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   2020| September-December  | Volume 17 | Issue 3  
    Online since January 20, 2021

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Accidental levothyroxine ingestion in children: Review of four cases
Hanumantha Rao Maddukuri, Pramila Kalra, BP Karunakara, Poornima Venugopal
September-December 2020, 17(3):146-148
Incidence of accidental levothyroxine ingestion in children has been increasing in recent times, mainly because of increasing prescriptions. We present four such cases, who presented to the pediatrics department in the past year. Four children aged 2–14 years presented to the emergency department with accidental consumption of levothyroxine tablets, total strength ranging from 1000 to 3000 μg. All were reported within half an hour to 8 h of consumption. Three of them were asymptomatic at presentation and one had one episode of vomiting. Gastric lavage was done and activated charcoal was given to all. Vitals were normal, except one had tachycardia for which the child received propranolol tablet for 1-week duration to control heart rate. Baseline free T4 was high and thyroid-stimulating hormone was normal in all. They were admitted for observation for 2–6 days and later followed on an outpatient basis. Ingestion of large doses of levothyroxine in children typically follows a benign course. Patients may be asymptomatic or have thyrotoxic symptoms and rarely significant complications, including seizures and arrhythmias. The severity of symptoms does not correlate with plasma levels of T4, and the onset of symptoms can be delayed for up to 6–11 days. Asymptomatic children can be monitored at home following gastrointestinal decontamination. In cases with severe symptoms, children should be monitored in the hospital for cardiac or neurological instability. Propranolol is used in the presence of features of toxicity. Levothyroxine is colorful and palatable that can be attractive to young children. Gastric lavage and activated charcoal is the mainstay of treatment in accidental levothyroxine ingestion in children.
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Role of dietary factors in thyroid disorders: Current evidences and way forwards
MD Abu Bashar, Nazia Begam
September-December 2020, 17(3):104-109
Thyroid disorders are one of the most common endocrine problems encountered at primary care. The role and importance of dietary factors in their prevention and management are largely unknown with inadequate scientific evidence. In this review, we examine the scientific evidence of the effect of various dietary elements in causation, prevention, and management of common thyroid disorders.
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The way to a patient's heart: Simple recommendations for a resident doctor
Saurav Khatiwada, Hiya Boro
September-December 2020, 17(3):101-103
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Rising prevalence of Thyroid disorders in India - The time to act is now
Arun S Menon
September-December 2020, 17(3):99-100
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Thyroid disease in older people: Nursing perspectives
Suresh K Sharma, Shiv K Mudgal, Anindita Mandal
September-December 2020, 17(3):110-117
Old age refers to ages nearing or surpassing the life expectancy of human beings. Older people are an important and distinct yet sometimes the heterogeneous group of persons living with thyroid diseases. They have a unique biomedical, psychological, and social constitution. Their needs are different from those who are young adults. This implies that special care must be taken while planning, implementing, and evaluating nursing care for them. Management of different thyroid diseases in the elderly should provide attention on limitation of geriatric syndromes (medical conditions encountered in elderly persons) and neurocognitive dysfunction (impairment in the functioning of the brain and nervous system). This review takes a practical approach to the assessment, medical intervention along with nursing care for the elderly with thyroid diseases. It highlights major challenges and suggests solutions to these commonly encountered clinical nursing problems.
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Hypothyroidism and obesity: Is there a bidirectional link? What is the impact on our clinical practice?
Geeta Aurangabadkar, Sirisha Kusuma Boddu
September-December 2020, 17(3):118-122
It is well established that hypothyroidism causes weight gain, but novel emerging data suggest that obesity may actually lead to hypothyroidism. The interplay between leptin, thyroid hormones (THs), and thyroid autoimmunity in obese patients needs special attention. Clinicians need to be more cautious while interpreting elevated thyroid-stimulating hormone levels in obese individuals to avoid inappropriate labeling of hypothyroidism and unjustified use of TH therapy. It would seem reasonable to measure circulating plasma levels of THs and thyroid autoantibodies in these individuals. Stimulation of brown adipose tissue in adults, specifically through TH-mediated pathways, may seem a promising therapeutic target for obesity; however, the evidence has been inconclusive regarding effectiveness of TH therapy in treating obesity. Moreover, the effect of weight loss on thyroid function has been variable as per different studies. We aim to review the available evidence regarding the possible bidirectional link between hypothyroidism and obesity, explore responsible underlying mechanisms, and discuss the impact of this knowledge on our clinical practice.
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Antithyroid drug-induced pancytopenia followed by acute lymphoblastic leukemia: A rare case
Hardeva Ram Nehara, Bal Kishan Gupta, Sahil Parmar, Vipin Kumar, Dharmveer Sihag, Surendra Beniwal
September-December 2020, 17(3):149-151
Antithyroid drugs (ATDs) have been used for the management of hyperthyroidism and rarely may cause life-threatening side effects such as agranulocytosis and pancytopenia. Lymphocytes of patients who develop agranulocytosis while on ATD may undergo blast transformation when exposed in vitro to ATD. A 26-year-old man with Graves' disease was found to have pancytopenia after treatment with carbimazole for 2 months, which was improved with supportive treatment. The patient restarted carbimazole and presented 4 months later with a diagnosis of acute lymphoblastic leukemia (ALL). This case of ALL was likely attributed by re-exposure to carbimazole, though the association of ALL with autoimmune thyroid disease cannot be denied.
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Pattern of Vitamin D deficiency in Hashimoto's thyroiditis and its association with thyroid hormone
Nazma Akter, Tangera Akter
September-December 2020, 17(3):141-145
Objective: The role of Vitamin D as an immune modulator has been recently emphasized. However, at this time, the research on its role in autoimmune thyroid disease is not conclusive. The purpose of this study was to examine the association of Hashimoto's thyroiditis (HT) and Vitamin D deficiency and to clarify the correlation between Vitamin D levels with thyroid hormone in patients with HT. Methodology: In this cross-sectional study, hypothyroid HT patients were selected among referents to the endocrinology outpatient clinic of MARKS Medical College and Hospital, Dhaka, Bangladesh, for thyroid evaluation from January 2019 to March 2020. A total of 150 patients were enrolled and placed in the newly diagnosed hypothyroid HT “case group,” and a “control group” included 145 apparently healthy individuals (matched for age and gender). All the patients underwent thyroid function tests and serum 25-hydroxyvitamin D (25(OH)D) levels. The antibodies of interest were thyroid peroxidase antibody and thyroglobulin antibody, suggesting HT cases. Data were analyzed using SPSS version 18 statistical software. Results: In this study, Vitamin D deficiency was prevalent in 32.2% of the “HT group” and 1.0% of the “control group” (P < 0.001). The Vitamin D-deficient participants had a significantly higher thyroid-stimulating hormone (TSH) and lower free thyroxine (FT4) level than the Vitamin D insufficient participants (TSH: 18.58 ± 8.73 vs. 8.52 ± 9.61 [μIU/mL], t = −7.816, P < 0.001; FT4: 0.81 ± 0.15 vs. 1.12 ± 0.17 [ng/dL], t = 13.36, P < 0.001, respectively). Concerning the HT case group, there was a significant negative correlation between serum 25(OH) Vitamin D and TSH (r = −0.178, P < 0.05). On the other hand, a significant positive correlation was recorded between serum 25(OH)D and serum FT4 levels (r = 0.610, P < 0.001). Conclusions: Patients with HT present with a reduced serum 25(OH)D level, and low serum Vitamin D levels were independently associated with high serum TSH levels and low serum FT4 levels in those with subnormal levels of Vitamin D. TSH is negatively correlated with 25(OH)D level. On the other hand, FT4 levels are positively correlated with 25(OH)D levels.
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Pediatric hyperthyroidism research: A scientometric assessment of global publications during 1990–2019
Devi Dayal, Brij Mohan Gupta
September-December 2020, 17(3):134-140
Background: A systematic mapping of research in pediatric hyperthyroidism (PHT) is unavailable. Aims and Objectives: To provide a comprehensive assessment of PHT research over the past three decades. Materials and Methods: The data on publications in PHT were retrieved from the Scopus database using a defined search strategy, and analyzed using select bibliometric indicators. Results: During 1990-2019, global research in PHT registered 8.8% and 150.7% average annual and 15-year cumulative growth respectively, and averaged 30.6 citations per paper. Of the 111 participating countries, the USA leads the ranking with 28.9% share, followed by Italy, UK and Germany with 7.8%, 7.6% and 7.5% share, respectively. The number of participating organizations and authors was 555 and 1117 respectively. National Institute of Health, Bethesda, USA, INSERM, France and John Hopkins University, USA were the three most productive organizations. The most productive authors were F. Vargas, S. A. Rivkees, and F. De Luca, and the most productive journals were the Journal of Pediatric Endocrinology and Metabolism, Journal of Clinical Endocrinology and Metabolism, and Thyroid. Conclusions: The PHT research is largely conducted in developed countries of the North-American and European regions. The disparity in research needs to be addressed by fostering collaboration, and strengthening of institutional research capacities. This is the first sketch of global research architecture in PHT.
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Multiple myeloma masquerading as T3 toxicosis
P Veechika, S Chitra
September-December 2020, 17(3):152-154
We report a case of a 52-year-old man who was referred by his primary care physician to rule out thyroid illness. His thyroid function tests (TFTs) revealed isolated elevation of total T3 (TT3) with normal total T4 (TT4), free T3 (FT3), free T4 (FT4), and unsuppressed thyroid-stimulating hormone raising the suspicion of antibody interference or abnormal thyroid hormone-binding proteins. To identify antibody interference, we repeated the immunoassay using varied platforms and assay methods. The total T3 levels which were high in one-step immunoassay normalized in two-step immunoassay. On further evaluation, the patient was diagnosed with multiple myeloma and the antibody interference was secondary to IgG monoclonal antibody binding specifically to analog T3 leading to spurious results. Ours is the first report from India and the fourth case in literature to report a multiple myeloma antibody interfering with TFTs.
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Retrospective evaluation of clinicopathological characteristics of differentiated thyroid cancer patients with iodine-131-avid distant metastasis: A tertiary care centre experience
P Ram Manohar, Kavitha Nallapareddy, Madhur Kumar Srivastava, Vinodh Kumar Kendarla
September-December 2020, 17(3):123-127
Introduction: Among various prognostic indicators, distant metastases have a strong impact on the overall survival of differentiated thyroid cancer (DTC) patients. Aim: The aim of this study was to know the incidence, pattern of iodine-131-avid distant metastases in DTC patients at presentation, long-term survival probability in DTC patients with distant metastases and also to know the relationship between the distant metastases and clinicopathological variables such as age, gender, and histopathological subtypes. Materials and Methods: Retrospective evaluation of case records and whole-body iodine scans of DTC patients referred to our hospital between January 2013 and December 2018 was done. Results: A total of 1336 DTC patients' case records were analyzed. Among them, 157 patients (11.7%) had distant metastases at presentation. Majority were female patients (63%). The mean age of patients in the study group was 48.4 years. Most of the patients had papillary histopathology (58.6%), followed by follicular (34.4%), poorly differentiated (5.73%), and Hurthle cell carcinoma (1.27%). Bone was the most common site of metastases in 49% of patients, followed by the lung in 25% of patients. Two (1.27%) patients had an unusual site of metastases involving the kidney and adrenal gland. Nearly one-third patients (25.5%) had multi-organ metastases. The 5 years specific survival probability of DTC patients with distant metastases at presentation was 47.3%. Conclusion: The incidence of distant metastases in our study is similar to the incidence rate reported in the literature. Distant metastasis is higher in female patients and in the age group of 45 years and above. Bone is the most common organ site of metastases rather than lung in the present study, which is pointing towards the high incidence of skeletal metastases in Indian patients. The specific survival probability at 5 years is 47.3%.
  1,047 86 -
Comparative study on endoscopic versus open thyroidectomy
Pravallika Ponnada, Raja Rao Nudurupati, Tarun Kumar Suvvari
September-December 2020, 17(3):128-133
Background: In recent times, the demand for endoscopic techniques for thyroid tumors has been increased, and the aim of this study is to compare conventional open thyroidectomy (ConT) with endoscopic thyroidectomy (ET) in terms of duration of the procedure, blood loss during surgery, postoperative discomfort or pain, antibiotics, and analgesics requirement and other associated factors. Materials and Methods: The study was a prospective study carried out among 90 patients who were undergone endoscopic or open thyroidectomy at the government general hospital, Kakinada, between August 2017 and August 2019. Fifty-two patients have undergone ConT, and 32 patients have undergone ET. The Microsoft Excel 2016 and SPSS Version 20 were used for statistical analysis. A Chi-square test was performed to analyze surgical outcomes, and P < 0.05 was taken as statistically significant. Results: The majority of the study participants was females and belongs to the age group in between 31 and 40 years. The mean duration of surgery for ConT and ET is 79.13 and 135.15 min and has statistical significance (P < 0.01). The mean period of hospitalization was 2.1 days for ET, which was lesser than 4.21 for ConT The Wound Infection was found more in people who undergone ConT, and the postsurgery patient satisfaction was more among people who undergone ET. Conclusion: ET approach has several potential weaknesses in terms of operative time, cost factor, and invasiveness and In favor of shorter hospital stay, less postoperative pain, and excellent cosmetic results, especially in young women.
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