Iodine supplementation in pregnancy - is it time?

Iodine is essential for the synthesis of thyroid hormone and optimal foetal neurological development. Pregnant women living in borderline or moderate-severe iodine deficient areas are at particularly high risk of being iodine deficient, and this may have important clinical consequences, particularly for the neurocognitive development of the offspring. It is a substantial problem and many countries including the United Kingdom are mild-moderately iodine deficient. Although the detrimental effects of severe iodine deficiency are well recognized, the benefits of correcting mild-to-moderate iodine deficiency are unclear due to a lack of randomized controlled trials in this area. However, observational data increasingly indicate that there may be substantial health and economic benefits from correcting iodine deficiency in pregnancy. There is now a growing trend from learned societies that iodine supplementation should be utilized in pregnancy in countries with mild-to-moderate iodine deficiency. The dose of iodine supplement needs to reflect local iodine status and iodization policies and will need careful monitoring at the population level to ensure doses to prevent under/excess dosing which would undermine the potential benefits. National tailored guidance is therefore essential.

Thyroxine replacement: a clinical endocrinologist's viewpoint

BACKGROUND

Hypothyroidism affects 2-5% of the general population. Patients with uncorrected disease suffer significant morbidity and have an increased risk of cardiovascular disease and neurocognitive impairment. Levothyroxine, the treatment of choice, is inexpensive, easy to administer and in most cases restores well-being while normalizing thyroid function. However, 30-50% of individuals on levothyroxine are either over-treated or under-treated and others remain dissatisfied with treatment despite achieving thyroid hormone concentrations within the laboratory reference interval.

METHODS

This review is based on a systematic search of the literature for controlled trials, systematic reviews, guideline papers and cohort studies addressing best practice in thyroid hormone replacement.

RESULTS

Recent decades have seen improvements in patient management strategies driven by a better appreciation of levothyroxine pharmacokinetics. However, aspects of therapy such as the optimal timing of medication, strategies to overcome treatment non-adherence and target thyroid stimulating hormone concentrations in pregnancy and in patients with differentiated thyroid cancer remain challenging. Furthermore, there is now a substantial body of literature on common genetic variations in the deiodinases and thyroid hormone transporters and their role in the local regulation of thyroid hormone delivery. The benefits of combination therapy with liothyronine and levothyroxine are uncertain, and while it is theoretically probable that subsets of genetically predisposed individuals will benefit from combination therapy the existing evidence is as yet limited.

CONCLUSION

Despite the availability of thyroid hormone replacement for more than a century, there are still substantial challenges in practice and opportunities to improve treatment outcomes.

Paradoxical Relationship Between Body Mass Index and Thyroid Hormone Levels: A Study Using Mendelian Randomization

CONTEXT

Free T3 (FT3) has been positively associated with body mass index (BMI) in cross-sectional studies in healthy individuals. This is difficult to reconcile with clinical findings in pathological thyroid dysfunction.

OBJECTIVE

We aimed to investigate whether childhood adiposity influences FT3 levels.

DESIGN

Mendelian randomization using genetic variants robustly associated with BMI.

SETTING

Avon Longitudinal Study of Parents and Children, a population-based birth cohort.

PARTICIPANTS

A total of 3014 children who had thyroid function measured at age 7, who also underwent dual x-ray absorptiometry scans at ages 9.9 and 15.5 years and have genetic data available.

MAIN OUTCOME MEASURES

FT3.

RESULTS

Observationally at age 7 years, BMI was positively associated with FT3: β-standardized (β-[std]) = 0.12 (95% confidence interval [CI]: 0.08, 0.16), P = 4.02 × 10(-10); whereas FT4 was negatively associated with BMI: β-(std) = -0.08 (95% CI: -0.12, -0.04), P = 3.00 × 10(-5). These differences persisted after adjustment for age, sex, and early life environment. Genetic analysis indicated 1 allele change in BMI allelic score was associated with a 0.04 (95% CI: 0.03, 0.04) SD increase in BMI (P = 6.41 × 10(-17)). At age 7, a genetically determined increase in BMI of 1.89 kg/m(2) was associated with a 0.22 pmol/L (95% CI: 0.07, 0.36) increase in FT3 (P = .004) but no substantial change in FT4 0.01 mmol/L, (95% CI: -0.37, 0.40), P = .96.

CONCLUSION

Our analysis shows that children with a genetically higher BMI had higher FT3 but not FT4 levels, indicating that higher BMI/fat mass has a causal role in increasing FT3 levels. This may explain the paradoxical associations observed in observational analyses. Given rising childhood obesity levels, this relationship merits closer scrutiny.

HYPOTHYROXINAEMIA AND BRAIN DEVELOPMENT

The aim of this review is to indicate the current position on the role of thyroxine (T4) and fetal brain development with particular relevance to the human situation. Adequate maternal iodine nutrition and maternal circulating thyroxine (T4) concentrations are essential to ensure optimum T4 placental passage which in turn will ensure transport of T4 into fetal brain cells. These processes are discussed and the role of thyroid hormone transporters is considered. The emphasis on isolated maternal hypothyroxinaemia (IH) as an important factor affecting brain development is discussed from the animal experimental point of view as well as in the clinical setting. There is evidence of neurocognitive impairment as assessed by different modalities in children up to the age of 8 years and some suggestion of increased psychiatric disorder in older persons whose mothers had IH during gestation. Although international guidelines have not in general recommended thyroxine therapy for IH the recent demonstration of adverse obstetric outcomes in women with isolated maternal hypothyroxinaemia may warrant a revision of this strategy.

Predicting Surgery Targets in Temporal Lobe Epilepsy through Structural Connectome Based Simulations

Temporal lobe epilepsy (TLE) is a prevalent neurological disorder resulting in disruptive seizures. In the case of drug resistant epilepsy resective surgery is often considered. This is a procedure hampered by unpredictable success rates, with many patients continuing to have seizures even after surgery. In this study we apply a computational model of epilepsy to patient specific structural connectivity derived from diffusion tensor imaging (DTI) of 22 individuals with left TLE and 39 healthy controls. We validate the model by examining patient-control differences in simulated seizure onset time and network location. We then investigate the potential of the model for surgery prediction by performing in silico surgical resections, removing nodes from patient networks and comparing seizure likelihood post-surgery to pre-surgery simulations. We find that, first, patients tend to transit from non-epileptic to epileptic states more often than controls in the model. Second, regions in the left hemisphere (particularly within temporal and subcortical regions) that are known to be involved in TLE are the most frequent starting points for seizures in patients in the model. In addition, our analysis also implicates regions in the contralateral and frontal locations which may play a role in seizure spreading or surgery resistance. Finally, the model predicts that patient-specific surgery (resection areas chosen on an individual, model-prompted, basis and not following a predefined procedure) may lead to better outcomes than the currently used routine clinical procedure. Taken together this work provides a first step towards patient specific computational modelling of epilepsy surgery in order to inform treatment strategies in individuals.

Temporal lobe epilepsy (TLE) is a disorder characterised by unpredictable seizures, where surgical removal of brain tissue is often the final treatment option. In roughly 30% of cases surgery procedures are unsuccessful at preventing future seizures. This paper shows the application of a computational model which uses patient derived brain connectivity to predict the success rates of surgery in people with TLE. We consider the brains of 22 patients as networks, with brain regions as nodes and the white matter connections between them as edges. The brain network is unique to each subject and produced from brain imaging scans of 22 patients and 39 controls. Seizures are simulated before and after surgery, where surgery in the model is the removal of nodes from the network. The model successfully identifies regions known to be involved in TLE, and its predicted success rates for surgery are close to the results found in reality. The model additionally provides patient specific recommendations for surgical procedures, which in simulations show improved results compared to standard surgery in every case. This is a first step towards designing personalised surgery procedures in order to improve surgery success rates.

Resistant hypertension with adrenal nodule: are we removing the right gland?

Resistant hypertension is often difficult to treat and may be associated with underlying primary aldosteronism (PA). We describe the case of an elderly gentleman who presented with severe and resistant hypertension and was found to have a left adrenal incidentaloma during evaluation but had aldosterone excess secondary to unilateral adrenal hyperplasia (UAH) of the contralateral gland, which needed surgical intervention. A 65-year-old gentleman was evaluated for uncontrolled high blood pressure (BP) in spite of taking four antihypertensive medications. The high BP was confirmed on a 24-h ambulatory reading, and further biochemical evaluation showed an elevated serum aldosterone renin ratio (ARR) (1577 pmol/l per ng per ml per h). Radiological evaluation showed an adrenal nodule (15 mm) in the left adrenal gland but an adrenal vein sampling demonstrated a lateralization towards the opposite site favouring the right adrenal to be the source of excess aldosterone. A laparoscopic right adrenalectomy was performed and the histology of the gland confirmed nodular hyperplasia. Following surgery, the patient's BP improved remarkably although he remained on antihypertensives and under regular endocrine follow-up. PA remains the most common form of secondary and difficult-to-treat hypertension. Investigations may reveal incidental adrenal lesions, which may not be the actual source of excess aldosterone, but UAH may be a contributor and may coexist and amenable to surgical treatment. An adrenal vein sampling should be undertaken for correct lateralization of the source, otherwise a correctable diagnosis may be missed and the incorrect adrenal gland may be removed.

Upper limb functional electrical stimulation devices and their man-machine interfaces

Functional Electrical Stimulation (FES) is a technique that uses electricity to activate the nerves of a muscle that is paralysed due to hemiplegia, multiple sclerosis, Parkinson's disease or spinal cord injury (SCI). FES has been widely used to restore upper limb functions in people with hemiplegia and C5-C7 tetraplegia and has improved their ability to perform their activities of daily living (ADL). At the time of writing, a detailed literature review of the existing upper limb FES devices and their man-machine interfaces (MMI) showed that only the NESS H200 was commercially available. However, the rigid arm splint doesn't fit everyone and prevents the use of a tenodesis grip. Hence, a robust and versatile upper limb FES device that can be used by a wider group of people is required.

Susceptibility to exertional heat illness and hospitalisation risk in UK military personnel

Background

Susceptibility to exertional heat illness (EHI) is considered multifactorial in nature. The aims of this study were to (1) review traditional susceptibility factors identified in cases of EHI and (2) determine how they are related to risk of hospitalisation.

Methods

Review of an electronic database of EHI reported in the British Army between 1 September 2007 and 31 December 2014. Cases were categorised by demographic, situational and susceptibility variables. Univariate and multivariate logistic regression was performed for the OR for hospitalisation by risk factor.

Results

361 reports were included in the analysis. 33.5% of cases occurred in hot climates, 34.6% in temperate climates during summer months and 31.9% in temperate climates outside of summer months. Traditional susceptibility factors were reported in 193 but entirely absent from 168 cases. 137 cases (38.0%) were admitted to hospital. Adjusted OR for hospitalisation was lower for recruits (OR 0.42, 95% CI 0.18 to 0.99, p<0.05) and for personnel wearing occlusive dress (OR 0.56, 95% CI 0.34 to 0.93, p<0.05) or unacclimatised to heat (OR 0.31, 95% CI 0.15 to 0.66, p<0.01).

Conclusions

The global, year-round threat of EHI is highlighted. Absence of susceptibility factors in nearly half of reports highlights the challenge of identifying EHI-prone individuals. Paradoxical association of traditional susceptibility factors with reduced hospitalisation risk may reflect the contemporary contexts in which severe EHI occurs. These findings also suggest a need for better evidence to inform guidelines that aim to prevent severe EHI concurrent to reducing overall morbidity.

Genetic abnormalities in thyroid hormone deiodinases

PURPOSE OF REVIEW

The purpose of this study was to review several of the most recent and most important clinical studies regarding the effects of how genetic variation in the deiodinases can influence health.

RECENT FINDINGS

Common variation in DIO1 but not DIO2 or DIO3 is robustly associated with thyroid hormone levels at genome-wide levels of significance although the effect is modest. There is growing evidence that common variation in DIO2, particularly the Thr92Ala substitution, is associated with important clinical endpoints including osteo-arthritis and intelligence quotient; however, the mechanism of action appears to vary between tissues with several unexpected pathways recently being elucidated including effects on Golgi function and DNA methylation. In addition, there is emerging evidence of interaction with iodine and thyroid status.

SUMMARY

The clinical importance of genetic variation in the deiodinases has yet to be fully elucidated and their impact is likely to vary between individuals and body systems dependent on multiple factors within tissues and coexistent diseases and environmental factors. Exploration of whether there are rare functional variants in the deiodinases is now possible in population studies, which may yield greater insight in the near future. Studies of the impact of genetic variation in the deiodinases in individuals with iodine deficiency, subclinical thyroid disease, or those on levothyroxine are urgently needed.

Optimal control based seizure abatement using patient derived connectivity

Epilepsy is a neurological disorder in which patients have recurrent seizures. Seizures occur in conjunction with abnormal electrical brain activity which can be recorded by the electroencephalogram (EEG). Often, this abnormal brain activity consists of high amplitude regular spike-wave oscillations as opposed to low amplitude irregular oscillations in the non-seizure state. Active brain stimulation has been proposed as a method to terminate seizures prematurely, however, a general and widely-applicable approach to optimal stimulation protocols is still lacking. In this study we use a computational model of epileptic spike-wave dynamics to evaluate the effectiveness of a pseudospectral method to simulated seizure abatement. We incorporate brain connectivity derived from magnetic resonance imaging of a subject with idiopathic generalized epilepsy. We find that the pseudospectral method can successfully generate time-varying stimuli that abate simulated seizures, even when including heterogeneous patient specific brain connectivity. The strength of the stimulus required varies in different brain areas. Our results suggest that seizure abatement, modeled as an optimal control problem and solved with the pseudospectral method, offers an attractive approach to treatment for in vivo stimulation techniques. Further, if optimal brain stimulation protocols are to be experimentally successful, then the heterogeneity of cortical connectivity should be accounted for in the development of those protocols and thus more spatially localized solutions may be preferable.

Should All Women Be Screened for Thyroid Dysfunction in Pregnancy?

The subject of universal thyroid screening in pregnancy generates impassioned debate. Thyroid dysfunction is common, has significant adverse implications for fetal and maternal well-being, is readily detectable and can be effectively and inexpensively treated. Furthermore, the currently recommended case-finding strategy does not identify a substantially proportion of women with thyroid dysfunction thus favoring universal screening. On the other hand subclinical thyroid dysfunction forms the bulk of gestational thyroid disorders and the paucity of high-level evidence to support correction of these asymptomatic biochemical abnormalities weighs against universal screening. This review critically appraises the literature, examines the pros and cons of universal thyroid screening in pregnancy, highlighting the now strong case for implementing universal screening and explores strategies for its implementation.

Structural connectivity changes in temporal lobe epilepsy: Spatial features contribute more than topological measures

Background

Previous studies reported reduced volumes of many brain regions for temporal lobe epilepsy (TLE). It has also been suggested that there may be widespread changes in network features of TLE patients. It is not fully understood, however, how these two observations are related.

Methods

Using magnetic resonance imaging data, we perform parcellation of the brains of 22 patients with left TLE and 39 non-epileptic controls. In each parcellated region of interest (ROI) we computed the surface area and, using diffusion tensor imaging and deterministic tractography, infer the number of streamlines and their average length between each pair of connected ROIs. For comparison to previous studies, we use a connectivity ‘weight’ and investigate how ROI surface area, number of streamlines & mean streamline length contribute to such weight.

Results

We find that although there are widespread significant changes in surface area and position of ROIs in patients compared to controls, the changes in connectivity are much more subtle. Significant changes in connectivity weight can be accounted for by decreased surface area and increased streamline count.

Conclusion

Changes in the surface area of ROIs can be a reliable biomarker for TLE with a large influence on connectivity. However, changes in structural connectivity via white matter streamlines are more subtle with a relatively lower influence on connection weights.

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Using MRI data, we analyse 22 patients with left TLE and 39 non-epileptic controls.

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With a connectomics approach we investigate how nodal properties such as surface area influence connectivity weight.

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We find significant atrophy (reduced node size) in many brain areas in patients with TLE.

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We show only subtle changes in connectivity.

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When both node size and node connectivity are combined we find significant changes in connection weight.

The second wave of the Controlled Antenatal Thyroid Screening (CATS II) study: the cognitive assessment protocol

BACKGROUND

Children whose mothers had low thyroid hormone levels during pregnancy have been reported to have decreased cognitive function. The reported research is part of the follow-on study of the Controlled Antenatal Thyroid Screening Study (CATS I), a randomised controlled trial which investigated the impact of treated vs. untreated low thyroid hormone level in women during pregnancy with the primary outcome being the child's IQ at age 3. No significant differences in IQ were found between the treated and untreated groups. These children are now aged between 7 and 10 years and aspects of their cognitive functioning including their IQ are being reassessed as part of CATS II.

METHODS/DESIGN

Cognitive assessments generate an IQ score and further tests administered will investigate long term memory function and motor coordination. The aim is to complete the assessments with 40% of the children born to mothers either in the treated or untreated low thyroid hormone groups (n = 120 per group). Also children born to mothers who had normal thyroid functioning during CATS I are being assessed for the first time (n = 240) to provide a comparison. Assessments are conducted either in the research facility or the participant's home.

DISCUSSION

The study is designed to assess the cognitive functioning of children born to mothers with low thyroid hormone levels and normal thyroid functioning during pregnancy. This is the largest study of its type and also is distinguishable in its longitudinal design. The research has the potential to have a significant impact on public health policy in the UK; universal screening of thyroid hormone levels in pregnancy may be the recommendation.

Maternal perchlorate levels in women with borderline thyroid function during pregnancy and the cognitive development of their offspring: data from the Controlled Antenatal Thyroid Study

OBJECTIVE

Thyroid dysfunction is associated with impaired cognitive development. Perchlorate decreases thyroidal iodine uptake, potentially reducing thyroid hormone production. It is unclear whether perchlorate exposure in early life affects neurodevelopment.

DESIGN

Historical cohort analysis.

PATIENTS

From 2002 to 2006, 21,846 women at gestational age <16 weeks recruited from antenatal clinics in Cardiff, UK and Turin, Italy were enrolled in the Controlled Antenatal Thyroid Screening Study (CATS). We undertook a retrospective analysis of 487 mother-child pairs in mothers who were hypothyroid/hypothyroxinemic during pregnancy and analyzed whether first trimester maternal perchlorate levels in the highest 10% of the study population were associated with increased odds of offspring IQ being in the lowest 10% at 3 years of age.

MAIN OUTCOME MEASURES

Maternal urinary perchlorate, offspring IQ.

RESULTS

Urine perchlorate was detectable in all women (median 2.58 μg/L); iodine levels were low (median 72 μg/L). Maternal perchlorate levels in the highest 10% of the population increased the odds of offspring IQ being in the lowest 10% OR = 3.14 (95% CI 1.38, 7.13) P = .006 with a greater negative impact observed on verbal OR = 3.14 (95% CI 1.42, 6.90) P = .005 than performance IQ. Maternal levothyroxine therapy did not reduce the negative impact of perchlorate on offspring IQ.

CONCLUSIONS

This is the first study using individual-level patient data to study maternal perchlorate exposure and offspring neurodevelopment and suggests that high-end maternal perchlorate levels in hypothyroid/hypothyroxinemic pregnant women have an adverse effect on offspring cognitive development, not affected by maternal levothyroxine therapy. These results require replication in additional studies, including in the euthyroid population.

TSH levels and risk of miscarriage in women on long-term levothyroxine: a community-based study

CONTEXT

Thyroid dysfunction is associated with adverse obstetric outcomes, but there is limited information on pregnancy outcomes in women established on levothyroxine.

OBJECTIVE

The objective of the study was to determine the relationship between TSH levels and pregnancy outcomes in levothyroxine-treated women in a large community-based database.

DESIGN

This was a historical cohort analysis.

PATIENTS

Individuals with a first prescription of levothyroxine from 2001 through 2009 (n = 55 501) were identified from the UK General Practice Research Database (population 5 million). Of these, we identified 7978 women of child-bearing age (18-45 y) and 1013 pregnancies in which levothyroxine had been initiated at least 6 months before conception.

MAIN OUTCOME MEASURES

TSH, miscarriage/delivery status, and obstetric outcomes were measured.

RESULTS

Forty-six percent of levothyroxine-treated women aged 18-45 years had a TSH level greater than 2.5 mU/L (recommended upper level in the first trimester). Among pregnant women who had their TSH measured in the first trimester, 62.8% had a TSH level greater than 2.5 mU/L, with 7.4% greater than 10 mU/L. Women with TSH greater than 2.5 mU/L in the first trimester had an increased risk of miscarriage compared with women with TSH 0.2-2.5 mU/L after adjusting for age, year of pregnancy, diabetes, and social class (P = .008). The risk of miscarriage was increased in women with TSH 4.51-10 mU/L [odds ratio (OR) 1.80, 95% confidence interval (CI) 1.03, 3.14)] and TSH greater than 10 mU/L (OR 3.95, 95% CI 1.87, 8.37) but not with TSH 2.51-4.5 mU/L (OR 1.09, 95% CI 0.61, 1.93).

CONCLUSIONS

The majority of levothyroxine-treated women have early gestational TSH levels above the recommended targets (>2.5 mU/L) with a strong risk of miscarriage at levels exceeding 4.5 mU/L. There is an urgent need to improve the adequacy of thyroid hormone replacement in early pregnancy.

An in silico approach for pre-surgical evaluation of an epileptic cortex

Clinical evidence indicates that a third of patients with epilepsy are refractory to anti-epileptic drug treatment. For some of these patients better seizure control can be achieved by surgical treatment in which the seizure focus is localised and resected while avoiding injury to crucial cortical tissues. In this paper, non-seizure (interictal) epoch of electrographic recording was used to calculate the functional synchrony between different cortical regions. This synchrony measure was then used as the connectivity parameter in a computational model of transitions to a seizure like state. The seizure focus was localised using this model and the surgical intervention procedure was simulated. It was shown that the in silico removal of a subset of seizure focus can decrease the likelihood of a seizure in the model. The in silico results were also compared with the clinical outcomes and a convincing agreement was shown for five out of six patients; sixth being a counter-example. These methods may aid in the identification of the seizure onset zone using the interictal electrographic data. Moreover, it may facilitate neurosurgeons to investigate alternative cortical tissues to operate on if the seizure focus cannot be operated.

Falling threshold for treatment of borderline elevated thyrotropin levels-balancing benefits and risks: evidence from a large community-based study

IMPORTANCE

Rates of thyroid hormone prescribing in the United States and the United Kingdom have increased substantially. If some of the increase is due to lowering the thyrotropin threshold for treatment, this may result in less benefit and greater harm.

OBJECTIVE

To define trends in thyrotropin levels at the initiation of levothyroxine sodium therapy and the risk of developing a suppressed thyrotropin level following treatment. DESIGN, SETTING, PARTICIPANTS, AND EXPOSURE: Retrospective cohort study using data from the United Kingdom Clinical Practice Research Datalink. Among 52,298 individuals who received a prescription for levothyroxine between January 1, 2001, and October 30, 2009, we extracted data about the thyrotropin level before levothyroxine therapy initiation, clinical symptoms, and thyrotropin levels up to 5 years after levothyroxine was initiated. We excluded persons who had a history of hyperthyroidism, pituitary disease, or thyroid surgery; those who were taking thyroid-altering medication or if the levothyroxine prescription was related to pregnancy; and those who did not have a thyrotropin level measured within 3 months before the initiation of levothyroxine.

MAIN OUTCOMES AND MEASURES

The median thyrotropin level at the time of the index levothyroxine prescription, the odds of initiation of levothyroxine therapy at thyrotropin levels of 10.0 mIU/L or less, and the age-stratified odds of developing a low or suppressed thyrotropin level after levothyroxine therapy.

RESULTS

Between 2001 and 2009, the median thyrotropin level at the initiation of levothyroxine therapy fell from 8.7 to 7.9 mIU/L. The odds ratio for prescribing levothyroxine at thyrotropin levels of 10.0 mIU/L or less in 2009 compared with 2001 (adjusted for changes in population demographics) was 1.30 (95% CI, 1.19-1.42; P < .001). Older individuals and individuals with cardiac risk factors had higher odds of initiation of levothyroxine therapy with a thyrotropin level 10.0 mIU/L or less. At 5 years after levothyroxine initiation, 5.8% of individuals had a thyrotropin level of <0.1 mIU/L. Individuals with depression or tiredness at baseline had increased odds of developing a suppressed thyrotropin level, whereas individuals with cardiac risk factors (eg, atrial fibrillation, diabetes mellitus, hypertension, and raised lipid levels) did not.

CONCLUSIONS AND RELEVANCE

We observed a trend toward levothyroxine treatment of more marginal degrees of hypothyroidism and a substantial risk of developing a suppressed thyrotropin level following therapy. Large-scale prospective studies are required to assess the risk-benefit ratio of current practice.

Therapy of endocrine disease: Impact of iodine supplementation in mild-to-moderate iodine deficiency: systematic review and meta-analysis

BACKGROUND

Although the detrimental effects of severe iodine deficiency are well recognised, the benefits of correcting mild-to-moderate iodine deficiency are uncertain.

OBJECTIVES

We undertook a systematic review of the impact of iodine supplementation in populations with mild-to-moderate iodine deficiency.

METHODS

We searched Medline and the Cochrane library for relevant articles published between January 1966 and April 2013, which investigated the effect of iodine supplementation on maternal and newborn thyroid function, infant neurodevelopment and cognitive performance in school-age children. The quality of studies was graded and eligible trials were evaluated in the meta-analysis.

RESULTS

Nine randomised controlled trials (RCTs) and eight observational studies met the inclusion criteria. Controlled trials on infant neurodevelopment were lacking; gestational iodine supplementation reduced maternal thyroid volume and serum thyroglobulin and in some studies prevented a rise in serum thyroid-stimulating hormone. None of the intervention trials recorded an excess frequency of thyroid dysfunction in contrast to observational studies. A pooled analysis of two RCTs which measured cognitive function in school-age children showed modest benefits of iodine supplementation on perceptual reasoning (standardised mean difference (SMD) 0.55; 95% CI 0.05, 1.04; P=0.03) and global cognitive index (SMD 0.27; 95% CI 0.10, 0.44; P=0.002) with significant heterogeneity between studies.

CONCLUSION

Iodine supplementation improves some maternal thyroid indices and may benefit aspects of cognitive function in school-age children, even in marginally iodine-deficient areas. Further large prospective controlled studies are urgently required to clarify these findings and quantify the risk/benefits of iodine supplementation in regions previously believed to be iodine sufficient such as the UK.

Effects of prostaglandin F(2α) on adipocyte biology relevant to graves' orbitopathy

BACKGROUND

In Graves' orbitopathy (GO), increased proliferation, excess adipogenesis, and hyaluronan overproduction produce GO exophthalmos. Enophthalmos occurs in some glaucoma patients treated with Bimatoprost (prostaglandin F2α, PGF2α) eye drops. We hypothesized that enophthalmos is secondary to reductions in orbital tissue proliferation, adipogenesis, and/or increased lipolysis. We aimed to determine which of these is affected by PGF2α by using the 3T3-L1 murine preadipocyte cell line and primary human orbital fibroblasts (OFs) from GO patients (n=5) and non-GO (n=5).

METHODS

3T3-L1 cells and orbital OFs were cultured alone or with PGF2α (all experiments used 10(-8) to 10(-6) M) and counted on days 1/2/3 or 5, respectively; cell cycle analysis (flow cytometry) was applied. Adipogenesis (in the presence/absence of PGF2α) was evaluated (day 7 or 15 for 3T3-L1 and primary cells, respectively) morphologically by Oil Red O staining and quantitative polymerase chain reaction measurement of adipogenesis markers (glycerol-3-phosphate dehydrogenase and lipoprotein lipase, respectively). For lipolysis, in vitro-differentiated 3T3-L1 or mature orbital adipocytes were incubated with norepinephrine and PGF2α and free glycerol was assayed. Appropriate statistical tests were applied.

RESULTS

The population doubling time of 3T3-L1 was 27.3±1.4 hours-significantly increased by dimethyl sulfoxide 0.02% to 44.6±4.8 hours (p=0.007) and further significantly increased (p=0.049 compared with dimethyl sulfoxide) by 10(-8) M PGF2α to 93.6±19.0 hours, indicating reduced proliferation, which was caused by prolongation of G2/M. GO OFs proliferated significantly more rapidly than non-GO (population doubling time 5.36±0.34 or 6.63±0.35 days, respectively, p=0.035), but the proliferation of both was significantly reduced (dose dependent from 10(-8) M) by PGF2α, again with prolongation of G2/M. Adipogenesis in 3T3-L1 cells was minimally affected by PGF2α when assessed morphologically, but the drug significantly reduced transcripts of the glycerol-3-phosphate dehydrogenase differentiation marker. GO OFs displayed significantly higher adipogenic potential than non-GO, but in both populations, adipogenesis, evaluated by all 3 methods, was significantly reduced (dose dependent from 10(-8) M) by PGF2α. There was no effect of PGF2α on basal or norepinephrine-induced lipolysis, in 3T3-L1 or human OFs, either GO or non-GO.

CONCLUSIONS

The results demonstrate that PGF2α significantly reduces proliferation and adipogenesis and that human OFs are more sensitive to its effects than 3T3-L1. Consequently, PGF2α could be effective in the treatment of GO.

Clinical review: A review of the clinical consequences of variation in thyroid function within the reference range

CONTEXT

Overt thyroid disease is associated with profound adverse health outcomes; however, data are conflicting for studies of borderline/subclinical thyroid dysfunction. Many studies of subclinical thyroid disease have had low power and were prone to selection bias. In contrast, large datasets are available from community studies in healthy individuals. Studies of the effects of variation of thyroid function across the reference range on health outcomes in these populations may provide useful information regarding thresholds for treatment of abnormal thyroid function.

EVIDENCE ACQUISITION

MEDLINE and the Cochrane Database of Systematic Reviews and Controlled Trials Register were searched for articles studying the effect of variation in thyroid hormone parameters within the reference range on cardiovascular, bone, metabolic, pregnancy, neurological, and psychological outcomes.

EVIDENCE SYNTHESIS

Higher TSH/lower thyroid hormone levels are associated with more cardiovascular risk factors and cardiovascular events and worse metabolic parameters and pregnancy outcomes, whereas lower TSH/higher thyroid hormone levels are associated with reduced bone mineral density and increased fracture risk. The evidence base was good for cardiovascular, metabolic, bone, and pregnancy outcomes; however, high-quality data remained lacking for neurological and psychological outcomes.

CONCLUSIONS

Common variation in persons with thyroid function in the normal range are associated with adverse health outcomes. These data suggest, by extrapolation, that carefully monitored treatment of even modest elevations of TSH may have substantial health benefits. Appropriately powered large-scale clinical trials analyzing the risks vs benefits of treating subclinical thyroid disease are required to determine whether these benefits can be achieved with levothyroxine therapy.

Side effects of anti-thyroid drugs and their impact on the choice of treatment for thyrotoxicosis in pregnancy

INTRODUCTION

Hyperthyroidism in pregnancy is a serious condition and its management is complex. Whilst carbimazole/methimazole (CBZ/MMI) and propylthiouracil (PTU) have similar efficacies in controlling hyperthyroidism, their risk of side effects such as major congenital abnormalities and hepatotoxicity are different.

METHODS

Various combinations of the terms 'anti-thyroid drugs', 'thionamide', 'carbimazole', 'methimazole', 'propylthiouracil', 'pregnancy', 'side effects', 'agranulocytosis', 'birth defects', 'congenital malformations', 'embryopathy', 'aplasia cutis', 'hepatotoxicity', 'hepatic failure', 'maternal' and 'fetus' were used to search MEDLINE and the Cochrane library. The references of retrieved papers were also reviewed.

RESULTS

There is increasing evidence for a CBZ/MMI embryopathy, whilst data remain lacking for major congenital abnormalities with PTU. In contrast, PTU is associated with increased risk of severe liver injury. Management strategies to reduce these risks by using PTU in the first trimester and CBZ/MMI in the later trimesters remain untested.

CONCLUSION

More evidence is still needed in defining the relative risks between CBZ/MMI and PTU of major congenital abnormalities and severe liver injury in pregnancy. Studies are also needed to establish the suitability of recent management suggestions in switching from PTU to CBZ/MMI after the first trimester. Major adverse outcomes secondary to CBZ/MMI and PTU are rare, and inadequately treated hyperthyroidism poses a far greater risk.

The importance of modeling epileptic seizure dynamics as spatio-temporal patterns

The occurrence of seizures is the common feature across the spectrum of epileptic disorders. We describe how the use of mechanistic neural population models leads to novel insight into the dynamic mechanisms underlying two important types of epileptic seizures. We specifically stress the need for a spatio-temporal description of the rhythms to deal with the complexity of the pathophenotype. Adapted to functional and structural patient data, the macroscopic models may allow a patient-specific description of seizures and prediction of treatment outcome.

A meta-analysis of the associations between common variation in the PDE8B gene and thyroid hormone parameters, including assessment of longitudinal stability of associations over time and effect of thyroid hormone replacement

OBJECTIVE

Common variants in PDE8B are associated with TSH but apparently without any effect on thyroid hormone levels that is difficult to explain. Furthermore, the stability of the association has not been examined in longitudinal studies or in patients on levothyroxine (l-T(4)).

DESIGN

Totally, four cohorts were used (n=2557): the Busselton Health Study (thyroid function measured on two occasions), DEPTH, EFSOCH (selective cohorts), and WATTS (individuals on l-T(4)).

METHODS

Meta-analysis to clarify associations between the rs4704397 single nucleotide polymorphism in PDE8B on TSH, tri-iodothyronine (T(3)), and T(4) levels.

RESULTS

Meta-analysis confirmed that genetic variation in PDE8B was associated with TSH (P=1.64 × 10(-10) 0.20 s.d./allele, 95% confidence interval (CI) 0.142, 0.267) and identified a possible new association with free T(4) (P=0.023, -0.07 s.d./allele, 95% CI -0.137, -0.01), no association was seen with free T(3) (P=0.218). The association between PDE8B and TSH was similar in 1981 (0.14 s.d./allele, 95% CI 0.04, 0.238) and 1994 (0.20 s.d./allele, 95% CI 0.102, 0.300) and even more consistent between PDE8B and free T(4) in 1981 (-0.068 s.d./allele, 95% CI -0.167, 0.031) and 1994 (-0.07 s.d./allele, 95% CI -0.170, 0.030). No associations were seen between PDE8B and thyroid hormone parameters in individuals on l-T(4).

CONCLUSION

Common genetic variation in PDE8B is associated with reciprocal changes in TSH and free T(4) levels that are consistent over time and lost in individuals on l-T(4). These findings identify a possible genetic marker reflecting variation in thyroid hormone output that will be of value in epidemiological studies and provides additional evidence that PDE8B is involved in TSH signaling in the thyroid.

Impact on activities of daily living using a functional electrical stimulation device to improve dropped foot in people with multiple sclerosis, measured by the Canadian Occupational Performance Measure

Background: Dropped foot is a common problem following multiple sclerosis. Functional electrical stimulation can elicit an active muscle contraction providing dorsiflexion and eversion.

Objective: To determine if the Odstock dropped foot stimulator (ODFS), improved Activities of Daily Living for people with multiple sclerosis.

Method: 64 people with unilateral dropped foot due to secondary progressive multiple sclerosis took part in a randomized controlled trial. Research volunteers were assigned to a group using the ODFS or a group who received physiotherapy exercises for 18 weeks. Outcome measures were the Canadian Occupational Performance Measure (COPM) and a falls diary.

Results: Results of 53 research volunteers are reported. Improvements in performance and satisfaction scores were greater in the ODFS group than the exercise group; ( p < 0.05). Use of the ODFS was also perceived as effective in reducing tripping and increasing walking distance. The median number of falls were 5 in the ODFS group and 18 in the exercise group ( p = 0.036) over the study period.

Conclusion: The study shows that people with multiple sclerosis using the ODFS increased their COPM performance and satisfaction scores of their identified problems of Activities of Daily Living more than a matched group who received physiotherapy exercises. ODFS users also experienced fewer falls.

A randomized trial to investigate the effects of functional electrical stimulation and therapeutic exercise on walking performance for people with multiple sclerosis

Background

Functional electrical stimulation (FES), is a means of producing a contraction in a paralyzed or weak muscle to enable function through electrical excitation of the innervating nerve.

Objective

This two-group randomized trial assessed the effects of single channel common peroneal nerve stimulation on objective aspects of gait relative to exercise therapy for people with secondary progressive multiple sclerosis (SPMS).

Methods

Forty-four people with a diagnosis of SPMS and unilateral dropped foot completed the trial. Twenty patients were randomly allocated to a group receiving FES and the remaining 24 to a group receiving a physiotherapy home exercise program for a period of 18 weeks.

Results

The exercise group showed a statistically significant increase in 10 m walking speed and distance walked in 3 min, relative to the FES group who showed no significant change in walking performance without stimulation. At each stage of the trial, the FES group performed to a significantly higher level with FES than without for the same outcome measures.

Conclusion

Exercise may provide a greater training effect on walking speed and endurance than FES for people with SPMS. FES may provide an orthotic benefit when outcome is measured using the same parameters. More research is required to investigate the combined therapeutic effects of FES and exercise for this patient group.

Extremely strong near-IR two-photon absorption in conjugated porphyrin dimers: quantitative description with three-essential-states model

Two-photon absorption spectra (2PA) of a series of conjugated dimers and the corresponding monomer were studied in the near-IR region. All of the dimers show very large peak cross section values, sigma(2) = (3-10) x 10(3) GM (1 GM = 1 x 10(-50) cm(4) s photon(-1)), which is several hundred times larger than that obtained for the corresponding monomer in the same region. We explain such dramatic cooperative enhancement by a combination of several factors, such as strong enhancement of the lowest one-photon Q-transition, better resonance conditions in the three-level system, dramatic enhancement of the excited-state singlet-singlet transition, and parallel arrangement of consecutive transitions in dimers, as compared to perpendicular arrangement in the monomer. We show that the absolute values of the 2PA cross section in these molecules are quantitatively described by a quantum-mechanical expression, derived for the three-level model. We also demonstrate the possibility of singlet oxygen generation upon one- and two-photon excitation of these dimers, which makes them particularly attractive for photodynamic therapy.

The functional form of the lognormal distribution as a sum of decaying exponential and sinusoidal terms applied to the isometric pinch force of human fingers

The transient data of the pinch force produced between the human forefinger and thumb have been shown to fit the functional form of the well-known lognormal density function. Isometeric force generation is achieved by the stochastic recruitment of individual motor units, which sum together. Evidence from animal and human experiments demonstrates that the force generation can be modelled by underdamped terms. It is shown that a lognormal time series (distribution) can be fitted to a sum of exponential decaying sinusoidal terms.

A microcontroller system for investigating the catch effect: functional electrical stimulation of the common peroneal nerve

Correction of drop foot in hemiplegic gait is achieved by electrical stimulation of the common peroneal nerve with a series of pulses at a fixed frequency. However, during normal gait, the electromyographic signals from the tibialis anterior muscle indicate that muscle force is not constant but varies during the swing phase. The application of double pulses for the correction of drop foot may enhance the gait by generating greater torque at the ankle and thereby increase the efficiency of the stimulation with reduced fatigue. A flexible controller has been designed around the Odstock Drop Foot Stimulator to deliver different profiles of pulses implementing doublets and optimum series. A peripheral interface controller (PIC) microcontroller with some external circuits has been designed and tested to accommodate six profiles. Preliminary results of the measurements from a normal subject seated in a multi-moment chair (an isometric torque measurement device) indicate that profiles containing doublets and optimum spaced pulses look favourable for clinical use.

Understanding Strong Two-Photon Absorption in π-Conjugated Porphyrin Dimers via Double-Resonance Enhancement in a Three-Level Model

We present the two-photon absorption (2PA) spectra of a series of conjugated porphyrin dimers and show that they possess extremely large intrinsic (femtosecond) peak 2PA cross sections, up to sigma2 = 1 x 104 GM in the near-IR region; these are among the highest values measured for any organic molecule. Moreover, we demonstrate that the second-order perturbation theory applied to a simple three-level model gives a perfect quantitative description of the observed 2PA cross section. By comparing all the factors of the three-level model for dimers with those of corresponding monomer (for which sigma2 = 20 GM), we explain an approximately 500-fold cooperative enhancement in sigma2 and find that the most important factor is the strength of excited-state transition. The matrix element of dipole moment of this transition amounts gigantic values of 30-40 D for conjugated porphyrin dimers, which can be accounted for a large delocalization radius (large electron-hole separation) in this state. We also demonstrate efficient generation of singlet oxygen upon one- and two-photon excitation of these porphyrin dimers, which can be useful for two-photon initiated photodynamic therapy of cancer.

Hindered fluorescence quenching in an insulated molecular wire

A [3]rotaxane 2 within 1(2) consisting of an anionic phenylene ethynylene dumbbell 2(4-) threaded through two cationic cyclophanes 1(2+) has been prepared using aqueous Glaser coupling. Stern-Volmer analysis of the fluorescence quenching using three different electron-acceptors (methyl viologen 13(2+), dipropyl-4,4'-bipyridinium disulfonate 14 and anthraquinone-2,6-disulfonate 15(2-)) shows that the threaded cyclophanes inhibit electron-transfer from the excited state of the dumbbell by steric shielding, and by electrostatic shielding in the case of methyl viologen.

Benzofuran Trimers for Organic Electroluminescence

Four linear benzofuran trimers have been prepared by a two-stage synthetic procedure. They were tested as materials for organic electroluminescence (OEL). Precursor phenylene ethynylene oligomers were formed in the first stage, then after removal of the phenolic hydroxyl protecting groups, a base was used to promote the cyclization of ortho-hydroxy phenylene ethynylenes to benzofurans. Both acetate esters and tert-butyl carbonates were employed as protecting groups. tert-Butyl and n-hexyl substituents on the benzofurans were used to modulate solubility, aggregation, and film-forming properties; two tert-butyl groups prevented aggregation in the solid state, thus maintaining emission in the blue region of the visible spectrum. The OEL characteristics of the tert-butyl-substituted benzofuran trimer were explored, and blue emission was observed. The two-stage synthetic procedure employed for the preparation of these benzofuran trimers may be applied to a wide variety of benzofuran oligomer and polymer targets.

Synthesis of Conjugated Polyrotaxanes

A series of conjugated polyrotaxane insulated molecular wires are synthesised by aqueous Suzuki polymerisation, using hydrophobic binding to promote threading of the cyclodextrin units. These polyrotaxanes have conjugated polymer cores based on poly(para-phenylene), polyfluorene, and poly(diphenylene-vinylene), threaded through 0.9-1.6 cyclodextrins per repeat unit. Bulky naphthalene-3,6-disulfonate endgroups prevent the macrocycles from slipping off the conjugated polymer chains. Dialysis experiments show that the cyclodextrins become unthreaded only if smaller stoppers are used. MALDI TOF mass spectra detect oligomers with up to ten threaded cyclodextrins, and reveal the presence of some defects that result for oxidative homo-coupling of boronic acids. Weight-average molecular weights were determined by analytical ultracentrifugation, demonstrating that step-growth polymerisation is efficient enough to achieve degrees of polymerisation up to approximately 20 repeat units (84 para-phenylenes). The fluorescence spectra of these polyrotaxanes indicate that the presence of the threaded cyclodextrin macrocycles reduces the flexibility of the conjugated polymer pi-systems. Both the solution and the solid-state photoluminescence quantum yields are enhanced upon threading of the conjugated polyaromatic cores through alpha- or beta-cyclodextrins, and the emission spectra of the polyrotaxanes are blue-shifted compared to the corresponding unthreaded polymers. The greater weight of the 0-0 transition in the emission spectra, as well as the smaller Stokes shift, indicate that the polyrotaxanes are more rigid than the unthreaded polymers.

Cyclodextrin-threaded conjugated polyrotaxanes as insulated molecular wires with reduced interstrand interactions

Control of intermolecular interactions is crucial to the exploitation of molecular semiconductors for both organic electronics and the viable manipulation and incorporation of single molecules into nano-engineered devices. Here we explore the properties of a class of materials that are engineered at a supramolecular level by threading a conjugated macromolecule, such as poly(para-phenylene), poly(4,4'-diphenylene vinylene) or polyfluorene through alpha- or beta-cyclodextrin rings, so as to reduce intermolecular interactions and solid-state packing effects that red-shift and partially quench the luminescence. Our approach preserves the fundamental semiconducting properties of the conjugated wires, and is effective at both increasing the photoluminescence efficiency and blue-shifting the emission of the conjugated cores, in the solid state, while still allowing charge-transport. We used the polymers to prepare single-layer light-emitting diodes with Ca and Al cathodes, and observed blue and green emission. The reduced tendency for polymer chains to aggregate allows solution-processing of individual polyrotaxane wires onto substrates, as revealed by scanning force microscopy.

Electrical stimulation of abdominal muscles for control of blood pressure and augmentation of cough in a C3/4 level tetraplegic

OBJECTIVES

Evaluation of a FES (Functional Electrical Stimulation) device for the relief of postural hypertension and augmentation of cough in a C3 ventilator-dependent tetraplegic.

STUDY DESIGN

A single case study.

SETTING

A supra regional spinal unit in the UK.

METHOD

A dual channel stimulator was designed that allowed selection and initiation of two predetermined stimulation intensities using a chin controlled joystick. Two sets of 70 mm diameter electrodes were placed either side of the abdomen. Approximately 80 mA, 300 micros, 40 Hz was required for assisted cough while about 40 mA was required for maintenance of blood pressure. After eating, the lower level stimulus is self-administered every 3 to 5 min gradually increasing the time between groups of burst to once every hour after 90 min.

RESULTS

Following eating, a blood pressure of 60/45 mmHg was recorded. After five 1 s bursts of stimulation in quick repetition, this was increased to 133/92 mmHg. After 2 min blood pressure had fallen to 124/86 mmHg and to 93/66 after a further 4 min. The electrical stimulation was then repeated, returning the blood pressure to the previous higher level. Measurement of peak expiratory flow showed an increase from 275 l/min for an unassisted cough to 425 l/min when using the device.

CONCLUSION

The device is used every day. The user is now independent in coughing function and no longer requires suction or manual assistance. Maintenance of blood pressure has significantly improved his quality of life.

Restoration of tetraplegic hand function by use of the neurocontrol freehand system

Nine tetraplegic patients with C5 or C6 level spinal cord lesions had the Freehand System, an eight channel Functional Electrical Stimulation device, implanted to allow of hand opening and grasp. This paper describes the surgical implementation of the system and the challenges encountered. Seven of the subjects are currently daily users of the device. One subject is unable to use the system due to disruption of bowel function when the system is used. A second subject suffered a lesion of the posterior interosseous nerve, but this was not thought to be related to system use. Additionally, one subject exhibited symptoms of autonomic dysreflexia, which were alleviated by reduction of the strength of the stimulus. Despite such problems, the Freehand system can significantly improve the functional ability of C5 and C6 lesion tetraplegics.

Indices to describe different muscle activation patterns, identified during treadmill walking, in people with spastic drop-foot

This study was concerned with individuals who were unable to effectively dorsiflex their ankle when walking, as a result of a lesion of the central nervous system (CNS). Indices that categorise and quantify different patterns of calf and anterior tibial muscle activation patterns during treadmill walking have been derived from a sample of fifteen individuals with established hemiplegia following stroke and twelve age-matched individuals without impairment. As subjects walked on a treadmill, force sensitive foot-switches under the heel and first metatarsal head allowed EMG signals from the calf and anterior tibial muscles to be related to phases of the gait cycle. Normal activation periods for each muscle group were identified as percentiles of the gait cycle and indices for muscle activation periods were derived using ratios of integrated EMG during selected periods. Indices were derived that identified statistically significant differences, between normal and hemiplegic subjects, in calf activation during both push-off phase (P<0.001) and early stance phase (P<001), but not activation of tibialis anterior during swing (P=0.325) Observation suggested that integrated tibialis anterior activity during swing phase in hemiplegic subjects was not dissimilar to normal subjects, but the profile in hemiplegic subjects tended to lack the normal second peak of activity at initial foot contact. The reasons for drop-foot were shown to be varied and complex. The indices defined may be useful for directing therapy and measuring outcome.

Clinical use of the Odstock dropped foot stimulator: its effect on the speed and effort of walking

OBJECTIVE

To assess the clinical effectiveness of the Odstock dropped foot stimulator by analysis of its effect on physiological cost index (PCI) and speed of walking. This functional electrical stimulation (FES) device stimulates the common peroneal nerve during the swing phase of gait.

DESIGN

A retrospective study of patients who had used the device for 4 1/2 months.

SUBJECTS

One hundred fifty-one patients with a dropped foot resulting from an upper motor neuron lesion.

SETTING

A medical physics and biomedical engineering department of a district general hospital specializing in the clinical application of FES and a neurophysiotherapy department at a separate hospital.

MAIN OUTCOME MEASURES

Changes in walking speed and effort of walking, as measured by PCI over a 10-meter course.

RESULTS

There was a 92.7% compliance with treatment. Stroke patients showed a mean increase in walking speed of 27% (p<.01) and reduction in PCI of 31% (p<.01) with stimulation, and changes of 14% (p<.01) and 19% (p<.01), respectively, while not using the stimulator. Multiple sclerosis patients gained similar orthotic benefit but no "carry-over."

CONCLUSIONS

The measured differences in walking with and without stimulation were statistically significant in the stroke and multiple sclerosis groups. In this study use of the stimulator improved walking. Those with stroke demonstrated a short-term "carry-over" effect.