1. Welcome to journal club Subclinical Hypothyroidism Imran Bashir

2. Subclinical hypothyroidism TSH above the limit of reference range when FT4 levels are normal Prevalence 4-15% Prevalence rises with age, higher in females

3. SH Can be an incidental finding Can present with non-specific symptoms of hypothyroidism like fatigue, constipation Patients with chronic autoimmune thyroiditis Prior ablative or anti thyroid drug therapy Drugs impairing thyroid functions Most patients with TSH < 10 are asymptomatic If elevated, should be repeated with FT4 levels

4. SH: D/D During period of recovery from nonthyroidal illness Untreated adrenal insufficiency TSH producing pituitary adenomas and resistance to thyroid hormone Central hypothyroidism

5. SH: Progress Spontaneous recovery Overt hypothyroidism Cardiovascular risk & neuropsychiatric symptoms

6. SH: treat or not treat? TSH values 4.5-10, unlikely to benefit Those with sign and symptoms and TSH 10-15 likely to benefit Treatment in specific group of population

7. Prospective evaluation of the natural course of idiopathic subclinical hypothyroidism in childhood and adolescence Malgorzata Wasniewska, Mariacarolina Salerno1, Alessandra Cassio2, Andrea Corrias3, Tommaso Aversa, Giuseppina Zirilli, Donatella Capalbo1, Milva Bal2, Alessandro Mussa3 and Filippo De Luca

8. Prospective study to evaluate course of SH in children & adolescents

9. Design Clinical status, thyroid function, and autoimmunity evaluated at entry, 6, 12 & 24months in 92 patients with idiopathic SH

10. Did the study address a clearly focused issue? –Yes: prospective study for children with subclinical hypothyroidism

11. Did the author use an appropriate method to answer their question? –Yes: Prospective study is the best way to evaluate the progress

12. Results 38 patients normalized their TSH (Group A) –16 between 6-12 months –22 between 12-24 months 54 maintained TSH within baseline values (Group B) 11 exhibited a further increase in TSH (Group C) No patient showed any signs of hypothyroidism

13. Results Majority of patients (88%) normalized or maintained their TSH TSH changes were not associated with either FT4 values or clinical status or auxological parameters

14. Was the cohort recruited in an acceptable way? –Yes: appropriate inclusion and exclusion criteria used

15. Was the exposure accurately measured to minimize bias? –Yes Was the outcome accurately measured to minimize bias? –Yes:

16. Confounding factors accounted for? –Possibly yes Family history not very well explained

17. Was the follow up of subjects long enough? –Can’t tell: Probably long term follow up is required to see progress of TSH and FT 4

18. How precise are the result? And do we believe the results? –Yes: Same laboratory and analyzer used

19. Can the results be applied to local population? –Yes: With same group of subclinical hypothyroid children who don’t have any clinical sign & symptoms or risk factor for thyroid disease.

20. Do the results of the study fit with other available evidence? –Can’t tell: Need more randomized multicenter trials

21. Thank you….