Aeromedical Decision Making for Military Aircrew with Graves’ Disease

2021 ◽  
Vol 92 (12) ◽  
pp. 980-986
Author(s):  
Edwin Hong-Teck Loh ◽  
Feng Wei Soh ◽  
Brian See ◽  
Benjamin Boon Chuan Tan
Keyword(s):  
Decision Making ◽  
Air Force ◽  
Case Series ◽  
Definitive Treatment ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
First Line Therapy ◽  
The Mean ◽  
Stable Maintenance ◽  
The Impact

BACKGROUND: Graves’ Disease (GD) is a common cause of hyperthyroidism. Although definitive treatment with radioactive iodine (RAI) is preferred for military aircrew, there are cultural and individual differences in receptivity toward RAI, and clinical guidelines that recommend antithyroid drugs (ATD) as the first line therapy. We examined a case series of Republic of Singapore Air Force (RSAF) aviators with GD treated with ATD and the impact of their condition on aeromedical disposition.CASE SERIES: All RSAF aircrew diagnosed with GD and treated with ATD over a 15-yr period were retrospectively identified and analyzed to determine the impact on their fitness for flying duties. The mean age of the 13 aircrew was 33 ± 7.1 yr (range, 25–47 yr), with 11 (84.6%) being males. There were 10 (76.9%) who had ATD as the only treatment while 3 (23.1%) were initially treated with ATD but subsequently underwent RAI or surgery. Of the 10 treated with only ATD, 3 (30.0%) were returned to restricted flying, 6 (60.0%) were returned to unrestricted flying, and 1 (10.0%) is still undergoing ATD titration. There were 10 (76.9%) aircrew who were returned to some form of flying duties while on low doses of ATD.DISCUSSION: This case series suggests that ATD is a viable treatment modality in the aeromedical management of military aviators with GD and it is possible to return military aircrew on a stable maintenance dose of ATD to flying duties. A framework is proposed to support the aeromedical decision-making process for military aircrew in the treatment of GD.Loh EH-T, Soh FW, See B, Tan BBC. Aeromedical decision making for military aircrew with Graves’ disease. Aerosp Med Hum Perform. 2021; 92(12):980–986.

Graves’ disease in a five-month-old boy with an unusual treatment course

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Svetlana Azova ◽  
Farrah Rajabi ◽  
Biren P. Modi ◽  
Laura Mansfield ◽  
Maureen M. Jonas ◽  
...  
Keyword(s):  
De Novo ◽  
Thyroid Autoimmunity ◽  
Mitochondrial Disorder ◽  
Male Infant ◽  
Left Ventricular ◽  
Definitive Treatment ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
First Line Therapy ◽  
Hpt Axis

AbstractObjectivesGraves’ disease (GD) is rare in children under age five years. Antithyroid drugs are typically first-line therapy but carry the risks of agranulocytosis and liver dysfunction.Case presentationA male infant with multiple congenital anomalies, left ventricular hypertrophy, and neurologic dysfunction developed GD at five months of life. The presence of chronic hepatitis complicated medical management. Potassium iodide was effective temporarily, but urgent thyroidectomy was required at nine months of age. Postoperatively, the patient developed a thyroid function pattern consistent with impaired pituitary sensitivity to thyroid hormone (TH) that responded to the addition of liothyronine. Exome sequencing revealed a heterozygous de novo duplication of the ATAD3 gene cluster, suggesting a possible mitochondrial disorder.ConclusionsThis case describes the youngest child to date to be diagnosed with endogenous GD and to successfully undergo definitive treatment with thyroidectomy. An underlying defect in mitochondrial function is suspected, suggesting a potential novel pathophysiologic link to early-onset thyroid autoimmunity. Additionally, this case illustrated the development of impaired pituitary sensitivity to TH following thyrotoxicosis of postnatal onset, which may contribute to our understanding of hypothalamic-pituitary-thyroid (HPT) axis development.

Graves' disease and radioiodine therapy

2008 ◽  
Vol 47 (04) ◽  
pp. 153-166 ◽  
Author(s):  
I. Weber ◽  
W. Eschner ◽  
F. Sudbrock ◽  
M. Schmidt ◽  
M. Dietlein ◽  
...  
Keyword(s):  
Success Rate ◽  
Thyroid Function ◽  
Therapeutic Dose ◽  
Radioiodine Therapy ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Inclusion Criteria ◽  
End Point ◽  
Point Measure ◽  
The Impact

SummaryAim: This study was performed to analyse the impact of the choice of antithyroid drugs (ATD) on the outcome of ablative radioiodine therapy (RIT) in patients with Graves' disease. Patients, material, methods: A total of 571 consecutive patients were observed for 12 months after RIT between July 2001 and June 2004. Inclusion criteria were the confirmed diagnosis of Graves' disease, compensation of hyperthyroidism and withdrawal of ATD two days before preliminary radioiodine-testing and RIT. The intended dose of 250 Gy was calculated from the results of the radioiodine test and the therapeutically achieved dose was measured by serial uptake measurements. The end-point measure was thyroid function 12 months after RIT; success was defined as elimination of hyperthyroidism. The pretreatment ATD was retrospectively correlated with the results achieved. Results: Relief from hyperthyroidism was achieved in 96 % of patients. 472 patients were treated with carbimazole or methimazole (CMI) and 61 with propylthiouracil (PTU). 38 patients had no thyrostatic drugs (ND) prior to RIT. The success rate was equal in all groups (CMI 451/472; PTU 61/61; ND 37/38; p=0.22). Conclusion: Thyrostatic treatment with PTU achieves excellent results in ablative RIT, using an accurate dosimetric approach with an achieved post-therapeutic dose of more than 200 Gy.

scholarly journals Sialendoscopy With Intraductal Steroid Irrigation in Patients With Sialadenitis Without Sialoliths

2019 ◽  
Vol 98 (5) ◽  
pp. 291-294 ◽  
Author(s):  
Saudamini J. Lele ◽  
Mickie Hamiter ◽  
Torrey Louise Fourrier ◽  
Cherie-Ann Nathan
Keyword(s):  
Treatment Option ◽  
Case Series ◽  
Complete Response ◽  
Definitive Treatment ◽  
Invasive Technique ◽  
Effective Treatment Option ◽  
Patient Reported ◽  
History Of ◽  
The Mean

Sialendoscopy has emerged as a safe, effective and minimally invasive technique for management of obstructive and inflammatory salivary gland disease. The aim of our study was to analyze outcomes of sialendoscopy and steroid irrigation in patients with sialadenitis without sialoliths. We performed a retrospective analysis of patients who underwent interventional sialendoscopy with steroid irrigation from 2013 to 2016, for the treatment of sialadenitis without sialolithiasis. Twenty-two patients underwent interventional sialendoscopy with ductal dilation and steroid irrigation for the treatment of sialadenitis without any evidence of sialolithiasis. Conservative measures had failed in all. Eleven patients had symptoms arising from the parotid gland, 4 patients had symptoms arising from the submandibular gland, while 6 patients had symptoms in both parotid and submandibular glands. One patient complained of only xerostomia without glandular symptoms. The mean age of the study group which included 1 male and 21 females was 44.6 years (range: 3-86 years). Four patients had autoimmune disease, while 7 patients had a history of radioactive iodine therapy. No identifiable cause for sialadenitis was found in the remaining 11 patients. The mean follow-up period was 378.9 days (range: 16-1143 days). All patients underwent sialendoscopy with ductal dilation and steroid irrigation. Twelve patients showed a complete response and 9 patients had a partial response, while 1 patient reported no response. Only 3 patients required repeat sialendoscopy. The combination of sialendoscopy with ductal dilation and steroid irrigation is a safe and effective treatment option for patients with sialadenitis without sialoliths refractory to conservative measures. Prospective studies with a larger case series are needed to establish its role as a definitive treatment option.

Effects of high and low doses of methimazole in patients with Graves' thyrotoxicosis

1987 ◽  
Vol 116 (1_Suppl) ◽  
pp. S312-S317 ◽  
Author(s):  
G. Benker ◽  
D. Reinwein ◽  
H. Creutzig ◽  
H. Hirche ◽  
W. D. Alexander ◽  
...  
Keyword(s):  
Antithyroid Drug ◽  
Drug Dosage ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Duration Of Treatment ◽  
Disease Heterogeneity ◽  
Remission Rates ◽  
Set Up ◽  
The Many ◽  
The Impact

Abstract. In spite of the long-established use of antithyroid drugs, there are many unsettled questions connected with this treatment of Graves' disease. There is a lack of controlled prospective trials studying the results of antithyroid drug therapy while considering the many variables such as disease heterogeneity, regional differences, drug dosage and duration of treatment. Therefore, a multicenter study has been set up in order to compare the effects of two fixed doses of methimazole (10 vs 40 mg) with thyroid hormone supplementation on the clinical, biochemical and immunological course of Graves' disease and on remission rates. Experience accumulated so far suggests that treatment is safe using either 10 or 40 mg of methimazole. While there is a tendency for an advantage of the higher dose within the first weeks (higher effectiveness in controlling hyperthyroidism), this difference is not significant. The impact of dosage on remission rates remains to be shown.

Postural neurologic deficits after decompressive craniectomy: A case series of sinking skin flap syndrome in traumatic brain injury

2020 ◽  
pp. 1-10
Author(s):  
Emma A. Bateman ◽  
Jordan VanderEnde ◽  
Keith Sequeira ◽  
Heather M. MacKenzie
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Rare Complication ◽  
Skin Flap ◽  
Case Series ◽  
Cognitive Outcome ◽  
Definitive Treatment ◽  
Care Providers ◽  
Neurologic Deficits ◽  
The Impact

BACKGROUND: Hemicraniectomy to manage raised intracranial pressure following traumatic brain injury (TBI) has improved survival but may increase the incidence of Sinking Skin Flap Syndrome (SSFS). SSFS is a clinical syndrome in which patients with craniectomy develop objective neurologic abnormalities due to the pressure of the atmosphere on the unprotected brain, often presenting with postural headaches and neurologic deficits that localize to the craniectomy site. Previously thought to be a rare complication of craniectomy after TBI, evidence suggests SSFS is under-recognized. OBJECTIVE: To describe the clinical and radiographic features leading to diagnosis and the impact of temporizing and definitive management of SSFS on outcomes in inpatients with moderate/severe TBI. METHODS: Two patients’ symptoms, qualitative behaviour observation, physical and cognitive outcome measures, and neuroimaging pre- and post-temporizing measures and cranioplasty are presented. RESULTS: Both patients demonstrated partial improvements with temporizing measures and substantial improvements in functional, cognitive, physical, and rehabilitation outcomes from the cranioplasty and resolution of SSFS. CONCLUSIONS: Rehabilitation care providers are critical to the timely diagnosis and management of SSFS, including the use of temporizing measures and advocacy for definitive treatment with cranioplasty. These cases highlight the diverse clinical presentations and importance of SSFS diagnosis to improve patient outcomes.

scholarly journals Remission Rate of Graves' Disease and the Trend of Changes in Serum TSH Receptor Antibodies in Prolonged Antithyroid Drug Treatment

2020 ◽  
Vol 18 (Suppl) ◽  
Author(s):  
Danilo Villagelin ◽  
Roberto Bernardo Santos ◽  
João Hamilton Romaldini
Keyword(s):  
Drug Treatment ◽  
Remission Rate ◽  
Antithyroid Drug ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Remission Rates ◽  
Thyrotropin Receptor Antibodies ◽  
Antithyroid Drug Treatment ◽  
The Impact ◽  
Receptor Antibodies

Context: Graves’ disease is an autoimmune disease caused by thyrotropin receptor antibodies (TRAb). These antibodies can be measured and used for the diagnosis, prediction of remission, and risk of Graves’ orbitopathy development. There are three treatments for Graves’ disease that have remained unchanged for the last 75 years: Antithyroid drugs, radioiodine, and surgery. Antithyroid drugs are the first treatment option worldwide and are usually used for 12 - 18 months. Recent reports suggest the use of antithyroid drugs for more than 18 months with better outcomes. This review focuses on two aspects of treatment with antithyroid drugs: The impact of using antithyroid drugs for more than 12 - 18 months on remission rates and the trend of TRAb during prolonged antithyroid drug treatment. Evidence Acquisition: A review was performed in Medline on the published work regarding the duration of ATD treatment and remission of Graves' disease and also ATD treatment and TRAb status during the 1990 - 2019 period. Results: Remission rates are variable (30% - 80%), and many clinical and genetic factors serve as predictors. The long-term use of antithyroid drugs appears to increase remission rates. TRAb values usually decline during ATD treatment, but the trend could occur in two ways: Becoming negative or showing a fluctuating pattern. However, approximately 10% of the patients will remain TRAb-positive after five years of treatment with antithyroid drugs. Conclusions: Antithyroid drugs can be used for long periods with an increase in remission rates, and a gradual decrease in TRAb levels, with the disappearance of TRAb in 90% of the patients after 60 months.

scholarly journals Call for Emergency Room Guidelines to Identify Hyperthyroid Patients Prior to Contrast Imaging

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A922-A923
Author(s):  
Sandhya Bassin ◽  
Louis F Amorosa
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Room ◽  
Definitive Treatment ◽  
Graves Disease ◽  
Contrast Imaging ◽  
Iodinated Contrast ◽  
Increased Risk ◽  
History Of ◽  
The Impact ◽  
Hyperthyroid Patients

Abstract Background: Thyrotoxicosis can be mistaken for conditions such as atrial fibrillation and pulmonary embolism (PE) given the nonspecific symptoms of fatigue, palpitations, and dyspnea. Patients often undergo further imaging on presentation to the emergency room (ER), many of which use iodine for contrast. This can put patients at increased risk for iodine induced hyperthyroidism and delay definitive treatment in patients with Graves’ disease, the most common cause of hyperthyroidism. Clinical Case: A 53-year-old male with history of hyperthyroidism, atrial fibrillation, and prior PE presented with palpitations to the ER. He developed worsening dyspnea on exertion and palpitations over the last three days. He was unable to afford his medications, including methimazole, for the last nine months. In the ER he was in atrial fibrillation with rapid ventricular response. Due to concern for PE, he underwent a CTA with contrast, which was negative. His physical exam was notable for a diffusely enlarged goiter. His labs showed low TSH <0.01 (norm 0.35-5.50mIU/L) and high free T4 >7.77 (norm 0.9-1.8ng/dL). TSH stimulating antibodies were elevated at 1.9 (norm <1.3 TSI index), consistent with Graves’ hyperthyroidism. Endocrinology was then consulted for severe thyrotoxicosis, initially treating the patient with PTU and propranolol. The patient was transitioned to methimazole and continued propranolol on discharge. Since he was given contrast, plan was for repeat thyroid uptake scan and iodine ablation in 3 months. However, patient was not compliant with medications, resulting in readmission for thyrotoxicosis 3 months later. Conclusion: This case highlights the impact of increased use of contrast in imaging in hyperthyroid patients. Hyperthyroid patients are at an increased risk for emboli. However, iodine can cause contrast-induced hyperthyroidism and delay definitive treatment of Graves’ disease. As almost half of thyrotoxic patients receive iodinated contrast prior to an endocrine consultation, endocrinologists should work with emergency physicians to develop a set of guidelines to identify at risk populations for hyperthyroidism (1). We advocate for urgent thyroid testing in patients with new onset atrial fibrillation, a history of Graves’ disease, specific symptoms of Graves’, or those taking thyrotoxic-inducing medications. This will assist in determining if patients should receive a prophylactic dose of anti-thyroid medication prior to iodinated contrast imaging. These guidelines can help prevent contrast induced hyperthyroidism and disruptions in treatment of Graves’ while still imaging patients for other diagnoses on the differential. Reference: (1) Giacomini A, et al. Urgent thyroid-stimulating hormone testing in emergency medicine: A useful tool? J Emerg Med. 2015;49(4):481-487.

scholarly journals SAT-434 Phenotype and Genotype Analysis of Patients with Resistance to Thyroid Hormone β: A Single-Center Experience

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Karn Wejaphikul ◽  
Prapai Dejkhamron ◽  
Stefan Groeneweg ◽  
W Edward Visser ◽  
Kevalee Unachak ◽  
...  
Keyword(s):  
Thyroid Hormone ◽  
Mutation Analysis ◽  
Novel Mutation ◽  
Family Members ◽  
Antithyroid Drugs ◽  
Thyroid Function Tests ◽  
Resistance To Thyroid Hormone ◽  
The Mean ◽  
The Impact

Abstract Introduction Resistance to thyroid hormone β (RTHβ) is caused by mutations in THRB, the gene that encodes thyroid hormone receptor β. The clinical phenotype is variable and may include goiter, tachycardia, and learning disability with or without hyperactive behavior. The biochemical hallmark of RTHβ is elevated T4 and T3 with non-suppressed TSH concentrations. We here describe the phenotype and genotype of three Thai patients diagnosed with RTHβ in a pediatric referral center. Patients had previously been misdiagnosed and inappropriately treated with antithyroid drugs (ATDs). Methods Clinical features and thyroid function tests (TFTs) of three unrelated RTHβ patients were retrospectively reviewed. Genomic DNA of the RTHβ patients and affected family members was amplified for exon 7-10 of the THRB gene and sequenced to identify mutation by Sanger sequencing. The impact of the p.L341V novel mutation on the affinity for T3 and T3-induced transcriptional activity was previously determined in vitro. Results Three female patients were diagnosed with RTHβ. All of them had been misdiagnosed with hyperthyroidism and treated with ATDs prior to referral. The mean age at diagnosis was 8 years. The main presenting symptoms were diffuse goiter and tachycardia. The mean duration of ATD treatment was 3 years. During the treatment, patients had fluctuating thyroid hormone and increased TSH levels. An older sister and mother of one patient also had similar TFTs abnormalities, for which the mother had undergone a subtotal thyroidectomy. RTHβ was diagnosed based on the high FT3 and FT4 with normal (non-suppressed) TSH concentrations and confirmed by mutation analysis. Anti-thyroid peroxidase, anti-thyroglobulin, and TSH receptor antibody (TRAb) were negative, excluding autoimmune thyroid disease. Heterozygous missense mutations of the THRB gene were identified in all patients and affected family members. Two mutations had been previously reported (p.R243W and p.L456F), and one mutation was novel (p.L341V). In vitro studies confirmed an important role of Leu341 in T3 binding of the TRβ and functional impairment of the p.L341V novel mutation and were reported separately. According to available literature, only nine Thai RTHβ patients (in three families) carrying three different mutations (p.G251V, p.M313T, and p.A317T) had been previously reported. Goiter was the most common clinical finding, and almost all patients had a history of receiving unnecessary treatment with ATDs. Conclusion We report a series of RTHβ patients carrying THRB gene mutations, including one novel mutation (p.L341V). Clinicians should be alert that RTHβ can be found in patients with goiter and tachycardia. Elevated T4 and T3 with non-suppressed TSH concentration is the main diagnostic clue for this disease. Mutation analysis allows definitive diagnosis of RTHβ and may help to avoid potential misdiagnosis and improper treatment.

Application of Computerized Adaptive Testing to the Foot and Ankle Ability Measure

2020 ◽  
pp. 107110072097266
Author(s):  
Joseph T. O’Neil ◽  
Otho R. Plummer ◽  
Steven M. Raikin
Keyword(s):  
Computerized Adaptive Testing ◽  
Case Series ◽  
Adaptive Testing ◽  
Mean Difference ◽  
Foot And Ankle ◽  
Level Of Evidence ◽  
Patient Reported ◽  
The Mean ◽  
Ability Measure ◽  
The Impact

Background: Patient-reported outcome measures are an increasingly important tool for assessing the impact of treatments orthopedic surgeons render. Despite their importance, they can present a burden. We examined the validity and utility of a computerized adaptive testing (CAT) method to reduce the number of questions on the Foot and Ankle Ability Measure (FAAM), a validated anatomy-specific outcome measure. Methods: A previously developed FAAM CAT system was applied to the responses of patients undergoing foot and ankle evaluation and treatment over a 3-year period (2017-2019). A total of 15 902 responses for the Activities of Daily Living (ADL) subscale and a total of 14 344 responses for the Sports subscale were analyzed. The accuracy of the CAT to replicate the full-form score was assessed. Results: The CAT system required 11 questions to be answered for the ADL subscale in 85.1% of cases (range, 11-12). The number of questions answered on the Sports subscale was 6 (range, 5-6) in 66.4% of cases. The mean difference between the full FAAM ADL subscale and CAT was 0.63 of a point. The mean difference between the FAAM Sports subscale and CAT was 0.65 of a point. Conclusion: The FAAM CAT was able to reduce the number of responses a patient would need to answer by nearly 50%, while still providing a valid outcome score. This measure can therefore be directly correlated with previously obtained full FAAM scores in addition to providing a foot/ankle-specific measure, which previously reported CAT systems are not able to do. Level of Evidence: Level IV, case series.

Polysomnography Outcomes after Supraglottoplasty in Children with Obstructive Sleep Apnea

2019 ◽  
Vol 161 (4) ◽  
pp. 694-698 ◽  
Author(s):  
Bharat Bhushan ◽  
James W. Schroeder ◽  
Kathleen R. Billings ◽  
Nicholas Giancola ◽  
Dana M. Thompson
Keyword(s):  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Tertiary Care ◽  
Case Series ◽  
Apnea Hypopnea Index ◽  
Historical Cohort ◽  
Tertiary Care Medical Center ◽  
Obstructive Sleep ◽  
The Mean ◽  
The Impact

ObjectiveLaryngomalacia has been reported to contribute to the severity of obstructive sleep apnea (OSA) in children. It is unclear if surgical treatment of laryngomalacia improves polysomnography (PSG) outcomes in these patients. The objective of this study is to report the impact of supraglottoplasty on PSG parameters in children with laryngomalacia-related OSA.Study DesignRetrospective case series.SettingTertiary care medical center.Subjects and MethodsHistorical cohort study of consecutive children with laryngomalacia who underwent supraglottoplasty and who had undergone overnight PSG before and after surgery.ResultsForty-one patients were included in the final analysis: 22 (53.6%) were male, and 19 (46.3%) were female. The mean ± SEM age of patients at preoperative PSG was 1.3 ± 0.89 years (range, 0.003-2.9). In entire cohort, the mean obstructive apnea-hypopnea index score was reduced from 26.6 events/h before supraglottoplasty to 7.3 events/h after surgery ( P = .003). Respiratory disturbance index was reduced from 27.3 events/h before supraglottoplasty to 7.8 events/h after surgery ( P = .003). The percentage of REM sleep decreased from 30.1% ± 2.4 to 24.8% ± 1.3 ( P = .04). Sleep efficiency was improved ( P = .05).ConclusionOverall, supraglottoplasty significantly improved several PSG outcomes in children with laryngomalacia. However, mild to moderate OSA was still present postoperatively in most children. This suggested a multifactorial cause for OSA in this population.

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