geoffrey modest medical blogs

A randomized controlled trial assessed the effect of levothyroxine therapy in older adults with subclinical hypothyroidism, finding no clear benefit (see  hypothyroid subclinical elderly replacement nejm2017  in dropbox, or DOI: 10.1056/NEJMoa1603825 ) Details: -- 737 adults at least 65-years-old who had persistent subclinical hypothyroidism were randomized to levothyroxine starting at a dose of 50 µg a day, or 25 µg if their body weight were <50 kg or had coronary heart disease, with subsequent dose adjustment to achieve a TSH between 0.4 and 4.6, versus placebo. --  Subclinical hypothyroidism was defined as TSH of 4.60-19.99, with a free thyroxine level that was within the normal reference range. -- Mean age 74, 54% women, 98% white, 97% in non-sheltered community housing, 50% with hypertension/15% diabetes/14% ischemic heart disease/13% osteoporosis/9% smokers, mean baselineTSH level was 6.4 -- Primary outcomes were changes in the Hypothyroid ...

The US Preventive Services Taskforce ( USPSTF ) just published an update of their recommendations for  TSH  screening of  nonpregnant , asymptomatic adults (see  thyroid dysfunction screen  USPSTF  annals 2015  in  dropbox , or  doi:10.7326 / M15 -0483). For formal  USPSTF  recommendation, see http://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/thyroid-dysfunction-screening    Details: --definitions:      --hypothyroidism: subclinical = asymptomatic, serum  TSH  between 4.5-10 (varies a bit by lab), and normal  T3  and  T4 ; overt = can be asymptomatic, but high TSH  and low  T4  levels --hyperthyroidism: subclinical = asymptomatic,  TSH  < 0.4 and normal  T3 and  T4 . subdivided into "low but detectable", with  TSH  0.1-0.4, and "undetectable" with  TSH  <0.1. ove...

An Italian study looked at the natural history of apparently benign thyroid nodules, with unexpected findings  (see  thyroid nodule natural history JAMA 2015  in dropbox, or JAMA. 2015;313(9):926-935​). In this prospective, multicenter, observational study, researchers followed 992 consecutive patients with 1-4 asymptomatic nodules which were either benign by ultrasound or fine-needle aspirate (FNA), and followed them for 5 years.  results: --mean age of patients was 52.4 years, 82% women, half with family history of nodular thyroid disease, and  none  were on levothyroxine therapy . 60% of the nodules were solitary , 80% solid. --40.2% of the nodules were benign by FNA and  59.8% had no suspicious ultrasound features [suspicious ultrasound features were at least one of: hypoechogenicity, irregular margins, taller-than-wider shape, intranodular vascular spots, and microcalcifications) --nodule growt...

endocrine society and am assn of clinical endocrinologists added their suggestions to the choosing wisely website (see  http://www.choosingwisely.org/doctor-patient-lists/the-endocrine-society-and-american-association-of-clinical-endocrinologists/  , or   choosing wisely endocrine 2013  in dropbox). this website in general has suggestions about unnecessary tests from many of the major specialty and primary care organizations and is really well-organized.   the endocrine society points:   avoid routine daily self-glucose monitoring in adults with stable DM2 or agents not causing hypoglycemia (eg metformin).  The issue here is that it does not make sense to have patients check their fingersticks more than once a day if they are well-controlled.  There was a study in BMJ a couple of years ago suggesting that glucose self-monitoring in the aggregate did not change diabetes management, largely because physicians did not act on that information...