Hyperthyroidism Awareness

It is important to remember that hyperthyroidism can occur at any age. While most may present with a rather typical constellation of symptoms, many may present with exacerbation of pre-existing conditions which may make the diagnosis initially elusive. Worsening anxiety, insomnia, fatigue, panic attacks, palpitations, hypertension or diarrhea may not initially signal that the thyroid is involved. Clinicians must have a low threshold to check thyroid function early to rule out a component of hyperthyroidism.

Once a suppressed thyrotropin (TSH) has been detected, further investigation with serum triiodothyronine (T3) and free thyroxine (free T4) can help delineate overt from subclinical disease. A thorough history of past thyroid disease, as well as current medications and supplements, can help detect any pre-existing diagnoses or exogenous sources of thyroid hormone or over supplementation with iodine. More commonly, hyperthyroidism is due to either Graves diseasetoxic multinodular goiter or toxic adenoma. Distinction between these can usually be made with the assistance of a thyroid uptake scan, TSH receptor antibody measurement, and thyroid ultrasound. An additional physical exam finding of exophthalmos can further support the diagnosis of Graves’ disease. Understanding the etiology can help guide patient expectations. A small percentage of patients with Graves’ Disease may undergo spontaneous remission after 1 to 2 years, which may prompt patients to wait before considering a definitive treatment option.

With confirmation of the diagnosis of hyperthyroidism, focus is on hormonal control with an antithyroid medication (ATM, most commonly Methimazole in the United States). This may be augmented with beta-blockade, steroids, cholestyramine or SSKI for those who are difficult to control.

Many patients may need further consideration for definitive management with either radioactive iodine ablation (RAI) or thyroidectomy. Your local resources may also influence these options, but it is critical to understand that all three treatments (ATM, RAI and thyroidectomy) are possible options. Certain patient factors and priorities may alter the preferred definitive treatment. Smaller gland size, easy to control hormones, and lack of eye symptoms are factors that may favor continued ATM management. A large goiter with compressive symptoms, difficult to control hormones requiring high dose medications/ multiple modalities, pregnancy, severe eye disease, multiple nodules within the thyroid with or without thyroid cancer, or desire for rapid and reliable hormone control may favor thyroidectomy. RAI is a good option for patients with a smaller gland size, and a desire to pursue definitive management but avoid surgery.

There are also relative contraindications for treatment options. ATMs may have serious side effects, like agranulocytosis or liver failure, which prevent further use, or may cause skin eruptions making long term use intolerable. Additionally, high dose requirements or fluctuating doses may make long term use of ATMs not reliable. Women who are pregnant, wanting to become pregnant in the next 6 months to 1 year, breast feeding or have small children in the home will want to avoid RAI. Patients with severe eye involvement, have a large goiter with compressive symptoms, or are smokers should also avoid RAI. Thyroidectomy will be a poor option for patients with multiple previous neck operations on or around the thyroid due to internal scarring, or who are high risk for general anesthesia. Additionally, if they have a history of previous gastric bypass surgery, they are higher risk for major complications from hypocalcemia/hypoparathyroidism after thyroidectomy.

To help the patient navigate these decisions, it is important to allow them the opportunity to discuss each treatment option with respective physician experts – medical management with endocrinology, RAI with endocrinology and potentially nuclear medicine as well, and thyroidectomy with the thyroid surgeon.

In summary, patients with hyperthyroidism require medical control, as well as a clear understanding of the etiology of their hyperthyroidism. Patients with Graves disease, toxic multinodular goiter and toxic adenoma have more than one treatment option, and it is important for patients to be educated and engaged in treatment decisions.

For Further Reference:
American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and other causes of Thyrotoxicosis| by the American Thyroid Association

What Kind of Introvert Are You?

Are you an introvert? It depends on which book you read. Here’s a sampling of the various conceptualizations of introversion in pop culture [1]: Preference for quiet, minimally stimulating environments: Quiet by Susan Cain Preference for concentration and solitude: The Introvert’s Way by Sophia Dembling Rechargeable battery: The Introvert Advantage by Marti Olsen Laney Thoughtful-introspective

Are you an introvert? It depends on which book you read.

Here’s a sampling of the various conceptualizations of introversion in pop culture [1]:

Historically, there has been just as much confusion in the psychological literature. Carl Jung originally defined introversion as a focus on one’s “inwardly directed psychic energy”. However, in the 30s, the psychologist J.P. Guilford showed that various attempts to measure Jung’s conceptualization of introversion resulted in multiple, distinct factors. In other words, there didn’t appear to be a single dimension of personality that captured all of introversion.

In the 60s Patricia Carrigan echoed this point, arguing that introversion was not effectively captured by a single scale. She cautioned that if the phrase introversion is to continue to be used, “care must be taken to specify its conceptual and operational referent. What appear to be minor distinctions between the various conceptions may in fact be crucial ones.” In the 70s, the heated debate continued, with a much older Guilford arguing with H.J. Eysenck over whether introversion can possibly, or even should, be captured by a single scale.

All seemed to be settled in the 90s with the emergence of the “Big Five” framework of personality. The five main factors of personality– extraversion, neuroticism, agreeableness, conscientiousness, and intellect/imagination– were empirically derived based on what patterns of behavior tend to go together within individuals. Under this framework, introversion is merely defined as the opposite of extraversion.

In the Big Five framework, extraversion comprises two main aspectsenthusiasm (reflecting sociability, positive emotions, and warmth) and assertiveness (reflecting the tendency to take charge, become a leader, and captivate attention). The common factor seems to be high sensitivity to rewards in the environment— which due to the highly social nature of humans throughout the course of human evolution, most prominently consists of rewards associated with social attention.

Therefore, under the dominant personality framework in modern psychology, if you score low in enthusiasm and assertiveness, you’re an introvert

Here’s the problem: the Big Five framework forces a definition of introversion onto people, many of whom do not conceptualize introversion in the same way. For instance, one study did a comparison of common-sense/everyday notions of introversion and ‘scientific’ conceptions of introversion. They found that the most prototypical characteristic of introversion, as identified by the general public, was the following item:

Clearly, many people equate introversion with introspection. In the Big Five framework, however, this item is classified as part of the intellect/imagination domain of personality, not the introversion domain. So there’s a serious mismatch between folk definitions of introversion and scientific definitions. People who view themselves as introverted because they are highly introspective are being told by scientists: “You aren’t really introverted based on patterns of covariation among the general population.” To which everyday people rightfully respond: “WTF?” [3]

As noted personality psychologist Jonathan Cheek told me, “by invalidating the ordinary language meaning of introversion by defining it solely as the opposite of Big Five Extraversion, the Big Five researchers are guilty of Psychological Imperialism [4].” Influenced by the seminal work of Jung, Guilford, and Carrigan, Cheek and his colleagues have decided to take a different approach, by focusing on the phenomenon of introversion on its own, free from having to be force-fit into one scheme or another.

As Carl Jung said, each individual is ultimately a unique crystal, but type theories can be helpful for navigating social life. Embracing this Jungian philosophy, Cheek and his colleagues argue that when people use the term “introversion”, they should never just use it by itself. Instead, they argue that researchers should put a specific modifier in front of the term. What modifiers could be used?

In her masters thesis (written under the advisement of Cheek), Jennifer Odessa Grimes defined four meanings of introversion: social, thinking, anxious, and restrained (which happens to form the positive acronym STAR). It’s possible to score high or low on either of these flavors of introversion. For instance, you could be low in social introversion by preference but not be particularly anxious in the presence of people. Or you could suffer from crippling social anxiety, but still have the desire to be highly social. Or any other combination of these four meanings of introversion.

By this point you’re probably wondering what kind of introvert you are. Well, you’re in luck. There’s a new test for that.

The Case for a New Avenger

S.H.I.E.L.D. might have missed assembling team members from India, but it is never too late to correct an oversight. Imagine our larger-than-life superhero, Rajinikanth, partnering with other Avengers in a combined mission to save the planet from dangerous predators with bad intentions. Some aliens, some familiar ones! Yes, India is far from America, and the distance seems to have increased during the pandemic, but Rajinikanth could give some worthy company to Iron Man and perhaps teach him a trick or two, too, through holographic interfaces and augmented reality. Who knows, he could also kill all the mutants of Coronaviruses in this quest!

I wish to present some facts now to give you a background of my strategic human resource and leadership plan for S.H.I.E.L.D. India has one of the largest numbers of gig workers in the world. As per a March 2021 report by consulting firm Boston Consulting Group (BCG) and Michael & Susan Dell Foundation, the gig economy in India is expected to soar to 90 million in approximately a decade from now. Choose any vocation here and you will be spoilt for choices. Almost everyone is an expert on politics, economics, socio-cultural issues, fashion, sports, career, marriage, children, nature, animals, traffic, the dos, and don’ts … the list is endless. People can even advice others on how they should lead their lives. It’s affection, silly!

War for talent? Clearly, recruiters have not been able to explore the depth of this vast pool. To reiterate, India is a land bubbling with high potentials. Now let us go back to the topic of superpowers. There is plan B too. Rajinikanth could have a serious competition in a plain-looking community here. S.H.I.E.L.D. could consider appointing some members from this fraternity too.

You are rolling your eyes? Why? Hear me out. Presenting to you the case of beholders of the mighty pen (over a sword or a gun), and the upholders of fine speech. Their words hit no less than the missiles unleashed by Israel over the Gaza strip. Let me walk you through the innate gifts of a less publicized community with an immensely amoeba-like (plasma membrane) flexibility.

The teachers.

The extremely sturdy ones can stand the whole day, operate (teach) without a table and a chair, or, the basic infrastructure, and sometimes work even at low or no salaries for months. The strengths, struggles and coping mechanism of the privileged ones out of this lot are embedded in different realms. More on that, later! You will be astonished to learn how many hats teachers can don at the same time. They juggle between being a mentor, coach, counsellor, Devil’s advocate, friend, philosopher, or guide. Interestingly, even their DNA personifies versatility. Over the years, the mutations in their genetic material have helped them learn how to make milestones of the stones thrown at them by students unhappy with their marks, and parents unhappy with the teachers for giving those marks! Talk about heightened senses, their eyes can easily observe and sense the intention behind each greeting, smile and calls to the office. They are like Sharma ji ka beta/beti’, always expected to excel at everything and set an ideal example for the others to emulate.

Here, I would take a detour and ask you to recall the violinists who continued to play music for as long as they were alive, just to calm the passengers on the sinking Titanic ship. On similar lines, teachers continued to teach while the pandemic unleashed havoc around the world. The unlearning of years of classroom teaching was replaced by the immediate need to adopt new technological tools and re-learn the art of virtual teaching. The new and changed landscape was no less than the one post Thanos snapping his finger.

Aren’t convinced yet? Go to the polling booths and follow the polio immunization drives, you will know what I mean.

Now the final hook. Except for some teachers working with elite institutions, the rest won’t even charge much for their services. You can simply smile, appreciate their work, show some respect, and boy, see how they melt! Just watch how it lights up their faces. They are so motivated, especially on September 5 every year in India, that even Abraham Maslow bows to them from time to time from his grave. Had told you about their genetic sequencing earlier, remember? I do hope I have presented their (our) case well, S.H.I.E.L.D. Hopefully, you will have a relook at your current team now.

On a sidenote, can I be a contender too? Just saying. I can take it up as a gig assignment during the semester breaks. Imagine the newest Avenger on the block and that too a female from India! It will further boost the diversity and inclusion factors for you. If you can give equitable salary and perks, you could even find yourself on the pages of Harvard cases.

You might want to provide supplements of Vitamin T(eacher) to your team if Rajinikanth’s diary of appointments is full. Professor Hulk would not mind some more erudite company. In return, I vow to start quoting your example in my classes as a great employer brand with an excellent employee value proposition. Who knows, I might even write a research article. Told you, pen and words are the weapons here. Think about it. What say? Are you game?

P.S. I have recently bought a telescope to keep an eye on the stars and planets too. Taking my possible future role tad too seriously, eh?

True friends

“Good friends care for each other…close friends understand each other, but TRUE FRIENDS stay forever…beyond words, beyond distance, beyond time…!”

Many of us have friends in our lives over the years. Some friends we make as children and then lose contact as we grow older. Other friends we make as adults and stay in touch with as long as we are in close proximity to and it is convenient to keep in touch but then over time one moves away or busy schedules slowly pull us apart and we start to lose touch.  Those friendships fall into the “good friends” or “close friends” as the opening quote cites. But then there is that last group of friends – those we call true friends – they are those we have a mutual caring about, and we understand each other’s hearts, and where bonds are formed between us that span any distance in proximity and where the bonds run so deep that no amount of time apart or lack of words will change the way we feel about that friend. These are our true friends, and when one comes into your life cherish it!

As a child our family moved often and so I was constantly making new friends each place we moved. Often the contact was lost with friends in past locations, although my memories of them were treasured. As an adult it is often harder to find the time to form those deep friendships outside your immediate family members because we are all trying to juggle a million balls in the air with work and church and service and community all while trying to give our greatest attention to our own children and spouses  where it rightfully belongs. And as a single mother for many years of my life it was even more difficult to make time for friends because playing the role of two parents by yourself while also being the sole support of your family was overwhelming to say the least.

But even during those challenging years there were individuals during that time who came into my life that I consider my truest of friends. They are individuals who saw me through tough times and who always saw the best in me despite any of my shortcomings. They picked me up at times I was down. They stood by me when I felt alone. They taught me things about life and about myself with patience and understanding. They lifted my children’s spirits and made them laugh when they were going through tough times of their own. They forgave at times when I was grumpy or obstinate. They loved me without judgment and without expectations. They gave me hugs, even at times that I may not have deserved one.  These true friends were individuals who were there for me…maybe not always in person or in word every time, but always in heart…and knowing that helped me through incredible challenges throughout the years.

True friends just do that – they help us grow and change for the better.  They support us in good times and bad. They can make us laugh when all we want to do is cry. And no matter how far apart time and distance may cause us to grow from one another, and even if death takes one of them from this world to the next, we always have the comfort of knowing that these true friends are still there for us, even if only in spirit, cheering us on and wishing us the best, because that is what true friends do for each other.

“A strong friendship doesn’t need daily conversation, doesn’t always need togetherness as long as the relationship lives in the heart, true friends will never part…”

When someone is genuinely your true friend they leave an impression on your heart that will never go away…not with time and not with distance. True friends secure a place in your heart forever.  I am forever grateful for the true friends in my life, both those who are alive and those who have passed away, thank you so much for being my true friends!

The irrational things about trust

The obvious and rational equation is that being trustworthy plus being transparent will lead you to be trusted. Verification of trustworthiness should lead to trust.

This makes sense. Being trustworthy (acting in a way that’s worthy of trust) plus being transparent so that people can see your trustworthiness—this should be sufficient.

How then, do we explain that brands like Coke and Google are trusted? The recipe is secret, the algorithm is secret, and competitors like DuckDuckGo certainly act in a more trustworthy way.

In fact, trust often comes from something very different. It’s mostly about symbols, expectations and mystery.

Consider the relationship you might enter into if you need surgery. You trust this woman to cut you open, you’re putting your life in her hands… without the transparency of seeing all of her surgical statistics, interviewing all previous patients, evaluating her board scores.

Instead, we leap into surgery on the basis of the recommendation from one doctor, on how the office feels, on a few minutes of bedside manner. We walk away from surgery because of a surly receptionist, or a cold demeanor. 

The same is true for just about all the food we eat. Not only don’t we visit the slaughterhouse or the restaurant kitchen, we make an effort to avoid imagining that they even exist.

In most commercial and organizational engagements, trust is something we want and something we seek out, but we use the most basic semiotics and personal interactions to choose where to place our trust. And once the trust is broken, there’s almost no amount of transparency that will help us change our mind.

This is trust from ten thousand years ago, a hangover from a far less complex age when statistical data hadn’t been conceived of, when unearthing history was unheard of. But that’s now hard-wired into how we judge and are judged.

Quick test: Consider how much you trust Trump, or Clinton, Cruz or Sanders, Scalia or RBG. Is that trust based on transparency? On a rational analysis of public statements and private acts? Or is it more hunch-filled than that? What are the signals and tropes you rely on? Tone of voice? Posture? Appearance? Would more transparency change your mind about someone you trust? What about someone you don’t? (Here’s a fascinating story on that topic, reconstructed and revealed).

It turns out that we grab trust when we need it, and that rebuilding trust after it’s been torn is really quite difficult. Because our expectations (which weren’t based on actual data) were shown to be false.

Real trust (even in our modern culture) doesn’t always come from divulging, from providing more transparency, but from the actions that people take (or that we think they take) before our eyes. It comes from people who show up before they have to, who help us when they think no one is watching. It comes from people and organizations that play a role that we need them to play.

Top 5 Best Android Games in 2021


There are countless games on any normal android platform that’s available. Usually, people connect and share their experiences about a particular game and this way the popularity increases. It won’t matter if you have a favourite genre, you’ll find many games that you will love to play. Android games are quite popular because of the features they provide, their advanced modes and the whole concept. They keep growing and getting better.
This article conveys information about the top 5 android games in 2021.

  1. Call of Duty
    Earlier this position belonged to Pubg Mobile but it was banned so people had to switch to something similar, i.e., COD(Call of Duty). Call of duty is a first-person shooter video game franchise published by Activision. It allows players to advance through World War 2 in a continuous series of campaigns or to battle it out against human opponents from all over the world in its multiplayer mode. It is also the world’s best-selling video game franchise.
  2. Garena Free Fire
    It is also free to play battle royale game just like COD, developed by 111 Dots Studio and published by Garena. It achieved the title of the most downloaded game in the year 2019 and was also awarded “Best Popular Vote Game” by Google Play Store in the same year. It is the ultimate shooter survival game where players enter a battlefield where there is only one winner – the last man standing. There are also 34 characters, out of which 15 are female characters and 19 are male. Some of them are even real.
  3. Among Us
    Among us is a 2018 online multiplayer social deduction game developed and published by Innersloth Studios. It is like a detective murder mystery where everyone gets their roles as crewmates and impostors. The imposters have to kill the crewmates to win. While the crewmates have to do all the assigned tasks to win the game or if they vote out the imposter. It is a game of teamwork and betrayal. Among us was entitled as the Best Multiplayer Game in the Game Awards 2020.
  4. Asphalt 9: Legends
    This is a racing video game developed by Gameloft Barcelona and published by Gameloft. It is the ninth main instalment in the Asphalt series, released in 2018. Right now, it is the #1 top-grossing in racing. It is an amazing 3D driving game where you speed around in fast cars on routes that will lead you to different places all around the world. Its visuals are mind-blowing and exemplary for a mobile game with a mix of modern audio and fast-paced electronic music that goes along with the action.
  5. Minecraft
    Minecraft is a sandbox video game developed by Mojang. The game was developed by Markus “Notch” Persson in the Java programming language. It was fully released in 2011. It has Realms which are personal multiplayer servers run by Minecraft just for you and your people. This game is online and accessible even after you log off. Here only the people you invite can join your world, no one else can and you can whatever you wish to like.

There are many games which are liked by a group of people but disliked by another so it depends on you, which game suits you better, you go with it.

-SNEHA RAM