变化情况。方法 70例甲亢患者于131I治疗前和其中37例于131I治疗后临床缓解小于6个月、9-12个月和大于18个月,分别用双能X线骨密度仪(DEXA)进行骨密度(BMD)测定,并分别与年龄匹配正常健康者95例进行对照分析。结果 (1)甲亢131I治疗前和治疗后临床缓解小于6个月、9-12个月的L2-4BMD均明确低于正常对照组,差异有非常显著性,股骨上段各区(股骨颈、Ward's区、大转子区)虽低于正常对照组,但差异无明显性;(2)131I治疗后临床缓解大于18个月的L2-4及股骨上段各区的BMD改善至接近正常人的水平,差异无显著性;(3)131I治疗后临床甲低组L2-4及股骨上段各区(尤其Ward's区)的BMD均明显低于正常对照组,差异有非常显著性。结论 甲亢经131I治疗后临床缓解6-12个月骨矿含量改善不明显,至18个月逐渐增加接近正常对照组水平;131I治疗后临床甲低持续时间大于6个月者,同样会导致骨矿含量的降低。