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


It’s a very general notion that law of torts work on fault based liability means whenever there is a wrongful act or omission, liability would be there. But what about the no fault liability? Have you heard about that? In this article, I’ll be dealing with the major judgments explaining what a no- fault liability is and how it helps the plaintiff or the victims.



It was midnight of 3-4 December, 1984 when nearly 3000 thousand lost their lives just due to a gas leak called methyl Isocyanate which mixed with air causing breathing problems to the people who inhaled it. It affected plant and animal species as well. These symptoms and injuries continued to persist even after 30 years of this incident. The leak was happened because of negligence on the part of company as no proper maintenance was given to the plant.


Many people suffered due to this gas leak so, they moved to court filling their petitions against Union Carbide Corporation. As a result, Union of India taking into consideration all the complaints passed an ordinance and filed a petition in Bhopal district court and in US district court as well. US court directed Union of India to approach in India only for convenience. Bhopal court ordered Union Carbide Corporation to pay 3.3 Billion dollar, then Union Carbide Corporation moved to High Court to reduce the amount and as a result, the amount was reduced but the conflict wasn’t solved yet.

So, the parties decided to approach SC who evolved the concept of no-fault liability and ordered the Union Carbide Corporation to pay 470 million by 31st march, 1989.


No- fault liability is also known as absolute liability evolved in 1989 with 100% liability. It is a liability when the defendant is held liable and he doesn’t have any remedies or defenses as compared to the strict liability. In case of no- fault liability, person will be held liable whether he has any intention to commit the crime or not, whether he took all reasonable care or not. Even act of god and plaintiff’s own fault can’t save him. Absolute liability is just a modified version of strict liability.  Earlier defendants used to make excuses and take advantage of defenses available that’s why govt. introduced absolute liability to make them held liable.


No matter government has introduced many new laws after this incident but its effects are still seen in the lives of people living there having breathing problems still going on from one generation to another. But this principle of absolute liability proves to be beneficial in cases when the harm caused is serious and threatening to the lives of many people.