Surviving complications of retroperitoneal fibrosis with intermittent relapses over a period of 20 years: case report and literature review / Sobrevivir a las complicaciones de la fibrosis retroperitoneal con recaídas intermitentes durante un período de 20 años: reporte de un caso y revisión de la literatura

Idiopathic retroperitoneal fibrosis is a rare fibro-inflammatory disease of varied etiology which usually originates around aorta and spreads caudally along Iliac vessels into adjacent retroperitoneum causing ureteral obstruction as the most frequent complication.A 53-year-old male patient presented with complaint of mild pain in both the legs off and on. On investigating further, we found that he had been struggling with intermittent relapses every 3-4 years for last 20 years since he was first diagnosed with Idiopathic Retroperitoneal Fibrosis. He was 33-year-old when he first developed the symptoms of anuria for 48 hours and was diagnosed with Idiopathic retroperitoneal fibrosis. This was followed by atrophy of left kidney and hypertension 6 years later, then hypothyroidism after another 3years and finally involvement of Inferior Vena Cava and acute Deep Vein Thrombosis of lower limbs after another 3-4 years. His deep vein thrombosis was well managed in time. He was put on glucocorticoids everytime he had a relapse and a complication.We did a review of literature to understand recent advances about its pathogenesis, diagnosis, investigations and management. We searched in PubMed using terms like retroperitoneal fibrosis alone and in combination with related terms such as Inferior Vena Cava thrombosis, Deep Vein Thrombosis, Tamoxifen, Methotrexate. This case is unique as it is very rare to find acute Deep Vein Thrombosis in Idiopathic retroperitoneal fibrosis without development of any collaterals when Inferior Vena Cava lumen is compromised to almost complete obstruction.After a follow up of 20 years patient is doing well in terms of physical activity and psychological wellbeing with anti-hypertensives, thyroxine and anti-coagulants. Is the disease-free interval actually free of the disease or it just subsided with immunosuppressants to become active after some time?

La fibrosis retroperitoneal idiopática es una enfermedad fibroinflamatoria rara, de etiología variada que generalmente se origina alrededor de la aorta y se propaga caudalmente a lo largo de los vasos ilíacos en retroperitoneo adyacente causando obstrucción ureteral como la complicación más frecuente.Reportamos el caso de un paciente varón de 53 años que se presentó con un dolor leve en ambas piernas. Al investigar más a fondo, descubrimos que había estado luchando con recaídas intermitentes cada 3-4 años durante los últimos 20 años desde que se le diagnosticó por primera vez fibrosis retroperitoneal idiopática. Tenía 33 años cuando desarrolló por primera vez los síntomas de anuria durante 48 horas y se le diagnosticó fibrosis retroperitoneal idiopática. Esto fue seguido por atrofia del riñón izquierdo e hipertensión 6 años después, luego hipotiroidismo después de otros 3 años y finalmente afectación de la vena cava inferior y trombosis venosa profunda aguda de las extremidades inferiores después de otros 3-4 años. Su trombosis venosa profunda se controló bien a tiempo. Le recetaron glucocorticoides cada vez que tenía una recaída y una complicación.Hicimos una revisión de la literatura para comprender los avances recientes sobre su patogenia, diagnóstico, investigaciones y manejo. Se realizaron búsquedas en PubMed utilizando términos como fibrosis retroperitoneal sola y en combinación con términos relacionados como trombosis de la vena cava inferior, trombosis venosa profunda, tamoxifeno, metotrexato. Este caso es único, ya que es muy raro encontrar trombosis venosa profunda aguda en fibrosis retroperitoneal idiopática sin desarrollo de colaterales cuando la luz de la vena cava inferior está comprometida hasta una obstrucción casi completa.Después de un seguimiento de 20 años, el paciente se encuentra bien en términos de actividad física y bienestar psicológico con antihipertensivos, tiroxina y anticoagulantes. ¿El intervalo libre de enfermedad está realmente libre de la enfermedad o simplemente disminuyó con inmunosupresores para activarse después de algún tiempo?

Alteraciones tiroideas en la infancia y en la adolescencia. Parte 2: hipotiroidismo / Thyroid disorders in childhood and adolescence. Part 2: Hypothyroidism

El hipotiroidismo es la disfunción tiroidea más frecuente, resultante de una disminución de la actividad biológica de las hormonas tiroideas en los tejidos. El objetivo es realizar una revisión y actualización del hipotiroidismo adquirido en la infancia y adolescencia con énfasis en el hipotiroidismo primario. La causa más común es la tiroiditis de Hashimoto o tiroiditis linfocitaria crónica. La característica distintiva es el impacto profundo en el crecimiento esquelético, maduración y desarrollo puberal, con potencial repercusión en la talla adulta. Los signos y síntomas del hipotiroidismo adquirido son similares a los adultos y, en general, no se asocia con compromiso del desarrollo neuromadurativo.La presunción clínica se confirma con niveles elevados de tirotrofina y disminuidos de tiroxina libre. Las metas del tratamiento incluyen lograr adecuado crecimiento, maduración sexual, desarrollo neuromadurativo y cognitivo óptimo. En la mayoría de los pacientes, el tratamiento de reemplazo revierte los signos y síntomas.

Hypothyroidism is the most frequent thyroid dysfunction. It is the consequence of a decrease in the biological activity of thyroid hormones in target tissues. The aim of this paper is to review and update acquired hypothyroidism in childhood and adolescence with emphasis on primary hypothyroidism due to its greater frequency. Hashimoto's thyroiditis, also known as chronic lymphocytic thyroiditis, is the most common cause of primary acquired hypothyroidism. The distinctive feature is the profound impact on skeletal growth, maturation, and pubertal development, with potential implications on adult height. Signs and symptoms of acquired hypothyroidism are similar to those reported in adults and are generally not associated with neurodevelopmental impairment. Biochemi confirmation of primary hypothyroidism requires the finding of elevated thyrophine and decreased free thyroxine levels. Treatment goals are to achieve normal growth and maturation as well as cognitive development. In most of the patients, replacement treatment reverses symptoms and signs of hypothyroidism and may decrease goiter size.

A practical contemporary approach to decision-making on subclinical hypothyroidism

ABSTRACT Subclinical hypothyroidism (Shypo) is an increasingly frequent condition in common medical practice. Its diagnosis continues to pose a challenge since a series of non-thyroidal and temporary conditions can elevate serum TSH levels. In addition, the consequences of Shypo are still up for debate. Although detrimental cardiovascular effects have been consistently demonstrated in the young, they are less evident in older adults (65-79 years), and even more so in the oldest old (≥80 years). In the absence of evidence of any benefits of treating Shypo in patients' clinical manifestations and unfavorable outcomes, the most effective decision-making approach should include a thorough investigation of the patient's condition integrating all relevant clinical data, such as TSH levels, age, quality of life, comorbidities, cardiovascular risk, safety, and personal preferences. The decision-making process needs to take into account the risk of levothyroxine overtreatment and the resulting adverse consequences, such as reduction of bone mineral density, heart failure, and atrial fibrillation. Hence, current evidence suggests that individuals with TSH > 10 mU/L, who test positive for TPO Ab or are symptomatic may benefit from levothyroxine treatment. However, a more cautious and conservative approach is required in older (≥65 years of age), and oldest-old (≥80 years) patients, particularly those with frailty, in which the risk of treatment can outweigh potential benefits. The latter may benefit from a wait-and-see approach.

Treatment of hypothyroidism in special situations / Tratamiento del hipotiroidismo en situaciones especiales

Abstract The treatment of hypothyroidism is aimed at restoring the euthyroid state. In most cases, the signs and symptoms of thyroid deficiency generally resolve, which is particularly gratifying for the treating physician and mainly, for patients. However, there may be coexisting special situations that can potentially hinder or interfere with a successful treatment, as in the case of the elderly, patients suffering from heart disease, hematological diseases or dyslipidemia, hypothyroid patients who will undergo an emergency surgery, those with chronic kidney failure, or adrenal insufficiency, among others. Besides management of hypothyroidism in time of COVID-19 is also included. Some patients may experience intolerance to treatment and others persistent symptoms of hypothyroidism even under adequate replacement therapy, requiring a special approach. Being aware of these special situations will provide benefits to the patient and will also prevent treatment failure or complications.

Resumen El tratamiento del hipotiroidismo tiene como objetivo restaurar el estado eutiroideo. En la mayoría de los casos los signos y síntomas del déficit tiroideo en general se resuelven, lo cual es muy gratificante para el médico tratante y en especial para los pacientes. Sin embargo, pueden coexistir situaciones especiales que potencialmente dificulten o interfieran con un tratamiento exitoso como en el caso de los pacientes ancianos, aquellos con cardiopatías, enfermedades hematológicas o dislipemia, pacientes hipotiroideos que requieran cirugía de urgencia, aquellos con insuficiencia renal crónica, o insuficiencia adrenal, entre otras. Además, se incluye el manejo del hipotiroidismo en la era del COVID-19. Algunos pacientes pueden manifestar intolerancia al tratamiento y otros, persistencia de síntomas de hipotiroidismo aun bajo un adecuado reemplazo hormonal, lo cual requerirá un abordaje especial. Estar advertido de estas situaciones especiales redundará en el beneficio del paciente y evitará fracasos o complicaciones terapéuticas.

Livro de resumos: XVII Jornada Acadêmica de Saúde Mental da Faculdade de Medicina da Universidade Federal de Minas Gerais / Livro de resumos: XVII Jornada Acadêmica de Saúde Mental da Faculdade de Medicina da Universidade Federal de Minas Gerais

A XVII Jornada Acadêmica de Saúde mental é um evento que busca aproximar os estudantes de cursos variados do campo de estudo da Saúde Mental. Além de aulas ministradas na forma de palestras, os acadêmicos são convidados a produzirem trabalhos para serem apresentados aos demais participantes, ampliando o leque de assuntos abordados. Além de proporcionar aos estudantes interessados maior contato com temas específicos da área, a produção de resumos para apresentação é uma ferramenta para aprimoramento das técnicas de escrita e produção de conteúdo. Elaborar os trabalhos amplia os conhecimentos dos alunos sobre escrita científica e os aproxima do meio acadêmico científico. Ademais, o contato com professores e pesquisadores da área, que orientam os participantes durante o processo, cria canais de comunicação e abre novas oportunidades para os estudantes. Para esta edição do evento, os trabalhos foram selecionados pela Comissão Científica da Jornada, que verificou um alto nível nas submissões. Aqueles mais originais, relevantes e bem produzidos foram aprovados e compõem esse livro, mostrando à comunidade a qualidade dos estudantes e do conteúdo apresentado na XVII JASME. Os assuntos discutidos nos próximos capítulos, desenvolvidos por estudantes de cursos da área da saúde, abrangem a saúde mental por variados ângulos e sob diversas abordagens. Escolher alguns trabalhos significa, necessariamente, prescindir de outros. Cientes do desafio de estabelecer uma coletânea que tivesse o padrão de qualidade e a feição da UFMG sem nos obnubilar pela subjetividade, estabelecemos critérios objetivos e submetemos cada resumo à apreciação independente de pelo menos três integrantes da junta científica para apreciação. Por fim, aferimos que não houve divergência de rigor entre os subgrupos e selecionamos os trinta melhores, ou seja, os mais inovadores, bem escritos, objetivos e bem fundamentados. Procuramos, diante dos diversos recortes da pandemia da COVID-19, incluir aqueles que, em vez de vagos de tão abrangentes, descreviam impactos tangíveis, mensuráveis e inusitados, isto é, Relacionados a grupos que não têm sido abordados pela grande mídia e tampouco pelo profissional de saúde médio. Assim, cremos que os resumos a seguir são os que mais bem abordam tanto questões atemporais em saúde mental quanto aquelas que emergiram nos últimos meses e ainda não sabemos por quanto tempo perdurarão. Os trabalhos tratam desde questões relacionadas aos fatores de risco para o desenvolvimento de transtornos psiquiátricos aos aspectos do tratamento farmacológico. Com uma perspectiva atual e relevante para as condições de saúde vigente, as temáticas se relacionam com diversas áreas da saúde mental, como as consequências da pandemia da SARS-COV2, aspectos da saúde mental em jovens e idosos, condutas da saúde mental na saúde primária, psicofarmacologia, transtornos psiquiátricos.

Suicidabilidad y apoyo social percibido en estudiantes universitarios con enfermedades crónicas no transmisibles / Suicidality and perceived social support in university students with chronic non-communicable diseases

Resumen El objetivo fue identificar las asociaciones entre apoyo social percibido, riesgo suicida y presencia de enfermedad crónica no transmisible en estudiantes universitarios. Utilizando un diseño de casos y controles, con 41 estudiantes universitarios por grupo. La mediana de edad fue de 22 años (R = 9), un 81,8% eran mujeres, el 26,8% de los sujetos tenía Asma y el 26,8% Hipotiroidismo, y el 63,6% pertenecía a la Facultad de Educación. No se comprobó la asociación entre enfermedad crónica, apoyo social, ni tampoco con riesgo suicida. Hay asociación indirecta entre riesgo suicida y apoyo social, no así cuando se evalúa el intento de suicidio previo. El nivel de riesgo suicida y apoyo social se asocian independiente de la presencia de enfermedad crónica. Esperamos que nuestros resultados permitan fomentar el apoyo social como una herramienta fundamental para la prevención de la suicidabilidad, especialmente en sujetos con enfermedad crónica.

Abstract The objective was to identify associations between perceived social support, suicidal risk and the presence of chronic or communicable disease in university students. Using a case-control design, consisting of 41 subjects in each group. The median age was 22 years (R = 9), 81,8% were women, 26,8% of the subjects had asthma and 26,8% had hypothyroidism, 63,6% were students of the faculties of Education. The association between chronic disease and social support was not proven, nor was there a suicidal risk. There is an indirect association between suicide risk and social support, not so when assessing the previous suicide attempt. The levels of suicide risk and social support are associated, independent of an existing chronic disease. We are hopeful that our results will be effective in promoting social support as a basic tool for suicide prevention, especially in subjects with chronic disease.

Asociación entre hipotiroidismo y diagnóstico psiquiátrico en una Unidad Técnica de un hospital de tercer nive / Association between hypothyroidism and psychiatric diagnosis in a Technical Unit of a third-level hospital

INTRODUCCIÓN. La relación entre el eje tiroideo y las patologías psiquiátricas, ha sido tema de amplio estudio, siendo la de mayor interés los trastornos afectivos y el hipotiroidismo. No solo la similitud de los síntomas que presentan las patologías, sino también la terapéutica esta-blecida, son argumentos a favor de la existencia de una relación significativa. A pesar de esto, la información de la que se dispone de estudios realizados es dividida. OBJETIVO. Describir la influencia del hipotiroidismo en el tipo de diagnóstico psiquiátrico y características clínicas en pacientes hospitalizados en la Unidad Técnica de Salud Mental. MATERIALES Y MÉTODOS. Estudio descriptivo y retrospectivo con una población de 678 pacientes y, muestra de 472, los criterios de inclusión fueron: mayores a 18 años: adultos de mediana edad de 18 a 64 y adultos mayores de 65 años, con diagnóstico definitivo de egreso acorde a la Clasificación Internacional de Enfermedades - 10 de trastornos mentales y del comportamiento; muestra subcategorizada en trastornos: 259 afectivos, 131 psicóticos, 44 por consumo de sustancias y 38 ansiosos; y, en los que se investigó hipotiroidismo, estuvieron hospitalizados y atendidos en la Unidad Técnica de Salud Mental del Hospital de Especialidades Carlos Andrade Marín, durante los años 2014 y 2015. Los datos fueron analizados con el programa estadístico International Business Machines Statistical Package for the Social Sciences, Versión 22.0. RESULTADOS. El 51,50% (243; 472) fueron de sexo masculino; el 90% (425; 472) fueron adultos de mediana edad; 54,9% (259; 472) fueron trastornos afectivos; 18,4% (87; 472) fueron pacientes hipotiroideos con diagnóstico defini-tivo de egreso de trastornos mentales y del comportamiento que correspondieron a los mayores de 65 años. Trastornos afectivos 19,7% (51; 259), psicóticos 16,8% (22; 131), por consumo de sustancias 13,6% (6; 44) y ansiosos 21,1% (8; 38). CONCLUSIÓN. Se evidenció una relación significativa entre hipotiroidismo y trastornos mentales y del comportamiento sobre todo del tipo afectivo en adultos mayores.

INTRODUCTION. The relationship between the thyroid axis and psychiatric pathologies has been the subject of extensive study, with affective disorders and hypothyroidism. Being of greatest inte-rest. Not only the similarity of the symptoms presented by the patologies,, but also the established therapeutic, are arguments in favor of the existence of a significant relationship. Despite this, from which studies are availablet is divided. OBJECTIVE. Describe the influence of hypothyroidism on the type of psychiatric diagnosis and clinical characteristics hospitalized patients at the Technical Unit for Mental Health. MATERIALS AND METHODS. Descriptive and retrospective study with a population of 678 patients and, sample of 472, the inclusion criteria were: older than 18 years: mi-ddle-aged adults aged 18 to 64 and adults over 65 years old, with definitive diagnosis of dischargeaccording to the Classification International Diseases - 10 of mental and behavioral disorders; sample subcategorized in disorders: 259 affective, 131 psychotic, 44 for substance use and 38 anxious; and, in which hypothyroidism was investigated, they were hospitalized and attended for in the Technical Mental Health Unit of the Carlos Andrade Marín Specialities Hospital, during the years 2014 and 2015. The data were analyzed using the Statistical Program International Bu-siness Machines Statistical Package for the Social Sciences, Version 22.0. RESULTS. 51,50% (243; 472) were male; 90% (425; 472) were middle-aged adults; 54,9% (259; 472) were affecti-ve disorders; 18,4% (87; 472) were hypothyroid patients with definitive discharage diagnosis of mental and behavioral disorders that corresponded to the elderly 65 years. Affective disorders 19,7% (51; 259), psychotic 16,8% (22; 131), substance use 13,6% (6; 44) and anxious 21,1% (8; 38). CONCLUSION. There was a significant relationship was shown between hypothyroidism and mental and behavioral disorders especially of the affective type in older adults.

Influencia del hipotiroidismo e hipertiroidismo en el desarrollo de enfermedad cardiovascular / Influence of hypothyroidism and hyperthyroidism in the development of cardiovascular disease

INTRODUCCIÓN. El hipotiroidismo e hipertiroidismo, constituyen patologías tiroideas, que si no reciben tratamiento apropiado llegan a provocar alteraciones sistémicas, siendo una de las principales las cardiovasculares. OBJETIVO. Conocer la influencia que tiene el hipotiroidismo e hipertiroidismo como factores de riesgo para el desarrollo de enfermedad cardiovascular. MATERIALES Y MÉTODOS. Estudio retrospectivo de enfoque cuantitati-vo; desarrollado en una población y muestra conocida de 111 pacientes, que acudieron al Servicio de Endocrinología del Hospital Manuel Ygnacio Monteros Valdivieso de la ciudad de Loja, atendidos en el año 2015. RESULTADOS. Predominó el sexo femenino, con un 20,72% (23; 69) en el grupo etario de 61 a 70 años de las pacientes hipotiroideas; y las de 51 a 60 años en 5,40% (6; 11) de las hipertiroideas. De acuerdo a los parámetros que pue-den condicionar mayor riesgo cardiovascular, el sobrepeso y obesidad presentaron una mayor frecuencia para hipotiroidismo en 67,70% (65; 111) e hipertiroidismo en un 66,67% (10; 111). El riesgo bajo cardiovascular prevaleció en 75,00% (72; 96) de la población hipo-tiroidea y 93,33% (14; 15) de la hipertiroidea. La hipertensión arterial fue la patología car-diovascular diagnosticada con mayor frecuencia sobre todo en los pacientes hipotiroideos representado por el 14,58% (14; 19). CONCLUSIÓN. Estas patologías, de no controlarse pudieran condicionar en la población de estudio un mayor riesgo cardiovascular.

INTRODUCTION. Hypothyroidism and hyperthyroidism, constitute thyroid pathologies, that if they do not received appropriate treatment, cause systematic alterations, treatment, cause systematic cardiovascular diseases being one of the main ones. OBJECTIVE. Know the influence of hypothyroidism and hyperthyroidism as risk factors for the development of cardiovascular disease. MATERIALS AND METHODS. Retrospective study of quantitative approach; developed in a population and known sample of 111 patients, who went to the Endocrinology Service of the Manuel Ygnacio Monteros Valdivieso Hospital in the city of Loja, attended in 2015. RESULTS. The female sex predominated, with 20,72% (23; 69) in the age group predominated 61 to 70 years of age in 5,40% (6; 11) of hyperthyroids. According to the parameters that may condition higher cardiovascular risk, overweight and obesity presented a higher frequency for hypothyroidism in 67,70% (65; 111) and hyperthyroidism in 66,67% (10; 111). Low cardiovascular risk prevailed in 75,00% (72; 96) of the hypothyroid population and 93,33% (14; 15) of the hyperthyroid population. Arterial hypertension was the most frequently diagnosed cardiovascular disease, especially in hypothyroid patients by 14,58% (14; 19). CONCLUSION. These pathologies, if not controlled, could condition a higher cardiovascular risk in the study population.

Relación entre hipotiroidismo y artritis reumatoide / Relationship between hypothyroidism and rheumatoid arthritis

Introducción: el hipotiroidismo es una enfermedad sistémica, crónica caracterizada por la disminución de la producción de hormonas tiroideas, en muchas ocasiones el trastorno inmunológico forma parte del mecanismo etiopatogénico de la enfermedad. Se asocian con otras enfermedades autoinmunes como es el caso de la artritis reumatoide, generando de esta forma un complejo cortejo sintomático en el que ambas afecciones pueden coexistir provocando importantes grados de discapacidad funcional y de disminución de la percepción de calidad de vida relacionada con la salud. Objetivo: describir la relación existente entre las enfermedades tiroideas y la artritis reumatoide. Método: estudio descriptivo en 265 pacientes con artritis reumatoide según los criterios del Colegio Americano de Reumatología para describir la relación entre esta enfermedad y los trastornos de la glándula tiroides. Se utilizó coeficiente de correlación de Pearson para determinar la relación existente entre ambas afecciones. Resultados: promedio de edad general de 58,39 años y de pacientes con hipotiroidismo de 66,32 años. Predominio de pacientes femeninas (76,98 por ciento ) y con tiempo de evolución entre 3 y 5 años. El 29,81 por ciento de los casos presentó diagnóstico de hipotiroidismo confirmado, con predominio en pacientes femeninas (86,08 por ciento ), edad mayor de 65 años (49,37 por ciento ) y tiempo de evolución de la artritis reumatoide mayor de cinco años (53,16 por ciento ). Conclusiones: existe un elevado por ciento de pacientes con hipotiroidismo y artritis reumatoide; aunque ambas afecciones comparten mecanismos inmunológicos comunes, no se encuentra una relación directa entre ambas, no pudiéndose establecer una relación causa efecto entre ambas afecciones(AU)

Introduction: hypothyroidism is a systemic, chronic disease characterized by decreased production of thyroid hormones, in many cases the immune disorder is part of the etiopathogenic mechanism of the disease. They are associated with other autoimmune diseases such as rheumatoid arthritis, thus generating a complex symptomatic courtship in which both conditions can coexist leading to significant degrees of functional disability and decreased perception of quality of life related to health. Objective: to describe the relationship between thyroid diseases and rheumatoid arthritis. Method: descriptive study in 265 patients with rheumatoid arthritis according to the criteria of the American College of Rheumatology to describe the relationship between this disease and disorders of the thyroid gland. Pearson's correlation coefficient was used to determine the relationship between both conditions. Results: average age of 58.39 years and of patients with hypothyroidism of 66.32 years. Predominance of female patients (76.98 percent) and with evolution time between 3 and 5 years. The 29.81 percent of the cases presented a diagnosis of confirmed hypothyroidism, with predominance in female patients (86.08 percent), age over 65 years (49.37 percent) and time of evolution of rheumatoid arthritis greater than five years (53.16 percent). Conclusions: there is a high percentage of patients with hypothyroidism and rheumatoid arthritis; although both conditions share common immunological mechanisms, there is no direct relationship between the two, and a causal relationship can´t be established between the two conditions(AU)

Modelo ambulatorial de atendimento de nódulo de tireoide / Ambulatory care model thyroid nodule

A prevalência de detecção de nódulos na tireoide através da palpação é de aproximadamente 5%. Essa prevalência sobe para 19 a 67% quando utilizada a avaliação ecográfica. A importância da avaliação clínica dessa entidade está na necessidade de diagnosticar o câncer de tireoide que ocorre em 5 a 10% dos casos. O relato descreve o perfil dos atendimentos realizados no ambulatório de nódulos de tireoide do Hospital Municipal Dr. Mário Gatti no período de 01/05/17 a 27/07/18 de pacientes que tiveram diagnóstico ultrassonográfico de nódulo de tireoide e realizaram punção aspirativa por agulha fina, a fim de inferir a respeito da capacidade de resolutividade do ambulatório interdisciplinar (endocrinologia e cirurgia de cabeça e pescoço) no diagnóstico e tratamento do câncer de tireoide. A organização do ambulatório com atendimento integral e por equipe multidisciplinar, possibilita uma melhora na qualidade assistencial além de ser elemento facilitador para o ensino, aprendizado e pesquisa. (AU)

The rate of thyroid node detection by touch is approximately 5%. This rate goes up to a range between 19 and 67% when a sonographic evaluation is used. The importance of the clinical evaluation of those thyroid nodes is within the need of diagnosing the cancer that occurs in 5 to 10% of the cases. This paper describes the profile of consultations performed at the Outpatient Clinic Thyroid Node Unit of the Municipal Hospital Dr. Mário Gatti (HMMG) from 01/05/17 to 07/27/18, of patients who had ultrasonographic diagnostics of thyroid node and underwent fine-needle aspiration, in order to draw conclusions about the capacity of the interdisciplinary clinic (Endocrinology and Head and Neck surgery) to diagnose and treat thyroid cancer effectively. The organization of the outpatient clinic, with comprehensive care and multidisciplinary team, enables an improvement in medical assistance as well as facilitating teaching, learning and research. (AU)

Sexual function in female juvenile idiopathic arthritis patients

Abstract Objective: To evaluate sexual function female adolescents and young adults with juvenile idiopathic arthritis (JIA) and healthy controls. Methods: After exclusion, 21 female adolescent and young JIA patients and 25 healthy controls were selected for this study. Sexual function was assessed by the Sexual Quotient Questionnaire for Females (SQQ-F) score, which is a validated tool and adapted for Brazilian Portuguese language. Demographic data, JIA clinical/laboratory parameters and treatment were also assessed. Results: The median current age [26.5 (17-38.1) vs. 29.3 (19.7-35.8) years, p = 0.700)] as well as age at the first sexual activity [18 (14-30) vs. 17 (10-24) years, p = 0.158] were similar in JIA patients and healthy controls. The median of SQQ-F score was alike in both groups [75.9 (50-92) vs. 78.2 (58-94), p = 0.529], as well as frequencies of sexual dysfunction (14% vs. 12%, p = 1.000). The frequencies of all sexual domains (desire/sexual fantasies, desire/interest, arousal/foreplay, arousal/lubrication, arousal/in tune with partner, penetration/relaxation, pain/penetration, desire/involvement, orgasm and general satisfaction scores) were similar in JIA patients and healthy controls (p > 0.05). Conclusions: To our knowledge, this was the first study using a validated sexual score in a chronic arthritis population suggesting a low frequency of overall sexual dysfunction in young JIA patients. Future multicenter studies with a large sample will be necessary to confirm this finding.

Caracterización de la disfunción tiroidea en adultos con enfermedad renal crónica en diálisis / Characterization of thyroid dysfunction in adults with chronic renal disease in dialysis

Resumen Introducción: existe una clara relación entre la disfunción tiroidea y la enfermedad renal crónica (ERC) que se evidencia por el aumento de la prevalencia de hipotiroidismo primario a medida que disminuye la tasa de filtración glomerular. Objetivo: caracterizar los pacientes adultos con disfunción tiroidea y enfermedad renal crónica en terapia dialítica. Métodos: e realizó un estudio observacional de tipo descriptivo, transversal, que caracterizó y recolectó datos de laboratorio en pacientes mayores de 18 años con ERC. Estos pacientes se encontraban en terapia dialítica en una unidad renal de la ciudad de Cartagena (Colombia) y se les practicó un control de TSH en el año 2016. Resultados: se incluyeron 350 pacientes con registro de TSH. La mediana de edad fue de 59 años y el 49.1% eran mujeres. La principal causa de la ERC fue la hipertensión (36.3%) y la principal comorbilidad fue el hiperpatioidismo (56%). En relación con la disfunción tiroidea, se evidenció que el 25.4% de la población presentó niveles de TSH mayores a 4.5 uIU/mL. Dentro de este segmento, un 5.7% se encontraba en rango de hipotiroidismo (TSH>10 uIU/mL). Conclusiones: la prevalencia de la disfunción tiroidea fue mayor en la muestra, en comparación con la población general. No obstante, se requieren estudios adicionales con medición de T4L para realizar una adecuada categorización.

Abstract Background: There is a clear relationship between thyroid dysfunction and chronic kidney disease (CKD), which is evidenced by the increase in the prevalence of primary hypothyroidism when the glomerular filtration rate decreases. Objectives: Characterize adult patients with thyroid dysfunction and chronic kidney disease on dialysis therapy. Methods: An observational, descriptive, cross-sectional study was carried out that characterized and collected laboratory reports of patients >18 years of age with CKD in dialysis therapy of a renal unit of the city of Cartagena/Bolívar with TSH control in 2016. Results: 350 patients with TSH registry were included, with a median age of 59 years and 49.1% were women. The main cause and comorbidity of CKD was hypertension in 36.3% and hyperpatioidism in 56% respectively. In relation to thyroid dysfunction, 25.4% of the population had TSH levels> 4.5 uIU/mL, of which 5.7% had TSH levels> 10 uIU/mL (hypothyroidism). Conclusions: The prevalence of thyroid dysfunction was higher than in the general population, however additional studies with measurement of FT4 are necessary to achieve an adequate categorization.

Prevalencia de hipotiroidismo subclínico, deterioro cognitivo y su posible asociación en adultos mayores de una clínica de la Ciudad de México 2016 / Prevalence of subclinical hypothyroidism and cognitive impairment and its possible linkage in older adults from a clinic in Mexico City 2016

Resumen Introducción: el hipotiroidismo se ha asociado con deterioro cognitivo, así como con reducción en la calidad de vida; sin embargo, existe controversia al respecto porque la evidencia es contradictoria. El hipotiroidismo parece provocar alteraciones en el estado cognitivo y en el estado de ánimo en adultos mayores, por lo que se requieren estudios para establecer dicha asociación y de esta manera evaluar el tratamiento sustitutivo hormonal. Objetivo: determinar la prevalencia de hipotiroidismo subclínico, deterioro cognitivo en el adulto mayor y su posible asociación en pacientes adultos mayores. Material y métodos: estudio transversal, descriptivo, y analítico, realizado en el módulo de gerontología en la Clínica Medicina Familiar "Dr. Ignacio Chávez", Ciudad De México, de junio a noviembre de 2016. Se realizó muestreo no probabilístico por conveniencia. Se aplicó el examen Mini mental para deterioro cognitivo. Se enviaron las muestras de sangre al laboratorio para la realización de pruebas de función tiroidea. El análisis estadístico se realizó con la prueba de chi cuadrado de independencia con nivel de significancia de 0,05. Se utilizó el programa estadístico Statistical Package for the Social Sciences, versión 22. Resultados: se estudiaron 120 adultos mayores con un promedio de edad de 78,2 años. El 35,8% de los pacientes presentaron hipotiroidismo subclínico, y el 63% presentó algún grado de deterioro cognitivo. Al asociar estas variables, no se obtuvo significancia estadística (p=0,556). Conclusiones: este estudio demuestra una alta prevalencia de hipotiroidismo subclínico y de deterioro cognitivo en la población de estudio, sin que se haya presentado asociación entre ambas variables. MÉD.UIS. 2018;31(3):21-25.

Abstract Introduction: hypothyroidism has been related to cognitive impairment, as well as a reduction in life quality, however, controversy exists in this matter because evidence is contradictory. Hypothyroidism seems to cause changes in elderly's cognitive and emotional state. Studies are required to establish such relationship, and to evaluate substitute hormonal treatment. Objective: to determine the prevalence of subclinical hypothyroidism and cognitive impairment in older adults and its possible association in elderly patients. Material and Methods: cross-sectional, analytic, descriptive study, carried out in a Gerontology Module from Family Medicine Clinic "Dr. Ignacio Chávez" in Mexico City, from June to November 2016. Non probabilistic convenience sampling was done. Mini Mental Status Exam was applied for cognitive impairment. Blood Samples were sent to laboratory to make thyroid function tests. Statistical Analysis including independence Chi-Square with significance level 0,05. Statistical Package for the Social Science version 22 was used. Results: 120 older adults were studied, the average age was 78,2. 35.8% of the patients presented subclinical hypothyroidism, and 63% presented some degree of cognitive impairment. While relating this variables, no statistical significance was obtained (p=0,556). Conclusions: The present study demonstrated a high prevalence of subclinical hypothyroidism and cognitive impairment in the study population. The relationship between the two variables was not demonstrated. MÉD.UIS. 2018;31(3):21-25.

Prevalência de disfunções tireoidianas em pacientes atendidos no Laboratório Clínico do Hospital da Polícia Militar do Estado de Goiás no período de 2015 a 2016 / Prevalence of thyroid dysfunctions in patients attended at the Clinical Laboratory of the Military Police Hospital of the Goias State in the period from 2015 to 2016

Objetivo: Realizar o rastreamento da prevalência das disfunções tireoidianas dos pacientes atendidos no Laboratório Clínico do Hospital do Policial Militar de Goiás, em Goiânia, GO. Métodos: Foi realizada a coleta de dados de 3.365 indivíduos com idades entre 01 e 99 anos, apresentando resultados das dosagens de TSH e T4 Livre e autoanticorpos tireoidianos (antitireoglobulina e antitireoperoxidase). A metodologia utilizada foi a eletroquimio- luminescência. Resultados: Dos 3.365 pacientes, 31,0% eram do sexo masculino e 69,0% do sexo feminino. Desse total, 25,9% utilizavam medicamento para tireoide e 74,1% não. A classificação quanto à disfunção tireoidiana foi baseada no número de indivíduos que não realizavam uso de medicamentos para tireoide, dos quais, 81,4% apresentaram resultados normais e 18,6% resultados alterados. Dentre os resultados alterados, o hipotireoidismo subclínico apresentou prevalência de 64,9% no sexo feminino, sendo a faixa de 40 a 49 anos a mais acometida. No sexo masculino, a prevalência foi de 35,1% sendo a faixa de 50 a 59 anos a mais atingida. As mulheres apresentaram 36,1% de positividade para um ou dois dos autoanticorpos e os homens um percentual de 26,3%. Indivíduos com hipotireoidismo subclínico associado ao índice de massa corporal alterado, exibiram um percentual de 69,8%. Conclusão: Na triagem das disfunções tireoidianas, é indispensável a solicitação do TSH, pois esse teste aponta pequenas variações séricas dos hormônios tireoidianos, porém a adoção do T4 Livre é fundamental quando o TSH apresenta limitações. O hipotireoidismo subclínico foi mais prevalente em mulheres, sendo justificado por idade avançada, menopausa e maior procura pelos serviços de saúde.

Relationship between heart rate variability and subclinical thyroid disorders of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

The association between subclinical thyroid dysfunctions and autonomic modulation changes has been described by many studies with conflicting results. We aimed to analyze the association between subclinical hyperthyroidism (SCHyper), subclinical hypothyroidism (SCHypo), and heart rate variability (HRV) using the baseline from ELSA-Brasil. SCHyper and SCHypo were classified by use of medication to treat thyroid disorders, thyrotropin levels respectively above and under the reference range, and normal free thyroxine levels. For HRV, the participants underwent 10 min in supine position and the R-R intervals of the final 5 min were selected for analysis. We first used linear regression models to report crude data and then, multivariate adjustment for sociodemographic (age, sex, and race) and cardiovascular risk factors (hypertension, dyslipidemia, diabetes, smoking, body mass index, use of alcohol, and leisure physical activity) using the euthyroid group as reference. From 9270 subjects (median age, 50; interquartile range: 44-56), 8623 (93.0%) were classified as euthyroid, 136 (1.5%) as SCHyper, and 511 (5.5%) as SCHypo. Compared to euthyroid subjects, SCHyper participants presented significantly higher heart rate (68.8 vs 66.5 for euthyroidism, P=0.007) and shorter R-R intervals (871.4 vs 901.6, P=0.007). Although SCHyper was associated with lower standard deviation of NN interval (SDNN) (β: -0.070; 95% confidence interval (95%CI): -0.014 to -0.009) and low-frequency (LF) (β: -0.242, 95%CI: -0.426 to -0.058) compared to the euthyroid group, these differences lost significance after multivariate adjustment for confounders. No significant differences were found for HRV in SCHypo. No association was found between HRV and SCHyper or SCHypo compared to euthyroid subjects in this sample of apparently healthy subjects.

Hypothyroidism is a risk factor for atrial fibrillation after coronary artery bypass graft

Abstract Introduction: Few reports in the world have shown a differential effect of hypothyroidism in relation to morbidity and mortality following cardiac surgery. Objective: To determine the association between preoperative hypothyroidism, composite and disaggregated outcomes of mortality and complications in patients undergoing first-time isolated myocardial revascularization surgery. Methods: Historical cohort of patients undergoing myocardial revascularization between January 2008 and December 2014, with 626 patients included for evaluation of the composite and disaggregated outcomes of in-hospital mortality and complications (atrial fibrillation, surgical site infection and reoperation due to bleeding). A logistic regression model was used to determine the association between hypothyroidism and the onset of those outcomes. Results: Cohort of 1696 eligible patients for the study, with 1.8 mortality. Median age, female gender and prevalence of arterial hypertension were all significantly higher among hypothyroid patients. No differences were found in other preoperative or intraoperative characteristics. Hypothyroidism was associated with the presence of the composite outcome, RR 1.6 (1.04-2.4) and atrial fibrillation 1.9 (1.05-3.8). No association with mortality, infections or reoperation due to bleeding was found. Conclusion: Hypothyroidism is a disease that affects females predominantly and does not determine the presence of other comorbidities. Hypothyroidism is a risk factor for the onset of postoperative fibrillation in patients undergoing myocardial revascularization surgery. Postoperative care protocols focused on the prevention of these complications in this type of patients must be instituted.

Síndrome metabólico, hipotiroidismo y riesgo cardiovascular en licenciadas y auxiliares de enfermería, Hospital Escuela Universitario octubre-noviembre 2016 / Metabolic syndrome, hypothyroidism and cardiovascular risk in registered and auxiliary nurses, Hospital Escuela Universitario October-November 2016

Antecedentes y objetivo: La disfunción tiroidea en la población tiene considerables consecuencias en numerosos problemas de salud, incluyendo enfermedades cardiovasculares y síndrome metabólico. El objetivo del estudio fue analizar la relación entre el riesgo cardiovascular, hipotiroidismo y síndrome metabólico en una muestra de enfermeras del Hospital Escuela Universitario entre octubre y noviembre 2016. Pacientes y métodos: Estudio descriptivo, transversal. Muestreo estratificado por adecuación: 150 auxiliares y 50 licenciadas en enfermería del sexo femenino. Se utilizó la técnica de entrevista, mediante un cuestionario con 20 preguntas cerradas. Los resultados fueron tabulados en el programa estadístico EPI-INFO versión 7.2.0.1 y Microsoft Office Excel 2013, se realizó análisis univariado y bivariado. Resultados: Se encontró que 94 (47%) no presentaron síndrome metabólico ni hipotiroidismo, 82 (41%) fueron diagnosticadas únicamente con síndrome metabólico, 12 (6%) hipotiroidismo subclínico y 12 (6%) ambas enfermedades. Los principales criterios de síndrome metabólico cumplidos por la población de estudio fueron: 159 (79,5%) con perímetro abdominal ≥ 88 cm y 151 (75,5%) con colesterol HDL < 50 mg/dL. El criterio de síndrome metabólico con mayor importancia en la población de estudio fue triglicéridos ≥ 150 mg/dL con un puntaje de 16. En riesgo cardiovascular, 194 (97%) enfermeras presentaron un nivel de riesgo bajo. Conclusiones: La mayoría de la población presentó índice de masa corporal alterado y algún tipo de dislipidemia asociada. La prevalencia de hipotiroidismo subclínico en el personal de enfermería fue similar a la encontrada en otros estudios y la de síndrome metabólico fue mayor a la reportada a nivel mundial (20-25%) y nacional (23%).

Background and objective: Thyroid dysfunction in the population has significant consequences for numerous health problems, including cardiovascular diseases and metabolic syndrome. The objective of this study was to analyse the relationship between cardiovascular risk, hypothyroidism, and metabolic syndrome in nurses of the Hospital Escuela Universitario from October to November 2016. Patients and methods: A descriptive, cross-sectional study was conducted on a stratified sample consisting of 150 auxiliary nurses and 50 registered nurses, all females. The interview technique was used in the data collection process, using a questionnaire consisting of 20 closed questions. The results were tabulated using the statistical software EPI-INFO version 7.2.0.1 and Microsoft Office Excel 2013. Univariate and bivariate analyses were performed. Results: The study showed that 94 (47%) had neither non-metabolic syndrome nor sub-clinical hypothyroidism. The metabolic syndrome criteria was fulfilled by 82 (41%), 12 (6%) were only diagnosed with subclinical hypothyroidism, and 12 (6%) had both pathologies. The two main criteria for metabolic syndrome fulfilled by the study group were: 159 (79.5%) with central obesity and 151 (75.5%) with an HDL-cholesterol < 50 mg/dL. The most important metabolic syndrome criteria found in this study group was triglycerides ≥ 150 mg/dL, with a score of 16. As regards cardiovascular risk, 194 (97%) nurses had a low risk. Conclusions: Most of the study group had an altered body mass index and some associated dyslipidaemia. The prevalence of sub-clinical hypothyroidism in the nursing staff was similar to that found in other studies, and the prevalence of metabolic syndrome was higher than the reported worldwide (20-25%) and nationally (23%).

Síndrome de apneas del sueño: revisión de 25 años de experiencia / Sleep apnea syndrome: review of 25 years of experience / Síndrome da apnéia do sono: revisão de 25 anos de experiência

El conocimiento científico y clínico sobre los trastornos respiratorios del sueño se ha desarrollado de manera acelerada en las últimas décadas. El objetivo de este estudio es presentar la experiencia adquirida en nuestro país, en el diagnóstico y tratamiento del síndrome de apneas del sueño de tipo obstructivo, durante el desarrollo de una nueva disciplina en el ámbito de la neumología. Se revisaron los registros de 3109 pacientes; 447 con historias clínicas electrónicas y cuestionarios para cuantificación de síntomas y 1779 polisomnografías de pacientes con apneas de tipo obstructivo. Se presenta la evolución de la referencia de pacientes, las características demográficas (en especial el aumento de la prevalencia en jóvenes) y los hallazgos clínicos más frecuentes. Se destacan los factores de riesgo relevantes: obesidad y su relación con la severidad, enfermedades endocrinas y desplazamiento cefálico de fluidos. Se destaca el modo de acceso y la adherencia al tratamiento. La implementación de unidades clínicas de sueño permitió la referencia de pacientes para el diagnóstico y el tratamiento, dando lugar a una nueva disciplina de la neumología. La prevalencia de las apneas obstructivas del sueño es muy elevada, con progresivo y sostenido incremento. El tratamiento con aplicación de presión nasal no invasiva es factible. Aunque con distintos grados de accesibilidad y adherencia, ha permitido la corrección del trastorno respiratorio del sueño más relevante.

Scientific and clinical knowledge on sleep-disordered breathing has developed at an accelerated pace in the last decades. The objective of this study is to present the experience gained in our country in the diagnosis and treatment of obstructive sleep apnea syndrome during the development of a new discipline in the field of pneumology. Clinical records of 3109 patients were reviewed; 447 with electronic medical records and questionnaires for quantification of symptoms and 1779 polysomnographies of patients with obstructive apneas. The time evolution of the patient referral, the demographic characteristics (especially the increase in the prevalence in young people) and the most frequent clinical findings are presented. We highlight the relevant risk factors: obesity and its relationship with severity, endocrine diseases and cephalic fluid displacement. Access mode and adherence to treatment are highlighted. The implementation of sleep clinics allowed the referral of patients for diagnosis and treatment, giving rise to a new discipline of pneumology. The prevalence of obstructive sleep apnea is high, with progressive and sustained increase. Treatment with non-invasive nasal pressure application is feasible. Although with different degrees of accessibility and adherence, it has allowed the correction of the most relevant respiratory sleep disorder

O conhecimento científico e clínico sobre os transtornos respiratórios do sono desenvolveu-se rapidamente nas últimas décadas. O objetivo deste estudo é apresentar a experiência adquirida em nosso país no diagnóstico e tratamento da síndrome da apneia obstrutiva do sono durante o desenvolvimento de uma nova disciplina no campo da pneumologia. Os registros de 3109 pacientes foram revisados; 447 com registros médicos eletrônicos e questionários para quantificação de sintomas e 1779 polissonografias de pacientes com apnéia obstrutiva. Apresentamos a evolução da referência do paciente, as características demográficas (especialmente o aumento da prevalência em jovens) e os achados clínicos mais freqüentes. Destacamos os fatores de risco relevantes: obesidade e sua relação com severidade, doenças endócrinas e deslocamento do cefálico de fluídos. O modo de acesso e a adesão ao tratamento são destacados. A implementação de unidades de sono clínicas permitiu a referência de pacientes para diagnóstico e tratamento, dando origem a uma nova disciplina de pneumologia. A prevalência da apneia obstrutiva do sono é muito alta, com aumento progressivo e sustentado. O tratamento com pressão nasal não invasiva é viável. Embora com diferentes graus de acessibilidade e adesão, permitiu a correção do transtorno do sono respiratório mais relevante.

Hipotiroidismo subclínico en pacientes con enfermedad renal crónica que concurren a centros de salud pública de la ciudad de Posadas, Misiones / Sub-clinical hypothyroidism in patients with chronic renal disease attending health centres in Posadas, Misiones, Argentina

Los objetivos del presente trabajo fueron: 1) determinar la frecuencia de hipotiroidismo subclínico (HSC) en pacientes con enfermedad renal crónica (ERC), y 2) evaluar los cambios en la función renal de pacientes con ERC e HSC luego del tratamiento con levotiroxina. Se estudió a 182 pacientes, 99 con ERC y 83 sin ERC (grupo control), entre 20 y 70 años de edad, de ambos sexos, atendidos en centros de salud y consultorios hospitalarios de Posadas, Misiones. La frecuencia de HSC en el grupo con ERC fue del 28,3% y en el grupo control 14,5% (p = 0,025). Los pacientes con ERC e HSC fueron derivados al servicio de endocrinología, donde luego de 3 meses de tratamiento con levotiroxina, se revaluó la función renal, observando en todos los pacientes disminución en los niveles de creatinina sérica y aumento del índice de filtrado glomerular. Sobre la base de estos hallazgos se podría recomendar el estudio de la función tiroidea a todo paciente con ERC de causa desconocida, considerando al HSC entre las posibles causas de deterioro de la función renal.

The objectives of the present study were: 1) to determine the frequency of Subclinical Hypothyroidism (SCH) in patients with Chronic Renal Disease (CKD), and 2) to evaluate the changes in renal function in patients with CKD and SCH after treatment with levothyroxine. A total of 182 patients were studied, 99 with CKD and 83 without CKD (control group), with ages between 20 and 70 years old, of both sexes, attending health centres and hospital clinics in Posadas, Misiones, Argentina. The frequency of SCH was 28.3% in the CKD group, and 14.5% in the control group (P=.025). Patients with CKD and SCH were referred to medical endocrinology, where after three months of treatment with levothyroxine, renal function was evaluated, after which a decrease in serum creatinine levels and an increase in the glomerular filtration rate were observed in all patients. Based on these findings, the study of thyroid function should be recommended for all patients with CKD of unknown cause, considering SCH among the possible causes of impaired renal function.

Calidad de vida en pacientes con hipotiroidismo / Quality of life in patients with Hypothyroidism

Introduction: Patients with hypothyroidism may have worse quality of life, specially in Hashimoto's Thyroiditis (HT). Objective: Describe differences in the quality of life in patients with HT, compared to other causes of hypothyroidism in ambulatory patients. Method: Cross sectional, observational and descriptive study. The survey SF36 was applied, with prior authorization, to hypothyroid outpatients over 18 years without psychiatric, physical or mental disorder, dividing the sample into two groups: patients with TH and other causes of hypothyroidism. We used QualityMetric Health OutcomesTM Scoring Software 5.0, that gives a descriptive analysis of each area included in the instrument. Results: 53 patients, of whom 30 where diagnosed with TH, and 23 with other causes of hypothyroidism were surveyed. The characteristics were similar in both groups. The total group of hypothyroid patients had mental component under the average. In the specific analysis of the groups, the physical component was within the average general population. The mental component, was decreased in patients with other causes of hypothyroidism, but not in patients with TH. Conclusion: Comparing both groups, there were no differences in the physical component of patients with hypothyroidism. The mental component of the total group of hypothyroid patients compared to the general population was below average, especially in patients with other causes of hypothyroidism. The reason is unclear, but could be related to the absence of endogenous thyroid hormones