Metabolic effects of brown fat in transitioning from hyperthyroidism to euthyroidism.

OBJECTIVE: Brown adipose tissue (BAT) controls metabolic rate through thermogenesis. As its regulatory factors during the transition from hyperthyroidism to euthyroidism are not well established, our study investigated the relationships between supraclavicular brown adipose tissue (sBAT) activity and physiological/metabolic changes with changes in thyroid status. DESIGN: Participants with newly diagnosed Graves' disease were recruited. A thionamide antithyroid drug (ATD) such as carbimazole (CMZ) or thiamazole (TMZ) was prescribed in every case. All underwent energy expenditure (EE) measurement and supraclavicular infrared thermography (IRT) within a chamber calorimeter, as well as 18F-fluorodeoxyglucose (18F-FDG) positron-emission tomography/magnetic resonance (PET/MR) imaging scanning, with clinical and biochemical parameters measured during hyperthyroidism and repeated in early euthyroidism. PET sBAT mean/maximum standardized uptake value (SUV mean/max), MR supraclavicular fat fraction (sFF) and mean temperature (Tscv) quantified sBAT activity. RESULTS: Twenty-one (16 female/5 male) participants aged 39.5 ± 2.5 years completed the study. The average duration to attain euthyroidism was 28.6 ± 2.3 weeks. Eight participants were BAT-positive while 13 were BAT-negative. sFF increased with euthyroidism (72.3 ± 1.4% to 76.8 ± 1.4%; P < 0.01), but no changes were observed in PET SUV mean and Tscv. Significant changes in serum-free triiodothyronine (FT3) levels were related to BAT status (interaction P value = 0.04). FT3 concentration at hyperthyroid state was positively associated with sBAT PET SUV mean (r = 0.58, P = 0.01) and resting metabolic rate (RMR) (P < 0.01). CONCLUSION: Hyperthyroidism does not consistently lead to a detectable increase in BAT activity. FT3 reduction during the transition to euthyroidism correlated with BAT activity.

Redistribution of body composition in patients with Graves' disease after iodine-131 treatment.

OBJECTIVE: The objective of this study was to investigate body composition redistribution at 3 months after radioactive iodine therapy (RAI). METHODS: Eighty patients with Graves' disease (GD) for RAI and 18 volunteers were recruited. All patients underwent thyroid status test and dual-energy x-ray absorptiometry at baseline and 3 months after RAI. According to the second thyroid status test, patients were divided into the following groups: A, with aggravated hyperthyroidism; B-1, with improved hyperthyroidism; B-2, with euthyroidism; and B-3, with hypothyroidism. RESULTS: Total lean mass (LM) but fat mass (FM) and bone mineral content (BMC) of whole GD patients after RAI recovered to be not different with controls. Compared with baseline, in group A, FM in the left leg increased, and LM in left arm, right arm, trunk and total LM decreased (P<0.05). In B-2, FM in the head increased, and LM in the head, right arm, trunk and total LM increased (P<0.05). In B-3, FM in the right leg and total body fat percentage decreased, but FM in the head, android-to-gynoid fat ratio and body mass index increased (P<0.05); LM of all sites, weight and total mass increased (P<0.05); BMC in lumbar spine and left leg, and total BMC decreased (P<0.05). Body composition of unmentioned sites was retained after RAI in each group (P>0.05). CONCLUSIONS: Replenishment of LM gets priority rather than FM and BMC during the first 3 months after RAI, and the increase in LM starts from the upper body; head is the regional site in which FM recovery occurs first.

Assessing quality of life in Australian patients with Graves' ophthalmopathy.

AIMS: To determine quality of life and adequacy of education and counselling in Australian patients with Graves' ophthalmopathy during the course of their illness. METHODS: A cross sectional study was conducted at the orbital and endocrinology clinics of Royal Brisbane Hospital on 162 consecutive patients with Graves' ophthalmopathy who were managed between the 1992 and 2000. The Graves' ophthalmopathy quality of life (GO-QOL) survey modified for Australian conditions was distributed to study participants. Of the 19 questions asked, nine questions related to visual functioning, eight questions were about the psychosocial consequences of changed appearance, and two questions referred to education and counselling. Additionally, clinical data on the severity of illness were collected retrospectively from the medical notes of these patients. RESULTS: Completed questionnaires were received from 128 patients. The majority of patients reported limitations in daily activities such as hobbies, driving, watching television and reading, as well as impaired self confidence. The mean GO-QOL scores in this study were (100 representing maximum QOL): visual functioning 59.0 (SD 28.0), psychosocial consequences of changed appearance 54.5 (28.4), and education and counselling 59.1 (38.8). Only about a quarter of patients indicated that education and counselling were adequate and helpful. CONCLUSION: Graves' ophthalmopathy profoundly affects QOL and adequate education and counselling are essential for helping patients to cope with their illness. The GO-QOL survey is a simple, practical tool that can be used easily in a clinic to determine the QOL issues in subjects with Graves' ophthalmopathy.

Minimally invasive orbital decompression for Graves' ophthalmopathy.

We reviewed a 7-year experience at a tertiary-care, academic medical center with balanced, minimally invasive decompression for Graves' ophthalmopathy, in an effort to define the goals, risks, and outcomes of surgical intervention. Endoscopic medial decompression was performed in 26 patients; 23 underwent lateral decompression as well, and 13 also had inferior decompression. Septoplasty, turbinate reduction, and orbital rim augmentation were performed as needed. The indications for surgery were threat to vision (n = 10) and proptosis with a desire to return to the predisease state (rehabilitative, n = 16). The exophthalmos improved by a mean of 4.4 mm (p < .001). All patients who had surgery for threatened vision had improved vision after the operation. There were 3 patients with new-onset postoperative diplopia, 2 of whom underwent strabismus surgery. There was 1 case of postoperative sinusitis, which resolved with oral antibiotics and nasal decongestion, and 1 case of transient ulnar neuropathy. There were no other intraoperative or postoperative complications. Modern methods of orbital decompression provide a minimally invasive, effective, and relatively safe approach to the treatment of Graves' ophthalmopathy.

Graves' ophthalmopathy: a rational approach to treatment.

The past decade has witnessed great progress in our understanding of Graves' opthalmopathy (GO), although its precise immunopathogenesis remains an enigma. Several clinical studies have provided a more rational basis for treatment of this distressing disease, which significantly lowers the quality of life. A management plan tailored to the patient's needs can be devised according to the severity and activity of the eye disease. In active GO, immunosuppression might be considered. The combination of intravenous pulses of methylprednisolone and retrobulbar irradiation improves eye changes in 88% of patients, and is well tolerated. Once the disease has become inactive, rehabilitative surgery could be performed (orbital decompression, strabismus surgery and eyelid surgery, in that order). The patient should be reassured that functional and cosmetic improvement of eye changes is feasible, but restoration can require one to two years. To a certain extent, refraining from smoking prevents the development or worsening of GO.

Management of Graves' ophthalmopathy: reality and perspectives.

Graves' ophthalmopathy is an debilitating disease impairing the quality of life of affected individuals. Despite recent progress in the understanding of its pathogenesis, treatment is often not satisfactory. In mild cases, local therapeutic measures (artificial tears and ointments, sunglasses, nocturnal taping of the eyes, prisms) can control symptoms and signs. In severe forms of the disease (3-5%), aggressive measures are required. If the disease is active, high-dose glucocorticoids and/or orbital radiotherapy, or orbital decompression represent the mainstay of treatment. If the disease is severe but inactive, orbital decompression is preferred. Novel treatments such as somatostatin analogs or intravenous immunoglobulins are under evaluation. Rehabilitative (extraocular muscle or eyelid) surgery is often needed after treatment and inactivation of eye disease. Correction of both hyper- and hypothyroidism is crucial for the ophthalmopathy. Antithyroid drugs and thyroidectomy do not influence the course of the ophthalmopathy, whereas radioiodine treatment may cause the progression of preexisting ophthalmopathy, especially in smokers. The exacerbation, however, is prevented by glucocorticoids. In addition, thyroid ablation may prove beneficial for the ophthalmopathy in view of the pathogenetic model relating eye disease to autoimmune reactions directed against antigens shared by the thyroid and the orbit.

Staged operation for Graves' ophthalmopathy.

A four-staged operation is currently the most effective treatment available in the management of stable Graves' ophthalmopathy. This report describes the results of four-staged therapy in 51 patients with Graves' ophthalmopathy. Stage I, orbital decompression: 58 orbits in 32 patients underwent orbital decompression, with an average retroplacement effect of 4.2 +/- 2.2 mm (mean +/- SD). This procedure is effective to restore vision and correct the proptosis due to Graves' ophthalmopathy. Careful intraoperative titration of the retroplacement effect during orbital decompression is very important to achieve successful results. Stage II, strabismus surgery: 24 patients underwent strabismus surgery, including 11 with previous decompression surgery and six with previous simultaneous decompression and strabismus surgery. The overall success rate was 87% and previous decompression or strabismus surgery had no influence on the final results. Stage III, fissure width adjustment: 28 patients (45 eyes) received fissure width adjustment. Various procedures were performed and we found Müllerectomy with levator muscle stripping to be the most useful procedure for fissure width adjustment. The average improvement of fissure height was 3.1 +/- 1.8 mm. The rate of overall satisfactory results was 89%. There were five patients who received Staged IV cosmetic procedures with satisfactory results. Graves' ophthalmopathy is a chronic disease that needs thorough cooperation between doctor and patient. Careful evaluation of clinical parameters and individualized surgical goals are the keys to success.