scholarly journals Sensory Neuropathy in Hypothyroidism: Electrophysiological and Clinical Findings

1970 ◽  
Vol 2 ◽  
pp. 1-6 ◽  
Author(s):  
Sabina Yeasmin ◽  
Noorzahan Begum ◽  
Shelina Begum ◽  
Shah M Hafizur Rahman
Keyword(s):  
Healthy Subjects ◽  
Hormone Replacement ◽  
Clinical Signs ◽  
Sensory Neuropathy ◽  
Clinical Findings ◽  
Ultra Sound ◽  
Personal Contact ◽  
Control Group ◽  
Group B ◽  
Hypothyroid Patients

Peripheral neuropathy may be a manifestation of hypothyroidism which usually develops insidiously over a long period of time due to irregular taking of drugs or lack of thyroid hormone replacement. The present study was designed to observe the clinical and electro-physiological findings in hypothyroid patients in order to evaluate the neuromuscular dysfunction as well as sensory neuropathy. For this purpose, 70 subjects with the age range of 20 to 50 years of both sexes were included in the study. Among them, 40 hypothyroid patients were taken in study group (Group B) and 30 aparently healthy subjects were taken as control (Group A). On the basis of their TSH levels, group B was further divided into group B1 with TSH <60 MIU /L or (less severe) and group B2 with TSH >60 MIU /L (severe group). The duration of the disease ranged from 6 months to 5 years. All the hypothyroid patients were selected from Thyroid Clinic, Center of Nuclear Medicine and Ultra sound, Dhaka Medical College and Hospital, Dhaka, during the period from January 2005 to December 2005. Healthy subjects were selected from personal contact. Most of the hypothyroid patients were under hormone replacement therapy. Diagnosis of hypothyroidism was done by serum levels of TT3, TT4 and the TSH. In this study, both TT3, TT4 levels were significantly (P<0.01) lower in hypothyroids in comparison to those of control. The patients were searched for the clinical signs of sensory neuropathy. Clinical findings revealed diminished or absence of most of the deep tendon reflexes. The nerve conduction studies for sensory nerve function were done in all the subjects by electrophysiological technique. All the tests were done in median and ulnar nerve for upper limb and in sural nerve for lower limb and these parameters were measured on the day 1 (one) of their first visit. Data were compared among the different groups. Most of the patients had higher sensory distal latencies (SDL) with lower conduction velocities (SNCV) which were more marked in severe cases. About 67.5% of hypothyroid patients had shown abnormal sensory NCV when compared to that of euthyroids. Therefore, this study concludes that sensory neuropathy may be a consequence of hypothyroidism. Key Words: Hypothyroidism; Neuropathy; ElectrophysiologyDOI:10.3329/jbsp.v2i0.975  J Bangladesh Soc Physiol. 2007 Dec;(2): 1-6.

Histopathologic lesions in conventional pigs experimentally infected with Haemophilus parasuis serovar 5

2015 ◽  
Vol 43 (02) ◽  
pp. 91-96 ◽  
Author(s):  
R.-L. Austin-Busse ◽  
A. Ladinig ◽  
G. Balka ◽  
S. Zoels ◽  
M. Ritzmann ◽  
...  
Keyword(s):  
Clinical Signs ◽  
Control Group ◽  
Post Inoculation ◽  
Haemophilus Parasuis ◽  
Tissue Samples ◽  
Group A ◽  
Pathologic Lesions ◽  
Group B ◽  
Kidney Lesions ◽  
Challenge Group

Summary Objective: In the present study various tissues of pigs were investigated for the presence of histopathologic lesions after an experimental infection with Haemophilus (H.) parasuis serovar 5. Material and methods: Conventional pigs (n = 36) were divided into a control group B (n = 9) and a challenge group A (n = 27), which was infected intratracheally. Pigs that did not die prior to study termination were euthanized on day 14 post inoculation. Postmortem samples of the lung, heart, liver, kidney, spleen, left tarsal joint capsule and brain were collected. Results: All but one pig with detectable histopathologic lesions (n = 11) showed typical macroscopic changes. Histopatho logic examination of all tissue samples identified pyelitis (n = 10), synovitis (n = 7) and meningitis (n = 7) and all those animals were euthanized prior to study termination. No histopathologic lesions were found in pigs of the control group. The correlations between pyelitis and meningitis, pyelitis and synovitis and synovitis and meningitis were significant (p < 0.001). No significant correlation could be observed between the histopathologic and the clinical examination of the joints. The investigation of samples from the joints by PCR was not significantly correlated with the observed synovitis. The clinical observation of neurologic signs was significantly correlated with meningitis (p = 0.03). A significant correlation (p < 0.001) could be detected between meningitis and the detection of H. parasuis by PCR in brain samples. Conclusions: H. parasuis constantly causes clinical signs and pathologic lesions as soon as it infects the brain while it can infect the joints without causing histopathologic lesions. Pigs with histopathologic lesions do not always show typical clinical signs. Only few studies described the finding of kidney lesions in pigs with Glässer’s disease and this is the first study to describe a pyelitis in pigs experimentally infected with H. parasuis. The observed pyelitis mainly occurred in acute cases.

ELECTRODIAGNOSTIC CRITERIA FOR DIAGNOSING CARPAL TUNNEL SYNDROME NEED TO BE REVISED IN HYPOTHYROID PATIENTS

2017 ◽  
Vol 20 (03) ◽  
pp. 1750014
Author(s):  
Mahdieh Asadi ◽  
Sharareh Roshanzamir
Keyword(s):  
Carpal Tunnel Syndrome ◽  
Carpal Tunnel ◽  
Clinical Symptoms ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Control Group ◽  
Tunnel Syndrome ◽  
Clinical Signs And Symptoms ◽  
Relationship Of ◽  
Hypothyroid Patients

Background: Previous studies do not agree with each other on the association between electrodiagnostic findings and clinical symptoms of Carpal tunnel syndrome (CTS). In most of these studies, many variables such as age, sex, obesity and hypothyroidism have not been taken into account. Material & methods: About 62 patients with hypothyroidism and 62 patients without hypothyroidism with sign and symptoms of CTS were included in this study. Electrodiagnostic tests were done for all patients. And relationship of the severity of CTS signs and symptoms with electrodiagnostic parameters was examined statistically in each group. Results: This study showed that distal motor latency in control group (without hypothyroidism) is significantly more prolonged than hypothyroid patients. Also there was significant correlation between clinical symptoms and electrodiagnostic findings in control group, but there was not such correlation in hypothyroid patients. In 62% of hypothyroid patients with clinical signs and symptoms of CTS, electrodiagnostic findings were normal and only in 38% of cases, electrodiagnostic findings were suggestive of CTS. Conclusion: Relationship of the severity of CTS signs and symptoms with electrodiagnostic parameters is very weak in hypothyroid patients. Many hypothyroid patients with clinical signs and symptoms of CTS have normal electrodiagnostic findings; so we need more studies for revising the para-clinic criteria of labeling patients having CTS in hypothyroid patients.

Prognostic value of mean platelet volume on tinnitus

2015 ◽  
Vol 130 (2) ◽  
pp. 162-165 ◽  
Author(s):  
O Kemal ◽  
T Müderris ◽  
F Başar ◽  
G Kutlar ◽  
F Gül
Keyword(s):  
Mean Platelet Volume ◽  
Healthy Subjects ◽  
Clinical Findings ◽  
University Hospital ◽  
Control Group ◽  
Study Group ◽  
Pathophysiological Mechanism ◽  
Platelet Volume ◽  
Significant Difference ◽  
Healthy Control

AbstractObjective:This study aimed to determine whether there was any relationship between tinnitus and mean platelet volume.Methods:This retrospective study was conducted between January 2013 and January 2014 in Ankara Atatürk Hospital and Ondokuz Mayıs University Hospital, Turkey, on a study group of 86 patients with tinnitus and a control group of 84 healthy subjects. Mean platelet volume was recorded and comparisons were made between the two groups.Results:Mean (± standard deviation) platelet volume was 7.67 ± 0.83 μm3 in the study group and 7.28 ± 0.56 μm3 in the control group. There was a statistically significant difference in mean platelet volume between the tinnitus patients and the healthy subjects (p < 0.05).Conclusion:The clinical findings indicated that tinnitus patients had a higher mean platelet volume than the healthy control subjects; however, the pathophysiological mechanism remains unclear.

scholarly journals The expression levels of MicroRNA-146a, RANKL and OPG after non-surgical periodontal treatment

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Mandana Sattari ◽  
Ramezan Ali Taheri ◽  
Reza ArefNezhad ◽  
Hossein Motedayyen
Keyword(s):  
Healthy Subjects ◽  
Soft Tissues ◽  
Alveolar Bone ◽  
Periodontal Treatment ◽  
Control Group ◽  
Mrna Levels ◽  
Clinical Attachment Loss ◽  
Periodontal Tissues ◽  
Group A ◽  
Group B

Abstract Objective MicroRNA-146a (miR-146a) is a regulator of inflammatory response. Periodontitis is a disease with immune pathophysiology of the periodontium in which the inflammation results in the destruction of the soft tissues and alveolar bone. Therefore, the aim of this study was to investigate the expressions of miR-146a, OPG, and RANKL in diseased and healthy periodontal tissues to understand whether miR-146a expression level may associate with OPG and RANKL mRNA levels and OPG/RANKL ratio after non-surgical periodontal treatment. Methods The levels of miR-146a, RANKL, and OPG in gingival tissues from patients with generalized periodontitis stages II and III and grades A and B (n = 15, group A), patients with generalized periodontitis stages III and IV and grade C (n = 15, group B), and healthy individuals (n = 10) were determined by real-time PCR. The associations of miR-146a expression with OPG and RANKL levels were evaluated. Results The levels of miR-146a in two subgroups within periodontitis patients were significantly higher than healthy subjects (P < 0.0001). MiR-146a showed the increased level in group A of patients compared with group B (P < 0.05). Clinical parameters such as probing depth (PD) and clinical attachment loss (CAL) were significantly higher in patients than control group (P < 0.05). The levels of OPG and RANKL were increased in patients compared with healthy subjects, although the elevated levels were not statistically significant. MiR-146a was not associated with OPG and RANKL levels and OPG/RANKL ratio. Conclusions The results of this study failed to show the associations of miR-146a level with OPG and RANKL levels and OPG/RANKL ratio in periodontitis after non-surgical periodontal treatment.

PREPARATION AND EVALUATION OF AVIAN INFLUENZA (H9) AND NEWCASTLE DISEASE (THERMOSTABLE I-2 STRAIN) BIVALENT VACCINE FOR COMMERCIAL POULTRY

2020 ◽  
Vol 3 ◽  
pp. 17-23
Author(s):  
Rabia Sabir
Keyword(s):  
Avian Influenza ◽  
Newcastle Disease ◽  
Geometric Mean ◽  
Clinical Signs ◽  
Control Group ◽  
Broiler Chicks ◽  
Group A ◽  
Commercial Poultry ◽  
Group B ◽  
Preparation And Evaluation

The goal of current research was production of bivalent adjuvant based inactivated I-2 strain of Newcastle Disease (ND) and Avian Influenza (AI) vaccine and to compare efficacy with commercially available bivalent inactivated vaccine. Experiment was carried out on one-day-old broiler chicks by dividing them into 3 groups A, B & C. Vaccine was injected on 7, 14, 21 and 28 day. Blood samples were collected on 7, 14, 21, 28 and 35 day. Results of Hemagglutination Inhibition (HI) test presented the geometric mean titers of group A and B were <1:4, 1:18.8, 1:115.2, 1:358.4, 1:128 & <1:4, 1:8.4, 1:36.8, 1:56, 1:22.4 respectively for AI. Similarly the geometric mean titers of group A and B were <1:4, 1:19.6, 1:89.6, 1:320, 1:115.2 & <1:4, 1:9.2, 1:25.6, 1:36.8, 1:22.4, respectively for ND. However, control group showed <1:4 geometric mean titer. The challenge was given on 28th day and birds were monitored for next 7 days for clinical signs. The chicks of group A showed no clinical signs of diseases (AI, ND). However, in group B 60% morbidity and 90% mortality was recorded on 4th and 6th day of post challenge, respectively. While 100% mortality was recorded in control group.

scholarly journals Time-Dependent Testicular and Epididymal Damage in Rabbit Bucks Experimentally Infected with Trypanosoma brucei brucei

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Adewale Ayodeji Adeyeye ◽  
Musbaudeen Olayinka Alayande ◽  
Monsurat Bansima Adio ◽  
Lauratu Lawal Haliru ◽  
Aliyu Abdulrafiu
Keyword(s):  
Trypanosoma Brucei ◽  
Clinical Signs ◽  
Control Group ◽  
Pathological Changes ◽  
Epididymal Sperm ◽  
Trypanosoma Brucei Brucei ◽  
Group A ◽  
Time Of Infection ◽  
Gross Lesions ◽  
Group B

Abstract This study was designed to determine the progressive pathological changes in the testis and epididymis of rabbit bucks experimentally infected with Trypanosoma brucei brucei (T. brucei). Fifteen local rabbit bucks were divided into 2 groups comprising 8 bucks in group A and 7 bucks in group B. Bucks in group A were infected intraperitoneally with approximately 1.0x106 of T. brucei while bucks in group B served as the uninfected control. The bucks were closely monitored for clinical signs of trypanosomosis from the time of infection till the end of the study. One buck from each group was humanely sacrificed on days 9, 19, 29 and 38 post-infection (pi) and its testis and epididymis were examined for pathological changes. At post mortem, no gross lesions were observed in the infected bucks except for adhesion of the testis and epididymis to the scrotum on days 29 and 38 pi. There were no histological changes in the testis and epididymis of the infected buck sacrificed on day 9 pi apart from mild depletion of the epididymal sperm reserve. The buck infected on day 19 pi had moderate testicular degeneration but the epididymis was devoid of sperm reserve. Severe testicular and epididymal degeneration was observed in the buck on days 29 and 38 pi. The testis and epididymis of bucks from the control group were normal with evidence of spermatogenic activities and full epididymal sperm reserve throughout. The study shows that infected bucks were unfit for breeding from day 19 pi.

scholarly journals Catalase and Glutathione Peroxidase in Dogs Naturally Infected by Leishmania infantum

2018 ◽  
Vol 44 (1) ◽  
pp. 6 ◽  
Author(s):  
Belarmino Eugênio Lopes-Neto ◽  
Glauco Jonas Lemos Santos ◽  
Adam Leal Lima ◽  
Maritza Cavalcante Barbosa ◽  
Talya Ellen Jesus dos Santos ◽  
...  
Keyword(s):  
Glutathione Peroxidase ◽  
Pearson Correlation ◽  
Clinical Signs ◽  
Erythrocyte Count ◽  
Control Group ◽  
Positive Correlation ◽  
Antioxidant Agents ◽  
Group A ◽  
Group B ◽  
Gpx Activity

Background: Canine leishmaniasis (CanL) is caused by an obligatory intracellular parasite of Leishmania genus that  affects organs and tissues. Several studies evaluate the role of reactive oxygen species (ROS) in the pathogenesis of many diseases. The overproduction of ROS on infectious diseases can induce an imbalance between oxidants and antioxidants at cellular or systemic level. Thus, the aim of this study was to evaluate the activity of antioxidant enzymes in CanL.Materials, Methods & Results: Females (n = 17) and males (n = 10), at different ages and with different weight, were selected for this study. Dogs were divided into two groups according classical clinical signs and sorological test to CanL. Animals were considered infected based on indirect immunofluorescent assay and ELISA titration ≥ 1:40.  Group B (n = 15) composed by positive dogs to CanL from Zoonosis Control Center of Fortaleza (Ceará, Brazil) and group A (n = 12) was composed by dogs from private kennel that were serologically negative to L. infantum and had absence of clinical signs to CanL. Blood sample were collected for evaluation of hematological and biochemical parameters and glutathione peroxidase (GPx) and catalase (CAT) enzymatic activity. Data were analyzed by Student’s t-test and Pearson correlation coefficient (P < 0.05). Total proteins (TP, mg/dL) and alkaline phosphatase (ALP, U/L) were increased (P < 0.05) on group B (8.2 ± 1.2; 165.4 ± 46.4) when compared to group A (6.5 ± 1.1; 109.1 ± 38.3), respectively. Hemoglobin (Hb; g/dL) and hematocrit (Hct; %) were decreased (P < 0.05) on Group B (14.7 ± 1.8; 48.2 ± 5.7) when compared to group A (16.5 ± 1.3; 52.1 ± 2.4), respectively. Group B presented CAT (U/g Hb) and GPx (mU/mg Hb) lower (189.4 ± 90.4; 3,609.6 ± 1,569.1) than group A (326.6 ± 104.5; 5,055.6 ±1,569.1), respectively (P < 0.001). Positive correlation was observed between RBC and CAT; however, it was not significant.Discussion: Organisms require a good defense system in order to revert the overproduction of free radicals and consequently the injuries caused by them. This is possible through the production of antioxidant agents, which act on oxidative prevention and on tissue and cellular regeneration, by taking the reduced glutathione (GSH), superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) enzymes in the frontline. Erythrocyte changes promoted by CanL suggest possible correlation between anemia and the appearance of clinical signs, which in many cases is not seen. Erythrocytes contain SOD, CAT and GPx enzymes, thus, changes in these cells will reflect on the activity of these enzymes. In our results only CAT showed positive correlation with erythrocyte count, however it was not significant. GPx activity was lower (P < 0.001) in infected dogs than control group. This result agrees with another study, which showed a decrease in GPx levels in CanL, although it was not significant. However, it was found a positive correlation (P < 0.001) between erythrocytes and GPx activity and between hemoglobin and GPx activity in animals with leishmaniasis. These results suggest that the reduction in detoxification activity can be related to the decrease in erythrocyte count and that the GPx activity depends on the control mechanism of the antioxidant system in CanL. Furthermore, this result could be associated with decrease of blood cell count in animals with CanL, once GPx is an erythrocyte enzyme, which plays an important role in hemoglobin protection against oxidative damage. This study was carried out in naturally infected dogs with L. infantum. In conclusion, CAT and GPx activities are relate to oxidative stress induced by L. infantum infection and can be used as biomarkers on CanL.

scholarly journals Micro RNA-146a effect on Periodontitis is Independent on OPG/RANKL Axis

2021 ◽  
Author(s):  
Mandana Sattari ◽  
Somayeh Ghotloo ◽  
Ramezan-Ali Taheri ◽  
Reza ArefNezhad ◽  
Hossein Motedayyen
Keyword(s):  
Healthy Subjects ◽  
Soft Tissues ◽  
Alveolar Bone ◽  
Micro Rna ◽  
Control Group ◽  
Clinical Attachment Loss ◽  
Probing Depth ◽  
Independent Mechanism ◽  
Group A ◽  
Group B

Abstract Background MicroRNA-146a (miR-146a) is a regulator of inflammatory response. Periodontitis is a disease with immune pathophysiology of the periodontium in which the inflammation results in the destruction of the soft tissues and alveolar bone. Therefore, this study was investigated whether miR-146a may contribute to periodontitis through affecting the levels of OPG and RANKL. Methods The levels of miR-146a, RANKL, and OPG in gingival tissues from patients with generalized periodontitis stages II and III and grades A and B (n = 15, group A), patients with generalized periodontitis stages III and IV and grade C (n = 15, group B), and healthy individuals (n = 10) were determined by real-time PCR. The associations of miR-146a expression with OPG and RANKL levels were evaluated. Results The levels of miR-146a in two subgroups within periodontitis patients were significantly higher than healthy subjects (P < 0.0001). MiR-146a showed the increased level in group A of patients compared with group B (P < 0.05). Clinical parameters such as probing depth (PD) and clinical attachment loss (CAL) were significantly higher in patients than control group (P < 0.05). The levels of OPG and RANKL were increased in patients compared with healthy subjects, although the elevated levels were not statistically significant. MiR-146a was not associated with the levels of OPG and RANKL. Conclusion The results of this study failed to show the effect of miR-146a on the pathophysiology of disease through OPG/RANKL axis. Clinical Relevancy: MiR-146a may participate in the pathophysiology of disease through independent mechanism(s) of OPG/RANKL axis.

scholarly journals Electroneuromyography for early diagnosis of diabetic distal polyneuropathy

2019 ◽  
Vol 22 (2) ◽  
pp. 141-150
Author(s):  
Elena S. Mazurenko ◽  
Lyudmila A. Ruyatkina ◽  
Igor A. Pakhomov ◽  
Elena V. Chesheva ◽  
Larisa O. Gavrilova
Keyword(s):  
Early Diagnosis ◽  
Lower Limb ◽  
Clinical Signs ◽  
Sensory Neuropathy ◽  
Limb Amputation ◽  
Control Group ◽  
Ulcer Formation ◽  
Neurological Assessment ◽  
Motor Nerves ◽  
Neuropathy Symptom Score

BACKGROUND: Diabetic distal polyneuropathy (DDPN) is a predictor of diabetic foot syndrome development, ulcer formation and lower limb amputation. An early DDPN diagnosis is therefore relevant. AIM: To investigate the effectiveness and suitability of electroneuromyography (ENMG) for early DDPN diagnosis. MATERIALS AND METHODS: This study was performed in the Novosibirsk Research Institute of Traumatology and Orthopaedics n.a. Ya. L. Tsivyan. A total of 80 participants were examined, including 30 DM2 patients, 30 patents without carbohydrate metabolism disorders, and 20 healthy volunteers aged 2030 years. None of the participants showed clinical signs of distal polyneuropathy (DPN). All participants underwent evaluation of neuropathy symptoms by the Neuropathy Symptom Score scale, neurological assessment using on the scale of Neuropathic Dysfunctional Score and stimulating ENMG. RESULTS: ENMG revealed the presence of neuropathy in 86.7% of DM2 patients. Moreover, among DM2 patients, 12 (40%) presented sensory DDPN, 13 (43.3%) presented sensorimotor neuropathy and 1 (3.3%) presented motor DDPN. The medial and lateral plantar nerves were the most commonly affected (p = 0.018 and p = 0.002, respectively). Among the 30 control individuals, 9 (30%) showed signs of DPN in combination with radiculopathy. ENMG - indicators of DDPN: latency and amplitude and speed for 3 sensory (n. Plantaris lateralis, n. Plantaris medialis, n. Suralis) and 2 motor nerves (n. Peroneus, n. Tibialis) were significantly worse in individuals with DM2 than in the control group, both for those with and without radiculopathy. Among participants with DM2, those sensorimotor DDPN tended to have a longer diabetes duration (p = 0.503), higher levels of HbA1c (p = 0.077) and higher BMI (p = 0.050) than those with sensory neuropathy, although the differences were not significant. CONCLUSION: This study confirms the effectiveness and suitability of ENMG for the early diagnosis of DDPN. Moreover, the optimal ENMG indices necessary for this diagnosis were identified.

Sixty children with congenital hypothyroidism detected by neonatal thyroid: Mental development at 1,4, and 7 years: a longitudinal study

1986 ◽  
Vol 113 (4_Suppl) ◽  
pp. S346-S353 ◽  
Author(s):  
R. ILLIG ◽  
R.H. LARGO ◽  
M. WEBER ◽  
TH. AUGSBURGER ◽  
A. LIPP ◽  
...  
Keyword(s):  
Risk Factors ◽  
Congenital Hypothyroidism ◽  
Hormone Replacement ◽  
Clinical Signs ◽  
Bone Age ◽  
Mental Development ◽  
Skeletal Maturation ◽  
Control Group ◽  
Mean Values ◽  
A Prospective Study

Abstract A prospective study of mental development has been carried out in 60 unselected children with congenital hypothyroidism (C.H.) detected between 1976 and February 1985. Treatment with 1-thyroxin was initiated at the age of 10.4 + 2.5 days and supervised by T4 and TSH monitoring in 3-6 monthly intervals. Although clinical signs were mild or missing, skeletal maturation was prenatal in more than half. Developmental testing was carried out at 1, 4 and 7 years by the Brunet-Lezine (n=60), the non-verbal Snijders-0omen (n=40), and the german version of the Wechsler intelligence test (n=20), respectively. The global DQ/IQ in all but a few children at each age group are within the 3rd and 97th percentile of the DQ/IQ distribution in a control group tested during the same period of time. The mean values of all global and subscores, however, are lower than that one in the control group, differences being highly significant at 1 year. In 21 of our 60 children, associated findings and/or risk factors were present. The DQ/IQ in children without risk factors are identical to that of the control group. There are no significant DQ/IQ differences neither between athyroidism and ectopic thyroid glands, nor between prenatal bone age and normal skeletal maturation at diagnosis. We assumethat the favourable results in our children with C.H. may be ascribed to the early onset of thyroid hormone replacement and the strictly controlled compliance.

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