Joaquin Lado-Abeal

Aims: To evaluate whether an endocrinology‐integrated transplant clinic and differing healthcare delivery models are associated with metabolic outcomes during the first year after kidney transplantation in recipients with pre‐existing diabetes. Materials and Methods: We conducted a retrospective longitudinal cohort study of adult kidney transplant recipients with diabetes at a US and a European academic centre. Participants were classified by post‐transplant diabetes care model: Cohort 1, endocrinology‐led Endocrine Transplant Clinic (ETC; n = 99); Cohort 2, historical standard transplant care at the same US centre ( n = 81); and Cohort 3, standard endocrinology care at a Spanish academic centre ( n = 40). Pre‐specified outcomes included HbA1c, body mass index (BMI), blood pressure, and lipid levels measured at baseline and 3, 6, and 12 months. Linear mixed‐effects models adjusted for demographic and clinical covariates were applied. Missing longitudinal data were addressed using multiple imputation with complete‐case sensitivity analyses. Results: Among 220 recipients, adjusted metabolic trajectories were broadly similar across cohorts. HbA1c was unchanged at 3 and 6 months but higher at 12 months; >50% had HbA1c >7% at 1 year. BMI remained stable, with ≥30% meeting obesity criteria throughout follow‐up. Blood pressure did not improve, and systolic hypertension (>130 mmHg) remained common (49%–77%). At 12 months, LDL‐C ≥70 mg/dL was present in 20.8%, 63.3%, and 42.3% of Cohorts 1–3. Findings were consistent in sensitivity analyses. Conclusions: Metabolic control in the first post‐transplant year showed stabilisation rather than improvement, with many recipients above cardiometabolic targets. Prospective studies should test whether earlier, protocolised multidisciplinary management improves cardiovascular and graft outcomes.

Context: The clinical relevance of thyroid hormone–mediated inotropic effects in humans remains uncertain. Objective: We evaluated ventricular function in patients with severe hypothyroidism and myxedema coma using transthoracic echocardiography and speckle-tracking echocardiography. Methods: Multicenter, retrospective cross-sectional study of adults admitted to intensive care units with severe hypothyroidism who underwent transthoracic echocardiography during hospitalization. Left ventricular (LV) systolic and diastolic function and myocardial deformation, assessed by global longitudinal strain (GLS), were analyzed. Results: One hundred and twelve patients were included (mean age 53.9 ± 13.7 years; 64.3% female). Myxedema coma was present in 33 patients (29.5%), and 13 (11.6%) had severe hypothyroidism with altered mental status without hypothermia or bradycardia. Median admission thyroid-stimulating hormone was 113.9 (41.9-500.0) mIU/L. The mean LV ejection fraction (LVEF) was 53.9 ± 13.7%, LV GLS −13.5 ± 4.2% (reference −24% to −16%), and right ventricular (RV) GLS −17.9 ± 6% (reference −35% to −17%). Reduced LVEF occurred in 37.5% of patients, abnormal LV diastolic function in 66.7%, and impaired LV and RV GLS in 68.2% and 34.0%, respectively. In multivariable models, β-blocker treatment was associated with lower LVEF and worse biventricular GLS; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker treatment with lower LVEF; and calcium channel blocker exposure was associated with improved RV GLS. In-hospital mortality was 4.5% and occurred in patients with preserved LVEF. Conclusion: Severe hypothyroidism is associated with frequent systolic and diastolic ventricular dysfunction and prevalent impairment of myocardial deformation. Associations between cardiovascular medication exposure and echocardiographic abnormalities likely reflect confounding by indication and underlying clinical phenotype rather than reflecting causal drug effects. Despite substantial myocardial abnormalities, short-term mortality was low.

Purpose: Transgender women experience higher-than-average rates of multiple medical conditions. Thyroid cancer occurs more frequently in those assigned female at birth than in those assigned male at birth. We sought to characterize thyroid cancer among transgender female veterans. Methods: We reviewed charts of veterans who were (1) seen in Veterans Affairs clinics across the United States from July 2017 to December 2022, (2) had an International Classification of Diseases, revision 10, diagnosis code for thyroid cancer, and (3) had an International Classification of Diseases, revision 10, diagnosis code for gender dysphoria or were assigned male at birth and ever had a prescription for estrogens. Charts of cisgender veterans were also reviewed for comparison. Results: Compared with calculated estimates of 0.641% (95% CI, 0.572-0.724) among cisgender females and 0.187% (95% CI, 0.156-0.219) among cisgender males, the measured prevalence among transgender female veterans was 0.341% (34/9988). Average age at thyroid cancer diagnosis in this population was 53.8 (± SEM 2.61) years. A total of 32.3% (11/34) of these patients had extrathyroidal disease at diagnosis. Discussion: To our knowledge, this study represents the first report of thyroid cancer prevalence among transgender women in the United States. Risk exposure among all transgender veterans including further assessment of the possible contributions of obesity, smoking, and gender-affirming hormone therapy are important future analyses.

Purpose Patients in acute care hospitals are often transferred to long-term care (LTC) when there is an expectation for a lengthy recovery. Prolonged non-thyroidal illness syndrome (NTIS) creates a state of hypothyroidism. We aimed to investigate the prevalence of NTIS in patients at LTC facilities. Methods A cross-sectional study at University Hospitals and Rehabilitation and Skilled Nursing facility was performed. Four groups: control (n:33), intensive care unit (ICU) (n:34), long-term care hospital (LTCH) (n:50), and long-term care on chronic ventilatory support (LTCVS) (n:30). Serum levels of TSH, free T4 (FT4), free T3 (FT3), and interleukin 6 (IL6) measured at admission day in controls, within 48 h of admission in the intensive care group, between days 31 and 120 in the LTC hospital group and days 31 and 6 years in the LTC on chronic ventilatory support group. Results Serum FT3 levels were lower in groups intensive care unit ICU, LTCH, and LTCVS than control. Low serum FT3 levels were observed in 80% ICU, 54% LTCH, 37% LTCVS, and 6% control patients. Low serum FT4 levels were observed in 32% ICU, 16% LTCH, and 20% LTCVS patients. Both low serum FT4 and FT3 levels were observed in 32% ICU, 16% LTCH, and 13% LTCVS patients. Serum IL6 and FT3 levels showed a negative correlation. Conclusions NTIS is highly prevalent in patients in LTC, creating a state of persistent hypothyroidism. The effects of thyroid hormone replacement in patients at LTC with non-thyroidal illness deserve further investigation.

Objective: Our institution, a safety net, university, tertiary hospital located in West Texas has a high number of hospital admissions for complicated thyrotoxicosis. We hypothesized that unfavorable socioeconomic conditions result in increased risk of poor outcomes in hyperthyroid patients, and upshot rates of hospitalization for thyrotoxicosis in West Texas. The primary aim of our study was to identify factors associated with admission for complicated thyrotoxicosis in patients living in the Panhandle and Llano Estacado of Texas. Method: A retrospective chart review of patients aged 18 years and older with a diagnosis of thyrotoxicosis evaluated at our institution from January 2011 to January 2017. Patients were divided into two groups: a hospitalized group, consisting of patients that required hospitalization for complicated thyrotoxicosis, and an outpatient group. Demographics, clinical, and biochemical data were reviewed to identify factors associated with hospitalization for complicated thyrotoxicosis. Results: The hospitalized group consisted of 80 patients and the outpatient group consisted of 294 patients. Thyrotoxicosis accounted for 0.05% of all-cause hospital admissions during the study period. Patients with thyrotoxicosis and lack of health insurance had 12 times higher odds of being hospitalized for complicated thyrotoxicosis compared to patients with commercial insurance. Conversely, the odds of hospitalization for complicated thyrotoxicosis were reduced by 63% in patients with higher median income, and by 33% in those with college or university studies vs. high school studies. Thirty-two percent of patients hospitalized for complicated thyrotoxicosis presented with thyroid storm, this accounted for 7% of the studied cohort. Conclusion: Socioeconomic conditions are the main factors associated with the odds of being admitted to a hospital in West Texas for complicated thyrotoxicosis, including thyroid storm. Patients without health care insurance have higher odds of admission while patients with higher education and living in areas of higher income have lower odds of hospital admission due to thyrotoxicosis.

Energy deficiency is a cause for myocardial dysfunction during septic shock. In rodents, septic shock decreases the oxidation of long-chain fatty acids and glucose in the myocardium causing energy deficiency. However, the effect of septic shock on myocardial energy metabolites in large animals and human is unknown.

Pneumocephalus (PNC) is a rare complication of transsphenoidal surgery that can result from cerebrospinal fluid (CSF) leak, allowing air entry into the CSF. We report the case of a 49-year-old female patient who presented to the emergency department three weeks after a transsphenoidal pituitary tumor resection, with symptoms of generalized throbbing headache associated with nausea. The patient was alert and oriented without any focal neurological deficit. A head computed tomography (CT) scan showed air in the subarachnoid space and ventricles. She was admitted to the hospital and was initially treated conservatively. However, her symptoms persisted, and a repeat head CT scan demonstrated worsening PNC. She then underwent lumbar drain placement and sellar floor repair. Her symptoms resolved postoperatively. When PNC results in intracranial hypertension, it is referred to as tension PNC, a complication that can be fatal. Conservative treatment involves analgesics and therapy for intracranial hypertension. Surgical intervention to decrease intracranial hypertension and repair the CSF leakage may also be necessary.

Summary: Objective: Alterations in the hypothalamic–pituitary–thyroid axis have been reported following growth hormone (GH) replacement. The aim was to examine the relationship between changes in serum concentration of thyroid hormones and deiodinase activity in subcutaneous adipose tissue, before and after GH replacement.Design: A prospective, observational study of patients receiving GH replacement as part of routine clinical care.Patients: Twenty adult hypopituitary men.Measurements: Serum TSH, thyroid hormones – free and total thyroxine (T4) and triiodothyronine (T3) and reverse T3, thyroglobulin and thyroid‐binding globulin (TBG) levels were measured before and after GH substitution. Changes in serum hormone levels were compared to the activity of deiodinase isoenzymes (DIO1, DIO2 and DIO3) in subcutaneous adipose tissue.Results: The mean daily dose of growth hormone (GH) was 0·34 ± 0·11 mg (range 0·15–0·5 mg). Following GH replacement, mean free T4 levels declined (−1·09 ± 1·99 pmol/l, P = 0·02). Reverse T3 levels also fell (−3·44 ± 1·42 ng/dl, P = 0·03) and free T3 levels increased significantly (+0·34 ± 0·15 pmol/l, P = 0·03). In subcutaneous fat, DIO2 enzyme activity declined; DIO1 and DIO3 activities remained unchanged following GH substitution. Serum TSH, thyroglobulin and TBG levels were unaltered by GH therapy.Conclusions: In vitro analysis of subcutaneous adipose tissue from hypopituitary human subjects demonstrates that GH replacement is associated with significant changes in deiodinase isoenzyme activity. However, the observed variation in enzyme activity does not explain the changes in the circulating concentration of thyroid hormones induced by GH replacement. It is possible that deiodinase isoenzymes are differentially regulated by GH in other tissues including liver and muscle.