The Natural Thyroid Diet

The Natural Thyroid Diet

The Natural Thyroid Diet is a guide written to show people suffering from thyroid how to treat it the most natural and effective way. The guide was put together to be something that can be done at home without a need to visit an expert as regards its use. This program is a proven home method useful in eliminating Thyroid rapidly and permanently. It is a combination of useful diets system to help you permanently get rid of your thyroid within 4 weeks. The foods have been tested and have been proven to solve this problem for you. The book is a quick fix that has been designed to help you get a cure for your Thyroid in 4 Weeks. The methods employed in this book are natural ones that have been proven by many specialists. The book is in a digital format (PDF) and has been created at a very affordable price. There are a lot of stress, frustrations and disappointments that come with trying programs after programs. This is one thing that happens in the name of fighting Thyroid; however, this program has been designed to help you stop worrying about programs after programs. The creator is assured of its work that you are allowed to ask for a refund if nothing happens after 4 weeks of its usage. Read more here...

The Natural Thyroid Diet Summary

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Iatrogenic Hypoparathyroidism

She had just undergone a total thyroidectomy for papillary thyroid cancer. The nerve was damaged during thyroid surgery while suturing the blood vessels of the inferior pole of the thyroid. There are two recurrent laryngeal nerves (also called inferior laryngeal), both of which are branches of the vagus nerve they are called recurrent because they loop around the subclavian artery on the right and the aortic arch on the left before asccnding in the tracheoesophageal groove in closc proximity to the thyroid gland to end up in the larynx. If the left recurrent laryngeal nerve is involved, one should consider mass lesions such as enlarged lymph nodes in the aorticopulmonary window.

Thyroid Function Tests

Anterior lobe of the pituitary gland. TSH stimulates the thyroid to produce and secrete the thyroid hormones thyroxine, triiodothyronine, and calcitonin. Assessment of thyroid function can be accomplished by measuring serum thyroid hormone levels and TSH levels. Clinical implications of increases or decreases of these substances are discussed individually. Thyroxine (T4) is the most abundant thyroid hormone secreted by thyroid follicular cells. Thyroxine increases the body's metabolic rate, sensitizes the cardiovascular system in order to increase cardiac output, stimulates cellular differentiation, affects the maturation of the skeletal and central nervous systems, and is involved in other physiological processes. Measuring thyroxine levels provides a reliable test of thyroid function, assists in ruling out hypothyroidism and hyperthyroidism, and is useful in the evaluation of thyroid hormone replacement therapy. Variations from Normal. Increased thyroxine levels are associated with...

Thyroid Stimulating hormone TSH

Thyroid stimulating hormone (TSH) is secreted by the anterior lobe of the pituitary gland and, as the name implies, stimulates the thyroid gland to produce and secrete thyroxine (T4) and triiodothyronine (T3). Measuring TSH levels is the most sensitive test for identifying and differentiating primary and secondary hypothyroidism. Primary hypothyroidism is a result of thyroid gland malfunction or disease. In secondary hypothyroidism, the thyroid gland is unable to secrete adequate levels of T3 and T4 due to the failure of the pituitary gland or hypothalamus to secrete appropriate amounts of thyroid-related hormones. Variations from Normal. Increased TSH levels are indicative of primary hypothyroidism, thyroiditis, and lack of thyroid growth or development. Decreased TSH levels are associated with secondary hypothyroidism, hyperthyroidism, and pituitary dysfunction.

Euthyroid sick syndrome

The assessment of thyroid function is difficult in the seriously ill patient. This is because a variety of abnormalities of thyroid function tests may be found which seemingly reflect hypothyroidism, even in the absence of intrinsic thyroid disease. This state has thus been referred to as the euthyroid sick syndrome, and it may reflect the neuroendocrine effects of cytokines. It can occur very early in the course of serious illness, especially sepsis. Many aspects of serious illness affect thyroid function tests, including notably dopamine, which decreases all thyroid function indices In the euthyroid sick syndrome, abnormalities of most thyroid function tests are found. The clinical significance of these abnormalities of thyroid function tests is uncertain. While the low T3 may be homeostatic and thus possibly beneficial, a low T4 is associated with an increased mortality, though it is presumably only a marker as replacement therapy does not improve survival. In general, the normal...

The Thyroid Parathyroid System for Calcium Regulation

3) calcitonin secreted by the thyroid and with no relationship whatsoever with the hypothalamic-adenohypophyseal system. Figure 2.68 sumarizes calcium regulation mechanisms. Vitamin D, supplied by the daily diet, is essential for DHC production in the liver and kidneys. In the intestine, an increase of DHC stimulates absortion of calcium (second row inset) and, thus, an increase in its blood level (far right inset, lines b). DHC and PTH cause calcium resorption (release) from bone, thus, the curves relating it to DHC and PTH increase with an increase in calcium liberation (third row, center inset) and that calcium from bone contributes to an increase in blood calcium that is represented by the input termed c in the figure. In turn, blood calcium (dashed-dotted arrows) acts as input to the thyroid and parathyroid gland, the latter decreasing its PTH production when blood calcium level increase (hence, the inverse relationship shown in the third row, left hand inset) while the former...

Hyperthermia s ee Pyrexia Hyperthyroidism

Graves' disease refers to autoimmune thyroid disease characterized by diffuse toxic goitre and caused by the production of antibodies to TSH receptors (and thus loss of endogenous TSH control). Other associated features of an autoimmune nature may sometimes be seen, particularly including ophthalmopathy and pretibial myxoedema.

BDiseases Involving the Parathyroid Glands

Calcitonin apparently performs as a sort of fine control of the blood's calcium level. Its action is essentially the reverse of parathormone. Calcitonin causes the body to build more bone-thus decreasing the serum calcium level. Calcitonin is produced by both parathyroid and thyroid glands.

The Natural Thyroid Hormones

Two hormones are responsible for the major functions of the thyroid. These hormones are thyroxine (T4) and triiodothyronine (T3). The notation T4 reflects that the thyroxine nucleus has four iodine atoms attached to it. The notation T3 means that three iodine atoms are attached to the thyroxine nucleus. Approximately, 10 times as much T4 is secreted from the thyroid than T3. As the T4 circulates, some of it has iodine removed from the molecule. Hence, in terms of availability to body tissues, only about three times as much T4 is available than T3. Basically, because of differences in serum concentration and activity, the effects produced by these two hormones are identical for practical purposes. In order for these hormones to be synthesized in the body, sources of iodine must be present. When sufficient iodine is lacking in the diet, endemic goiters (enlarged thyroid) result. Such enlargement is due to hypersecretion of thyroid stimulating hormone (TSH) in an attempt by the body to...

Resistance to Thyroid Hormone RTH and Hypothyroidism

RTH patients display insensitivity to thyroid hormone regulation of serum levels of TSH. RTH usually occurs as an inherited disorder that segregates as a single dominant allele. The patient population has been subdivided into two groups those displaying resistance at the level of the pituitary, resulting from a loss of appropriate regulation of TSH by thyroid hormone (PRTH) and those that are more generally thyroid-hormone resistant (GRTH). In most cases, the allele underlying RTH corresponds to a dominant negative mutation in the thyroid-hormone receptor (174). Multiple mutations have been identified. To model PRTH, two different groups have developed transgenic mice that express mutant forms of the thyroid-hormone receptor exclusively in the pituitary. In one case, Refetoff and colleagues used the 1-kb TSHp promoter to direct expression of the G345R mutant of TR 1, which has been identified in humans with severe RTH (88). This transgene was mostly expressed in the pituitary,...

Congenital Hypothyroidism

Congenital hypothyroidism results from a deficiency of thyroid hormone. Risk Factors Etiology. Congenital hypothyroidism occurs in about 1 4000 births. The majority of cases occur because of thyroid dysgenesis. This is either caused by complete absence of or ectopic thyroid tissue. Congenital hypothyroidism is twice as common in females. Diagnostic Tests. Serum levels of T4 are low, whereas thyrotropin (TSH) levels are elevated. Newborn screening tests detect most cases of congenital hypothyroidism. Retardation of osseous development can be shown on radiographs. Thyroid scans with technetium or radiolabeled iodine detect absence of or ectopic thyroid tissue. Treatment. Replacement of thyroid hormone with thyroxine is the therapy. Thyroxine should v' nr J ' ' not be mixed with soy formula or iron.

Acquired Hypothyroidism

Thyroiditis is the most common cause of acquired hypothyroidism. Down, Turner, and Klinefelter syndromes carry a higher risk for autoimmune thyroid disease. Irradiation and ingestion of iodides can also lead to hypothyroidism. Presentation. Growth deceleration is usually the first sign, but may be subtle. Patients also develop constipation, cold intolerance, and decreased energy. Schoolwork and grades do not suffer. Osseous maturation is delayed. In lymphocytic thyroiditis, growth retardation and goiter are the first signs.

Hyperthyroidismgraves Disease

Hyperthyroidism results from overproduction of thyroid hormone. Presentation. Symptoms develop over 6-12 months. Patients may have emotional disturbances, motor hyperactivity, emotional lability, and deterioration in school performance. Tremors of the fingers may be noticed on extension of the arms. Voracious appetite without weight gain may be described. Exophthalmos results from binding of antibodies to extraocular muscles, producing a cytotoxic effect. Sweating and flushing are common. Tachycardia and palpitations are cardiac manifestations. Thyroid storm is a severe presentation, which can lead to death, but is rare in children. Diagnostic Tests. T4, free T4, T3, and free T3 are elevated, whereas TSH levels are low. Thyroid receptor stimulating antibodies are often present.

Thyroid Ultrasonography

Thyroid ultrasonography is an ultrasound examination of the thyroid gland that is performed to evaluate the size, structure, and position of the thyroid gland and to detect thyroid abnormalities. During the thyroid ultrasonography, the individual is placed in a supine position with the neck hyperex-tended. Once the conductive gel is applied to the neck, the transducer is moved in small increments over the area of the thyroid gland. Images are projected on a screen, recorded, and photographed. Normal Findings. The thyroid gland is normal in size and structure. Variations from Normal. Thyroid ultrasonography can reveal abnormalities such as nodules, goiters, tumors, cysts, adenoma, or carcinoma. Interfering Circumstances. A circumstance that can interfere with thyroid ultrasonography is the inability of the patient to cooperate during the procedure.

Interaction between the thyroid hormone receptor and the retinoic acid receptor

The thyroid hormone receptors (TR) are encoded by two different genes, giving rise to subtypes a and p. Thyroid hormone response elements (TRE) are typically composed of two or more sequences of a consensus AGGTCA half-site arranged as an inverted repeat (palindrome), everted repeat or direct repeat (Ribeiro et al., 1995), thereby allowing a great flexibility in half-site arrangement and orientation. Palindromic TREs are responsive to both thyroid hormone (tri-iodothyronine) and retinoic acid. The two hormones interact co-operatively to stimulate transcription of the growth hormone gene in the rat pituitary gland (Bedo et al, 1989 Morita et al., 1989, 1990). The presence or absence of thyroid hormone dictates how these dual-responsive elements are regulated. In the presence of thyroid hormone, TRs activate the TRE and also allow some degree of positive co-operativity with RARs. In the absence of thyroid hormone, the unliganded TR functions as a repressor, preventing either TR and RAR...

Relationship of RLN with Inferior Thyroid Artery

The recurrent laryngeal nerve's intimate course with the inferior thyroid artery has long been the subject of anatomists endeavors in an effort to simplify the surgical approach and technique. Unfortunately, the course of the RLN as it relates to the inferior thyroid artery does not lend itself to broad and safe generalizations. Historically, the left RLN is described coursing deep to the inferior thyroid artery (ITA) in the majority of cases, and the right RLN passing deep to, superficial to, or between branches of the ITA in approximately equal proportions 1 . There is clear variability in these findings among investigators, and all variations have been documented on both sides including a spiraloid relationship of the artery around the nerve encountered by Ardito et al. 29 . Most

De Quervains Thyroiditis

PE anxious Eye exam reveals bilateral exophthalmos, lid lag, stare (due to lid retraction), and convergence weakness smooth, nontender diffuse goitre bruit over thyroid no cervical lymphadenopathy fine tremor of fingers of outstretched hands onycholysis and palmar erythema ( THYROID ACROPACHY) nontender purplish edematous plaques on shin ( PRETIBIAL MYXEDEMA). CBC normocytic, normochromic anemia. Elevated T4 and T3 levels TSH levels undetectable elevated thyroid-stimulating immunoglobulin (TSI) (TSH receptor antibody that stimulates thyroid hormone production). Radioactive iodine or thionamides (methimazole and propylthiouracil) are treatment of choice radioactive iodine cannot be used in pregnancy subtotal thyroidectomy required in selected cases beta-blockers such as propranolol

Hypothyroidism

Estimated to occur in 40 of such patients. Psychiatric symptoms typically begin with mental slowing, followed by a decline in short-term memory, progressive dysphoria, affective lability and emotional withdrawal. Symptoms such as insomnia, decreased self-esteem and worthlessness are reported to be more common in major depressive disorder 95 . When compared to individuals with normal thyroid function, patients with subclinical hypothy-roidism have been found in one study to have a significantly higher frequency of lifetime depression, suggesting that subclinical hypothyroidism may lower the threshold for the occurrence of depression 106 . Since most depressives are not hypothyroid, there is no necessity for a routine checking of thyroid function, unless they are under lithium prophylactic treatment. Thyroid screening should be obtained in patients with treatment refractory depression, as hypothyroidism may contribute to this condition 107 . The relationship of thyroid function and...

Hyperparathyroidism

Intracellular part via transmembrane elements characteristic of the G protein-coupled receptor superfamily. A similar receptor is also present on the thyroid C cells, where it controls calcitonin secretion, in the kidney, where it controls calcium and phosphorus exchange, and in the central nervous system, where its role is presently uncertain.

The Thyroid Gland

The thyroid gland is located in the neck just below the larynx (voice box). The thyroid gland secretes the hormone thyroxin. a. Background. Thyroxin is synthesized within the thyroid gland by the combination of several amino acids with four atoms of iodine. Once made, the hormone is stored in the thyroid gland in combination with a protein. This protein-hormone complex is called thyroglobulin. The hormone is released into the blood by breaking the bonds between thyroxin and the protein. The thyroxin is then released into the bloodstream. The release of the hormone is stimulated by the thyroid-stimulating hormone from the anterior pituitary gland. c. Diseases Involving the Thyroid Gland. There are several diseases involving the thyroid gland. (1) Goiter. Goiter is an abnormal enlargement of the thyroid gland producing a distinct swelling at the base of the neck just below the larynx (Adam's Apple). Simple goiters result from a dietary lack of iodine. This occurs most commonly in areas...

Thyroid Scans

There are several nuclear medicine thyroid studies, four of which are presented in this chapter. These scans are the general thyroid scan, iodine-131 scan, radioactive iodine uptake (RAIU) test, and thyroid stimulating hormone (TSH) study. Each scan is presented individually, although all have the same basic goal to assess the function and health of the thyroid gland. Thyroid Scan A thyroid scan is a radionuclide study of the thyroid gland. It is used to evaluate the size, position, shape, and function of the thyroid gland. The patient must remain in the supine position, with the neck well exposed so that the scanner can be passed over the area of the thyroid. Thyroid scanning assists in the identifications and evaluation of masses in the thyroid gland and other areas of the neck, as well as abnormalities associated with hyperthyroidism or hypothyroidism. Thyroid scans are particularly useful in evaluating thyroid nodules. Pregnant women are not candidates for radionuclide thyroid...

Thyroid Preparations

You will see a variety of thyroid preparations in the pharmacy. Some of the medications you may dispense are discussed below. a. Thyroid, USP. Thyroid, USP, is prepared from the thyroid glands of domesticated animals. Once the thyroid gland is obtained from the slaughtered animal, the gland is cleaned, dried, and powdered. Thyroid, USP, contains both the T3 and T4 hormone. This preparation is used in the treatment of hypo-thyroidism. The dosage of this product must be tailored to meet the needs of the individual patient. Side effects associated with this agent include changes in appetite, chest pain, diarrhea, and hand tremors. b. Levothyroxine (Synthroid ). Levothyroxine is a synthetic source of the T4 hormone. Once taken, approximately 30 percent of the levothyroxine is converted to the T3 hormone. Levothyroxine is used in the treatment of hypothyroidism. Like Thyroid, USP, the dosage of levothyroxine must be individualized to meet the patient's needs. The usual dosage prescribed is...

Parathyroid Scan

A parathyroid scan is a radionuclide scan of the parathyroid gland performed to assess the size, position, function, and location of parathyroid glands or tissue. This scan helps identify parathyroid adenomas and locate unusually placed parathyroid glands or tissue prior to surgery. The function of both the parathyroid and thyroid gland can be evaluated by measuring the radionuclide absorption of each of these glands. The patient is prepared for the parathyroid scan in the same manner as the thyroid scan. The parathyroid scan involves individual intravenous administration of two distinct radionuclides one that targets the parathyroid gland and another for the thyroid gland. Each injection of a radionuclide is followed by a scan of the neck and mediastinum. If each gland absorbs the appropriate radionuclide, both thyroid and parathyroid gland functioning is normal. Pregnancy is the contraindication for this scan, unless testing is essential to maternal welfare. Normal Findings. Normal...

Multiple Pulmonary Nodules

Characteristically, miliary nodules are less than 4 mm in size. They are generally noncalcified and diffuse and are seen in many conditions, such as TB fungal infections pneumoconiosis and certain malignancies such as melanomas thyroid cancer. Larger, more confluent lesions can be seen in alveolar sarcoid, Wegener's granulomatosis, and metastatic disease. The clinical hints that aid diagnosis include 8-9. The answers are 8-b, 9-d. This elderly patient has all the stigmata of chronic illness. Although the PPD skin test and sputum studies are negative (seen in about 30 of cases), the history and CXR are consistent with miliary TB. Hyponatremia and hypercalcemia are common findings in TB. In this age group sarcoidosis is unlikely. In the absence of occupational exposure, silicosis is also unlikely. Bone marrow aspirate may be positive for TB culture in 60 of patients with miliary TB, and aspiration is a logical step in the diagnostic evaluation. CT scan will not aid further in the...

Postnatal Depressive Disorders

These disorders present in three forms. The first is a transient anxiety-depressive state known as postpartum blues that occurs a few days after delivery, peaks within 10 days and subsides usually within 3 weeks after delivery. About half of the mothers experience the blues in various degrees 4,10, 79 . The symptoms are mild, not necessitating medical attention. Characteristic symptoms include mild depressive mood, crying, fatigue. The second form occurs in almost 10-15 of mothers 80 , as a rule within the first month after delivery. The symptoms do not essentially differ from the moderate and severe non-psychotic DE MD. They have a disrupting and long-term effect on the personal and family life of the mother. The third, known as post-partum depression with psychotic features, occurs in about one out of 1000 mothers. In this form of postnatal depression, the first month after delivery is characterized, in addition to DE MD symptomatology, by psychotic features among which are...

Ventricular Septal Defect

HPI The patient has spastic contracture of the feet and wrists in outward rotation and flexion, with her fingertips touching each other (carpopedal spasm). She had just had a total thyroidectomy. Resected thyroid tissue shows anaplastic carcinoma with incipient invasion into trachea (a small square of anterior wall was resected) on careful examination, all four parathyroid glands found to be deeply adherent to the thyroid no evidence of nerve tissue (laryngeal nerve). The glands may be found anywhere from the superior mediastinum to the carotid bifurcation but are usually located on the posterior aspect and in close proximity to or embedded in the thyroid gland. Usually there are two superior and two inferior glands, but supernumerary and absent glands are not uncommon.

Orexigenic Gut Peptides Ghrelin

Variations, being high at night and declining in the early hours of the morning along with leptin levels. The postprandial decline of ghrelin is proportional to calorie intake and nutrient sensing but not stomach volume load. In keeping with this, glucose, but not water saline, infusion into the stomach caused suppression of ghrelin (105). However, no changes in ghrelin level were observed without normal gastric emptying, which suggests a requirement for a postgastric factor. The effect of glucose on ghrelin is independent of insulin actions. Further studies in humans showed that carbohydrate, and to a lesser extent fat, reduces, whereas protein appears to stimulate, ghrelin levels in normal (106) and type 1 diabetic patients (107). However, the micronutrient content and calorie load can not wholly explain the postprandial suppression of ghrelin other factors might be involved. Whereas leptin, GHRH, testosterone, thyroid hormone, and para-sympathetic activity upregulate ghrelin,...

Molecular Mechanism Of Action Of Ra

RA functions by binding to ligand-inducible transcription factors (nuclear receptor proteins belonging to the steroid thyroid hormone receptor super-family) that activate or repress the transcription of downstream target genes (for review see Chambon, 1996 Soprano and Soprano, 2003). Six nuclear receptors (termed RARa, RARb, RARg, RXRa, RXRb, and RXRg), encoded by distinct genes, have been demonstrated to mediate the actions of RA. The natural metabolites all-trans RA (atRA) and 9-cis RA are high-affinity ligands for RARs, whereas 9-cis RA, phytanic acid, docosahexanoic acid, and unsaturated fatty acids, have been suggested to bind RXRs.

Cancer Treatment and Research

Kirsch, Matthias Black, Peter McL. (ed.) Angiogenesis in Brain Tumors. 2003. ISBN 1-4020-7704-1. Keller, E.T., Chung, L.W.K. (eds) The Biology of Skeletal Metastases. 2004. ISBN 1-4020-7749-1. Kumar, Rakesh (ed.) Molecular Targeting and Signal Transduction. 2004. ISBN 1-4020-7822-6. Verweij, J., Pinedo, H.M. (eds) Targeting Treatment of Soft Tissue Sarcomas. 2004. ISBN 1-4020-7808-0. Finn, W.G., Peterson, L.C. (eds.) Hematopathology in Oncology. 2004. ISBN 1-4020-7919-2. Farid, N. (ed) Molecular Basis of Thyroid Cancer. 2004. ISBN 1-4020-8106-5. Khleif, S. (ed) Tumor Immunology and Cancer Vaccines. 2004. ISBN 1-4020-8119-7.

Hormones and cell signalling General principles

There are three general classes of hormones (1) peptide hormones, e.g. thyroid-stimulating hormone and adrenocorticotropic hormone (2) steroid hormones, e.g. oestrogens, testosterone and cortisol and (3) derivatives of the amino acid tyrosine, e.g. thyroxine and adrenaline (epinephrine). Peptide and amine hormones are stored in secretory vesicles until needed. Steroid hormones are not stored they are synthesized from intracellular stores of cholesteryl esters after a stimulus.

The Identification of Diagnostic Subtypes of Depressive Disorders

In our department we conducted studies involving 217 inpatients with DD occurring after a significant loss. These studies revealed several psychobi-ological changes in neuroendocrine and immune systems hypothalamic-pituitary axis (HPA) activation, increase of plasma concentration of beta-endorphin, reduction of thyroid secretion and significantly increased levels of thyrotropic hormone decreased levels of insulin an imbalance of cellular and humoral immunity. These changes were observed in patients with depressive disturbances of various degrees of severity 73.7 of the cases did not meet the criteria for a depressive adaptive reaction according to duration and severity. In 120 inpatients (females) having experienced the loss of a parent (21.7 ), a spouse (42.5 ) or a child (35.8 ), the criteria were fulfilled for DE in 33.3 of cases, for bereavement in 35.0 of cases, and for subsyndromal depression with unstable neurovegetative symptoms in 31.7 of cases. In 40 of patients dysthymia...

Cervical Segmentof SLN

The internal branch of the SLN is predominantly a sensory nerve, though there may be a small degree of motor input 15-17 . After dividing from the SLN trunk, the internal branch of SLN runs parallel and medial to the superior laryngeal artery 15 . As it passes the greater cornu of the hyoid it turns medially, passing deep to thyrohyoid muscle 10,15 . The inSLN then enters the larynx through the thyrohyoid membrane just superior to the superior border of the inferior pharyngeal constrictor muscle 10 . Prior to entering the larynx, this branch runs deep or superior to the superior laryngeal artery which ramifies from the superior thyroid artery 10, 13 . After entrance into the larynx, the inSLN branches into three main divisions superior middle and inferior. Sanders and Mu 16 studied the course of these branches using the Sihler neurospecific staining technique to demonstrate the fine terminal branches of the nerves which are often too delicate for anatomical dissection 18 ....

Internal Branch of SLN

Ter the external branch separates from the main trunk of SLN, in the region of the greater cornu of the hyoid bone, it courses posterior to the superior thyroid artery (STA) in 96 of cases 10 . Kierner et al. 22 examined the SLNs of 31 cadavers and classified the course of the SLN into four types. In type-i nerves (42 ), the exSLN crossed the STA greater than 1 cm cephalad to the superior pole of the thyroid gland. Type-2 nerves (30 ) crossed the STA within 1 cm of the superior pole of the thyroid gland. Type-3 nerves (14 ) crossed the STA under cover of the superior pole of the thyroid gland. Type-4 nerves (14 ) descended dorsal to the STA and crossed branches of the STA immediately above the superior pole of the thyroid gland. The nerve generally travels from posterior to anterior passing beneath the superior thyroid vessels on its way to the CT muscle. Prior to entering the CT muscle, the exSLN usually pierces the inferior pharyngeal constrictor muscle. In 17-22 of cases, however,...

Answers and Explanations

Parafollicular C cells are neural crest cells that migrate into the fourth pharyngeal pouch and embed themselves in the thyroid gland adjacent to thyroid follicles. Choices A, B, and E are all derived from neuroectoderm and are found inside the CNS. Cells producing aldosterone in the adrenal cortex are derived from mesoderm.

Anterior access according to Meier

The interscalene nerve block is a modification of the technique described by Winnie in 1970. In the classical technique of Winnie, the interscalene nerve block is performed at the posterior scalene gap. This puncture site is thus at the level of the cricoid. The puncture is made in the medial, dorsal and caudal direction. In the modified technique, by contrast, the puncture point is located at the height of the superior thyroid notch at the posterior edge of the sternocleidomastoid muscle. The puncture is directed caudad, slightly to the lateral and aims at the puncture site of the vertical-infraclavicular blockade (see Chapter 2.2).

Chapter Summary continued

Lymphatic spread is the most common route of spread for epithelial carcinomas. Hematogenous spread is most likely to be seen with sarcomas, renal-cell carcinoma, hepatocellular carcinoma, follicular carcinoma of the thyroid, and choriocarcinoma. Tumors are also less commonly spread by seeding of body cavities and surfaces and via mechanical manipulations such as surgical incisions and needle tracts.

Physical and laboratory assessment

Physical examination and laboratory investigations serve primarily to identify comorbid conditions that could have precipitated the episode of MDD and or are likely to complicate its management. Investigations are targeted to the needs of the individual patient. They may include complete blood count, thyroid studies, assessment of electrolyte (sodium, potassium, calcium) and glucose levels, and evaluation of hepatic and renal function. Menopausal status maybe confirmed by increased levels of follicle-stimulating hormone (FSH) (greater than 20 IU dl) and decreased estradiol (less than 60 pg ml) on day two or three of the menstrual cycle. Physical examination and laboratory findings are normal in many women with depression.

Laryngeal Segment of RLN

When the RLN reaches the inferior cornu of the thyroid cartilage it begins its intralaryngeal course. At this point the branching, although still variable, is more predictable. The RLN ramifies into a posterior or abductor division, and an anterior or adductor division. The abductor portion supplies the posterior cricoarytenoid (PCA) muscle and the adductor division supplies the interarytenoid (IA) muscle, lateral cricoarytenoid (LCA) muscle, and thyroarytenoid (TA) muscle. In addition to the efferent axons there are sensory branches providing sensation, temperature, and pressure signals to the brainstem 53,54 .

Testicular Feminization Syndrome

VS fever (39.3 C) tachycardia with irregular pulse hypotension (BP 100 50). PE irritability delirium exophthalmos diffuse increase in size of thyroid gland ( GOITER) lungs clear abdomen soft and nontender no masses no peritoneal irritation deep tendon reflexes brisk no neck stiffness or focal neurologic signs. Thyroid storm, a medical emergency, is usually precipitated by surgical or medical stress (e.g., infection) placed on untreated or undertreated hyperthyroid patients. Prevention of postoperative crises is effected through use of iodine and antithyroid drugs.

Pathogenesis of Organ Dysfunction and Toxemia

Various authors have suggested that anemia, vitamin deficiencies, zinc and other trace metal deficiencies, thyroid dysfunction, tryptophan metabolites, other amino acids, and the time of day that infection occurs or treatment is initiated are all important in the pathogenesis of the disease and the host's ability to mobilize adequate defenses. Although it is likely that many of these factors may be important in determining the ultimate expression of the disease, it is unlikely that any of them are the major determinants of how the disease is expressed or how the host defends against the infection.

Antidepressants in Broader Context

There is currently a trend to transform custodial psychiatric care toward more community-based service. This also necessitates developing drugs with higher compliance and safety. On the other hand, the need for treatment of pharmacoresistant depression has become more important in inpatient facilities. The change of one antidepressant for another, their combination or augmentation with lithium, with thyroid hormones (for review see 6 ), with pindolol 7 or with other drugs (e.g. buspirone 8 ) has been recommended to overcome resistance. In bipolar depression, calcium channel blockers have also been studied (for review, see 9 ). Verapamil has been superior to placebo in the treatment of mania in a double-blind study, but failed in the treatment of depressive episode 10 . Serious attempts to develop practically useful treatment guidelines have recently been made 11 .

The Progesterone Receptor

Most of the physiological effects of progesterone are now known to be mediated by a specific intracellular transcription factor termed the progesterone receptor (PR) (14,15). As for all classical steroid hormone receptors, the PR is believed to undergo an activation step upon ligand binding, which permits the activated ligand receptor complex to interact effectively with specific response elements located in the promoters of target genes, the activation or repression of which manifests the progesterone-extracellular signal into an appropriate physiological response (16,17). Although many steps in the mechanism of PR action have been elucidated, the specific target genes for this receptor have not yet been defined. The first cloning of PR (18,19) revealed it as a member of the nuclear-receptor superfamily of transcription factors, which now includes receptors for a number of potent effector molecules including steroids, retinoids, prostanoids, thyroid hormone, and vitamin D3, as well...

Surgery Trauma Surgery in the Neck

Thyroid Surgery The close anatomical relationship of both the recurrent and superior laryngeal nerves with the blood vessels supplying the thyroid gland represents a well-recognized challenge to surgeons. Vocal fold paralysis does not result only from nerve section but also from nerve manipulation, sometimes minor a paralyzed vocal fold has surprised many an experienced thyroid surgeon who is certain that nerve has been left intact. In recent series, the number of patients experiencing temporary vocal fold dysfunction following thyroidectomy varies from 1.0 to 5.1 , and permanent paralysis from o to 5.8 , with most series reporting less than 3 , and in some cases less than 1 (Table 3.7). If this is judged as a percentage of nerves at risk rather than patients, a common means of tabulating this complication, the incidence may be up to 50 lower depending on the proportion of patients undergoing total thyroidectomy. Principal vari- Number Thyroid and of Cases parathyroid

LDL Total cholesterol HDL [Triglycerides5

The answer is a. (Tierney, 39 e, pp 1148-1149.) The patient most likely has multiple endocrine neoplasia or MEN 1 (Wermer syndrome), an autosomal dominant disorder, consisting of tumors of the Pancreas, Pituitary, and Parathyroid gland (PPP). MEN 2A (Sipple syndrome) consists of Pheochromocytoma, hyperParathyroidism, and medullary carcinoma of the Thyroid (PPT). Patients with MEN 2B syndrome present with Pheochro-mocytoma, Neuromas, and medullary carcinoma of the Thyroid (PNT).

ASomatotropic Hormone Growth Hormone

The thyroid-stimulating hormone (Thyrotropic Hormone, TSH). stimulates the growth of the thyroid gland. It thus promotes the growth of the thyroid gland as well as the production and secretion of the hormones made by the thyroid gland. The secretion of the thyroid-stimulating hormone as well as the thyroid hormones is controlled by a negative feedback mechanism. That is, a high level of TSH causes an increase in the amount of thyroid hormones produced. Once the levels of the thyroid hormones reach a certain level in the bloodstream, the amount of TSH secreted is reduced and the secretion of the thyroid hormones is decreased.

Effectors and Reagents for the Assay see Note

125I-albumin (Molecular Wt 70,000D) (Amersham Pharmacia Biotech Limited) specific activity 10 MBq, (250 Ci). 125I belongs to the second radiotoxicity group. Whoever handles 125I-albumin must adopt the following precautions use 2 pairs of gloves and plumb screens (thickness 0.02 mm). Because iodine accumulates in thyroid tissue and is volatile, it is important to avoid breathing it. Handling within a hood or glove box is recommended.

Gases Respiratory Care

Just below the cricoid cartilage, the strap muscles are spared and retracted, the thyroid isthmus is divided if necessary, and the trachea is entered at the second tracheal ring. The second and third tracheal rings are incised vertically, allowing placement of the tracheostomy tube. The first tracheal ring and the cricoid cartilage must be left intact.

Surgery at the Skull Base

Radiation causes fibrosis in and around the nerve which may interfere with blood supply, compress the nerve, or otherwise compromise axonal flow. Cases of vocal fold paralysis have been documented following radiation treatment of nasopharyngeal carcinoma (along with other cranial neuropathies) 63-65 and mediastinal irradiation for the treatment of mediastinal tumors or breast cancer 66, 67 . Vocal fold paralysis has also been related to radioactive iodine treatment of thyroid malignancy 68-70 . A unique feature of vocal fold paralysis in this scenario is its latency it may occur from 12 months to 34 years following radiation. quire little or no further diagnostic evaluation. Of the remainder of cases, 29-50 are caused by malignancy. Because of the obvious change in voice, vocal fold paralysis is often the presenting symptom for occult cancer. In modern series, mediastinal metastases from primary pulmonary tumors account for the large majority of such cases. Esophageal cancer is a less...

DNA in Dis Diagnostic Medicine

These altered animals are known in general as 'transgenic' or 'knockout' mice, where certain genes have been added to or deleted from, respectively, the normal mouse set of chromosomes. Often very small changes to the total DNA of an organism will produce large changes in its physical appearance, behavior, or intelligence. Transgenic mice have proved useful for creating animal models of human disease, for instance prostate cancer, thyroid deficiency, obesity, lateral sclerosis, or Alzheimer's disease. Such genetically-altered mice may also be used to test new drugs which might potentially cure disease in humans.

Continue with Exercises

Suprarenal (adrenal) glands, thyroid gland, and salivary glands. c. Thyroid gland, Islets of Langerhans, and sweat glands. e. Thyroid gland. LESSON 7 Thyroid, Antithyroid, and Parathyroid Preparations. 7-1. From a list of functions, select the function performed by the thyroid hormones. statement(s) that best describe precautions for persons who take thyroid preparations. 7-4. Given the trade and or generic name of a thyroid preparation and a group of uses and side effects, select the use(s) or side effect(s) associated with the given agent. 7-9. Given the trade or generic name of a thyroid, antithyroid, or parathyroid preparation and a group of trade and generic names, select the trade or generic name that corresponds to the given name.

Thoracoscopic Sympathectomy

A 22-year-old female undergraduate student who had had bilateral palmar hyperhydrosis since the fifth grade presented with hyperhydrosis that was refractory to noninvasive treatment. Her sweating was severe, to the point that it dripped and was thus incapacitating. Her symptoms become more severe primarily when she was anxious or upset, but they also increased with physical activity or elevated temperatures. She was unable to shake or hold hands in social settings. She had difficulty taking exams because the sweat made the paper wet. She was currently looking for a job and felt socially inhibited when being interviewed. Conservative therapy had failed, trying Drysol, Robinul, Drionic and roll-ons. Her hyperhydrosis had also proven refractory to hypnotherapy, biofeedback and iontophoresis. She denied any axillary hyperhydrosis. Her past medical history was negative for any major illnesses, and she denied any thyroid conditions, hypertension or diabetes. She had had no previous lung...

Learning Objectives

Radionuclide scans are presented in relation to the anatomical area under study. Head and neck scans include studies of the brain, thyroid, and parathyroid glands. Scans of the chest cover heart and lung radionuclide examinations. Abdominal radionuclide scans pertain to studies of the gastrointestinal tract, gallbladder, liver, spleen, and kidneys. Miscellaneous scans include evaluations of the scrotum, bone, and gallium-67 studies.

Targeted Disruption of the Common aSubunit Gene

Organ axes associated with the glycoprotein hormones. Pituitary expression of LH, FSH, and TSH require stimulation by the hypothalamic trophic factors GnRH (gonadotropin-releasing hormone) and TRH (thyrotropin-releasing hormone). LH and FSH then stimulate the gonads to produce the sex steroids estrogen (E2), progesterone (P4), and testosterone (T). In humans, placental production of chorionic gonadotropin (hCG) also promotes ovarian steroid synthesis and release. On the other hand, TSH stimulates thyroid production of thyroxine (T4) and triiodothyronine (T3). Thyroid hormones and sex steroids then feedback to suppress their respective axes, both at the hypothalamic and pituitary levels. Fig. 1. Organ axes associated with the glycoprotein hormones. Pituitary expression of LH, FSH, and TSH require stimulation by the hypothalamic trophic factors GnRH (gonadotropin-releasing hormone) and TRH (thyrotropin-releasing hormone). LH and FSH then stimulate the gonads to produce the sex...

Overview of Nuclear Scanning Studies

The particular radionuclide utilized varies with the organ and type of nuclear test being performed. Technetium-99m is used in studies of the brain, heart, gastrointestinal tract, liver, spleen, and bone marrow. Iodine is associated with scans of the thyroid gland, brain, and deep veins. Indium is identified with cerebrospinal fluid, bone marrow, and gastric function nuclear studies. Tumor scans are performed with gallium, and cardiac function scans often involve the radionuclide thallium.

Muscles of the Larynx

The second pair of muscles, the thyroarytenoid and cricothyroid, relax and tense the vocal ligaments, respectively. Contraction of the thyroarytenoid muscles pulls the arytenoid cartilages closer to the thyroid and relaxes the vocal ligaments. The vocalis muscle, which is the medial part of the thyroarytenoid, adjusts the tension on small segments of the vocal ligament. The cricothyroid muscles, which lie on the anterior aspect of the larynx between the cricoid and thyroid, tense the vocal ligament by rocking the superior aspect of the thyroid anteriorly at its articulation with the cricoid, increasing the distance between the thyroid and arytenoid cartilages. Both recurrent laryngeal nerves are susceptible to injury in surgical procedures involving the thyroid gland. Lesions of a recurrent laryngeal nerve result in a fixed vocal cord and transient hoarseness. Evaluation of the vagus nerve includes examination of palatal movements when the patient says Aah, because the palate moves...

Thyrotropin TSH 5Subunit Gene Expression

Unlike the FSHp and LHp genes, there are numerous thyrotrope models available for study of TSHp gene expression. These include the primary cell culture of pituitaries, thyrotropic tumors perpetuated in mice (MGH101A TtT-97), and a cell line derived from MGH101A that is denoted aTSH. TtT-97 and primary pituitary cells are the only models that continue to express TSH. Because of the relative abundance of cells from the TtT-97 tumors, these are most commonly used. Using these models, several transcription factors have been characterized that appear to directly regulate expression of TSHp. These include Pit-1 (76-78) and Pit-1T (76,79), thyroid hormone receptor (80-83), an AP-1-like factor (84), retinoid X-receptor (85), Oct-1 (86), and GATA-2 (87). Although the regions necessary and sufficient for activity of the TSHp promoter have not been confirmed in transgenic mice, in at least three instances either the murine or human promoters were used to target informative transgenes to...

Miscellaneous Preparation

Strong Iodine Solution, USP (Lugol's solution). This preparation is used to provide the patient with a source of iodine. As noted in paragraph 7-2, a sufficient amount of iodine must be available to synthesize thyroid hormones. If iodine in the required amounts is lacking in the diet, the thyroid gland can become enlarged. The usual dosage of this product is 0.1 milliliters to 0.3 milliliters three times a day. The patient can take this medication in orange juice to mask the iodine taste.

Trans Vitreal Incisional Biopsy

Fig. 8.2 Excision biopsy of a multicystic iridociliary tumor in the right eye of a 15-year-old male. a Preoperative appearance. b Intraoperative photograph. c Light micrograph, showing thyroid tissue. d Postoperative appearance, when the vision had improved to 6 6. A diagnosis of ectopic thyroid was made, based on negative systemic findings, even after prolonged follow-up 10 Fig. 8.2 Excision biopsy of a multicystic iridociliary tumor in the right eye of a 15-year-old male. a Preoperative appearance. b Intraoperative photograph. c Light micrograph, showing thyroid tissue. d Postoperative appearance, when the vision had improved to 6 6. A diagnosis of ectopic thyroid was made, based on negative systemic findings, even after prolonged follow-up 10

Classification of nuclear hormone receptors into types I and II

Vitamin A (as retinoic acid) and vitamin D (as 1,25-dihydroxyvitamin D3) also induce the synthesis of specific proteins through receptor-mediated regulation of gene transcription. Receptors for vitamins A and D share certain structural and functional properties with steroid hormone receptors, and all may be considered as members of a nuclear hormone receptor superfamily. The superfamily can be conveniently divided into two types based on functionally distinct properties. Type I comprise receptors (R) for the classic steroid hormones such as (o)estrogen (ER), progesterone (PR), androgen (AR), glucocorticoid (GR) and mineralocorticoid (MR). Type II comprise receptors for thyroid hormone (TR), retinoic acid (RAR and RXR), vitamin D3 (VDR) and prostanoids (PPAR). Also included in the superfamily are orphan receptors whose cognate ligands (if any exist) are as yet unidentified.

Retinoidbinding proteins

A tetrameric protein composed of apparently identical subunits, each with a molecular weight of 14 kDa, and possesses a single thyroid hormone-binding site. Although transthyretin would seem to be capable of binding four molecules of RBP, it only binds one. Apparently, the binding of one molecule of RBP to one transthyretin subunit causes the remaining subunits to lose their affinity for RBP. Hence, under normal physiological conditions, with transthyretin in molar excess, holoRBP-transthyretin exists as a 1 1 molar complex. In blood, approximately 95 of the reti-nol-RBP is complexed with transthyretin - the rest is free. As will become evident, retinol nutritional status strikingly influences the metabolism and tissue levels of RBP.

Nuclear retinoid receptors

Nuclear retinoid receptors are implicated in various aspects of cell growth, development and homeostasis by controlling expression of specific genes through their hormonal ligands, which act as signals. The two classes of receptor - retinoic acid receptors (RARs) and retinoid X receptors (RXRs) - differ in their primary structure, their binding affinity to retinoids, and their ability to regulate expression of different target genes. The retinoid receptors belong to a subfamily of the superfamily of receptors that function as lig-and-dependent transcription factors the subfamily includes receptors for steroid hormones, thyroid hormone and vitamin D.

Retinoic acidresponsive genes

The promoters of some genes contain composite response elements which can selectively bind and initiate transcription from multiple nuclear hormone receptors, thereby allowing cross-talk between different hormonal pathways. For example, the rat oxytocin promoter contains a RARE that is predominantly responsive to retinoic acid, but also permits binding of TR and ER (oestrogen receptor) to mediate transcription in the presence of thyroid hormone and oestradiol (Adan et al., 1993). Kato et al. (1995) described a novel class of response elements which are widely spaced (10 to 200 base pairs) direct repeats of the consensus AGGTCA motif (DR10 to DR200) and which act as promiscuous transactivation sites for ER, RAR-RXR and VDR-RXR, but not TR-RXR.

Specific Discussion

The answers are 153-b, 154-b. The thymus is composed of two lobes, which are frequently asymmetrical. With increasing age it atrophies and is replaced by fat with streaky or nodular densities. Cystic transformation can occur along the developmental pathway of the thy-mopharyngeal duct, and in patients with Hodgkin's lymphoma, persistence of these cysts can be seen due to thymic involution. These cysts can persist or even enlarge after radiation treatment or chemotherapy. Rebound thymic hyperplasia is seen in children, where a period of stress associated with thymic involution is followed by regrowth or overgrowth of the gland. However, despite an abnormal increase, the gland maintains its normal arrowhead configuration. Thymomas are neoplasms of the thymic epithelial cells with cystic degeneration and calcification. They are seen in adults, usually in the fifth decade of life. About 40 of adults with thymomas have myasthenia gravis and 15 of patients with myasthenia gravis...

Pathology and Immunohistochemical Profile

The morphology of small cell carcinoma of the prostate is identical to that seen in the bladder (see above) and lung. In about 50 of cases, the tumors are composed of a mixture of small cell carcinoma and acinar adenocarcinoma 110 . The small cell component is positive for CD56, neuron-specific enolase (NSE), and chromo-granin A, and shows dot-like positivity using CAM5.2, but is negative for PSA and prostatic acid phosphatase (PSAP). The acinar component shows the reverse immunoprofile. It has been suggested that primary small cell carcinoma of the prostate may be distinguished from a metastasis from the lung by the absence of staining for thyroid transcription factor-1 (TTF-1),but there

Trisomy 21 Down Syndrome

Overfolding upper helix, and small or absent earlobes. Hypoplastic teeth are common. Hand findings include short metacarpals and fingers, clinodactyly (60 ), simian crease (45 ), and characteristic prints. They exhibit a wide gap between the first and second toes. Cardiac abnormalities are present in 49 , with endocardial cushion defects, ventricular septal defects (VSDs), patent ductus arteriosus (PDA), and atrial septal defects (ASDs). Cutaneous manifestations include dry skin, cutis marmorata, fine, soft sparse hair, and straight pubic hair. Occasionally, patients have seizures, strabismus, and low-set ears. Patients are at higher risk for duodenal atresia, atlantoaxial instability, leukemia, and thyroid disease.

Zollinger Ellison syndrome

The tumour arises either in the duodenal wall or more particularly in the pancreas, with about 25 of cases having other additional endocrine tumours. These include especially pancreatic insulinoma, but also adrenal, parathyroid and thyroid adenomas and pituitary chromophobe adenoma (see Multiple endocrine neoplasia). Two thirds of cases are malignant.

Description of Xrays in This Chapter

This PA chest film demonstrates a large superior mediastinal shadow with marked right displacement of the trachea. There is minimum thickening of the minor fissure with some small atelectatic streaks on the left. The descending aorta is tortuous and shows a small amount of calcification in the aortic knob. Although this film is most consistent with a thyroid goiter, a CT scan would be definitive.

The VoCoM Vocal Cord Medialization System

Medialization Thyroplasty

Tive time or manipulation, can make it difficult for the surgeon to judge the appropriate vocal endpoint. A specially designed surgical instrument set facilitates window placement, determination of implant size and optimal location, and insertion of the implant. The graduated pre-fabricated implants and shims obviate the need to hand carve implants on the back table during the procedure, saving valuable operative time. The implant is made of hydroxylapatite with proven biocompatibility that generates a thin fibrous encapsulation. In some individuals, there may be osteogenesis in the region of the fenestra creating lamellar bone bridging between the implant and the thyroid lamina 2 . For individuals with paresis and residual motion, this provides implant stability and minimizes the risk of migration or extrusion. Although the osteogenesis is localized and does not preclude implant removal, this system The main disadvantage of the system is that the firm nature of the implant does not...

Drugs on the Near and Distant Horizons

Leptin has been found to ameliorate many of the symptoms of lipodystrophy (86). Nine female patients with lipodystrophy and a serum leptin level of less than 4 mg mL were treated with recombinant methionyl human leptin for 4 mo. Eight of the women had diabetes. During treatment with leptin, the glycosylated hemoglobin decreased an average of 1.9 . During the 4 mo of therapy, triglyceride levels decreased by 60 . Liver volume was also reduced by an average of 28 , and resting metabolic rate also decreased significantly with therapy (87). A reduced body weight is associated with decreased 24-h energy expenditure and decreased leptin and thyroid hormone levels. When body weight was reduced by 10 , circulating T3, T4, and leptin concentrations were decreased. All these endocrine changes were reversed by administration of replacement doses of recombinant human methionyl leptin. Total energy expenditure increased in all subjects during treatment with leptin, indicating that decreased leptin...

Innervation and Functional Anatomy of Laryngeal Muscles

Laryngeal Nerve Stimulator

As a matter of basic orientation, a conventional view of laryngeal anatomy is briefly presented. The intrinsic laryngeal muscles have both their origin and insertion on the cricoid, thyroid, or arytenoid cartilage. In concert, they orchestrate the motion of the vocal folds during respiration, vocalization, and airway protection. The paired posterior cricoarytenoid (PCA) muscles are situated on the posterior larynx (Fig. 2.1A). When the PCA contracts, it rocks the arytenoid cartilage in a posteromedial direction to swing open the vocal process and fold (Fig. 2.1B). The articular facets of the cricoarytenoid joint are contoured to also permit a sliding motion along the mediolateral axis. The PCA is the sole abductor of the vocal folds during inspiration and acts as a co-contractor antagonist to the adductors during phonation. The thyroarytenoid (TA) muscle is the principal adductor and intrinsic tensor of the vocal fold (Fig. 2.1C). In synergy with the lateral cricoarytenoid (LCA) and...

Kurz Titanium Thyroplasty Prosthesis

Vocal Cord Medialization

After infiltration with lidocaine hydrochloride 1 (plus epinephrine hydrogen tartrate 1 200,000), a horizontal skin incision of about 3 cm is made at the level of the mid-thyroid ala of the appropriate side. The thyroid cartilage is exposed with the perichondrium preserved from the midline laterally. The overlying strap muscles are cut using the electrocautery. A reference line is drawn parallel to the inferior thyroid margin, beginning from the anterior midline at the midpoint between the superior and inferior thyroid notches. This line corresponds to the free edges of the vocal folds endolaryn-geally. With a preformed silicone template the cartilage window should be marked caudal to the reference line and near the oblique line of the thyroid ala. In patients with a very lateral position of the paralyzed vocal fold, a combination of medialization thyroplasty with approximation of the cricoid and thyroid cartilages, or with endoscopic fat augmentation, is possible. In very rare cases...

RLN Branching Patterns

As the RLN ascends in the neck it courses from lateral to medial until it reaches the tracheoesophageal (TE) groove prior to entering the larynx. Ardito et al. 29 studied 2626 RLNs during 1543 thyroidectomies over 10 years and found that 61.4 of right RLNs reach the TE groove and ascend in this sulcus, 37.8 remain lateral to the TE groove then enter the larynx, and 0.6 course anterolateral to the TE groove prior to entering the larynx. This variability, especially when the nerve travels anterolateral to the TE groove, may pose significant risk for iatrogenic injury. Nemiroff and Katz 32 reviewed the ex-tralaryngeal branching patterns of 153 RLNs in patients undergoing thyroid or parathyroid surgery. They found that 41.2 of the nerves branched prior to entering the larynx. There was no difference in incidence among right and left sides in 14.5 of patients bilateral branching was present. The branching occurred between 0.6 and 4.0 cm from the inferior border of the cricoid cartilage,...

Success Rate Of Gore Tex Thyroplasty

Gore Tex Thyroplasty

When viewed from above, by mirror examination or endoscopy, the vocal folds appear to open and close in an axial plane, pivoting at the anterior commissure, like opposing windshield wipers however, vocal fold motion is considerably more complex. The chief major moving parts of the larynx are the arytenoid cartilages, which articulate with the cricoid cartilage in shallow, ball, and socket-type joints and rotate around variable axes. The membranous vocal folds are rigidly fixed anteriorly to the thyroid cartilage and posteriorly to the vocal processed of the arytenoid cartilages. Opening and closing of the glottis is achieved by motion of the arytenoids, so that the vocal processes move medially and laterally. The membranous vocal folds are passively dragged to and from, varying the angle between the vocal folds. The only muscles that abduct the vocal fold are the posterior cricoarytenoid muscles (PCA), which originate on the posterior cricoid and insert on the muscular process of the...

Protein Differences Between Omnivores And Vegetarians Or Vegans

Increased thyroid activity is evident from the higher resting metabolic rate of vegans32 and of the elevated thyrotropin levels in vegans.33 This serves to explain why vegans are, on the average, leaner with lower body mass indexes (BMI).32 Also, the immune status in vegans is elevated compared with omnivore subjects in terms of significantly elevated cytokine 2 and gamma interferon levels.34

The answer is d Fauci 14e pp 21162118 Gynecomastia is

The answer is c. (Fauci, 14 e, pp 2057-2059.) Pheochromocy-toma is a life-threatening disease if left undiagnosed. Patients present with episodic symptoms of headache, sweating, and palpitations. Pheochromo-cytoma may be associated with von Recklinghausen syndrome, neurofibromatosis, and von Hippel-Lindau's disease. The diagnosis is made by 24-h urine for catecholeamines and metanephrines. Ten percent of pheochro-mocytomas are bilateral and 10 are extraadrenal. Increased levels of 5-HIAA are associated with carcinoid syndrome (facial flushing and diarrhea) from a tumor usually located in the lung or ileum. Patients with thyroid storm present with nausea, diarrhea, jaundice, fever, dyspnea, shortness of breath, diaphoresis, delirium, and tachyhcardia. The combination of diabetes mellitus, hypertension, obesity, insulin resistance, and dyslipidemia (increased VLDL, increased triglyceride, and decreased HDL) is called syndrome X or Coronary artery disease, Hypertension,...

The answer is a Fauci 14e pp 14511455 Massive lifethreatening hemoptysis is 100 cc of blood in 24 h The most common

The answer is d. (Seidel, 4 e, pp 353-358, 363.) The trachea is 2 cm in diameter and 10-11 cm long. It lies anterior to the esophagus and posterior to the isthmus of the thyroid gland. The trachea is a midline structure and divides into the right and left main stem bronchi at the level of T4 or T5 below the manubriosternal joint (angle of Louis). 135. The answer is e. (Seidel, 4 e, p 184, 371.) Clubbing is associated with cystic fibrosis, lung cancer, congenital heart disease, cirrhosis, colitis, and thyroid disease. Clubbing is due to the formation of new periosteal bone and the development of synovial effusions. Emphysema and asthma do not cause clubbing. 142-144. The answers are 142-a, b, c, d, 143-e, f, 144-g, h. (Fauci, 14 e, p 1475.) The area between the pleural sacs the mediastinum is divided anatomically into the anterior mediastinum, middle mediastinum, and posterior mediastinum. The most common masses found in the anterior mediastinum are the four Ts Thymomas,...

Subglottic Jet Ventilation

Radiesse can be injected percutaneously either through the cricothyroid membrane or directly through the thyroid cartilage under transnasal fiberoptic laryngoscopy (TFL) guidance. The CaHA can also be injected in the office setting per-orally through a curved laryngeal needle. Anesthesia can be achieved with a combination of superior laryngeal nerve blocks and an instillation of 2 cc of 1 lidocaine into the trachea as described by Sulica and Blitzer 13 . We have found that injecting lidocaine at the site of skin puncture is also beneficial. The CaHA can be injected through a 25-G needle or larger. The disadvantage of injection through the thyroid cartilage is that the needle can become blocked with cartilage or bone. The disadvantage of injection through the cricothyroid membrane or per-orally is that these procedures are technically difficult for most otolaryngologists. Because of the potential for permanent augmen The location of CaHA injection is crucial. The implant must be...

Decreased arousal andor plateau

Arousal difficulties leading to delayed vaginal engorgement, reduced vaginal lubrication, pain with intercourse, and decreased vaginal, clitoral, and orgasmic sensation can be caused by or exacerbated by athlerosclerotic disease.35 Screening laboratory testing should include lipid profile, glucose with or without insulin levels, thyroid stimulating hormone (TSH), and androgen levels (DHEAs and free testosterone).

Is Livergen Suitable For Three Months Pregnancies

The answer is d. (Braverman, 8 e, pp 578-589.) The patient's clinical presentation is most consistent with postpartum thyroiditis, a form of autoimmune-induced thyrotoxicosis that occurs 3 to 6 months after delivery. The hyperthyroid state usually lasts for 1 to 3 months and is generally followed by a hypothyroid state of limited duration. The patient's thyroid gland would not be enlarged if she were taking exogenous thyroid medications. Subacute thyroiditis almost always presents with a tender, enlarged thyroid gland. The patient's thyroid gland is described as homogeneous, not nodular, which would be inconsistent with toxic multinodular goiter. Struma ovarii is unlikely because of the enlargement of the thyroid gland. Struma ovarii is the name given to the approximately 3 of ovarian dermoid tumors or teratomas that contain thyroid tissue. This tissue may autonomously secrete thyroid hormone. Graves' disease is another possibility. These two abnormal thyroid states could be...

Thiamine Diphosphate Activate The Aldehyde Is Transferred Beriberi

The answer is c. (Murray, pp 627-661. Scriver, pp 3897-3964. Sack, pp 121-138. Wilson, pp 287-320.) Certain amino acids and lipids are dietary necessities because humans cannot synthesize them. The energy usually obtained from carbohydrates can be obtained from lipids and the conversion of some amino acids to intermediates of the citric acid cycle. These alternative substrates can thus provide fuel for oxidation and energy plus reducing equivalents for biosynthesis. Iodine is important for thyroid hormone synthesis, while calcium is essential for muscle contraction and bone metabolism.

Complications and Unusual Manifestations

DIC is rarely of clinical importance, but thrombocytopenia, hypofibrinogenemia, elevated prothrombin (PT) and partial thromboplastin times (PTT), and elevated levels of fibrin degradation products are found in most patients.68 The hemolytic-uremic syndrome and severe intravascular hemolysis have been reported. Because of the sustained bacteremia, focal infections can develop at any site of the body, but these occur rarely. The most common sites of infection are in the bones (extremities, spine, ribs), but infections have been reported in the brain, liver, spleen, muscles, breast, thyroid, salivary glands, and cervical lymph nodes. In the past, thrombophlebitis, parotitis, and decubitus ulcers were common complications but they now occur rarely.

Chromatin Immunoprecipitation for Studying Transcriptional Regulation in Xenopus Oocytes and Tadpoles

Key Words Chromatin immunoprecipitation (ChIP) tadpole thyroid hormone receptor transcription Xenopus oocyte. Although the basic ChIP protocol for tissue culture cells has been extensively described (5,6), we present and discuss here the protocols we have developed over the years for ChIP assays using Xenopus oocytes (9-11) and tadpole tissues as experimental materials (12-14). Xenopus oocytes have been extensively used as a model system for studying transcriptional regulation in the context of chromatin because circular plasmid reporter DNA injected into the nucleus of a Xenopus oocyte is efficiently assembled into chromatin, and remodeling of chromatin structure by transcription factors such as thyroid hormone receptor (TR) can be studied by various assays, including DNase I hypersensitivity, regularity of the nucleosomal ladder, and DNA topology (15-17). The basic protocols for the chromatin remodeling assays described above have been extensively described (18) and thus are not...

Endocrine Causes of Obesity

Many patients are concerned that they have a metabolic or glandular cause for their obesity. This may be a reflection of the frustration that some of these individuals feel over the difficulties that they have had in battling a weight problem over many years. They may be looking for a medical explanation of why they have not succeeded in their goal of losing weight. Endocrine causes of serious obesity are not common. The three most commonly cited are hypothyroidism, Cushing's syndrome, and hypothalamic obesity. To evaluate the patient for hypothyroidism, questions can be asked about cold intolerance, constipation, irregular menses, fatigue, or depression. The presence of easy bruisability, proximal muscle weakness (difficulty getting out of a chair, trouble getting things out of a high cupboard), a change in appearance, or osteoporosis may be signs of hypercortisolism. The patient can be examined for signs of hypothyroidism including bradycardia, cool dry skin, a firm palpable...

Trophic Factors for Gonadotropes and Thyrotropes

TRH is expressed in the hypothalamus as well as a number of other organs. The tripeptide was originally characterized for its ability to regulate serum levels of TSH, but it also appears to function as a neurotransmitter or neuromodulator. Although TRH is a well-known regulator of TSH synthesis and secretion, its role in regulating thyrotrope development was unknown. To assess the thyrotrope-specific effects as well as any other biological target of TRH, the gene was specifically disrupted in mice. Mice lacking the TRH gene exhibit hyperglycemia, because of a profound decrease in insulin secretion, and tertiary hypothyroidism (105). Unexpectedly, although TRH levels were non-detectable in these mice, serum levels of TSH were nearly twice that of a wild-type mouse (105). This suggests that negative feedback by thyroid hormones plays a more significant role than TRH in regulating TSH levels. In other words, the loss of negative regulation by thyroid hormones was sufficient to overcome...

Fruits And Vegetables A Population Studies

Different fruits and vegetables have been investigated separately and appear to provide protection against cancer at certain locations. For example, the use of carrots and green, leafy vegetables provides substantial protection against lung and stomach cancers, while the cruciferous vegetables (cabbage, broccoli, cauliflower, etc.) provide useful protection against colorectal and thyroid cancers. In addition, the regular use of onions or garlic can decrease the risk of stomach and colon cancer by 50-60 ,3,10,11 while the regular consumption of tomatoes and strawberries was recently found to substantially protect against prostate cancer.12

RLN Communication with SLN

Anastomotic sites between branches of superior and recurrent laryngeal nerves. SLN superior laryngeal nerve, ILN internal branch superior laryngeal nerve, ELN external branch superior laryngeal nerve, RN recurrent laryngeal nerve, 1 Galen's anastomosis, 2 deep arytenoid plexus, 2' superficial arytenoid plexus, 3 cricoid anastomosis, 4 thyroarytenoid anastomosis, 5 thyroid foramen, 6 cricothyroid anastomosis. (Adapted from 17 ) Fig. 1.2. Anastomotic sites between branches of superior and recurrent laryngeal nerves. SLN superior laryngeal nerve, ILN internal branch superior laryngeal nerve, ELN external branch superior laryngeal nerve, RN recurrent laryngeal nerve, 1 Galen's anastomosis, 2 deep arytenoid plexus, 2' superficial arytenoid plexus, 3 cricoid anastomosis, 4 thyroarytenoid anastomosis, 5 thyroid foramen, 6 cricothyroid anastomosis. (Adapted from 17 ) The communicating nerve as described by Sanders et al. 18 and Wu et al. 41 links the exSLN with the RLN in 44 of the...

Overview Of The Nuclear Receptor Superfamily

A classification according to the position along the phylogenetic tree provided a practical and significant tool for unifying the nomenclature of all nuclear receptors across species. This system is based on the evolution of the two well-conserved domains of nuclear receptors (the DBD and the LBD) and distinguishes six subfamilies (Nuclear Receptors Nomenclature Committee, 1999). Interestingly, besides their phylogenic relationship, some common functional properties may be found within each group. All receptors contained in subfamily I are forming heterodimers with RXR. The three RARs (RARa, RARb, and RARg), the thyroid hormone receptors (TRa and TRb), the vitamin D receptor (VDR), and the peroxisome proliferator-activated receptors (PPARa, PPARb, and PPARg) belong to this subfamily. Steroid receptors, which comprise the estrogen receptor, androgen receptor, progesterone receptor, mineralocorticoid receptor, and glucocorticoid receptor (ER, AR, PR, MR, and GR, respectively), mostly...

Hyperaldosteronism Primary

PE lungs clear no neck masses thyroid not palpable no lymphadenopathy muscle weakness with hypore-flexia abdomen soft with decreased bowel sounds no masses no abnormal pigmentation soft tissue calcification in skin of arms and legs. VS mild hypertension. PE no neck masses thyroid not palpable no lymphadenopathy lungs clear heart sounds normal abdomen soft no masses.

Other Procedures and Interventions

Vocal fold paralysis occasionally follows surgery that does not place the nerve at risk. Such cases have been occasionally attributed to cricoarytenoid dislocation, but damage to this well-supported joint has been shown by anatomical study to be extremely unlikely 52,53 , especially when no note was made of difficulty at intubation. Careful dissection has shown that the anterior branch of the recurrent laryngeal nerve is subject to compression between a high-riding endotracheal tube cuff and the thyroid cartilage, particularly if the cuff is over-inflated 54, 55 . Brief reflection on the number of intubations in comparison with the frequency of this cause of paralysis suggests that it is an extremely rare occurrence. No study has been made of its natural history, but as a neura-praxic injury, spontaneous resolution is probably the rule. As noted previously, it is entirely possible that many short-lived paralyses go undiagnosed, attributed to routine voice change following intubation.

Introduction

'Abbreviations ADH, alcohol dehydrogenase AhR, aryl hydrocarbon receptor ALDH, aldehyde dehydrogenase Arnt, AhR nuclear translocator atRA, all-trans RA CRABP, cellular retinoic acid-binding protein CRBPI, cellular retinol-binding protein type I CYP450, cytochrome P450 GST, glutathione S-transferases HAT, histone acetyltransferase HDACs, histone deacetylases HMTs, histone methyltransferases LRAT, lecithin retinol acyltransferase MMPs, matrix metalloproteinases RAL, retinal RALDH, retinaldehyde dehydrogenase RAR, RAR gene RAREs, retinoic acid response elements RARs, retinoic acid receptors RBP, retinol-binding protein RDH, retinol dehydrogenase RE, retinyl ester REHs, retinyl ester hydrolases ROH, retinol RXR, RXR gene RXRs, retinoid X receptors SCADs, short-chain alcohol dehydrogenases SMRT, silencing mediator of retinoid and thyroid receptors TCDD, 2,3,7, 8-tetrachlorodibenzo-p-dioxin UGTs, UDP-glucuronosyltransferases XREs, xenobiotic response elements N-CoR, nuclear receptors...

Sialolithiasis

Labs Basic lab work and thyroid function tests normal. Imaging XR, lateral neck may see mass composed of soft tissue with no calcification. Ntic radioactive iodine may localize in cyst if cyst contains functioning thyroid tissue. Treatment Surgical removal of thyroglossal duct, cyst, and midportion of hyoid after confirming presence of adequate-functioning thyroid tissue elsewhere. Discussion Cysts may arise from the remnant of the thyroglossal duct, an embryologic structure formed during migration of the thyroid from the base of the tongue (at the foramen cecum) to its final position in the neck. They frequently become infected. The foramen cecum is the normal remnant of the thyroglossal duct.

Choking

The patient has spastic contracture of the feet and wrists in outward rotation and flexion, with her fingertips touching each other ( carpopedal spasm). She had just had a total thyroidectomy. Resected thyroid tissue shows anaplastic carcinoma with incipient invasion into trachea (a small square of anterior wall was resected) on careful examination, all four parathyroid glands found to be deeply adherent to the thyroid no evidence of nerve tissue (laryngeal nerve). The parathyroid glands are the embryologic derivatives of the dorsal endodeftn of the third and fourth branchial pouches. The glands may be found anywhere from the superior mediastinum to the carotid bifurcation but are usually located on the posterior aspect and in close proximity to or embedded in the thyroid gland. Usually there are two superior and two inferior glands, but supernumerary and absent glands are not uncommon.

Neuroendocrine Tests

The hypothalamic-pituitary-thyroid axis. Concerning the hypothalamic-pit-uitary-thyroid axis, depressed patients have been reported to have (a) alterations in TSH response to the TRH (b) an abnormally high rate of antithyroid antibodies and (c) elevated CSF TRH concentrations. Consistently, a subgroup of depressive patients (about 30 or more) have a decreased response of TSH, to TRH and a variable prolactin (PRL) response 146,147 . The blunted response persists in some patients after recovery and is not connected with cortisol levels or DST response. Both T4 and TSH response to TRH is reported to relate to the treatment outcome of depressed patients 148 . The significance of the pituitary-thyroid axis abnormalities in depression, however, still remains unclear.

Psoriasis

Several systemic disorders occur more often in patients with vitiligo, including thyroid disease (e.g., hyperthyroidism, Graves' disease and thyroiditis), Addison's disease, pernicious anemia, alopecia areata, uveitis, and diabetes mellitus. Vitiligo may be inherited as an autosomal-dominant trait with incomplete penetrance and variable expression. Most studies, however, point to an autoimmune basis (circulating complement binding anti-melanocyte antibodies have been detected).

Triiodothyronine T3

Triiodothyronine (T3) is another hormone secreted by the follicular cells of the thyroid gland and appears to have the same functions as thyroxine. Although triiodothyronine accounts for a very small percentage of thyroid hormone secretions, it is very concentrated and highly potent. As with thyroxine, triiodothyronine plays an important part in many cellular and metabolic processes. The serum T3 test is an important part of the thyroid function laboratory tests. Variations from Normal. Increased triiodothyronine levels are associated with hyperthyroidism, T3 thyrotoxicosis, thyroiditis, and thyroid tumor. Decreased levels are seen in hypothyroidism, starvation, and chronic illnesses.

Calcitonin

Calcitonin, the hormone secreted by the parafollicular cells of the thyroid gland, functions to lower blood calcium levels. As serum calcium levels increase, calcitonin secretion also increases and the hormone encourages the movement of calcium from blood to the bones. Calcitonin also inhibits calcium reabsorption by the kidneys. The serum calcitonin test is used to evaluate individuals with suspected medullary carcinoma of the thyroid gland. Variations from Normal. Increased calcitonin levels are indicative of medullary carcinoma of the thyroid. Other diseases associated with increased calcitonin include oat cell carcinoma of the lung breast and pancreatic cancers thyroiditis and pernicious anemia. Decreased calcitonin levels may not be diagnostically significant.

Pituitary Hormones

Spermatogenesis is under the hormonal control of the hypothalamo-pituitary axis (3). Gonadotropin-releasing hormone (GnRH) is released from the hypothalamus into the hypothalamo-pituitary vein, and stimulates the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the gonadotroph cells of the anterior pituitary. FSH and LH bind to receptors located respectively on the somatic Sertoli and Leydig cells of the testis. Pituitary gonadotropins (FSH and LH) and thyroid-stimulating hormone thyrotropin (TSH) are heterodimers composed of a common a-subunit (a-GSU) and a unique P-subunit.

Kaplan

The surgeon has asked the medical student to test for tetany, which can occur if the blood supply to the parathyroid glands (through the superior and inferior thyroid arteries) is disrupted during thyroid surgery. Specifically, the medical student is being asked to tap with his fingers the muscles of mastication, notably the masseter, which because of its strength is a sensitive indicator of tetany. Tetany will be seen as an abnormally strong jerk or contraction related to the hypocalcemia that can develop if secretion of parathyroid hormone is inadequate.

Margaret Gradison MD

Case S.J. is a 47-year-old woman who presents with abnormal uterine bleeding. She had regular periods until two years ago, at which time her periods became unpredictable. Her current menses started three weeks ago she says it alternates between needing to change pads hourly to requiring only a daily panty liner. Ms J. is obese and smokes a pack of cigarettes a day. Her only medication is thyroid supplements. Her obstetrical history is gravida three para two spontaneous abortion one (G3P2 AB 1). She uses condoms intermittently for contraception, and her first pregnancy was at age 29.

Tissues

HYPOTHALAMUS-ADENOHYPOPHYSIS-ADRENAL CORTEX SYSTEM. The relationship is similar to that of the thyroid gland. Higher nervous centers always influence the hypothalamus. Corticotropin Releasing Hormone (CRH) is another hypothalamic neurosecretion carried by the portal system blood to stimulate the adeno-hypophysis, which, in response, produces adrenocorticotropic hormone (ACTH). The latter, in turn, via the general circulation, reaches its target organ the adrenal cortex to elicit secretion of two types of hormones a mineralocorticoid (aldosterone), and glucocorticoids (corticosterone and cortisol).

Sf1 Knockout Mice

SF-1 initially was identified as a transcription factor that regulated the cell-specific expression of the cytochrome P450 steroid hydroxylases that catalyze most steroidogenic conversions (8,9). When a cDNA encoding SF-1 was isolated, its sequence established SF-1 as a member of the nuclear hormone-receptor family that mediates transcriptional regulation by steroid hormones, thyroid hormone, vitamin D, and retinoids. Subsequent studies have shown that SF-1 regulates adrenal and gonadal expression of many genes

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