2012 Clinical Practice guidelines for hypothyroidism in adults: American Asso...Jibran Mohsin
This is presentation format of 2012 Clinical Practice guidelines for hypothyroidism in adults: American Association of Clinical Endocrinologists (AACE) / American Thyroid Association (ATA)
Definition & incidence of Hypertension
Classification of Hypertension
Diagnosis/ Confirmation of Hypertension
Technique of Hypertension Measurement
White coat Hypertension
Type of Hypertension
Suspicion of secondary hypertension
Management of Hypertension(Stage 1& 2)
Why treatment is necessary
Life style modification
Drug treatment of Hypertension
Rationalae of combination
Hypertension management in special situation/ with complications
Indications of ARBs
Mechanism of action of ARBs
Comparison of different ARBs-pharmacology, efficacy
Safety of ARBs-Recall, Malignancy
Study on Telmisartan
2012 Clinical Practice guidelines for hypothyroidism in adults: American Asso...Jibran Mohsin
This is presentation format of 2012 Clinical Practice guidelines for hypothyroidism in adults: American Association of Clinical Endocrinologists (AACE) / American Thyroid Association (ATA)
Definition & incidence of Hypertension
Classification of Hypertension
Diagnosis/ Confirmation of Hypertension
Technique of Hypertension Measurement
White coat Hypertension
Type of Hypertension
Suspicion of secondary hypertension
Management of Hypertension(Stage 1& 2)
Why treatment is necessary
Life style modification
Drug treatment of Hypertension
Rationalae of combination
Hypertension management in special situation/ with complications
Indications of ARBs
Mechanism of action of ARBs
Comparison of different ARBs-pharmacology, efficacy
Safety of ARBs-Recall, Malignancy
Study on Telmisartan
Thyroid and critical illness
Non Thyroidal Illness Syndrome (NTIS)
Sick Euthyroid Syndrome
Euthyroid Sick Syndrome (ESS)
Low T3 Syndrome
NTIS, formerly known as euthyroid sick syndrome, often occurs in patients who have severe, prolonged critical illness and is essentially a laboratory abnormality to be monitored.
By Usama Ragab Youssif
Case history
Definition & incidence of Hypertension
Classification of Hypertension
Diagnosis/ Confirmation of Hypertension
Technique of Hypertension Measurement
White coat Hypertension
Type of Hypertension
Suspicion of secondary hypertension
Management of Hypertension(Stage 1& 2)
Why treatment is necessary
Life style modification
Drug treatment of Hypertension
Rationalae of combination
Hypertension management in special situation/ with coplications
Indications of ARBs
Mechanism of action of ARBs
Comparison of different ARBs-pharmacology, efficacy
Safety of ARBs-Recall, Malignancy
Study on Telmisartan
Hyperthyroidism is a disorder that occurs when the thyroid gland makes more thyroid hormone than the body needs. Hyperthyroidism is sometimes called thyrotoxicosis, the technical term for too much thyroid hormone in the blood. Thyroid hormones circulate throughout the body in the bloodstream and act on virtually every tissue and cell in the body. Hyperthyroidism causes many of the body’s functions to speed up.
Thyrotoxicosis is any syndrome caused by excess thyroid hormone and
can be related to excess hormone production (hyperthyroidism).It is Also called as overactive thyroid.Symptoms include unexpected weight loss, rapid or irregular heartbeat, sweating and irritability, although the elderly often experience no symptoms.
Treatments include radioactive iodine, medication and sometimes surgery.
Hyperthyroidism is a very common name, when it comes to lifestyle diseases. Often a deeper and holistic approach towards your health will help you find long term solution, and hence you will be able to recognize your symptoms of Hyperthyroidism. Your thyroid gland, when starts secreting more amount of hormone, the condition is referred as hyperthyroidism. Thereby speeding up the bodily functions, including metabolism.
Inpatient Diabetes Management - How to Control Hyperglycemia inhsopitalUsama Ragab
Inpatient Diabetes Management
By Dr. Usama Ragab Youssif
Lecturer of Medicine Zagazig University
Why we need this lecture?
Diabetes inhospital is common problem
Increased diabetes morbidities
Increased mortality
Hypothyroidism Diagnosis, Etiopathogenesis and TreatmentPranatiChavan
Hypothyroidism is a condition in which the thyroid gland doesn't produce enough thyroid hormone.
Hypothyroidism's deficiency of thyroid hormones can disrupt such things as heart rate, body temperature and all aspects of metabolism. Hypothyroidism is most prevalent in older women.
Major symptoms include fatigue, cold sensitivity, constipation, dry skin and unexplained weight gain.
Treatment consists of thyroid hormone replacement.
Clinical Practice Guidelines for hypothyroidism in adults: AACE and ATA 2012Jibran Mohsin
This is the original presentation published by American Association of Clinical Endocrinologist (AACE) regarding the clinical practice guidelines for hypothyroidism in adults
Thyroid and critical illness
Non Thyroidal Illness Syndrome (NTIS)
Sick Euthyroid Syndrome
Euthyroid Sick Syndrome (ESS)
Low T3 Syndrome
NTIS, formerly known as euthyroid sick syndrome, often occurs in patients who have severe, prolonged critical illness and is essentially a laboratory abnormality to be monitored.
By Usama Ragab Youssif
Case history
Definition & incidence of Hypertension
Classification of Hypertension
Diagnosis/ Confirmation of Hypertension
Technique of Hypertension Measurement
White coat Hypertension
Type of Hypertension
Suspicion of secondary hypertension
Management of Hypertension(Stage 1& 2)
Why treatment is necessary
Life style modification
Drug treatment of Hypertension
Rationalae of combination
Hypertension management in special situation/ with coplications
Indications of ARBs
Mechanism of action of ARBs
Comparison of different ARBs-pharmacology, efficacy
Safety of ARBs-Recall, Malignancy
Study on Telmisartan
Hyperthyroidism is a disorder that occurs when the thyroid gland makes more thyroid hormone than the body needs. Hyperthyroidism is sometimes called thyrotoxicosis, the technical term for too much thyroid hormone in the blood. Thyroid hormones circulate throughout the body in the bloodstream and act on virtually every tissue and cell in the body. Hyperthyroidism causes many of the body’s functions to speed up.
Thyrotoxicosis is any syndrome caused by excess thyroid hormone and
can be related to excess hormone production (hyperthyroidism).It is Also called as overactive thyroid.Symptoms include unexpected weight loss, rapid or irregular heartbeat, sweating and irritability, although the elderly often experience no symptoms.
Treatments include radioactive iodine, medication and sometimes surgery.
Hyperthyroidism is a very common name, when it comes to lifestyle diseases. Often a deeper and holistic approach towards your health will help you find long term solution, and hence you will be able to recognize your symptoms of Hyperthyroidism. Your thyroid gland, when starts secreting more amount of hormone, the condition is referred as hyperthyroidism. Thereby speeding up the bodily functions, including metabolism.
Inpatient Diabetes Management - How to Control Hyperglycemia inhsopitalUsama Ragab
Inpatient Diabetes Management
By Dr. Usama Ragab Youssif
Lecturer of Medicine Zagazig University
Why we need this lecture?
Diabetes inhospital is common problem
Increased diabetes morbidities
Increased mortality
Hypothyroidism Diagnosis, Etiopathogenesis and TreatmentPranatiChavan
Hypothyroidism is a condition in which the thyroid gland doesn't produce enough thyroid hormone.
Hypothyroidism's deficiency of thyroid hormones can disrupt such things as heart rate, body temperature and all aspects of metabolism. Hypothyroidism is most prevalent in older women.
Major symptoms include fatigue, cold sensitivity, constipation, dry skin and unexplained weight gain.
Treatment consists of thyroid hormone replacement.
Clinical Practice Guidelines for hypothyroidism in adults: AACE and ATA 2012Jibran Mohsin
This is the original presentation published by American Association of Clinical Endocrinologist (AACE) regarding the clinical practice guidelines for hypothyroidism in adults
Abstract—Subclinical Hypothyroidism is a much more common disorder with a world-wide occurrence as compared to overt Hypothyroidism. Overt Hypothyroidism is associated with abnormalities of lipid metabolism, but the significance of dyslipidemia in subclinical hypothyroidism (SCH) remains controversial.
Aims: To compare the lipid profile between subclinical hypothyroid patients & healthy controls (age & sex matched) so as to determine any association between lipid profile & subclinical hypothyroidism.
Materials and Methods: In a case-control study, Thyroid stimulating hormone (TSH), free T3, free T4, anti thyroperoxidase (TPO) antibodies, total cholesterol, high density lipoprotein(HDL) cholesterol, low density lipoprotein (LDL) cholesterol, Very low density lipoprotein (VLDL) cholesterol, serum triglycerides were measured in 50 patients with subclinical hypothyroidism and 50 age- and sex-matched Euthyroid controls after an overnight fasting.
Results: Mean serum triglycerides (TG) and very low-density cholesterol (VLDL) were significantly higher in patients with SCH than controls (P < 0.05). No association was found between serum total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol and SCH.
Conclusions: Dyslipidemia is more common in SCH compared to controls. High serum triglycerides and VLDL were observed in patients with SCH.
Hypothyroid Disorders in Obs & Gynae – Case based approach – Part -1 Lifecare Centre
Hypothyroid Disorders in Obs & Gynae – Case based approach – Part -1
Moderator - Dr Meenakshi Sharma
& Dr Puja Dewan
Panelist
Dr Dipti Nabh
Dr Richa Singhal
Dr Manju Sharma
Dr Deepa Gupta
Dr Renu Chawla
Dr Anita Agarwal
Infertility is defined as the inability of a couple to conceive after at least one year of regular unprotected intercourse.
Male infertility refers to a male's inability to cause pregnancy in a fertile female.
IDD situation in our country has improved
A good number of thyroid disorder patients are either undiagnosed and or untreated
Thyroid disorder in pregnancy- Rate high
As a sound thyroid functioning status is crucial for growth, development in children; reproduction, psychological and general wellbeing in adults, we must be proactive in screening, diagnosing and treating our patients.
Over the past several years it has been proved that maternal thyroid disorder influence the outcome of mother and fetus, during and also after pregnancy. The most frequent thyroid disorder in pregnancy is maternal hypothyroidism. It is associated with fetal loss, placental abruptions, pre-eclampsia, preterm delivery and reduced intellectual function in the offspring.1 In pregnancy, overt hypothyroidism is seen in 0.2% cases2 and sub clinical hypothyroidism in 2.3% cases3. Fetal loss, fetal growth restriction, pre-eclampsia and preterm delivery are the usual complications of overt hyperthyroidism (low TSH and high T3, T4) seen in 2 of 1000 pregnancies whereas mild or sub clinical hyperthyroidism (suppressed TSH alone) is seen in
1.7% of pregnancies and not associated with adverse outcomes4. Autoimmune positive euthyroid pregnancy shows doubling of incidence of miscarriage and preterm delivery. Worldwide more than 20 million people develop neurological sequel due to intra uterine, iodine deprivation5. Other problems of thyroid disorders in pregnancy are post partum thyroiditis, thyroid nodules and cancer, hyper emesis gravidarum etc. Debates and disputes persist regarding several protocol and management plan in this specific spectrum of diseases.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. Hypothyroidism has multiple etiologies and
manifestations. Appropriate treatment
requires an accurate diagnosis and is
influenced by coexisting medical
conditions. This paper describes evidence-
based clinical guidelines for the clinical
management of hypothyroidism in
ambulatory patients.
3. The ATA develops CPGs to provide guidance
and recommendations for particular practice
areas concerning thyroid disease, including
thyroid cancer. The guidelines are not
inclusive of all proper approaches or
methods, or exclusive of others. Treatment
decisions must be made based on the
independent judgment of health care
providers and each patient’s individual
circumstances.
4. The guidelines presented here principally address
the management of ambulatory patients with
biochemically confirmed primary hypothyroidism
whose thyroid status has been stable for at least
several weeks. They do not deal with myxedema
coma.
Serum thyrotropin (TSH) is the single best
screening test for primary thyroid dysfunction for
the vast majority of outpatient clinical situations.
The standard treatment is replacement with L-
thyroxine which must be tailored to the individual
patient.
5. Level Description
1 Prospective, randomized, controlled trials—large
2 Prospective controlled trials with or without
randomization—limited body of outcome data .
3 Other experimental outcome data and
nonexperimental data
4 Expert opinion
Levels 1, 2, and 3 represent a given level of scientific substantiation or
proof. Level 4 or Grade D represents unproven claims. It is the “best
evidence” based on the individual ratings of clinical reports that contributes
to a final grade recommendation.
6. Grade-Recommendation Protocol
Upgrading or downgrading a recommendation
Best evidence level Subjective factor
impact
Two-thirds
consensus
Mapping Recommendation grade
1 None Yes Direct A
2 Positive Yes Adjust up A
2 None Yes Direct B
1 Negative Yes Adjust down B
3 Positive Yes Adjust up B
3 None Yes Direct C
2 Negative Yes Adjust down C
4 Positive Yes Adjust up C
4 None Yes Direct D
3 Negative Yes Adjust down D
1,2,3,4 N/A No Adjust down D
Starting with the left column, best evidence levels (BELs) subjective factors, and consensus map to
recommendation grades in the right column. When subjective factors have little or no impact (“none”), then the
BEL is directly mapped to recommendation grades. When subjective factors have a strong impact, then
recommendation grades may be adjusted up (“positive” impact) or down (“negative” impact). If a two-thirds
consensus cannot be reached, then the recommendation grade is D.
7. Hypothyroidism may be either subclinical
or overt. Subclinical hypothyroidism is
characterized by a serum TSH above the
upper reference limit in combination with
a normal free thyroxine (T4). An elevated
TSH, usually above 10 mIU/L, in
combination with a subnormal free T4
characterizes overt hypothyroidism.
8. Prevalence of Hypothyroidism
Study Subclinical Overt TSH Comment
NHANES III 4.3% 0.3% 4.5
Colorado
Thyroid Disease
Prevalence
8.5% 0.4% 5.0 Not on thyroid
hormone
Framingham 10.0 Over age 60 years:
5.9% women; 2.3%
men; 39% of whom
had subnormal T4
British
Whickham
10.0 9.3% women; 1.2%
men
NHANES = National Health and Nutrition Examination Survey.
9. Environmental iodine deficiency (most
common cause worldwide)
Chronic autoimmune thyroiditis
(Hashimoto’s thyroiditis) (most common
cause in areas of iodine sufficiency)
Therapy with drugs such as lithium,
interferon alpha, and amiodarone
Radioiodine or thyroidectomy
insufficient production of bioactive TSH
10. The most common form of thyroid failure has an
autoimmune etiology. There is also an increased frequency
of other autoimmune disorders in this population such as :
Type 1 diabetes,
pernicious anemia,
primary adrenal failure (Addison’s disease),
myasthenia gravis
celiac disease,
rheumatoid arthritis,
systemic lupus erythematosis
thyroid lymphoma
11. Dry skin, cold sensitivity, fatigue, muscle
cramps, voice changes, and constipation are
among the most common
Less commonly appreciated and typically
associated with severe hypothyroidism are
carpal tunnel syndrome, sleep apnea,
pituitary hyperplasia with or without
hyperprolactinemia and galactorrhea, and
hyponatremia that can occur within several
weeks of the onset of profound
hypothyroidism.
12. T4 is bound to specific binding proteins
in serum. These are T4-binding globulin
(TBG) and, to a lesser extent,
transthyretin or T4-binding prealbumin
and albumin. Since approximately
99.97% of T4 is protein-bound, levels of
serum total T4 will be affected by
factors that alter binding independent of
thyroid disease.
13. Apart from pregnancy, assessment of
serum free T4 should be done instead of
total T4 in the evaluation of
hypothyroidism. An assessment of serum
free T4 includes a free T4 index or free
T4 estimate and direct immunoassay of
free T4 without physical separation using
anti-T4 antibody. (Grade A, BEL 1)
14. In pregnancy, the measurement of total T4 or
a free T4 index, in addition to TSH, should be
done to assess thyroid status. Because of the
wide variation in the results of different free
T4 assays, direct immunoassay
measurement of free T4 should only be
employed when method-specific and
trimester-specific reference ranges for serum
free T4 are available. (Grade B, BEL 2)
Total T3 or assessment of serum free T3
should not be done to diagnose
hypothyroidism. (Grade A, BEL 2)
15. A subnormal assessment of serum
free T4 serves to establish a
diagnosis of hypothyroidism, whether
primary, in which serum TSH is
elevated, or central, in which serum
TSH is normal or low.
16. Factors that Alter Thyroxine and
Triiodothyronine Binding in Serum
Increased
TBG
Decreased TBG Binding inhibitors
Inherited Inherited Salicylates
Pregnancy Androgens Furosemide
Neonatal state Anabolic steroids Free fatty acid
Estrogens Glucocorticoids Phenytoin
Hepatitis Severe illness Carbamazepine
Porphyria Hepatic failure NSAIDs
Heroin Nephrosis Heparin
Methadone Nicotinic acid
5- L-Asparaginase
17. Basal metabolic rate was the “gold standard” for
diagnosis. Extremely low values correlate with
marked hypothyroidism, but are affected by many
unrelated, diverse conditions, such as fever,
pregnancy, cancer, acromegaly, hypogonadism, and
starvation
Decrease in sleeping heart rate
Elevated total cholesterol as well as low-density
lipoprotein (LDL) and the highly atherogenic
subfraction Lp
Delayed Achilles reflex time
Increased creatine kinase
18. Clinical scoring systems should not be
used to diagnose hypothyroidism. (Grade A,
BEL 1).
Tests such as clinical assessment of
reflex relaxation time, cholesterol, and
muscle enzymes should not be used to
diagnose hypothyroidism. (Grade B, BEL 2)
19. Recommendations of Six Organizations Regarding
Screening of Asymptomatic Adults for Thyroid
Dysfunction
Organization Screening recommendations
American Thyroid
Association
Women and men >35 years of age should be
screened every 5 years.
American Association of
Clinical Endcrinologists
Older patients, especially women, should be
screened
American Academy of
Family Physicians
Patients ≥60 years of age should be screened
American College of
Physicians
Women ≥50 years of age with an incidental
finding suggestive of symptomatic thyroid
disease should be evaluated
U.S. Preventive
Services Task Force
Insufficient evidence for or against screening
Royal College of
Physicians of London
Screening of the healthy adult population
unjustified
20. One of the keys to diagnosing AITDs is
determining the presence of elevated anti-
thyroid antibody titers which include anti-
thyroglobulin antibodies (TgAb), anti-
microsomal/anti-thyroid peroxidase antibodies
(TPOAb), and TSH receptor antibodies
(TSHRAb). Many patients with chronic
autoimmune thyroiditis are biochemically
euthyroid. However, approximately 75% have
elevated anti-thyroid antibody titers.
21. The presence of elevated TPOAb titers in
patients with subclinical hypothyroidism
helps to predict progression to overt
hypothyroidism—4.3% per year with
TPOAb vs. 2.6% per year without
elevated TPOAb titers
Anti-thyroid peroxidase antibody (TPOAb)
measurements should be considered
when evaluating patients with subclinical
hypothyroidism. (Grade B, BEL 1)
22. TPOAb measurement should be
considered in order to identify
autoimmune thyroiditis when nodular
thyroid disease is suspected to be due to
autoimmune thyroid disease. (Grade D, BEL 4)
TPOAb measurement should be
considered when evaluating patients with
recurrent miscarriage, with or without
infertility. (Grade A, BEL 2)
23. Patients whose serum TSH levels exceed
10 mIU/L are at increased risk for heart
failure and cardiovascular mortality, and
should be considered for treatment with
L-thyroxine. (Grade B, BEL 1)
24. Treatment based on individual factors for
patients with TSH levels between the
upper limit of a given laboratory’s
reference range and 10 mIU/L should be
considered particularly if patients have
symptoms suggestive of hypothyroidism,
positive TPOAb or evidence of
atherosclerotic cardiovascular disease,
heart failure, or associated risk factors
for these diseases. (Grade B, BEL 1)
25. Patients with hypothyroidism should be
treated with L-thyroxine monotherapy.
(Grade A, BEL 1)
The evidence does not support using L-
thyroxine and L-triiodothyronine
combinations to treat hypothyroidism.
(Grade B, BEL 1)
26. The daily dosage of L-thyroxine is
dependent on age, sex, and body
size. Ideal body weight is best used
for clinical dose calculations because
lean body mass is the best predictor
of daily requirements
27. With little residual thyroid function,
replacement therapy requires
approximately 1.6 μg/kg of L-thyroxine
daily. Patients who are athyreotic (after
total thyroidectomy and/or radioiodine
therapy) and those with central
hypothyroidism may require higher doses
,while patients with subclinical
hypothyroidism or after treatment for
Graves’ disease may require less
28. When initiating therapy in young healthy
adults with overt hypothyroidism,
beginning treatment with full replacement
doses should be considered. (Grade B, BEL 2)
When initiating therapy in patients older
than 50-60 years with over
hypothyroidism, without evidence of
coronary heart disease, an L-thyroxine
dose of 50 μg daily should be considered.
(Grade D, BEL 4)
29. In patients with subclinical
hypothyroidism initially a daily dose of 25
to 75 μg should be considered,
depending on the degree of TSH
elevation. Further adjustments should be
guided by clinical response and follow
up laboratory determinations including
TSH values. (Grade B, BEL 2)
30. Among those with known coronary heart
disease (CHD), the usual starting dose is
reduced to 12.5-25 μg/day. Clinical
monitoring for the onset of anginal
symptoms is essential (178). Anginal
symptoms may limit the attainment of
euthyroidism
31. However, optimal medical management of
arteriosclerotic cardiovascular disease
(ASCVD) should generally allow for
sufficient treatment with L-thyroxine to both
reduce the serum TSH and maintain the
patient angina-free. Emergency coronary
artery bypass grafting in patients with
unstable angina or left main coronary artery
occlusion may be safely performed while the
patient is still moderately to severely
hypothyroid but elective cases should be
performed after the patient has become
32. Patients resuming L-thyroxine therapy
after interruption (less than 6 weeks) and
without an intercurrent cardiac event or
marked weight loss may resume their
previously employed full replacement
doses. (Grade D, BEL 4)
33. Treatment with glucocorticoids in
patients with combined adrenal
insufficiency and hypothyroidism should
precede treatment with L-thyroxine.
(Grade B, BEL 2)
L-thyroxine should be taken with water
consistently 30-60 minutes before
breakfast or at bedtime 4 hours after the
last meal
34. The most reliable therapeutic endpoint
for the treatment of primary
hypothyroidism is the serum TSH value
35. In patients with hypothyroidism who are
not pregnant, the target range should be
the normal range of a third generation
TSH assay. If an upper limit of normal for
a third generation TSH assay is not
available, in iodine-sufficient areas an
upper limit of normal of 4.12 mIU/L
should be considered and if a lower limit
of normal is not available, 0.45 mIU/L
should be considered. (Grade B, BEL 2)
36. Patients being treated for established
hypothyroidism should have serum TSH
measurements done at 4-8 weeks after
initiating treatment or after a change in
dose. Once an adequate replacement
dose has been determined, periodic TSH
measurements should be done after 6
months and then at 12-month intervals,
or more frequently if the clinical situation
dictates otherwise. (Grade B, BEL 2)
37. Although most physicians can diagnose and
treat hypothyroidism, consultation with an
endocrinologist is recommended in the following
situations:
• Children and infants
• Patients in whom it is difficult to render and
maintain a euthyroid state
• Pregnancy
• Women planning conception
• Cardiac disease
• Presence of goiter, nodule, or other
structural changes in the thyroid gland
38. • Presence of other endocrine disease such
as adrenal and pituitary disorders
• Unusual constellation of thyroid function
test results
• Unusual causes of hypothyroidism such as
those induced by agents that interfere with
absorption of L-thyroxine impact thyroid gland
hormone production or secretion, affect the
hypothalamic-pituitary-thyroid axis (directly or
indirectly), increase clearance, or peripherally
impact metabolism.(Grade C, BEL 3)
39. Pregnancy : Overt untreated
hypothyroidism during pregnancy may
adversely affect maternal and fetal
outcomes. These include increased
incidences of spontaneous miscarriage,
preterm delivery, preeclampsia, maternal
hypertension, postpartum hemorrhage, low
birth weight and stillbirth, and impaired
intellectual and psychomotor development
of the fetus .
40. There is evidence to suggest that
subclinical hypothyroidism in early
pregnancy may also be associated with
impaired intellectual and psychomotor
development, and that this impairment
may be prevented with L-thyroxine
treatment
41. The upper limit of the normal range of
TSH value in pregnancy: it should be
based on trimester-specific ranges for
that laboratory. If trimester-specific
reference ranges for TSH are not
available in the laboratory, the following
upper normal reference ranges are
recommended: first trimester, 2.5 mIU/L;
second trimester, 3.0 mIU/L; third
trimester, 3.5 mIU/L. (Grade B, BEL 2)
42. Maternal serum TSH (and total T4)
should be monitored every 4 weeks
during the first half of pregnancy and
at least once between 26 and 32
weeks gestation and L-thyroxine
dosages adjusted as indicated. (Grade
B, BEL 2)
43. Treatment with L-thyroxine should be
considered in women of childbearing
age with normal serum TSH levels when
they are pregnant or planning a
pregnancy, including assisted
reproduction in the immediate future, if
they have or have had positive levels of
serum TPOAb, particularly when there is
a history of miscarriage or past history
of hypothyroidism. (Grade B, BEL 2)
44. Diabetes Mellitus: Approximately 10%
of patients with type 1 diabetes mellitus
will develop chronic thyroiditis during
their lifetime, which may lead to the
insidious onset of subclinical
hypothyroidism.
45. Sensitive TSH measurements should be
obtained at regular intervals in patients
with type 1 diabetes, especially if a goiter
develops or if evidence is found of other
autoimmune disorders. In addition,
postpartum thyroiditis will develop in up
to 25% of women with type 1 diabetes
46. Infertility: Some patients with
infertility and menstrual irregularities
have underlying chronic thyroiditis in
conjunction with subclinical or overt
hypothyroidism. Moreover, TPOAb-
positive patients, even when euthyroid,
have an excess miscarriage rate.
Typically, these patients seek medical
attention because of infertility or a
previous miscarriage, rather than
hypothyroidism
47. In some patients with overt
hypothyroidism, thyroid hormone
replacement therapy may normalize the
menstrual cycle and restore normal
fertility .
48. Depression: a small proportion of
all patients with depression have
primary hypothyroidism—either overt
or subclinical. Those with
autoimmune disease are more likely
to have depression as are those with
postpartum thyroiditis regardless of
whether the hypothyroidism is
treated or not.