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PubMedDate not supplied

Rationale, development, and clinical outcomes of a multidisciplinary amiodarone clinic.

OBJECTIVES: To review the rationale and development of a multidisciplinary amiodarone clinic, and document the clinical outcomes resulting from its implementation. METHODS: A clinic was established to provide an ambulatory setting in which patients receiving amiodarone could be followed according to published guidelines by a multidisciplinary team of cardiovascular health care specialists. Patients receiving amiodarone were referred to the clinic by their primary physicians. A data base containing each patient's medical history, current drug therapy, and baseline laboratory values was developed during the initial visit. Liver function tests, thyroid function tests, and chest radiographs were performed every 6 months, and pulmonary function tests were scheduled on an annual basis. Dosage adjustments were performed in select patients. RESULTS: Since November 1996, 60 patients have been referred to the amiodarone clinic. Mean length of follow-up before and after referral was 16.3+/-25.5 and 9.2+/-5.5 months, respectively. Laboratory tests were performed according to accepted guidelines in 14 (23%) patients before referral compared with 54 (90%) patients after enrollment (p<0.001). Previously unrecognized adverse events were detected in 21 (35%) patients, including pulmonary fibrosis, QT prolongation, liver enzyme elevation, hypothyroidism, hyperthyroidism, and asthma exacerbation. Amiodarone was discontinued in six patients, four of whom had suspected pulmonary toxicity. The dose of amiodarone was adjusted in 29 (48.4%) patients. CONCLUSION: Many patients receiving amiodarone are not being followed according to published recommendations. Implementation of a specialized, multidisciplinary amiodarone clinic improves outcomes by monitoring for early detection of drug-related toxicities and by facilitating proper dosage modifications.

Adult↗
PubMed1987

Assessment of sensitive thyrotropin assays for an expanded role in thyroid function testing: proposed criteria for analytic performance and clinical utility.

Assays capable of detecting subnormal serum TSH concentrations can permit the prediction of response to TRH and the detection of hyperthyroidism. Five performance criteria for evaluating the eligibility of TSH assays for these new roles are proposed. Criterion 1 requires a less than 1% overlap between the variation of the lower normal value and the assay detection limit. Criteria 2 and 3 require subnormal basal TSH values in 95% of patients with subnormal TRH response, and detectable basal TSH values in 95% of patients with normal TRH responses. Criteria 4 and 5 require undetectable TSH values in 95% of hyperthyroid patients and detectable TSH values in 95% of clinically euthyroid subjects. Evaluation of 20 published studies using commercial reagents showed that only 5 assays met criterion 1; most reports did not provide adequate information for evaluation. We evaluated 2 sensitive assays by assessment of sera from 149 normal subjects and 893 patients. Substantial differences were found; only assay B met all performance criteria. With assay B, serum TSH levels were normal in 86%, increased in 7%, undetectable in 4%, and subnormal in 3% of 454 patients undergoing a screening T4 measurement. Sensitive TSH assays fulfilling our criteria may be useful as front-line thyroid function tests.

Ambulatory Care↗
PubMed2001

Thyroid function test abnormalities in newly admitted psychiatric patients residing in an iodine-deficient area: patterns and clinical significance.

OBJECTIVE: The prevalence of abnormal in-vitro thyroid function tests in psychiatric in-patients may be as high as 24%. Thus far, however, there is only limited data addressing the underlying causes of these abnormal test results, i.e. how often they can be attributed to genuine thyroid disease. METHOD: We conducted an observational study of all in-patients admitted to our institution during 1 calendar year running analyses of total thyroxin (T4), free thyroxin index (FTI) and thyroid-stimulating hormone (TSH). Patients with abnormal test results were classified according to an algorithm which had been established previously. RESULTS: In 243 of 880 patients with in-vitro thyroid function analysis, at least one concentration of either T4, FTI or TSH was found to be outside the reference range. Work-up according to the algorithm was completed in 848 patients; alterations were classified as representing thyroid dysfunction in 100 (41% of patients with abnormal test results), non-specific findings in 92 (38%), influence of ingested drugs in 18 (7%) and of severe physical disease in 1 (0.4%). As measures of T4 and/or FTI provided no essential information in 854 patients (97% of tested), we found that in most cases the determination of TSH alone was sufficient for demonstrating normal thyroid function. CONCLUSION: In 27.6% of newly admitted patients living in an iodine-deficient area, at least one abnormal result in either T4, FTI or TSH values was found. Genuine thyroid disease was found in slightly less than half the patients with an abnormal value.

Adolescent↗
PubMed1991

Effect of education and feedback on thyroid function testing strategies of primary care clinicians.

We examined the effect of an educational memorandum incorporating simple guidelines for thyroid function testing on test utilization in a primary care health maintenance organization practice. We then compared the effectiveness of a reminder alone or combined with individual test ordering feedback at maintaining an effect. The subjects were 17 physicians and 13 physician assistants and nurse practitioners separated into two similar study groups with little clinical interaction. Both groups responded to the education with increased compliance (from 36% to greater than 67%) with the recommended testing strategy. The group subsequently receiving only a reminder showed a further increase in compliance from 68% to 81% at 6 months and 79% at 12 months. The group receiving a reminder and feedback showed no subsequent change in testing pattern (65% compliance before the reminder-feedback and 64% at both subsequent measurements). The effect of the educational intervention was greater on nurse practitioners and physician assistants than physicians (absolute increase in compliance, 63% vs 28%). We conclude that education can be an effective tool for modifying clinician testing patterns to conform to simple clinical guidelines. Further study of the effect of education and other strategies on compliance with more complex guidelines is needed.

Attitude of Health Personnel↗
PubMed1986

Thyroid function tests in patients with familial dysalbuminaemic hyperthyroxinaemia (FDH).

Two patients with familial dysalbuminaemic hyperthyroxinaemia (FDH) are described in whom the albumin variant resulted in raised total T4 levels, and artefactually raised free T4 using a 'single-step' technique employing an analogue of T4 as tracer. The first patient was clinically euthyroid and presented with relapse of schizophrenia and abnormal thyroid function tests (total T4 336 nmol/L, total T3 4.2 nmol/L, TSH 1.8 mU/L, free T4 73 pmol/L). These results led to diagnostic confusion and the patient was treated with a short course of anti-thyroid drugs. The second patient had signs and symptoms of thyrotoxicosis at her first visit but was clinically euthyroid 5 months later when she was 10 weeks pregnant. Thyroid function tests were total T4 259 nmol/L, total T3 3.6 nmol/L, TSH 3.8 mU/L, free T4 46 pmol/L. Further studies showed both patients to be biochemically euthyroid. A variant albumin was confirmed in both patients by a screening test for FDH and by reverse-flow electrophoresis. Family studies on 10 relatives of the first patient identified eight with FDH. A simple screening procedure for the indentification of FDH is described and the use of laboratory tests in suspected cases is discussed.

Adult↗
PubMed2000

[Thyroid function tests in normal pregnant women (third trimester) and in pregnant women with pregnancy cholestasis or with acute hepatitis].

BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) is a disease of unknown cause characterized by pruritus and biochemical cholestasis in the 3rd trimester of pregnancy. Its pathogenesis may be due to the interaction of abnormalities in the metabolism of estrogens and progesterone, while still unknown environmental factor (s) modulate the expressivity of a genetic predisposing trait. AIMS: To verify if thyroid function tests (TFT) are altered in ICP as in other hepatic diseases and whether a dietary iodine deficiency could be involved. MATERIAL AND METHODS: From 1983 to 1986, 13 normal pregnancies (3rd trimester), 26 ICP patients (with 30 pregnancies) and 4 patients with acute non-A non-B hepatitis in pregnancy, were studied. Serum T3, rT3, T4, fT4 and TSH (before and after TRH) were measured by RIA; in ICP patients, measurements were repeated in puerperium. Urinary 24 h iodine excretion was measured in normal pregnancies and in 6 ICP patients. RESULTS: In normal pregnancies, T3 (3.00 +/- 0.22 nmol/L) and rT3 (0.40 +/- 0.03 nmol/L) were higher than the values detected in non-pregnant women; other TFT were unchanged. Urinary iodine excretion was normal in all individuals tested. Patients with acute hepatitis in pregnancy or with ICP had lower T3 than normal pregnancies (1.82 +/- 0.19 nmol/L in hepatitis; 2.24 +/- 0.12 nmol/L in ICP; p < 0.01) and higher rT3 (0.80 +/- 0.25 nmol/L in hepatitis; 0.54 +/- 0.05 nmol/L in ICP; p < 0.05), while other TFT were unchanged. None of them had clinical signs of hypo or hyperthyroidism. A "euthyroid sick syndrome" was detected in 2 ICP patients and in 2 acute hepatitis in pregnancy. In puerperium of ICP patients, T3 and rT3 returned to levels in non-pregnant women. CONCLUSIONS: In ICP patients, TFT show similar trends than in more severe hepatic and non-hepatic diseases. Although thyroid binding-globulin was not measured in our patients, the pattern of TFT suggests that an impaired peripheral (hepatic?) deiodination of T4 is responsible for these changes. The influence of a dietary iodine deficiency can be ruled out.

Acute Disease↗
PubMed2000

Value of thyroid function tests in routine screening of women investigated for infertility.

Women presenting with infertility traditionally have been screened for thyroid function, yet recent guidelines have indicated that this is unnecessary in asymptomatic patients. A retrospective analysis of the results of routine thyroid function screening showed that occult thyroid dysfunction is common: 5.1% of the population studied had abnormal thyroid function tests. Therefore, it is recommended that assessment of thyroid function in women attending an infertility clinic should be continued.

Journal Article↗