ABSTRACT Objective: The aim of this study was to determine whether classifying hypoechogenicity in three degrees (mild, moderate, and marked) could improve the distinction between benign and malignant nodules and whether such an approach could influence Category 4 of the Thyroid Imaging Reporting and Data System (TI-RADS). Materials and methods: In total, 2,574 nodules submitted to fine needle aspiration, classified by the Bethesda System, were retrospectively assessed. Further, a subanalysis considering solid nodules without any additional suspicious findings (n = 565) was performed with the purpose of evaluating mainly TI-RADS 4 nodules. Results: Mild hypoechogenicity was significantly less related to malignancy (odds ratio [OR]: 1.409; CI: 1.086-1.829; p = 0.01), compared to moderate (OR: 4.775; CI: 3.700-6.163; p < 0.001) and marked hypoechogenicity (OR: 8.540; CI: 6.355-11.445; p < 0.001). In addition, mild hypoechogenicity (20.7%) and iso-hyperechogenicity (20.5%) presented a similar rate in the malignant sample. Regarding the subanalysis, no significant association was found between mildly hypoechoic solid nodules and cancer. Conclusion: Stratifying hypoechogenicity into three degrees influences the confidence in the assessment of the rate of malignancy, indicating that mild hypoechogenicity has a unique low-risk biological behavior that resembles iso-hyperechogenicity, but with minor malignant potential when compared to moderate and marked hypoechogenicity, with special influence on the TI-RADS 4 category.

Key points Pregnancy places a metabolic overload on the maternal thyroid, especially in the first trimester, mainly because of the demand imposed by the conceptus. The fetal thyroid becomes functionally mature only around pregnancy week 20. Until then, the fetus depends on the transfer of maternal thyroid hormones (THs). Thyroid hormones are essential for the adequate fetal neurofunctional and cognitive development. Hypothyroidism brings higher risks of obstetric and fetal complications, namely, first-trimester miscarriage, preeclampsia and gestational hypertension, placental abruption, prematurity, low birth weight, and higher perinatal morbidity and mortality. Primary hypothyroidism (involvement of the gland with difficulty in producing and/or releasing TH) is the most common form of disease presentation, with the main etiology of Hashimoto's thyroiditis of autoimmune origin. In about 85%-90% of cases of Hashimoto's thyroiditis, antithyroid antibodies are present; the antithyroperoxidase (ATPO) is the most frequent. Positivity for ATPO is determined when circulating values exceed the upper limit of the laboratory reference. It implies greater risks of adverse maternal-fetal outcomes. Such a correlation occurs even in ranges of maternal euthyroidism. The critical point for the diagnosis of hypothyroidism during pregnancy is an elevation of thyroid-stimulating hormone (TSH). The measurement of free thyroxine (FT4) differentiates between subclinical and overt hypothyroidism. In subclinical hypothyroidism, FT4 is within the normal range, whereas in overt hypothyroidism, FT4 values are below the lower limit of the laboratory reference. Treatment of hypothyroidism is performed with levothyroxine (LT4) replacement with the aim of achieving adequate TSH levels for pregnancy. Some women have a previous diagnosis of hypothyroidism, and may or may not be compensated at the beginning of pregnancy. Even in compensated cases, the increase in LT4 dose is necessary as soon as possible. In the postpartum period, adjustment of the LT4 dose depends on the condition of previous disease, on the positivity for ATPO, and also on the value of LT4 in use at the end of pregnancy. Recommendations In places with full technical and financial conditions, TSH testing should be performed for all pregnant women (universal screening) as early as possible, ideally at the beginning of the first trimester or even in preconception planning. In places with less access to laboratory tests, screening is reserved for cases with greater risk factors for decompensation, namely: previous thyroidectomy or radioiodine therapy, type 1 diabetes mellitus or other autoimmune diseases, presence of goiter, previous history of hypo or hyperthyroidism or previous ATPO positivity. The TSH dosage should be repeated throughout pregnancy only in these cases. The diagnosis of hypothyroidism is made from the TSH value > 4.0 mIU/L. Pregnant women with previous hypothyroidism, overt hypothyroidism diagnosed during pregnancy or those with the above-mentioned higher risk factors for decompensation should be referred for risk antenatal care, preferably in conjunction with the endocrinologist. Overt hypothyroidism in pregnancy is identified when TSH > 10 mIU/L, and treatment with LT4 is readily recommended at an initial dose of 2 mcg/kg/day. TSH values > 4.0 mUI/L and ≤ 10.0 mUI/L require FT4 measurement with two diagnostic possibilities: overt hypothyroidism when FT4 levels are below the lower limit of the laboratory reference, or subclinical hypothyroidism when FT4 levels are normal. The treatment for subclinical hypothyroidism is LT4 at an initial dose of 1 mcg/kg/day, and the dose should be doubled upon diagnosis of overt hypothyroidism. In cases of TSH > 2.5 and ≤ 4.0 mIU/L, if there are complete conditions, ATPO should be measured. If positive (above the upper limit of normal), treatment with LT4 at a dose of 50 mcg/day is indicated. If conditions are not complete, the repetition of the TSH dosage should be done only for cases at higher risk. In these cases, treatment with LT4 will be established when TSH > 4.0 mIU/L at a dose of 1 mcg/kg/day; if needed, the dose can be adjusted after FT4 evaluation. Women with previous hypothyroidism should have their LT4 dose adjusted to achieve TSH < 2.5 mIU/L at preconception. As soon as they become pregnant, they need a 30% increase in LT4 as early as possible. In practice, they should double the usual dose on two days a week. Levothyroxine should be given 30-60 minutes before breakfast or three hours or more after the last meal. Concomitant intake with ferrous sulfate, calcium carbonate, aluminum hydroxide and sucralfate should be avoided. The target of LT4 therapy during pregnancy is to achieve a TSH value < 2.5 mIU/L. Once the therapy is started, monthly control must be performed until the mentioned goal is reached. In the postpartum period, women with previous disease should resume the preconception dose. Cases diagnosed during pregnancy in use of LT4 ≤ 50 mcg/day may have the medication suspended. The others should reduce the current dose by 25% to 50% and repeat the TSH measurement in six weeks. Cases of ATPO positivity are at higher risk of developing postpartum thyroiditis and de-escalation of LT4 should be performed as explained.

ABSTRACT Objective Maternal hypothyroidism during pregnancy may lead to adverse outcomes. Recently published guidelines by the American Thyroid Association (ATA) do not advocate for universal screening but recommend a case-finding approach in high-risk pregnant women. The present study aims to evaluate the accuracy of this approach in identifying women with thyroid dysfunction during early pregnancy. Subjects and methods This is a multiple-center, cross-sectional study. Three hundred and one pregnant women were enrolled. Anamnesis and a physical examination were performed to detect which women fulfilled the criteria to undergo laboratory screening of thyroid dysfunction, according to the ATA’s 2017 guidelines. The Zulewski’s validated clinical score was applied to assess signs and symptoms of hypothyroidism. Serum levels of thyrotropin (TSH), free thyroxine (FT4), anti-thyroperoxidase (TPO-Ab), and anti-thyroglobulin (Tg-Ab) antibodies were determined. Results Two hundred and thirty one women (78%) were classified as high risk, and 65 (22%) were classified as low risk for thyroid dysfunction. Regarding the clinical score, 75 patients (31.2%) presented mild symptoms that were compatible with SCH, of which 22 (7.4%) had symptoms as the only risk factor for thyroid disease. 17 patients (5.7%) had SCH, of which 10 (58.8%) belonged to the high-risk group, and 7 (41.2%) belonged to the low-risk group. OH was found in 4 patients (1.4%): 3 (75%) in the high-risk group and 1 (25%) in the low-risk group. Conclusions The ATA’s proposed screening criteria were not accurate in the diagnosis of thyroid dysfunction in pregnancy. Testing only the high-risk pregnant women would miss approximately 40% of all hypothyroid patients.

ABSTRACT Objective: Life expectancy is increasing worldwide and studies have been demonstrating that elevated serum thyroid stimulating hormone (TSH) concentration in elderly is associated with some better health outcomes. This elevation is somewhat physiological as aging. The aim of this study was to investigate the heart rate (HR) response during a graded exercise test and its recovery in healthy elderly, comparing subjects within serum TSH in the lower limit of reference range to those within the TSH in the upper limit. Subjects and methods: A cross-sectional study was conducted with 86 healthy elderly aged 71.5 ± 5.1 years, with serum TSH between 0.4 – 4.0 mUl/mL. The participants were divided into two groups according to TSH level: < 1.0 mUl/mL (n = 13) and ≥ 1.0 µUI/mL (n = 73). All participants performed an ergometric test on a treadmill. The HR was recorded and analyzed at rest, during exercise and during the three minutes immediately after exercise. Results: No differences were observed in relation to HR at peak of exercise (TSH < 1.0 µUI/mL: 133.9 ± 22.5 bpm vs. TSH ≥ 1.0 µUI/mL: 132.4 ± 21.3 bpm; p = 0.70) and during the first minute of recovery phase (TSH < 1.0 µUI/mL: 122.3 ± 23.1 bpm vs. TSH ≥ 1.0 µUI/mL: 115.7 ± 18.4 bpm p = 0.33). The groups also presented similar chronotropic index (TSH < 1.0 µUI/mL: 78.1 ± 30.6 vs. TSH ≥ 1.0 µUI/mL: 79.5 ± 26.4; p = 0.74). Conclusion: In this sample studied, there were no difference between lower and upper TSH level concerning HR response during rest, peak of exercise and exercise recovery.

ABSTRACT Objective: The aim was to evaluate the quality of life (HRQoL) in women with subclinical hypothyroidism (sHT) after 16 weeks of endurance training. Subjects and methods: In the first phase, a cross-sectional study was conducted in which 22 women with sHT (median age: 41.5 (interquartile range: 175) years, body mass index: 26.2 (8.7) kg/m2, thyroid stimulating hormone > 4.94 mIU/L and free thyroxine between 0.8 and 1.3 ng/dL were compared to a group of 33 euthyroid women concerned to HRQoL. In the second phase, a randomized clinical trial was conducted where only women with sHT were randomly divided into two groups: sHT-Tr (n = 10) - participants that performed an exercise program - and sHT-Sed (n = 10) - controls. Exercise training consisted of 60 minutes of aerobic activities (bike and treadmill), three times a week, for 16 weeks. The HRQoL was assessed by the SF-36 questionnaire in the early and at the end of four months. Results: Women with sHT had lower scores on functional capacity domain in relation to the euthyroid ones (770 ± 23.0 vs. 88.8 ± 14.6; p = 0.020). The sHT-Tr group improved functional capacity, general health, emotional aspects, mental and physical component of HRQoL after training period, while the sHT-Sed group showed no significant changes. Conclusion: After 16 weeks of aerobic exercise training, there were remarkable improvements in HRQoL in women with sHT.

ABSTRACT Objectives: American Thyroid Association (ATA)'s new guidelines recommend use of population-based trimester-specific reference range (RR) for thyrotropin (TSH) in pregnancy. The aim of this study was to determine first trimester TSH RR for a population of pregnant women in Rio de Janeiro State. Subjects and methods: Two hundred and seventy pregnant women without thyroid illness, defined by National Academy of Clinical Biochemistry, and normal iodine status were included in this sectional study. This reference group (RG) had normal median urinary iodine concentration (UIC = 219 μg/L) and negative anti-thyroperoxidase antibodies (TPOAb). Twin pregnancy, trophoblastic disease and use of drugs or supplements that influence thyroid function were excluded. In a second step, we defined a more selective reference group (SRG, n = 170) by excluding patients with thyroiditis pattern on thyroid ultrasound and positive anti-thyroglobulin antibodies. This group also had normal median UIC. At a final step, a more selective reference group (MSRG, n = 130) was defined by excluding any pregnant women with UIC < 150 μg/L. Results: In the RG, median, 2.5th and 97.5th percentiles of TSH were 1.3, 0.1, and 4.4 mIU/L, respectively. The mean age was 270 ± 5.0 and the mean body mass index was 25.6 ± 5.2 kg/m2. In the SRG and MSRG, 2.5th and 975th percentiles were 0.06 and 4.0 (SRG) and 0.1 and 3.6 mIU/L (MSRG), respectively. Conclusions: In the population studied,TSH upper limit in the first trimester of pregnancy was above 2.5 mIU/L. The value of 3.6 mIU/L, found when iodine deficiency and thyroiditis (defined by antibodies and ultrasound characteristics) were excluded, matches recent ATA guidelines.

Objetivo : Avaliar se um programa de exercícios supervisionado melhora a qualidade de vida (QV) de pacientes com carcinoma diferenciado de tireoide (CDT) em tratamento de supressão de TSH com levotirotoxina (L-T4).Sujeitos e métodos : Inicialmente, foi feito um estudo cruzado para se comparar a QV e a qualidade de vida relacionada à saúde (QVRS) em pacientes com hipertireoidismo subclínico (HSC, n = 33) e indivíduos eutiroides (EU; n = 49). Na fase prospectiva do estudo, os pacientes com HSC foram randomizados de forma não cega para participar (HSC-Tr = pacientes treinados; n = 16) ou não (HSC-Sed = pacientes não treinados; n = 17) de um programa de exercícios supervisionado. O programa de exercícios consistiu de 60 minutos de atividade aeróbica e alongamento, duas vezes por semana, por 12 semanas. A qualidade de vida foi avaliada pelos questionários WHOQOL-Bref, e a QVRS pelo SF-36.Resultados : Os pacientes com HSC apresentaram escores estatisticamente mais baixos do que os EU no domínio “físico” do WHOQOL-Bref, além dos domínios “função física”, “papel físico”, “dor corporal”, “saúde geral”, “vitalidade”, “papel emocional” e “saúde mental” do SF-36. Após três meses, os pacientes HSC-Tr mostraram melhora nos domínios “físico” e “psicológico” do WHOQOL-Bref (p &lt; 0,05) e nos domínios “função física”, “papel físico”, “dor corporal”, “vitalidade” e “saúde mental” do SF-36.Conclusão : Os pacientes em terapia de supressão de TSH com L-T4 para CDT apresentaram QV e QVRS afetados negativamente quando comparados com sujeitos EU, mas essas avaliações melhoraram após três meses de um programa de exercícios. O exercício parece ter um papel importante no acompanhamento de pacientes com CDT, já que ele parece minimizar os efeitos do tratamento na QV e QVRS. Arq Bras Endocrinol Metab. 2014;58(3):274-81

Objective : To evaluate if a supervised exercise training program improves the quality of life (QoL) of differentiated thyroid carcinoma (DTC) patients on TSH-suppressive therapy with levothyroxine (L-T4).Subjects and methods : Initially, a cross-sectional study was performed to compare the QoL and the health-related quality of life (HRQoL) between subclinical hyperthyroidism (SCH) patients (n = 33) and euthyroid subjects (EU; n = 49). In the prospective phase of the study, SCH patients were randomized in a non-blinded fashion to either participate (SCH-Tr = trained patients; n = 16) or not (SCH-Sed = untrained patients; n = 17) in a supervised exercise training program. The exercise program consisted of 60 minutes of aerobic and stretching exercises, twice a week, during twelve weeks. The QoL was assessed by the application of the WHOQOL-Bref, and the SF-36 was used to assess the HRQoL.Results : SCH patients had statistically lower scores than EU on the “physical” domain of WHOQOL-Bref, besides “physical function”, “role-physical”, “bodily pain”, “general health”, “vitality”, “role-emotional”, and “mental-health” domains of SF-36. After three months, SCH-Tr patients showed improvement in the “physical” and “psychological” domains of WHOQOL-Bref (p < 0.05), and in the “physical function”, “role-physical”, “bodily pain”, “vitality” and “mental health” domains of SF-36.Conclusion : Patients on TSH-suppressive therapy with L-T4 for DTC had impaired QoL and HRQoL compared to EU, but it was improved after 3-months of an exercise training program. Exercise seems to play an important role in the follow-up of DTC patients, since it seems to minimize the adverse effects of the treatment on QoL and HRQoL. Arq Bras Endocrinol Metab. 2014;58(3):274-81

Doenças tiroidianas autoimunes (DTAI) são a maior causa de disfunção tiroidiana e são as doenças autoimunes mais comuns no mundo. A associação entre DTAI e infecções com o vírus da imunodeficiência humana (HIV), em combinação com a terapia antirretroviral altamente ativa (HAART), foi sugerida por vários grupos de pesquisadores. O objetivo do presente estudo foi avaliar a fre-quência de disfunção tiroidiana e DTAI em mulheres com mais 35 anos de idade infectadas com o HIV e identificar fatores associados com a emergência dessas anormalidades tiroidianas. As mulheres infectadas com HIV (n = 153), selecionadas do ambulatório de doenças infecciosas de um hospital universitário do Rio de Janeiro, foram caracterizadas com base no nível de linfócitos CD4+ circulantes, carga viral, níveis de TSH sérico e presença de anticorpos FT4 e antitiroperoxidase (TPO-Ab). Um total de 129 participantes se tratava com HAART e 24 não. A frequência de desordens da tiroide foi 7,8% (12/153 pacientes) e todas estavam em tratamento com HAART no momento do diagnóstico, levando a uma prevalência 9,3% em pacientes recebendo HAART, em comparação com 0% em pacientes não tratadas com HAART. DTAI, hipertireoidismo e hipotireoidismo foram detectados em 4,6%, 3,1% e 4,1% das pacientes tratadas com HAART. Não foram detectadas disfunção tiroidiana ou autoimunidade em mulheres infectadas com HIV e não tratadas com HAART. Este estudo demonstrou uma associação entre a HAART e o desenvolvimento de DTAI. Além disso, a DTAI apenas se desenvolveu em pacientes tratadas com HAART e que apresentavam cargas virais indetectáveis e contagens de células CD4+ T levemente elevadas.

Autoimmune thyroid diseases (AITD) are the main causes of thyroid dysfunction and the most common autoimmune diseases in the world. An association between AITD and infections with the human immunodeficiency virus (HIV), in combination with the effects of highly active anti-retroviral therapy (HAART), has been suggested by several research groups. The aim of the present study was to evaluate the frequency of thyroid dysfunction and AITD in women > 35 years of age infected with HIV, and to identify factors associated with the emergence of these thyroid abnormalities. HIV-infected women (n = 153) selected from the infectious disease outpatient clinic at a University Hospital in Rio de Janeiro were characterized based on their circulating CD4+ lymphocytes levels, viral loads, serum TSH levels, and the presence of FT4 and anti-thyroperoxidase antibodies (TPO-Ab). A total of 129 participants were on HAART and 24 were not. The frequency of thyroid disorders was 7.8% (12/153 patients) and all were on HAART at the time of diagnosis, yielding a prevalence of 9.3% in patients receiving HAART compared with 0% in patients not on HAART. AITD, hyper, and hypothyroidism were detected in 4.6%, 3.1%, and 4.1% of HAART patients. It was not detected any thyroid dysfunction or autoimmunity in HIV-infected women not on HAART. This study demonstrated an association between HAART and the development of AITD. In addition AITD only developed in HAART patients also presenting with undetectable viral loads and slightly elevated CD4+ T cell counts.

OBJETIVOS: Avaliar a prevalência de bócio e doença nodular tireoidiana em pacientes com obesidade grau III e correlacionar os resultados com os níveis de leptina e parâmetros de resistência à ação da insulina (RI). SUJEITOS E MÉTODOS: Estudo seccional foi desenvolvido realizando ultrassonografia (US) tireoidiana e níveis séricos de HOMA-IR e TSH nos pacientes obesos e nos controles. RESULTADOS: Volume tireoidiano foi positivamente correlacionado com índice de massa corporal (IMC) (r = 0,240, p = 0,039) e com HOMA (r = 0,329; p < 0,01). Volume tireoidiano e prevalência de doença nodular tireoidiana foram similares entre os grupos. Quando avaliado o subgrupo masculino, maiores volumes tireoidianos foram detectados no grupo dos obesos comparados aos controles (10,8 vs. 8,5 cm³; p = 0,04), nódulos foram mais frequentes (67% vs. 18%), assim como nódulos com indicação de punção (33,3% vs. 0%, p ≥ 0,05-0,09). CONCLUSÃO: Embora RI não se correlacione diretamente com a presença de nódulos, os resultados suportam a hipótese da direta associação entre resistência à ação da insulina e volume tireoidiano.

OBJECTIVES: To evaluate the prevalence of goiter and nodular disease in patients with class III obesity, and to correlate results with serum leptin levels and insulin resistance (IR) parameters. SUBJECTS AND METHODS: A cross-sectional study was performed to assess thyroid ultrasound (US) patterns, HOMA-IR, serum leptin, and TSH levels in obese patients and controls. RESULTS: Thyroid volume was positively correlated with body mass index (BMI) (r = 0.240, p = 0.039) and with HOMA-IR (r = 0.329; p < 0.01). Thyroid US patterns were similar between groups. However, when data from the male group was considered, greater thyroid volume was detected in the obese group compared with controls (10.8 vs. 8.5 cm³; p = 0.04). Also, nodules were more frequently detected (67% vs. 18%), as were nodules requiring FNAB (33.3% vs. 0%, p ≥ 0.05-0.09), in this group. CONCLUSION: Although IR did not correlate directly with the presence of nodules, the results support the hypothesis of a direct association between insulin resistance and thyroid volume.

OBJETIVOS: Avaliar o impacto do tratamento do hipotireoidismo subclínico (sHT) na qualidade de vida relacionada à saúde (QoL), aos sintomas psiquiátricos, ao escore clínico e à função muscular. MATERIAIS E MÉTODOS: Em um ensaio randomizado duplo-cego, pacientes foram randomizados para tratamento (n = 35) ou uso de placebo (n = 36). Sintomas clínicos e psiquiátricos foram acessados por meio das escalas de Zulewski, Hamilton e Beck. A QoL foi avaliada pelo questionário SF-36. Medidas da força de quadríceps (QS) e inspiratória (IS) foram obtidas por um dinamômetro de cadeira e um manovacuômetro. RESULTADOS: O tratamento melhorou a IS (+11,5 ± 17,2; p = 0,041), assim como os domínios "Dor" e "Aspectos Físicos" da QoL (+19,7 ± 15,2, 0,039 e +22,1 ± 47,5, p = 0,054, respectivamente). Sintomas clínicos e psiquiátricos demonstraram respostas similares a ambas as formas de intervenção. CONCLUSÕES: Tratamento do sHT melhorou IS e aspectos físicos da QoL, apesar de não ter impacto em outros parâmetros musculares. Escore clínico, sintomas psiquiátricos e domínios do SF-36 que focam em dimensões mentais podem ser mais suscetíveis ao "efeito placebo" em pacientes com sHT.

OBJECTIVES: To evaluate the impact of subclinical hypothyroidism (sHT) treatment on health-related quality of life (QoL), psychiatric symptoms, clinical score, and muscle function. MATERIALS AND METHODS: In this randomized double-blind study, patients were assigned either to treatment (n = 35) or placebo (n = 36). Clinical and psychiatric symptoms were assessed by the Zulewski, Hamilton and Beck scales. QoL was assessed by the SF-36 questionnaire. Assessments of quadriceps (QS) and inspiratory muscle (IS) strength were performed by a chair dynamometer and a manuvacuometer. RESULTS: Treatment improved IS (+11.5 ± 17.2; p = 0.041), as did QoL domains "Pain" and "Role Physical" (+19.7 ± 15.2, 0.039 and +22.1 ± 47.5, p = 0.054; respectively). Clinical and psychiatric symptoms showed similar responses to both interventions. CONCLUSIONS: sHT treatment improved IS and physical aspects of QoL, despite no impact in other muscle parameters. Clinical score, psychiatric symptoms, and SF-36 domains, based on mental dimensions of QoL may be more susceptible to "placebo effect" in patients with sHT.

OBJETIVO: Avaliar os efeitos da reposição de levotiroxina (L-T4) nos parâmetros ecocardiográficos em mulheres de meia-idade com hipotireoidismo subclínico (HS). SUJEITOS E MÉTODOS: Realizado estudo duplo-cego, controlado com placebo com avaliação dos parâmetros ecocardiográficos no início e um ano após o restabelecimento do eutireoidismo. Trinta e três mulheres foram incluídas em dois grupos (uso de L-T4 ou placebo). RESULTADOS: Os dois grupos tinham características basais similares. Houve uma significativa piora do índice TEI do ventrículo esquerdo no grupo que usou placebo por um ano. Já no grupo em reposição com L-T4 observou-se uma leve melhora desse índice (+0,086 ± 0,092 vs. -0,014 ± 0,012; p = 0,047). Ocorreu também uma leve redução no débito cardíaco e no índice cardíaco com placebo, os quais não diferiram do efeito da reposição de L-T4. CONCLUSÃO: Os resultados sugerem um impacto positivo com a reposição de L-T4, na função cardíaca de mulheres de meia-idade, com HS.

OBJECTIVE: To evaluate the effects of levothyroxine (L-T4) replacement in echocardiographic parameters of middle-aged women with subclinical hypothyroidism (SH). SUBJECTS AND METHODS: This was a randomized, double-blind, placebo-controlled study. Echocardiographic evaluation was carried out at baseline and one year after restoration of euthyroidism. Thirty-three women with SH were assigned to one of two groups (L-T4 or placebo). RESULTS: The two groups had similar basal characteristics. There was a significant deterioration of left ventricular Tei index after one year of placebo use, which differed from the effect of L-T4 replacement (+0.086 ± 0.092 vs. -0.014 ± 0.012; p = 0.047). There was also a slight reduction in cardiac output and cardiac index with placebo use, which was not different from L-T4 effect. CONCLUSION: Results suggest a positive impact of L-T4 replacement in cardiac function of middle-aged women with SH.

OBJETIVO: Avaliar a capacidade funcional e hemodinâmica em esforço e durante a recuperação em pacientes com hipertireoidismo subclínico (SCH). SUJEITOS E MÉTODOS: Foi realizado um estudo seccional em que participaram 29 pacientes em terapia supressiva de TSH com levotiroxina para carcinoma diferenciado de tireoide e 35 indivíduos sem doença tireoidiana. Todos foram submetidos a um teste cardiopulmonar de esforço em esteira, no qual foram medidas variáveis funcionais e hemodinâmicas durante o exercício e a recuperação. RESULTADOS: Os pacientes apresentaram um comprometimento na capacidade funcional, evidenciado por menores valores de consumo de oxigênio e duração de exercício, além do alcance prematuro do limiar anaeróbio. Imediatamente após o exercício, os pacientes apresentaram uma curva mais lenta de recuperação da frequência cardíaca e da pressão arterial. CONCLUSÃO: O SCH está associado ao comprometimento na capacidade funcional e hemodinâmica em esforço e na recuperação.

OBJECTIVE: To evaluate the functional and hemodynamic responses during exercise and its recovery in patients with subclinical hyperthyroidism (SCH). SUBJECTS AND METHODS: A cross-sectional study was carried out with 29 patients on TSH-suppressive therapy with levothyroxine for thyroid carcinoma and 35 euthyroid subjects. All volunteers underwent a cardiopulmonary exercise testing on a treadmill and functional and hemodynamic variables were measured during exercise and its recovery. RESULTS: SCH patients showed impaired functional response to exercise, marked by lower values for oxygen consumption and exercise duration in addition to premature achievement of the anaerobic threshold. Heart-rate and blood pressure recovery immediately after exercise were slower among SCH patients when compared to euthyroid subjects. CONCLUSION: SCH is associated with impaired functional and hemodynamic responses during exercise and its recovery.

Relata-se que a disfunção tireoidiana induzida pela amiodarona afeta de 2 a 24% dos usuários. Embora seja fácil tratar o hipotireoidismo induzido pela amiodarona, o desenvolvimento da tireotoxicose leva a uma abordagem difícil na maioria dos casos. O objetivo deste estudo é descrever três casos diferentes de pacientes com tireotoxicose induzida por amiodarona e discutir os aspectos clínicos e laboratoriais, e as diferentes abordagens para esses casos. É essencial avaliar cuidadosamente os pacientes antes e durante o tratamento com amiodarona, tendo em vista que o diagnóstico e o tratamento imediato dessa condição são cruciais em pacientes com alto risco cardiovascular.

Amiodarone-induced thyroid dysfunction has been reported to affect 2-24% of users. Despite the easy management of amiodarone-induced hypothyroidism, the development of thyrotoxicosis leads to a difficult approach in most cases. The aim of this study is to describe three different cases of patients with amiodarone-induced thyrotoxicosis and discuss the clinical and laboratorial aspects, and the different approaches to them. It is essential to carefully evaluate patients before and during amiodarone therapy, since the prompt diagnosis and treatment of this condition is essential in patients with high cardiovascular risk.

Se relata que la disfunción tiroidea inducida por la amiodarona afecta de 2 a 24% de los usuarios. Aunque sea fácil tratar el hipotiroidismo inducido por la amiodarona, el desarrollo de la tirotoxicosis lleva a un abordaje difícil en la mayoría de los casos. El objetivo de este estudio es describir tres casos diferentes de pacientes con tirotoxicosis inducida por amiodarona y discutir los aspectos clínicos y de laboratorio, y los diferentes abordajes para esos casos. Es esencial evaluar cuidadosamente los pacientes antes y durante el tratamiento con amiodarona, teniendo en vista que el diagnóstico y el tratamiento inmediato de esa condición son cruciales en pacientes con alto riesgo cardiovascular.

OBJETIVO: Analisar e correlacionar características clínicas, sintomas psiquiátricos e dados laboratoriais no hipotireoidismo subclínico (HS). MÉTODOS: Estudo transversal comparando achados de 103 pacientes com HS aos de 60 indivíduos eutireoidianos. A avaliação clínica e a psiquiátrica foram baseadas, respectivamente, na escala de Zulewski e nos questionários de Hamilton A, Hamilton D e Beck. Todos foram submetidos a dosagens de tireotropina (TSH), T4 livre e antitireoperoxidase (ATPO). Variáveis contínuas foram analisadas por meio do teste t de Student, quando de distribuição normal, e dos testes de Mann-Whitney e Kruskal Wallis, quando "não normais". Variáveis categóricas por meio dos testes Qui-quadrado, exato de Fisher e Kruskal Wallis. Análise multivariada foi utilizada para estudo de variáveis de confundimento. RESULTADOS: O nível médio de TSH, no HS, foi 7,76 ± 2,9 µUI/mL e 1,66 ± 0,6 µUI/mL nos eutireoideanos (p=0,001). O nível de T4L foi menor no HS, apresentando correlação linear negativa com TSH. Ocorreu maior freqüência de escore clínico anormal (48,3 vs 67%; p=0,020), de sintomas de depressão, pela escala de Beck no HS (20,5 vs 44,2%; p=0,011) e de sintomas de ansiedade (86 vs 63,4%; p=0,004) no HS. A presença de sintomas de depressão e ansiedade associou-se de forma positiva com pontuação no escore clínico e níveis de TSH. Não houve associação entre achados clínicos ou psiquiátricos e etiologia do HS, presença de ATPO, idade ou menopausa. CONCLUSÃO: O estudo aponta para associação entre HS, achados clínicos e sintomas psiquiátricos. Ensaios clínicos são necessários para avaliar uma possível melhora com levotiroxina.

BACKGROUND: This investigation evaluated and correlated clinical, laboratorial aspects and psychiatric symptoms in sub clinical hypothyroidism (SH). METHODS: Cross sectional study involving 103 patients with SH and 60 subjects without thyroid disease. Clinical and psychiatric evaluation was respectively based on the Zulewski score and Hamilton A, Hamilton D and Beck questionnaires. Serum thyreotropin (TSH), (thyroxine) FT4 and (antithyroperoxidase) ATPO were measured in all participants. Analysis of continuums data was assessed by the Student t- test, for normally distributed data, and by the Mann- Whitney and Kruskal Wallis tests for non-parametric data. The chi2, Fisher's and Kruskal Wallis tests were used to study qualitative variables. Multivariate analyses were used to study confounding variables. RESULTS: Mean serum TSH level was 7.76 ± 2.9 µUI/mL in SH and 1.66 ± 0.6 µUI/mL in the group without thyroid disease (p=0.001). Mean serum T4L was slightly lower among patients with HS, and showed a negative linear correlation with TSH. Higher frequencies of abnormal clinical score (48.3 vs. 67.0%; p=0.02), depression self reported symptoms (20.5 vs. 44.2%; p=0.011) and anxiety symptoms (86.0 vs. 63.4%; p=0.004) occurred more frequently in SH. Frequency of psychiatric symptoms had a positive correlation with the clinical score and serum TSH. There was no association between the clinical and psychiatric findings and the etiology of SH, presence of ATPO, age or menopause. CONCLUSIONS: The study showed that SH was associated with clinical findings and with psychiatric symptoms. Clinical trials are required to evaluate possible improvement with levotiroxine.