Managing thyrotoxicosis in the acute medical setting
|
|
- Alexis Peters
- 5 years ago
- Views:
Transcription
1 44 Review Article Managing thyrotoxicosis in the acute medical setting C Napier MBBS MRCP (UK) Endocrine Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP UK c.napier2@newcastle. ac.uk Thyrotoxicosis is common and can present in numerous ways with patients exhibiting a myriad of symptoms and signs. It affects around 1 in 2000 people annually in Europe 1. The thyroid gland produces two thyroid hormones - thyroxine (T4) and triiodothyronine (T3). Thyroxine is inactive and is converted by the tissues and organs that need it into tri-iodothyronine. In health, the production of these thyroid hormones is tightly regulated by the secretion of thyroid stimulating hormone (TSH; thyrotropin) from the pituitary gland. The term thyrotoxicosis refers to the clinical manifestations of hyperthyroidism. Linking clinical presentation to aetiology The commonest cause of hyperthyroidism in the UK is Graves disease (GD), which accounts for around 75% of cases of thyrotoxicosis 2. GD exhibits a particularly strong female preponderance (F:M, 6:1), in common with other autoimmune disorders. It usually presents between years of age, but can occur in both sexes and at any age. Other common causes are a single toxic nodule or a multinodular goitre, and together, GD and nodular thyroid disease account for well over 90% of all cases of hyperthyroidism. Nodular thyroid disease is more often seen with advancing age. Histologically these nodules are follicular adenomas and excess thyroid hormone is secreted in an unregulated manner. Rarer causes of thyrotoxicosis include subacute, silent or post-partum thyroiditis; these conditions occur when inflammatory destruction of thyroid follicles causes a release of preformed thyroid hormones into the circulation, resulting in transient thyrotoxicosis. Subacute thyroiditis is usually caused by a viral infection and is characterised by fever and pain or thyroid tenderness. Painless thyroiditis can occur during or after treatment with lithium, cytokines (e.g. interferon alpha), tyrosine kinase inhibitor therapy, highly active retroviral therapy or in the postpartum period and appears with differing frequency between studied populations 3. A destructive (but nevertheless painless) thyroiditis occurs in 5-10% of patients on amiodarone 3. Abnormal thyroid biochemistry (with or without symptoms) is becoming more common with the wider use of biological therapies to treat cancer or other conditions. Almost all patients with thyroiditis should be referred for endocrine input, although symptomatic management can be instigated in the acute setting. Table 1 summarises the causes of thyrotoxicosis. In the acute setting, it is important to recognise that elderly patients with thyrotoxicosis may have a subtle presentation with fewer typical symptoms and signs; apathy and apparent depression may be the only clinical features. In any patient, symptoms of rapid onset (1-2 days duration) are more likely to suggest a diagnosis of thyroiditis rather than GD or nodular thyroid disease. All patients with unexplained weight loss, tachycardia or atrial fibrillation (AF) should have a diagnosis of thyrotoxicosis considered. Clinical features of hyperthyroidism Symptoms of thyrotoxicosis are often nonspecific and patients may present in numerous ways 2,4,5. In GD, onset is often gradual and poorly defined; most individuals have felt unwell for 3 to 6 months before they seek medical attention. If the onset of thyrotoxic symptoms is rapid or can be pinned down to a single day or a few days, the diagnosis is much more likely to be thyroiditis. In GD, the commonest precipitant of thyrotoxicosis, weight loss (despite an increase in appetite) is found in most patients. In a minority, the increase in appetite coupled with the free availability of calorie-dense food, leads to weight gain. Pervasive exhaustion is common but patients may find this alternates with periods of restlessness and hyperactivity. Heat intolerance is a typical feature and sweating at night is characteristic. Poor sleep with mental overactivity and physical hyperkinesis is often found. Palpitations at rest or on minimal exertion or shortness of breath during light exercise are common at all ages. Intestinal transit-time is shortened, leading to more frequent defecation. Menstrual bleeding may Table 1. Causes of Thyrotoxicosis Causes of thyrotoxicosis Autoimmune thyroid disease Graves disease Nodular thyroid disease Solitary toxic nodule Multinodular goitre Thyroiditis Viral Post-partum Drug-induced
2 45 Table 2. Symptoms and Signs of Thyrotoxicosis Symptoms and signs of thyrotoxicosis SYMPTOMS Tremor Palpitations Fatigue Heat intolerance Weight loss Breathlessness Increased frequency of defecation Anxiety Muscle aches Menstrual disturbance *Signs only seen in Graves disease SIGNS Tremor Palmar erythema Onycholysis Tachycardia Atrial fibrillation Brisk reflexes Orbitopathy* proptosis, eyelid retraction Goitre smooth or nodular Thyroid bruit Hypertension and signs of cardiac failure Weight loss Pretibial myxoedema* be light, decreased in frequency, or absent. Thyroid tenderness or pain is not a feature. Less commonly reported symptoms are thirst, nausea, generalised itch, and hair loss. In 5 10% of people, the first symptoms are due to Graves orbitopathy (GO) with itchy, gritty, or watering eyes, or an abnormal appearance 6. Thyrotoxicosis with extra-thyroidal features, such as orbitopathy or pretibial myxoedema, is pathognomic of GD. In the elderly, there may be little to suggest a diagnosis of hyperthyroidism, or the onset of AF may precipitate a cardiac presentation with dyspnea and/ or congestion. Table 2 lists the symptoms and signs of thyrotoxicosis. During clinical assessment, a thyrotoxic patient may struggle to sit still, with constant fidgeting and apparent anxiety or apprehension. The face, neck, and upper chest wall may be flushed. The palms may be warm and sweaty, with a symmetrical fine tremor when hands are outstretched. In GD, a smooth, diffuse goitre can be visible or palpable, with a systolic phase bruit audible over the gland due to increased blood flow. In nodular thyroid disease, a discrete nodule or uneven, multinodular goitre may be easily palpable. Patients with subacute thyroiditis may complain of tenderness on palpation. In all thyrotoxic patients, tachycardia (unless beta-blockers are already being taken) and rapid atrial fibrillation may be present, with an elevated systolic blood pressure. Hepatomegaly or splenomegaly may be found. Hyperreflexia is common and proximal musculature can be weak. Late features of thyrotoxicosis are frank spasticity and pseudobulbar paresis. Rapid onset of severe and generalized muscle weakness should raise suspicion of the possibility of hypokalemic periodic paralysis, a syndrome most common in men of Asian descent that is precipitated by thyrotoxicosis. In GD, pretibial myxoedema (infiltrative dermopathy) is usually manifest as discrete violaceous plaques on the shin or dorsum of the foot. Signs of GO include lid retraction, lid or conjunctival redness, periorbital oedema and proptosis. Rare signs of GD include chorea, onycholysis, or acropachy of the nails. Investigations in hyperthyroidism Hyperthyroidism can be easily and quickly confirmed on biochemical testing with elevation of one or both serum-free thyroid hormones (FT3, FT4) together with a low or undetectable TSH. Serum TSH measurement has the highest sensitivity and specificity of any single blood test used in the evaluation of suspected thyrotoxicosis and should be used as an initial screening test 3. However, when there is strong clinical suspicion of thyrotoxicosis, it is much more pragmatic to combine TSH testing with measurement of free thyroid hormones for diagnostic accuracy 3. About 5% of subjects, most commonly elderly, present with elevation of FT3 alone, with normal FT4 and undetectable TSH - this T3 thyrotoxicosis is often a manifestation of relatively mild hyperthyroidism. Elevation of free T4 alone, with normal free T3 and undetectable TSH, may be found in someone with co-existing major illness (a combination of thyrotoxicosis and sickeuthyroid syndrome), but is also typical of iodineinduced thyrotoxicosis or exogenous levothyroxine use. If there is doubt about the chronicity or severity of symptoms, then it is good practice to repeat the abnormal thyroid function tests after a short period, as a rapid fluctuation may be the clue to the diagnosis of destructive (silent) thyroiditis. If the TSH is low but still detectable, the diagnosis is almost certainly not GD and further investigations are needed 7. Individuals with a persistently undetectable TSH but normal free thyroid hormones (in the absence of pituitary disease and drug effects) are said to have subclinical hyperthyroidism (SH) and need further
3 46 Symptoms or signs of thyrotoxicosis If TSH low or undetectable with elevated FT4 +/- FT3 Refer to endocrinology; send TRAb Start beta blockers if symptomatic or tachycardic* Discharge unless features of thyroid storm or clinically unwell** Figure 1. Algorithm for Managing Suspected Thyrotoxicosis on the Acute Medical Unit * If any contraindications to beta blockade, diltiazem can be used as an alternative ** Patients with AF will need consideration re. anticoagulation investigation (i.e., serum thyroid antibodies, Holter monitor, DEXA bone scan) 7. There is little clear evidence to guide treatment in this situation and intervention depends on the degree of SH and the sequelae 7,8 - the presence of atrial fibrillation or established osteoporosis will mean patients are more likely to warrant treatment. In the setting of clear extrathyroidal signs of GD, no further testing beyond free thyroid hormones and TSH is necessary. In the absence of features of GO or pretibial myxoedema, it is useful to attempt to secure an aetiological diagnosis. The gold-standard test is a highly sensitive TSHR-stimulating antibody assay or TSH receptor antibodies (TRAb) 4,5. Other serum antibody tests, including indirect assay of TSH-stimulating antibodies by TSH-binding inhibitory immunoglobulin (TBI or TBII) or TPO antibody assay can be employed to confirm GD (TPO antibodies are also positive in autoimmune hypothyroidism). Imaging Imaging of the thyroid should not be routinely requested for all patients, even in the presence of a goitre. It is often beneficial if the antibody test is negative or if a nodular thyroid is found on palpation, but the decision about the indication for imaging and optimum imaging modality should ideally be left until the time of endocrine review. Although an ultrasound examination may demonstrate a single nodule or a multinodular goitre, radionuclide imaging with either technetium (99 Tc) or iodide (123 I) is often more useful because it gives practical data regarding the presence and distribution of functioning thyroid tissue. Other investigations, often routinely done on medical admission, will be worthwhile depending upon the clinical situation and likely treatment plan. An ECG should be documented in all thyrotoxic patients with tachycardia and a more detailed cardiac evaluation should be performed in those with AF. A full blood count with a white cell differential at baseline is helpful if antithyroid drug (ATD) treatment may be instigated in the future. A pregnancy test should be documented in women of childbearing age and a negative pregnancy test is absolutely mandatory if radioiodine treatment is later the chosen treatment modality. In thyrotoxic patients, microcytosis, elevation of serum alkaline phosphatase, and mildly deranged liver enzymes are often found on biochemical testing; mild hypercalcemia can also be present. Figure 1 outlines a suggested algorithm for the investigation of patients with suspected thyrotoxicosis. Managing hyperthyroidism Symptomatic management All thyrotoxic patients should gain symptomatic benefit from beta blockade (Propranolol 40mg TDS or Propranolol LA 80mg daily); this is contraindicated in those with asthma and caution should be exercised in patients with diabetes where beta blockade can mask the symptoms of hypoglycaemia. If beta blockade is contraindicated, diltiazem can be used in thyrotoxic patients with tachycardia. Treatment The treatment options for hyperthyroidism secondary to GD or nodular thyroid disease include ATDs (Carbimazole or Propylthiouracil in the UK), radioiodine therapy, or thyroid surgery. Each modality has its own pros and cons, and patient preference is frequently a deciding factor. Decisions regarding treatment should be taken in conjunction with the endocrine team and are usually made at the time of endocrine review. The pathway for this will vary between secondary and tertiary care settings; some acute medicals units can rapidly access endocrine telephone advice or review, whereas others will refer for outpatient clinic follow-up.
4 47 ATDs should only be started in conjunction with endocrine input mainly to ensure robust (verbal and written) warnings regarding the rare but serious and potentially lethal risk of agranulocytosis with Carbimazole (CBZ) or Propylthiouracil (PTU). This thionamide-induced agranulocytosis occurs in around 1 in 300 people 9 : symptoms include a sore throat and mouth ulcers and those affected will often have a high fever. Patients should be warned to stop the ATD immediately in the presence of these symptoms and have a full blood count taken on the same day. Agranulocytosis is most likely to occur in the early months after starting treatment. Liaising with the endocrine team will also help ensure that patients have a timely follow-up plan in place; those who start ATDS can become rapidly euor hypothyroid within a matter of weeks. The pros and cons of ATD treatment vs. radioactive iodine vs. surgery will be discussed at the time of endocrine review. If patients opt to complete a course of ATD therapy, then block and replace vs. a dose-titration regimen will be decided upon. Thyrotoxicosis in the context of thyroiditis is transient. Patients are likely to have a hyperthyroid phase followed by a hypothyroid phase and then spontaneous resolution. Patients with subacute thyroiditis may have pain and fever - analgesia (NSAIDs will be most effective) should be administered and a short course of systemic steroids may be helpful: advice on this can be taken from the endocrine team. ATDs are ineffective. The management of drug-induced thyrotoxicosis is more complex and is best managed by endocrinology (in conjunction with the cardiology team in the case of amiodarone-induced thyrotoxicosis). Other drugs may produce a self-limiting thyroiditis or a more complex picture a joint decision regarding management can be taken by the endocrine team in conjunction with the specialist prescribing the drug. When to admit The vast majority of thyrotoxic patients will not require hospital admission, and can be safely discharged once beta blockade has been instigated. The decision on when to admit should be based upon clinical features rather than serum biochemistry. Free thyroid hormone levels above the upper limit of the reference range are one indicator of severe hyperthyroidism, but should not alone prompt admission. Many patients who present with thyrotoxicosis will be tachycardic; this alone is not an indication for acute admission, although a cardiovascular examination should be performed and an ECG should be documented. Patients with clinical features which are suspicious of a thyroid storm should be admitted for close monitoring, supportive care and urgent endocrine input. In addition, those patients with significant tachycardia, AF or features of cardiac failure will require a short admission until any concern regarding cardiovascular instability has resolved. Special considerations Subclinical hyperthyroidism A number of patients may be found to have a low serum TSH (particularly if TSH testing is performed without specific clinical indication) this, in conjunction with normal levels of free thyroid hormones, is defined as subclinical hyperthyroidism (SH). Depending on the TSH assay cut-off value and the iodine intake of the population, SH may be found in up to 10% of the population 10. SH can be caused by endogenous thyroid disease, drug effects and nonthyroidal illness. A low or undetectable TSH is associated with significant morbidity and mortality in longitudinal epidemiological surveys 7. There is a paucity of evidence to guide the assessment or management of patients with SH, but they should be flagged for repeat biochemical assessment; if TFTs remain abnormal, a referral to endocrinology is appropriate. It is useful to assess for other causes of a low TSH including non-thyroidal illness, drugs that suppress TSH (glucocorticoids, dopaminergic medication, or octreotide) and drugs that alter thyroid hormone secretion (amiodarone, lithium or iodine-containing contrast dyes). If a cause is not found, TFTs should be repeated in 3-6 months (or earlier if the patient is elderly or has cardiovascular disease. If non-thyroidal illness is suspected to be the cause, it would be appropriate to arrange repeat testing after a shorter interval 11. Drug-induced thyroid dysregulation Amiodarone-induced thyrotoxicosis (AIT) encompassing type I, where excess thyroid hormone is synthesised and released, and type II, when a destructive thyroiditis prompts the release of preformed thyroid hormone - occurs in around 20% of patients on the drug. Distinguishing between type I and type II can be challenging: each subtype requires tailored management and endocrine input should be sought. Patients on lithium can present with hypothyroidism or thyrotoxicosis (via the effect of lithium on thyroid cells, or by inducing painless thyroiditis) 12. More recently, the increasing use of immune-checkpoint inhibitors in the management of cancer has resulted in greater numbers of patients presenting with drug-induced thyroid dysfunction (thyrotoxicosis can be secondary to thyroiditis or Graves disease). In drug-induced thyrotoxicosis,
5 48 the precipitating drug should not necessarily be stopped; endocrine input is paramount to ensure an appropriate management plan is promptly instigated. Thyroid storm A thyroid storm is a rare but life threatening condition. Signs include fever, tachycardia, agitation and altered mental state, deranged liver function tests and features of cardiac failure. It can be precipitated by infection, surgery, trauma childbirth or poor compliance to treatment. Pregnant women Untreated hyperthyroidism in pregnancy poses serious risks to both mother and baby. If uncontrolled, restricted foetal growth and low birthweight is likely 13,14. Maternal sequelae can include hypertension, congestive cardiac failure and thyroid storm 14 and obstetric complications may occur. The longer the duration of uncontrolled hyperthyroidism, the higher the likelihood of a detrimental impact on maternal and foetal outcome. Pregnant women with suspected hyperthyroidism should be urgently referred to medical obstetrics team or endocrinology for prompt assessment. Not all cases of apparent hyperthyroidism in pregnancy are pathological - high levels of ß human chorionic gonadotrophin can lead to gestational hyperthyroidism, with absent TSH receptor antibodies, no extrathyroidal features and no goitre; this will resolve by 20 weeks gestation. Conflict of Interest Nothing to declare. References 1. Garmendia Madariaga A et al; The incidence and prevalence of thyroid dysfunction in Europe: a meta-analysis. J Clin Endocrinol Metab 2014; 99(3): Vaidya B and Pearce SHS; Diagnosis and management of thyrotoxicosis. BMJ 2014; 349:g Ross DS et al; American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26(10): Burch HB and Cooper DS; Management of Graves Disease: A Review. JAMA 2015; 314(23): Smith TJ and Hegedüs L; Graves Disease. N Engl J Med 2016; 375(16): Mitchell AL et al; Diagnosis of Graves orbitopathy (DiaGO): results of a pilot study to assess the utility of an office tool for practicing endocrinologists. J Clin Endocrinol Metab 2015; 100(3):E Mitchell AL and Pearce SHS; How should we treat patients with low serum thyrotropin concentrations? Clin Endocrinol 2010; 72(3): Biondi B et al; The 2015 European Thyroid Association Guidelines on Diagnosis and Treatment of Endogenous Subclinical Hyperthyroidism. Eur Thyroid J 2015; 4(3): Watanabe N et al; Antithyroid-drug induced hematopoietic damage: a retrospective cohort study of agranulocytosis and pancytopenia involving 50,385 patients with Graves disease. JCEM 2012; 97:E Carle A et al; Management of Endocrine Disease: Subclinical thyrotoxicosis: prevalence, causes and choice of therapy. EJE 2017; 176: NICE CKS Hyperthyroidism June 2016 Accessed via nice.org.uk [November 2017]. 12. Pearce EN et al; Thyroiditis. N Engl J Med 2003; 348(26): Laurberg P et al; Management of Graves hyperthyroidism in pregnancy: Focus on both maternal and foetal thyroid function, and caution against surgical thyroidectomy in pregnancy. Eur Jour Endocrinol 2009; 160(1): Rivkees SA and Mandel SJ; Thyroid disease in pregnancy. Horm Res Paediatr 2011; 76 (supp.1):91-96.
Lecture title. Name Family name Country
Lecture title Name Family name Country Nguyen Thy Khue, MD, PhD Department of Endocrinology HCMC University of Medicine and Pharmacy, MEDIC Clinic Hochiminh City, Viet Nam Provided no information regarding
More informationSouthern Derbyshire Shared Care Pathology Guidelines. Hyperthyroidism
Southern Derbyshire Shared Care Pathology Guidelines Hyperthyroidism Purpose of Guideline The management and referral criteria of patients with newly diagnosed hyperthyroidism. Background Hyperthyroidism
More informationSlide notes: This presentation provides information on Graves disease, a systemic autoimmune disease. Epidemiology, pathology, complications,
1 This presentation provides information on Graves disease, a systemic autoimmune disease. Epidemiology, pathology, complications, including ophthalmic complications, treatments (both permanent solutions
More informationUpdate In Hyperthyroidism
Update In Hyperthyroidism CME Away India & Sri Lanka March 23 - April 7, 2018 Richard A. Bebb MD, ABIM, FRCPC Consultant Endocrinologist Medical Subspecialty Institute Cleveland Clinic Abu Dhabi Copyright
More informationThyroid Gland. Patient Information
Thyroid Gland Patient Information Contact details for Endocrine and Thyroid Clinics Hawke s Bay Fallen Soldiers Memorial Hospital Villa 16 Phone: 06 8788109 ext 5891 Text: 0274 102 559 Email: endoclinic@hbdhb.govt.nz
More informationEffect of thyroid hormones of metabolism Thyroid Diseases
Effect of thyroid hormones of metabolism Thyroid Diseases Medical Perspective Aspects That Will Be Addressed Regulation of thyroid hormone secretion Basic physiology Hyperthyroidism Hypothyroidism Thyroiditis
More informationCHAPTER-II Thyroid Diseases. by: j. jayasutha lecturer department of Pharmacy practice Srm college of pharmacy srm university
CHAPTER-II Thyroid Diseases by: j. jayasutha lecturer department of Pharmacy practice Srm college of pharmacy srm university Aspects That Will Be Addressed Hyperthyroidism Hypothyroidism Thyroiditis Hyperthyroidism
More informationHyperthyroidism. Objectives. Clinical Manifestations. Slide 1. Slide 2. Slide 3. Implications for Primary Care. hyperthyroidism
1 Hyperthyroidism Implications for Primary Care Laura A. Ruby, DNP, CRNP Wellspan Endocrinology 2 Objectives! Discuss the clinical manifestations of hyperthyroidism! Review the use of the diagnostic studies!
More informationHyperthyroidism Diagnosis and Treatment. April Janet A. Schlechte, M.D.
Hyperthyroidism Diagnosis and Treatment Family Practice Refresher Course April 2015 Janet A. Schlechte, M.D. Disclosure of Financial Relationships Janet A. Schlechte, M.D. has no relationships with any
More informationBELIEVE MIDWIFERY SERVICES
TITLE: THYROID DISEASE IN PREGNANCY EFFECTIVE DATE: July, 2013 POLICY STATEMENT: Pregnancy changes significantly the values influenced by the serum thyroid binding hormone level (i.e., total thyroxine,
More informationThe Number Games and Thyroid Function Arshia Panahloo Consultant Endocrinologist St George s Hospital
The Number Games and Thyroid Function Arshia Panahloo Consultant Endocrinologist St George s Hospital Presentation Today: Common thyroid problems and treatments Pregnancy related thyroid problems The suppressed
More informationOUTLINE. Regulation of Thyroid Hormone Production Common Tests to Evaluate the Thyroid Hyperthyroidism - Graves disease, toxic nodules, thyroiditis
THYROID DISEASE OUTLINE Regulation of Thyroid Hormone Production Common Tests to Evaluate the Thyroid Hyperthyroidism - Graves disease, toxic nodules, thyroiditis OUTLINE Hypothyroidism - Hashimoto s thyroiditis,
More informationThyroid disorders. Dr Enas Abusalim
Thyroid disorders Dr Enas Abusalim Thyroid physiology The hypothalamic pituitary thyroid axis And peripheral conversion of T4 to T3, WHERE, AND BY WHAT ENZYME?? Only relatively small concentrations of
More informationDiseases of thyroid & parathyroid glands (1 of 2)
Diseases of thyroid & parathyroid glands (1 of 2) Thyroid diseases Thyrotoxicosis Hypothyroidism Thyroiditis Graves disease Goiters Neoplasms Chronic Lymphocytic (Hashimoto) Thyroiditis Subacute Granulomatous
More information4) Thyroid Gland Defects - Dr. Tara
4) Thyroid Gland Defects - Dr. Tara Thyroid Pituitary Axis TRH secreted in the hypothalamus stimulates production and Secretion of TSH TSH stimulates secretion of T3, T4 T4 has negative feedback on secretion
More informationTHYROTOXICOSIS DR.J.BALA KUMAR 2 ND YR SURGERY PG
THYROTOXICOSIS DR.J.BALA KUMAR 2 ND YR SURGERY PG What is the difference between thyrotoxicosis and hyperthyroidism Thyrotoxicosis Thyrotoxicosis is defined as the state of thyroid hormone excess and is
More informationTANJA KEMP INTERNAL MEDICINE: ENDOCRINOLOGY
ENDOCRINE DISORDERS IN THE ELDERLY (part 2) TANJA KEMP INTERNAL MEDICINE: ENDOCRINOLOGY Pituitary axis Target organs of the pituitary gland Negative feedback Hypothalamus-Pituitary-Thyroid axis Thyroid
More informationToxic MNG Thyroiditis 5-15
Hyperthyroidism Facts Prevalence 0.5-1.0%, more common in women Thyrotoxicosis is excess thyroid hormones from endogenous or exogenous sources Hyperthyroidism is excess thyroid hormones from thyroid gland
More informationThyroid gland defects. Dr. Tara Husain
Thyroid gland defects Dr. Tara Husain Thyroid Pituitary Axis TRH secreted in the hypothalamus stimulates production and Secretion of TSH TSH stimulates secretion of T3,T4 T4 has negative feed back on secretion
More informationApproach to thyroid dysfunction
Approach to thyroid dysfunction Alice Y.Y. Cheng, MD, FRCPC Twitter: @AliceYYCheng Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or
More informationNeonatal Thyrotoxicosis Management of babies born to mothers with a history of hyperthyroidism (Grave s Disease)
MCN for Neonatology West of Scotland Neonatal Guideline Neonatal Thyrotoxicosis Management of babies born to mothers with a history of hyperthyroidism (Grave s Disease) This document is applicable to all
More informationHYPERTHYROIDISM. Hypothalamus. Thyrotropin-releasing hormone (TRH) Anterior pituitary gland. Thyroid-stimulating hormone (TSH) Thyroid gland T4, T3
HYPERTHYROIDISM Hypothalamus Thyrotropin-releasing hormone (TRH) Anterior pituitary gland Thyroid-stimulating hormone (TSH) Thyroid gland T4, T3 In hyperthyroidism, there is an increased production of
More informationClinical Guideline MANAGEMENT OF INFANTS BORN TO MOTHERS WITH GRAVES DISEASE AND AT RISK OF THYROTOXICOSIS
Clinical Guideline MANAGEMENT OF INFANTS BORN TO MOTHERS WITH GRAVES DISEASE AND AT RISK OF THYROTOXICOSIS Date of First Issue 18/07/2016 Approved 28/09/2017 Current Issue Date 16/06/2017 Review Date 01/09/2019
More informationB-Resistance to the action of hormones, Hormone resistance characterized by receptor mediated, postreceptor.
Disorders of the endocrine system 38 Disorders of endocrine system mainly are caused by: A-Deficiency or an excess of a single hormone or several hormones: - deficiency :can be congenital or acquired.
More informationDisorders of Thyroid Function
Disorders of Thyroid Function Michael T. McDermott MD Director, Endocrinology and Diabetes Practice University of Colorado Hospital Michael.mcdermott@ucdenver.edu Thyroid Hormone Axis Hypothalamus TRH
More informationNew diagnosis of hyperthyroidism in primary care
Page 1 of 7 1700 words 1607 10-Minute Consultation New diagnosis of hyperthyroidism in primary care Gabriella Bathgate 1, Efthimia Karra 2, Bernard Khoo 3 1 Specialist Trainee in General Practice 2 Consultant
More informationNon Thyroid Surgery. In patients with Thyroid disorders
Non Thyroid Surgery In patients with Thyroid disorders The Thyroid disease problem. Is Thyroid disease a problem with anaesthetic? Why worry? The Physiology The evidence. A pragmatic approach From: The
More informationDiagnosis and management of thyrotoxicosis
Link to this article online for CPD/CME credits Diagnosis and management of thyrotoxicosis 1 Department of Endocrinology, Royal Devon and Exeter Hospital, and University of Exeter Medical School, Exeter
More informationLothian Guidance for Diagnosis and Management of Thyroid Dysfunction in Pregnancy
Lothian Guidance for Diagnosis and Management of Thyroid Dysfunction in Pregnancy Early diagnosis and good management of maternal thyroid dysfunction are essential to ensure minimal adverse effects on
More informationWho is this leaflet for? What is hyperthyroidism? What is the thyroid gland? What causes hyperthyroidism? How is hyperthyroidism diagnosed?
Hyperthyroidism Who is this leaflet for? This leaflet is for patients who have been diagnosed with hyperthyroidism. It aims to give you some background information about the condition, its causes and the
More informationThyrotoxicosis in Pregnancy: Diagnose and Management
Thyrotoxicosis in Pregnancy: Diagnose and Management Yuanita Asri Langi email: meralday@yahoo.co.id Endocrinology & Metabolic Division, Internal Medicine Department, Prof.dr.R.D. Kandou Hospital/ Sam Ratulangi
More informationAn Approach to: Thyroid Function Tests. Rinkoo Dalan Consultant Department of Endocrinology Tan Tock Seng Hospital
An Approach to: Thyroid Function Tests Rinkoo Dalan Consultant Department of Endocrinology Tan Tock Seng Hospital Regulation of Thyroid axis Hypothalamus TRH T3,T4 ---- TRH Median Eminence (base of brain)
More informationHyperthyroidism and Hypothyroidism in Pregnancy Guideline
Aneurin Bevan University Health Board Hyperthyroidism and Hypothyroidism in Pregnancy Guideline N.B. Staff should be discouraged from printing this document. This is to avoid the risk of out of date printed
More informationThe Thyroid: No mystery. Just need all the pieces to the puzzle.
The Thyroid: No mystery. Just need all the pieces to the puzzle. Todd Chennell, MS, RN ANP-C Endocrine surgery University of Rochester 2018 1 According to the American Thyroid Association, 12 percent of
More informationThe Use of Iodine as First Line Therapy in Graves' Disease Complicated with Neutropenia at First Presentation in a Paediatric Patient
British Journal of Medicine & Medical Research 3(2): 324-328, 2013 SCIENCEDOMAIN international www.sciencedomain.org The Use of Iodine as First Line Therapy in Graves' Disease Complicated with Neutropenia
More informationAlvin C. Powers, M.D. 1/27/06
Thyroid Histology Follicular Cells ECF side Apical lumen Thyroid Follicles -200-400 um Parafollicular or C-cells Colloid Photos from University of Manchester and tutorial created by Dr. James Crimando,
More informationDisclosures. Learning objectives. Case 1A. Autoimmune Thyroid Disease: Medical and Surgical Issues. I have nothing to disclose.
Disclosures Autoimmune Thyroid Disease: Medical and Surgical Issues I have nothing to disclose. Chrysoula Dosiou, MD, MS Clinical Assistant Professor Division of Endocrinology Stanford University School
More informationuniversity sciences of Isfahan university Com
Introduce R. Gholamnezhad Lecturer of school of nursing & midwifery of Iran university Ph.D student tof Immunology, Sh School of medical sciences of Isfahan university E-Mail: Gholami278@gmail. Com Interpreting
More informationRequesting and Management of abnormal TFTs.
Requesting and Management of abnormal TFTs. At the request of a number of GPs I have produced summary guidelines surrounding thyroid testing. These have been agreed with our Endocrinology leads Dr Bell
More informationLaura Trask, MD FACP Central Maine Endocrinology Lewiston, ME
Laura Trask, MD FACP Central Maine Endocrinology Lewiston, ME 795-7520 traskla@cmhc.org No disclosures Objectives To have an understanding of hyperthyroidism To have an understanding of the management
More informationPathology. Hyperthyroidism (Overactive Thyroid), Graves Disease (Basedow Disease) and more. Definitions. See online here
Pathology Hyperthyroidism (Overactive Thyroid), Graves Disease (Basedow Disease) and more See online here Hyperthyroidism is caused by the excess of thyroid hormones T3 and T4. Graves disease is the most
More informationTHYROID DISEASES. CASE BASED WORKSHOP Z. Henry He, MD, PhD. Endocrinology, Diabetes, & Metabolism Cambridge Health Alliance Harvard Medical School
THYROID DISEASES CASE BASED WORKSHOP Z. Henry He, MD, PhD Endocrinology, Diabetes, & Metabolism Cambridge Health Alliance Harvard Medical School DISCLOSURE I have no relevant financial disclosure OBJECTIVES
More informationThyroid Disease. I have no disclosures. Overview TSH. Matthew Kim, M.D. July, 2012
Thyroid Disease I have no disclosures Matthew Kim, M.D. July, 2012 Overview Thyroid Function Tests Hyperthyroidism Hypothyroidism Subclinical Thyroid Disease Thyroid Nodules Questions TSH Best single screening
More informationThyroid Hormones (T 4 & T 3 )
1 Thyroid Hormones (T 4 & T 3 ) Normalize growth and development, body temperature, and energy levels. Used as thyroid replacement therapy in hypothyroidism. Thyroxine (T 4 ) is peripherally metabolized
More informationWomen s Health in General Practice Symposium 2015 Thyroid & Parathyroid Cases
Women s Health in General Practice Symposium 2015 Thyroid & Parathyroid Cases Bill Fleming Epworth Freemasons Hospital 1 Common Endocrine Presentations anatomical problems thyroid nodule / goitre embryological
More informationLothian Guidance for Diagnosis and Management of Thyroid Dysfunction in Pregnancy.
Lothian Guidance for Diagnosis and Management of Thyroid Dysfunction in Pregnancy. Early diagnosis and good management of maternal thyroid dysfunction is essential to ensure minimal adverse effects on
More informationSanjay B. Dixit, M.D. BHS Endocrinology Associates November 11, 2017
Sanjay B. Dixit, M.D. BHS Endocrinology Associates November 11, 2017 I will not be discussing this Outline of discussion Laboratory tests for thyroid function Diagnosis of hypothyroidism Treatment of
More informationThyroid Plus. Central Thyroid Regulation & Activity. Peripheral Thyroid Function. Thyroid Auto Immunity. Key Guide. Patient: DOB: Sex: F MRN:
Thyroid Plus Patient: DOB: Sex: F MRN: Order Number: Completed: Received: Collected: Sample Type - Serum Result Reference Range Units Central Thyroid Regulation & Activity Total Thyroxine (T4) 127 127
More informationClinical Guideline MEDICAL MANAGEMENT OF CHILDREN WITH THYROTOXICOSIS
Clinical Guideline MEDICAL MANAGEMENT OF CHILDREN WITH THYROTOXICOSIS Date of First Issue 01/10/2014 Approved 28 /01/2015 Current Issue Date 01/10/2014 Review Date 01 /10/2018 Version 1.0 Author / Contact
More informationAmiodarone Induced Thyrotoxicosis Treatment? (AIT)
Amiodarone Induced Thyrotoxicosis Treatment? (AIT) Presentation of a Case Report Annelies Tonnelier Brigitte Velkeniers 14-12-2013 1 1. Background 1. Case report 2. Investigations 3. Diagnosis 4. Treatment
More informationDharma Lindarto Div. Endokrin-Metabolisme dan Diabetes. Dep Ilmu Penyakit Dalam FK USU / RSUP HAM Medan
HYPERTHYROIDISM Dharma Lindarto Div. Endokrin-Metabolisme dan Diabetes. Dep Ilmu Penyakit Dalam FK USU / RSUP HAM Medan Anatomy of the Thyroid Gland Tiroid Disease Multi N Aspect fungtion morphology eutiroid,
More informationA RARE CASE OF THYROTOXICOSIS IN PEDIATRIC PRACTICE
Original Case Report DOI - 10.26479/2016.0204.13 A RARE CASE OF THYROTOXICOSIS IN PEDIATRIC PRACTICE Renata Markosyan 1,2, Natalya Volevodz 3,4, Lusine Navasardyan 1,2 and Karmella Pogosyan 2 1.Yerevan
More informationHyperthyroidism, Inflammatory Disorders
Hyperthyroidism, Inflammatory Disorders free T4 Howard J. Sachs, MD www.12daysinmarch.com Hyperthyroidism, Inflammatory Disorders The total T4 may be elevated in pregnancy and with OCP use Graves I 123
More informationThyroiditis Diagnosis and Management issues. Prof. Md. Enamul Karim Professor of Medicine Dhaka Medical College
Thyroiditis Diagnosis and Management issues Prof. Md. Enamul Karim Professor of Medicine Dhaka Medical College Definition Thyroiditis is a general term that refers to inflammation of the thyroid gland.
More informationEndocrine part two. Presented by Dr. Mohammad Saadeh The requirements for the Clinical Chemistry Philadelphia University Faculty of pharmacy
Endocrine part two Presented by Dr. Mohammad Saadeh The requirements for the Clinical Chemistry Philadelphia University Faculty of pharmacy Cushing's disease: increased secretion of adrenocorticotropic
More information1. Purpose of this document Guideline for the medical management of CHILDREN WITH THYROTOXICOSIS in secondary care
SPEG MCN guideline Thyrotoxicosis 1. Purpose of this document Guideline for the medical management of CHILDREN WITH THYROTOXICOSIS in secondary care 2. Who should use this document Paediatricians, paediatric
More informationSample Type - Serum Result Reference Range Units. Central Thyroid Regulation Surrey & Activity KT3 4Q. Peripheral Thyroid D Function mark
Thyroid Plus Sample Type - Serum Result Reference Range Units Central Thyroid Regulation Surrey & Activity KT3 4Q Total Thyroxine (T4)
More informationNone. Thyroid Potpourri for the Primary Care Physician. Evaluating Thyroid Function. Disclosures. Learning Objectives
Thyroid Potpourri for the Primary Care Physician Ramya Vedula DO, MPH, ECNU Endocrinology, Diabetes and Metabolism Princeton Medical Group Assistant Professor of Clinical Medicine Rutgers Robert Wood Johnson
More informationCommon Causes of Hypothyroidism
Common Causes of Hypothyroidism Autoimmune thyroidi4s Surgical removal of thyroid gland Medica4on Therapy Iodine and iodine containing medica4ons Neck radia4on Post Partum thyroidi4s Prevalence of Hypothyroidism
More informationScreening Babies at risk of Congenital Hyperthyroidism GL354
1 Screening Babies at risk of Congenital Hyperthyroidism GL354 Approval and Authorisation Approved by Job Title Date Paediatric Clinical Governance Chair of paediatric Clinical Governance March 2016 Change
More informationPathophysiology of Thyroid Disorders. PHCL 415 Hadeel Alkofide April 2010
Pathophysiology of Thyroid Disorders PHCL 415 Hadeel Alkofide April 2010 1 Learning Objectives Understand the pathophysiology of hyperthyroidism & hypothyroidism Describe the signs & symptoms of hyperthyroidism
More informationCommon Issues in Management of Hypothyroidism
Common Issues in Management of Hypothyroidism Family Medicine Refresher Course April 5, 2018 Janet A. Schlechte, M.D. Disclosure of Financial Relationships Janet A. Schlechte, M.D. has no relationships
More information03-Dec-17. Thyroid Disorders GOITRE. Grossly enlarged thyroid - in hypothyroidism in hyperthyroidism - production of anatomical symptoms
Thyroid Disorders GOITRE Grossly enlarged thyroid - in hypothyroidism in hyperthyroidism - production of anatomical symptoms 1 Physiological Goiter load on thyroid supply of I - limited stress due to:
More informationHyperthyroidism in Cats (icatcare) What is hyperthyroidism?
Kingsbrook Animal Hospital 5322 New Design Road, Frederick, MD, 21703 Phone: (301) 631-6900 Website: KingsbrookVet.com Hyperthyroidism in Cats (icatcare) Hyperthyroidism [1] What is hyperthyroidism? Hyperthyroidism
More informationUnderstanding Thyroid Labs
Understanding Thyroid Labs Chris Sadler, MA, PA-C, CDE, DFAAPA Senior Medical Science Liaison CVM Janssen Scientific Affairs Diabetes and Endocrine Associates La Jolla, CA Disclosures Employee of Janssen
More informationDiabetes Centre. Treatment for Overactive Thyroid Gland. Information
Diabetes Centre Treatment for Overactive Thyroid Gland Information Your doctor will have told you that you have an overactive thyroid. We hope the following information will help you to understand the
More informationPreoperative management in patients with Graves disease
Review Article Preoperative management in patients with Graves disease Eliana Piantanida Department of Medicine and Surgery, University of Insubria, Varese, Italy Correspondence to: Dr. Eliana Piantanida.
More informationArticle: Novodvorsky, P. orcid.org/ and Allahabadia, A. (2017) Thyrotoxicosis. Medicine, 45 (8). pp
This is a repository copy of Thyrotoxicosis. White Rose Research Online URL for this paper: http://eprints.whiterose.ac.uk/131322/ Version: Accepted Version Article: Novodvorsky, P. orcid.org/0000-0002-3292-7586
More informationUnderstanding thyroid function tests. Dr. Colette George
Understanding thyroid function tests Dr. Colette George Disclosures No financial disclosure I will present fictitious cases and thyroid function tests (TFTs) that are based on scenarios I commonly encounter.
More informationThyroid Storm: Uncommon Presentation. Noora M. Butti, MBBcH*
Bahrain Medical Bulletin, Vol. 36, No. 3, September 2014 Thyroid Storm: Uncommon Presentation Noora M. Butti, MBBcH* Thyroid storm could lead to mortality; it is rare and characterized by severe clinical
More informationDISORDERS OF THE THYROID GLAND SIGNS, SYMPTOMS, & TREATMENT ENDOCRINE SYSTEM AT A GLANCE OBJECTIVES ANATOMY OF THE THYROID
OBJECTIVES DISORDERS OF THE THYROID GLAND SIGNS, SYMPTOMS, & TREATMENT Stephanie Blackburn, MHS, MLS(ASCP) CM LSU Health Shreveport Clinical Laboratory Science Program Discuss the synthesis and action
More informationSummary of Treatment Benefits Page 72 of 111. Page 72
1.8.2 Page 72 of 111 Page 72 need surgery to remove part or all of the thyroid gland. This procedure is known as a thyroidectomy (removal of thyroid gland), and is followed by life-long intake of levothyroxine.
More informationThyroid Disorders. January 2019
Thyroid Disorders January 2019 What is the Thyroid? The thyroid is a small butterfly-shaped gland inside the neck, located in front of the trachea (windpipe) and below the larynx (voicebox). It produces
More information19th Century Thyroidology
1 19th Century Thyroidology Dr. Kinnicutt s patient (1893) A cold, tired, constipated middle aged woman Slow pulse rate Low body temperature From physiology it was likely patient needed thyroid replacement
More informationEFFECTIVE SHARE CARE AGREEMENT. For the specialist use of LIOTHYRONINE for patients registered with a Dudley GP.
Specialist details Patient identifier Name Tel: EFFECTIVE SHARE CARE AGREEMENT For the specialist use of LIOTHYRONINE for patients registered with a Dudley GP. The aim of an Effective Shared Care Agreement
More informationGraves Disease. What is Graves disease?
Graves Disease What is Graves disease? The thyroid gland s production of thyroid hormones (T 3 and T 4 ) is triggered by thyroidstimulating hormone (TSH), which is made by the pituitary gland. Graves disease,
More informationTHYROID AWARENESS. By: Karen Carbone. January is thyroid awareness month. At least 30 million Americans
THYROID AWARENESS By: Karen Carbone January is thyroid awareness month. At least 30 million Americans have a thyroid disorder and half-15 million-are silent sufferers who are undiagnosed, according to
More informationTHYROID DISEASE IN CHILDREN
THYROID DISEASE IN CHILDREN Michelle Schweiger, D.O. Center for Pediatric and Adolescent Endocrinology Cleveland Clinic Foundation Neither I nor any immediate family members have any financial interests
More informationBarns Medical Practice Service Specification Outline: Hypothyroidism
Barns Medical Practice Service Specification Outline: Hypothyroidism DEVELOPED March 2015 REVIEW August 2019 Introduction The thyroid is a gland in the neck which makes two thyroid hormones, thyroxine
More informationApproach to Thyroid Dysfunction in the Elderly
Approach to Thyroid Dysfunction in the Elderly Fernando Melaragno Endocrinology Objective The objective of this lecture is to review the epidemiology, clinical presentation, risks and complications, and
More informationHYPOTHYROIDISM AND HYPERTHYROIDISM
HYPOTHYROIDISM AND HYPERTHYROIDISM SHAHIDA PERVEEN, AMBREEN Post RN BSCN Semester II FACULTY SIR RAJA April 13, 016 Objectives: State the functions of thyroid hormone. Understand the pathologic mechanism
More informationCanadian Endocrine Review Course 2014
Canadian Endocrine Review Course 2014 Amiodarone & Thyrotoxicosis Iodine, A Catch 22 Ally P.H. Prebtani Associate Professor of Medicine Internal Medicine, Endocrinology & Metabolism McMaster University
More informationThyroid. Dr Jessica Triay November 2018
Thyroid Dr Jessica Triay November 2018 Hypothyroidism in Pregnancy Clinical update: Hypothyroidism in Pregnancy Take home messages Additional evidence supportive for more relaxed TSH targets for those
More informationSystemic Management of Graves Disease. Robert James Graves, M.D., FRCS ( ) Graves Disease: Endocrinopathy or Ophthalmopathy?
Systemic Management of Graves Disease Rona Z. Silkiss, M.D., FACS Associate Clinical Professor, UCSF Chief, Division of Ophthalmic Plastic and Orbital Surgery California Pacific Medical Center No financial
More informationHyperthyroidism. concepts. Graves Disease. Etiology 4/22/12
concepts Hyperthyroidism Dr. B. Paudel Thyroid overactivity F:M = 5:1 2.5% of all females at sometimes; get affected 20-40 years: peak 90% of cases are intrinsic thyroid disease, pituitary causes extremely
More information2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis
THYROID Volume 26, Number 10, 2016 ª American Thyroid Association ª Mary Ann Liebert, Inc. DOI: 10.1089/thy.2016.0229 SPECIAL ARTICLE 2016 American Thyroid Association Guidelines for Diagnosis and Management
More informationGuidance for Thyroid Function Testing in Primary Care in Lothian
Guidance for Thyroid Function Testing in Primary Care in Lothian In July 2006 following a lengthy consultation process, a joint working group comprising representatives from the Association of Clinical
More informationLectures presented. 3 rd year
Lectures presented 3 rd year-2016-2017 The metabolic response to trauma Basic concepts: Homeostasis is a mechanism by which the internal environment of the human being is driven constant. It involves a
More informationMastering Thyroid Disorders. Douglas C. Bauer, MD UCSF Division of General Internal Medicine
Mastering Thyroid Disorders Douglas C. Bauer, MD UCSF Division of General Internal Medicine Cases 68 yr old female with new atrial fibrillation and no other findings except TSH=0.04, normal free T4 79
More informationTransient Hypothyroidism after Radioiodine for Graves Disease: Challenges in Interpreting Thyroid Function Tests
Clinical Medicine & Research Volume 14, Number 1: 40-45 2016 Marshfield Clinic Health System clinmedres.org Clinical Overview Transient Hypothyroidism after Radioiodine for Graves Disease: Challenges in
More informationTargeted Issues in Endocrinology Joshua S. Coren, DO, MBA, FACOFP
Targeted Issues in Endocrinology Joshua S. Coren, DO, MBA, FACOFP Endocrine in 25 Minutes Joshua S. Coren, D.O., MBA, FACOFP Vice Chair and Associate Professor, Family Medicine Rowan University School
More informationThe Presence of Thyroid Autoantibodies in Pregnancy
The Presence of Thyroid Autoantibodies in Pregnancy Dr. O Sullivan does not have any financial relationships with any commercial interests. KATIE O SULLIVAN, MD FELLOW, ADULT/PEDIATRIC ENDOCRINOLOGY ENDORAMA
More informationDisorders of the Thyroid Gland
Disorders of the Thyroid Gland István Takács MD., PhD, 1st Department of Medicine, Semmelweis University Connection to the dentistry: close to each other higher operation risk radiating pain macroglossia
More informationGrave s disease (1 0 )
THYROID DYSFUNCTION Grave s disease (1 0 ) Autoimmune - activating AB s to TSH receptor High concentrations of circulating thyroid hormones Weight loss, tachycardia, tiredness Diffuse goitre - TSH stimulating
More informationThyroid disease for R2
Thyroid disease for R2 Rungnapa Laortanakul, MD. 5 February 2013 Thyroid Thyrotoxicosis/Thyroiditis Amiodarone and thyroid dysfunction Thyroid storm Hypothyroidism Thyroid nodule Thyrotoxicosis Refers
More informationA retrospective cohort study: do patients with graves disease need to be euthyroid prior to surgery?
Al Jassim et al. Journal of Otolaryngology - Head and Neck Surgery (2018) 47:37 https://doi.org/10.1186/s40463-018-0281-z ORIGINAL RESEARCH ARTICLE Open Access A retrospective cohort study: do patients
More informationChapter I.A.1: Thyroid Evaluation Laboratory Testing
Chapter I.A.1: Thyroid Evaluation Laboratory Testing Jennifer L. Poehls, MD and Rebecca S. Sippel, MD, FACS THYROID FUNCTION TESTS Overview Thyroid-stimulating hormone (TSH) is produced by the anterior
More informationCauses and management of hyperthyroidism in cats
Vet Times The website for the veterinary profession https://www.vettimes.co.uk Causes and management of hyperthyroidism in cats Author : Emma Garnett Categories : RVNs Date : May 1, 2008 Emma Garnett VN,
More informationReference intervals are derived from the statistical distribution of values in the general healthy population.
Position Statement Subject: Thyroid Function Testing for Adult Diagnosis and Monitoring Approval Date: July 2017 Review Date: July 2019 Review By: Chemical AC, Board of Directors Number: 1/2017 Introduction:
More informationHORMONES OF THE POSTERIOR PITUITARY
HORMONES OF THE POSTERIOR PITUITARY HORMONES OF THE POSTERIOR PITUITARY In contrast to the hormones of the anterior lobe of the pituitary, those of the posterior lobe, vasopressin and oxytocin, are not
More information