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


the morality

Morals are the right thing to do in a given situation or principles concerning the distinction between right and wrong or good and bad behavior, sometimes including or excluding if it’s illegal or not.

But there is always a conflict between the right thing and morally right thing to do. Let’s say someone’s family is extremely poor and the mother is very sick. The pharmacy has the exact medicine that could cure the mother but it is very expensive. What would the son do knowing it was right there but he couldn’t reach it? Would he break into the pharmacy? But that’s illegal but for him it’s also the right thing to do at that moment.

Of course some might say, he could be getting help from friends, going to the doctors, getting a loan and a job etc. the usual righteous heads, but that is the ambiguity of helplessness. One living in a peaceful place will easily  suggest the one living in Syria to improve their situation by talking to the government and rebel groups, talk and find a solution etc. etc. but that is and always had been the fight between practicality and idealism. Conviction is for those on the sidelines, and everyone has plans until getting punched in the face are the famous sayings which depict these situations, while there is always  what most would consider a right way out but only one in million has the ability to find and  go that path. Rest are just the common people.

There are various types of moral practices. One can practice utilitarianism where doing “what’s right” should help everyone in the long run. It has some downsides because sometimes, even if it benefits everyone, it’s not always the most moral thing to do  .

There’s also Kantianism aka deontology, where instead of considering everyone, one considers his duties to society. one does not think about the end goal or consequences, just do the duty as told by laws or what parents taught or universal duties. But even this is not the idealistic model.

Anything is wrong or imperfect to somebody. 

And that is why there is conflict between moral sets. With a deeper look in too ourselves we can see that we as human Beings are highly individualistic but also deeply social organisms.We have individualistic as well as societal interests that drive us in our decision making and choices and hence in our moral code.

Individuals aspire to fulfill personal needs and desires while societal interests are directed towards predictability in the group and enhance safety and growth and development of the group. Perceived societal interests are expressed/implied in the form of moral code because conflicts between morals can lead to unpredictability in human behaviour and cause physical or psychological harm and may not always benefit in the long run. Common morality prevents people to a certain extent from violating the societal code thereby ensuring peace and preventing chaos.

Therefore, whenever an individual or a set of individuals break the moral code, society tends to stigmatise them or outcast them as a form of punishment and also to deter further violations.

However, since moral codes are very abstract in nature and are just perceptions in their true nature, individuals with enough power or majority of individuals happen to redefine morals from time to time.

Since morals have been accepted as basic to co-living, they are deeply embedded in mind. When we find ourselves violating the moral code, we tend to feel guilty and unhappy with our actions.

Moral codes are not found only in human societies but in almost all animals which live in groups are found to be practicing moral codes. So in the end we can only say that the more we study morality, the more we encounter ambiguity.