Transient elevation of serum thyroid hormone concentration after initiation of replacement therapy in myxedema

Measurements of thyroid hormone concentrations in serum are commonly used to determine the proper dose of hormone replacement. We have noted that early in the course of thyroxine (T4) replacement in myxedema, serum T4 concentrations may be transiently elevated before reaching a lower "steady-state" level. This observation is illustrated in a study of six patients. Serum T4, free thyroxine index, and triiodothyronine (T3) rose to peak concentrations at 2 to 6 weeks, 35% to 120% above the values achieved 4 to 8 months later. Values were transiently in the thyrotoxic range in five of the six patients. This phenomenon is most likely due to a decrease in the metabolic clearance rate of the absorbed hormone associated with hypometabolism. Thus, serum T4 and T3 concentrations during the first 6 months of therapy do not reflect the optimal dose of T4 replacement on a long-term basis.     

Haemodynamic effects of beta-adrenergic blockade in hyperthyroid patients with and without heart failure

Haemodynamic studies were performed in 10 patients with uncomplicated thyrotoxicosis and seven with thyrotoxic cardiac failure. The cardiac output of those with uncomplicated hyperthyroidism was higher than normal at rest. After 2 mg of intravenous propranolol there was a 13% fall but the level was still higher than normal. In patients with thyrotoxic cardiac failure the resting cardiac output was normal, but it fell after propranolol by 30% to subnormal levels. In both groups there was an increase in right heart pressures and fall in the rate of increase in arterial pressure, which indicated a decrease in myocardial contractility. These results indicate that increased autonomic activity is a compensatory phenomenon in hyperthyroid heart failure and that its abolition by beta-blocking drugs has a deleterious effect on cardiac function. They are therefore contraindicated in patients with thyrotoxic heart failure.     

Dursban revisited: birth defects, U.S. Environmental Protection Agency, and Centers for Disease Control

A previously fit 37-year-old woman was admitted with acute left ventricular failure, atrial fibrillation and a left-sided thromboembolic stroke. Her ventricular rate progressively increased despite full digitalisation. She had a cardiac arrest and was successfully resuscitated. Investigations revealed evidence of hyperthyroidism and she was treated for thyrotoxic crisis. She has made a complete recovery from the hemiparesis and is now in sinus rhythm. She denied any symptoms of hyperthyroidism. This patient had apathetic thyroid crisis, which is exceedingly rare in the young.     

Ionized and total serum calcium and parathyroid hormone in hyperthyroidism

Total and ionized calcium concentrations as well as parathyroid hormone levels were measured in a group of hyperthyroid persons. Ionized and total calcium levels were elevated in 21 of 45 (47%) and in 12 of 45 (27%) thyrotoxic patients, respectively. Mean ionized and total calcium levels were higher in these 45 patients than in normal persons. Using two different radioimmunoassay systems for a total of 44 determinations, mean parathyroid hormone levels were lower in thyrotoxic patients than in subjects with proved hyperparathyroidism. These data suggest that [1] elevations of both ionized and total calcium concentrations occur frequently in thyrotoxic patients; [2] ionized calcium concentrations may be elevated in a higher percentage of hyperthyroid subjects than are total calcium concentrations; and [3] the hypercalcemia associated with thyrotoxicosis is not associated with elevated parathyroid hormone levels.     

Power, situation, and leaders' effectiveness: An organizational field study.

Studied prevalence and effectiveness of 8 types of influence in noncrisis and crisis circumstances, using 125 male leaders (aged 25–60 yrs). Subordinates assessed the leadership ability of their superiors by completing an influence analysis questionnaire. Results indicate that open consultation was judged to be used more often in noncrisis than in crisis circumstances; formal power, sanction power, and expert power were more prevalent in crisis situations. In addition, each leader's managerial qualities were evaluated by his superior. It was found that more formal power was ascribed to effective leaders in crisis circumstances than in noncrisis circumstances; for their less effective colleagues, no difference appeared between situations. Predicted interaction effects with regard to sanction power and expert power were not found; open consultation, however, was resorted to more often by the most effective leaders in noncrisis than in crisis situations. (9 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Inhibition of the development of Plasmodium yoelii in exoerythrocytic stage in rodents (rats) with Chrysanthemum morifolium

Salt iodination, in Lebanon, started partially in late 1992, and was implemented in a uniform manner by January 1995. Following salt iodination, an epidemic of iodine-induced thyrotoxicosis occurred, as noted by the author, in his private clinic. The number of thyrotoxic patients increased sharply by 2 to 6 folds, and the yearly incidence rose from a baseline of 0.02% up to 0.07%. The younger patients have predominantly Graves' disease (32% of the cases), while 17% have solitary thyroid nodules, and 44% of the cases were elderly subjects with multinodular goiter. The pathogenesis and possible causes of this epidemic are discussed.     

"An awful visitation of providence": the Irish Famine of 1845-49

We dispose of a database, constituted between 1987 and 1993, containing medical and cost information concerning 515 patients suffering from coma and admitted, after a period of resuscitation, to a French hospital establishment--Etablissement Hélio-Marin of Berck-sur-Mer (EHMB)--for short and medium term treatment, between 1974 and 1986. From this base, which contains demographic and clinical data (age, sex, condition upon admission, duration of consciousness disorders, Glasgow Outcome Scale (GOS) upon discharge) we devised a hierarchical classification analysis following a factorial analysis of multiple correspondences, on 2 sets: a sample of 515 patients (all causes of coma being merged) and a sample of 266 patients suffering from brain injuries. Four groups were determined for each typology. These groups were first described on the basis of the variables used for their construction, and later by considering other available variables: origin of coma, duration of stay at EHMB, future evolution of patients and cost of treatment (cost of specific care, average daily cost, total cost of hospitalization). Thus, typical clinical situations were identified in each classification, depending on age of patient, origin of coma and condition upon admission. These situations led to extremely different treatment costs (ratio from 1 to 5 in the general typology and 1 to 2.85 in the classification of brain injuries.     

CNS tryptamine metabolism in hepatic coma

Lumbar CSF indoleacetic acid (IAA) was higher in patients with cirrhosis of the liver than in controls. It was also higher in CSF of patients in coma than in those with hepatic cirrhosis but not in coma. There was a strong correlation (r = 0.89, p less than 0.01) between the grade of hepatic coma and CSF IAA. These data indicate that there is an association between elevated CNS tryptamine metabolism and hepatic coma. How far changes in the metabolism of tryptamine and other trace amines are relevant to the induction of hepatic coma or are simply a reflection of advanced liver dysfunction is unclear.     

The thyroid gland as an intrinsic biologic response-modifier in advanced neoplasia--a novel paradigm

The thyroid gland is the major endocrine modulator of physiological processes crucial to growth, maturation and metabolism. There is, however, a coherent body of evidence suggesting that the thyroid hormones modulate multiple neoplasia-dependent mechanisms. Recently spontaneous remission of metastatic non-small cell carcinoma of lung was reported in a man following recovery from myxedema coma. This rare biological event following a life-threatening clinical syndrome suggests that thyroid hormone deficiency directly or indirectly may significantly alter the balance between malignant tumor viability and growth on the one hand vs. cell death on the other. Evidence, therefore, is presented from clinical and experimental studies suggesting that decreased thyroid function (hypothyroidism) is associated with both enhanced response rates and unusual longevity. Possible mechanisms of action that may promote or retard neoplasia and are dependent on the functional state of the thyroid will be discussed. A novel paradigm is proposed; the thyroid gland aside from its known physiological activity is also the central modulator of solid neoplasia and therefore functions as an intrinsic biologic response-modifier of neoplasia. Induction of a clinically tolerable hypothyroid state in patients could become an integral part of the medical care of advanced cancer in conjunction with standard conventional modalities.     

Mushroom poisoning. New possibilities for treatment

Poisonous species of fungi in Germany are very few. Dangerous is the ingestion of raw, spoiled or poisonous mushrooms. There exist no reliable tests to determine whether a mushroom is safe except by expert examination and identification of the mushroom. In clinical practice the classification of mushroom poisoning is possible in muscarine-syndrome, gastroenteritic syndrome and in two-phase-syndrome. 90-95% of lethal mushroom poisonings are due to ingestion of Amanita phalloides. In severe cases extensive hepatic necrosis occurs, characterized by profound abnormalities in liver function caused by hepatic coma. In deep coma mortality rates amount to 70% or more. A new therapeutic measure (coated charcoal hemoperfusion)-first applied in liver failure by Chang (1972) and Williams (1973)-has been performed in 3 patients with severe poisoning after ingestion of Amanita phalloides (each patient had eaten at least 7-10 fungi Amanita phalloides). Two of the patients survived.     

Surgical management of amiodarone-associated thyrotoxicosis: too risky or too effective?

Amiodarone-associated thyrotoxicosis, often clinically mild and resolutive after amiodarone discontinuation or under medical therapy, is sometimes drug unresponsive and not uncommonly follows a dramatic, even fatal course. Therefore, we considered a surgical solution in 15 severely amiodarone-associated thyrotoxic patients. Twelve men and three women (mean age 68 years, range 50-84 years) underwent radical thyroidectomy for clinical and biologically proved amiodarone-associated thyrotoxicosis. In six surgery was the first-line therapeutic option. In the other nine thyroidectomy seemed unavoidable considering the unresponsiveness to medical therapy and rapid deterioration of the patients' clinical condition, with life-threatening cardiac failure in three. In every patient surgery was conducted without immediate or delayed complications. Total thyroidectomy proved uniformly, definitively, and rapidly effective in controlling thyrotoxicosis in all patients, with a spectacular reversal of cardiac failure in the three most critical cases. Surgery was beneficial to our 15 patients and undoubtedly life-saving in the three most worrying cases. These results suggest that thyroidectomy should be more liberally regarded as an interesting alternative to conventional, but unpredictably effective, medical therapies.     

Lions and tigers and bears, oh my!

OBJECTIVE: To examine the use of thrombolytic treatment in acute myocardial infarction when faced with perceived contraindications to treatment and to explore the justification for withholding treatment in such clinical situations. METHODS: Interview survey of all doctors responsible administering thrombolysis to patients with acute myocardial infarction at a teaching hospital in the UK from March to May 1997. RESULTS: 20 doctors were interviewed and asked whether they would give or withhold thrombolysis in a series of 19 clinical situations. These included patients presenting with both an acute myocardial infarction and one of the following associated conditions: a confirmed gastrointestinal haemorrhage, a suspected gastrointestinal haemorrhage, a peptic ulcer, an abdominal aortic aneurysm, a recent cerebrovascular accident, a known intracranial aneurysm, a known intracranial tumour, a recent dental extraction, recent surgery, severe hypertension, proliferative diabetic retinopathy, a history of bleeding diathesis, coma, recent cardiopulmonary resuscitation, pregnancy, menstruation, and a recent central venous puncture. In all but one of the clinical situations (definite current gastrointestinal haemorrhage) there was wide variation in response as to what constitutes a contraindication to thrombolytic treatment. Overall, a substantial proportion of doctors (35%-95%) would withhold treatment on account of any one of these clinical histories. CONCLUSION: Clinicians may be withholding thrombolysis in acute myocardial infarction on account of perceived contraindications for which there is little or no evidence of increased haemorrhagic risk. An effective treatment for acute myocardial infarction is probably being underused.     

Impaired renal concentrating ability in hypothyroid man

The renal concentrating ability was studied in ten patients with hypothyroidism and in 15 euthyroid controls. Solute-free water reabsorption was reduced in the patients with myxedema (4.2 +/- 0.3 ml/min: controls 5.8 +/- 0.6 ml/min; p less than 0.01). This defect was apparent at high rates of solute excretion, and was associated with enhanced excretion of sodium (p less than 0.01) despite a decreased filtered load (p less than 0.005). The myxedema patients had a modest reduction in maximal urine osmolality (p less than 0.04), which was entirely attributable to the lower values observed in younger patients. The results may be explained best by decreased sodium chloride reabsorption in the ascending limb of Henle's loop and/or diminished permeability of the distal nephron in myxedema.     

Thyroid dysfunction is not associated with alterations in serum leptin levels

To determine if serum leptin levels are affected by thyroid dysfunction, we measured its concentration in serum samples from 25 euthyroid controls and 25 subjects each with hypothyroidism and thyrotoxicosis collected over a 3-month period. Mean leptin levels in the euthyroid (24.1 +/- 8.3 microg/L), hypothyroid (22.7 +/- 7.0 microg/L) and thyrotoxic (23.3 +/- 4.3 microg/L) groups were not significantly different. Data were available to express leptin in terms of body mass index (BMI) in 11 euthyroid, and 6 untreated hypothyroid and thyrotoxic individuals. There was a significant positive correlation between BMI and leptin level (r = 0.60, p = .0002) for this subgroup, irrespective of their thyroid status. These data suggest that leptin levels are not affected by thyroid dysfunction.     

Retarded incorporation of [14C]mannose into thyroglobulin of human thyrotoxic thyroid glands

In vitro studies using thyroid slices from human non-toxic goitres and from thyrotoxic glands show retarded incorporation of [14C]mannose into the 19S protein of thyrotoxic glands. This was not found using [14C]galactose with thyrotoxic glands or using either labelled sugar with slices from non-toxic goitres. Experiments with thyroid tissue from rats on a variety of treatment regimes such as iodine supplements, carbimazole alone or with iodine supplements did not show this differential delay of [14C]mannose incorporation. This suggests that there may be some abnormality of carbohydrate incorporation into thyroglobulin in thyrotoxicosis.     

Crisis intervention training program: Influence on staff attitudes in a postacute residential brain injury rehabilitation setting.

Purpose/Objective: Acquired brain injury produces a host of behavioral changes, and specialized training in proper management of these behaviors is essential to resolve crises and calm aggressive clients. This study was conducted to determine whether crisis intervention training was effective in increasing staff comfort with difficult client behaviors in a residential rehabilitation program for individuals with postacute acquired brain injury and whether changes would be maintained over time. Research Method/ Design: Twenty-five rehabilitation staff members participated in Nonviolent Crisis Intervention training and completed the Rehabilitation Situations Inventory before training, immediately following completion of the program, and 1 month later. Results: Immediately following completion of the program, participants reported increased comfort when faced with client behaviors related to motivation and adherence, sexuality, and aggression and when interacting with other staff and client families. Changes in comfort level with sexual situations, aggression, and staff/staff interactions were maintained 1 month post training. Conclusions/Implications: These results suggest that crisis intervention training is effective in increasing levels of staff comfort with difficult situations commonly experienced in the rehabilitation setting and the changes are maintained following training. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessment of strategic self-regulation in traumatic brain injury: Its relationship to injury severity and psychosocial outcome.

Standard neuropsychological tests administered in a constrained and artificial laboratory environment are often insensitive to the real-life deficits faced by patients with traumatic brain injury (TBI). The Revised Strategy Application Test (R-SAT) creates an unstructured environment in the laboratory in which environmental cues and internal habits oppose the most efficient strategy, thus mimicking the real-life situations that are problematic for patients with TBI. In this study, R-SAT performance was related both to severity of TBI (i.e., depth of coma) sustained 2–3 years earlier and to quality of life outcome as assessed by the Sickness Impact Profile. This relationship held after accounting for variance attributable to TBI-related slowing and inattention. These findings support the validity of the R-SAT and suggest that behavioral correlates of quality of life outcome in TBI can be assessed in the laboratory with unstructured tasks. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Thyroid hormones modulate serum leptin levels: observations in thyrotoxic and hypothyroid women

Thyroid hormones and leptin are both involved in the regulation of energy metabolism. Serum leptin concentrations were measured in women with thyrotoxicosis (n = 21, mean age 45 years) or hypothyroidism (n = 14, mean age 44 years) before and 3 months after restoration of the euthyroid state. Serum leptin concentration tended to increase in both hypothyroid (14.7+/-3.5 vs 17.8+/-3.9 ng/ml, p = 0.06) and thyrotoxic (11.9+/-1.7 vs 14.4+/-2.0, p = 0.08) women after treatment (values given as mean +/- SE in the untreated and the euthyroid state respectively). Body mass index (BMI) was lower in thyrotoxic women than in hypothyroid women in the untreated state (22.1+/-0.7 vs. 26.2+/-1.9, p < 0.05). BMI was not different between both groups after treatment (24.5+/-0.7 vs. 26.3+/-2.1, p = 0.37), due to an increase of BMI in the thyrotoxic women; BMI did not change in the hypothyroid group. After controlling for BMI in a multivariate regression analysis, serum leptin concentrations were lower in hypothyroid women than in thyrotoxic women (p < 0.05), whereas posttreatment values of leptin did not differ (p = 0.44). When leptin concentrations were expressed as standard deviation scores (Z-scores) from the mean value of female controls matched for BMI and age as reported earlier, Z-scores were lower in the hypothyroid than in the thyrotoxic women (-0.63+/-0.21 vs. 0.53+/-0.18, p = 0.001). After treatment, Z-scores did not deviate from the expected values (0.05+/-0.28 vs. 0.08+/-0.16, p = 0.98). Z-scores differed before and after treatment in both hypothyroid (p = 0.01) and thyrotoxic (p = 0.02) patients. In conclusion, these data obtained in thyrotoxic and hypothyroid women indicate that thyroid states modulates serum leptin concentrations independent of BMI, with a small decrease in hypothyroidism and a small increase in thyrotoxicosis.     

Propranolol effect on plasma glucose, free fatty acid, insulin, and growth hormone in Graves' disease

A 3-hr glucose tolerance test was performed in 12 thyrotoxic patients before and after propranolol treatment for 30 days (120 mg/day). Plasma glucose, free fatty acid, insulin, and growth hormone levels were determined on each test and compared to each other and against nine clinically healthy volunteers. In eight thyrotoxic patients (subgroup A) an improvement in carbohydrate tolerance was observed after propranolol treatment, along with a fall in the previously elevated fasting FFA; no change in plasma insulin levels was observed. Plasma growth hormone levels were higher than normal both before and after propranolol; however, a 46% glucose-induced suppression was seen in both instances. In the other four patients (subgroup B) (who had had a marked and rapid weight loss) a deterioration of the previously normal glucosnificant changes in insulin levels. Elevated fasting plasma free fatty acids remained so despite propranolol treatment. Plasma growth hormone was higher than normal before and after propranolol; a late suppression (at 120 min) and no suppression at all were seen, respectively. After propranolol treatment, subgroup B had higher plasma free fatty acid than subgroup A in the fasting state and at 30 and 180 min. It is proposed that the improvement or deterioration in carbohydrate tolerance after propranolol treatment might be related to whether or not a satisfactory propranolol-induced lipolytic blockade is achieved, leading to a decrease in plasma free fatty acid levels, improved insulin sensitivity, and better peripheral glucose utilization. Therefore, a uniform dose of propranolol will not always be sufficient to obtain adequate lipolytic blockade, particularly if the thyrotoxic patient has had a marked and rapid weight loss.     

Effect of heavy metals and storage time on two types of forest litter: basal respiration rate and exchangeable metals

BACKGROUND: Techniques are needed to assess anesthesiologists' performance when responding to critical events. Patient simulators allow presentation of similar crisis situations to different clinicians. This study evaluated ratings of performance, and the interrater variability of the ratings, made by multiple independent observers viewing videotapes of simulated crises. METHODS: Raters scored the videotapes of 14 different teams that were managing two scenarios: malignant hyperthermia (MH) and cardiac arrest. Technical performance and crisis management behaviors were rated. Technical ratings could range from 0.0 to 1.0 based on scenario-specific checklists of appropriate actions. Ratings of 12 crisis management behaviors were made using a five-point ordinal scale. Several statistical assessments of interrater variability were applied. RESULTS: Technical ratings were high for most teams in both scenarios (0.78 +/- 0.08 for MH, 0.83 +/- 0.06 for cardiac arrest). Ratings of crisis management behavior varied, with some teams rated as minimally acceptable or poor (28% for MH, 14% for cardiac arrest). The agreement between raters was fair to excellent, depending on the item rated and the statistical test used. CONCLUSIONS: Both technical and behavioral performance can be assessed from videotapes of simulations. The behavioral rating system can be improved; one particular difficulty was aggregating a single rating for a behavior that fluctuated over time. These performance assessment tools might be useful for educational research or for tracking a resident's progress. The rating system needs more refinement before it can be used to assess clinical competence for residency graduation or board certification.