Riedel's thyroiditis associated with Hashimoto's thyroiditis.
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Adult↗
Biomedical subjects
D S Ross
Publications and source records attributed to D S Ross.
Thyroid hormone suppressive therapy of sporadic nontoxic goiter.
Thyroid hormone has been used to reduce the size of sporadic nontoxic goiter since 1894. Noncontrolled clinical studies suggest that about two thirds of goiters respond to therapy, and a recent randomized clinical trial confirms the efficacy of suppressive therapy for sporadic nontoxic goiter. Efficacy is at least partly correlated with suppression of pituitary TSH production, response is usually evident by 3 months, relapse occurs when therapy is withdrawn, and nodular goiters may be less responsive than diffuse goiters. Some, but not all, series suggest that postoperative use of thyroid hormone suppressive therapy prevents recurrence of benign goiter. Three recent randomized trials suggest that thyroid hormone administered for 6 months to 3 years does not reduce the size of solitary thyroid nodules. About one third of nodules regressed in both treatment and placebo groups. Long-term studies are needed to define the effects of thyroid hormone suppressive therapy on the growth of goitrous lesions based on their underlying pathophysiology.
Goiter↗
Increased rat femur osteocalcin mRNA concentrations following in vivo administration of thyroid hormone.
Thyroid hormone has a direct resorptive effect on bone. Thyroid hormone therapy in doses that suppress pituitary TSH production result in a reduction in bone density. Osteocalcin is a bone matrix protein. Serum levels are a sensitive marker for bone turnover and are increased in hyperthyroid patients. In order to establish an animal model to study the effects of thyroid hormone on bone turnover, we measured rat femur osteocalcin mRNA following in vivo administration of thyroid hormone. Young CD rats weighing 60-90 g were given daily ip injections of T3, T4, or saline (control) for 12 days. Blood was obtained for radioimmunoassays, and RNA was extracted from femurs and analyzed by Northern blot using a 60-mer synthetic oligonucleotide probe corresponding to bases 360-420 of rat osteocalcin mRNA, labeled with [32P] ATP by 5'-end-labeling. Serum TSH concentrations were suppressed to subnormal levels by the lowest doses of T3 and T4, and to undetectable levels by the higher doses. Increases in serum T3 and T4 concentrations were proportional to the dose of each administered hormone. T3, 5 and 10 micrograms/100 g body weight, resulted in a 43% and 62% increase in osteocalcin mRNA, respectively. T4, 5, 10, and 20 micrograms/100 g body weight, resulted in a 35%, 47%, and 135% increase in osteocalcin mRNA, respectively. These data demonstrate that in vivo administration of either T4 or T3 to young rats results in a significant dose-dependent increase in femur osteocalcin mRNA concentrations.
Animals↗
Monitoring L-thyroxine therapy: lessons from the effects of L-thyroxine on bone density.
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Bone Density↗
Surgical palliation for pancreatic carcinoma.
A review of 122 patients treated for pancreatic adenocarcinoma from January 1978 through December 1984 was accomplished to determine patient survival and the effect of surgical palliation. One hundred patients underwent laparotomy, including biopsy only (n = 42), biliary bypass (n = 30), gastric bypass (n = 1), biliary and gastric bypass (n = 14), and curative resection (n = 13). Total patient median survival was 3.6 months and no patient lived 5 years. No significant difference in survival was found between the biliary bypass and combined biliary-gastric bypass groups. Only 1 of 30 patients (3.3%) undergoing biliary bypass alone without evidence of pre-operative gastric outlet obstruction developed late gastric outlet obstruction requiring gastrojejunostomy. Operative time and postoperative morbidity were greater in the biliary-gastric bypass group. These results do not support routine prophylactic use of gastrojejunostomy at the time of biliary bypass for patients with unresectable carcinoma of the pancreas.
Adenocarcinoma↗
Serum osteocalcin in patients taking L-thyroxine who have subclinical hyperthyroidism.
Serum osteocalcin, an index of osteoblastic activity, is increased in hyperthyroidism. Serum osteocalcin levels are negatively correlated with bone density in patients with overt hyperthyroidism. Osteocalcin levels are also elevated in patients with multinodular goiter and subclinical hyperthyroidism. We therefore measured serum osteocalcin levels in patients taking T4 to determine if they correlated with the degree of TSH suppression. Despite an upward trend in serum osteocalcin measurements with decreasing TSH concentrations, there was no significant difference in serum osteocalcin among groups of patients with normal (0.5-5.0 mu/L), mildly reduced (0.1-0.5 mU/L), or undetectable serum TSH (less than 0.01 mU/L). However, a weak negative correlation was seen between serum TSH and osteocalcin concentrations (r = 0.29, slope = -0.28, P less than 0.05). Osteocalcin did not correlate with either serum free T4 or free T3 concentrations. Serum PTH concentrations were not different among the three patient groups. Our data suggest that osteocalcin is not a useful clinical marker for increased bone turnover in patients with subclinical hyperthyroidism due to T4 therapy. However, the trend towards higher osteocalcin levels in patients with suppressed serum TSH values, and the weak negative correlation between serum TSH and osteocalcin are consistent with findings of reduced bone density in these patients.
Adult↗
Evaluation of the thyroid nodule.
The evaluation and management of thyroid nodules remains an area of controversy. The past decade has witnessed two important advances. The increased availability and acceptance of fine-needle aspiration biopsy of thyroid nodules has dramatically altered the clinician's approach to this disease, and provides for the single most precise method for selecting appropriate patients for surgery. The introduction of high-resolution thyroid ultrasonography provides for anatomic definition that is clearly superior to thyroid scintigraphy. However, radionuclide imaging of the thyroid remains critical for determining the functional status of abnormal thyroid tissue. While aspiration, ultrasound, and scintigraphy all have appropriate indications, utility, and limitations, no single test or group of tests substitutes for careful clinical assessment and follow-up. This review attempts to provide a practical approach to the evaluation and management of the thyroid nodule.
Biopsy, Needle↗
Malignant eccrine spiradenoma of the hand.
A malignant eccrine spiradenoma (MES) of the hand is described in a patient who developed bilateral pulmonary metastasis more than 10 years later. A review of the literature including observations on clinical behavior and recommendations for treatment of this rare adnexal tumor is presented.
Adenoma, Sweat Gland↗
Acute withdrawal of short-term or prolonged L-triiodothyronine administration to thyroidectomized rats results in similar rapid increases in TSH beta mRNA.
In man, following the treatment of hyperthyroidism, or the withdrawal of prolonged suppressive thyroid hormone therapy, recovery from thyrotrope suppression may not occur until thyroid hormone concentrations have been subnormal for several weeks. Short-term studies in rodents have demonstrated a rapid increase in TSH synthesis after the acute withdrawal of thyroid hormones. We treated thyroidectomized rats with supraphysiologic doses of 1-triiodothyronine (T3) for 67 days, then abruptly withdrew treatment and compared the time course of thyrotrope recovery to that in animals given T3 for only 10 days. Increases in TSH beta mRNA after abruptly stopping T3 were qualitatively similar in both groups. After short-term T3 administration, TSH beta mRNA was detectable on the second day after stopping T3 administration and rose an additional 10-fold by day 5. After prolonged T3 administration, TSH beta mRNA was barely detectable on the second day after stopping T3 administration, clearly detectable on the third day, and increased an additional 20-fold by day 7. Compared to animals who received T3 for only 10 days, suppression of the thyrotrope by T3 administration for 67 days resulted in a nonsignificant delay in TSH beta mRNA synthesis of 24 h or less following the abrupt withdrawal of thyroid hormone. It is possible that differences in rat and human thyrotrope responsiveness account for the apparently different biologic behavior.
Animals↗
Testosterone increases TSH-beta mRNA, and modulates alpha-subunit mRNA differentially in mouse thyrotropic tumor and castrate rat pituitary.
TSH, LH and FSH, the three pituitary glycoprotein hormones, are each composed of a common alpha-subunit and a hormone specific beta-subunit. Testosterone is known to regulate all three intact hormones differently in the rodent. However, there is only one gene encoding the common alpha-subunit. In order to elucidate the effects of testosterone on TSH subunit synthesis and its regulation of the common alpha-subunit, two in vivo models were studied: castrate rat pituitary was used as a gonadotropin-enriched tissue; and mouse thyrotropic tumor was used as a thyrotropin-enriched tissue. Male castrate rats were treated with testosterone propionate, 500 micrograms/100 g BW, sc, for 11 days. Testosterone increased plasma TSH to 131% of control values (P less than 0.02), while plasma LH fell to undetectable levels, and plasma alpha-subunit fell to 14% of control values (P less than 0.001). Testosterone increased TSH-beta mRNA to 237% of control values (P less than 0.02), while alpha-subunit mRNA fell to 20% of control values (P less than 0.001). Hypothyroid mice bearing thyrotropic tumors were treated with testosterone propionate, 150 micrograms/100 g BW, sc, for 11 days. In this model plasma TSH-beta and alpha-subunit concentrations are 1000-fold higher than in non-tumor bearing animals, and the contribution of pituitary gonadotropes to plasma subunit concentrations is negligible. "Total" TSH-beta and alpha-subunit concentrations were estimated as one-half of intact TSH plus the respective free subunit concentration.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
The use and limitations of a chemiluminescent thyrotropin assay as a single thyroid function test in an out-patient endocrine clinic.
A chemiluminescent TSH assay (detection limit, less than 0.01 mU/L) allows for accurate measurement of subnormal TSH concentrations. We retrospectively analyzed serum TSH and the free T4 (fT4) index of 460 consecutive endocrine clinic visits to determine the usefulness of TSH measurements alone in the assessment of thyroid function. Additionally, case histories were presented nonconsecutively to one of us (TSH alone or TSH with fT4) to determine if knowledge of the fT4 level would alter management. Of hypothyroid patients on replacement therapy (n = 127), 60% had concordant fT4 and TSH, 14% had subnormal TSH with normal fT4, 18% had high TSH with normal fT4, and 4% normal TSH with high fT4; only 4% were managed differently when the fT4 level was known in addition to TSH. Of the patients receiving suppressive therapy with TSH levels above 0.05 mU/L (n = 81), only 4% were managed differently when fT4 was known; 4% had high fT4. With TSH levels below 0.05 mU/L (n = 64), knowledge of fT4 was felt to be necessary for management in all cases; 53% had high fT4. Twenty-three of 46 (50%) patients being treated for hyperthyroidism had discordant TSH and fT4, including 7 patients with low TSH and low fT4. Two of 21 (10%) patients screened with pituitary/hypothalamic disease had discordant TSH and fT4, and 4 of 9 (44%) patients treated with L-T4 for secondary hypothyroidism had subnormal TSH. Knowledge of fT4 was felt to be necessary in all these cases. We conclude that TSH alone is sufficient for screening and monitoring L-T4 replacement or suppression therapy if TSH levels are above 0.05 mU/L. These patients account for the majority of visits to our endocrine clinic. TSH alone is misleading in pituitary disease and during the treatment of hyperthyroidism. fT4 is needed if TSH levels are less than 0.05 mU/L to assess the degree of hyperthyroidism.
Aged↗
Guidelines for therapeutic decision in incidental appendectomy.
Incidental appendectomy is contraindicated in patients whose conditions are unstable, patients previously diagnosed with Crohn's disease, patients with an inaccessible appendix, patients undergoing radiation treatment, patients who are pathologically or iatrogenically immunosuppressed and patients with vascular grafts or other foreign material. In patients ten to 30 years of age--the age group associated with a higher incidence of acute appendicitis--who are otherwise healthy, incidental appendectomy is effective in preventing morbidity and death associated with acute appendicitis. In patients 30 to 50 years of age, incidental appendectomy should be left to the discretion of the surgeon. In this age group, the physician should give special consideration to the gender of the patient and the desire for future childbirth. In patients more than 50 years of age, the incidence of acute appendicitis decreases and the risk associated with operation and prolonged anesthesia is such that an incidental appendectomy is not beneficial. In mentally handicapped patients less than 50 years of age and who are physically healthy, incidental appendectomy should be performed. An inversion technique should be used in all instances of incidental appendectomy. In otherwise clean cases in which incidental appendectomy is anticipated, prophylactic antibiotics may be of value. Patients undergoing procedures that may compromise access to the appendix in the future should undergo incidental appendectomy.
Adult↗
Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements.
Twenty-nine patients with necrotizing fasciitis were treated from 1980 to 1988. This study evaluates how the addition of hyperbaric oxygen (HBO) therapy to surgical treatment has affected mortality and the number of debridements required to achieve wound control in these patients. Two groups of patients were viewed: group 1 (n = 12) received surgical debridement and antibiotics only; group 2 (n = 17) received HBO (90 minutes at 2.5 atm, average 7.4 treatments) in addition to surgery and antibiotics. Both groups were similar in age, race, sex, wound bacteriology, and antimicrobial therapy. Body surface area affected was similar, however, perineal involvement was more common in group 2 (53%) than in group 1 (12%). The admitting conditions of patients in group 1 (non-HBO) were diabetic, 33%; white blood cell count more than 12,000, 50%; and shock, 8%. The admitting conditions of patients in group 2 (HBO) were diabetic, 47%; white blood cell count more than 12,000, 59%; and shock, 29%. Although group 2 patients receiving HBO were more seriously ill on admission, mortality was significantly lower (23%) compared to group 1 (66%) (p less than 0.02). In addition, only 1.2 debridements per group 2 patient were required to achieve wound control versus 3.3 debridements per group 1 patient (p less than 0.03). The addition of HBO therapy to the surgical and antimicrobial treatment of necrotizing fasciitis significantly reduced mortality and wound morbidity (number of debridements) in this study, especially among nonclostridial infections. We conclude that HBO should be used routinely in the treatment of necrotizing fasciitis.
Adolescent↗
Long-term management of differentiated thyroid cancer.
The surveillance and long-term management of patients with differentiated thyroid cancer are highly dependent upon the individual patient's risk for recurrent disease. A 30-year-old woman who presents with a 1-cm intrathyroidal papillary cancer requires minimal surveillance following primary therapy: yearly examinations and thyroglobulin measurements on L-thyroxine suppressive therapy, periodic chest radiographs, and initially, periodic neck ultrasound examinations if the right equipment is available. These should be sufficient to identify the unexpected neck or distant recurrence. A 65-year-old man who presents with a 4-cm follicular cancer invading the thyroid capsule and intrathyroidal blood vessels needs more extensive surveillance. In addition to chest radiographs, neck ultrasound studies, and serum thyroglobulin measurements while the patient is off L-thyroxine therapy, total-body 131I scanning should be done 12 months after remnant ablation, and even if no uptake is demonstrated, 131I scanning should be repeated at 24 or 60 months. Any patient who presents with grossly invasive or metastatic disease should be treated aggressively. If feasible, aggressive surgical treatment of recurrent disease is optimal and may be curative. 131I scanning and treatment may be repeated at 6- to 12-month intervals for slow-growing functional metastases. Rapidly growing metastases should be treated by external beam radiotherapy, which can follow surgical debulking, or be combined with radioiodine or chemotherapy. Unfortunately, chemotherapy is of limited value in late metastatic disease, however, rarely it results in prolonged remission.
Biopsy, Needle↗
The efficacy of preoperative computed tomography in patients with colorectal carcinoma.
A retrospective study was performed to evaluate and compare preoperative computed tomography (CT) scanning with less expensive tests that are used to identify hepatic metastases in patients with colorectal carcinoma. Thirty-three patients treated for colorectal carcinoma from January 1985 to December 1986 had preoperative CT scans performed as well as serum levels of lactose dehydrogenase (LDH), and carcinoembryonic antigen (CEA) measured. All patients underwent intraoperative evaluation of the liver. Only one patient had metastases found by CT exam that was not apparent at laparotomy. The sensitivity and specificity of the CT scan for detecting hepatic metastases were 1.00 and 0.96, respectively. The sensitivity and specificity of elevations in LDH or CEA when used in combination for detecting liver involvement was 1.00 and 0.54, respectively. Although the CT scan is effective in detecting hepatic metastases in patients with colorectal carcinoma we found that its routine use is unnecessary and expensive.
Aged↗
Chronic radiation enteritis: a community hospital experience.
A retrospective study was undertaken to evaluate the operative management of patients with chronic radiation enteropathy. Thirty-eight affected patients from 1974 to 1986 were reviewed. Patients with recurrent cancer responsible for symptoms were excluded. Seventy-one percent of patients presented with bowel obstruction. Twenty-one patients were treated with bowel resection, while 17 were treated with a bypass procedure or diverting ostomy alone. Overall morbidity was 45%, and postoperative mortality was 16%. Patients in the bypass group were significantly older than those in the resection group (70.3 vs. 55.5 years, P = .024), suggesting that age may have been a determinant of the procedure performed. In our study there was no difference in outcome based on preexisting vascular disease, tumor site, type of procedure performed, or radiation dose. We conclude that resection is the procedure of choice in cases of chronic radiation enteritis requiring surgery except in cases with dense adhesions when enteroenterostomal bypass is a viable alternative.
Enteritis↗
Incidentally discovered adrenal masses.
It is becoming increasingly common to discover adrenal masses incidentally on radiologic imaging studies. Adrenal masses are also occasionally found unexpectedly during operation. Herein, we review 10 cases of incidentally discovered adrenal masses which illustrate the experience with the treatment of these lesions in the past 8 years. A management plan based on this experience and a review of previously published data are discussed.
Adenoma↗
Reciprocal changes in parathyroid hormone and thyroid function after radioiodine treatment of hyperthyroidism.
Hyperthyroidism is associated with negative calcium balance, normal to increased serum calcium concentrations, and decreased cortical bone mass. There is no agreement concerning serum PTH levels in such patients. In this study, we measured serum PTH concentrations using a newly developed sensitive 2-site immunoradiometric assay in 17 hyperthyroid patients before and after radioiodine therapy. The mean serum PTH and calcium concentrations were 28 +/- 15 (+/- SD) ng/L (normal range, 12-65 ng/L) and 2.4 +/- 0.5 mmol/L (normal range, 2.1-2.6 mmol/L) before therapy. After therapy serum PTH concentrations increased in 16 of the 17 patients. The increase in serum PTH was greater in the 9 patients who became hypothyroid rapidly (29 +/- 15 to 75 +/- 29 ng/L) compared with that in the 8 patients who became euthyroid gradually (26 +/- 16 to 45 +/- 24 ng/L). Serum PTH rose along with TSH as the patients became hypothyroid after radioiodine, and both serum PTH and TSH fell when L-T4 therapy was given. The reciprocal changes in serum PTH concentrations and thyroid function over time suggest a strong association of bone mineral metabolism and thyroid status.
Adolescent↗