Insight of the Biopharmaceutical Implication of Sleeve Gastrectomy on Levothyroxine Absorption in Hypothyroidism Patients.

PURPOSE: The growing rate of obesity led to an increased number of bariatric surgeries (BS) as a treatment option for obesity. The gastrointestinal tract (GIT) changes following BS can impact many drugs' absorption. Levothyroxine (LT4) is a synthetic thyroxine (T4) replacement used commonly as tablets to manage hypothyroidism disorder, which is more prevalent among patients with obesity. This study aims to examine the LT4 oral tablet form therapy after sleeve gastrectomy. MATERIALS AND METHODS: A retrospective cohort study was conducted in multi-center. The LT4 doses and TSH and T4 levels were compared before and after BS. The post-surgery readings were categorized into three periods: (one to three months), (four to six months), and (> six ) months after surgery. ANOVA test was used for analysis. RESULTS: A total of 14374 patients who underwent BS from (1/2019 to 3/2022) were screened for eligibility, and n = 101 participants matched the inclusion criteria. The TSH and T4 were not statistically significant differences before and after surgery (P-values of 0.4864 and 0.5970, respectively). However, the doses significantly differed before and after surgery in all the follow-up time point periods (P < 0.002). CONCLUSION: The LT4 required doses significantly reduced after sleeve gastrectomy, which can be related to the improved endogenous thyroid production in patients with obesity. However, the abnormality of the GIT induced by the sleeve gastrectomy may affect the exogenous LT4 absorption. Using liquid forms of LT4 while monitoring the thyroid function parameters can optimize the treatment after the procedure.

Attaining biochemical euthyroidism early after total thyroidectomy in Graves' disease may lower long-term morbidity risk.

BACKGROUND: The relationship between good early control of thyroid hormone levels after thyroidectomy for Graves' disease (GD) and subsequent risks of mortality and morbidities is not well known. The aim of this study was to examine the association between thyroid hormone levels within a short interval after surgery and long-term mortality and morbidity risks from a population-based database. METHODS: Patients with GD who underwent complete/total thyroidectomy between 2006 and 2018 were selected from the Hong Kong Hospital Authority clinical management system. All patients were classified into three groups (euthyroidism, hypothyroidism, and hyperthyroidism) according to their thyroid hormone levels at 6, 12, and 24 months after surgery. Cox proportional hazards models were performed to compare the risks of all-cause mortality, cardiovascular disease (CVD), Graves' ophthalmopathy, and cancer. RESULTS: Over a median follow-up of 68 months with 5709 person-years, 949 patients were included for analysis (euthyroidism, n = 540; hypothyroidism, n = 282; and hyperthyroidism, n = 127). The hypothyroidism group had an increased risk of CVD (HR = 4.20, 95 per cent c.i. 2.37 to 7.44, P < 0.001) and the hyperthyroidism group had an increased risk of cancer (HR = 2.14, 95 per cent c.i. 1.55 to 2.97, P < 0.001) compared with the euthyroidism group. Compared with patients obtaining euthyroidism both at 6 months and 12 months, the risk of cancer increased in patients who achieved euthyroidism at 6 months but had an abnormal thyroid status at 12 months (HR = 2.33, 95 per cent c.i. 1.51 to 3.61, P < 0.001) and in those who had abnormal thyroid status at 6 months but achieved euthyroidism at 12 months (HR = 2.52, 95 per cent c.i. 1.60 to 3.97, P < 0.001). CONCLUSIONS: This study showed a higher risk of CVD in postsurgical hypothyroidism and a higher risk of cancer in hyperthyroidism compared with achieving euthyroidism early after thyroidectomy. Patients who were euthyroid at 6 months and 12 months had better outcomes than those achieving euthyroidism only at 6 months or 12 months. Attaining biochemical euthyroidism early after thyroidectomy should become a priority.

Incidence of hypothyroidism after treatment for breast cancer: A Korean population-based study.

This Korean population-based study aimed to describe the patterns of hypothyroidism after adjuvant radiation therapy (RT) in patients with breast cancer. The Korean Health Insurance Review and Assessment Service database was searched for patients with invasive breast carcinomas. We calculated the cumulative incidence and incidence rates per 1,000 person-years of subsequent hypothyroidism and compared them using the log-rank test and the Cox proportional hazards model. Between 2007 and 2018, 117,135 women diagnosed with breast cancer with a median follow-up time of 4.6 years were identified. The 8-year incidence of hypothyroidism was 9.3% in patients treated with radiation and 8.6% in those treated without radiation (p = 0.002). The incidence rates per 1,000 person-years in the corresponding treatment groups were 6.2 and 5.7 cases, respectively. The hazard ratio (HR) in patients receiving RT was 1.081 (95% confidence interval [CI], 1.013-1.134; p = 0.002). After mastectomy, RT showed a trend toward a higher risk of hypothyroidism (HR = 1.248; 95% CI, 0.977-1.595; p = 0.076). Our study provides one of the largest population-based data analyses regarding the risk of hypothyroidism among Korean patients with breast cancer. The adjusted risk for patients treated with RT exceeded that for patients with breast cancer treated without RT. The effect was evident immediately after treatment and lasted up to approximately 9 years.

Long-term Effect of Bariatric Surgery on the Use of Levothyroxine and Thyroid Levels.

BACKGROUND: The aim of this study was to evaluate the effect of bariatric surgery on the defined daily dose of levothyroxine (DDD LT4), thyroid-stimulating hormone (TSH), and free thyroxine (fT4) in female patients with hypothyroidism until 48 months after surgery. METHODS: A retrospective observational study of hypothyroid patients who underwent bariatric surgery. Changes in DDD LT4, TSH, and fT4 over a 48 month period after surgery were analyzed. RESULTS: Thirty-seven patients were included: 27 Roux-en-Y gastric bypass (RYGB), 6 sleeve gastrectomy (SG), 3 adjustable gastric band, and 1 one anastomosis gastric bypass. The median DDD LT4 decreased from 125 µg at baseline to 100 µg 12 months after surgery. From 24 to 48 months after surgery, the median DDD LT4 was stable at 125 µg. Most dose adjustments occurred during the first 24 months after surgery. In the time period of 24-48 months after surgery, the dose remained stable in 73.1% of the RYGB patients and in 60.0% of the SG patients. After 48 months in the RYGB group, no significant change in TSH and fT4 levels was observed. CONCLUSIONS: Bariatric surgery led to frequent dose adjustments during the first 2 years after surgery. However, 24-48 months after surgery in the majority of patients, the dosage remained stable. No significant change in TSH and fT4 was observed 48 months after RYGB. In the first 2 years after surgery, clinicians should frequently monitor TSH and fT4 for individual dose adjustment of levothyroxine. Thereafter, the frequency of monitoring may be decreased.

Association of Economic Well-Being With Comorbid Conditions in Patients Undergoing Carpal Tunnel Release.

PURPOSE: Medical comorbidities have been associated with the development of carpal tunnel syndrome (CTS), severity at the time of presentation, and outcomes of carpal tunnel release (CTR). Socioeconomic factors have also been associated with worse function in patients with CTS at presentation and after surgery. However, the effects of economic well-being on the prevalence of medical comorbidities in patients with CTS have not been well-described. The objective of this study was to determine whether economic well-being is associated with medical comorbidities in a cohort of patients undergoing CTR. METHODS: Patients (n = 1,297) who underwent CTR at a single tertiary care referral center over a 5-year period from July 2008 to June 2013 were retrospectively identified. The exclusion criteria were acute trauma or infection, revision surgery, incomplete medical records, and neoplasm excision. Additionally, patients were excluded if they lacked documented confirmatory or normal electrodiagnostic study findings prior to CTR. Finally, this study comprised a cohort of 892 patients with electrodiagnostic study-confirmed CTS who underwent CTR. The economic well-being of patients was assessed using the Distressed Communities Index. The comorbidities of diabetes mellitus, chronic kidney disease, hypertension, hypothyroidism, cervical radiculopathy, tobacco use, and body mass index were assessed. Bivariate comparisons were used to determine the associations between the tiers of economic well-being and comorbidities. RESULTS: Lower economic well-being was associated with body mass index, diabetes mellitus, chronic kidney disease, and tobacco use in these patients. Although hypertension, hypothyroidism, and cervical radiculopathy were not associated with economic well-being, their comparisons were underpowered. CONCLUSIONS: Patients experiencing economic distress have a higher comorbidity burden, and as such, may be at an increased risk of complications or poorer outcomes. The association between economic well-being and comorbidities in this population suggests the need for a multidisciplinary care model that addresses both compressive neuropathy and the associated economic factors. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Cryopreserved Rat Thyroid Autotransplantation in the Treatment of Postoperative Hypothyroidism.

To verify the viability and functionality of cryopreserved thyroid autotransplantation in rats who underwent total thyroidectomy in the treatment of postoperative hypothyroidism. Thirty-two Wistar rats were randomly assigned into groups (G) with eight animals each: control (CG); simulation (SG); hypothyroidism (HTG) and transplanted (TG). At the beginning and in the 13th week of the experiment, serum levels of total T3, free T4, TSH and calcium were determined. In both the first and 14th weeks, scintigraphic examinations, 99m-Tc pertechnetate radioisotope biodistribution and histopathology were performed. In the 14th week, the expression of proliferating cell nuclear antigen (PCNA) and cellular apoptosis (caspase-3) were also evaluated. In the 13th week, the transplanted animals had normal serum levels of total T3 and free T4. TSH levels showed a tendency towards normality. In the 14th week, scintigraphic exams displayed graft isotopic uptake in all animals in the TG group. Histological examinations 13 weeks after transplantation showed the viability and functionality of thyroid follicles. PCNA revealed significant immunoreactivity of the graft (p < 0.001) when the TG was compared to the CG. There was no difference between CG and TG considering the expression of activated caspase-3. The experimental study confirmed the viability and functionality of thyroid autotransplantation implanted in skeletal muscle with evidence of cell proliferation without cellular apoptosis. This surgical strategy was effective in the treatment of postoperative hypothyroidism.

Hemiagenesia tiroidea: caso clínico y revisión de la literatura / Thyroid hemiagenesis: clinical case and review of the literature

La hemiagenesia tiroidea representa un trastorno congénito caracterizado por la ausencia de desarrollo de uno de los lóbulos tiroideos, asociado o no a ausencia del istmo. Es más frecuente en las mujeres y por lo general se presenta como falta del lóbulo izquierdo, con hipertrofia compensatoria del lóbulo contralateral. Su diagnóstico es generalmente incidental o por manifestaciones del lóbulo tiroideo presente. Se hizo una revisión bibliografía, en donde no se encontraron casos reportados en Venezuela de hemiagenesia o agenesia tiroidea, describiéndose el siguiente. Presentamos a una paciente de 50 años de edad, conocida con hipotiroidismo desde los 31 años, negando cualquier cirugía en el área de cabeza y cuello. Desde febrero 2019 presentó aumento progresivo de volumen en región anterior de cuello. Al examen físico se observó aumento de volumen en región anterior derecha del cuello, palpándose lóbulo tiroideo derecho aumentado de tamaño, de aspecto nodular, no doloroso. En ecosonograma tiroideo se concluyó como bocio tiroideo derecho de aspecto multinodular, con ausencia del lóbulo izquierdo. Perfil tiroideo dentro de límites normales. Se lleva a mesa operatoria corroborándose ausencia del lóbulo izquierdo y presentado en la biopsia definitiva hiperplasia nodular en el lóbulo derecho. Se discute su frecuencia, la forma de presentación y se hace revisión de la literatura(AU)

Thyroid hemiagenesis represents a congenital disorder characterized by the absence of development of one of thyroid lobes, associated or not with absence of isthmus. It is more frequent in women and generally presents as absence of the left lobe, with compensatory hypertrophy of the contralateral lobe. Its diagnosis is generally incidental or by manifestations of the present thyroid lobe. A bibliography review was made, where no cases reported in Venezuela of hemiagenesis or thyroid agenesis were found, describing the following. We present a 50-year-old patient, known with hypothyroidism since she was 31, denying any surgery in the head and neck area. Since February 2019, presented a progressive increase in volume in the anterior neck region. On physical examination, an increase in volume was observed in right anterior region of the neck, palpating an enlarged right thyroid lobe, with a nodular appearance and not painful. In a thyroid echo-sonogram, it was concluded as a right thyroid goiter with a multinodular appearance, with the absence of the left lobe. Thyroid profile within normal limits. It is taken to the operating table, confirming the absence of the left lobe and presented in the definitive biopsy nodular hyperplasia in the right lobe. Its frequency, form of presentation, and literature review are discussed(AU)

Thyroid hormones modulate irisin concentrations in patients with recently onset hypothyroidism following total thyroidectomy.

PURPOSE: Irisin is a newly discovered adipo-myokine known for having significant effects on body metabolism. Currently, there is a discussion regarding the relation between thyroid function and irisin concentration. This study was designed to evaluate the influential role of levothyroxine replacement therapy on circulating levels of irisin in patients with recently onset hypothyroidism following total thyroidectomy. METHODS: Circulating levels of thyroid hormones, irisin and other metabolic parameters, were assessed in 40 recently thyroidectomized patients (34 females, mean age 50.1 ± 15.2 years) at baseline (5-7 day after surgery) and after 2 months under replacement therapy with levothyroxine. RESULTS: At baseline, circulating levels of thyroid hormones were indicative of hypothyroidism (TSH 12.7 ± 5.0 µU/mL, FT3 1.9 ± 0.7 pg/mL, FT4 8.7 ± 3.6 pg/mL). Mean serum irisin concentrations significantly increased after 2 months under replacement therapy with levothyroxine (from 2.2 ± 0.6 to 2.9 ± 0.6 µg/mL, p < 0.0001). Variations of circulating levels of irisin under levothyroxine replacement therapy were directly correlated with those of FT3 (Rho = 0.454, p = 0.0033) and FT4 (Rho = 0.451, p = 0.0035). Multivariate regression analysis revealed that changes in thyroid hormones concentrations explained up to 10% of the variations of serum irisin levels under levothyroxine replacement therapy (FT3 R2 = 0.098, FT4 R2 = 0.103). CONCLUSION: Our study suggests that levothyroxine replacement therapy mildly influences irisin metabolism in patients with recently onset hypothyroidism following total thyroidectomy.

Epidemiology of thyroid disorders in the Lifelines Cohort Study (the Netherlands).

BACKGROUND: Thyroid hormone plays a pivotal role in human metabolism. In epidemiologic studies, adequate registration of thyroid disorders is warranted. We examined the prevalence of thyroid disorders, reported thyroid medication use, thyroid hormone levels, and validity of thyroid data obtained from questionnaires in the Lifelines Cohort Study. METHODS: We evaluated baseline data of all 152180 subjects (aged 18-93 years) of the Lifelines Cohort Study. At baseline, participants were asked about previous thyroid surgery and current and previous thyroid hormone use. At follow-up (n = 136776, after median 43 months), incident thyroid disorders could be reported in an open, non-structured question. Data on baseline thyroid hormone measurements (TSH, FT4 and FT3) were available in a subset of 39935 participants. RESULTS: Of the 152180 participants, mean (±SD) age was 44.6±13.1 years and 58.5% were female. Thyroid medication was used by 4790 participants (3.1%); the majority (98.2%) used levothyroxine, and 88% were females. 59.3% of levothyroxine users had normal TSH levels. The prevalence of abnormal TSH levels in those not using thyroid medication was 10.8%; 9.4% had a mildly elevated (4.01-10.0 mIU/L), 0.7% had suppressed (<0.40 mIU/L), while 0.7% had elevated (>10.0 mIU/L) TSH levels. Over 98% of subjects with TSH between 4 and 10 mIU/L had normal FT4. Open text questions allowing to report previous thyroid surgery and incident thyroid disorders proved not to be reliable and severely underestimated the true incidence and prevalence of thyroid disorders. CONCLUSIONS: Undetected thyroid disorders were prevalent in the general population, whereas the prevalence of thyroid medication use was 3.1%. Less than 60% of individuals using levothyroxine had a normal TSH level. The large group of individuals with subclinical hypothyroidism (9.4%) offers an excellent possibility to prospectively follow the natural course of this disorder. Both structured questions as well as linking to G.P.'s and pharmacists' data are necessary to improve the completeness and reliability of Lifelines' data on thyroid disorders.

Levothyroxine dose adjustment in hypothyroid patients following gastric sleeve surgery.

INTRODUCTION: Euthyroid patients show decreased TSH level following sleeve gastrectomy. However, studies of levothyroxine absorption after bariatric surgery reported contradictory results and data on levothyroxine dose adjustment according to weight are sparse. The aim of this study was to evaluate levothyroxine dose adjustment during weight loss following sleeve surgery. METHOD: This retrospective study assessed change in levothyroxine dose in patients undergoing sleeve gastrectomy at the university hospital center of Nîmes (France) between January 2010 and March 2016. Patients were receiving standard bariatric surgery follow-up with levothyroxine therapy for hypothyroidism. RESULTS: Fifty-two of the 271 patients who underwent sleeve gastrectomy (19.2%) were being treated with levothyroxine. Among these patients, 31 were followed up for 12 months, including 12 who were followed up for 24 months. Mean weight loss was 35±11kg at 12 months and 41.8±10.2 kg at 24 months. Daily levothyroxine dose decreased from 108 [88-144] µg/day to 94 [63-125] µg/day at 12 months and 69 [44-134] µg/day at 24 months, with positive correlation between dose and weight loss at 12 months (P=0.03). Weight-adjusted dose was 1.04 [0.81-1.24] µg/kg/day at baseline, 1.14 [0.85-1.66] µg/kg/day at 12 months, and 0.85 [0.53-2.10] µg/kg/day at 24 months, showing no correlation with weight loss. Median TSH level dropped to 1.30 [0.63-2.27] mIU/l at 12 months and 1.48 [1.08-2.42] mIU/l at 24 months. CONCLUSION: Despite a decrease in daily levothyroxine dose correlating with weight loss at 12 months, the absence of correlation with weight-adjusted dose suggests the involvement of confounding factors such as poor levothyroxine absorption or altered thyroid function. Further studies are required to elucidate the absorption of levothyroxine.

Anesthesia for Endocrine Emergencies.

Although endocrine emergencies are not common occurrences, their identification and careful perioperative management are of paramount importance for reduction of patient morbidity and mortality. The most common critical endocrine abnormalities are associated with functional tumors, such as pheochromocytomas, insulinomas, and carcinoid tumors, leading to carcinoid syndrome, abnormal thyroid function, or disturbances in the hypothalamus-pituitary-adrenal axis, causing adrenal insufficiency. This article aims to discuss the pathophysiology, diagnosis, and perioperative management of pheochromocytomas, hyperthyroidism, hypothyroidism, adrenal insufficiency, carcinoid disease, and insulinomas.

Myxoedematous tamponade as initial presentation of Hashimoto's thyroiditis.

Cardiac tamponade as the initial presentation of hypothyroidism is extremely rare. We report the case of a 48-year-old man admitted for acute respiratory distress, with cardiac ultrasound showing compressive pericardial effusion. Percutaneous pericardiocentesis was performed leading to a rapid clinical improvement. Laboratory tests confirmed severe hypothyroidism related to Hashimoto's disease. Despite hormone replacement therapy, pericardial effusion recurred after 3 weeks, requiring surgical drainage. Pericardial histology highlighted slight chronic fibrous pericarditis. The cardiac ultrasound scan performed 4 months later showed a well-tolerated chronic pericardial effusion. In conclusion, hypothyroidism should be suspected in case of cardiac tamponade especially in the absence of tachycardia, or in winter when myxoedema is prone to decompensation. Prognosis is generally good under hormone replacement therapy but ultrasound monitoring should be carried out at least until euthyroidism is achieved.

Increased cytokines production and oxidative stress are related with purinergic signaling and cell survival in post-thyroidectomy hypothyroidism.

Thyroid hormones have essential roles in regulation of cellular functions, including the immune system. The purinergic signaling, activated through extracellular nucleotides and nucleosides has also strong implications in immune response regulation. Hypothyroidism may involve effects on the immune and purinergic systems. In view of that, we evaluated cytokines levels, their relation with the expression of purinergic enzymes and the effects of this condition on immune system cells from patients with post-thyroidectomy hypothyroidism. Increased IL6, IL10, IL17 and TNF-α levels as well as an increase in CD73 expression in lymphocytes were observed in patients' blood. Moreover, augmented myeloperoxidase activity, lipid peroxidation and thiolgroup production were observed in post-thyroidectomy hypothyroidism. In addition, proliferation and cell death of lymphocytes were enhanced when exposed to patients' serum. This study demonstrates that hypothyroidism is related to changes in the purinergic system, increased cytokines production and oxidative stress, which interfere in the cell life and signaling.

Relationship Between Hormonal Mechanisms of Diabetes Mellitus and Hypothyroidism Post-Bariatric Surgery.

BACKGROUND: Obesity, diabetes mellitus may be related to the health, the relationship and the physiological capacity of the production of thyroid hormones (TH), triiodothyronine (T3) and thyroxine (T4). OBJECTIVES: The main aims of this review are to describe the relationship between obesity, appetite, weight management, hormonal mechanisms of diabetes mellitus and hypothyroidism post-bariatric surgery. METHODOLOGY: An in-depth literature search was conducted to identify scientific studies, which analyzed the correlation between diabetes mellitus and hypothyroidism post-bariatric surgery. RESULTS: Bariatric surgery decreases hypothyroidism, reduces the need for pharmacological action (such as levothyroxine), controls the weight and body fat and increases the sensitivity to leptin and insulin. CONCLUSION: The reduction of the stomach and intestine by bariatric surgery is an evolutionary and beneficial action, because it may lead to a drastic decrease on numbers of conditions such as diabetes, obesity, hypothyroidism, and others. Thus, new studies should also focus on patients' post-operatory conditions, such as lifetime, regulation and functioning of organs after reduced nutrition, and consumption and delivery of nutrients to health maintenance.

Negative pressure pulmonary edema: a case report.

BACKGROUND: The negative pressure pulmonary edema is rare clinical situation which caused mainly by upper airway obstruction. However except upper airway obstruction, there may be other pathophysiological disorders making patients more vulnerable to pulmonary edema. Based on these disorders, upper airway obstruction is the trigger to induce negative pressure pulmonary edema. CASE PRESENTATION: This case was a 5-year-old girl with tumor on saddle area, her hormones level were abnormal preoperatively, such as cortisol, adrenocorticotrophic hormone, free T4 and total T4. During the stage of induction, negative pressure pulmonary edema took place due to mild upper airway obstruction. And the instant chest Computer tomography proved diagnosis clue. After intensive care, most lung field of this girl recovered to normal within 48 h. CONCLUSION: The patient with abnormal hormone levels is vulnerable to pulmonary edema, mild upper airway obstruction triggered negative pressure pulmonary. Thus pre-operation hormones supplement is as important as keeping upper airway unobstructed.

Changes in Thyroid Replacement Therapy after Bariatric Surgery: Differences between Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy.

INTRODUCTION: Levothyroxine (LT4) requirements can presumably be modified differently after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). The present study compared changes in LT4 dose in hypothyroid subjects undergoing LRYGB or LSG 2 years after the procedure. MATERIAL AND METHODS: A 2-year follow-up observational study was conducted in a prospective cohort of obese patients who had undergone bariatric surgery and were receiving LT4. Indication for the type of surgical procedure was based on clinical criteria. Repeated measures ANOVA models were used to examine differences within and between groups. RESULTS: Thirty-five consecutive patients were included for analysis: 22 LRYGB and 13 LSG. Total daily LT4 dosage decreased in the LSG group (133.7 ± 50.3 mcg/day at baseline to 104.3 ± 43.3 mcg/day at 2 years; p = 0.047) whereas it remained stable in the LRYGB group (129.5 ± 46.1 mcg/day at baseline to 125.2 ± 55.7 mcg/day at 2 years; p = 1.000). Differences between groups became significant at 24 months. Daily weight-based LT4 dose increased in the LRYGB group (1.11 ± 0.38 mcg/kg day at baseline to 1.57 ± 0.74 mcg/kg day at 2 years; p = 0.005) with no significant changes in the LSG group (1.15 ± 0.35 mcg/kg day at baseline vs 1.11 ± 0.49 mcg/kg day at 2 years; p = 1.000). CONCLUSION: LRYGB and LSG showed different changes in LT4 requirements 2 years after surgery. There was an early decrease in daily total LT4 dose requirements after LSG, which suggests an early preventive reduction to be validated in future studies.

Critical Consideration of Myxedema Coma in the Postoperative Setting: A Case Report.

Myxedema coma is a rare but highly fatal condition with reported mortality >40%-50%. Early recognition and prompt treatment are critical for survival. Here we describe a case of possible postoperative myxedema coma after subacute neck hematoma evacuation after hemithyroidectomy in a patient on concurrent amiodarone therapy. Symptoms included somnolence, hypothermia, and prolonged QTc with torsades de pointes resistant to magnesium therapy requiring defibrillation and overdrive pacing. Consideration of the possible diagnosis of myxedema coma resulted in prompt therapy and symptom resolution within 48 hours. Thyroid disorders, although rare, should be considered in the postoperative setting.

Johanson-Blizzard syndrome with associated urogenital anomalies.

We present a case of a child with pancreatic insufficiency and facial defects typical of Johanson-Blizzard syndrome (JBS), along with the more facultative anomalies of the JBS, such as those of the urogenital system including persistent urogenital sinus, urethral duplication and dysplastic kidneys. Fetal ultrasound in a 21-year-old G1P1 woman revealed ambiguous genitalia. Examination at birth revealed a phallic structure with urethral meatus, non-palpable gonads, two orifices in close proximity in the perineum, with the anterior being a common urogenital channel and the posterior, the rectum. A voiding cystourethrogram/genitogram showed bilateral high-grade vesicoureteral reflux and a common urogenital sinus extending 1.5 cm before dividing into three channels: the native urethra, an accessory urethra directed anteriorly towards the clitoris and a septate vagina with uterus didelphys. JBS was suspected by clinical presentation and confirmed by UBR1 molecular testing (46,XX). At 16 months of age, she underwent feminising genitoplasty and posterior sagittal anorectoplasty.

Impact of subclinical hypothyroidism on clinical outcomes following percutaneous coronary intervention.

BACKGROUND: Similar to overt hypothyroidism, subclinical hypothyroidism (SCH) has been reported to increase the risk of cardiovascular disease. However, the influence of SCH on clinical outcomes following percutaneous coronary intervention (PCI) remains unclear. METHODS: We performed a prospective cohort study. SCH was defined as a thyroid-stimulating hormone (TSH) level ≥4.5mIU/l and a normal level of free thyroxine (FT4). A composite event was defined as the combination of cardiac death, non-fatal myocardial infarction (MI) and repeat revascularization. RESULTS: Of 936 patients, who were observed for 3.1years, 100 patients (10.7%) were diagnosed with SCH. Repeat revascularization, cardiac death and a composite event occurred more frequently in the SCH group than in the euthyroidism group, while the incidence of non-fatal MI was similar between the two groups. Multiple Cox regression analysis showed that SCH was associated with the risk of a composite event (hazard ratio, 1.52; 95% confidence interval, 1.04-2.22) after adjustment for age, sex, current smoking, ST-segment elevation MI, prior PCI, diabetes, hypertension, renal function, left ventricular ejection fraction, B-type natriuretic peptide, stent numbers, total stent length, stent types, obesity and lipid profiles. Serum TSH levels were also significantly associated with the risk of a composite event. SCH was not associated with repeat PCIs for de novo stenotic lesions but was associated with repeated PCIs for in-stent restenotic lesions. CONCLUSIONS: SCH negatively impacted clinical outcomes following PCIs. Therefore, patients with SCH should be carefully observed after undergoing a PCI.