Clinical efficacy of Bupleurum inula flower soup for immune damage intervention in Hashimoto's thyroiditis: A placebo-controlled randomized trial

Background: Antibody-mediated humoral immune response is involved in the damage process in Hashimoto's thyroiditis (HT). Although the traditional Chinese medicine (TCM) formula bupleurum inula flower soup (BIFS) is often used in HT treatment, it has not been evaluated through high-quality clinical research. Rigorously designed randomized, double-blind, prospective clinical studies are urgently needed to evaluate BIFS for intervening in the HT immune damage process, and to improve clinical prognosis and patient quality of life. Methods: A prospective randomized, double-blind, placebo-controlled trial was used to evaluate the efficacy of BIFS. Fifty participants diagnosed with HT with hypothyroidism were randomly assigned at a 1:1 ratio to the BIFS (levothyroxine with BIFS) or control (levothyroxine with placebo) group. Participants received 8 weeks of treatment and were followed for 24 weeks. They were monitored for: levels of thyroid peroxidase antibody (TPOAb), thyroglobulin antibody (TgAb), and thyroid stimulating hormone (TSH); scores for depression, anxiety, and health-related quality of life (HRQoL); thyroid volume; safety indicators including routine blood tests, liver and kidney functions, and electrocardiogram; and levothyroxine dose. Results: Forty-eight participants completed the study and were included in the final analysis. At baseline, there were no significant between-group differences in the observed indicators (p > 0.05). Post-treatment, compared with the control group, the BIFS group had significantly lower levels of TPOAb (275.77 ± 132.98 vs. 441.78 ± 195.50, p = 0.001), TgAb (385.92 ± 281.91 vs. 596.17 ± 282.26, p = 0.013), and TSH (6.57 ± 3.73 vs. 9.63 ± 5.34, p = 0.001). Compared with the control group, the BIFS group's scores improved significantly for depression (47.00 ± 5.12 vs. 51.04 ± 3.22, p = 0.002), anxiety (43.21 ± 4.22 vs. 48.08 ± 2.81, p = 0.005), and HRQoL physical (62.08 ± 5.97 vs. 57.96 ± 4.71, p = 0.011) and psychological (60.17 ± 5.94 vs. 55.75 ± 7.09, p = 0.024) subscores. At 24-week follow-up, levothyroxine combined with TCM allowed a significantly reduced levothyroxine dose (0.58 ± 0.43 vs. 1.02 ± 0.45, p = 0.001). The post-treatment clinical efficacy rates differed significantly (p = 0.03), with 75% (18/24) for the BIFS group and 46% (11/24) for the control group. There were no significant between-group differences in thyroid volume or safety indicators after eight treatment weeks or at the 24-week follow-up (p > 0.05). Conclusion: The TCM BIFS can effectively reduce thyroid titer, relieve clinical and emotional symptoms, and improve HRQoL in patients with HT. Clinical Trial Registration: https://www.chictr.org.cn/, identifier ChiCTR1900020987.

Vitamin D categories and postpartum thyroid function in women with hypothyroidism

Objective

To analyze the related factors of the postpartum thyroid function in women with overt hypothyroidism (OH)/subclinical hypothyroidism (SCH) and explore the effects of vitamin D categories.

Methods

Thyroid hormones, thyroid autoantibody, and serum 25OHD levels were continuously recorded from the first trimester of pregnancy (T1) to the 12th postpartum month. Logistic regression analysis and Cox regression analysis were used to screen the related factors of postpartum thyroid function, and the Latent Class Growth Model was performed to analyze the trajectory characteristics of serum 25OHD levels.

Results

Totally, 252 pregnant women with OH/SCH were enrolled in the study. In the 12th month postpartum, 36.5% of the patients improved thyroid function, 37.3% continued hypothyroidism, and 26.2% developed thyroid dysfunction. Vitamin D sufficiency, positive TPOAb, and positive TgAb in T1 were independent prognostic factors of postpartum thyroid function. Vitamin D sufficiency in T1 was illustrated as an independent factor of the improved postpartum thyroid function, but the protective effect for the developed postpartum thyroid dysfunction was only confirmed in TPOAb-positive patients. Cox regression analysis further confirmed the effects of vitamin D categories. Notably, the high-level 25OHD trajectory during pregnancy and postpartum could predict improved postpartum thyroid function and decrease the risk of developed postpartum thyroid dysfunction.

Conclusion

Appropriate vitamin D nutrition during pregnancy and postpartum may be beneficial to postpartum thyroid function.

Effect of Occupational Extremely Low-Frequency Electromagnetic Field Exposure on the Thyroid Gland of Workers: A Prospective Study

OBJECTIVE

The aim of this study was to investigate the biological effects of occupational extremely low-frequency electromagnetic field (ELF-EMF) exposure on the thyroid gland.

METHODS

We conducted a prospective analysis of 85 workers (exposure group) exposed to an ELF-EMF (100 μT, 10-100 Hz) produced by the electromagnetic aircraft launch system and followed up on thyroid function indices, immunological indices, and color Doppler images for 3 years. Additionally, 116 healthy volunteers were randomly selected as controls (control group), the thyroid function of whom was compared to the exposure group.

RESULTS

No significant difference was observed in thyroid function between the exposure and control groups. During the follow-up of the exposure group, the serum free triiodothyronine (FT3) level was found to slowly decrease and free thyroxine (FT4) level slowly increase with increasing exposure time. However, no significant difference was found in thyroid-stimulating hormone (TSH) over the three years, and no significant difference was observed in the FT3, FT4 and TSH levels between different exposure subgroups. Furthermore, no significant changes were observed in thyroid autoantibody levels and ultrasound images between subgroups or over time.

CONCLUSION

Long-term exposure to ELF-EMF may promote thyroid secretion of T4 and inhibit deiodination of T4 to T3. ELF-EMF has no significant effect on thyroid immune function and morphology.

Association of serum irisin concentration with thyroid autoantibody positivity and subclinical hypothyroidism

OBJECTIVE

This study evaluated the association of serum irisin level with thyroid autoantibody (TAA) positivity and subclinical hypothyroidism (SH).

METHODS

In this cross-sectional study, 334 participants were assigned to one of the following four age- and sex-matched groups: TAA plus SH (84 patients), isolated TAA (83 patients), isolated SH (83 patients), or healthy controls (84 individuals). Irisin and creatine kinase (CK) were measured in serum samples.

RESULTS

Patients with TAA plus SH, isolated TAA, and isolated SH had higher irisin levels compared with the controls. There was a significant increase in the irisin level in the TAA plus SH group compared with the control group. Among all participants, the irisin levels were positively associated with thyroglobulin and thyroid peroxidase antibody titers and high-density lipoprotein cholesterol levels, but negatively associated with waist circumference, glycated hemoglobin levels, and fasting plasma glucose levels. The irisin level was not associated with the thyroid-stimulating hormone, free thyroxine, or CK levels. Irisin levels were independently associated with TAA, with or without SH, but they were not associated with SH alone.

CONCLUSIONS

Irisin level may help to predict the risk of developing TAA with or without SH.

Iron Deficiency, a Risk Factor of Thyroid Disorders in Reproductive-Age and Pregnant Women: A Systematic Review and Meta-Analysis

BACKGROUND

Iron deficiency (ID) is concerned as the most common nutritional deficiency worldwide. The effects of ID on thyroid function and autoimmunity in pregnant women and reproductive-age women are controversial. The aim of the current study was to summarize the evidences and evaluate the relationship between ID and thyroid disorders.

METHODS

In this systematic review and meta-analysis, studies published on the Cochrane, Embase, Medline, and PubMed databases by October 2020 were searched. A total of 636 studies which discussed the correlation between ID and thyroid disorders were eligible in the initial search. Pooled mean differences (MD) and 95% confidence intervals (CI) were calculated for the assessment of thyrotropin (TSH) and free thyroxine (FT4) levels. Combined odd ratios (OR) and 95% CI were calculated for the assessment of the prevalence of overt and subclinical hypothyroidism, positive thyroid peroxidase antibody (TPOAb), and thyroglobulin antibody (TgAb).

RESULTS

For women of reproductive age, ID could significantly increase the risk of positive TPOAb (OR: 1.89; 95% CI: 1.17, 3.06: P = 0.01) and both positive TPOAb and TgAb (OR: 1.48; 95% CI: 1.03, 2.11: P = 0.03). The meta-analysis of pregnant women showed that pregnant women with ID had increased serum TSH levels (MD: 0.12; 95% CI: 0.07, 0.17; P < 0.00001) and decreased FT4 levels (MD: -0.73; 95% CI: -1.04, -0.41; P < 0.00001). Meanwhile, the prevalence of overt (OR: 1.60; 95% CI: 1.17, 2.19; P = 0.004) and subclinical (OR: 1.37; 95% CI: 1.13, 1.66; P = 0.001) hypothyroidism in pregnant women with ID was significantly increased.

CONCLUSIONS

ID may adversely affect thyroid function and autoimmunity of pregnant and reproductive-age women and it is very necessary for monitoring iron nutritional status and early treatment of ID for them.

Urinary Iodine and Genetic Predisposition to Hashimoto's Thyroiditis in a Chinese Han Population: A Case-Control Study

Background: We aimed to examine the association of urinary iodine concentration with Hashimoto's thyroiditis (HT) risk, and particularly, to investigate whether the HT-related genetic variations might modify the effects of urinary iodine on HT in the Chinese Han population. Methods: We conducted a case-control study with 1723 Chinese (731 cases, 992 controls). The associations between urinary iodine concentration and HT risk were analyzed using logistic regression models. The effects of interactions between the genetic risk scores (GRSs) and urinary iodine on HT risk were assessed by including the respective interaction terms in the models. We also applied restricted cubic spline regression to estimate the possible nonlinear relationship. The multinomial logistic regression models were performed to determine the associations of urinary iodine with euthyroid-HT and hypothyroidism-HT. Results: After controlling for potential confounders, the odds of HT increased with increasing quartiles of urinary iodine concentration: adjusted odds ratios (ORs) and 95% confidence intervals [CIs] were 1.45 [1.06-1.99], 1.66 [1.17-2.34], and 2.07 [1.38-3.10] for the quartiles 2, 3, and 4, respectively, compared with the first quartile (p for trend <0.001). Multivariable restricted cubic spline regression analysis further demonstrated that there was a near-linear association between urinary iodine concentration and HT risk (p-overall <0.001; p-nonlinear = 0.074). However, we did not find significant interactions between urinary iodine and GRSs on the risk of HT (all p for interaction >0.05). Interestingly, we found that each increment of urinary iodine was associated with a more than twofold increase in the odds of hypothyroidism-HT (adjusted OR = 2.64 [CI = 1.73-4.05]), but not with euthyroid-HT (p > 0.05). Conclusions: Higher urinary iodine concentration was associated with increased risk of HT, and this association was near linear, indicating that increased urinary iodine has a continuous and graded impact on HT risk. Moreover, the iodine-HT association was not modified by genetic predisposition to HT. Interestingly, urinary iodine concentration was significantly associated with increased risk of hypothyroidism.

The prevalence of thyroid autoantibodies in autoimmune connective tissue diseases: a systematic review and meta-analysis

AIM

Patients with autoimmune connective tissue disease (ACTD) may have anti-thyroid peroxidase antibody (TPOAb) and anti-thyroglobulin antibody (TgAb). This study aimed to compare the prevalence of thyroid autoantibodies in ACTD patients and controls.

METHODS

All case-control studies published between 1980 and 2019 in English were searched from Medline, Embase, Web of Science, PubMed databases for meta-analysis and subgroup analyses.

RESULTS

Total 10,321 ACTD cases and 12,949 healthy controls were included, and the prevalence of thyroid autoantibody positivity was higher in ACTD patients than in controls. Subgroup analysis revealed positive association between TgAb and ACTD in populations from all continents including European, Asian, African, and American. In addition, we found positive association between TgAb positivity and most ACTD cases including RA, SLE, pSS, and UCTD, positive association between TPOAb positivity and all ACTD cases including RA, SLE, pSS, SSc, and UCTD, and positive association between TPOAb positivity and ACTD in European, Asian, and African but not in American populations.

CONCLUSION

Thyroid autoantibodies are more prevalent in ACTD patients than in healthy controls. It is important to screen patients with ACTD for the presence of thyroid autoimmunity, and perform thyroid function tests in clinical evaluation of ACTD patients.

Serum cystatin C is closely associated with euthyroid Hashimoto's thyroiditis in adult female Chinese patients

Objective

The aim of our study was to explore the association between serum cystatin C (CysC) and euthyroid Hashimoto’s thyroiditis.

Methods

There were 119 female euthyroid Hashimoto’s thyroiditis patients and 225 healthy controls who were recruited. Serum CysC, thyroid function, thyroid autoantibodies, fasting glucose, liver enzymes, and lipid profile were determined. Clinical parameters were compared between two groups.

Results

Serum CysC levels were significantly higher in euthyroid Hashimoto’s thyroiditis patients compared with controls. In the lowest, middle, and highest tertile groups of CysC, the percentage of Hashimoto’s thyroiditis was 15.9%, 34.2%, and 53.5%, respectively. The percentage of Hashimoto’s thyroiditis was significantly higher in the highest tertile than in the lowest and middle tertiles. Spearman’s correlation analysis showed that serum CysC levels were negatively correlated with free triiodothyronine (FT₃), and positively correlated with serum thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TGAb). Logistic regression analysis showed that serum CysC was independently related to the status of euthyroid Hashimoto’s thyroiditis.

Conclusions

The present study shows the first evidence suggesting that serum CysC levels are positively correlated with TPOAb and TGAb. Serum CysC might underlie the pathophysiologic features of euthyroid Hashimoto’s thyroiditis.

Thyroid autoantibodies in pregnancy are associated with hypertensive disorders of pregnancy: Ma'anshan Birth Cohort Study

OBJECTIVE

Hypertensive disorders of pregnancy (HDP) have been associated with adverse health outcomes for both mothers and children. Previous studies examining associations of maternal thyroid autoantibodies with HDP indicate conflicting results. The objective of this study was to examine associations of maternal thyroid autoantibody positivity in the first and the second trimesters with the risk of HDP.

DESIGN, PARTICIPANTS AND MEASUREMENTS

In the Ma'anshan Birth Cohort study, a population-based prospective study in China, a total of 3474 pregnant women were enrolled between May 2013 and September 2014. Thyroid autoantibodies, including antithyroperoxidase autoantibody (TPOAb) and antithyroglobulin autoantibody (TgAb), as well as thyroid function tests, were measured in both the first and the second trimesters in 2893 pregnant women. Multivariate logistic regression analyses were conducted to calculate the odds ratio (OR) and 95% confidence interval (CI) for the associations between thyroid autoantibodies and HDP.

RESULTS

Multivariate logistic regression analyses showed that TPOAb positivity in the first trimester was associated with a 1.80 (95% CI = 1.17-2.78) increased odds of HDP after adjustment for confounders, which was mainly due to an increased risk of gestational hypertension (OR = 1.93, 95% CI = 1.17-3.18). In addition, TgAb positivity in the first trimester was associated with a higher risk of HDP (OR = 1.78, 95% CI = 1.16-2.73) after adjustment for confounders, which was mainly due to an increased risk of gestational hypertension (OR = 1.89, 95% CI = 1.15-3.11). These associations were also seen among euthyroid women. Women with positive TPOAb in the second trimester seemed to have a higher risk of gestational hypertension (OR = 1.87, 95% CI = 1.02-3.43) after adjustment for confounders. However, among euthyroid women, TPOAb positivity in the second trimester was not associated with HDP. The TgAb status in the second trimester was not associated with HDP.

CONCLUSIONS

Our results show that TPOAb positivity and TgAb positivity in the first trimester are associated with an increased risk of HDP. These data demonstrate that these associations are even seen among euthyroid women.

Thyroid Autoantibodies and the Clinical Presentation of Moyamoya Disease: A Prospective Study

BACKGROUND

Moyamoya is a rare cerebrovascular disease characterized by the progressive occlusion of the intracranial carotid artery. Thyroid autoantibodies have been found to be associated with the disease, but their clinical significance has never been studied. The objective of this study was to investigate the relationship between thyroid autoantibodies and the clinical presentation of moyamoya.

METHODS

This is a prospective study including 37 patients with moyamoya disease (MMD) or unilateral moyamoya (uMM). Thyroid function and thyroid autoantibodies (e.g., antithyroperoxidase and antithyroglobulin) were investigated. We studied the effect of gender, age, type of moyamoya (uMM versus MMD), and thyroid autoantibodies on the clinical presentation, dichotomized into aggressive (hemorrhage, major stroke, or frequent transient ischemic attack [TIA]) and nonaggressive presentation (headache, rare TIAs, and incidental diagnosis) according to the criteria of the Research Committee on Spontaneous Occlusion of the Circle of Willis.

RESULTS

Of the 37 patients included in the study, the autoantibodies were elevated in 9 (24.3%). An aggressive presentation occurred in 21 patients (hemorrhage in 11, major stroke in 9, frequent TIAs in 1). The autoantibodies were elevated in 8 of the 21 patients (38.09%) with an aggressive presentation and in 1 of those presenting with minor symptoms (6.2%). The presence of elevated autoantibodies was the only variable associated with an aggressive presentation in the multivariate logistic analysis (P = .048).

CONCLUSIONS

When the serum concentration of the thyroid autoantibodies is increased, the patients have a higher risk of an aggressive presentation. Our results support the hypothesis that activation of immune-mediated processes affects the moyamoya physiopathology.

Clinical Implications of Immunoglobulin G4 to Graves' Ophthalmopathy

BACKGROUND

This study aimed to explore the relation of immunoglobulin G4 (IgG4) to clinical and laboratory characteristics of patients newly diagnosed with Graves' disease (GD) without or with Graves' ophthalmopathy (GO) and to analyze association of IgG4 with development and grade of GO in GD patients.

METHODS

Sixty-four GD patients and 64 sex- and age-matched euthyroid subjects were enrolled. Serum levels of thyroid hormones, thyroid autoantibodies, immunoglobulin G (IgG), and IgG4 were measured, and ophthalmological and ultrasonographical evaluation was performed.

RESULTS

In GD patients compared with euthyroid subjects, levels of thyroid hormones, thyroid autoantibodies and IgG4 as well as the IgG4/IgG ratio were elevated. GD patients having GO in comparison to not having GO were characterized by a female predominance; a high incidence of smoking history; high levels of T3, free T4, TSH receptor autoantibody (TRAb) and IgG4; and a high IgG4/IgG ratio after adjusting for sex. In GD patients, the IgG4 level was the independent factor associated with GO development on multivariate analysis. When severity and activity of GO were classified using the European Group on Graves' Orbitopathy criteria in GD patients with GO, IgG4 levels and IgG4/IgG ratio were elevated in the moderate-to-severe group compared with the mild group and in the active group compared with the inactive group. IgG4 levels and IgG4/IgG ratio became elevated as clinical activity score increased. IgG4 levels were positively correlated with TRAb levels. The high IgG4 group in comparison to the normal IgG4 group had a high incidence of family history of autoimmune thyroid disease, high levels of free T4, TRAb and IgG4, a high IgG4/IgG ratio and extensive hypoechogenicity.

CONCLUSIONS

These results suggest that IgG4 levels are elevated in newly diagnosed GD patients compared with euthyroid subjects and in the presence of GO compared with the absence of GO. Moreover, our findings suggest that IgG4 levels are associated with the development and grade of GO in GD patients.

The Relationship of TPOAb and TGAb with Risk of Thyroid Nodules: A Large Epidemiological Study

Objective: The association between thyroid hormones, thyroid autoantibodies, and thyroid nodules are still not clear. The cross-sectional study, conducted in Hangzhou, China in 2010, aimed to identify the relationship of thyroid hormones and autoantibodies with thyroid nodules. Methods: Information regarding social demography was collected by a questionnaire. Thyroid hormones (triiodothyronine, thyroxin, free triiodothyronine, free thyroxin, thyrotropin), thyroid autoantibodies (thyroid peroxidase antibody, antithyroglobulin antibody), and thyroid nodules (diagnosed by ultrasonography) was measured in 1271 adults. The association of thyroid hormones and thyroid autoantibodies with thyroid nodules was evaluated using multiple logistic regression models. Results: The prevalence of thyroid nodules among males and females was 29.49% and 33.15%, respectively. The thyroid hormone level in the thyroid nodules group was significantly higher than the non-nodules group (all p values < 0.05), except reversely in TSH (thyroid stimulating hormone) (p = 0.0532) and TGAb (thyroglobulin antibody) (p = 0.0004). High levels of TPOAb (thyroid peroxidase antibody) (OR (Odds Ratio) = 1.51, 95% CI (confidence interval): 0.99–2.30) and TGAb (OR = 2.86, 95% CI: 1.49–5.51) were associated with increased risk of thyroid nodules, compared with corresponding low levels. However, following sub-analyses in two genders, the similar associations were only observed in females (TPOAb: OR = 1.63, 95% CI: 0.99–2.68; TGAb: OR = 3.13, 95% CI: 1.53–6.40). Conclusions: The present study indicated that thyroid autoantibodies were positively associated with the risk of thyroid nodules in Chinese coastal adults.

Thyroid Autoantibody Positive Anti-N-Methyl-D-Aspartate Receptor Encephalitis

Background

Hashimoto's encephalopathy (HE) and anti N-methyl-D-aspartate receptor (NMDAR) encephalitis have clinical overlaps.

Case Report

A 70-year-old woman presented with acutely developed confusion, disorientations and psychosis. HE was suspected based on goiter, markedly elevated anti-thyroglobulin and anti-thyroid peroxidase antibody. She was placed on high dose steroid and intravenous immunoglobulins administration, which did not ameliorate her symptoms. After the antibodies to the NMDAR were identified, weekly 500 mg of rituximab with 4 cycles were started. The current followed up indicated a complete recovery.

Conclusions

The possible associations between NMDAR antibody and autoimmune thyroid antibodies in anti-NMDAR encephalitis with positive thyroid autoantibodies remain unclear. However, a trend toward a higher incidence of NMDAR antibody in patients with autoimmune thyroid antibodies than without has been observed. Cases of encephalitis with only NMDAR antibody (pure anti-NMDAR encephalitis) also occur. Therefore, it is important for clinicians to know the clinical and pathogenic differences between anti-NMDAR encephalitis with positive thyroid autoantibody and pure anti-NMDAR encephalitis for relevant treatment, predicting prognosis, and future follow-up.

The prevalence of antithyroid autoantibodies in normal Korean population--age, sex distribution and its relation to thyroid function

The prevalence of antithyroid autoantibodies and the relationship between the presence of autoantibodies and thyroid functions were studied in 848 apparently normal Korean adults with tanned red cell agglutination technique. Results are summarized as follows: 1) The prevalence of antimicrosimal antibody (MCHA) and antithyroglobulin antibody (TGHA) were 4.4% and 1.9% in 458 males, and 12.4% and 5.0% in 390 females, respectively. Both autoantibodies were more prevalent in female (p<0.001, p<0.01). 2) The age-specific prevalence of MCHA was 4.0% in their twenties, 10.1% in their thirties, 12.5% in their forties, 12.0% in their fifties, 8.3% over sixty, and those of TGHA were 2.0% in their twenties, 3.0% in their thirties, 7.0% in their forties, 4.2% in their fifties, 2.5% in subjects over sixty, respectively. Both showed maximal values around forty and fifty and tended to be lower thereafter. 3) Mean T₃, T₄ and TSH values of high titer group (⩾1:100²) (n=32) were 125 ± 20.6 ng/dl, 9.1 ± 1.7μg/dl and 4.0 ± 1.8 uU/ml, and those of low titer group (<1:100²) (n=44) were 134 ± 24.3 ng/dl, 9.6 ± 1.7 ug/dl and 3.2 ± 1.2 νU/ml. T₃ was lower and TSH, higher in high titer group than in low titer group (p<0.05, p<0.05), and no significant difference was observed in T₄ level (p<0.1). In conclusion, the prevalence of MCHA and TGHA were higher in apparently normal females than in males with their peaks around forty and fifty, being lower thereafter, and antithyroid autoantibody of high titer (⩾1:100²) was related to alteration of thyroid functions suggesting the existence of “subclinical autoimmune thyroiditis” state.