Presence Of Graves Research Articles

Serum Lipoprotein(a) Is Not Associated with Graves' Ophthalmopathy.

Aim: To investigate the relationship of serum lipoprotein(a) [Lp(a)] and other serum lipids with presence of Graves' ophthalmopathy (GO). Methods: A total of 99 consecutive patients diagnosed with Graves' disease (GD), aged 18-65 years, who had not received prior treatment for GO, thyroid surgery, or radioactive iodine therapy, were recruited between June 2020 and July 2022. In addition, 56 healthy controls (HCs) were included as the control group. All patients underwent an ophthalmological examination, and were classified based on the presence of GO into the GO group (n = 45) and no GO group (n = 54). Fasting blood samples were collected from all participants to analyze serum lipid parameters, including Lp(a), total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides. Results: The median serum levels of Lp(a) were 5.7 [4.3-9.2] in the GO group, 6.7 [3.7-9.9] in the no GO group, and 4.7 [3-7.6] in the HC group. The intergroup comparisons of serum Lp(a) levels showed no significant result. The serum levels of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides were also similar between the groups (P > 0.05 for all). However, when analyzing only euthyroid GD patients and the control group, the serum LDL cholesterol levels were found to be significantly higher in the euthyroid GO group [median: 132 interquartile range (IQR) (110-148) mg/dL] than in the HCs [median: 96 IQR (94-118) mg/dL] (P = 0.002). Conclusion: The findings of our study did not support the association between serum Lp(a) levels and GO.

Association between high mobility group box-1 circulation level and Graves' ophthalmopathy

Background: Graves' disease is a prevalent autoimmune disorder that causes hyperthyroidism. Despite being widely recognized, the risk factors for its associated condition, ophthalmopathy, are not well understood. High Mobility Group Box 1 (HMGB1), a damage-associated molecular pattern biomarker, has been linked to autoimmune diseases and may play a role in Graves' ophthalmopathy. The aim of this study is to assess the correlation between the levels of circulating HMGB1 and the occurrence of Graves' ophthalmopathy (GO). Methods: This cross-sectional study evaluated 44 recently diagnosed Graves' disease patients at Sardjito Hospital. The presence of Graves' ophthalmopathy (GO) was determined using criteria set by Bartley and Gormans. The levels of HMGB1 were measured in the blood of both groups (22 GO patients and 22 controls without GO) using ELISA. Statistical analysis, including binomial logistic regression and Mann-Whitney test, was conducted to analyze the data and adjust for confounding factors with multinomial logistic regression. Results: The baseline characteristics of 22 GO patients and 22 non-GO patients were similar, including age (30.91±6.06 vs. 30.68±6.63 years, p>0.05), gender distribution (77.3% vs. 81.8% female, 22.7% vs. 18.2% male, p>0.05), and duration of diagnosis (5.13±2.21 vs. 4.82±1.89 months, p>0.05). However, a significant difference (p<0.001) was found in the levels of circulating HMGB1, with GO patients having a median value of 15.49 pg/mL (5.12-47.59 pg/mL) compared to 2.33 pg/mL (0.82-15.66 pg/mL) in the control group. The risk of developing ophthalmopathy increased 12 times when Graves disease patients had HMGB1 levels above 8.86 pg/mL. Conclusion: The study found a significant association between elevated levels of HMGB1 (> 8.86 pg/mL) and an increased risk (12 times) of Graves’ ophthalmopathy in newly diagnosed Graves' disease patients. The results suggest that HMGB1 may be a potential biomarker for predicting the development of ophthalmopathy in Graves' disease patients.

Abstract 90: Graves disease and parkinsonism: Is there a link?

Background: Symptoms of Parkinsons Disease can be easily overlooked in a patient with Graves disease. We report a case of Graves's disease whose tremors persisted despite adequate therapy with beta blockers and anti-thyroid drugs.Case Report: A sixty-five-year-old gentleman was diagnosed with Graves's disease three years ago. He was started on carbimazole, optimal doses. At the same time, the patient had slowness of movements, short stepping gait, and rigidity of limbs. The patient was diagnosed with Parkinsonism. The patient was started on optimal doses of dopaminergic drugs and was lost to follow up. The patient presented in October 2021, with weight loss, palpitations, diarrhoea, excess sweating, fine tremors of hands, anxiety and irritability, altered mental status, muscle stiffness which worsened over 4 weeks. The work up was negative for autoimmune Parkinsonism. Patient had stopped all the medications for Graves's disease and also dopaminergic drugs. Optimisation of carbimazole dose and dopaminergic drugs was done; patient is currently doing well and on regular follow up.Conclusion: This case report highlights the coexistence of Graves and Parkinsonism and importance of distinguishing immune mediated from degenerative Parkinsonism that can coexist in the presence of Graves which is an autoimmune disorder.

Thyroid-Stimulatory Antibody as a Predictive Factor for Graves' Disease Relapse.

Introduction: Thyroid-stimulatory antibody (TSAb) assays have been recently optimized, potentially allowing to determine thyrotropin receptor antibodies' (TRAbs) functionality in routine clinical practice. We aimed to determine TSAb's predictive role of relapse at antithyroid drug (ATD) withdrawal in Graves’ disease (GD).Methods: Retrospective study of GD patients with stable normal thyroid function under low ATD doses that were proposed for withdrawal. Thyroid function tests and TRAb and TSAb levels were obtained at ATD suspension and every three to six months after that, for a minimum of 16 months. Clinical factors associated with GD relapse, such as age at diagnosis, sex, smoking status, thyroid volume, and presence of orbitopathy, were also evaluated.Results: Thirty-five patients with GD were included for analysis, with a median follow-up period of 24 months, during which 14 patients (40%) relapsed. Relapse was more common in patients with positive TSAb than patients with negative TSAb at ATD withdrawal (79% vs. 33%, p=0.01). Relapse-free survival was shorter in TSAb-positive patients (p=0.01). There were no differences in relapse rates according to TRAb positivity at ATD withdrawal (42.9% vs. 36.4%, p=0.74). We also did not find any differences in relapse rate regarding age, sex, smoking status, thyroid volume, or presence of Graves’ orbitopathy. On multivariate analysis, only TSAb positivity at ATD withdrawal was independently associated with relapse (hazard ratio [HR] 6.63, 95% confidence interval [CI], 1.30-33.7, p=0.02).Conclusion: At ATD withdrawal, TSAb-positive patients demonstrated a higher risk for GD relapse. Measuring TSAb before ATD suspension, instead of TRAbs, could become an important tool for the clinical management of these patients.

ДО БІОГРАФІЇ РОДИНИ ВОЛИНСЬКИХ ЧЕХІВ-КАМЕНОТЕСІВ ДЛОУГІ

The article presents biographical facts from the life of family members of the Volyn Czech stonemasons Dlougi. The first known mention of Vaclav Yosypovich Dlouga’s activity belongs to Oleksiy Abramov, the author of the book «Lenin’s Mausoleum», the first edition of which was published in 1963. It contains the stonecutter’s recollections of the search for black labradorite in the Golovinsky quarry in the Zhytomyr region for the Mausoleum. The results of the study of Zhytomyr cemeteries for the presence of graves of members of the Dlougi family, as well as for the presence of monuments made in the Dlougi workshop are described. Tombstones made in Dlouga’s workshop have been preserved in the historical cemeteries of Zhytomyr, in particular in Poland, Vilsk (Russia), Smolyan, and Pylypon. The metric records of members of the Dlougi family are analyzed, and the transformation of the Czech surname in the records of that period is traced. Data on the main achievements of masters on outstanding constructions are given, technological features of processing of a stone which were advanced at that time are described. Dloughy’s stone-cutting workshop made monuments from labradorite, gray and red granite, plinths, stairs and iron fences. At the same time, data on the birth, professional and social activities of members of this family are generalized. The results of research of cemeteries in Zhytomyr, where there are graves of family members, as well as monuments made in Dlougi’s workshops are presented. The facts of political repressions on the basis of ethnicity of family members are described. In the late 1920s and early 1930s, the Czech population of the Zhytomyr region fully experienced the punitive policies of the Soviet government, suffering significant losses during «linear» arrests on national grounds. Family ties of Czechs with the surname Dlougi, who lived on the territory of Volyn Gubernia at that time, have been established. The contribution of the Czech family to the technology of stone processing, the ability to be enterprising and socially active is emphasized.

Basedow-Graves\u2019 disease in a pediatric patient with Sticlker syndrome, a new endocrine finding to improve personalized treatment

BackgroundStickler syndrome is a connective tissue disorder with predominantly autosomal dominant inheritance, with ocular, auditory and joint involvement.Thyroid dysfunction was not described as part of alterations in Stickler syndrome and in particular, the association between Stickler’s syndrome and Graves’ disease has never been previously reported in literature.Moreover, the presence of Graves’ disease is uncommon in the pediatric age (especially in children younger than 6 years old).Case presentationWe report the case of a 5-years old child affected by Stickler syndrome who received the diagnosis of Graves’s disease, in absence of suggestive symptoms, during health supervision.ConclusionsThis is the first evidence of thyroid dysfunction and autoimmune pattern for Sticker syndrome.Further clinical reports are expected before suggesting the implementation of new clinical skills for Stickler syndrome, but this paper may contribute to improve personalized management of this rare disorder.

Thyroid Storm in a Young Woman: A Clinical Case

Thyroid storm is a rare condition, but it can be characterized as a threat to life. It presents as an increase in the functions of the thyroid gland due to dysfunction of the central nervous system. It is characterized by pyrexia, tachycardia, heart failure and alterations in the digestive system. The objective of this report is to describe the case of a young woman with no previously reported diseases, who was affected by the thyroid storm, without the presence of Graves' disease.

The clinical phenotype of Graves' disease occurring as an isolated condition or in association with other autoimmune diseases.

Graves' disease (GD) can present as an isolated disease (iGD) or in association with other autoimmune diseases (aGD). The aim of this study, performed in two Endocrine referral centers settled in different geographical areas of Italy, was to compare the anthropometric, clinical, and biochemical phenotype of iGD patients with that of the aGD ones. Clinical history, physical examination data, serum levels of TSH, FT4, FT3, thyroglobulin (TgAb), thyroid-peroxidase (TPOAb) and TSH-receptor (TRAb) antibody, presence of Graves' orbitopathy (GO), and thyroid ultrasound examination at disease diagnosis were recorded. 68 aGD and 136 iGD patients were consecutively recruited. At diagnosis, aGD and iGD patients did not differ for F/M ratio, age at presentation, thyroid function parameters, serum levels of TRAb, TgAb, TPOAb, presence of GO, and thyroid volume. The serum levels of TRAb were strongly correlated with the circulating concentrations of both FT3 (ρ = 0.667; p < 0.0001) and FT4 (ρ = 0.628; p < 0.001) in iGD patient, but not in the aGD ones (FT3: ρ = 0.231; p = 0.058; FT4: ρ = 0.096; p = 0.435). Compared with iGD patients, the aGD ones displayed a higher rate of transition from the previous hypothyroidism to hyperthyroidism (χ2 = 6.375; p = 0.012). Despite similar anthropometric, clinical, and biochemical features at diagnosis, aGD patients display a higher rate of transition from a thyroid functional status to the other as compared with iGD patients.

SUN-621 Lessons from beyond the Graves'

Introduction: The coexistence of thyrotoxicosis and thyroid carcinoma is a well-recognised clinical phenomenon. Patients with Graves’ disease have an increased risk of developing thyroid carcinomas than in patients with toxic adenoma or toxic multinodular goiter. We report a patient with Graves’ disease who had a ‘silent’ thyroid cancer. Clinical Case: A 20 year-old female was diagnosed with Graves’ disease. She had clinical signs of Graves’ ophthalmopathy, a thyroid goiter, sinus tachycardia and unintentional weight loss. Her TSH level was <0.005 mIU/L [0.40 - 3.50 mIU/L], free T4 level was 40.9 pmol/L [9.0 - 19.0 pmol/L], free T3 level was >46.1 pmol/L [2.6 - 6.0 pmol/L] and TSH receptor antibody (TRAb) level was 27.5 IU/L [<1.0 IU/L]. She denied prior head/neck irradiation or a family history of thyroid disorders. She was commenced on carbimazole. Her initial thyroid ultrasound (January 2016) demonstrated a heterogenous, hypervascular goiter (right lobe measured 65 x 31 x 25 mm and left lobe measured 50 x 21 x 31 mm). On her repeat thyroid ultrasound (April 2017), the heterogeneous hypervascular goiter had increased in size (right lobe 81 x 37 x 36 mm and left lobe 64 x 31 x 36 mm). A thyroid technetium scan identified diffuse radiotracer uptake (82.51%), consistent with Graves’ disease. Due to refractory Graves’ disease and the presence of Graves’ ophthalmopathy, a total thyroidectomy was performed (February 2018). Surprisingly, post-operative histopathology identified a 60 mm papillary thyroid carcinoma in the right lobe and a 36 mm papillary thyroid carcinoma in the left lobe, with lymphovascular and adipose tissue invasion. The tumours were negative for BRAF V600E. The remaining thyroid tissue showed Graves’ thyroiditis. Six weeks post-thyroidectomy, she had a thyroglobulin level at 16.3 μg/L [0 - 28 μg/L], undetectable anti-thyroglobulin antibody and TRAb level at 4.4 IU/L. Radioactive iodine remnant ablation was performed (August 2018) with steroid cover for persisting Graves’ ophthalmopathy. Her whole body I-131 scan identified residual thyroidal type tissue in the thyroid bed and diffuse uptake throughout both lungs, likely secondary to inflammation from a flu-like illness prior to her scan. Her thyroglobulin levels had reduced to 1.1 μg/L, with TSH level of 12 mIU/L, free T4 level of 18 pmol/L and free T3 level of 3.3 pmol/L. Conclusions: Patients with Graves’ disease have an increased risk of thyroid carcinomas, possibly related to TSH receptor antibodies. It is usually either clinically apparent or occult micro-carcinomas. Large papillary thyroid carcinomas in Graves’ disease not detected by thyroid technetium scan or thyroid ultrasound is rare.

Long-term remission following antithyroid drug withdrawal in patients with Graves' hyperthyroidism: parameters with prognostic value.

To assess the predictive value of some clinical and biochemical parameters, and of the +49 A/G polymorphism of the CTLA-4 gene, for long-term remission following the withdrawal of antithyroid drugs before starting antithyroid drug therapy. Observational, prospective and longitudinal study. Seventy-two patients (11 of whom were men) with newly diagnosed Graves' hyperthyroidism who had been attended consecutively at a University Clinic in a population with sufficient iodine intake were included in the study. patients under the age of 18, pregnant women and non-Caucasian patients. All subjects were treated following a well-defined protocol. Long-term remission was calculated at 12 and 36 months following withdrawal of the antithyroid drug. Thirty-six of the 72 study subjects experienced a remission of at least 12 months following withdrawal of methimazole, with no differences according to their age or sex. A comparison made between the remission rates seen in both groups yielded significant differences regarding the presence of Graves' orbitopathy, the duration of the treatment with methimazole and the absence of the CTLA-4 G/G genotype. In the univariate and multivariate analyses performed, only lower frequencies of Graves' orbitopathy and an absence of the CTLA-4 G/G genotype were considered independent predictors of long-term remission. The absence of Graves' orbitopathy and of the CTLA-4 G/G genotype are independent predictors of long-term remission following a first course of antithyroid drugs.

Pola Spasial Permukiman Tradisional Bali Aga di Desa Sekardadi, Kintamani

The Bayung Gede village has derived smaller traditional settlements around Kintamani. Sekardadi is one of these settlements that has an inherent consociates with the village of origin, or the Bayung Gede. Despite the fact that the Sekardadi has a uniqueness on spatial pattern and house lay out, this village has not been welldocumented as an old village in Bali. These uniqueness are interesting to be indepth explored. It is not only on the basic philosophy of the house pattern, but also how this pattern to be physical implemented. This study aims to describe some characteristics of the village, both physical and nonphysical aspects, through the way of descriptive exploratory qualitative approach. According to the theory housing pattern of Habraken (1978) and Turgut (2001), research variables are determined into three variables: 1) Cultural setting; 2) Behavioural setting; and 3) Spatial setting. The result shows that macro spatial pattern of the Sekardadi village is divided into three zones: 1) Utama Mandala locates in the north of the village; 2) Madya Mandala is in the middle of the village, and 3) Nista Mandala in the south. Spatial pattern follows the hulu-teben conception or linear pattern with the main road as a cardinal orientation. Higher land means a sacred area (parahyangan) that is characterized by the existence of Pura Puseh. Meanwhile, the opposite is defined as a profane area (palemahan) with the presence of graves; and in the middle is the settlement (pawongan). Keywords: spatial pattern; traditional settlement; Sekardadi village

Kinetic analyses of changes in serum TSH receptor antibody values after total thyroidectomy in patients with Graves' disease.

We often recommend total thyroidectomy for patients with Graves' disease who wish to have a child in the near future in order to prevent fetal or neonatal hyperthyroidism, especially if the patients' serum thyrotropin receptor antibody (TRAb) values are high. The aim of this study was to analyze changes in serum TRAb values using a quantitative third-generation assay after total thyroidectomy and the half-lives of serum TRAb values to estimate the postoperative time needed to achieve the safe TRAb value for mothers. We retrospectively examined the records of 45 Graves' disease patients who underwent a total thyroidectomy and had high serum TRAb values. We also evaluated factors that prolonged the postoperative reduction of serum TRAb values. The serum TRAb values decreased rapidly in most of the patients, especially within the early postoperative (3-month) period. The presence of Graves' ophthalmopathy (GO) (p=0.001), smoking (p=0.004), and serum thyroglobulin values > 0.5 ng/mL at postoperative 12 months (p=0.039) were significantly associated with prolonged half-lives of the serum TRAb values. The median TRAb value half-life was 93.5 days in the patients without GO or smoking, 162.5 days in the patients with GO or smoking, and 357.4 days in the patients with both GO and smoking. Our findings indicate that using the half-life of patients' serum TRAb values determined by this third-generation assay would be effective to evaluate the reduction of serum TRAb values after total thyroidectomy and to estimate the postoperative time needed to achieve the maternal safe value.

Indications for surgical treatment in benign thyroid disease

The treatment of thyroid cancer involves surgery. However, treatment of benign thyroid disease is debatable. Goitre should be treated by surgery if malignancy is suspected and if there are compressive signs and symptoms. Similarly, true recurrence of goitre should be treated surgically in the case of suspected malignancy and in the case of compressive symptomatology. Thyroid nodules should also be treated surgically if there is suspicion of malignancy and if there are compressive signs and symptoms. Surgery for the treatment of Graves’ disease is indicated in the case of suspected malignancy within a thyroid nodule and in the presence of Graves’ ophthalmopathy. In conclusion, indications for surgical treatment in benign thyroid disease are the suspicion of malignancy, compressive signs and symptoms, and the presence of Graves’ ophthalmopathy in Graves’ disease.

Tubulointerstitial nephritis and uveitis syndrome complicated by IgA nephropathy and Graves’ disease: a case report

IntroductionTubulointerstitial nephritis and uveitis syndrome is a disorder characterized by a combination of acute tubulointerstitial nephritis and uveitis. Immunoglobulin A nephropathy is defined by the presence of immunoglobulin A deposits in glomerular mesangial areas. In this report, we describe a rare case of tubulointerstitial nephritis and uveitis syndrome complicated by immunoglobulin A nephropathy and Graves’ disease, which was successfully treated with corticosteroids. To the best of our knowledge, this is the first time such a case has been documented since tubulointerstitial nephritis and uveitis syndrome was first described.Case presentationA 64-year-old Japanese woman presented with tubulointerstitial nephritis and uveitis syndrome accompanied by immunoglobulin A nephropathy and Graves’ disease. She had renal dysfunction, proteinuria, and hematuria. Two weeks after her admission, she developed anterior chamber uveitis. She received corticosteroids, resulting in significant clinical improvement.ConclusionTubulointerstitial nephritis and uveitis syndrome is a relatively uncommon cause of tubulointerstitial nephritis. Clinicians should recognize that tubulointerstitial nephritis and uveitis syndrome with immunoglobulin A nephropathy can occur in the presence of Graves’ disease. Additionally, this report may provide important clues in terms of the management of a concomitant case of these diseases.

Predictors of Nondiagnostic Cytology in Surgeon‐Performed Fine‐Needle Aspiration Biopsy of Thyroid Nodules

Objectives: (1) List the factors that are predictive of non-diagnostic cytology in surgeon-performed ultrasound-guided fine-needle aspiration (FNA) of thyroid nodules. (2) Describe a patient cohort that may benefit from early referral to other clinicians. Methods: Retrospective chart review. Patients included all adults who underwent thyroid nodule FNA by a staff, fellow, or resident otolaryngologist at our center between January 2011 and June 2013. Cytology was interpreted by a staff cytopathologist according to the Bethesda classification system. The predictive factors analyzed were patient age, sex, body mass index (BMI), thyroid gland size, thyroid function, presence of multinodular goiter, presence of Graves’ disease or thyroiditis, nodule size, location, vascularity, echogenicity, calcifications, cystic component, level of performer training, and level of FNA experience. Results were analyzed using chi-squared, Fisher exact test, or unpaired t test. Results: A total of 190 patients were reviewed, for a total of 301 nodules. The average age was 53 years, with an 88% female predominance. The overall nondiagnostic rate was 23%. Nodules with a predominant cystic component and those less than 1 cm were more likely to yield nondiagnostic cytology ( P = .04, P = .05, respectively). FNA performed by a trainee with experience of less than 50 FNA were also more likely to yield nondiagnostic cytology ( P = .04). No other factors significantly influenced the nondiagnostic rate. Conclusions: Cystic nodules and nodules less than 1 cm are more likely to yield non-diagnostic cytology in surgeon-performed thyroid FNA. Caution should be used in trainee-performed FNA for which the nondiagnostic risk is high. These patients may benefit from early referral to other clinicians.

A Case of simultaneous occurrence of Marine – Lenhart syndrome and a papillary thyroid microcarcinoma

BackgroundMarine-Lenhart syndrome is defined as the co-occurrence of Graves’ disease and functional nodules. The vast majority of autonomous adenomas are benign, whereas functional thyroid carcinomas are considered to be rare. Here, we describe a case of simultaneous occurrence of Marine-Lenhart syndrome and a papillary microcarcinoma embedded in a functional nodule.Case presentationA 55 year-old, caucasian man presented with overt hyperthyroidism (thyrotropin (TSH) <0.01 μIU/L; free thyroxine (FT4) 3.03 ng/dL), negative thyroid peroxidase and thyroglobulin autoantibodies, but elevated thyroid stimulating hormone receptor antibodies (TSH-RAb 2.6 IU/L). Ultrasound showed a highly vascularized hypoechoic nodule (1.1 × 0.9 × 2 cm) in the right lobe, which projected onto a hot area detected in the 99mtechnetium thyroid nuclear scan. Overall uptake was increased (4.29%), while the left lobe showed lower tracer uptake with no visible background-activity, supporting the notion that both Graves’ disease and a toxic adenoma were present. After normal thyroid function was reinstalled with methimazole, the patient underwent thyroidectomy. Histological work up revealed a unifocal papillary microcarcinoma (9 mm, pT1a, R0), positively tested for the BRAF V600E mutation, embedded into the hyperfunctional nodular goiter.ConclusionsNeither the finding of an autonomously functioning thyroid nodule nor the presence of Graves’ disease rule out papillary thyroid carcinoma.

Surgical Treatment of Graves’ Disease: Evidence‐Based Approach

The optimal treatment of Graves disease (GD) is still controversial. Surgery is one treatment option along with radioactive iodine (RAI) and antithyroid medication. In this evidence-based review, we examine four issues: (1) Is surgery better than RAI or long-term antithyroid medication? (2) What is the recommended surgical approach? (3) How does the presence of Graves' ophthalmopathy (GO) influence the role of surgery? (4) What is the role of surgery in children with GD? We conducted a systematic review of the literature using evidence-based criteria regarding these four issues. (1) There are no recommendations reaching any grade of evidence for which treatment to choose for adults with GD. (2) Total thyroidectomy has complication rates equal to those seen with lesser resections but it has higher cure rates and negligible recurrence rates (Level I-IV data leading to a grade A recommendation). (3) Data support surgery when severe GO is present, but RAI combined with glucocorticoids may be equally safe (Level II-IV data, grade B recommendation). The extent of thyroid resection does not influence the outcome of GO (Level II data, grade B recommendation). (4) Based on the available data, definitive treatment can be advocated for children (Level IV data, grade C recommendation) using either RAI or surgery. No recommendation can be given as to whether RAI or surgery is preferred owing to the lack of studies addressing this issue. Increased cancer risk with RAI in children below the age of 5 years supports surgery in this setting (Level I data, grade A recommendation). If surgery is considered for definitive management, evidence-based criteria support total thyroidectomy as the surgical technique of choice for GD. Available evidence also supports surgery in the presence of severe endocrine GO. Children with GD should be treated with an ablative strategy. Whether this is achieved by total thyroidectomy or RAI may still be debatable. Data on long-term cancer risk are missing or conflicting; and until RAI has proven harmless in children, we continue to recommend surgery in this group.

Treatment-Resistant Severe, Active Graves' Ophthalmopathy Successfully Treated with B Lymphocyte Depletion

Treatment-Resistant Severe, Active Graves' Ophthalmopathy Successfully Treated with B Lymphocyte Depletion

The origin of ethics

The evidence of ethics attitudes are quite difficult to be identified in the archaeological record. One of the first attitudes we can assume from the archeological record are those related with the recognition of death and how this recognition change the attitudes related with the deposition of humans corpses when death. The presence of graves or burials are firstly related with the Middle Palaeolithic in Eurasia. Its presence and distribution present many questions not so easy to solve. With the Upper Palaeolithic, the presence of items like decoration elements and those related broadly with “offerings”, give us the opportunity to understand the role of the individuals in the society.

Radioiodine therapy for Graves' disease: case selection and restrictions recommended to patients in North America.

Each of the three major therapies for Graves' disease has its own advantages, disadvantages, indications, and contraindications. Today, radioactive iodine (RAI) therapy is the most commonly employed means of therapy for Graves' disease in the United States, with approximately 70% of patients so treated after initial presentation and an additional fraction of arguably 10-15% treated with RAI after failure of antithyroid drugs or surgery. RAI therapy is acknowledged to have the clear-cut advantage of being safe, with low morbidity and cost. The indications for RAI therapy are clear and noncontroversial for most patients with Graves' disease. Moreover, RAI treatment is employed by some thyroidologists for subclinical thyrotoxicosis (normal T4 or T3 but immeasurable TSH), particularly in patients > age 45 due to risks of atrial fibrillation. RAI therapy is not considered indicated or is contraindicated during breast feeding and in pregnancy, subacute thyroiditis, postpartum thyroiditis, struma ovarii, pituitary (TSH-driven) hyperthyroidism, euthyroid, hyperthyroxinemia, and thyroid hormone resistance. Opinions vary on the use of RAI therapy in children with Graves' disease; generally, a lower age cutoff of 17 years is acceptable in most clinics. Even more controversial is whether RAI therapy in the presence of Graves' ophthalmology constitutes a risk for worsening ophthalmopathy. Resolution of this latter issue awaits more definitive studies, but RAI therapy is likely to remain the first choice for most patients with Graves' disease.