Traumatic brain injuries induced pituitary dysfunction: a call for algorithms

Traumatic brain injury affects many people each year, resulting in a serious burden of devastating health consequences. Motor-vehicle and work-related accidents, falls, assaults, as well as sport activities are the most common causes of traumatic brain injuries. Consequently, they may lead to permanent or transient pituitary insufficiency that causes adverse changes in body composition, worrisome metabolic function, reduced bone density, and a significant decrease in one's quality of life. The prevalence of post-traumatic hypopituitarism is difficult to determine, and the exact mechanisms lying behind it remain unclear. Several probable hypotheses have been suggested. The diagnosis of pituitary dysfunction is very challenging both due to the common occurrence of brain injuries, the subtle character of clinical manifestations, the variable course of the disease, as well as the lack of proper diagnostic algorithms. Insufficiency of somatotropic axis is the most common abnormality, followed by presence of hypogonadism, hypothyroidism, hypocortisolism, and diabetes insipidus. The purpose of this review is to summarize the current state of knowledge about post-traumatic hypopituitarism. Moreover, based on available data and on our own clinical experience, we suggest an algorithm for the evaluation of post-traumatic hypopituitarism. In addition, well-designed studies are needed to further investigate the pathophysiology, epidemiology, and timing of pituitary dysfunction after a traumatic brain injury with the purpose of establishing appropriate standards of care.

Decision-Analytic Modeling Studies in Prevention and Treatment of Iodine Deficiency and Thyroid Disorders: A Systematic Overview

Background: Prevention and treatment of iodine deficiency-related diseases remain an important public health challenge. Iodine deficiency can have severe health consequences, such as cretinism, goiter, or other thyroid disorders, and it has economic implications. Our aim was to give an overview of studies applying decision-analytic modeling to evaluate the effectiveness and/or cost-effectiveness of iodine deficiency-related prevention strategies or treatments related to thyroid disorders. Methods: We performed a systematic literature search in PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica Database), Tuft's Cost-Effectiveness Analysis Registry, and National Health System Economic Evaluation Database (NHS EED) to identify studies published between 1985 and 2018 comparing different prevention or treatment strategies for iodine deficiency and thyroid disorders by applying a mathematical decision-analytic model. Studies were required to evaluate patient-relevant health outcomes (e.g., remaining life years, quality-adjusted life years [QALYs]). Results: Overall, we found 3950 studies. After removal of duplicates, abstract/title, and full-text screening, 17 studies were included. Eleven studies evaluated screening programs (mainly newborns and pregnant women), five studies focused on treatment approaches (Graves' disease, toxic thyroid adenoma), and one study was about primary prevention (consequences of iodine supplementation on offspring). Most of the studies were conducted within the U.S. health care context (n = 7). Seven studies were based on a Markov state-transition model, nine studies on a decision tree model, and in one study, an initial decision tree and a long-term Markov state-transition model were combined. The analytic time horizon ranged from 1 year to lifetime. QALYs were evaluated as health outcome measure in 15 of the included studies. In all studies, a cost-effectiveness analysis was performed. None of the models reported a formal model validation. In most cases, the authors of the modeling studies concluded that screening is potentially cost-effective or even cost-saving. The recommendations for treatment approaches were rather heterogeneous and depending on the specific research question, population, and setting. Conclusions: Overall, we predominantly identified decision-analytic modeling studies evaluating specific screening programs or treatment approaches; however, there was no model evaluating primary prevention programs on a population basis. Conclusions deriving from these studies, for example, that prevention is cost-saving, need to be carefully interpreted as they rely on many assumptions.

Difficulties in the diagnosis and treatment of malignant paraganglioma of the urinary bladder

Not required for Clinical Vignette.

Pregnancy, thyroid, and the potential use of selenium

The management of pregnant women is a major concern of health care around the world. There is growing evidence regarding the influence of selenium (Se) on pregnancy and fetus outcomes. However, due to as yet insufficient evidence, lack of measurable markers to assess the effect of Se supplementation on the human metabolism, and Se's narrow therapeutic index, the majority of experts and the current guidelines published by several scientific societies do not recommend the use of Se in pregnancy and in women of childbearing age. Further research based on well-designed studies, including assessment of the complex interactions between different micronutrients and individual response to different doses of Se, is needed.

Radiological and hormonal improvements in a 22-year-old patient with lymphocytic hypophysitis - the watchful waiting approach

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The effectiveness of a community-based, type 2 diabetes prevention programme on health-related quality of life. The DE-PLAN study

Background and aims

The DE-PLAN was a European multicenter study, with the primary objective of testing whether a community-based lifestyle modification programme could serve as a means of primary prevention for type 2 diabetes (T2D) in high-risk individuals (based on the FINDRISC questionnaire). The aim of this study was to examine the impact of a 1-year community-based lifestyle intervention on health-related quality of life (HRQOL) in individuals from four participating European centers (Athens, Barcelona, Krakow, Kaunas), through a post-hoc analysis.

Materials and methods

Each center was allowed to implement different intervention strategies specifically tailored to the needs of their corresponding population sample. Before and after the intervention, participants underwent clinical evaluation, anthropometric measurements, an oral glucose tolerance test and lipid profile measurements. Health-related quality of life was assessed using the validated HRQOL-15D questionnaire. A difference of ±0.015 in the 15D questionnaire score was set as the threshold of clinically meaningful change.

Results

Data from 786 participants (67% females, mean age 59.7±9.4 years, BMI 31.5±4.5 kg/m²) with complete data regarding the HRQOL were analyzed (Athens: 104, Barcelona: 434, Krakow: 175, Kaunas: 70). After 1 year, a significant overall improvement in HRQOL was shown, as depicted by a change of 15D score from baseline value (0.88±0.9) to post-intervention (0.90±0.87, P<0.001), achieving the threshold of clinically meaningful change. A significant weight reduction was also observed (-0.8±4.0 kg, P<0.001). In multivariate analysis, improvement in HRQOL was independently associated with lower 15D score at baseline (P<0.001) and self-reported increase in overall exercise time (P<0.001) as assessed through specifically designed trial questionnaires.

Conclusion

A community-based lifestyle intervention programme aiming at T2D prevention, applied on a heterogeneous population and with varied methods, was shown to improve overall health-related quality of life to a clinically meaningful degree.

Optimization of parathyroid 11C-choline PET protocol for localization of parathyroid adenomas in patients with primary hyperparathyroidism

PURPOSE

To evaluate the optimal tracer uptake time, the minimal amount of radioactivity and the inter-observer agreement for ¹¹C-choline positron emission tomography/computed tomography (PET/CT) in patients with primary hyperparathyroidism (pHPT).

METHODS

Twenty-one patients with biochemically proven pHPT were retrospectively studied after injection of 6.3 ± 1.2 MBq/kg ¹¹C-choline. PET data of the first nine patients, scanned for up to 60 min, were reconstructed in 10-min frames from 10- to 60-min postinjection (p.i.), mimicking varying ¹¹C-choline uptake times. Parathyroid adenoma to background contrast ratios were calculated and compared, using standardized uptake values (SUVs). Data was reconstructed with varying scan durations (1, 2.5, 5, and 10 min) at 20-30-min p.i. (established optimal uptake time), mimicking less administered radioactivity. To establish the minimal required radioactivity, the SUVs in the shorter scan durations (1, 2.5, and 5 min) were compared to the 10-min scan duration to determine whether increased variability and/or statistical differences were observed. Four observers analyzed the ¹¹C-choline PET/CT in four randomized rounds for all patients.

RESULTS

SUVpeak of the adenoma decreased from 30 to 40 p.i. onwards. All adenoma/background contrast ratios did not differ from 20- to 30-min p.i. onwards. The SUVs of adenoma in the scan duration of 1, 2.5, and 5 min all differed significantly from the same SUV in the 10-min scan duration (all p = 0.012). However, the difference in absolute SUV adenoma values was well below 10% and therefore not considered clinically significant. The inter-observer analysis showed that the Fleiss' kappa of the 1-min scan were classified as "moderate," while these values were classified as "good" in the 2.5-, 5-, and 10-min scan duration. Observers scored lower certainty scores in the 1- and 2.5-min scans compared to the 5- and 10-min scan durations.

CONCLUSION

The optimal time to start PET/CT scanning in patients with pHPT is 20 min after mean injection of 6.3 MBq/kg ¹¹C-choline, with a recommended scan duration of at least 5 min. Alternatively, the radioactivity dose can be lowered by 50% while keeping a 10-min scan duration without losing the accuracy of ¹¹C-choline PET/CT interpretation.

Diagnostics and treatment of acromegaly - updated recommendations of the Polish Society of Endocrinology

Acromegaly is a rare disease caused by excessive production of growth hormone (GH), typically by a pituitary tumour. The diagnosis is usually delayed, and patients frequently develop various complications that cause premature mortality. In patients with hypertension, heart failure, diabetes, and arthropathies that are not age-specific, attention should be paid to signs of acromegaly. Insulin-like growth factor 1 (IGF-1) assay should be used as a screening test whenever acromegaly is suspected. Further diagnostic investigations and treatment should be carried out at specialist centres. First-line treatment involves selective excision of pituitary adenoma using transsphenoidal access. Patients with chances of cure with surgical removal of the pituitary tumour should be referred to centres that have experience in this type of procedure, following pharmacological preparation. Other patients, as well as patients after failed neurosurgical treatment, should first receive chronic treatment with first-generation somatostatin analogues. For second-line treatment, pasireotide, pegvisomant, cabergoline, or combinations thereof should be considered. In every case, acromegaly sequelae require life-long monitoring and active treatment. Current recommendations, being an updated version of the recommendations published in Endokrynologia Polska in 2014, which take into account the Polish situation, should prove useful in the management of patients with acromegaly.

MON-584 Iodine Nutrition Status in Pregnancy: Is the Situation in Poland Improving?

Iodine deficiency is considered the most common preventable cause of brain damage worldwide. It is particularly important during pregnancy, as it influences not only mothers but their fetuses as well. The Polish model of iodine prophylaxis is based on the obligatory household salt iodization and recommendation of iodine-containing supplements use by pregnant women. The aim of the study was to assess the current iodine status of pregnant women in Poland, and to compare it with earlier results. Material and methods: 1208 pregnant women aged 16-46 years (median 29 years) were included. 911 of them (75.4%) were investigated between 2007 and 2011, remaining 297 (24.6%) were studied in 2017. A signed informed consent was obtained from every participating woman. The urinary iodine concentration (UIC) in a casual morning sample was assessed by Sandell-Kolthoff reaction. Thyroid volume was measured by ultrasound. Iodine supplements intake was assessed by a questionnaire. The study protocol was approved by the Local Ethics Board. Results: The studied population of pregnant women proved to be iodine insufficient: median UIC was 94.9 mcg/l (lower quartile - 61.85 mcg/l, upper quartile - 149.0 mcg/l). The UIC significantly increased between 2007-2011 and 2018 (median 92.47 mcg/l and 111.45 mcg/l, respectively; p=008), but still did not meet the iodine sufficiency criterion (median UIC between 150 and 249 mcg/l). In only 17.4% of investigated women, UIC value was within the optimal range of 150 to 249 mcg/l: in 17.3% between 2007 and 2011, and 17.5% in 2018. 62.2% of pregnant women were taking iodine supplements: 63.3% of women investigated between 2007 and 2011, and 58.6% in 2011 (p=0.14). The median thyroid volume in the investigated group was 11.8 mL (lower quartile 9.2 mL, upper quartile 15.0 mL). There was no significant difference in thyroid volume between two groups: 11.9 mL in women investigated between 2007 and 2011, and 11.6 mL in 2017. Conclusions. Although during last years iodine status of Polish pregnant women has improved, it has not reached a sufficiency level. Therefore the current Polish iodine prophylaxis model should be adjusted to provide pregnant women with adequate iodine intake.

MON-013 Nutritional Approach To Autoimmune Thyroiditis (AIT) - The Patients’ And Medical Professionals’ View

An increasing interest in improving the quality of life of patients with autoimmune thyroid disorders has been noted during recent years. Although there is little scientific evidence, many patient-oriented publications, websites and support groups recommend changes in diet as well as nutritional supplement use as a cure for thyroid disease and the mean for ailments reduction. The presented survey aimed to explore the patients’ and medical professionals’ approach to nutritional treatments of AIT. Material and methods. (1) Medical professionals: 30 physicians, 32 nutritionists, 35 medical students and 27 dietetics students responded to an internet questionnaire on the recommendations for a nutritional approach in AIT (gluten-free and lactose-free diet, selenium, vitamin D, and iodine supplementation). (2) AIT patients: 150 subjects aged 18 to 70 years (146 females, 4 males) responded to an internet questionnaire on the nutritional approach in their disease. Questions concerned: gluten-free and lactose-free diet, as well as vitamins and microelements use, the source of the patients’ knowledge, and the recommending body behind their decision on changes in nutrition. Results. (1) Medical professionals. 54% of the surveyed subjects recommended their patients the use of selenium supplements (9.7% in Graves’ ophthalmopathy), 41.3% - iodine supplements, 92.3% -vitamin D supplements. 6.4% of responders advised a gluten-free diet regardless of the coexistence of gluten-related disorders, and 4.8% - a lactose-free diet even in the absence of lactose intolerance. There were discrepancies in recommendations between professionals: physicians advised iodine and selenium least often. (2) AIT patients. 44.3% of responders were on a lactose-free, and 37.3% - on a gluten-free diet. Only 2% of responders were diagnosed with celiac disease. 38% of responders who had modified their diet have decided to do so following the recommendation of a medical professional, the remaining 62% - without any advice. 36.7% of responders were using selenium supplements (27.3% following a physician’s recommendation), 8% - iodine supplements (all advised by a physician), 74.7% - vitamin D supplements (48.7% of them have obtained recommendations). Websites (80.7%) and patients-oriented publications (50.7%) were the main sources of AIT patients’ knowledge and opinions on the role of nutrition in AIT management. Conclusions. AIT patients commonly decide to implement a nutrition-based approach to their disease, even without any professional advice. Although the results of the survey are biased by internet methodology, it is worrying that many medical professionals advise introduction of diets and supplements which have not been proven to be effective and may even be harmful (gluten-free diet) against guidelines of medical societies.

Consolidation with 90Y ibritumomab tiuxetan radioimmunotherapy in mantle cell lymphoma patients ineligible for high dose therapy: results of the phase II multicentre Polish Lymphoma Research Group trial, after 8-year long follow-up

Polish Lymphoma Research Group performed a phase-II trial to test whether ⁹⁰Y ibritumomab tiuxetan radioimmunotherapy (Y90) may constitute an alternative consolidation for mantle cell lymphoma patients unfit for high-dose therapy. Forty-six patients were consolidated with Y90 following response to the 1st (n = 34) or 2nd line (n = 12) (immuno)chemotherapy. Majority of the patients had advanced disease (stage IV and presence of B-symptoms in 85% and 70%, respectively) and high MIPI (5.8, range 4-7). Consolidation with Y90 increased the complete remission (CR) rate obtained by the 1st line therapy from 41% to 91% and allowed for median PFS of 3.3 and OS of 6.5 years. In the first relapse, CR rate increased from 16% to 75%, while median PFS and OS totaled 2.2 and 6.5 years, respectively. At 8 years, 30% of patients, consolidated in the 1st line CR were alive, without relapse. Toxicity associated with Y90 is manageable, more severe after fludarabine-based regimens.

The value of the free androgen index depends on the phenotype of polycystic ovary syndrome - a single-centre experience

INTRODUCTION

The free androgen index (FAI) values differ among patients with polycystic ovarian syndrome; however, the differences are not fully understood or known. The aim of the study was to evaluate FAI in women with polycystic ovary syndrome (PCOS) in regard to the phenotype of the PCOS and insulin resistance status.

MATERIAL AND METHODS

Anthropometric, hormonal, and biochemical parameters were assessed in 312 recruited women with PCOS. The FAI values were calculated in the reproductive and metabolic phenotypes of PCOS in groups of insulin resistance status based on the homeostasis model assessment-insulin resistance (HOMA-IR) > 2.0 or fasting insulin (FI) > 10 mmol/L. To test the relationship between individual variables, Spearman's correlation analysis, the Kolmogorov-Smirnov test, and Student's t-test were used.

RESULTS

The correlation between FAI values and HOMA-IR and FI was 0.42 and 0.47, respectively, in PCOS patients. A two fold higher FAI value was observed in metabolic PCOS phenotype when compared to the reproductive one (8.51 ± 5.56 vs. 4.40 ± 2.45 for HOMA-IR and 8.73 ± 6.09 vs. 4.31 ± 3.39 for FI, respectively; p < 0.05).

CONCLUSIONS

PCOS patients are not a homogenous group in terms of FAI value. Patients with metabolic PCOS phenotype are characterised by two-fold higher FAI values compared with reproductive PCOS phenotype. Further studies on the metabolic and androgenic status of different types of PCOS phenotypes should be carried out.

Clinical translation of theranostic radiopharmaceuticals: Current regulatory status and recent examples

With the development of ever more radiopharmaceuticals suitable for theranostic applications, translation of novel compounds from the preclinical stage towards clinical application becomes a bottleneck for the advances in Nuclear Medicine. This review article summarizes the current regulatory framework for clinical trials with radiopharmaceuticals in the European Union, provides a general overview of the documentation required, and addresses quality, safety, and clinical aspects to be considered. By using a recent successful example of translating a theranostic peptide radioligand, namely ¹¹¹In‐CP04, which targets receptors expressed in medullary thyroid carcinoma, the pathway from the preclinical development over establishing the required pharmaceutical documentation to designing and submitting a clinical trial is reviewed. Details regarding preclinical data, generation of the documentation, and final successful application are described. This article should provide an insight in an ever more complex process to bring innovations in the field of radiopharmaceuticals into patients.

CT Characteristics of Pheochromocytoma: Relevance for the Evaluation of Adrenal Incidentaloma

Background

Up to 7% of all adrenal incidentalomas (AIs) are pheochromocytomas (PCCs). In the evaluation of AI, it is generally recommended that PCC be excluded by measurement of plasma-free or 24-hour urinary fractionated metanephrines. However, recent studies suggest that biochemical exclusion of PCC not be performed for lesions with CT characteristics of an adrenocortical adenoma (ACA).

Aim

To determine the proportion of PCCs with ACA-like attenuation or contrast washout on CT.

Methods

For this multicenter retrospective study, two central investigators independently analyzed the CT reports of 533 patients with 548 histologically confirmed PCCs. Data on tumor size, unenhanced Hounsfield units (HU), absolute percentage washout (APW), and relative percentage washout (RPW) were collected in addition to clinical parameters.

Results

Among the 376 PCCs for which unenhanced attenuation data were available, 374 had an attenuation of >10 HU (99.5%). In the two exceptions (0.5%), unenhanced attenuation was exactly 10 HU, which lies just within the range of ≤10 HU that would suggest a diagnosis of ACA. Of 76 PCCs with unenhanced HU > 10 and available washout data, 22 (28.9%) had a high APW and/or RPW, suggestive of ACA.

Conclusion

Based on the lack of PCCs with an unenhanced attenuation of <10 HU and the low proportion (0.5%) of PCCs with an attenuation of 10 HU, it seems reasonable to abstain from biochemical testing for PCC in AIs with an unenhanced attenuation of ≤10 HU. The assessment of contrast washout, however, is unreliable for ruling out PCC.

How much of the predisposition to Hashimoto's thyroiditis can be explained based on previously reported associations?

PURPOSE

Our insight in the genetics of Hashimoto's thyroiditis (HT) has become clearer through information provided by genome-wide association studies and candidate gene studies, but remains still not fully understood. Our aim was to assess how many different genetic risk variants contribute to the development of HT.

METHODS

147 HT cases (10.2% men) and 147 controls (13.6% men) were qualified for the analysis. Intrinsic and environmental factors were controlled for. Polymorphisms (SNP) were chosen based on the literature and included markers of the genes PTPN22, CTLA4, TG, TPO among others, and of genomic regions pointed by GWAS studies. SNP were typed on a microarray. Variants in the HLA-DRB1 gene were identified by Sanger sequencing.

RESULTS

Multivariate predisposition to HT was modeled. Based on the investigated group, a model of seven variables was obtained. The variability explained by this model was assessed at only 5.4821% (p = 2 × 10^-6), which indicates that many dozens of factors are required simultaneously to explain HT predisposition.

CONCLUSIONS

We analyzed genetic regions commonly and most significantly associated with autoimmune thyroid disorders in the literature, on a carefully selected cohort. Our results indicated a lack of possibility to predict the risk of HT development, even with a multivariate model. We therefore conclude that strong associations of single genetic regions with HT should be interpreted with great caution. We believe that a change in the attitude towards genetic association analyses of HT predisposition is necessary. Studies including multiple factors simultaneously are needed to unravel the intricacies of genetic associations with HT.

Coexistence of neurofibromatosis type 1 with multiple malignant neoplasia

Neurofibromatosis type 1 (NF1, von Recklinghausen disease) is inherited in autosomal dominant way genetic disorder, with an incidence at birth 1:3000. It is one of the most common congenital disorders. It is characterized by café-au-lait spots, neurofibromas, and less common MPTST and gliomas of the optic nerve. It is caused by germline mutations of the NF1 gene, which acts as tumor suppressor. Inactivation of the gene leads to increased activation of the kinase pathways, and in consequence, uncontrolled proliferation of cells. The disease predisposes to the development of both benign and malignant tumors. Malignant tumors, but not related to the nervous system occur in neurofibromatosis quite rare. The aim of the study is a literature review of NF1, with presentation of a patient with NF1 and coexisting numerous tumors: synchronous somatostatinoma and gastrointestinal stromal tumor with metachronous prostate adenocarcinoma and non-small cell lung carcinoma. And attempt to answer the question if there is a common pathway for oncogenesis of these four tumors.

Ten-Year Follow-Up of a Randomized Clinical Trial of Total Thyroidectomy Versus Dunhill Operation Versus Bilateral Subtotal Thyroidectomy for Multinodular Non-toxic Goiter

Background

The aim of this study was to validate in a 10-year follow-up the initial outcomes of various thyroid resection methods for multinodular non-toxic goiter (MNG) reported in World J Surg 2010;34:1203–13.

Materials and methods

Six hundred consenting patients with MNG were randomized to three groups of 200 patients each: total thyroidectomy (TT), Dunhill operation (DO), bilateral subtotal thyroidectomy (BST). Obligatory follow-up period of 60 months was extended up to 120 months for all the consenting patients. The primary outcome measure was the prevalence of recurrent goiter and need for revision thyroid surgery. The secondary outcome measure was the cumulative postoperative and post-revision morbidity rate.

Results

The primary outcomes were twice as inferior at 10 years when compared to 5-year results for DO and BST, but not for TT. Recurrent goiter was found at 10 years in 1 (0.6%) TT versus 15 (8.6%) DO versus 39 (22.4%) BST (p < 0.001), and revision thyroidectomy was necessary in 1 (0.6%) TT versus 5 (2.8%) DO versus 14 (8.0%) BST patients (p < 0.001). Any permanent morbidity at 10 years was present in 5 (2.8%) TT patients following initial surgery versus 7 (4.0%) DO and 10 (5.7%) BST patients following initial and revision thyroidectomy (nonsignificant differences). At 10 years, 23 (11.5%) TT versus 25 (12.5%) DO versus 26 (13.0%) BST patients were lost to follow-up.

Conclusions

Total thyroidectomy can be considered the preferred surgical approach for patients with MNG, as it abolishes the risk of goiter recurrence and need for future revision thyroidectomy when compared to more limited thyroid resections, whereas the prevalence of permanent morbidity is not increased at experienced hands.

Registration number:

NCT00946894 (http://www.clinicaltrials.gov).

How Do We Improve the Impact of Iodine Deficiency Disorders Prevention in Europe and Beyond?

BACKGROUND

Iodine deficiency disorders (IDD) represent a global health threat to individuals and societies. IDD prevention programmes have been introduced in many parts of the world. However, challenges remain, particularly in Europe due to fragmentation and diversity of approaches that are not harmonized.

OBJECTIVES

This review is dedicated to the public-health impact of IDD prevention programmes. It sums up experiences collected by the EUthyroid consortium so far and provides information on stakeholders that should be involved in actions directed to improve the impact of IDD prevention.

METHODS

A joint European database for combining registry-based outcome and monitoring data as well as tools for harmonizing study methods were established. Methods for analyzing thyroglobulin from a dried blood spot are available for assessing the iodine status in the general population and at-risk groups. Mother-child cohorts are used for in-depth analysis of the potential impact of mild-to-moderate iodine deficiency on the neurocognitive development of the offspring. A decision-analytic model has been developed to evaluate the long-term effectiveness and cost effectiveness of IDD prevention programmes.

RESULTS

EUthyroid has produced tools and infrastructure to improve the quality of IDD monitoring and follows a dissemination strategy targeting policymakers and the general public. There are tight connections to major stakeholders in the field of IDD monitoring and prevention.

CONCLUSIONS

EUthyroid has taken steps towards achieving a euthyroid Europe. Our challenge is to inspire a greater sense of urgency in both policymakers and the wider public to address this remediable deficit caused by IDD.

Guidelines of Polish National Societies Diagnostics and Treatment of Thyroid Carcinoma. 2018 Update

Significant advances have been made in thyroid can-cer research in recent years, therefore relevant clinical guidelines need to be updated. The current Polish guidelines "Diagnostics and Treatment of Thyroid Carcinoma" have been formulated at the "Thyroid Cancer and Other Malignancies of Endocrine Glands" conference held in Wisła in November 2015 [1].

Predictors of long term weight loss maintenance in patients at high risk of type 2 diabetes participating in a lifestyle intervention program in primary health care: The DE-PLAN study

Lifestyle interventions in type 2 diabetes (DM2) prevention implementation studies can be effective and lasting. Long-term weight loss maintenance enhances the intervention effect through a significant decrease in diabetes incidence over time. Our objective was to identify factors predicting long-term successful weight reduction maintenance achieved during a DM2 prevention program in patients with high DM2 risk in primary health care. Study participants (n = 263), middle-aged, slightly obese with baseline increased DM2 risk (Finnish Diabetes Risk Score (FINDRISC)>14), but no diabetes were invited to receive 11 lifestyle counselling sessions, guided physical activity sessions and motivational support during 10-months. The study participants had three clinical examinations during the study (baseline, one and three years). Stepwise regression analysis was used to determine demographic, clinical, and lifestyle predictors of weight reduction maintenance two years after the discontinuation of the intervention. Out of 105 patients who completed all three examinations (baseline age 56.6 (standard deviation (SD) = 10.7), body mass index 31.1 kg/m2 (SD = 4.9), FINDRISC 18.6 (SD = 3.1)), 73 patients (70%) showed weight loss during the intervention (mean weight loss 4.2 kg, SD = 5.1). The total weight loss achieved in the maintainers (27 of 73 study participants) two years after the intervention had finished was 6.54 kg (4.47 kg+2.0 kg). The non-maintainers, on the other hand, returned to their initial weight at the start of the intervention (+0.21 kg). In multivariable analysis baseline history of increased glucose (odds ratio (OR) = 3.7; 95% confidence interval (CI) 1.0-13.6) and reduction of total fat in diet during follow-up (OR = 4.3; 95% CI 1.5-12.2) were independent predictors of successful weight loss. Further studies exploring predictors of weight loss maintenance in diabetes prevention are needed to help health care providers to redesign interventions and improve long-term outcomes of real life interventions.

2018 European Thyroid Association (ETA) Guidelines for the Management of Amiodarone-Associated Thyroid Dysfunction

Treatment with amiodarone is associated with changes in thyroid function tests, but also with thyroid dysfunction (amiodarone-induced hypothyroidism, AIH, and amiodarone-induced thyrotoxicosis, AIT). Both AIH and AIT may develop in apparently normal thyroid glands or in the presence of underlying thyroid abnormalities. AIH does not require amiodarone withdrawal, and is treated with levothyroxine replacement if overt, whereas subclinical forms may be followed without treatment. Two main types of AIT are recognized: type 1 AIT (AIT 1), a form of iodine-induced hyperthyroidism occurring in nodular goitres or latent Graves disease, and type 2 AIT (AIT 2), resulting from destructive thyroiditis in a normal thyroid gland. Mixed/indefinite forms exist due to both pathogenic mechanisms. AIT 1 is best treated with thionamides that may be combined for a few weeks with sodium perchlorate to make the thyroid gland more sensitive to thionamides. AIT 2 is treated with oral glucocorticoids. Once euthyroidism has been restored, AIT 2 patients are followed up without treatment, whereas AIT 1 patients should be treated with thyroidectomy or radioiodine. Mixed/indefinite forms of AIT are treated with thionamides. Oral glucocorticoids can be added from the beginning if a precise diagnosis is uncertain, or after a few weeks if response to thionamides alone is poor. The decision to continue or to stop amiodarone in AIT should be individualized in relation to cardiovascular risk stratification and taken jointly by specialist cardiologists and endocrinologists. In the presence of rapidly deteriorating cardiac conditions, emergency thyroidectomy may be required for all forms of AIT.