Maternal and fetal thyroid profiles differ throughout gestation. Due to many physiological changes during pregnancy, interpretation of thyroid function tests needs trimester specific reference intervals. American Thyroid Association strongly recommends to refer to population defined trimester-specific reference ranges with optimal iodine intake Though some studies have reported this reference range in South and a few in North, there has been no data from Central India yet. Aims and Objectives: To establish normative range of TSH in each trimester of pregnancy, To establish normative range of f T3 and f T4 in each trimester of pregnancy and to know the prevalence of subclinical hypothyroidism in normal pregnancies. Materials and Methods: in all 177 normal singleton pregnant women were screened and out of them 150 enrolled in the study(50 in each trimester). Their TSH, fT3, fT4 and urinary iodine was estimated. Observations and Results: The reference range of thyroid hormones for 1st trimester found in the present study are as follows: TSH: 0.24-4.17 (uIU/ml), fT3: 0.29-3 .1 (ng/100 ml), fT4: 01-2.2 (ng/100 ml). For 2 ^nd trimester: the reference range for TSH , fT3 and fT4 are 0.78-5.67 (uIU/ml) , 0.27-3.34(ng/100 ml) ,and 0.45-2.24 (ng/100 ml) respectively. For 3 ^rd trimester, the reference range for TSH , fT3 and fT4 are 0.47-5.78 (uIU/ml), 0.24-3.61(ng/100 ml) and 0.47-5.1 (ng/100 ml). Prevalence of subclinical hypothyroidism was found to be 4% in first and second trimesters and 8% in third trimester. No case was seen with clinical hypothyroidism. Conclusion: This study states the range of thyroid hormones in all 3 trimesters of pregnancy. The prevalence of subclinical hypothyroidism was found out to be 4% in first and second trimesters each and 8% in third trimester.

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Thyroid hormone is required for the normal growth and maturation of the skeleton. The action of thyroid hormone on skeleton is varied, including direct chondrocyte and osteoblast stimulation, as well as potentiating the action of growth hormone on the bone. Juvenile hypothyroidism is evolving as the most common form of thyroid dysfunction in the growing age, and it has different radiological manifestations from that of congenital hypothyroidism. We present the skeletal X-rays of a 24-year-old man with juvenile onset autoimmune hypothyroidism (duration of illness of approximately 16 years), who came for evaluation of short stature.

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Objectives: To review the cytohistological features of 14 cases of thyroglossal duct cyst (TDC), to ascertain the role of fine needle aspiration cytology (FNAC) in the diagnosis and treatment, and to discuss the diagnostic pitfalls. Materials and Methods: FNAC of 14 patients of TDC diagnosed clinically and by ultrasound examination of neck was studied. Cytology features were correlated with histopathologic features. Results: Cytology smears showed most commonly few macrophages (n = 7), followed by polymorphonuclear leukocytes (n = 4). One case showed few small sheets and many dispersed follicular cells showing features suspicious of papillary thyroid carcinoma (PTC). Histopathology showed pseudostratified columnar and cuboidal epithelium (n = 6) in maximum cases and confirmed PTC in one case. Conclusion: Imaging techniques or FNAC alone is not adequate for pre-treatment assessment of all TDC cases. All TDC patients must be subjected to image-guided FNAC for early and accurate diagnosis of TDC carcinoma for timely clinical intervention.

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Autoimmune polyendocrine syndrome II (APS II) is defined as Primary adrenal insufficiency with Autoimmune hypothyroidism and/or Type 1 Diabetes. Hypothyroidism is commonly diagnosed but adrenal insufficiency often gets missed out. Levothyroxine replacement before glucocorticoid replacement in a patient APS II can lead to precipitation of adrenal crisis. We report a case of Autoimmune polyendocrine syndrome type II (Schmidt syndrome) who presented to us in adrenal crisis after having started on Levothyroxine without glucocorticoid replacement.

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Chronic autoimmune thyroiditis is the most common cause of hypothyroidism worldwide. Sometimes, it is associated with a transient hyperthyroid phase. This hyperthyroid phase, called Hashitoxicosis (the term generally refers to a combination of thyrotoxicosis/hyperthyroidism in the setting of ongoing autoimmune thyroiditis), is self limiting, and lasts for a period of a few weeks to some months. During this time, classical symptoms of mild to moderate hyperthyroidism may co-exist with a diffuse, firm, painless goiter. Thyroid scintigraphy may show normal or a slightly increased uptake. Anti-thyroid antibodies are often positive, and ultrasound with Doppler is a useful test. A combination of clinical features, thyroid function tests, and appropriate radiology will help make the diagnosis. This mini review will touch upon the clinical aspects of Hashitoxicosis.

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Neurological sequelae such as neuromuscular or primary muscle disorders are well recognized complications of hyperthyroidism. However, the association of neuropathy with thyrotoxicosis is uncommon. Thyrotoxic neuropathy or Basedow's paraplegia is a rarely reported entity, which was first described by Charcot in 1889. We are reporting the case of a middle-aged man with subacute distal neuropathy as the presenting manifestation of thyrotoxicosis which improved on antithyroid treatment. Peripheral neuropathy in hyperthyroidism is underdiagnosed and may be found even in patients with mild thyrotoxicosis. Thyroid function tests can be helpful in the diagnosis of this treatable neuropathy in such cases and hence should be included in the routine workup in patients with peripheral neuropathy.

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Background: Association studies between the vitamin D deficiency (VDD) and hypothyroidism have given mixed results. Because of this controvery and relatively common prevalence of these two conditions, we conducted a case-control study investigating the prevalence of VDD in patients with hypothyroidism (both TPO-Ab positive and negative) and compared it with euthyroid controls. Methodology: This is a single centre cross sectional study. Adults (aged 18 years or more) of both the sexes diagnosed with primary hypothyroidism (TSH >5.1 mIU/L) were included (n = 115) along with age and sex matched euthyroid (TSH <5 mIU/ml) controls (n = 120) chosen from the outpatients' department. Biochemical parameters like Thyroid stimulating hormone (TSH), free T4 (fT4), 25 hydroxy vitamin D (Vit D) and thyroid peroxidase antibody (TPO-Ab) were tested in both the groups. Results: Patients in the hypothyroid group [38 (males) and 77 (females)] had a mean (SD) age 46 (15) years, while the euthyroid control group [24 (males) and 96 (females) had a mean (SD) age of 45 (17) years. In the hypothyroid group, 96% (110/115) had VDD as compared to 90% (108/120) in the control group with a significantly lower mean Vit D level was observed in the hypothyroid group as compared to the euthyroid group (12+8.6 vs 17.49+11.89 ng/ml; P < 0.001). While 27 cases with hypothyroidism had severe VDD (Vit D levels <4.2 ng/ml) only 10 among the control group had severe VDD (OR 2.04, CI: 1.03-4.05, P < 0.05)). The mean level of Vit D in the TPO-Ab positive hypothyroid group was 10.4+7.2 ng/ml in comparison to the TPO-Ab negative group 15.3+10.3 (P = 0.004) (OR 3.39, CI:1.18-9.80; P < 0.05) 3.62). Conclusion: The vitamin D levels in patients with hypothyroidism were significantly lower compared to euthyroid controls.TPO-Ab positive patients had lower levels of vitamin D in comparison with negative

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Insulin-like growth factor 1 (IGF-1) regulates growth. 1,250HD _{3((1,25 dihydroxy vitamin D3)} promotes IGF-1 action, hence vitamin D deficiency may impair growth. This retrospective study showed that vitamin D supplementation in vitamin D deficient children promoted growth.

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Hypothyroidism is one of the most prevalent endocrine disorders in the world, with a sharp rising incidence. The evaluation of recurrent hypoglycemia in the light of hypothyroidism still remains a major diagnostic challenge for most clinicians. We report a rare case of hypothyroidism presenting as recurrent hypoglycemia with relative adrenal insufficiency. Blunting of hypophyseal–pituitary–adrenal axis, pituitary dysfunction, delayed gastric emptying, decreased production and effect of glucagon on hepatocytes, reduced insulin clearance, gluconeogenesis, and glycogenolysis in patients with hypothyroidism may be the plausible mechanisms of hypoglycemia in such individuals. This will enable clinicians to consider thyroid dysfunction while evaluating causes of hypoglycemia in individuals without diabetes mellitus or treating unexplained hypoglycemic episodes in individuals with diabetes.

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A psychoactive substance is any chemical that, upon consumption, leads to a state of intoxication and alteration of physiological functions. Tobacco is the most common licit psychoactive substances being used globally and is the biggest contributors to mortality and morbidity. Tobacco has multiple effects on the hypothalamic-pituitary-thyroid axis and the functioning of the thyroid gland. This article presents a review of the clinically relevant effects of tobacco on the hypothalamic-pituitary-thyroid axis. This review mainly focuses on clinical issues. Tobacco smoking modifies almost all functions of the thyroid gland.

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Sjogrens syndrome is a slowly progressing autoimmune disease, primarily affects exocrine glands, in addition non-exocrine glands affected as well. The coexistence of Sjogrens syndrome and autoimmune thyroiditis is frequent and suggests a common genetic or environmental factor predisposition with similar pathogenic mechanisms. We herein report three cases of this association, who presented to us with different manifestations of Sjogrens syndrome.

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The role of thyroid hormone in pubertal development is complex, with majority of the hypothyroid patients failing to attain puberty. However, isosexual precocious puberty with delayed bone age has been described in female hypothyroid patients, and is called Van Wyk Grumbach Syndrome (VWGS). The presentation of VWGS in boys is different, with the major presentation being isolated enlargement of the testes, with no signs of virilisation. The cross over action of Thyroid Stimulating Hormone (TSH) on Follicle Stimulating Hormone (FSH) receptor producing Sertoli cell hyperplasia produces testicular enlargement, and lack of action of TSH on Luteinizing hormone (LH) with no Leydig cell hyperplasia explaining lack of virilisation. Delayed bone age and typical features of hypothyroidism help to differentiate this condition from other causes of precocious puberty.

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Introduction: Hypocalcemia is an important and common complication following thyroid surgery with reports varying from 0.5% to 75%. Despite being self-limiting in most patients, symptomatic hypocalcemia is of particular concern because of a delay in its manifestation and the consequent need for prolonged patient hospitalization or re-admission. Aim of the Work: The aim of this study is to evaluate the clinical usefulness of oral calcium and vitamin D administration after total thyroidectomy in the prevention of post-operative hypocalcemia. Materials and Methods: Fifty patients who underwent total thyroidectomy for non-toxic goiters were randomly assigned to routinely receive or not receive oral calcium (1.5 g/d) and vitamin D (0.5 μg/d) for 4 weeks. Hypocalcemic symptoms and signs and total serum calcium levels were monitored and compared between the 2 groups. Results: The incidence of symptomatic and laboratory hypocalcemia was lower in the treatment group receiving the supplement than in the control group not receiving the supplement: 6 of 25 patients (24%) versus 11of 25 (44%). The hypocalcemic symptoms were minimal in the treatment group but more severe in the control group not receiving the supplement. Serum calcium levels decreased in both groups after surgery but were less in the treatment group. Conclusion: Routine administration of a supplement containing oral calcium and vitamin D may be effective in reducing the incidence and severity of hypocalcemia after total thyroidectomy.

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Background: There is some "gray zone" of thyroid cytology, where the diagnostic efficacy declines sharply rendering it difficult to exactly categorize the lesion resulting in discrepancy. The aim of the study is to assess the accuracy of fine needle aspiration of the thyroid and critically evaluate the cytohistological discordant cases. Materials and Methods: A total of 447 patients with thyroid swelling were aspirated during a seven-year study period. Cases showing cytohistologic disparity were reevaluated for the detection of possible causes of failure. Results: In our study, cytohistologic concordance was achieved in 80.28% of the cases. Of the discordant cases, false positives accounted for 11.60% and false negatives for 9.8%. Suboptimal material and underdiagnosis of papillary carcinoma due to cystic degeneration were recognized as common pitfalls. Too much emphasis on cellularity and architectural pattern led to the erroneous false positive diagnoses. Conclusion: Strict adherence to adequacy criterion and meticulous examination of all the smears are of paramount importance in reducing discrepant cases.

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Context: Radioactive iodine (RAI) therapy for hyperthyroidism is safe and definitive, although, post-treatment hypothyroidism and the need for life-long thyroxine are to be expected. The optimal dose of I-131 for hyperthyroidism is still debated. Aims: The aim of this study is to evaluate the response rate of hyperthyroidism to RAI treatment, optimum effective dose, effect of pre-treatment with anti-thyroid medications, ophthalmopathy, and hypothyroidism incidence post RAI therapy. Subjects and Methods: A prospective study was conducted in a tertiary care center to look at the therapeutic practice of use of RAI in the treatment of hyperthyroidism, to determine whether the expected or desired therapeutic outcome is achieved. Seventy consecutive subjects of hyperthyroidism, treated with RAI were followed-up. Results: Grave's disease was the most common cause of hyperthyroidism. The dose of RAI ranged from 4 mCi to 17.5 mCi. Over 95% cure rate achieved with RAI dose 4-7 mCi. Hypothyroidism occurred in 52.17% cases with this dose. Goiter size significantly decreased with RAI therapy. No deterioration of eye signs observed with RAI therapy. Pre-treatment with anti-thyroid drugs had no influence on outcome. Conclusions: RAI treatment is an effective modality for definitive treatment of hyperthyroidism with long-term cure approaching 95%. Its efficacy, safety and low cost made it the preferred definitive treatment for most patients with hyperthyroidism.

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Background: The goal of prenatal care is mother's and baby's health. Pregnancy is the time of hormonal changes, which cause endocrine disorders in pregnant woman encountering risk to the mother and fetus. Two important and more common problems in pregnancy are gestational diabetes mellitus (GDM) and thyroid disorders. Approximately 1.1-14.3% of pregnant women suffer from GDM and hypothyroidism affects 2.5-6.47% of them. There are some recommendations for diagnosis and screening of GDM but there is no clear advice about the need for performing thyroid function tests during pregnancy. In this study, we aimed to evaluate the need for measurement of thyroid function tests in pregnant women with GDM. Materials and Methods: In this case-control study, 210 pregnant women (105 with and 105 without GDM) were enrolled during 2011-2012 and serum levels of free thyroxine (FT4) and thyroid-stimulating hormone (TSH) were compared between two groups. Results: Mean TSH levels in case and control groups were 3.43 ± 2.06 and 1.74 ± 1.47 μIU/mL, respectively and was statistically higher in case group (P = 0.023). Mean FT4 levels in case and control groups were respectively 1.41 ± 0.69 and 1.5 ± 0.61 ng/dL, which were not statistically different in both groups (P = 0.67). Among patients with GDM, 18 (17.1%) had subclinical hypothyroidism and 11 (10.48%) had clinical hypothyroidism, while among non-GDM patients, 7 (6.66%) had subclinical hypothyroidism and 4 (3.81%) had clinical hypothyroidism. Conclusion: In patients with GDM, hypothyroidism (clinical and subclinical) was obviously higher, the mean serum TSH level was higher in these women, and it was within a range that required treatment. So, it is suggested considering screening and treatment of hypothyroidism in patients with gestational diabetes.

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Introduction: Hypothyroidism is a common functional disorder of the thyroid gland. Despite extensive research, data on this subject are lacking from the northeastern part of India, which falls in the Sub-Himalayan goitrogenic belt. Therefore, we decided to study the profile of hypothyroidism in Assam, a northeastern state with the following objectives: to determine the prevalence of hypothyroidism and to describe the various modes of clinical presentation. Materials and Methods: The study was conducted at a clinic-cum-radioimmunoassay laboratory in Guwahati, Assam, from January to November 2011. Two thousand and four hundred fifty-six patients referred to our center from different parts of Assam were evaluated clinically and their thyroid profile was estimated. Antithyroid peroxidase (TPO) antibody was estimated in 1950 patients. Results: The prevalence of overt hypothyroidism was 10.9% (n = 267) and that of subclinical hypothyroidism was 13.1% (n = 321). Male:female ratio was 1:3. Among the cases of overt hypothyroidism, 247 (92.51%) were adult hypothyroids, 15 (5.62%) juvenile hypothyroids, and 5 (1.87%) cretins. The common presenting features of hypothyroidism were weakness (98%), lethargy (95%), dry and coarse skin (87%), and body ache (85%). Uncommon modes of presentation were pleural and pericardial effusion, low body weight, frequent motions, and palpitations. Postthyroidectomy and drug-induced hypothyroidism accounted for 2.38% cases each and postpartum hypothyroidism for 3.74% cases. Thirteen percent cases presented with goiter. The prevalence of anti-TPO antibody in the study population was 8.41%. Conclusion: Hypothyroidsm is no longer a rarity, and Assam is no exception to this phenomenon. A population-based epidemiological study of thyroid disorders in Northeast India is an urgent need.

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Congenital hypothyroidism (CH) is a preventable cause of mental retardation in neonates. In India, CH is compounded by a lack of efficient newborn screening (NBS) programs, nonavailability of infrastructure, and the rising cost of health care. This review focuses on NBS techniques for early detection of CH, along with management strategies in the Indian scenario. Guidelines recommend measuring thyroid-stimulating hormone (TSH) or thyroxine (T4) levels or combined TSH and T4 as an ideal approach for screening CH within 2–4 days after birth. In preterm and low birth weight neonates, additionally, after 2–4 weeks, a follow-up screening has been suggested. If laboratory test is positive, a noninvasive scintigraphy and/or ultrasound has also been suggested as additional test to identify underlying etiology. Levo-T4 (L-T4) has been recommended as the first-line treatment with an initial standard dose of 10–15 μg/kg/day, based on the disease severity; with regular follow-up, up to 3 years of age. Although L-T4 tablet form is the standard of care in many developing countries like India, liquid formulations of L-T4 have been found to possess some additional beneficial effects. In summary, the government or policymakers should encourage mandatory cost-effective NBS for the early detection and treatment of CH.

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Objective: To evaluate the effects of cultural beliefs and attitudes on goiter and thyroidectomy and assess their psychosocial and economic implications on patients. Patients and Methods : In a 3-year period, between January 2008 and December 2011, a total of 65 patients were randomly selected and interviewed by using an interviewer administered questionnaire in our surgical outpatient department. Standard expressions and explanations in English and local dialects were used. Results: The patients consisted of 60 females and 5 males with a male to female ratio 1:12. Age range was 20-69 years. Major ethnic groups were Yoruba 60%, Ibo 20%, and Hausa 8%. Most of the patients, 72% believed goiter was caused by poison from witchcraft/devil and only 10% have the true knowledge of causes of goiter. In 60%, the most common psychosocial problem was exploitation by the traditional healers (THs), 15% were withdrawn and 12% were apprehensive. About 88% could not afford surgical bill until 2-7 months after initial hospital attendance. Failure of trado-medical treatment and cosmetics were the reasons for advancement in 44 patients for seeking orthodox medical services. In 16 patients, thyroidectomy was successful because neighbors encouraged them to come to hospital, while in 9 patients, it was a result of health education (HE) from electronic media, and in 3 patients, it was because of toxicity and malignant transformation. Formal education had some influence on the attitudes of patients toward goiter and modified their behavior and cultural beliefs. Conclusion: Goiter is believed by some patients to be one of psychic and psychosomatic disorders as a result of cultural beliefs and attitudes. Hence, trado-medical treatments are sought to cure it to no avail. This eventually inflicts a lot of psychosocial and economic problems on patients. HE and medical services need to be improved upon.

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Introduction: Iodine is an essential micronutrient with an RDA of 100-150 μg for normal human growth and mental development. Iodine deficiency disorder (IDD) refers to complex clinical and subclinical disorder caused mainly due to inadequate intake of food with sufficient iodine . Aims and Objectives: The objective was to find out the prevalence of goiter in primary school children; to determine median urinary iodine concentration; to assess the level of iodine in salt samples at household. Materials and Methods: A 30-cluster survey was done in Jamnagar district in primary school children (6-12 years). A total of 70 children from first to seventh standards (35 boys and 35 girls) and 20 children from the community in each cluster were included. Total 2792 children were taken for the total goiter examination by population proportion to size in each cluster with informed consent. A total of 360 children were tested for the median urinary concentration and 750 salt samples were tested on the spot with a test kit from the households of the study population. Results: The total goiter rate was 4.83% among primary school children aged 6-12 years with no significant difference between age and sex. As the age increased the goiter prevalence also increased but the difference was not statistically significant (P > 0.05). The median urinary iodine excretion level of the district was found 80 mcg/l. It was observed that 81.9% salt samples had more than 15 ppm (as recommended) iodine content. Conclusion: The goiter prevalence is less in the study district but low median urinary iodine excretion and use of insufficient iodized salt at households describe the inadequacy in efforts to eliminate IDDs in the district.

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Objective: The objective of this study is to assess the knowledge, attitude, and practices (KAP) in patients with hypothyroidism in India. Methods: This was a questionnaire-based, cross-sectional KAP study conducted in patients with hypothyroidism across 16 centers in India. The questionnaire was validated initially by a panel of experts, followed by 120 patients with primary hypothyroidism. Results: Out of 500 patients enrolled, about three-fourths (72.4%) were women. Most patients had low levels of knowledge (66.6%), were quite concerned (46.6%), and practiced a moderate level of precaution (77.8%). Around 18.4%, 26.2%, 27.8%, and 37.6% of patients had incorrect/no knowledge that weight gain, fatigue, muscle aches/pain, and dry skin were effects of hypothyroidism, respectively. Patients had poor knowledge regarding various risks associated with hypothyroidism such as abnormal menstruation (41.6%), depression (47%), hypercholesterolemia (65.6%), and medications causing hypothyroidism (74.2%). Most patients (91.4%) affirmed the need to consult a physician for or seek medical advice before treatment initiation. However, a small percentage did not agree on testing pregnant women (20.2%) and family members (26.2%) for hypothyroidism. Most patients (93.2% and 92.6%) practiced compliance to frequency and timings for medications; however, one-thirds reported missing doses. There was lack of knowledge-seeking behavior both from online sources (57.4%) and treating doctors (24.2%). Significant associations were found between education and the levels of knowledge, concern, and precautions taken. Conclusion: This study identified significant gaps in the knowledge about the risks associated with hypothyroidism, importance of laboratory investigation, and dietary precautions.

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Background: Change in dosage timing and frequency of L-thyroxine administration may decrease the severity of "hypothyroid" symptoms and contribute to patient satisfaction. This clinical audit was planned to assess the patterns of L-thyroxine replacement in hypothyroid patients. Materials and Methods: A pretested, structured questionnaire collecting information about age, gender, duration of disease, concomitant morbidity and therapy, patient concerns, and thyroid control was administered to 100 consecutive hypothyroid patients attending an endocrine clinic in Karnal, Haryana, North India. Analysis was carried out using the SPSS version 19.0. Results: The mean age of patients was 42.14 ± 13.14 yr, with an average duration of hypothyroidism of 5.12 ± 6.87 yr. Thirty-two subjects were euthyroid (thyroid stimulating hormone (TSH) 0.35-5.00 mIU/l).Eleven subjects reported a TSH < 0.35 and 57 reported TSH ≥5.00 mIU/l. The commonest dose of L-thyroxine used was 100 mcg/day (n = 35), followed by 125 mcg/day (n = 20). The mean total daily dose was 101.17 ± 24.91 (range 50-150) mcg/day. The daily dose per body weight was 1.452 ± 0.38 (range 0.67-2.56) mcg/kg). Nine patients were on atypical regimes: five took their medication in divided daily doses, two took it at night, and two preferred a time "two hours after breakfast and two hours before lunch." They shifted from early morning administration of L-thyroxine because of uneasiness (n = 5/9), palpitation (n = 2/9), and increased hunger (n = 1/9) post-tablet ingestion. The symptoms subsided after the timing or frequency of L-thyroxine intake was changed. Conclusions: Changing the time and/or frequency of L-thyroxine dosage helps in alleviating some of the distressful symptoms among the hypothyroid subjects.

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