Hypothyroidism is caused by insufficient thyroid hormone secretion or loss of thyroid function. Treatment with levothyroxine sodium replacement therapy is nearly always successful and allows patients to live normal lives. Approximately 5% of the global population has hypothyroidism. Hypothyroidism treatment aims to replace thyroid hormones and maintain euthyroidism by monitoring TSH levels and adjusting levothyroxine doses accordingly. Congenital hypothyroidism requires early diagnosis and treatment to prevent intellectual disability and developmental delays.
Many have troubles choosing the proper insulin type and dosing for their patients.. Here is a quick presentation that introduce you to different studies in that matter.
This presentation is intended for healthcare prfessionals
Congenital hypothyroidism is quite common in Indians and is the most common reversible congenital cause of mental retardation.
Early identification and intervention is important as Thyroid dependent brain development is complete by 3 years of age.
Universal screening is ideal as most cases are sporadic.
Positive cases on screening by filter paper test should be confirmed by serum levels estimation.
Serum Thyroid hormone levels are of primary importance in diagnosing and managing this condition, other investigations are ancillary.
Age based reference values must be followed in interpreting the results.
Timely monitoring (serum hormone levels, compliance, growth & development) and adequate counseling of care givers are key in managing this condition.
Many have troubles choosing the proper insulin type and dosing for their patients.. Here is a quick presentation that introduce you to different studies in that matter.
This presentation is intended for healthcare prfessionals
Congenital hypothyroidism is quite common in Indians and is the most common reversible congenital cause of mental retardation.
Early identification and intervention is important as Thyroid dependent brain development is complete by 3 years of age.
Universal screening is ideal as most cases are sporadic.
Positive cases on screening by filter paper test should be confirmed by serum levels estimation.
Serum Thyroid hormone levels are of primary importance in diagnosing and managing this condition, other investigations are ancillary.
Age based reference values must be followed in interpreting the results.
Timely monitoring (serum hormone levels, compliance, growth & development) and adequate counseling of care givers are key in managing this condition.
DEFINITION
• Myxedema coma is a rare life-threatening condition.It is the decompensated state of severe hypothyroidism in whichthe patient is hypothermic and unconscious.The condition occurs most often among elderly women in the winter months and appears to be precipitated by cold.
• Myxedema coma, occasionally called myxedema crisis, is a rare life- threatening clinical condition that represents severe hypothyroidism with physiological decompensation. The condition usually occurs in patients with long-standing, undiagnosed hypothyroidism and is usually precipitated by infection, cerebrovascular disease, heart failure, trauma, or drug therapy.
• Myxedema is also used to describe the dermatologic changes that occur in hypothyroidism which refers to deposition of mucopolysaccharides in the dermis, which results in swelling of the affected area.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
DEFINITION
• Myxedema coma is a rare life-threatening condition.It is the decompensated state of severe hypothyroidism in whichthe patient is hypothermic and unconscious.The condition occurs most often among elderly women in the winter months and appears to be precipitated by cold.
• Myxedema coma, occasionally called myxedema crisis, is a rare life- threatening clinical condition that represents severe hypothyroidism with physiological decompensation. The condition usually occurs in patients with long-standing, undiagnosed hypothyroidism and is usually precipitated by infection, cerebrovascular disease, heart failure, trauma, or drug therapy.
• Myxedema is also used to describe the dermatologic changes that occur in hypothyroidism which refers to deposition of mucopolysaccharides in the dermis, which results in swelling of the affected area.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
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.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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.
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
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.
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.
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
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
5. Hypothyroidism is caused by insufficient
secretion of thyroid hormones by the thyroid
gland or by the complete loss of its function.
Hypothyroidism is usually progressive and
irreversible.
Treatment, however, is nearly always
completely successful and allows a patient to
live a fully normal life.
6. Globally, approximately 200 million people have
thyroid disorders of various types, with more than
50% remaining undiagnosed.
About 5% of the global population has
hypothyroidism, and about 2% has hyperthyroidism.
Thyroiditis has been seen in as many as 12.5% of
populations in various countries.
Global prevalence of thyroid disorders
Taylor, P., Albrecht, D., Scholz, A. et al. Global epidemiology of hyperthyroidism and hypothyroidism. Nat Rev Endocrinol 14, 301–316 (2018).
7. 1. Taylor, P., Albrecht, D., Scholz, A. et al. Global epidemiology of hyperthyroidism and hypothyroidism. Nat Rev Endocrinol 14, 301–316 (2018).
https://doi.org/10.1038/nrendo.2018.18
2. Vanderpump, M. P. The epidemiology of thyroid disease. Br. Med. Bull. 99, 39–51 (2011).
…Global prevalence of hypothyroidism
Incidence of Hashimoto’s thyroiditis increases with
aging and affects about 5% of the global population,
usually between ages 30 and 60.1
In iodine-sufficient countries, the prevalence of
hypothyroidism ranges from 1% to 2%, rising to 7%
in individuals aged between 85 and 89 years.2
Hypothyroidism is 8-15 times more prevalent in
women than men.2
8. 1. Unnikrishnan, A. G. et al. Prevalence of hypothyroidism in adults: an epidemiological studyin eight cities of India. Indian J. Endocrinol. Metab. 17, 647–652 (2013).
Regional variations were reported in India, with
higher rates of hypothyroidism in inland than in
coastal regions.1
Among all cities, Kolkata recorded the highest
prevalence of hypothyroidism (21.67%). Cities
located in the inland regions of India (Delhi,
Ahmedabad, Kolkata, Bangalore and Hyderabad)
reported a significantly higher prevalence of
hypothyroidism (11.73%) than those in the coastal
areas (Mumbai, Chennai and Goa) (9.45%; P =
0.01).1
9. Classification of Hypothyroidism
A. Primary
1. Enlarged Thyroid
- Hashimoto’s (65%)
- Iodine Deficiency (25%)
- Drug-induced (Lithium)
- Dysharmonogenesis
- Infiltrative Diseases
2. Normal Thyroid
- Spontaneous Atrophic
- Post thyroidectomy
3. Post Ablative
- Permanent
- Transient
- Sub-clinical
4. Congenital
www.drsarma.in 9
B. Secondary / Central
Pituitary/ hypothalamic
11. Progression of Thyroid Disease
Ayala AR, et al. Endocrinologist. 1997;7:44-50.
Years
Normal
Range
TSH
Overt
Hypothyroidism
Subclinical
HypothyroidismEuthyroid
T3
T4
12. Subclinical Hypothyroidism-
This is a biochemical diagnosis and describes
the finding of elevated serum TSH with normal
free thyroid hormones.
Symptoms may be present or absent
1. Cooper DS. N Engl J Med. 2001;345:260-265.
2. Vanderpump MP, Tunbridge WM, French JM, et al. The incidence of thyroid disorders in the community:
a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf) 1995; 43: 55e68.
Subclinical hypothyroidism is found in 5e10% of the
population, being more common in women and
increasing with age.
It can progress to overt hypothyroidism, particularly
if patients have elevated concentrations of thyroid
antibodies. The most common etiology is chronic
autoimmune thyroiditis.2
13. Subclinical Hypothyroidism-
An isolated elevated TSH level in the
setting of normal T3 and T4 levels
Symptoms may be present or absent
1. Cooper DS. N Engl J Med. 2001;345:260-265.
Definition1
14. Potential benefits from treatment1
Prevent progression to overt hypothyroidism
Improve serum lipid profile, which may reduce the
cardiovascular disease risks
Reduce symptoms, including psychiatric and
cognitive abnormalities
Better fertility outcome
Improves menses irregularities
1.Cooper DS. N Engl J Med. 2001;345:260-264.
Rationale for Treating Subclinical
Hypothyroidism
16. HYPOTHYROIDISM TREATMENT GOAL:
EUTHYROIDISM
The goal of hypothyroidism therapy is to
replace thyroxine to mimic normal,
physiologic levels and alleviate signs,
symptoms, and biochemical abnormalities.1
Braverman LE, et al. Werner & Ingbar’s The Thyroid. A
Fundamental and Clinical Text. 8th ed. 2018.
17. THERAPY INITIATION AND TITRATION
Endocr Pract. 2019;8:457-469.Singer PA, et al. JAMA. 1995;273:808-812.
Therapy requires individualized patient dosing
Careful titration: use a formulation with consistent
doses
Clinical evaluation: symptoms resolve more slowly
than TSH response
Laboratory monitoring: need consistent, sensitive
TSH measurements (preferably 3rd gen assay)
Individualized patient dosing is influenced by
Age and weight
Cardiovascular health
Severity and duration of hypothyroidism
Concomitant disease states and treatment
18. Hypothyroidism Treatment
Levothyroxine sodium is the treatment
of choice for the routine management of
hypothyroidism
Adults: about 1.7 g/kg of body weight/d
Children up to 4.0 g/kg of body weight/d
Elderly <1.0 g/kg of body weight/d
Singer PA, et al. JAMA. 2019;273:808-812.Endocr Pract. 2002;8:457-469.
19. Hypothyroidism Treatment
Clinical and biochemical evaluations at 6- to
8 week intervals until the serum TSH
concentration is normalized
Given the narrow and precise treatment
range for levothyroxine therapy, it is preferable
to maintain the patient on the same brand
throughout treatment
Singer PA, et al. JAMA. 2019;273:808-812.Endocr Pract. 2002;8:457-469.
20. Primary Hypothyroidism Treatment and Follow-Up
Algorithm1,2
TSH >3.0 IU/mL TSH <0.5 IU/mL
Initial Levothyroxine Dose
Increase
Levothyroxine
Dose by
12.5 to 25 g/d
Repeat TSH Test
6-8 Weeks
TSH 0.5- 2.0 IU/mL
Symptoms Resolved
Measure TSH at 6 Months,
Then Annually or
When Symptomatic
Continue Dose Decrease
Levothyroxine
Dose by
12.5 to 25 g/d
1, Singer PA, et al. JAMA. 1995;273:808-812.
2. Demers LM, Spencer CA, eds. The National Academy of Clinical Biochemistry Web site.
Available at: http://www.nacb.org/lmpg/thyroid_lmpg.stm. Accessed July 1, 2003.
21.
22. Caution in Patients with Underlying
Cardiac Disease
Using LT4 in those with ischemic heart disease
increases the risk of MI, aggravation of angina, or
cardiac arrhythmias
For patients <50 years of age with underlying cardiac
disease, initiate LT4 at 25-50 g/d with gradual dose
increments at 6- to 8-week intervals
For elderly patients with cardiac disease, start LT4 at
12.5-25 g/d, with gradual dose increments at 4- to
6-week intervals
The LT4 dose is generally adjusted in 12.5-25 g
increments
Braverman LE, et al. Werner & Ingbar’s The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000.
Kohno A, et al. Endocr J. 2001;48:565-572.
Synthroid® [package insert]. Abbott Laboratories; 2003.
24. Congenital Hypothyroidism
Congenital hypothyroidism (CH) is
defined as thyroid hormone
deficiency present at birth
It can occur because of an anatomic
defect in the gland, an inborn error of
thyroid metabolism, or iodine
deficiency.
Diseases may manifest from birth
or later
25. Epidemiology
Incidence increased to about 1 in 2,000 due to
more stringent screening strategies.
Incidence in Bangladesh 1: 1,300, According to
the research paper of 'Institute of Nuclear
Medicine, Dhaka, Bangladesh'.
Male: Female = 1:2
1: 4000
26. Neonatal Physiology
Surge in
TSH
30 mins
after
delivery
peak at
6 hours
rapid decline
over 24hrs.
T3 and
T4 levels
increase sharply
within 24 hours slow decline
Preterm infant-TSH
surge is less
marked
T4 and T3 responses are blunted.
28. Clinical Manifestations..
95% -asymptomatic at birth
Some infants escape newborn screening, and
laboratory errors occur, so pediatricians must still
be alert for symptoms and signs of
hypothyroidism if they develop.
29. Clinical Manifestations…..
Early
Prolong gestation
LGA
Large poterior fontanelle
Hypotonia.
Feeding / respiratory difficulty
Delayed passage of meconeum
Constipation
Umbilical hernia
Prolonged neonatal jaundice
Hypotharmia
• Late
Coarse/puffy face
Coarse hair
Large Tongue
Myxedema, Hoarse cry
Hearing Impairment
Speech delay
31. Newborn at High Risk..
Preterm and low birth weight infants
Infants with trisomy 21 or cardiac defects have an
increased risk of congenital hypothyroidism.
Monozygotic twins , if they are monochorionic,
fetal hypothyroidism in the affected twin may get
compensated by the normal twin through their
shared fetal circulation.
32. A cord blood TSH value of >20 mIU/L can be used for
the purpose of screening for congenital hypothyroidism.
For logistic angles, a higher cutoff of >30 mIU/L can be
used.
33. Thyroid Ultrasonography- helpful to
separate a structural defect from normal or
enlarged gland. But may miss some ectopic
glands.
Thyroid Scan (Scintigraphy)- most
accurate diagnostic modality to detect
dysplastic or ectopic thyroid tissue Iodide 123
or sodium pertechnetate (tc99m) is preferred.
Diagnostic studies to determine
underlying etiology
34. Serum thyroglobulin
Anti thyroid antibody (TBG-AB)- In case of maternal
autoimmune disease
CBC with PBF- anemia (normo, micro and macro)
CXR- Cardiomegaly
ECG- bradycardia and low voltage ECG
CT Scan and MRI
Other relevant Investigation
35. TSH > 20 MIU/L
High TSH
Low T4
Transient Hypothyroidism or
permanent Hypothyroidism
Start treatment soon,
Further investigation to identify the cause
High TSH
Normal T4
FT4, TSH again
TSH > 20mIU/L
TSH 6 -20 mIU/L:
Repeat FT4, TSH weekly until normal,
≥10 mIU/L Persistently consider Rx
When to Start Treatment?
New born screening
36. Treatment
The aim of therapy is to ensure normal growth
and development by maintaining :
- serum TSH in the reference (optimally 0.5–2.0
mU/L) and
- FT4 in the upper half of the reference range for
age.
Treatment preferably within the 2nd wk of
life is essential to prevent irreversible brain
damage
37. Levothyroxine
The recommended dose of L -T4 is 10-15
μg/kg/day given orally
Rapid normalization of thyroid function (ideally
within 2 wk) is important in achieving optimal neuro-
developmental outcome.
LT4 must be ingested in the empty stomach, avoid
soya, calcium and iron containing diet
Treatment..
39. Lab Follow-up
Serum T4 and TSH measurements should be performed
1. 2 and 4 weeks after the initiation of LT4 treatment
2. 4 weeks after any change in LT4 dosage.
3. every 1 to 2 months during the first 6 months of life
4. every 3 to 4 months between 6 months and 3 years
5. every 6 to 12 months until growth is completed; and
6. at more frequent intervals when compliance is questioned, or
abnormal values are obtained.
40. Myxedema denotes uncompensated form of severe
hypothyroidism.
Myxedema coma is a severe and life-threatening form
of decompensated hypothyroidism with an underlying
precipitating factor(s).
The mortality rates may be as high as 25–60% even
with best possible treatment.
Myxedema and
Myxedema Coma
1. Wartofsky, “Myxoedema coma,” Endocrinology Metabolism Clinics of North America, vol. 35, pp. 687–698, 2006.
2.. Rodr´ıguez, E. Fluiters, L. F. Pe´rez-Me´ndez, R. Luna, C. Pa´ramo, and R. V. Garc´ıa-Mayor, “Factors associated with mortality of patients with myxoedema coma: prospective study in 11 cases treated in a single
institution,” Journal of En- docrinology, vol. 180, no. 2, pp. 347–350, 2004.
3. Yamamoto, J. Fukuyama, and A. Fujiyoshi, “Factors associ- ated with mortality of myxedema coma: report of eight cases and literature survey,” Thyroid, vol. 9, no. 12, pp. 1167–1174, 1999.
41. Low intracellular T3 leads to cardiogenic shock, respiratory
depression, hypothermia and coma.
Hypothermia
Infections and septicemia
CVDs
Congestive heart failure
Gastrointestinal bleeding
Trauma and fractures
Drugs—anesthetics, sedatives, tranquilizers, narcotics,
amiodarone, and lithium Withdrawal of thyroid supplements
Precipitating factors of myxedema crisis
Precipitation of Myxedema Coma
Literature reveals that most cases present in winter, and
hypothermia is a common manifestation. Low ambient temperature
may alter thermoregulatory mechanisms and hence will lower the
threshold for encephalopathy.
43. Treatment should be prompt, vigorous and multidimensional
with attention to:
a) intensive care treatment with ventilator support, central
venous pressure monitoring, and pulmonary capillary
wedge pressure if feasible in patients with cardiac disease,
b)Wrap up the pt in a ‘space blanket’ which retains the heat
in a warm room
c) Maintain adequate airway to prevent hypoxemia.
Prevention of hypoxemia is the single important step to
prevent catastrophe.
d) Monitor ABG regularly
Treatment of Myxedema Crisis
44. e) appropriate fluid management and correction of hypotension
and dyselectrolytemia
f) aggressive management of precipitating factors and steroid
supplementation if required
g) Cardiac monitoring
h) Combat hyponatremia:
i) In mild (Na+- 120-140 mEq/L)- fluid restriction
ii) In severe (Na+- 105-10 mEq/L)- 3% NaCl and 40-120mg
frusemide
….Treatment of MyxedemaCrisis
45. i) Combat hypotension:
i) IV NS or 5% to 10% DA
ii) IV or IM 50 to 100mg hydrocortisone 6/8 hourly
iii) Judicious use of dopamine
j) Thyroid hormone therapy:
50-100 µ LT4 by NG tube
+
5µ T3- twice daily
• If IV LT4 is available: 200–300 µ LT4 (4 µ/KBW) + 25µ
T3+ hydrocortisone 5 mg/h
46. This may be followed by IV 100µ LT4 after 24 h +
25µ T3 after 12 h.
This is continued till pt is unconscious. Then LT4
is to be given PO and dose should be determined
by measuring S FT4 and TSH
k) If CCF is present, should be treated as per
standard protocol.
47. Thyroid hormones are essential for
growth, neuronal development, reproduction
and regulation of energy metabolism.
Hypothyroidism is common, readily
identifiable and easily treatable, but if
undiagnosed or untreated, it can have
profound adverse effects
Carry Home Messages
48. Iodine nutrition is a key determinant of
thyroid disease risk; however, we are
transforming to ATD era gradually.
Other factors, such as ageing, smoking
status, genetic susceptibility, ethnicity,
endocrine disruptors and the advent of novel
therapeutics, including immune checkpoint
inhibitors, also influence thyroid disease
epidemiology.
…Carry Home Messages
49. CH is not uncommon and is a treatable
condition.
Myxedema is potentially preventable
condition but if occurs, mortality is very high,
even in most advanced centres.
…Carry Home Messages