Intralesional and topical glucocorticoids for pretibial myxedema: A case report and review of literature

Pretibial myxedema(PTM), an uncommon manifestation of Graves' disease(GD), is a local autoimmune reaction in the cutaneous tissue. The treatment of PTM is a clinical challenge. We herein report on a patient with PTM who achieved complete remission by multipoint subcutaneous injections of a long-acting glucocorticoid and topical glucocorticoid ointment application for a self-controlled study. A 53-year-old male presented with a history of GD for 3.5 years and a history of PTM for 1.5 years. Physical examination revealed slight exophthalmos, a diffusely enlarged thyroid gland, and PTM of both lower extremities. One milliliter of triamcinolone acetonide(40 mg) was mixed well with 9 mL of 2% lidocaine in a 10 mL syringe. Multipoint intralesional injections into the skin lesions of the right lower extremity were conducted with 0.5 mL of the premixed solution. A halometasone ointment was used once daily for PTM of the left lower extremity until the PTM had remitted completely. The patient's PTM achieved complete remission in both legs afteran approximately 5-mo period of therpy that included triamcinolone injections once a week for 8 wk and then once a month for 2 mo for the right lower extremity and halometasone ointment application once daily for8 wk and then once 3-5 d for 2 mo for the left lower extremity. The total dosage of triamcinolone acetonide for the right leg was 200 mg. Our experience with this patient suggests that multipoint subcutaneous injections of a long-acting glucocorticoid and topical glucocorticoid ointment application are safe, effective,and convenient treatments. However, the topical application of a glucocorticoid ointment is a more convenient treatment for patients with PTM.

Multi-modality imaging on multiple evanescent white dot syndrome-A Spectralis Study

AIM: To present retinal microstructure, metabolism and function abnormalities in the course of multiple evanescent white dot syndrome (MEWDS) by Heidelberg spectralis modality imaging platform and observe its outcome by EDI-SD-OCT and two wavelength autofluorescence. METHODS: A case of multiple evanescent white dot syndrome in a 23-year-old female presented initially with a 15-day history of floaters and a central scotoma in the right eye. To establish the diagnosis, multimodality imaging was performed, namely, blue light-fundus autofluorescence (BL-FAF, excitation 488nm, emission >500nm), near-infrared fundus autofluorescence (NIR-FAF, excitation 787nm, emission >800nm) using a confocal scanning laser ophthalmoscope, fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), spectrum-domain enhance depth imaging optical coherence tomography (SD-EDI-OCT), multifocal eleclroretinography (mf-ERG) and fundus photogragh were performed and followed up at the eighth month after initially visiting. RESULTS: Optical coherence tomography (OCT) showed a transient disruption of the foveal photoreceptor outer segments in correspondence to foveal granularity. NIR-FAF showed hypoautofluorescent areas, <= 40 mu m in size, mostly concentrated around the posterior pole and its temporal side less than that in BL-FAF. Mf-ERG show pinnade disappeared in fovea and macula and responses decreased markedly compared with the follow eye. At the eighth month follow up, hyperfluorescence in BL-FAF were disappear, while, NIR-FAF Hypofluorescent spots in early stage of such lesion were reduced. But OCT demonstrated the structure was recovered in residual Hypofluorescent area in NIR-FAF. The subfoveal choroidal thickness was decreased from 372 mu m to 307 mu m slightly and cost line was recovered. CONCLUSION: MEWDS is a benign self-healing disease and there is no pathological evidence to investigate the natural course of such disease. SD-OCT allows highly detailed images approaching histopathology to certify the microstructural changes. Two-wave length FAF and mf-ERG provide more information about metabolism in outer retina especial RPE and photoreceptor. Spectralis OCT combined with two-wavelength FAF and mf-ERG provide a new way to analyze this disease and offer more details for therapy and follow-up.

MULTIVARIATE ANALYSIS OF RELATIONSHIPS BETWEEN IODINE BIOLOGICAL EXPOSURE AND SUBCLINICAL THYROID DYSFUNCTIONS

Objective To assess the relationships between iodine biological exposure and subclinical thyroid dysfunctions. Methods The cross-sectional survey was performed to obtain the epidemiologic data of population in three communities with different iodine biological exposure： mild iodine deficiency [median urinary iodine concentration （MUI） of 50-99 μg/L], more than adequate iodine intake （MUI of 200-299 μg/L）, and excessive iodine intake （MUI over 300 μg/L）. Univariate and multivariate analysis （logistic regression analysis） were used to analyze the risk factors of subclinical hypothyroidism and subclinical hyperthyroidism. Logistic regression analysis with sex and age controlled suggested that more than adequate iodine intake （OR = 3.172, P = 0.0004） and excessive iodine intake （OR = 6.391, P = 0.0001） increased the risk of subclinical hypothyroidism, while excessive iodine intake decreased the risk of subclinical hyperthyroidism （OR = 0.218, P= 0.0001）. Logistic regression analysis including interaction of iodine intake and antibodies [tryroid peroxidase antibody （TPOAb） and thyroglobulin antibody （TgAb）] suggested that excessive iodine intake was an independent risk factor of subclinical hypothyroidism （OR = 6.360, P= 0.0001）, but independent protect factor of subclinical hyperthyroidism （OR = 0.193, P= 0.0001）. More than adequate iodine intake and it＇s interaction with TgAb increased the risk of subclinical hypothyroidism independently, in addition, it decreased the risk of subclinical hyperthyroidism at the present of TPOAb. Conclusion Both excessive iodine intake and more than adequate iodine intake could increase risk of subclinical hypothyroidism, supplement of iodine should be controlled to ensure MUI within the safe range.

Novel frameshift mutation causes early termination of the thyroxine-binding globulin protein and complete thyroxine-binding globulin deficiency in a Chinese family: A case report

BACKGROUND Thyroxine-binding globulin(TBG;the gene product of SERPINA7)is the main transporter of thyroid hormones in humans.Mutations in the TBG gene may lead to inherited TBG deficiency.There have been 28 reported mutations that associate with complete TBG deficiency(TBG-CD).Here we identified a novel frameshift mutation causing early termination of the TBG protein and TBG-CD in a Chinese family.CASE SUMMARY A 46-year-old Chinese man was referred to our hospital with normal free thyroxine,free triiodothyronine,thyrotropin,but lower total thyroxine and total triiodothyronine,and undetectable serum TBG,indicative of TBG-CD.Blood samples were obtained from the patient’s family members and thyroid function and serum TBG were evaluated.Genomic DNA from peripheral blood was sequenced to detect possible TBG mutation(s).Quantitative PCR high-resolution melting curve analysis was used to screen TBG-Poly(L283F)among 117 Chinese men.A novel mutation of TBG(p.Phe135Alafs*21),a 19-nucleotide insertion in exon 1,was identified,which resulted in a truncated TBG protein product and caused TBG-CD.The other mutation,identified in the proband’s father,is a known polymorphism,TBG-Poly(L283F).The frequency of the TBG-Poly allele among 117 unrelated Han Chinese men from northeast China was 21.37%.CONCLUSION A novel mutation in the TBG gene associated with the TBG-CD phenotype was identified in a Chinese family.Additionally,it was found that 21.37%of Chinese males had TBG-Poly(L283F).

Development and validation of a risk assessment model for prediabetes in China national diabetes survey

BACKGROUND Prediabetes risk assessment models derived from large sample sizes are scarce.AIM To establish a robust assessment model for prediabetes and to validate the model in different populations.METHODS The China National Diabetes and Metabolic Disorders Study(CNDMDS)collected information from 47325 participants aged at least 20 years across China from 2007 to 2008.The Thyroid Disorders,Iodine Status and Diabetes Epidemiological Survey(TIDE)study collected data from 66108 participants aged at least 18 years across China from 2015 to 2017.A logistic model with stepwise selection was performed to identify significant risk factors for prediabetes and was internally validated by bootstrapping in the CNDMDS.External validations were performed in diverse populations,including populations of Hispanic(Mexican American,other Hispanic)and non-Hispanic(White,Black and Asian)participants in the National Health and Nutrition Examination Survey(NHANES)in the United States and 66108 participants in the TIDE study in China.C statistics and calibration plots were adopted to evaluate the model’s discrimination and calibration performance.RESULTS A set of easily measured indicators(age,education,family history of diabetes,waist circumference,body mass index,and systolic blood pressure)were selected as significant risk factors.A risk assessment model was established for prediabetes with a C statistic of 0.6998(95%CI:0.6933 to 0.7063)and a calibration slope of 1.0002.When externally validated in the NHANES and TIDE studies,the model showed increased C statistics in Mexican American,other Hispanic,Non-Hispanic Black,Asian and Chinese populations but a slightly decreased C statistic in non-Hispanic White individuals.Applying the risk assessment model to the TIDE population,we obtained a C statistic of 0.7308(95%CI:0.7260 to 0.7357)and a calibration slope of 1.1137.A risk score was derived to assess prediabetes.Individuals with scores≥7 points were at high risk of prediabetes,with a sensitivity of 60.19%and specificity of 67.59%.CONCLUSION An easy-to-use assessment model for prediabetes was established and was internally and externally validated in different populations.The model had a satisfactory performance and could screen individuals with a high risk of prediabetes.

Association between iron deficiency and prevalence of thyroid autoimmunity in pregnant and non-pregnant women of childbearing age: a cross-sectional study

Background: Thyroid autoimmunity (TAI) is prevalent among women of reproductive age and associated with adverse pregnancy outcomes. This study aimed to investigate the association between iron nutritional status and the prevalence of TAI in women during the first trimester of pregnancy and in non-pregnant women of childbearing age. Methods: Cross-sectional analysis of 7463 pregnant women during the first trimester of pregnancy and 2185 non-pregnant women of childbearing age nested within the sub-clinical hypothyroid in early pregnancy study, a prospective collection of pregnant and non-pregnant women’s data, was conducted in Liaoning province of China between 2012 and 2015. Serum thyrotropin, free thyroxine, thyroid peroxidase antibodies (TPOAbs), thyroglobulin antibodies (TgAbs), serum ferritin, and urinary iodine were measured. Iron deficiency (ID) was defined as serum ferritin <15 μg/L and iron overload (IO) was defined as ferritin >150 μg/L. TPOAb-positive was defined as >34 U/mL and TgAb-positive was defined as >115 U/mL. Multilevel logistic regression was conducted to examine the association between TAI and different iron nutritional status after adjusting for potential confounders. Results: The prevalence of isolated TPOAb-positive was markedly higher in women with ID than those without ID, in both pregnant and non-pregnant women (6.28% vs. 3.23%,χ^2 = 10.264, P = 0.002;6.25% vs. 3.70%,χ^2 = 3,791, P = 0.044;respectively). After adjusting for confounders and the cluster effect of hospitals, ID remained associated with TPOAb-positive in pregnant and non-pregnant women (odds ratio [OR]: 2.111, 95% confidence interval [CI]: 1.241–3.591, P = 0.006;and OR: 1.822, 95% CI: 1.011–3.282, P = 0.046, respectively). Conclusion: ID was associated with a higher prevalence of isolated TPOAbs-positive, but not with isolated TgAb-positive, in both pregnant women during the first trimester of pregnancy and non-pregnant women of childbearing age, while IO was not associated with either isolated TPOAb-positive or isolated TgAb-positive.

Consensus on the Prevention of Type 2 Diabetes in Chinese Adults

INTRODUCTIONHigh-risk population of Type 2 diabetes mellitus （T2DM） includes both euglycemic （normal glucose tolerance [NGT]） population with high risk of diabetes （EPWHROD） and prediabetic population. Between these two groups,