Zeitschrift fur die gesamte innere Medizin und ihre Grenzgebiete最新文献

Recent in vitro and in vivo data indicate that intrathyroidal iodine deficiency is the most important factor for the development of endemic goitre. Normalisation of the thyroid iodine content is essential to achieve regression of hyperplasia of iodine-depleted thyroid tissue. As clinical studies clearly demonstrate iodine should always be part of therapy of euthyroid diffuse endemic goitre. After therapy with levothyroxine alone the intrathyroidal iodine deficiency remains unchanged, and relapse of goitre will soon occur. There are the following indications for conservative therapy of euthyroid diffuse endemic goitre: 1. Children and adolescents should be treated by iodine alone (100-200 micrograms/die). 2. For adults a combined therapy with levothyroxine (100 micrograms/die) plus iodine (200 micrograms/die) is to be preferred to avoid the possible induction of thyrotoxicosis or autoimmune thyroid disease by high iodine doses (monotherapy with iodine would need 400-500 micrograms/die). In addition no reduction of goitre volume can be expected in adults older than 40 years because of an increasing number of thyroid nodular formations. 3. During pregnancy the combination therapy has advantages as high iodine dosages of iodine, potentially dangerous for the foetus, can be avoided whereas goitre formation in the mother is effectively suppressed and iodine deficiency in mother and child is compensated. Goitre therapy should be carried out at least for 6 months. The efficacy of goitre therapy should be controlled by sonographic determination of thyroid volume at least once a year after the end of treatment. An effective goitre prophylaxis with 100-200 micrograms iodine per day is recommended following the actual therapy period.

We tested the haemorheological effects of the addition of 3.5% oxypolygelatine, 10% dextran 40, 6% dextran 75 or 5% albumin, respectively, to fresh donor blood of 25 healthy young persons. We examined the aggregation and the viscosity of substituent plasma mixtures in such various, but constant volume relations as may be present during intravenous infusion. Albumin reduced viscosity and aggregation, but especially dextran 75 increased both parameters significantly.

Thyroiditis are common causes of the goitrous enlargement of the thyroid, and comprise a number of inhomogeneous disorders. The only criterion they have in common is an inflammatory infiltration of thyroid tissue. The following diseases belong to this group: Hashimoto's thyroiditis, thyroiditis de Quervain, acute thyroiditis, Riedel's thyroiditis and rare forms of thyroiditis. These diseases are reviewed with regard to incidence, etiology, pathogenesis, clinical features, diagnosis and treatment.

Goitre defines any enlargement of the thyroid independent of its cause. Worldwide iodine deficiency is the single most common cause of a goitre. However, before iodine deficiency is established, other thyroid diseases need to be ruled out. Very rarely increased production of TSH (secondary hyperthyroidism) or of hormones with TSH activity (e.g. hCG producing tumours), inborn errors of iodine metabolism, and defects of the thyroid hormone receptor (thyroid hormone resistance) are the cause of a goitre. Furthermore, malignancy of the thyroid and autoimmune disease (e.g. Grave's disease) may lead to a thyroid enlargement. Still, worldwide more than 90% of the 200 million patients with goitre suffer from iodine deficiency. In Germany, as in only few other European countries which lack any nation-wide prophylactic iodine supplementation, goitre is endemic with a prevalence of about 25%. The classical concept on the mechanism of iodine deficiency induced goitre is based on decreased thyroid hormone synthesis in the presence of iodine depletion, which leads to increased production of TSH, stimulating thyroidal growth. Recent in vitro findings using thyroid cell cultures expand this concept by demonstrating that TSH regulates the differentiation and function of thyroid cells and may induce hyperplasia, but not cell proliferation. In contrast to TSH, the locally produced growth factors IGF I (insulin-like growth factor I) and EGF (epidermal growth factor) stimulate thyroid cell proliferation. Intrathyroidal iodine antagonises the effects of IGF I and EGF and simultaneously stimulates transforming growth factor beta (TGF-beta), which inhibits thyroid cell proliferation. Thus, intrathyroidal iodine appears to regulate thyroidal growth by controlling proliferation stimulating (IGF I, EGF) and proliferation inhibiting (TGF-beta) growth factors. Though these new insights fill several gaps of the classical concept on the pathogenesis of endemic goitre, open questions remain.

The influence of a standardised fatty test meal on the composition of high-density lipoprotein (HDL) subfractions (HDL3, HDL2) and the concentration of other lipid parameters was investigated in a group of young women of the age 20-25 years, in women of the age range 60-90 years, and in a group of patients with arteriosclerotic diseases. Total cholesterol and HDL cholesterol in serum do not change significantly under extreme conditions of postprandial lipaemia. This is true also regarding persons in high age groups and patients with arteriosclerotic diseases. In contrast to the group of young subjects, 60-90 years old women show both elevated HDL triglyceride levels under basal conditions and a greater magnitude of HDL triglyceride enrichment under the conditions of postprandial lipaemia. Patients with arteriosclerotic diseases also exhibit a marked postprandial HDL triglyceride enrichment. It is concluded that there are metabolic relations between the observed low HDL2 cholesterol concentrations in the group of older subjects and in patients with arteriosclerotic diseases and the high magnitude of HDL triglyceride increase in the postprandial state which are relevant within the risk syndrome hypertriglyceridaemia-low HDL2 levels.

The evaluation and management especially of cold thyroid nodules remains an area of controversy. The past decade has witnessed two important advances. The increased availability of fine-needle aspiration of thyroid nodules has altered the clinician's approach to this disease, and provides for the single most precise method for selecting appropriate patients for surgery. The introduction of high-resolution thyroid ultrasonography provides for anatomic definition that is clearly superior to thyroid scintigraphy. However, radionuclide imaging remains critical for determining the functional status of abnormal thyroid tissue. This review attempts to provide a practical approach to the evaluation and management of the thyroid nodule. Only rare data exists concerning the therapeutic approach of cold thyroid nodules and non-toxic nodular goitre. There seems to be a size-reducing effect by thyroxin-treatment, but no data are reported from iodine deficient areas. Concerning the treatment of differentiated thyroid carcinoma total thyroidectomy combined with eradication of remaining thyroid tissue with iodine 131 is usually preferred. In case of smaller or occult carcinoma various modes of uni- or bilateral subtotal resection are used. Chemotherapy is of little use in treating differentiated thyroid carcinoma and remains as a last possibility if usual approaches are no longer effective. To control local-invasive growth of anaplastic thyroid carcinoma combined treatment with mitoxantrone and hyperfractionated irradiation seems to be a successful approach.

Thirteen percent of all dementia disorders are potentially reversible. Hypothyroidism is among the most frequent causes of reversible dementias. Although it is generally accepted that dementia symptoms in hypothyroidism can be significantly reduced, many questions about the therapeutic efficacy are unexplained. It has not been systematically investigated which psychopathological symptoms respond well to thyroid hormone substitution, how long the treatment should last and whether duration of symptoms or severity of dementia have an influence on the degree of remission of psychopathological impairment. We investigated these questions in two prospectively studied cases with dementia in hypothyroidism.

New therapeutic modalities have shown remarkable advances in the fields of systemic lupus erythematosus and Wegener's granulomatosis. For an optimal clinical outcome therapy has to be started early and must be adapted to disease activity. Concerning these two points early diagnosis is essential. This aim can be reached by a detailed evaluation of the patient's history by focusing on early symptoms and on typical clinical constellations, taking into account that both diseases show a great variability and sometimes even an insidious course. Immunological tests, capillary microscopy, echocardiography and computed tomography can be very helpful in the diagnosis of these diseases.