Factors Predicting Time to TSH Normalization and Persistence of TSH Suppression After Total Thyroidectomy for Graves' Disease

Radiofrequency Ablation for Solitary Autonomously Functioning Thyroid Nodules: Multicenter Study from Latin America

Background: Autonomously functioning thyroid nodules (AFTNs) represent ∼5% of all thyroid nodules and often necessitate definitive treatments such as surgery or radioiodine (131I), both of which have inherent risks. Radiofrequency ablation (RFA) has emerged as an effective and safe therapeutic option for managing AFTNs. This study aims to assess the effectiveness and safety of RFA for solitary AFTNs in various countries across Latin America. Methods: This retrospective, observational, multicenter cohort study included patients with a solitary AFTN that was histologically confirmed as benign and treated with a single session of RFA. The study included an analysis of patient demographics, sonographic characteristics of the nodules, thyroid profile assessment at each follow-up visit, evaluation of clinical symptoms to determine the achievement of a euthyroid state, and the measurement of nodule volume reduction. In addition, a bivariate analysis was conducted to identify associations between these variables and the resolution of hyperthyroidism. Results: Our study enrolled 81 patients with a solitary, benign AFTN. The volume reduction ratio (VRR) consistently increased over the follow-up period, with medians of -50%, -74.9%, -78.4%, and -90.2% at 1, 3, 6, and 12 months, respectively. The rate of resolution of hyperthyroidism was 93.8% (76/81). Following the RFA procedure, 58.02% of patients (47/81) normalized their thyrotropin levels within 1 month of follow-up, and by 3 months, an additional 33.3% had achieved normalization (27/81). Notably, a baseline volume ≥10, 20, or 30 mL did not affect the achievement of clinical success. In bivariate analyses, a VRR ≥50% at the 6-month follow-up was associated with the resolution of hyperthyroidism. Overall complications occurred in 6.2% of patients (5/81), including 1.2% (1/81) of a major complication (transient Horner syndrome), 3.7% cases of transient dysphonia (3/81), and 1.2% (1/81) of hypothyroidism requiring low-dose levothyroxine replacement. Conclusions: The results of this multicenter study suggest that RFA is a promising treatment option for patients with solitary AFTN, regardless of their baseline characteristics, including volume, age, or composition. The clinical success of the intervention may be related to the VRR at 6 months.

Computer-Assisted Levothyroxine Dose Selection for the Treatment of Postoperative Hypothyroidism

Background: Thyroid hormone replacement with levothyroxine (LT4) is a recommended treatment for patients undergoing thyroidectomy. The starting LT4 dose is frequently calculated based on the patient's weight. However, the weight-based LT4 dosing performs poorly in clinical practice, with only ∼30% of patients achieving target thyrotropin (TSH) levels at the first thyroid function testing after treatment initiation. A better way to calculate the LT4 dose for patients with postoperative hypothyroidism is needed. Methods: In this retrospective cohort study we used demographic, clinical, and laboratory data for 951 patients after thyroidectomy and several regression and classification machine learning methods to develop an LT4 dose calculator for treating postoperative hypothyroidism targeting the desired TSH level. We compared the accuracy with the current standard-of-care practice and other published algorithms and evaluated generalizability with fivefold cross-validation and out-of-sample testing. Results: The retrospective clinical chart review showed that only 285/951 (30%) patients met their postoperative TSH goal. Obese patients were overtreated with LT4. An ordinary least squares regression based on weight, height, age, sex, calcium supplementation, and height:sex interaction predicted prescribed LT4 dose in 43.5% of all patients and 45.3% of patients with normal postoperative TSH (0.45-4.5 mIU/L). The ordinal logistic regression, artificial neural networks regression/classification, and random forest methods achieved comparable performance. LT4 calculator recommended lower LT4 doses to obese patients. Conclusions: The standard-of-care LT4 dosing does not achieve the target TSH in most thyroidectomy patients. Computer-assisted LT4 dose calculation performs better by considering multiple relevant patient characteristics and providing personalized and equitable care to patients with postoperative hypothyroidism. Prospective validation of LT4 calculator performance in patients with various TSH goals is needed.

In silico dose adjustment of levothyroxine after total thyroidectomy using fuzzy logic methodology: A proof-of-concept study

Thyroid hormone replacement therapy is used to raise undesirably low concentrations of natural thyroid hormones, commonly by administrating levothyroxine (LT4). Finding the appropriate LT4 dose regime, particularly for patients undergone thyroidectomy, is still demanding more effort, and much research has been conducted. Providing a new fuzzy logic system, a useful control algorithm, we aim to introduce a proper LT4 dosing regimen for every thyroidectomized patient in a computerized environment. Consequently, we contrast the differences between our proposed dose regime and conventional monotherapy methods using THYROSIM, a thyroid simulation application. Considering our nine defined comparative criteria, results reveal that the FLS dose regime is dominant in terms of six indexes, while the discrepancies are not noticeable in the other three indexes. A great superiority of FLS dose regime is its ability to reduce the time to reach desirable thyrotropin (Thyroid Stimulating Hormone, TSH) serum concentration to 6 days post-thyroidectomy, and keep the T4, T3, and TSH values in the normal window afterward. The proposed FLS could be an applicable decision support system for physicians as they can define their intended Individual Target Value of TSH for each patient to optimize LT4 dose adjustment.

Graves' disease induced by Alemtuzumab in relapsing-remitting multiple sclerosis patients: an observational study in a reference center

OBJECTIVES

Graves' disease induced by Alemtuzumab (GD-IA) is one of the most frequently observed adverse events in patients with multiple sclerosis (MS) treated with this drug. The aim of this study is the sequencing and description of these events, along with the identification of the risk factors leading to their development.

MATERIALS AND METHODS

We conducted a retrospective observational study identifying patients with relapsing-remitting multiple sclerosis (RRMS) and GD-IA, studying their baseline clinical features and variables related to the natural history of the disease.

RESULTS

A total of 121 participants treated with Alemtuzumab were included, of whom 41 developed GD-IA (33.9%). A higher percentage of first-degree relatives with autoimmune thyroid disease was documented in the subgroup who developed the abovementioned event (14.6% vs 1.5%; p < 0.01). A total of 70.7% of patients diagnosed with GD-IA (n = 29/41) had fluctuations in thyroid function during follow-up, and 24.4% (n = 10/41) required total thyroidectomy for resolution of the condition. In 54.8% of participants diagnosed with GD-IA, a pattern of significant TSH decline was identified in the month prior to diagnosis of the event, with high predictive ability and associated with a more favorable clinical course (fewer weeks to normalization of thyroid function, HR = 8.99; 95% CI [2.11-38.44]; p = 0.0003).

CONCLUSION

GD-IA has an atypical course compared to classical forms of the disease. The identification of risk factors for the development of the disease before starting treatment with Alemtuzumab and early monitoring of thyroid function once this treatment is initiated prove to be useful strategies in the diagnosis and clinical management of this condition.

Analytical validation of the LiCA® high-sensitivity human thyroid stimulating hormone assay

BACKGROUND

We aimed to assess the analytical characteristics of a new high-sensitivity human thyroid stimulating hormone (hTSH) assay on a light-initiated chemiluminescent immunoassay system (LiCA Smart) and examine the utility of this assay in the context of profoundly low TSH levels (<0.01 mIU/L).

METHODS

Analytical validations included precision, linearity, reportable range, analytical sensitivity, interference, reagent lot-to-lot and between-instrument variability, and method comparisons. Additionally, a cross-sectional study was performed to evaluate the assay for the detection of profoundly low TSH levels in comparison to those of two other ultrasensitive hTSH assays.

RESULTS

Within-run and within-lab imprecisions (%CV) were < 5% at all concentrations studied. A satisfactory linearity (R = 0.998, change in recovery < 5%) was verified over the entire measuring range. Method comparisons demonstrated a reasonable agreement (R > 0.99, median bias < 5%) between LiCA and Cobas, ADVIA, UniCel or Architect. The limit of quantitation was 0.0019 mIU/L. Comparative measurements of 236 patient samples with profoundly low TSH levels (<0.01 mIU/L) by LiCA, Cobas, and Architect revealed that the detection rate observed with LiCA (67.8%) was significantly higher than that with Cobas (28.0%) or Architect (21.7%). In a further comparative follow-up of patients with overt hyperthyroidism who were receiving treatment, an earlier recovery response of TSH was observed in LiCA.

CONCLUSIONS

The LiCA Smart hTSH is a precise and highly sensitive fourth-generation assay. The assay demonstrated superior detection sensitivity for profoundly low TSH levels and was acceptable for clinical use.

Comparison of long-term antithyroid drugs versus radioactive iodine or surgery for Graves' disease: A review of the literature

BACKGROUND

The management of Graves' disease (GD) in the US is shifting towards increased use of anti-thyroid drugs (ATD). If patients fail to achieve remission after a standard course of therapy of 12-18 months, long-term treatment with ATD (≥24 months) may be chosen over definitive therapy with radioiodine (RAI) or surgery. Clinicians will need to contrast this strategy to ablative therapies as they help patients in decision making.

SUMMARY

Review of the literature illustrates that long-term ATD delivers euthyroidism with minimal complications, low financial cost and with an advantageous profile regarding quality of life (QoL) and other biological outcomes.

CONCLUSIONS

Long-term ATD is a viable alternative to ablative therapies in the management of GD offering advantages across multiple patient centred outcomes. Decision making must factor differences in this approach compared to ablative therapies and ultimately be tailored to individualized patient situations.

Effectiveness of Pharmacological Agents and Validation of Diagnostic Scales for the Management of Paroxysmal Sympathetic Hyperactivity in Hispanics

The identification and treatment of paroxysmal sympathetic hyperactivity (PSH) still present a significant challenge. We assessed the efficacy of pharmacological agents in treating PSH symptoms and the validity of the diagnostic scales in a cohort of Hispanic patients. A retrospective chart review of cases from a single hospital was conducted in 464 records. Exclusion criteria included underlying conditions such as severe infection. Only nine patients remained in the cohort after examining their clinical records, corresponding to the following diagnoses: traumatic brain injury, subdural hemorrhage, anoxic or ischemic encephalopathy, pneumocephalus, and cerebral palsy. Using the PSH likelihood scale, six of the nine patients were identified with a score of 17 or higher, corresponding to a "probable" PSH, and three patients obtained a score between 8 and 16, corresponding to a "possible" PSH diagnosis. The top three classes of medications used were beta-blockers, antipyretics, and opioids. Benzodiazepines and neuromodulators were also frequently used in patients with trauma, but not in the ones with non-traumatic injuries. Interestingly, 75% of the patients have prescribed levothyroxine as a home medication after the PSH presentation. Medication administration did not follow a specific pattern, suggesting high variability in the management of PSH within our setting, requiring further research. Our results suggest that the pituitary axis might be involved in the progression of PSH. Establishing a specific medical code (e.g., ICD-10) describing PSH as a single entity is essential for appropriate identification and management.