Nepal is a cragged landlocked country, situated far off from the sea. The geographical arrangement of the state along with high one-year rainfall leads to moo dirt I content. These factors lead to a really high incidence of iodine lack upsets, which include the spectrum of thyroid disfunction diseases. The purpose of the survey was to happen out the fluctuations of thyroid endocrines and lipid profile in thyrotoxicosis, subclinical hypothyroidism and hypothyroidism.
Material and methods
It was a infirmary based retrospective survey carried out from the informations retrieved from the registry maintained in the Department of Biochemistry of the Manipal Teaching Hospital, Pokhara, Nepal between 1st July, 2009 and 30th June, 2010. The variables collected were age, sex, entire T4, entire T3, TSH, fT4, entire cholesterin and triglycerides.
122 out of the 365 topics selected for the survey had some signifier of thyroid upset. Among these 122 instances, 40 had thyrotoxicosis, 42 had hypothyroidism and the staying 40 were diagnosed to hold subclinical hypothyroidism. Our consequences showed that all the variables ( T3, T4, TSH, fT4, entire cholesterin and triglycerides ) except for age were statistically important when compared to instances. The frequence of thyroid upsets was much higher in females as compared to their male opposite numbers.
Thyroid disfunction is really common both in aged and younger age groups. Therefore, seasonably testing and look into up is a must in order to restrict the job of undiagnosed instances, giving specific consideration to patients who have high artherogenic profile.
Cardinal Wordss: Hyperthyroidism, Hypothyroidism, Subclinical Hypothyroidism, Thyroid endocrines
Thyroid endocrines are important for growing, and to modulate the metamorphosis of protein, saccharides and fat. Endocrine disease of the thyroid may ensue in either under- or overactivity of the secretory organ and may be due to inborn factors, familial sensitivity, unequal degrees of dietetic I consumption, gestation, radiation therapy, viral infection, surgery, underlying disease such as infiltrative upsets, or autoimmunity 1-3. Graves Disease ( spread toxic goiter ) is the most common status of thyrotoxicosis and is caused by overactivity of the immune system ( autoimmunity ) . Other subtypes are sub-acute ( painful, viral ) thyroiditis, soundless thyroiditis ( painless or postpartum thyroiditis ) and toxic multinodular goitre 4. In the UK, thyrotoxicosis has a prevalence of around 2.7 % in females which is about 10 times more than the prevalence in males. Thyroid upsets remain undiagnosed in about 0.5 % of the female population in the UK 5. In a community study comprising of 1210 participants ( age? 60 old ages ) from the UK, the prevalence of undiagnosed open thyrotoxicosis was really low 6. In a similar survey conducted in Sweden, out of 1442 participants ( age ? 60 year ) , merely 2 % of topics were diagnosed to hold hyperthyroidism 7. Hypothyroidism is more common among aged females, holding 15 to 20 times higher hazard for developing the disease when compared to work forces and its incidence is 0.3 to 5 people/1000/yr in America 8. The prevalence of hypothyroidism has been found to be between 0 and 7·8/1000 work forces and between 0 and 20·5/1000 adult females, and for thyrotoxicosis, between 2·0 and 19·4/1000 adult females in Caucasic populations chiefly from Scandinavia, Spain, the UK and the USA 9.
The major cause of hypothyroidism is Hashimoto ‘s disease ( chronic autoimmune thyroiditis ) . Other causes are chiefly due to iodine lack, over treated Graves disease, anti-thyroid drugs and radioactive therapy 13.
Womans are 10 times at higher hazard of developing hypothyroidism compared to work forces, with the difference being important after 34 old ages of age. This is because the symptoms of hypothyroidism and climacteric go manus in manus, go forthing behind more opportunities of losing hypothyroid instances 9. Pregnant adult females are besides at higher hazard 10. The addition in TSH degrees with fT4 in mention scope defines the scaling of subclinical hypothyroidism. The prevalence of subclinical hypothyroidism ranges from 1 % to 10 % worldwide, with prevalence in adult females above 60 old ages of age nearing 20 % in some studies 12. About 6.5 million Americans have undiagnosed and hypoactive or subclinical hypothyroidism and bulk are at the hazard of patterned advance to overt hypothyroidism. Subclinical hypothyroidism is a more common upset than open hypothyroidism, with a prevalence of 1.4-7.8 % in aged population and even greater percentiles among adult females 17. A recent survey by Walsh et Al. confirmed that subclinical hypothyroidism, but non subclinical thyrotoxicosis, is associated with an increased hazard of fatal and nonfatal coronary bosom disease18.
Nepal is a cragged landlocked country, situated far off from the sea. The geographical arrangement of the state along with high one-year rainfall leads to moo dirt I content. These factors lead to a really high incidence of iodine lack upsets, which include the spectrum of thyroid disfunction diseases 14. About 172 million people, or 12 % of the population of South East Asia, are affected by goitre and prevalence in Nepal surpasses all South East Asiatic states. 41 % of the general population here is at higher hazard of developing goitre and betterment is anticipated by the increased ingestion of iodinated salt. The bulk of patients with thyroid disfunction autumn within the 21-40 twelvemonth age group 15. A study done in Nepal in 1996 indicated that 55 % of the population with goitre was localized to cragged parts like Khumbhu and Jumla 16.
Both hypothyroidism and thyrotoxicosis have potentially fatal systemic manifestations. Therefore, accurate and timely diagnosing of thyroid abnormalcies is critical for clinicians every bit good as medical research labs worldwide for appropriate direction. Lab measurings of T3, T4 and TSH are important in assisting clinicians to name thyroid abnormalcies. Historically, hypercholesteremia and Low Density Lipoprotein cholesterin degrees have been found to be associated with subclinical hypothyroidism, hence appraisal of altered lipid profile plays a supportive function in thyroid disfunction. ( REF ) The purpose of the current survey was to happen out the fluctuations of thyroid endocrines and lipid profile in thyrotoxicosis, subclinical hypothyroidism and hypothyroidism.
Materials and Methods
It was a infirmary based retrospective survey carried out utilizing informations retrieved from the registry maintained in the Department of Biochemistry of the Manipal Teaching Hospital, Pokhara, Nepal between 1st July 2009 and 30th June 2010. The variables collected were age, sex, T3, T4, TSH, fT4, entire cholesterin and triglycerides.
Analysis of T3, T4, TSH and fT4 degrees was done by ELISA ( HUMAN ) 19-21. Appraisal of entire cholesterin and triglycerides was done by semi autoanalyser Human 3500, Germany 22. The commercially available kits of Human, Germany were used for all biochemical parametric quantities.
Choice of Subjects:
Inclusion Standards: Patients with unnatural thyroid profile
Exclusion Standards: Patients holding hepatic or nephritic disfunction ; history of bosom failure, diabetes mellitus, stroke or ischaemic bosom disease ; malignance ; alcohol or drug maltreatment were excluded from the survey. Patients who had used any medicines ( within the old six months ) that might hold contained corticoids, antifolates and lipid take downing agents were besides excluded from the survey.
The information collected was analyzed utilizing Excel 2003, R 2.8.0, Statistical Package for the Social Sciences ( SPSS ) for Windows Version 16.0 ( SPSS Inc ; Chicago, IL, USA ) and EPI Info 3.5.1 Windows Version. Z-test was used to compare the significance difference between two variables. A p-value of & A ; lt ; 0.05 ( two-tailed ) was used to set up statistical significance.
122 out of the 365 topics selected for the survey had some signifier of thyroid upset. Among these 122 instances, 40 had thyrotoxicosis, 42 had hypothyroidism and the staying 40 were diagnosed to hold subclinical hypothyroidism.
Our consequences showed that all the variables ( T3, T4, TSH, fT4, entire cholesterin and triglycerides ) except for age were statistically important when compared to instances. The TSH values were markedly increased while T4 and T3 values were found to be less than the mention scope in instances of hypothyroidism. The addition in TSH degrees with fT4 in mention scope defines the scaling of subclinical hypothyroidism. Elevated degrees of T3 and T4 associated with reduced TSH degrees were found in instances of thyrotoxicosis. In hypothyroidism and subclinical hypothyroidism, the entire cholesterin values were reasonably increased and there was no gross mental unsoundness of TG degrees. In thyrotoxicosis, entire cholesterin and triglycerides degrees were mildly decreased but remained within the mention scope.
Table 2: Comparison of gender in controls and instances
** Statistically important ( p value & A ; lt ; 0.05 )
The above consequences show that the frequence of developing thyroid upsets is much higher in females in comparing to males.
Table 3: Gender wise comparing of biochemical variables in instances
Mean ± SD
Mean ± SD
35.47 ± 15.61
53.33 ± 21.80
38.81 ± 13.26
56.83 ± 25.57
35.94 ± 13.95
2.33 ± 0.74
0.40 ± 0.10
0.37 ± 0.20
0.86 ± 0.29
1.02 ± 0.29
13.97 ± 3.36
2.65 ± 0.53
2.13 ± 0.88
5.86 ± 0.60
6.33 ± 1.24
0.32 ± 0.10
14.70 ± 5.40
21.48 ± 11.89
19.98 ± 9.00
15.34 ± 8.31
2.5 ± 0.54
2.7 ± 0.47
0.45 ± 0.25
0.58 ± 0.30
1.10 ± 0.60
1.15 ± 0.22
145.4 ± 10.12
142.37 ± 9.25
265.00 ± 23.15
281.69 ± 35.89
283.50 ± 16.15
265.12 ± 22.25
84.40 ± 15.98
88.30 ± 19.18
152.17 ± 42.16
171.14 ± 45.47
167.50 ± 67.85
176.74 ± 50.59
hyper M-10, F-30: Hypo M-6, F-36: schypo M-6, F-34
** Statistically important ( p value & A ; lt ; 0.05 ) , T Cho ( Total Cholesterol ) , TG ( Triglycerides )
The consequences show that these variables of T3, T4, TSH, fT4, entire cholesterin, triglycerides do non hold any statistical significance with regard to gender. Males and females had about equal fluctuation among the biochemical parametric quantities and the several values do non demo any important difference.
Hyperthyroidism is associated with increased mortality in persons over 60 old ages of age, peculiarly from circulatory incompetency and atrial fibrillation19. ( Sawin CT, Geller A, Wolf PA, et al. Low serum thyrotropic hormone concentrations as a hazard factor for atrial fibrillation in older individuals. N Engl J Med. 1994 ; 331:1249-1252. ) Other effects of thyrotoxicosis include decreased systemic vascular opposition, reduced bone mineral denseness, increased cardiac contractility cardiac end product, bosom rate, left ventricular mass to do diastolic disfunction ( delayed relaxation ) and atrial arrhythmias. Our survey was to emphasize upon the essentialness of laboratory diagnosing before any farther probe or intervention for thyroid upsets. The individual most of import biochemical parametric quantity for corroborating thyrotoxicosis was serum TSH degrees. Our consequences showed low or undetectable serum TSH, good below the mention scope, along with raised serum T4 and T3 degrees in hyperthryoidism. The values obtained were specific for diagnosing of thyrotoxicosis20. ( Jayne Franklyn, MD and James Parle, MD: Hyperthyroidism – ripening, Chapter 8 December 16, 2006 ) . The entire cholesterin and TG values were lowered but remained within normal scope. The values obtained were 143.12 ± 9.43mg/dl, 87.32 ± 18.31 mg/dl which were rather close to the values found by Abrams et al i.e.155±10mg/dl, 106±10mg/dl, of entire cholesterin and TG severally in hyperthyroidism.21. ( J J Abrams and S M Grundy ; Cholesterol metamorphosis in hypothyroidism and thyrotoxicosis in adult male. J. Lipid Res. 1981 22: ( 2 ) 323-338. art23 ) There was addition in post-heparin plasma hepatic lipase activity which led to diminish in serum entire cholesterin while lipoprotein lipase activity and serum triglycerides degrees were normal in instances of thyrotoxicosis ( KAREN S. L. LAM, MAN KAM CHAN ROSE T. T. YEUNG High-Density Lipoprotein Cholesterol, Hepatic Lipase and Lipoprotein Lipase Activities in Thyroid Dysfunction – Effectss of Treatment QJM ( 1986 ) 59 ( 2 ) : 513-521. art24 )
Hypothyroidism was separated into either overt or subclinical disease and that diagnosing was determined on the footing of the TSH research lab blood trials. Hypothyroidism is characterized by low T3 and T4 values with raised TSH degrees. Decreased degrees of T4 and T3 due to iodine lack during the first trimester could ensue in unnatural fetal development. Neurological cretinism is associated with increased degrees of TSH and is characterized by hapless cognitive ability, deaf muteness, address defects and proximal neuromotor rigidness. The female parents with really low serum T4 have higher incidence of still births, abortions and inborn abnormalcies, lending to the higher rate of perinatal deceases as T4 and T3 have strong modulating consequence on the immune system. ( REF? ? ? ? ? ? )
Hypothyroidism is associated with unnatural lipid metamorphosis, cardiac disfunction, diastolic high blood pressure confabulating the elevated hazard of artherosclerosis and if ignored, as in most of the undiagnosed instances, could ensue in ischemic bosom disease and myocardial infarction. ( Morris MS, Bostom AG, Jacques PF, Selhub J, Rosenberg IH. Hyper-homocystinemia and hypercholesteremia associated with hypothyroidism in the 3rd US National Health and Nutrition Examination Study. Atherosclerosis 2001 ; 155:195-200 )
Our survey showed important lower degrees of T4 and T3 with raised Thyrotropin degrees ( 20.5 ± 11.4 mU/L ) . Other surveies reveal that most sensitive index for hypothyroidism was TSH, more than10mU/l, along with decreased degrees of T421. ( . J J Abrams and S M Grundy ; Cholesterol metamorphosis in hypothyroidism and thyrotoxicosis in adult male. J. Lipid Res. 1981 22: ( 2 ) 323-338. art23 ) . In hypothyroidism, there is increased soaking up of cholesterin from bowels, decreased clearance of cholesterin and low denseness lipoproteins from plasma and reduced synthesis of bile acids from cholesterin in the liver.Rosenman, R. H. , S. 0. Byers, and M. Friedman. 1952. The mechanism responsible for the altered blood cholesterin content in crazed thyroid provinces. J. ClinEndocrinol. Metab. 12: 1287- 1299.art25. In our survey, there was important addition in the average concentration of entire cholesterin ( 279.31 ± 34.65mg/dl ) and triglycerides ( 168.43 ± 45.02mg/dl ) in instances of hypothyroidism. In a similar survey done by Texeira at Al in 2008 showed that hypothyroidism could significantly increase the degrees of most of lipoids, most significantly that of cholesterin and LDL. In contrast thyrotoxicosis was non associated with plasma lipid variation23. art27 Teixeira PDE F, Reuters VS, Ferreira MM, Almeida CP, Reis F. A, Buescu A, et Al. Lipid profile in different grades of hypothyroidism and effects of levothyroxine replacing in mild thyroid failure. J. Transl Res. 2008 ; 151:224-31. The mean and SD of cholesterin in hypothyroid topics was 283 ± 53 mg/dl which were rather similar to our values.25 Risal P, Maharjan BR, Koju R, Makaju RK, Gautam M Variation of entire serum cholesterin among the patient with thyroid disfunction Kathmandu University Medical Journal ( 2010 ) , Vol. 8, No. 2, Issue 30, 265-268 art27. In another survey, triglycerides degrees were significantly high in hypothyroid patients when compared with the controls. Torun AN, Kulaksizoglu S, Kulaksizoglu M, Pamuk BO, Isbilen E, Tutuncu NB. Serum entire antioxidant position and lipid peroxidation marker malondialdehyde degrees in overt and subclinical hypothyroidism. Clin Endocrinol ( Oxf ) 2008 ; 34:45-52. art28
The post-heparin plasma hepatic lipase and lipoprotein lipase activity are reduced which leads to increase in serum entire cholesterin and triglyceride in instances of open hypothyroidism. KAREN S. L. LAM, MAN KAM CHAN ROSE T. T. YEUNG High-Density Lipoprotein Cholesterol, Hepatic Lipase and Lipoprotein Lipase Activities in Thyroid Dysfunction – Effectss of Treatment QJM ( 1986 ) 59 ( 2 ) : 513-521. art24 Unlike increased serum cholesterin degrees, triglyceride metamorphosis is non grossly deranged in hypothyroidism28. Abrams J J and Grundy S M. Metabolism of plasma triglycerides in hypothyroidism and thyrotoxicosis in adult male. The Journal of Lipid Research 1981 ; 22: 307-322.
In instances of subclinical thyrotoxicosis, fT4 ( 1.15 ± 0.21 pg/ml ) degrees were in mention scope and TSH degrees ( 10.04 ± 1.46 mU/L ) were reasonably raised. These values were rather close to values found in other surveies i.e TSH ( 11.43 ± 5.50 mU/L ) and fT4 ( 1.05 ± 0.21 pg/ml ) .25. Risal P, Maharjan BR, Koju R, Makaju RK, Gautam M ; Variation of entire serum cholesterin among the patients with thyroid disfunction: Kathmandu University Medical Journal ( 2010 ) , Vol. 8, No. 2, Issue 30, 265-268.
Our consequences showed that the degrees of entire cholesterin was increased ( 257.88 ± 22.29mg/dl ) while triglyceride degrees were near the upper bound of the mention scope ( 152.35 ± 53.55mg/dl ) . The serum entire cholesterin was increased while serum triglyceride degrees, activity of post-heparin plasma hepatic lipase and lipoprotein lipase were normal in instances of subclinical hypothyroidism KAREN S. L. LAM, MAN KAM CHAN ROSE T. T. YEUNG High-Density Lipoprotein Cholesterol, Hepatic Lipase and Lipoprotein Lipase Activities in Thyroid Dysfunction – Effectss of Treatment QJM ( 1986 ) 59 ( 2 ) : 513-521. In other surveies, entire cholesterin and TG degrees were 237.50+1.01mg/dl and 168.53+0.89mg/dl severally in instances of subclinical hypothyroidism, slightly similar to above mentioned results26. Ibrahim M Madani, EL amin Ammar M, Mahmoud Niamat O, EL Sanosi Mai M, EL Bagir Nabiela M. Effect on subclinical hypothyroidism on of import serum lipid values of Sudanese adult females. Journal of Chinese Clinical Medicine 2010 ; 7 ; Vol.5, no.7
Similar consequences obtained from other surveies show that serum degrees of entire cholesterin and LDL were increased in patients of subclinical hypothyroidism in comparing to the normal controls ( euthyroid ) 27. Bauer D C, Ettinger B, Browner WS, Thyroid maps and serum lipoids in older adult females ; A population based survey, AMJ Med, 1998,104 ( 6 ) :546-551.
Therefore, it is seen that patients with thyroid disfunction had important reversible changes in degrees of serum entire cholesterin and triglycerides.
Thyroid disfunction is really common both in aged and younger age groups so regular testing shall be at that place to minimise the job of undiagnosed instances peculiarly the patients holding the artherogenic profile.
Future Directions of the Study Multi-centered randomized and population based surveies is needed to acquire the association between hypothyroidism and cardiovascular upsets. The maximal randomised, placebo-controlled tests of iodine supplementation should be started such as salt iodization. Regular medical examinations of adult females & A ; gt ; 50 old ages old to avoid confusion as the symptoms of climacteric and hypothyroidism are similar. Early showing is cheap and would forestall patterned advance to hypothyroidism. The prenatal medical examinations ( peculiarly in the first trimester ) aid in forestalling the premature bringing and birth defects. Maternal iodine supplementation is necessary earlier or during gestation. Iodine lack continues to be a major job in Nepal and demands a clear control scheme, uniting ongoing iodine supplementation and instruction.