MON-501 Physician-Reported Misuse of Thyroid Ultrasound

Abstract BACKGROUND: Over the past four decades, there has been a substantial increase in the incidence of thyroid cancer with studies suggesting that greater use of thyroid ultrasound contributes to the rise in incidence. However, little is known about physician reported practice patterns on ultrasound use. Methods: Patients diagnosed with differentiated thyroid cancer in 2014–15 from the Surveillance, Epidemiology and End Results registries of Georgia and Los Angeles were surveyed and asked to identify the surgeon who performed their thyroid surgery, and the endocrinologist and other doctors most involved in their thyroid cancer treatment decision making. We surveyed all physicians identified by more than one patient, and a random sample of physicians identified by one surveyed patient (N=610; 65% response rate). Surveyed physicians were asked to identify the clinical scenarios in which they would schedule a thyroid or neck ultrasound. We generated descriptive statistics for all categorical variables and used multivariable logistic regression to identify factors associated with thyroid ultrasound misuse. Results: The cohort consisted of primary care physicians (PCPs; N=162), endocrinologists (N=176), otolaryngologists (N=130), and general surgeons (N=134). In addition to physicians reporting ultrasound use for accepted reasons such as palpable nodule on exam (98%), large goiter (92%), and nodule seen on other imaging test (88%), a substantial number of physicians endorsed ultrasound use for clinically unsupported reasons: patient request (33%); abnormal thyroid function tests (28%); and positive thyroid antibodies (22%). In multivariable analysis, compared to PCPs, endocrinologists, otolaryngologists, and general surgeons were significantly more likely to schedule an ultrasound in response to patient request (odds ratio (OR) 2.52, 95% confidence interval (CI) 1.27–5.11; OR 2.98, 95% CI 1.57–5.79; OR 2.14, 95% CI 1.17–3.97, respectively). Physicians in private practice were more likely to schedule an ultrasound for abnormal thyroid function tests (OR 2.44, 95% CI 1.33–4.73) and positive thyroid antibodies (OR 2.47, 95% CI 1.27–5.21) compared to those in academic medical centers. Physicians who managed ten patients or less, compared to more than 50 patients, with thyroid nodules in the past 12 months were less likely to schedule an ultrasound for positive thyroid antibodies (OR 0.43, 95% CI 0.19–0.95). Conclusion: Physicians report scheduling thyroid ultrasound for reasons not supported by clinical guidelines and in conflict with the Choosing Wisely recommendations. Understanding why physicians use thyroid ultrasound and factors that correlate with clinically unsupported reasons is essential to creating targeted educational interventions to improve physician adherence to guidelines, reduce unnecessary imaging, and curb the overdiagnosis of low-risk thyroid cancer.

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Thyroid dysfunction in chronic schizophrenia in albania

European Psychiatry ◽

10.1016/s0924-9338(11)73219-9 ◽

2011 ◽

Vol 26 (S2) ◽

pp. 1515-1515 ◽

Cited By ~ 1

Author(s):

Y. Themeli ◽

I. Aliko ◽

A. Hashorva

Keyword(s):

Thyroid Hormones ◽

Thyroid Function ◽

Thyroid Dysfunction ◽

Chronic Schizophrenia ◽

Hashimoto Thyroiditis ◽

Diabetes Mellitus Type 1 ◽

Thyroid Function Tests ◽

Thyroid Antibodies ◽

Normal Thyroid ◽

Function Tests

BackgroundThyroid dysfunction is relatively common in patients with schizophrenia.This study seeks to determine the prevalence and pattern of thyroid dysfunction and thyroid antibodies presence in a group of adult psychiatric inpatients with chronic schizophrenia.MethodsThyroid function tests and thyroid antibodies measurement were performed on 88 patients hospitalized in Psichiatric Clinic of UHC “Mother Teresa” from december 2006 to december 2007.55 of them (62,5%) were females and 33 of them (37,5%) males. A median age of 43 years (range16 to 70 years) and a median duration of hospitalization of 10 years (range 1 to 30 years) was assessed.ResultsTAb were found in 22 patients (25%), of which 18 females and 4 males. 16% of them resulted with positive anticorps for Hashimoto Thyroiditis; 9% for Graves‘disease.According to thyroid function tests70% had normal test, 8% had elevated TSH: 3% of them with low thyroid hormones and 5% with normal thyroid hormones. 20% of cases had low TSH: 5% of them with high level of thyroid hormones, 15% with normal thyroid hormones. Hypothyroidism was more frequent in elderly patients ( > 60 years old), and in those treated with Risperidone. Most of cases (73%) with thyroid disorders resulted from endemic geographic areas. 37% of them mentioned familial history for thyroid pathology, and 23% for diabetes mellitus type 1.ConclusionThyroid abnormalities are common in patients with chronic schizophrenia.This fact call for caution in the use and interpretation of thyroid function tests in these patients.

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An autoimmune cause of confusion in a patient with a background of hypothyroidism

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-19-0014 ◽

2019 ◽

Vol 2019 ◽

Author(s):

Jonathan Brown ◽

Luqman Sardar

Keyword(s):

Thyroid Function ◽

Thyroid Stimulating Hormone ◽

Healthy Population ◽

List Type ◽

Thyroid Function Tests ◽

Thyroid Antibodies ◽

Fluid Analysis ◽

Normal Thyroid Function ◽

Function Tests ◽

Antibody Titres

Summary A 68-year-old previously independent woman presented multiple times to hospital over the course of 3 months with a history of intermittent weakness, vacant episodes, word finding difficulty and reduced cognition. She was initially diagnosed with a TIA, and later with a traumatic subarachnoid haemorrhage following a fall; however, despite resolution of the haemorrhage, symptoms were ongoing and continued to worsen. Confusion screen blood tests showed no cause for the ongoing symptoms. More specialised investigations, such as brain imaging, cerebrospinal fluid analysis, electroencephalogram and serology also gave no clear diagnosis. The patient had a background of hypothyroidism, with plasma thyroid function tests throughout showing normal free thyroxine and a mildly raised thyroid-stimulating hormone (TSH). However plasma anti-thyroid peroxidise (TPO) antibody titres were very high. After discussion with specialists, it was felt she may have a rare and poorly understood condition known as Hashimoto’s encephalopathy (HE). After a trial with steroids, her symptoms dramatically improved and she was able to live independently again, something which would have been impossible at presentation. Learning points: In cases of subacute onset confusion where most other diagnoses have already been excluded, testing for anti-thyroid antibodies can identify patients potentially suffering from HE. In these patients, and under the guidance of specialists, a trial of steroids can dramatically improve patient’s symptoms. The majority of patients are euthyroid at the time of presentation, and so normal thyroid function tests should not prevent anti-thyroid antibodies being tested for. Due to high titres of anti-thyroid antibodies being found in a small percentage of the healthy population, HE should be treated as a diagnosis of exclusion, particularly as treatment with steroids may potentially worsen the outcome in other causes of confusion, such as infection.

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Goiter in Children

Pediatrics in Review ◽

10.1542/pir.5.9.259 ◽

1984 ◽

Vol 5 (9) ◽

pp. 259-272

Author(s):

Thomas P. Foley

Keyword(s):

Thyroid Gland ◽

Thyroid Nodule ◽

Thyroid Function ◽

Graves Disease ◽

Thyroid Function Tests ◽

Thyroid Antibodies ◽

Presumptive Diagnosis ◽

Function Tests ◽

Serum Tsh

The diagnostic evaluation of the patient with thyromegaly will be determined by the clinical history and an examination of the thyroid gland (Table 9). In most instances the diagnosis will not be in doubt, and only a few tests will be necessary. For example, the euthyroid adolescent female with an asymmetrically or symmetrically enlarged, firm thyroid gland has a presumptive diagnosis of CLT, and only tests of thyroid function (T4 and TSH) and thyroid antibodies may be needed for confirmation. Similarly, the patient with clinical symptoms and signs of hyperthyroidism, exophthalmus, and a diffusely enlarged, soft thyroid gland has a presumptive diagnosis of Graves disease. The necessary tests include only a measurement of T4, an estimate of free T4, and WBC and differential counts prior to the initiation of antithyroid drug therapy. [See table in the PDF file] In the absence of an obvious diagnosis, the clinician will select the specific diagnostic tests depending upon the examination of the thyroid gland. The cause of smooth, symmetrical, diffuse enlargement of the thyroid gland can be suspected with careful history for familial disease, history of exposure to goitrogens and goitrogenic drugs, and the determination of thyroid antibodies in serum. If the clinical history is suggestive of hyperthyroidism, the tests of thyroid function tests should include determination of serum T3 concentration; if the history is compatible with euthyroidism or hypothyroidism, thyroid function tests should include determination of serum TSH concentration for the presence of compensated primary hypothyroidism. If results of these tests are normal, no additional tests are necessary, and the patient should be reassured and seen again in six months. If the patient has a test that is negative for thyroid antibodies and an elevation of serum TSH concentration, a radioactive [123I]iodide uptake and perchlorate discharge test will be helpful in the diagnosis of familial dyshormonogenesis. The patient with constitutional symptoms of inflammatory disease, history of a recent upper tract respiratory infection, and a tender or nontender enlarged thyroid gland may have subacute thyroiditis; a low or absent uptake of radioiodine with high-normal or elevated T4 and T3 concentrations will be suggestive of that diagnosis. In patients with thyromegaly and mild symptoms of hyperthyroidism, a TRH test will help to discriminate hyperthyroxinemia secondary to increased or abnormal serum thyroxine binding proteins from early Graves disease, factitious hyperthyroidism, toxic thyroiditis, and TSH-mediated hyperthyroidism. The T3 suppression test is a definitive diagnostic test for early, mild Graves disease. The euthyroid patient with mild-to-moderate thyromegaly and tests that are negative for thyroid antibodies usually deserves no further diagnostic evaluation, but should be followed with a presumptive diagnosis of idiopathic goiter or mild CLT. On follow-up evaluation, initially at six-month intervals and subsequently at yearly intervals, the patient should have a clinical and biochemical assessment until thyromegaly regresses and the gland is normal in size and consistency. The patient with a nontender, firm, irregular enlargement of the thyroid gland usually has CLT. If results of thyroid function tests are normal and tests for thyroid antibodies are negative, the patient should be seen again in four to six months and serum thyroid antibody determinations again performed. Another test that may give abnormal results in patients with CLT is the perchlorate discharge test. The approach to the patient with the solitary thyroid nodule differs from that of the previously described clinical presentations. The most important studies for the patient with a thyroid nodule are those designed to determine the structure and consistency of the thyroid gland, namely, ultrasonography to distinguish between solid and cystic lesions, and the radionuclide scan to determine whether the nodule is functioning (hot) or nonfunctioning (cold). To assure that the thyroid nodule is not associated with a nonsurgical lesion such as Hashimoto thyroiditis, serum thyroid antibody determinations are important. As malignancy of the thyroid gland is usually not associated with abnormalities of thyroid function, it is important to perform laboratory tests to exclude hyperthyroidism (a serum T3 determination) and hypothyroidism (a serum TSH determination) at the time of initial evaluation. Additional tests are usually not necessary unless the patient had mild hyperthyroidism with an autonomously functioning nodule, in which case the T3 suppression test and TRH test are often useful; rarely, the TSH stimulation test is helpful in determing whether thyroid tissue throughout the remainder of the gland is suppressed. A solitary, solid, nonfunctioning (cold) nodule requires excisional biopsy.

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