Smoking and thyroid

Thyroid eye disease (Graves' orbitopathy): clinical presentation, epidemiology, pathogenesis, and management

Thyroid eye disease (TED; also known as Graves' orbitopathy), causes swollen extraocular muscles and orbital fat. Mechanistically, TED involves lid retraction, oedema and redness of the eyelids and conjunctiva, proptosis, diplopia, and optic neuropathy. Investigation of TED involves assessment of disease activity (inflammation) and disease severity. TED is predominantly mild in 77% of cases, moderate-to-severe in 22%, and rarely sight-threatening in 1% of patients. While most patients with TED have Graves' hyperthyroidism, up to 5% are euthyroid or even hypothyroid. Risk factors include male sex, older age, smoking, diabetes, hypercholesterolaemia, duration of hyperthyroidism, radioactive iodine therapy, and the presence of thyrotropin receptor (TSHR) antibodies (detectable in more than 95% of patients and directly related to TED activity and severity). Genetic immunisation of mice with TSHR, but not with insulin-like growth factor-1 receptor (IGF-1R), provides a reliable animal model of TED, demonstrating that TSHR is the primary autoantigen in the disease. Crosstalk between TSHR and IGF-1R occurs via a β-arrestin scaffold. Teprotumumab, a human monoclonal antibody that blocks IGF-1R without binding to TSHR, has been shown to significantly improve outcomes in moderate-to-severe TED, including greater proptosis reduction compared with intravenous methylprednisolone. However, its disadvantages include side effects (eg, hearing loss in 30% of patients), a high cost, and a high relapse rate. Therefore, intravenous steroids remain the treatment of choice in many parts of the world. Tocilizumab, which blocks the interleukin-6 receptor, is an effective treatment option for patients with TED who are steroid-resistant. This Review further discusses alternative medications, surgical treatments, local measures, and the importance of quality-of-life assessments and multidisciplinary care.

Risk Role of Genetically Predicted Serum Iron Status on Thyroid Cancer

Previous research has not clearly illustrated the impact of serum iron status on thyroid cancer. Bi-directional and multivariable Mendelian randomization (MVMR) analyses were conducted to determine the causative effects of serum iron status on thyroid cancer. Genetic markers for serum iron status, including serum iron, ferritin, transferrin saturation (TSTA), and transferrin, were acquired from the Genetics of Iron Status. The primary analytical method employed was inverse variance weighting, supplemented by other sensitivity approaches to validate the consistency of the results. Genetically predicted serum iron, ferritin, and TSTA were found to increase the risk of thyroid cancer. However, there was no causal link between transferrin levels and the risk of thyroid cancer. The causal link remained strong in the reverse MR and MVMR. Furthermore, serum iron status had no causal effect on benign neoplasms of the thyroid gland based on the two-sample MR analysis. Our MR study provides novel evidence that serum iron, ferritin, and TSTA are associated with thyroid cancer, but not with benign neoplasms of the thyroid gland. These markers could be useful for differential diagnosis. Strategies to lower serum iron levels may reduce the burden of thyroid cancer.

Importance of iodide sufficiency and normal thyroid function in fertility and during gestation

Appropriate management of thyroid dysfunction in pregnancy is challenging in both its primary, secondary and tertiary forms of the disease. Primary hypothyroidism is by far most prevalent globally. Main causes are insufficiency of iodide supplementation in developing countries and autoimmunity in developed countries. However, after a very successful global implementation by World Health Organisation over decades accompanied by specific recommendations for management of the iodide supplementation during pregnancy, recent studies found that women both in USA and EU are again mild to moderately iodide deficient during pregnancy or going through assisted fertility treatment. This poses a disturbing risk in relation to foetal neurological and brain development. The diagnosis and treatment monitoring of the thyroid function during pregnancy are very challenged due to the extensive physiological as well as pathophysiological adaptations of the thyroid axis hormones to encompass a sufficient foetal supply. This is distorting the hormone measurements, since the normal limits are exceeded, and current biochemical methods are not calibrated for the adapted concentrations. Even though clinical guidelines exist there are still gaps in the evidence-based recommendations to guide clinicians to thyroid function management during pregnancy. Debut of hypothyroidism during pregnancy requires immediate diagnosis as it can lead to poor foetal outcome with intrauterine growth restriction and foetal demise on top of the risk for the neurocognition. Hypothyroidism in stable replacement treatment needs careful monitoring during pregnancy to adapt to the physiological changes in the requirement of the thyroid hormone thyroxine, and combination therapy with triiodothyronine is contraindicated. The frequent use of assisted reproduction technology (ART) with controlled ovarian hyperstimulation in these patient groups having disease induced low fertility has created an unrecognised risk of under-replacement due to accelerated oestrogen stimulation with increased risk of severe complications for both the woman and foetus. Longitudinal studies of the thyroid function bridging pre-ART, through ART to pregnancy and postpartum in different clinical settings are recommended. The area needs consensus recommendations between gynaecologists and endocrinologists in specialised centres to alleviate such increased gestational risk. There is a strong need of more research on improvement of thyroid hormone replacement, and biomarkers for treatment optimisation in this field of non-communicable diseases, which suffers from both limited attention from the health authorities and poor funding.

Soluble Immune Checkpoints Associated With Disease Activity and Treatment Response in GD and TED

CONTEXT

Soluble immune checkpoints play an important role in peripheral tolerance that has seldom been investigated in Graves' disease (GD) and thyroid eye disease (TED).

OBJECTIVE

The objective of this work is to examine the alteration of soluble immune checkpoints in GD and TED.

METHODS

We performed a quantitative multiplex analysis of 17 immune checkpoint proteins in serum from 50 GD patients without TED, 28 GD patients with TED, and 40 healthy controls. The association with demographic, serologic, clinical features and 27 cytokines was analyzed. A follow-up was conducted in GD patients without TED. Functional outcomes of sLAG-3 and sGITR were assessed in cell cultures using rh-LAG3, rh-GITR, an antagonistic LAG-3 antibody, and an antagonistic GITR antibody.

RESULTS

GD Patients with TED had distinct sICP and cytokine profiles compared with GD patients without TED. Active patients with TED exhibited elevation in the levels of sBTLA, sLAG-3, sGITR, sCD80, sCD86, and sPD-L1. Further, GD patients without TED with high sBTLA, sCD27, and sCD40 levels at baseline showed a better improvement in thyrotropin receptor antibody titers after antithyroid drug treatment. Adding recombinant human GITR and LAG-3 to peripheral blood mononuclear cell cultures resulted in increased inflammatory cytokine secretion and decreased anti-inflammatory cytokine secretion.

CONCLUSION

The present study uncovers disturbed soluble immune checkpoints and cytokines in GD patients with and without TED and may pave the way for novel immunological screening, allowing for identification of patients with TED at higher risk of developing active disease and patients with GD a better treatment response after antithyroid drug treatment.

Optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) for assessing thyroid-associated ophthalmopathy activity

PURPOSE

To explore the role of retinal and choroidal parameters obtained via optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) in predicting thyroid-associated ophthalmopathy (TAO) activity, providing a scientific basis for improved clinical diagnosis and treatment.

METHOD

This study included 90 active TAO patients (178 eyes), 69 inactive TAO patients (138 eyes), and 66 healthy individuals (132 eyes). It compared choroidal and retinal parameters and magnetic resonance imaging structural differences, analyzed correlations between these parameters, and developed a predictive model for TAO activity.

RESULTS

Compared to control and inactive groups, active group had thicker subfoveal choroidal thickness (SFCT) and reduced luminal area, stromal area, and total choroidal area. Active group showed reduced vessel density in the foveal and nasal regions versus inactive group, and in the foveal, superior, and nasal regions versus controls. Foveal avascular zone (FAZ) area was larger in active group than in both control and inactive groups. Active group also had larger inner diameters and signal intensity ratio (SIR) of the extraocular muscles than inactive group. SFCT correlated with proptosis, and FAZ correlated with proptosis, maximum extraocular muscle diameter, and SIR. The multivariate model achieved area under the curve values of 0.836 in overall TAO population and 0.855 in hyperlipidemia subgroup, outperforming the univariate model.

CONCLUSION

Retinal and choroidal parameters, obtained via OCT/OCTA, are keys to developing TAO activity predictive models, with enhanced accuracy in TAO patients with hyperlipidemia.

Association between maternal urinary cotinine concentrations during pregnancy and neonatal blood thyroid-stimulating hormone levels: The Japan environment and Children's study (JECS)

Thyroid hormones are crucial for neurodevelopment and somatic growth, with blood thyroid-stimulating hormone (TSH) levels indicating thyroid function. The effects of maternal smoking on neonatal TSH levels remain inconclusive. In this study, we used data from the Japan Environment and Children's Study to investigate the relationship between maternal urinary cotinine concentrations during pregnancy and neonatal blood TSH levels, stratified by newborn sex. We analyzed data from 52,552 mother-child pairs. Maternal smoking status was categorized as non-smoker, passive smoker, or active smoker based on urinary cotinine concentrations. For visual analysis, cotinine concentrations were divided into deciles. Linear and modified Poisson regression models were used to examine the relationship between maternal smoking and neonatal TSH levels. Increasing maternal urinary cotinine concentrations were associated with higher neonatal blood TSH levels in both sexes, with a more pronounced increase in female newborns. Beyond a specific cotinine threshold, indicative of higher passive smoking exposure, TSH levels declined in both male and female newborns. Passive smoking was significantly associated with increased TSH levels in female newborns compared to those born to non-smoking mothers. No such associations were observed for active smoking status in either male or female newborns. Maternal tobacco smoke exposure during pregnancy was associated with a dose-dependent increase in blood TSH levels in offspring of both sexes. In particular, female neonates whose mothers were exposed to higher levels of passive smoking had the highest risk of elevated TSH levels, suggesting potential adverse effects on neonatal thyroid function.

Association between anti-thyroid peroxidase antibody and insufficient sleep in euthyroid population

Background

Low sleep quality induces inflammation. Because anti-thyroid peroxidase antibody (TPO-Ab) is an autoantibody that induces inflammation in the thyroid, insufficient sleep may stimulate the production of TPO-Ab. However, the thyroid function is also associated with sleep. Therefore, to evaluate the association between TPO-Ab positivity and insufficient sleep, the target population should be limited to euthyroid individuals whose free triiodothyronine (T3), free thyroxine (T4), and thyroid-stimulating hormone (TSH) are within the normal ranges.

Method

This cross-sectional study recruited 1324 euthyroid individuals who participated in annual health checkups. Insufficient sleep was assessed by using a questionnaire. Individuals with free T3, free T4, and TSH levels within the normal ranges were defined as euthyroid.

Results

Among the study population, 406 had insufficient sleep, and 242 were TPO-Ab-positive. Insufficient sleep was associated with a higher likelihood of TPO-Ab positivity. Sex and age adjusted odd ratios (95 % confidence intervals, p) of TPO-Ab positive for insufficient sleep was 1.47 (1.08, 2.01, p = 0.014). These associations remained unchanged even after further adjustment for free T4 and TSH, status of body mass index, smoking status, drinking status, mental distress, and physical activity; 1.53 (1.11, 2.10, p = 0.009).

Conclusion

Euthyroid individuals with insufficient sleep may be at risk of autoimmune thyroiditis. Although further investigations are necessary, sleep disorder therapy might reduce the risk of the incidence of autoimmune thyroiditis.

Rituximab Treatment as Second-Line Therapy in Glucocorticoid Nonresponsive Graves' Orbitopathy: A Nonrandomized, Controlled, Interventional Study

OBJECTIVE

In moderate-to-severe Graves' orbitopathy, rituximab is recommended as second-line therapy in patients nonresponsive to intravenous glucocorticoids. We aimed to evaluate rituximab as early second-line therapy, as data are scarce and contradictory.

METHODS

In this nonrandomized, controlled, interventional study, patients with Graves' orbitopathy started on intravenous glucocorticoids. After 4 weeks, patients with < 2 points improvement in clinical activity score (CAS) were switched to rituximab [Non-Responders Rituximab (NR-RTX) group] and were compared to the remaining patients who continued with intravenous glucocorticoids for 12 weeks [Responders-Glucocorticoid (R-GC) group]. A retrospective group of non-responsive patients who were provided regular care with intravenous glucocorticoids for 12 weeks was used as control [Non-Responders-Regular Care group]. Background data and CAS were recorded for all groups at 0, 4, 12, 18, and 68 weeks. Quality of life (QoL) and safety data were collected from the NR-RTX and R-GC groups.

RESULTS

The NR-RTX group (n = 12) was similar to the others at baseline except for a 1-point lower median CAS compared to the NR-RC group (n = 12) (P = .03), and for having twice as many men compared to the R-GC group (n = 13) (P = .03). At 4 weeks, a linear mixed model indicated that the R-GC group had a 1.21-point (95% CI: -2.40 to -0.02) lower value for CAS compared to the NR-RTX group. CAS for all groups converged over time. Similar models for QoL revealed no treatment or time effects.

CONCLUSION

Switch to RTX early in the treatment course did not result in better CAS or QoL, compared to continuous intravenous glucocorticoids.

Unveiling Risk Factors for Treatment Failure in Patients with Graves' Disease: A Nationwide Cohort Study in Korea

BACKGRUOUND

Antithyroid drug (ATD) treatment is the preferred initial treatment for Graves' disease (GD) in South Korea, despite higher treatment failure rates than radioactive iodine (RAI) therapy or thyroidectomy. This study aimed to evaluate the incidence of treatment failure associated with the primary modalities for GD treatment in real-world practice.

METHODS

We included 452,001 patients diagnosed with GD between 2004 and 2020 from the Korean National Health Insurance Service-National Health Information Database. Treatment failure was defined as switching from ATD, RAI, or thyroidectomy treatments, and for ATD specifically, inability to discontinue medication for over 2 years.

RESULTS

Mean age was 46.2 years, with females constituting 70.8%. Initial treatments for GD included ATDs (98.0%), thyroidectomy (1.3%), and RAI (0.7%), with a noted increment in ATD application from 96.2% in 2004 to 98.8% in 2020. During a median follow- up of 8.5 years, the treatment failure rates were 58.5% for ATDs, 21.3% for RAI, and 2.1% for thyroidectomy. Multivariate analysis indicated that the hazard ratio for treatment failure with ATD was 2.81 times higher than RAI. RAI treatments ≥10 mCi had 37% lower failure rates than doses <10 mCi.

CONCLUSION

ATDs are the most commonly used for GD in South Korea, followed by thyroidectomy and RAI. Although the risk of treatment failure for ATD is higher than that of RAI therapy, initial RAI treatment in South Korea is relatively limited compared to that in Western countries. Further studies are required to evaluate the cause of low initial RAI treatment rates in South Korea.

Smoking timing, genetic susceptibility, and the risk of incident atrial fibrillation: a large prospective cohort study

AIMS

Although smoking is a well-known risk factor for atrial fibrillation (AF), the association of smoking timing with AF risk remains unclear. This study aimed to prospectively investigate the association of smoking timing with the risk of incident AF and test the modification effect of genetic susceptibility.

METHODS AND RESULTS

A total of 305 627 participants with detailed information for time from waking to the first cigarette were enrolled from UK Biobank database. The Cox proportional hazard model was employed to assess the relationship between smoking timing and AF risk. The weighted genetic risk score for AF was calculated. Over a median 12.2-year follow-up, 13 410 AF cases were documented. Compared with non-smokers, time from waking to the first cigarette showed gradient inverse associations with the risk of incident AF (P-trend <0.001). The adjusted hazard ratio related to smoking timing was 1.13 [95% confidence interval (CI): 0.96-1.34] for >120 min, 1.20 (95% CI: 1.01-1.42) for 61-120 min, 1.34 (95% CI: 1.19-1.51) for 30-60 min, 1.43 (95% CI: 1.26-1.63) for 5-15 min, and 1.49 (95% CI: 1.24-1.63) for <5 min, respectively. Additionally, we found that the increased risk of AF related to shorter time from waking to the first cigarette was strengthened by the genetic susceptibility to AF.

CONCLUSION

Our findings suggest gradient inverse association between time from waking to the first cigarette and risk of incident AF, and the association is strengthened by the genetic susceptibility to AF.

Trends of Pathological Findings in Patients with Thyroid Diseases: A Single-center, Retrospective Study

Background

Globally, a rising trend has been observed in the prevalence of thyroid disorders, with many demographic and geographic factors influencing its epidemiology. Nonetheless, some cases often go undetected due to the inconsistent and non-specific nature of the clinical symptoms. Therefore, we aimed to determine the trend and relationship between various pathological findings in thyroid disease patients and their demographic factors to aid clinicians in making a prompt diagnosis and treatment plan.

Methods

A descriptive correlational study was conducted from January 2020 to May 2022 at Jinnah Postgraduate Medical Center, Karachi. We collected data via random sampling from 258 patients suffering from thyroid disorders. We evaluated baseline patient characteristics, along with, thyroid scan and fine needle aspiration cytology (FNAC) reports, and local thyroid gland examination findings.

Results

Out of 258 participants, 192 (74.4%) were females, whereas 66 (25.6%) were males, giving a female: male ratio of 2.9: 1. On local examination, 167 (64.7%) were found to have a solitary nodule, 79 (30.6%) had multinodular goiter. Findings revealed that benign follicular lesions had the highest prevalence (35.3%). Moreover, among the cancerous growth, papillary carcinoma presented the highest cases (12.4%). Of 258 cases, 24 patients had non-surgical interventions, while most (234) had surgical interventions. Total thyroidectomy was the most common procedure opted for by 45.3% (n = 117) of the participants, followed by lobectomy 70 (27.1%), near total thyroidectomy 43 (13.2%), modified radical neck dissection 5 (1.9%).

Conclusion

Our study showed that nearly all thyroid-related pathologies were more prevalent amongst females than males, with the majority having an acute to sub-acute clinical presentation. Multinodular goiter was a prominent finding indicating a greater need for screening tools and access to healthcare facilities, especially in rural areas, to allow future studies to compare provinces accurately.

Immune checkpoint inhibitors-related thyroid dysfunction: influencing factor analysis, prediction model development, and management strategy proposal

BACKGROUND

With the extensive utilization of immune checkpoint inhibitors (ICIs) across various cancers, ICIs-related thyroid dysfunction (ICI-TD) has become a growing concern in clinical practice. This study aimed to devise an individualized management strategy for ICI-TD to enhance the early identification and proactive management in cancer patients.

METHODS

We designed and conducted a three-phase study. Initially, we analyzed the influencing factors through a systematic review and meta-analysis, which adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Moreover, the study protocol was registered with PROSPERO (CRD42019131133). Subsequently, prediction models for ICI-TD were developed utilizing 11 algorithms based on the real-world cohort data from July 20, 2018 (the approval date of the first ICIs, Pembrolizumab in China), to October 31, 2022. Considering discrimination, calibration, and clinical utility, we selected the model with the best performance for web calculator development. Finally, individualized management strategies for ICI-TD were proposed by combining evidence-based analysis with practical considerations.

RESULTS

The systematic review encompassed 21 observational studies involving 4,145 patients, revealing associations between ICI-TD and factors such as female gender, age, receipt of Pembrolizumab (versus other ICIs), and baseline levels of thyroid-stimulating hormone, free thyroxine, and antithyroid antibodies. In the prediction model development phase, 621 participants were enrolled, with 36 patients developing ICI-TD. The model based on the LightGBM algorithm demonstrated superior performance, leading to the development of a web calculator. Based on these findings and existing guidelines, individualized monitoring and treatment pathways for pharmacists were devised.

CONCLUSION

This study offers comprehensive insights into managing ICI-TD, potentially enhancing tailored cancer immunotherapy management.

Severity Identification of Graves Orbitopathy via Random Forest Algorithm

This study aims to establish a random forest model for detecting the severity of Graves Orbitopathy (GO) and identify significant classification factors. This is a hospital-based study of 199 patients with GO that were collected between December 2019 and February 2022. Clinical information was collected from medical records. The severity of GO can be categorized as mild, moderate-to-severe, and sight-threatening GO based on guidelines of the European Group on Graves' orbitopathy. A random forest model was constructed according to the risk factors of GO and the main ocular symptoms of patients to differentiate mild GO from severe GO and finally was compared with logistic regression analysis, Support Vector Machine (SVM), and Naive Bayes. A random forest model with 15 variables was constructed. Blurred vision, disease course, thyroid-stimulating hormone receptor antibodies, and age ranked high both in mini-decreased gini and mini decrease accuracy. The accuracy, positive predictive value, negative predictive value, and the F1 Score of the random forest model are 0.83, 0.82, 0.86, and 0.82, respectively. Compared to the three other models, our random forest model showed a more reliable performance based on AUC (0.85 vs. 0.83 vs. 0.80 vs. 0.76) and accuracy (0.83 vs. 0.78 vs. 0.77 vs. 0.70). In conclusion, this study shows the potential for applying a random forest model as a complementary tool to differentiate GO severity.

Comparison of Thyroid Size-Specific Radioiodine Dose and New Modified Dose Calculation in the Treatment of Graves' Disease

BACKGRUOUND

Previous studies of fixed-dose radioiodine therapy (RIT) for Graves' disease (GD) have utilized a variety of techniques and reported differing success rates. This study sought to compare the efficacy of RIT using two fixed-dose protocols and to estimate the optimal radioiodine (RAI) activity for the treatment of GD.

METHODS

This retrospective trial enrolled 658 patients with GD who received RIT between January 2014 and December 2021. Participants were divided into two groups: protocol 1, which utilized a thyroid size-specific RAI dose, and protocol 2, which employed a modified dose calculation approach. The primary outcome assessed was the presence of euthyroidism or hypothyroidism at the 6-month follow-up. The success rates of RIT were compared between the two protocols.

RESULTS

The RIT success rate was marginally lower for protocol 2 than for protocol 1 (63.6% vs. 67.2%); however, the risk of treatment failure did not differ considerably between the groups (relative risk, 1.1089; 95% confidence interval, 0.8937 to 1.3758; P=0.3477). The median RAI activity associated with protocol 2 was lower than that for protocol 1 (10.7 mCi vs. 15.0 mCi, P=0.0079), and the frequency of hypothyroidism was significantly lower in the protocol 2 group (39.0% vs. 48.9%, P=0.0117).

CONCLUSION

The success rate of the modified dose calculation protocol was comparable to that of the thyroid size-specific RAI dose protocol. The former approach reduced RAI activity and the incidence of hypothyroidism following RIT without compromising the success rate.

Public Awareness of the Symptoms and Risk Factors of Thyroid Disease in Saudi Arabia

INTRODUCTION

Thyroid disorders are a common manifestation of hormonal disorders that result from either excessive or insufficient production of thyroid hormones and the swelling of the thyroid gland. A lack of information and awareness of the signs and risk factors of thyroid problems can lead to untreated patients, thereby harming public health.

METHODS

Observational cross-sectional research was conducted in the Al-Baha region of Saudi Arabia, with 531 residents selected from the general population. The data were analyzed using SPSS to derive significant insights, and questionnaires were used to collect the data.

RESULTS

The results revealed that 79 (14.9%) of the participants had been diagnosed with thyroid disease. The risk factors for thyroid diseases reported were as follows: female gender (386, 72.7%); exposure to radiation (329, 62.0%); smoking (312, 58.8%); family history (300, 56.5%); and insufficient or excess intake of iodine (277, 52.2%). Only 110 (20.7%) of the participants knew that the use of amiodarone medication is a risk factor for thyroid diseases. The symptoms reported included fatigue (430, 81.0%), feeling cold, and weight gain (409, 77.0%); neck lump (379, 71.4%); depression (367, 69.1%); and hair loss (336, 63.3%). Early diagnosis (426, 80.2%), a well-exercised program (394, 74.2%), and a well-balanced diet (392, 73.8%) were the prevention methods reported by a majority of the participants. The study results revealed an average score of 13.57±2.11, with a minimum knowledge score of 0 and a maximum of 25. A statistically significant difference was observed in knowledge scores based on the participant's gender, age, education level, previous diagnosis with thyroid diseases, family history of thyroid diseases, and having performed thyroid gland investigation with p-values <0.05 (<0.001, 0.019, 0.027, <0.001, 0.023, and 0.031), respectively.

CONCLUSION

Nearly half of the participants had low knowledge scores regarding the risk factors and clinical manifestations of thyroid diseases. Although a sizable proportion of participants demonstrated awareness of some clinical presentations and prevention methods, there are serious knowledge gaps regarding the risk factors and symptoms of thyroid disease among the general population in the Al-Baha region. There is a need for targeted health education programs to improve public awareness of risk factors and early detection and prevention measures of thyroid diseases to improve the quality of life among community members.

Temporal trends in the clinical presentation of Graves' orbitopathy: a single-center retrospective study

PURPOSE

Graves' ophthalmopathy (GO) is an autoimmune disease that affects orbital soft tissues and represents the most common extrathyroidal manifestation of Graves' disease (GD). The European Group of Graves' Ophthalmopathy (EUGOGO) has attempted to shed light on the European epidemiological picture of GO, suggesting that GO in newly diagnosed patients in recent years has a trend towards a less severe clinical presentation. There are no studies that focus this issue on the population of our area; we aimed to evaluate the trend of GO clinical presentation in our outpatient clinic through an observation period of 10 years.

METHODS

We compared 55 consecutive patients, 11 males (F) and 44 females (M), who came to our observation from January 2005 to December 2006 [Group 1 (G1)], with 56 patients, 15 males, and 41 females, who were referred to us from 2015 to 2016 [Group 2 (G2)]. We studied the following putative predictors of GO presentation and severity: thyroid function, smoking, diabetes, hypercholesterolemia, time from GO diagnosis to referral to our thyroid centre (TGOD), sex and age.

RESULTS

GO severity was significantly reduced in G2 vs. G1 (p = 0.04). TGOD ≥ 3 months was related to clinical characteristics of GO (severity and Clinical Activity Score ≥ 4) and was an independent predictor of GO severity (p = 0.01). The other variables evaluated had no independent effects.

CONCLUSIONS

We found that GO severity at presentation was significantly reduced over a ten-year observation period (2005-2006 vs. 2015-2016) in GO patients referred to our tertiary thyroid centre. TGOD ≥ 3 months was an independent predictor of GO severity.

The Impact of Environmental Factors on the Development of Autoimmune Thyroiditis-Review

Autoimmune thyroiditis (Hashimoto's thyroiditis) is the most common autoimmune disease. It most often manifests itself as hypothyroidism but may also present with euthyroidism or even hyperthyroidism. The etiopathogenesis of autoimmune thyroiditis is still unclear. However, in addition to genetic and epigenetic factors, many environmental factors are known to increase the risk of developing AIT. In this review, we aimed to collect and analyze data connected with environmental factors and autoimmune thyroiditis development. Our review indicates iodine intake, vitamin D deficiency, selenium deficiency, viral infections caused by Epstein-Barr Virus (EBV), Human parvovirus B19 (PVB19), Human herpesvirus 6A (HHV-6A) and Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), bacterial infection caused by Helicobacter pylori, microbiome disruption, medications such as interferon-alpha and tyrosine kinase inhibitors, as well as stress, climate, and smoking can influence the risk of the occurrence of autoimmune thyroiditis. Having knowledge of risk factors allows for making changes to one's diet and lifestyle that will reduce the risk of developing the disease and alleviate the course of autoimmune thyroiditis.

Association between tobacco smoke exposure and serum parathyroid hormone levels among US adults (NHANES 2003-2006)

Tobacco smoke exposure has been demonstrated to impede bone remodeling and diminish bone density, yet research regarding its correlation with parathyroid hormone (PTH) remains limited. This study aims to investigate the relationship between tobacco smoke exposure and serum PTH levels in adults aged 20 years and older. This study included 7,641 participants from two cycles of the National Health and Nutrition Examination Survey (NHANES, United States, 2003- 2006). Reflect tobacco smoke exposure through serum cotinine levels, and use an adjusted weighted multivariate linear regression model to test the independent linear relationship between serum cotinine and PTH. Stratified analysis was conducted to validate the sensitivity of the conclusions. Smooth curve fitting and threshold effect analysis were performed to assess the non-linear relationship. After comprehensive adjustment using weighted multivariate regression analysis, a negative correlation was found between serum cotinine and PTH levels. The interaction p-values in subgroup analyses were all greater than 0.05. Moreover, smooth curve fitting indicated a non-linear relationship between serum cotinine and PTH, with a turning point observed. Our research indicates that tobacco smoke exposure is negatively correlated and independent of serum parathyroid hormone levels, indicating that long-term tobacco smoke exposure may lead to parathyroid dysfunction in adults.

The Association between Depression, Anxiety, and Thyroid Disease: A UK Biobank Prospective Cohort Study

Background

There is a lack of comprehensive data regarding the association of depression and anxiety for the subsequent risk of thyroid disease.

Aim

To examine this prospective association between depression and anxiety and the risk of potential thyroid diseases, a large prospective study was conducted using data from UK Biobank.

Materials and Methods

Depression and anxiety were measured through self-reported Patient Health Questionnaire-4 (PHQ-4) at baseline, thyroid disease was diagnosed by corresponding hospital data documented through International Classification of Diseases (ICD)-10 codes. Cox proportional hazard models and restricted cubic splines were employed to analyze the associations.

Results

In a 13-year follow-up cohort study involving 349,993 participants, 9,877 (2.82%) individuals developed thyroid disease. Significant associations were observed between depression, anxiety, and risk of both hypothyroidism and hyperthyroidism among all participants, the adjusted hazard ratios (HRs) for PHQ scores were as follows: mild 1.27 (95% CI, 1.20-1.36), moderate 1.33 (95% CI, 1.17-1.51), and severe 1.56 (95% CI, 1.31-1.85). For hyperthyroidism, the HRs were mild 1.19 (95% CI, 1.03-1.38), moderate 1.43 (95% CI, 1.08-1.90), and severe 1.84 (95% CI, 1.28-2.66). The adjusted HRs indicating the association between depression, anxiety, and hypothyroidism remained significant for both males and females. The relationship between PHQ score and the risk of thyroid disease shows linear in restricted cubic spline.

Conclusion

Depression and anxiety exposure is associated with subsequent risk of thyroid diseases, the more severe the depression and anxiety, the greater the associated risk. Therefore, any level of depression and anxiety should be taken into consideration in thyroid disease risk prediction and prevention.

Glycemic Trends in Patients with Thyroid Eye Disease Treated with Teprotumumab in 3 Clinical Trials

PURPOSE

Assess incidence, severity, and glucose excursion outcomes in thyroid eye disease (TED) patients receiving the insulin-like growth factor-1 receptor inhibitor teprotumumab from 3 clinical trials.

DESIGN

Analysis of pooled glycemic data over time.

PARTICIPANTS

Eighty-four teprotumumab- and 86 placebo-treated active TED patients from the phase 2 and phase 3 (OPTIC) controlled clinical trials and 51 teprotumumab-treated patients from the OPTIC extension (OPTIC-X) trial.

METHODS

Eight intravenous infusions were given over 21 weeks. Phase 2 serum glucose was measured at weeks 1, 4, 15, and 21, with fasting measurements at weeks 1 and 4. Serum glucose was measured at each study visit in OPTIC and OPTIC-X, with fasting measurements at weeks 1 and 4 (in patients without diabetes) or all visits (in patients with diabetes). In all studies, hemoglobin A1c (HbA1c) was measured at baseline, 12, and 24 weeks plus weeks 36 and 48 in OPTIC-X.

MAIN OUTCOME MEASURES

Serum glucose and HbA1c.

RESULTS

In the phase 2 and 3 studies, 9 hyperglycemic episodes occurred in 8 teprotumumab patients; mean HbA1c level increased 0.22% from baseline to week 24 (to 5.8%; range, 5.0%-7.9%) versus 0.04% in patients receiving the placebo (to 5.6%; range, 4.6%-8.1%). At study end, 78% (59/76) of teprotumumab patients and 87% (67/77) of patients receiving placebo had normoglycemic findings. Normoglycemia was maintained in 84% (57/68) of patients receiving teprotumumab and 93% (64/69) of patients receiving placebo. Among baseline prediabetic patients, 43% (3/7) remained prediabetic in both groups, and 29% (2/7) of teprotumumab patients and 14% (1/7) of patients receiving placebo had diabetic findings at week 24. OPTIC-X patients trended toward increased fasting glucose and HbA1c whether initially treated or retreated with teprotumumab. Fasting glucose commonly rose after 2 or 3 infusions and stabilized thereafter. Most hyperglycemic incidents occurred in patients with baseline prediabetes/diabetes but were controlled with medication. No evidence was found for progression or increased incidence of hyperglycemia with subsequent doses.

CONCLUSIONS

Serious glycemic excursions are uncommon in patients with normoglycemia before teprotumumab therapy. Patients with controlled diabetes or impaired glucose tolerance can be treated safely if baseline screening, regular monitoring of glycemic control, and timely treatment of hyperglycemia are practiced.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Association Between Hashimoto's Thyroiditis and Rheumatoid Arthritis: A Bidirectional Mendelian Randomization Study

Background: We aim to investigate the possible causal association between Hashimoto's thyroiditis (HT) and rheumatoid arthritis (RA) using Mendelian randomization (MR) methods. Methods: A bidirectional MR analysis was conducted to evaluate the causal association between HT and RA. We obtained summary statistics data from two extensive genome-wide association studies (GWAS) comprising 15,654 cases of HT and 14,361 cases of RA. The primary effect estimate utilized in this study was the inverse-variance weighted (IVW) method. To ensure the reliability and stability of the results, we employed several additional methods for testing, including MR-Egger, weighted median, simple mode, weighted mode, and MR-PRESSO. Results: Our study revealed compelling evidence of bidirectional causality between HT and RA. When HT was considered as an exposure factor and RA was considered as an outcome factor, this study revealed a positive correlation between HT and RA (IVW: odds ratio [OR] = 2.4546, 95% confidence interval [CI], 1.1473-5.2512; p = 0.0207). Conversely, when we examined RA as the exposure factor and HT as the outcome factor, we still found a positive correlation between them (IVW: OR = 1.2113, 95% CI, 1.1248-1.3044; p = 3.9478 × 10-7). Conclusions: According to our research findings, there exists a bidirectional positive causal relationship between HT and RA among European populations. This implies that individuals with HT have an elevated risk of developing RA, and conversely, individuals with RA have an increased risk of developing HT.

Predictive factors of development of dysthyroid optic neuropathy among individuals with thyroid-eye disease

PURPOSE

Dysthyroid optic neuropathy (DON) is a severe visual loss condition in thyroid eye disease (TED). This study aimed to identify factors affecting moderate-to-severe TED or DON in Thai populations.

METHODS

We retrospectively reviewed the records of 230 TED patients at Rajavithi Hospital between January 1, 2017, and October 31, 2022.

RESULTS

Mild, moderate-to-severe TED, and DON were found in 60.43%, 22.61%, and 16.96% of participants, respectively. Female predominance was noted in all groups. The proportion of older age, hyperthyroidism, current smokers, and type 2 diabetes mellitus (T2DM) participants were significantly higher in the DON group. Multivariable logistic-regression analysis revealed that hyperthyroidism and current smoking significantly increased the risk of developing moderate-to-severe TED (OR = 3.001, p = 0.010, and OR = 4.153, p = 0.015, respectively). Exophthalmos was the strongest predictor (OR = 6.834, p < 0.001). Regarding DON risk factors, older age (≥55 years) had OR = 3.206 (p = 0.003), hyperthyroidism had OR = 3.228 (p = 0.005), and being a current smoker had OR = 3.781 (p = 0.011). T2DM posed the greatest risk of DON development (OR = 4.111, p = 0.004).

CONCLUSIONS

Hyperthyroidism and current smoking are significant risk factors for moderate-to-severe TED and DON. TED patients with diabetes mellitus or older age should be closely monitored and informed about their risk of developing DON.

Redox mechanisms in autoimmune thyroid eye disease

Thyroid eye disease (TED) is an autoimmune condition affecting the orbit and the eye with its adnexa, often occurring as an extrathyroidal complication of Graves' disease (GD). Orbital inflammatory infiltration and the stimulation of orbital fibroblasts, triggering de novo adipogenesis, an overproduction of hyaluronan, myofibroblast differentiation, and eventual tissue fibrosis are hallmarks of the disease. Notably, several redox signaling pathways have been shown to intensify inflammation and to promote adipogenesis, myofibroblast differentiation, and fibrogenesis by upregulating potent cytokines, such as interleukin (IL)-1β, IL-6, and transforming growth factor (TGF)-β. While existing treatment options can manage symptoms and potentially halt disease progression, they come with drawbacks such as relapses, side effects, and chronic adverse effects on the optic nerve. Currently, several studies shed light on the pathogenetic contributions of emerging factors within immunological cascades and chronic oxidative stress. This review article provides an overview on the latest advancements in understanding the pathophysiology of TED, with a special focus of the interplay between oxidative stress, immunological mechanisms and environmental factors. Furthermore, cutting-edge therapeutic approaches targeting redox mechanisms will be presented and discussed.

Iodine status and determinants in adults in Norway - results from a population-based health examination survey (The HUNT Study)

Background

In Norway, there is a lack of knowledge about the iodine status in the general and older adult population, and there is no established national monitoring programme for iodine. Several studies have indicated that iodine deficiency is prevalent in subgroups of the population. Salt iodisation is currently being considered as a measure to increase the population iodine status. In this cross-sectional study, the aim was to evaluate iodine status and determinants in the adult and older adult population in Mid-Norway, before salt iodisation is likely to be initiated.

Methods

The study sample was a subsample of participants in the fourth wave of the population-based Trøndelag Health Study (HUNT4, 2017-2019) with available spot-urine samples. This subsample included participants with 25-64 years (n = 500) and 70-79 years (n = 250). The urine samples were analysed for iodine and creatinine. Information on the habitual intake of milk/yoghurt, fish, supplement use, use of thyroid medication and relevant background factors was collected through a general questionnaire. Multivariable quantile regression was used to model differences in the median urinary iodine concentration (UIC) by determinants. Estimates were weighted to match the age and sex distribution of the Norwegian population aged 25-79 years in 2019.

Results

Median UIC was 97 µg/L (95% confidence interval [CI]: 92, 103) indicating borderline iodine deficiency at a group level. The median UIC increased with age, and iodine status was insufficient in participants below age 55 years (median 92 µg/L [95% CI: 85, 99]). Important determinants of UIC were habitual milk/yoghurt intake, daily supplement use and current use of thyroid medication, but not intake of lean or fatty fish. Risk of mild-to-moderate iodine deficiency was seen in those with a low intake of milk/yoghurt, no supplement use and who did not use thyroid medication. No group was identified as being at risk of iodine excess.

Conclusion

Iodine status was adequate in older adults but mildly deficient in adults under 55 years. Milk intake, supplement use and use of thyroid medication are important determinants of iodine intake in Norway.

Husband smoking is associated with Wife's thyrotropin abnormality: A population-based cohort study among Chinese reproductive-aged women

OBJECTIVES

To comprehensively assess the association of husband smoking with wives' thyrotropin abnormality.

METHODS

This population-based retrospective cohort study included 2 406 090 Chinese reproductive-aged women who had participated twice in the National Free Pre-pregnancy Checkups Project between 2010 and 2020. Multivariate-adjusted odds ratios and 95% confidence intervals for subnormal and supranormal thyrotropin were estimated according to the husband's smoking status.

RESULTS

Husband smoking at the first visit was associated with a 17% (15%-20%) and 26% (24%-28%) increased odds of subnormal thyrotropin and supranormal thyrotropin respectively compared to participants in neither-smoker group. In non-smoking participants with normal thyrotropin levels at the first visit, the corresponding increased risk of subnormal thyrotropin and supranormal thyrotropin at the second visit were 15% (12%-18%) and 19% (16%-21%) in contrast to participants without husband-smoking exposure. In non-smoking participants with abnormal thyrotropin levels at their first visit, husband smoking cessation was associated with 27% (17%-35%) and 36% (31%-40%) reduced odds of subnormal thyrotropin and supranormal thyrotropin at the second visit compared with the participants whose husband still smoking at the second visit.

CONCLUSION

Husband smoking was associated with wives' subnormal thyrotropin and supranormal thyrotropin, and cessation of husband smoking could reduce the odds of thyrotropin abnormality. Couple-focused smoking intervention should be developed to reduce the burden of asymptomatic thyroid disease in females.

Knowledge of Thyroid Disease Manifestation and Risk Factors Among the General Population in the Tabuk Region of Saudi Arabia

Background Thyroid disorders are caused either by excessive or inadequate thyroid hormone production or by the enlargement of the thyroid gland. Various types of thyroid disorders exist, including primary (related directly to the gland itself), secondary (related to thyroid function), and other types. This study aimed to assess the knowledge of thyroid disease manifestation and its risk factors among individuals living in Tabuk, Saudi Arabia. Methodology An observational cross-sectional study was conducted among 400 adults living in Tabuk city of Saudi Arabia aged 18 years or above. Data was collected using an electronic questionnaire through a simple random sampling method. Data was then coded, entered, and analyzed using both descriptive and inferential statistical methods using IBM SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, New York, United States). Results A total of 403 participants were enrolled in this study. More than half (n=265, 65.8%) were females, and 188 (46.7%) were in the age group of 18-35 years. The educational level of the majority of them was a bachelor's degree (n=296, 73.4%). Hypothyroidism was the most common thyroid disorder among family members (n=51, 62.4%). Inadequate iodine intake was thought to be a risk factor for thyroid disorders, as mentioned by 276 (68.5%) participants. Exact 284 (70.5%) participants believed that females are more at risk of having thyroid disease. The mean total knowledge score was found to be 25.1±4.48 out of a total of 34. Exact 216 (53.6%) participants had good knowledge about thyroid disorders. The female gender had significantly higher levels of knowledge as compared to males (p-value=0.002) regarding the manifestation and risk factors of thyroid disorders. In terms of educational level, a bachelor's or above was found to be significantly associated with a higher level of knowledge (p-value=0.003). Conclusion A good level of knowledge and awareness about thyroid disorders was observed among more than half of the participants. Few knowledge gaps were identified regarding knowledge about symptoms of hypothyroidism and certain medications which might cause thyroid disorders.

Retinal nerve fiber layer and ganglion cell complex thickness in diabetic smokers without diabetic retinopathy

PURPOSE

To compare the thickness of the retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GC-IPL) in smoker and nonsmoker diabetics without diabetic retinopathy.

MATERIALS AND METHODS

Patients with diabetes were divided into two groups according to their smoking status: Group 1 consisted of 38 smoker diabetics who had chronically smoked more than 20 cigarettes per day for more than five years; Group 2 consisted of 38 nonsmoker diabetics. After a detailed ophthalmologic examination, the mean and regional (superior, supratemporal, inferior, inferotemporal, temporal, nasal, superonasal, and inferonasal) RNFL and GC-IPL thicknesses were measured with spectral-domain optic coherence tomography (SD-OCT) and compared between groups.

RESULTS

The mean age was 54.7 ± 10.5 and 51.2 ± 9.7 years in the smoker and nonsmoker groups, respectively (p = 0.14). Gender, duration of diabetes, and the mean axial length were similar between groups (p:0.43, p:0.54, p: 0.52, respectively). Mean RNFL thickness was 89.1 ± 8.0 µm in the smoker group and 93.4 ± 7.0 µm in the nonsmoker group, and it was significantly thinner in the smoker group (p = 0.01). The temporal RNFL thickness in the smoker group was thinner than in the nonsmoker group (p = 0.02). There was no difference in superior, inferior, and nasal RNFL thicknesses between the groups (p = 0.31, p = 0.12, p = 0.39, respectively). The mean macular GC-IPL thickness of the smoker and nonsmoker groups was 78.53 ± 15.74 µm and 83.08 ± 5.85 µm, respectively (p = 0.09). Superior, superonasal, inferonasal, inferior, inferotemporal, and superotemporal quadrant GC-IPL thicknesses were similar between the groups (p = 0.07, p = 0.60, p = 0.55, p = 0.77, p = 0.71, p = 0.08, respectively). The groups showed no difference in minimum GC-IPL thickness (p = 0.43). There was a significant negative correlation between smoking exposure and mean, inferior quadrant RNFL thicknesses in the smoker group (p = 0.04, r= -0.32, and p = 0.01, r= -0.39, respectively).

CONCLUSION

Mean RNFL thickness was significantly thinner in smoker diabetics. Although not statistically significant, especially mean, superior, and superotemporal GC-IPL was thinner in smoker diabetics. The results suggest a potential association between the coexistence of diabetes and smoking with alterations in RNFL and GC-IPL thickness.

Autoimmune thyroid disease and rheumatoid arthritis: where the twain meet

Autoimmune thyroid disease (AITD) is the most prevalent autoimmune disease. It shares multiple genetic, clinical, and serologic characteristics with rheumatoid arthritis (RA). Although frequently described as a classic form of single-organ autoimmunity, the AITD disease burden in a subset of patients extends well beyond the thyroid gland. This review explores the complex interaction between the two diseases and the clinical consequences when they overlap. Beyond the well-known effects of AITD on thyroid function in RA, there is mounting evidence of the association of both conditions impacting the presentation and outcomes of diabetes, metabolic syndrome, and cardiovascular disease. An increasing number of studies suggest that there are negative effects of AITD on RA disease activity both in the presence and in the absence of thyroid dysfunction. Recent evidence suggests that AITD may not only worsen the cumulative damage of RA through higher disease activity but may also worsen secondary osteoarthritis changes. Less well-known is the significant association between AITD and chronic widespread pain syndromes including fibromyalgia. Importantly, the presence of fibromyalgia, which is increased in RA patients, appears to be further increased when it overlaps with AITD. Lastly, we probe the possible influence of AITD interacting with RA on fertility and clinical depression. Key Points • Autoimmune thyroid disease is the most common autoimmune disease and is frequently associated with rheumatoid arthritis. • Autoimmune thyroid disease can present with osteoarthritis, inflammatory arthritis, and chronic widespread pain syndromes. • The co-occurrence of autoimmune thyroid disease and rheumatoid arthritis may worsen disease activity and exacerbate other disease manifestations including cardiovascular disease, fertility, and depression. • The overlap of rheumatoid arthritis with autoimmune thyroid disease needs further research and should be sought in general clinical practice.

Understanding the clinical and molecular basis of thyroid orbitopathy: a review of recent evidence

Thyroid eye disease (TED) is an autoimmune orbital inflammatory disease which ranges from mild to severe. Tissue remodeling, fibrosis and fat proliferation cause changes in the orbital tissues which can affect esthetics and visual function. In its severe form, it is sight threatening, debilitating, and disfiguring and may lead to social stigma, the embarrassment about which has an impact on the quality of life of those affected and the family members. The pathogenesis of TED, which is influenced by genetic, immunological, and environmental factors, is complex and not fully elucidated. However, it remains unknown what factors determine the severity of the disease. Recent research has revealed a number of diagnostic and prognostic biomarkers of this disease. In this overview of TED, we focus on new insights and perspectives regarding biological agents that may provide a basis for new treatment modalities.

Outcomes of Patients With Graves Disease 25 Years After Initiating Antithyroid Drug Therapy

CONTEXT

Graves disease (GD) is a leading cause of hyperthyroidism. Detailed investigations and predictors of long-term outcomes are missing.

OBJECTIVE

This work aimed to investigate the outcomes in GD 25 years after initiating antithyroid drug treatment, including disease course, clinical and biochemical predictors of relapse, and quality of life.

METHODS

A retrospective follow-up was conducted of GD patients that participated in a randomized trial from 1997 to 2001. Demographic and clinical data were obtained from medical records and questionnaires. Biobank samples were analyzed for inflammatory biomarkers and compared with age- and sex-matched healthy individuals.

RESULTS

We included 83% (182/218) of the patients from the original study. At the end of follow-up, normal thyroid function was achieved in 34%. The remaining had either active disease (1%), spontaneous hypothyroidism (13%), or had undergone ablative treatment with radioiodine (40%) or thyroidectomy (13%). Age younger than or equal to 40 years, thyroid eye disease (TED), smoking, and elevated levels of interleukin 6 and tumor necrosis factor receptor superfamily member 9 (TNFRS9) increased the risk of relapsing disease (odds ratio 3.22; 2.26; 2.21; 1.99; 2.36). At the end of treatment, CD40 was lower in patients who maintained normal thyroid function (P = .04). At the end of follow-up, 47% had one or more autoimmune diseases, including vitamin B12 deficiency (26%) and rheumatoid arthritis (5%). GD patients who developed hypothyroidism had reduced quality of life.

CONCLUSION

Careful lifelong monitoring is indicated to detect recurrence, hypothyroidism, and other autoimmune diseases. Long-term ATD treatment emerges as a beneficial first-line treatment option, especially in patients with young age at onset or presence of TED.

Bacteroidaceae, Bacteroides, and Veillonella: emerging protectors against Graves' disease

Background

Graves' disease (GD) is the most common cause of hyperthyroidism, and its pathogenesis remains incompletely elucidated. Numerous studies have implicated the gut microbiota in the development of thyroid disorders. This study employs Mendelian randomization analysis to investigate the characteristics of gut microbiota in GD patients, aiming to offer novel insights into the etiology and treatment of Graves' disease.

Methods

Two-sample Mendelian randomization (MR) analysis was employed to assess the causal relationship between Graves' disease and the gut microbiota composition. Gut microbiota data were sourced from the international consortium MiBioGen, while Graves' disease data were obtained from FINNGEN. Eligible single nucleotide polymorphisms (SNPs) were selected as instrumental variables. Multiple analysis methods, including inverse variance-weighted (IVW), MR-Egger regression, weighted median, weighted mode, and MR-RAPS, were utilized. Sensitivity analyses were conducted employing MR-Egger intercept test, Cochran's Q test, and leave-one-out analysis as quality control measures.

Results

The Mendelian randomization study conducted in a European population revealed a decreased risk of Graves' disease associated with Bacteroidaceae (Odds ratio (OR) [95% confidence interval (CI)]: 0.89 [0.89 ~ 0.90], adjusted P value: <0.001), Bacteroides (OR: [95% CI]: 0.555 [0.437 ~ 0.706], adjusted P value: <0.001), and Veillonella (OR [95% CI]: 0.632 [0.492 ~ 0.811], adjusted P value: 0.016). No significant evidence of heterogeneity, or horizontal pleiotropy was detected. Furthermore, the preliminary MR analysis identified 13 bacterial species including Eubacterium brachy group and Family XIII AD3011 group, exhibiting significant associations with Graves' disease onset, suggesting potential causal effects.

Conclusion

A causal relationship exists between gut microbiota and Graves' disease. Bacteroidaceae, Bacteroides, and Veillonella emerge as protective factors against Graves' disease development. Prospective probiotic supplementation may offer a novel avenue for adjunctive treatment in the management of Graves' disease in the future.

Hyperthyroidism and cardiovascular disease: an association study using big data analytics

BACKGROUND

The cardiovascular (CV) system is profoundly affected by thyroid hormones. Both hypo- and hyperthyroidism can increase the risk of severe CV complications.

OBJECTIVE

To assess the association of hyperthyroidism with major CV risk factors (CVRFs) and CV diseases (CVDs) using a big data methodology with the Savana Manager platform.

MATERIAL AND METHODS

This was an observational and retrospective study. The data were obtained from the electronic medical records of the University Hospital Puerta de Hierro Majadahonda (Spain). Artificial intelligence techniques were used to extract the information from the electronic health records and Savana Manager 3.0 software was used for analysis.

RESULTS

Of a total of 540,939 patients studied (53.62% females; mean age 42.2 ± 8.7 years), 5504 patients (1.02%; 69.9% women) had a diagnosis of hyperthyroidism. Patients with this diagnosis had a significantly (p < 0.0001) higher frequency of CVRFs than that found in non-hyperthyroid subjects. The higher frequency of CVRFs in patients with hyperthyroidism was observed in both women and men and in patients younger and older than 65 years of age. The total frequency of CVDs was also significantly (p < 0.0001) higher in patients diagnosed with hyperthyroidism than that found in patients without this diagnosis. The highest odds ratio values obtained were 6.40 (4.27-9.61) for embolic stroke followed by 5.99 (5.62-6.38) for atrial fibrillation. The frequency of all CVDs evaluated in patients with a diagnosis of hyperthyroidism was significantly higher in both women and men, as well as in those younger and older than 65 years, compared to subjects without this diagnosis. A multivariate regression analysis showed that hyperthyroidism was significantly and independently associated with all the CVDs evaluated except for embolic stroke.

CONCLUSION

The data from this hospital cohort suggest that there is a significant association between the diagnosis of hyperthyroidism and the main CVRFs and CVDs in our population, regardless of the age and gender of the patients. Our study, in addition to confirming this association, provides useful information for understanding the applicability of artificial intelligence techniques to "real-world data and information".

Presentation of Graves' orbitopathy within European Group On Graves' Orbitopathy (EUGOGO) centres from 2012 to 2019 (PREGO III)

BACKGROUND

Graves' orbitopathy (GO) is subject to epidemiological and care-related changes. Aim of the survey was to identify trends in presentation of GO to the European Group On Graves' Orbitopathy (EUGOGO) tertiary referral centres and initial management over time.

METHODS

Prospective observational multicentre study. All new referrals with diagnosis of GO within September-December 2019 were included. Clinical and demographic characteristics, referral timelines and initial therapeutic decisions were recorded. Data were compared with a similar EUGOGO survey performed in 2012.

RESULTS

Besides age (mean age: 50.5±13 years vs 47.7±14 years; p 0.007), demographic characteristics of 432 patients studied in 2019 were similar to those in 2012. In 2019, there was a decrease of severe cases (9.8% vs 14.9; p<0.001), but no significant change in proportion of active cases (41.3% vs 36.6%; p 0.217). After first diagnosis of GO, median referral time to an EUGOGO tertiary centre was shorter (2 (0-350) vs 6 (0-552) months; p<0.001) in 2019. At the time of first visit, more patients were already on antithyroid medications (80.2% vs 45.0%; p<0.001) or selenium (22.3% vs 3.0%; p<0.001). In 2019, the initial management plans for GO were similar to 2012, except for lid surgery (2.4% vs 13.9%; p<0.001) and prescription of selenium (28.5% vs 21.0%; p 0.027).

CONCLUSION

GO patients are referred to tertiary EUGOGO centres in a less severe stage of the disease than before. We speculate that this might be linked to a broader awareness of the disease and faster and adequate delivered treatment.

Trends in Prevalence of Thyroid Dysfunction and its Associations With Mortality Among US Participants, 1988-2012

CONTEXT

Various dynamic factors could influence the prevalence and distribution of thyroid dysfunction.

OBJECTIVE

To provide national estimates and temporal trends in prevalence of thyroid dysfunction over the past 3 decades in United States and determine the impact of thyroid dysfunction on mortality in US adults.

METHODS

A cross-sectional analysis of data from 33 117 participants aged 12 years or older in the National Health and Nutrition Examination Survey III (1988-1994), 1999-2002, and 2007-2012.

RESULTS

The weighted mean age was 41.6 years, and 48.3% were men. In 2007 through 2012, the prevalence of subclinical and overt hypothyroidism, subclinical and overt hyperthyroidism was 4.3%, 0.33%, 3.2%, and 0.2% respectively. Eighty percent of individuals with thyroid dysfunction were previously undiagnosed. The prevalence of subclinical hypothyroidism and hyperthyroidism was stable, whereas overt hypothyroidism (0.54% [95% CI, 0.35-0.8] vs 0.33% [95% CI, 0.23-0.48]) and hyperthyroidism (0.8% [95% CI, 0.58-1.1] vs 0.2% [95% CI, 0.12-0.33]) were less prevalent in 2007-2012 compared to 1988-1994. Older age, White Americans, obesity, and positivity for thyroid peroxidase antibody and thyroglobulin antibody were risk factors for hypothyroidism, whereas older age, women, and Black Americans were risk factors for hyperthyroidism. Over a median follow-up of 17.2 years, no significant association was observed between any type of thyroid dysfunction with the risk of total or cardiovascular mortality. However, among individuals aged 65 years or older, subclinical hypothyroidism was associated with a higher risk of total mortality (hazard ratio, 1.17; 95% CI, 1.00-1.37; P = .05) and cardiovascular mortality (HR, 1.29; 95% CI, 1.04-1.62; P = .02).

CONCLUSIONS

The prevalence of subclinical thyroid dysfunction remained relatively unchanged, whereas that of overt thyroid dysfunction decreased. Subclinical hypothyroidism was associated with a higher mortality among individuals aged 65 years or older.

Iodine: a scoping review for Nordic Nutrition Recommendations 2023

Iodine is essential for the synthesis of the thyroid hormones thyroxine (T4) and triiodothyronine (T3). As in many other parts of the world, insufficient iodine intake and consequently insufficient iodine status is a public health challenge in the Nordic and Baltic countries. The main dietary sources of iodine in the Nordic and Baltic countries include cow's milk, saltwater fish, eggs, products containing iodised salt, and iodised table salt. Only Denmark (DK), Finland (FI) and Sweden (SE) have implemented mandatory (DK) or voluntary (SE, FI) salt iodisation. New data, as well as recent studies from the Nordic and Baltic countries, strengthen the evidence that the main health challenges related to insufficient iodine intake remain thyroid function and thyroid disease, mental development, and cognitive function. Excessive intakes can also cause hyperthyroidism, autoimmune thyroid disease, and thyroid cancer.

Thyroid Eye Disease: Epidemiology, Natural History, and Risk Factors

BACKGROUND

Thyroid eye disease (TED) is an autoimmune disorder of the orbit and the most frequent extrathyroidal manifestation of Graves' disease but it may rarely occur in euthyroid/hypothyroid patients with chronic autoimmune thyroiditis.

EPIDEMIOLOGY

TED is a relatively infrequent disorder, particularly in its severe forms. Men tend to have more severe TED at an older age. The prevalence of TED is lower than in the past among patients with recent onset Graves' hyperthyroidism, and moderate-to-severe forms requiring aggressive treatments are no more than 5% to 6% of all cases.

NATURAL HISTORY

After an initial inflammatory (active) phase and a plateau phase, TED stabilizes and eventually inactivates (inactive or burnt-out phase) after an estimated period of 18-24 months. Minimal-to-mild TED often remits spontaneously, but complete restitutio ad integrum almost never occurs when TED is more than mild.

RISK FACTORS

Several risk factors contribute to its development on a yet undefined genetic background. Cigarette smoking is the most important of them, but thyroid dysfunction (both hyper- and hypothyroidism), radioactive iodine therapy (if not accompanied by low-dose steroid prophylaxis), elevated thyrotropin receptor antibodies, and, probably, hypercholesterolemia represent relevant modifiable risk factors. Early diagnosis, control and removal of modifiable risk factors, and early treatment of mild forms of GO (local treatment and selenium) may effectively limit the risk of progression to more severe forms.

Influencing Factors and New Reference Intervals of Adult Thyroid Volume in Iodine-Sufficient Areas of China

The diagnosis of goiter is based on the thyroid volume measured by ultrasound in which iodine plays an important role. The purpose of this study was to evaluate the factors that affect thyroid volume and update the reference range of thyroid volume to provide a new basis for the diagnosis and treatment of goiter. A study population from mainland China was evaluated in the Thyroid disorders, Iodine status and Diabetes Epidemiological (TIDE) study. Thyroid size was measured by ultrasound, and thyroid volume was calculated. A quantile regression model was used to analyze the influence of related factors on the thyroid volume at each percentile. The median urinary iodine concentration (UIC) was 185.54 μg/l. The quantile regression model suggested that body surface area (BSA) and thyroid-stimulating hormone (TSH) were positive and negative factors for thyroid volume, respectively (p < 0.01). Excess iodine reduces the median and lower limits of thyroid volume. In iodine-sufficient areas, smoking is no longer a risk factor. The reference value range of thyroid volume stratified by sex was 3.92-19.06 ml for males and 3.1-16.17 ml for females. The maximum reference ranges for stratification by sex and BSA were 4.25-20.98 ml for men and 3.44-18.31 ml for women. The iodine nutrition level of the population in mainland China is sufficient. Iodine has the potential to alter the effect of certain factors on thyroid volume and effect is not regional. The new reference interval of adult thyroid volume based on sex and BSA has been updated, which can be used as a reliable reference for updating the diagnostic criteria of endemic goiter.

Dysthyroid Optic Neuropathy

PURPOSE

Dysthyroid optic neuropathy (DON) is a sight-threatening complication of thyroid eye disease (TED). This review provides an overview of the epidemiology, pathogenesis, diagnosis, and current therapeutic options for DON.

METHODS

A literature review.

RESULTS

DON occurs in about 5% to 8% of TED patients. Compression of the optic nerve at the apex is the most widely accepted pathogenic mechanism. Excessive stretching of the nerve might play a role in a minority of cases. Increasing age, male gender, smoking, and diabetes mellitus have been identified as risk factors. Diagnosis of DON is based on a combination of ≥2 clinical findings, including decreased visual acuity, decreased color vision, relative afferent pupillary defect, visual field defects, or optic disc edema. Orbital imaging supports the diagnosis by confirming apical crowding or optic nerve stretching. DON should be promptly treated with high-dose intravenous glucocorticoids. Decompression surgery should be performed, but the response is incomplete. Radiotherapy might play a role in the prevention of DON development and may delay or avoid the need for surgery. The advent of new biologic-targeted agents provides an exciting new array of therapeutic options, though more research is needed to clarify the role of these medications in the management of DON.

CONCLUSIONS

Even with appropriate management, DON can result in irreversible loss of visual function. Prompt diagnosis and management are pivotal and require a multidisciplinary approach. Methylprednisolone infusions still represent first-line therapy, and surgical decompression is performed in cases of treatment failure. Biologics may play a role in the future.

The Effects of Maternal Smoking on Thyroid Function: Findings from Routine First-Trimester Sonographic Anomaly Screening

AIM

This study aimed to assess the effect of tobacco exposure on maternal thyroid function and investigate its relationship to subclinical hypothyroidism in pregnant women during the first trimester.

SUBJECTS AND METHOD

A comparison of maternal thyroid function was made on 45 smokers, who composed the study group, and 72 non-smokers, pregnant women, who constituted the control group. After determining smokers by questionnaire, carbon monoxide (CO) levels in the expiratory air of the participants in both groups were measured and recorded, and the smokers' exposure was objectively confirmed.

RESULTS

Smoking and non-smoking pregnant women were similar regarding body mass index (BMI). While the TSH and fT4 levels were respectively 1.48 mlU/L and 11.43 pmol/L in pregnant women who smoked, that ratio changed to 1.72 mlU/L and 11.17 pmol/L in the non-smokers' group. But the differences between the groups were not statistically significant (p=0.239, p=0.179). Even though the rate of subclinical hypothyroidism was 8.9% in the smoking group, it was approximately 19.4% in the non-smoker group; the difference was not statistically significant (p=0.187).

CONCLUSION

This study proved that there is no statistically significant difference between maternal serum TSH and fT4 levels and the rate of subclinical hypothyroidism in smokers during pregnancy in the first trimester.

Sex-specific risk factors associated with graves' orbitopathy in Korean patients with newly diagnosed graves' disease

OBJECTIVE

To assess sex-specific risk factors for Graves' orbitopathy (GO) in newly diagnosed Graves' disease (GD) patients.

METHODS

A retrospective cohort study was conducted using the National Health Insurance Service's sample database, which consisted of 1,137,861 subjects from 2002 to 2019. The international classification of disease-10 codes was used to identify those who developed GD (E05) and GO (H062). A multivariable Cox proportional hazards model was used to estimate the effect of risk factors on GO development.

RESULTS

Among 2145 male and 5047 female GD patients, GO occurred in 134 men (6.2%) and 293 women (5.8%). A multivariable Cox regression model revealed that GO development was significantly associated with younger age (HR = 0.84, 95% CI = 0.73-0.98), low income (HR = 0.55, 95% CI = 0.35-0.86), and heavy drinking (HR = 1.79, 95% CI = 1.10-2.90) in men, and with younger age (HR = 0.89, 95% CI = 0.81-0.98), lower body mass index (HR = 0.55, 95% CI = 0.33-0.90), high total cholesterol (HR = 1.04, 95% CI = 1.01-1.06), hyperlipidaemia (HR = 1.37, 95% CI = 1.02-1.85), and lower statin dose (HR = 0.37, 95% CI = 0.22-0.62) in women. There was no association between smoking and GO development in both men and women.

CONCLUSIONS

The risk factors for GO development were sex-dependent. These results show the need for more sophisticated attention and support considering sex characteristics in GO surveillance.

Relationship between TSH and free thyroxine in outpatient cancer patient population

BACKGROUND

The inverse log-linear relationship between Thyroid-stimulating hormone (TSH) and free thyroxine (FT4) is well established and reliably used for evaluation of hypothalamus-pituitary-thyroid (HPT) axis function. However, there are limited data regarding oncologic states in the TSH-FT4 relationship. The purpose of this study was to evaluate thyroid pituitary hypothalamic feedback regulation by the inverse log TSH and FT4 relationship in the cancer patient population at the Ohio State University Comprehensive Cancer Center (OSUCCC-James).

METHODS

This retrospective study analyzed the correlation between TSH and FT4 results from 18846 outpatient subjects collected in August 2019-November 2021 at the Department of Family Medicine (OSU Wexner Medical Center), Department of Oncology (OSUCCC-James). Patients with diagnoses related to cancers were included in the oncology group. Patients with diagnoses not related to cancers were included in the non-oncology group. Patients of the Department of Endocrinology, Department of Cardiology, Department of Obstetrics & Gynecology and Department of Hematology were excluded from this study. Time of collection for TSH and FT4 was from 7am to 7 pm. Data were analyzed by morning (7am-12pm) and afternoon (12pm-7pm). Spearman correlation and non-linear fit were used for data analysis. Sex differences were analyzed as well in each group.

RESULTS

Overall, an inverse correlation was observed between TSH and FT4 in both groups (non-oncology and oncology) regardless of sample collection time and sex differences. Further analysis by linear model in log TSH and FT4 showed a significant inverse fit in males compared with females in the group of oncology, both in the afternoon (p < 0.05). Data were further analyzed by ranges of FT4, as lower or higher (pathophysiology) or within (physiology) the reference interval of FT4. There was no statistical significance between the non-oncology and oncology groups, but relatively good correlation in non-oncology group in either physiologic or pathophysiologic FT4 levels and sample collection time. Interestingly, the best correlation between TSH and FT4 was found in the non-oncology group at pathophysiologic FT4 concentrations (abnormally high). In addition, at pathophysiologic FT4 concentrations (abnormally low), the oncology group demonstrated a significant TSH response in the morning than in the afternoon (p < 0.05).

CONCLUSIONS

Though overall the TSH-FT4 curves showed an inverse relationship, there are variations of TSH-FT4 relationship for collection times when considering FT4 in physiologic or pathophysiologic states. The results advance understanding of TSH response, which is beneficial for the interpretation of thyroid disease. We recommend re-evaluation for interpretation of pituitary hypothalamic axis by TSH results when FT4 is abnormally high in oncology patients or low in non-oncology patients, due to poor predictability and the potential for misdiagnosis. A better understanding of the complex nature of the TSH-FT4 relationship may need further study with better defining subclinical states of cancer patients.

Cerebral Venous Thrombosis during Thyrotoxicosis: Case Report and Literature Update

Cerebral venous thrombosis (CVT) is a rare cause of stroke, particularly in young adults. Several known thrombophilic conditions may lead to an increased CVT risk. Interestingly, few cases in the literature have reported an association between CVT and thyrotoxicosis. Here, we describe the case of a young woman with CVT and concomitant thyrotoxicosis, without any other known prothrombotic conditions. We also performed a literature review of CVT cases and hyperthyroidism, searching for all articles published in peer-reviewed journals. We identified 39 case reports/case series concerning patients with CVT associated with thyrotoxicosis, highlighting, in most cases, the association with additional known prothrombotic factors. We then discussed the possible mechanisms by which hyperthyroidism could underlie a pro-coagulative state resulting in CVT. Thyroid disease might be a more common prothrombotic risk factor than expected in determining CVT. However, in most cases, a coexistence of multiple risk factors was observed, suggesting a multifactorial genesis of the disorder. We hope that this work may alert clinicians to consider thyrotoxicosis as a potential risk factor for CVT, even in patients who apparently have no other pro-coagulative conditions.

Cigarette smoking and thyroid cancer risk: A Mendelian randomization study

BACKGROUND

The association between cigarette smoking and thyroid cancer has been reported in prospective cohort studies, but the relationship remains controversial. To investigate this potential correlation further, we employed Mendelian randomization methodology to evaluate the causative impact of smoking on thyroid cancer incidence.

METHODS

From the genome-wide association study and Sequencing Consortium of Alcohol and Nicotine use, we obtained genetic variants associated with smoking initiation and cigarettes per day (1.2 million individuals). We also extracted genetic variants associated with past tobacco smoking from the UK Biobank (424,960 individuals). Thyroid cancer outcomes were selected from the FinnGen GWAS (989 thyroid cancer cases and 217,803 control cases). Sensitivity analyses employing various approaches such as weighted median, MR-Egger, and MR-pleiotropy residual sum and outlier (MR-PRESSO) have been executed, as well as leave-one-out analysis to identify pleiotropy.

RESULTS

Using the IVW approach, we did not find evidence that any of the three smoking phenotypes were related to thyroid cancer (smoking initiation: odds ratio (OR) = 1.56, p = 0.61; cigarettes per day: OR = 0.85, p = 0.51; past tobacco smoking: OR = 0.80, p = 0.78). The heterogeneity (p > 0.05) and pleiotropy (p > 0.05) testing provided confirmatory evidence for the validity of our MR estimates.

CONCLUSIONS

The MR analysis revealed that there may not exist a causative link between smoking exposure and elevated incidence rates of thyroid malignancies.

Exploring the oral-gut microbiota during thyroid cancer: Factors affecting the thyroid functions and cancer development

Thyroid cancer (TC) is categorized into papillary, follicular, medullary, and anaplastic. The TC is increasing in several countries, including China, the United States, the United Kingdom, Canada, France, Australia, Germany, Japan, Spain, and Italy. Thus, this review comprehensively covers the factors that affect thyroid gland function, TC types, risk factors, and symptoms. Lifestyle factors (such as nutrient consumption and smoking) and pollutants (such as chemicals and heavy metals) increased the thyroid-stimulating hormone (TSH) levels which are directly related to TC prevalence. The conventional and recent TC treatments are also highlighted. The role of the oral and gut microbiota as well as the application of probiotics on TC are also discussed. The variations in the composition of oral and gut microbes influence the thyroid function indirectly through alteration in metabolites (such as short-chain fatty acids) that are eminent for cellular energy metabolism. Maintenance of healthy gut and oral microbiota can help in regulating thyroid function by regulating iodine uptake. Oral or gut microbial dysbiosis can be considered as an early diagnosis factor or TC marker. High TSH during TC can increase the oral microbial diversity while disrupting the high ratio of Firmicutes and Bacteroidetes in the gut. Supplementation of probiotics as an adjuvant in TC treatment is beneficial. However, needs more extensive research to explore the direct effect of probiotics on thyroid function.

The relationship between dietary inflammatory index values and thyroid function in the US adult population: An analysis of the NHANES 2007-2012 cohort

OBJECTIVE

Researchers have developed the Dietary Inflammatory Index (DII) as a tool to quantify the inflammatory potential of a given diet. Higher DII scores indicated a more proinflammatory diet. While inflammation is known to have a strong impact on thyroid function, the precise nature of the association between DII scores and thyroid function has yet to be clarified. This study was conducted with the goal of exploring this relationship in a representative population of adults from the United States.

METHODS

For this study, we used data from the National Health and Nutrition Examination Survey (NHANES). Standardized questionnaires were used to collect demographic and dietary data from the participants, and laboratory tests were used to collect data on the participants' thyroid parameters and other relevant data. Linear regression models and smoothed curve fitting were used to assess the relationship between DII scores and thyroid function, with weighted data analyses and subgroup analyses being conducted as appropriate.

RESULTS

In total, 7712 subjects were recruited from the NHANES 2007-2012 cohort. Their weighted mean age was 44.87 (0.47) years, mean DII score was 1.41 (0.05). Mean FT3 was 3.20 (0.01) pg/mL and mean TT4 was 7.81 (0.03) µg/dL. In adjusted analyses, higher DII values were related to increases in FT3 (β = .007; p = .027) and TT4 (β = .050; p = .005) levels. Subgroup analyses showed a negative correlation between FT3 levels and DII scores in a population with high urinary iodine concentrations.

CONCLUSION

These data indicate that the consumption of a more proinflammatory diet, as evidenced by elevated DII scores, is correlated with significant increases in FT3 and TT4 levels. However, for people with high urinary iodine concentrations, a more proinflammatory diet was associated with lower FT3 levels. Additional research will be vital to clarify the mechanistic basis for these findings.

[Sociodemographic, clinical and ultrasound characterization of thyroid nodule pathology and its association with malignancy in a Colombian high-complexity center]

BACKGROUND AND OBJECTIVE

Thyroid nodules are among the most frequent conditions, with a 10% risk of malignancy. The objective is to describe the frequency of demographic, clinical, and ultrasonographic characteristics of thyroid nodule pathology in adults and to explore the relationship with tumor malignancy.

METHODS

An analytical, retrospective cross-sectional study in adults with thyroid nodules and nodular fine-needle aspiration performed in adult patients from a Colombian reference center between 2009-2019. Data were obtained from the clinical history, descriptive measures of the patient's demographic, clinical, and ultrasound variables were estimated, and their relationship with the malignancy of the tumor was explored.

RESULTS

A total of 445 patients and 515 nodules were included. The median age was 55 years (IQR 44-64), 86.8% of women, and 54.8% had a single lesion. Percentages of 80.2 and 19.8 were benign and malignant nodules, with a median of 15.7mm (IQR 11-25) and 12.7mm (IQR 8.5-18.3), respectively (p<0.001). Hypothyroidism and levothyroxine consumption were higher in those with malignant nodules (p<0.001). The echographic characteristics were statistically different between the nodules. In the malignant ones, there was a higher frequency of solid composition, hypoechogenicity, and irregular margins. In contrast, in the benign ones, the absence of echogenic focus stood out (p<0.001).

CONCLUSION

The ultrasound characteristics are essential to define the risk of malignancy of a thyroid nodule. Therefore, considering the most frequent ones can help in the most appropriate approach to primary care.

Association between thyroid stimulating hormone levels and papillary thyroid cancer risk: A meta-analysis

High thyroid stimulating hormone (TSH) levels may stimulate papillary thyroid cancer (PTC) cell proliferation; however, the relationship between TSH levels and PTC risk remains controversial. We aim to ascertain the association through a meta-analysis. Literature searches were conducted in PubMed, Embase, and Web of Science databases. After literature screening, the methodological quality was assessed using the Newcastle-Ottawa Scale and Agency for Healthcare Research and Quality methods. Cochran's Q and I 2 tests were used to evaluate heterogeneity in the meta-analysis. Egger's test was applied to assess publication bias. A total of 12 eligible studies were included in this meta-analysis; all were of moderate and high methodological quality. The pooled results suggested that increased TSH levels were significantly associated with PTC risk; however, the included studies were significantly heterogeneous. Stratification analysis indicated that the heterogeneity might be from the area or type of control. Although significant publication bias existed among the studies, the trim-and-fill method and sensitivity analysis revealed that the combined results were stable and robust. TSH levels are significantly associated with the PTC risk; however, more high-quality studies in large sample sizes are recommended to verify the extrapolation of these findings.

Gut Microbiome Associated With Graves Disease and Graves Orbitopathy: The INDIGO Multicenter European Study

CONTEXT

Gut bacteria can influence host immune responses but little is known about their role in tolerance-loss mechanisms in Graves disease (GD; hyperthyroidism caused by autoantibodies, TRAb, to the thyrotropin receptor, TSHR) and its progression to Graves orbitopathy (GO).

OBJECTIVE

This work aimed to compare the fecal microbiota in GD patients, with GO of varying severity, and healthy controls (HCs).

METHODS

Patients were recruited from 4 European countries (105 GD patients, 41 HCs) for an observational study with cross-sectional and longitudinal components.

RESULTS

At recruitment, when patients were hyperthyroid and TRAb positive, Actinobacteria were significantly increased and Bacteroidetes significantly decreased in GD/GO compared with HCs. The Firmicutes to Bacteroidetes (F:B) ratio was significantly higher in GD/GO than in HCs. Differential abundance of 15 genera was observed in patients, being most skewed in mild GO. Bacteroides displayed positive and negative correlations with TSH and free thyroxine, respectively, and was also significantly associated with smoking in GO; smoking is a risk factor for GO but not GD. Longitudinal analyses revealed that the presence of certain bacteria (Clostridiales) at diagnosis correlated with the persistence of TRAb more than 200 days after commencing antithyroid drug treatment.

CONCLUSION

The increased F:B ratio observed in GD/GO mirrors our finding in a murine model comparing TSHR-immunized with control mice. We defined a microbiome signature and identified changes associated with autoimmunity as distinct from those due to hyperthyroidism. Persistence of TRAb is predictive of relapse; identification of these patients at diagnosis, via their microbiome, could improve management with potential to eradicate Clostridiales.

Tocilizumab improves clinical outcome in patients with active corticosteroid-resistant moderate-to-severe Graves' orbitopathy: an observational study

Background

Graves' orbitopathy (GO) is an autoimmune disorder affecting the orbital fat and muscles. A significant role of IL-6 in the pathogenesis of GO has been described and tocilizumab (TCZ), an IL-6 inhibitor targeting IL-6R has been given in some patients. The aim of our case study was to evaluate the therapeutic outcome of TCZ in non-responders to first line treatments with corticosteroids.

Methods

We conducted an observational study of patients with moderate to severe GO. Twelve patients received TCZ in intravenous infusions at a dose of 8mg/kg every 28 days for 4 months and followed up for additionally 6 weeks. The primary outcome was improvement in CAS by at least 2 points, 6 weeks after the last dose of TCZ. Secondary outcomes included CAS <3 (inactive disease) 6 weeks after TCZ last dose, reduced TSI levels, proptosis reduction by > 2mm and diplopia response.

Results

The primary outcome, was achieved in all patients 6 weeks after treatment course. Furthermore all patients had inactive disease 6 weeks after treatment cessation. Treatment with TCZ reduced significantly median CAS by 3 units (p=0.002), TSI levels by 11.02 IU/L (p=0.006), Hertel score on the right eye by 2.3 mm (p=0.003), Hertel score on the left eye by 1.6 mm (p=0.002), while diplopia persisted in fewer patients (25%) after treatment with TCZ (not statistically significant, p=0.250). After treatment with TCZ, there was a radiological improvement in 75% of patients, while 16.7% showed no response, and in 8.3% of patients deterioration was established.

Conclusion

Tocilizumab appears to be a safe and cost effective therapeutic option for patients with active, corticosteroid-resistant, moderate to severe Graves' orbitopathy.

Smoking Is Associated With a Higher Risk of Surgical Intervention for Thyroid Eye Disease in the IRIS Registry

PURPOSE

To describe the association of smoking status with surgical intervention for thyroid eye disease (TED) at the population-level.

DESIGN

Retrospective cohort study.

METHODS

This study included all adults (aged ≥18 years) with Graves disease in the Intelligent Research in Sight (IRIS) Registry (January 1, 2013, to December 31, 2020). The primary outcome was surgical intervention for TED, stratified into orbital decompression, strabismus surgery, and eyelid recession surgery. The Kaplan-Meier estimated 5-year cumulative probability for each surgical intervention was calculated. Multivariable Cox regression was used to evaluate the association between smoking status and each surgical intervention, adjusting for age, sex, race, ethnicity, and geographic region.

RESULTS

This study included 87,774 patients. Median age was 59 years (IQR, 48-68 years); 81% were female patients. Current smokers had a greater 5-year cumulative probability of orbital decompression (3.7% vs 1.9%; P < .001), strabismus surgery (4.6% vs 2.2%; P < .001), and eyelid recession (4.1% vs 2.6%; P < .001) compared to never smokers. After adjusting for demographic factors, current smokers were at greater risk for orbital decompression (hazard ratio [HR], 2.1; 95% CI, 1.8-2.4; P < .001), strabismus surgery (HR, 2.0; 95% CI, 1.8-2.3; P < .001), and eyelid recession (HR, 1.7; 95% CI, 1.5-1.9; P < .001) than never smokers. Former smokers were at higher risk for each type of surgery for TED, albeit at lower levels than current smokers.

CONCLUSIONS

Smoking was associated with increased risk of surgical intervention for TED in the IRIS Registry. Former smokers were at a lower risk than current smokers, supporting the role of smoking cessation on lowering the burden of surgical disease at the population-level.