Background Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition. Methods The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. Results Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded. Conclusions One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

/pdf/2016-american-thyroid-association-guidelines-for-diagnosis-1a9h72rzxu.pdf

2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis

http://medclerk.weebly.com/uploads/6/8/9/5/6895084/aace_hyper_thyroidism.pdf

Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists

Background: The purpose of this study was to estimate the sensitivity and specificity of diagnostic tests for gallstones and acute cholecystitis. Methods: All English-language articles published from 1966 through 1992 about tests used in the diagnosis of biliary tract disease were identified through MEDLINE. From 1614 titles, 666 abstracts were examined and 322 articles were read to identify 61 articles with information about sensitivity and specificity. Application of exclusion criteria based on clinical and methodologic criteria left 30 articles for analysis. Cluster-sampling methods were adapted to obtain combined estimates of sensitivities and specificities. Adjustments were made to estimates that were biased because the gold standard was applied preferentially to patients with positive test results. Results: Ultrasound has the best unadjusted sensitivity (0.97; 95% confidence interval, 0.95 to 0.99) and specificity (0.95; 95% confidence interval, 0.88 to 1.00) for evaluating patients with suspected gallstones. Adjusted values are 0.84 (0.76 to 0.92) and 0.99 (0.97 to 1.00), respectively. Adjusted and unadjusted results for oral cholecystogram were lower. Radionuclide scanning has the best sensitivity (0.97; 95% confidence interval, 0.96 to 0.98) and specificity (0.90; 95% confidence interval, 0.86 to 0.95) for evaluating patients with suspected acute cholecystitis; test performance is unaffected by delayed imaging. Unadjusted sensitivity and specificity of ultrasound in evaluating patients with suspected acute cholecystitis are 0.94 (0.92 to 0.96) and 0.78 (0.61 to 0.96); adjusted values are 0.88 (0.74 to 1.00) and 0.80 (0.62 to 0.98). Conclusions: Ultrasound is superior to oral cholecystogram for diagnosing cholelithiasis, and radionuclide scanning is the test of choice for acute cholecystitis. However, sensitivities and specificities are somewhat lower than commonly reported. We recommend estimates that are midway between the adjusted and unadjusted values. (Arch Intern Med. 1994;154:2573-2581)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=intemed&articleId=619694&pdfFileName=archinte_154_22_008.pdf

Revised Estimates of Diagnostic Test Sensitivity and Specificity in Suspected Biliary Tract Disease

US is a frequently used modality in current practice to detect acute cholecystitis, but its diagnostic accuracy has a substantial margin of error.

A Systematic Review and Meta-Analysis of Diagnostic Performance of Imaging in Acute Cholecystitis

Background Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This article describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspeciality physicians and others providing care for patients with this condition. Methods The development of these guidelines was commissioned by the American Thyroid Association in association with the American Association of Clinical Endocrinologists. The American Thyroid Association and American Association of Clinical Endocrinologists assembled a task force of expert clinicians who authored this report. The task force examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to develop the text and a series of specific recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. Results Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' ophthalmopathy; and management of other miscellaneous causes of thyrotoxicosis. Conclusions One hundred evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists.

Adolescent varicocele: objective indications for treatment.

To assess the medium- to long-term effects of I-131 therapy of hyperthyroidism in children and adolescents, we studied 51 patients (age range 6 to 18; 8 boys, 43 girls) treated with I-131 for Graves' disease with hyperthyroidism at the University of Michigan Medical Center (1951 to 1972). Patients received total doses ranging from 3 to 81.6 mCi. The mean followup period was 14.6 +- 7.9 yr. Hyperthyroidism was effectively treated in 49 within 1 to 12 months. One patient failed to respond to three treatment doses, and hyperthyroidism recurred in two patients: 2 and 11 yr after initial therapy. Of these three patients, two were treated by thyroidectomy and was retreated successfully with I-131. There were no cases of thyroid cancer, other malignancies or leukemia. The patients' reproductive histories and the health of their offspring were as in the general population. At the time of study, the prevalence of hypothyroidism was 92%, with no recurrent goiters or thyroid nodules. Iodine-131 is found to be safe and effective treatment of hyperthyroidism in children and adolescents and should be the preferred mode of therapy.

Iodine-131: Optimal Therapy for Hyperthyroidism in Children and Adolescents?

Pituitary gonadal dysfunction in adolescents with varicocele

To assess the value of serum prostate-specific antigen (PSA) in prostate cancer follow-up, we prospectively studied 107 consecutive patients with: (1) pathologically confirmed prostate cancer; (2) definitive prostatectomy and/or radiation therapy greater than or equal to 3 mo prior to bone scanning; and (3) one bone scan and serum PSA sampling within 3 mo of each other. The mean and range of patient follow-up since definitive therapy was 1.6 and 0.5-8 yr, respectively. Abnormal bone scans were correlated with pertinent radiographs. Of 107 bone scans, 16 demonstrated metastatic bone disease. A PSA value of less than or equal to 8 ng/ml excluded bone metastases with a predictive value of a negative test of 98.5%. Without radiographic correlation, abnormal bone scans rarely represented metastases if the PSA value was less than or equal to 8 ng/ml. In summary, serum PSA concentration determines the need for follow-up bone scanning and assists in scan interpretation in patients status post definitive therapy for prostate cancer.

http://jnm.snmjournals.org/content/32/7/1387.full.pdf

The clinical utility of prostate-specific antigen and bone scintigraphy in prostate cancer follow-up.

The influence of scan and pathological criteria on the specificity of cholescintigraphy was assessed by a prospective study of 211 patients with suspected acute cholecystitis who underwent cholescintigraphy. Sufficient data were available in all to confirm a final diagnosis. Cholescintigraphy was performed in the standard fashion using 5 mCi of Tc-99m disofenin. Sixty patients had acute cholecystitis, 64 had chronic cholecystitis, and 87 had no demonstrable gallbladder disease. As the scan and pathological criteria for acute cholecystitis were varied from strict to liberal, the sensitivity of cholescintigraphy decreased (100% to 95.3%), the specificity increased (85.1 to 98.6%, and the predictive value increased (68.4% to 96.8%). The use of strict scan and pathological criteria for acute cholecystitis obscures the advantages that accure from such early detection of acute cholecystitis by cholescintigraphy, and thus are to be avoided.

https://jnm.snmjournals.org/content/jnumed/24/10/876.full.pdf

John E. Freitas

Papers

Adolescent varicocele: objective indications for treatment.

Iodine-131: Optimal Therapy for Hyperthyroidism in Children and Adolescents?

Pituitary gonadal dysfunction in adolescents with varicocele

The clinical utility of prostate-specific antigen and bone scintigraphy in prostate cancer follow-up.

Influence of Scan and Pathologic Criteria on the Specificity of Cholescintigraphy: Concise Communication