New(ish) discussion paper by Bianco et al

[diogenes]

An editorial type paper has been issued by Orgiazzi J, Peterson SJ , McAninch EA, Bianco AC. for open access till November 30. Title: Does normal TSH mean euthyroidism in L-T4 treatment? Source Clinical Thyroidology, 2016: 28 (11) 325-328. though it is 1 year old, it does raise questions re the value of TSH in T4 treatment. And also does include a paper of ours as reference.

[Nanaedake]

Have you got a link to the paper?

[RedApple Administrator in reply to Nanaedake]

I think this is it online.liebertpub.com/doi/f...

[linda96]

Not sure about this paper Diogenes. Despite the Dio2 gene polymorphism being known about since the late 1970's its not mentioned once in this paper. I cannot believe they didn't check their patient cohort to see if they were converts or non-converters, surely all the data gathered is meaningless if no account is made of this gene polymorphism? I won't be adding it to my collection of other thyroid clinical papers. Dr Bianco has published widely about DIO2, and not to mention it seems almost a step backwards... I take particular offence to the phrase "Several possible reasons for the persistence of symptoms include thyroid autoimmunity itself, the possible presence of associated autoimmune diseases, and ...awareness of a chronic disease (3) !!! Somatatisation again! I'm sure I've read that line almost word for word somewhere else?

[greygoose in reply to linda96]

How you manage to translate 'awareness of a chronic disease' into 'somatisation'? 'Awareness' isn't the same as 'imagination', surely? Or, am I being thick?

[linda96 in reply to greygoose]

Hi, Greygoose,

I have come across 'awareness of a chronic disease' before in another medical context and it was explained to me that it meant 'knowing you were ill, could make you sicker'. I agree with you that 'awareness' is not the same as 'imagination' although I think imagination might be the wrong word to have used here. I have argued elsewhere recently that we need to be aware of how our bodies perform under stress situations so that we can be ready to alert those around us to possible changes of plans, needing to visit a Dr urgently, etc and that being 'aware' is generally a good thing. I think 'awareness of a chronic disease' is itself worded badly as it could be interpreted differently depending on who is reading it.

[greygoose in reply to linda96]

I have a raging fever. 'Imagination' was the best word I could come up with. It didn't please me, either.

But, I really do think you're reading too much into this. I don't think somatisation is at all what they were talking about.

[diogenes Remembering in reply to linda96]

There are all sorts of reasons why some patients need T3 to attain a good QoL. Not just D102 mutation. There are three interlocking problems; 1) how sensitive are the tissues to T3 - that is what level of FT3 does a patient need when healthy to maintain health? There is a factor of 2 from one extreme to the other. 2) how well does T4 get converted to T3 by the tissue enzymes? This is mutational probably. 3) How does direct supply of T3 by the thyroid interact with 1) and 2); in health how much thyroid T3 is needed to help the other processes, and if it is lost, how does the body respond to T4 only? Bianco's article only touchesd on this but it is the problem that needs solving.

[linda96 in reply to diogenes]

I would agree with you that Dr AC Bianco has only touched on it. Perhaps I am a little disappointed because having read some of his articles I want so much more from these clinical papers having spent a lifetime of being ill, (but not just with hypothyroidism) although it is very high on my list of priorities. I am a great admirer of Dr AC Bianco and I must say I like his apparent dogged determination to get to the bottom of our thyroid problems. I have re-read the paper again and he does make a passing nod to T4 - T3 conversion problems, in the Background paragraph. As he says towards the end of Analysis and Commentary " The present study in itself does not appear to help dissect the mechanisms involved in the deviation from normalcy that persists in L-T4 treated subjects despite normal TSH. ...lack of information on the previous values of the thyroid function tests and the cause of the hypothyroidism".

If you add in the extra parameters of converters and non-converters, thyroid transport problems, methylation polymorphisms, the individual's H-T-P axis points, and as he said, not having access to previous test results, I'm not sure that he will find an answer. Not yet anyway. I hope he does. I like Prof Hoermann's papers too, they both seem to be working very hard to find the answers.

[Nanaedake in reply to linda96]

I'm sure Dio2 is mentioned towards the end of the document isn't it?

[SilverAvocado]

There is a tiny mention at the end, almost the final line: "Finally, further work is needed to better identify and characterize the patients with poor T4-to-T3 conversion efficiency, including studies of the impact of genetic variation in the deiodinase"

This is part of a brief discussion saying this paper isn't addressing these mechanisms.

For patients this is a bit of a strange paper, as it's kind of repeating what we already know - T4-only patients feel worse than other people, and you can find that on some biological and self-report measures when you look at a large population. But its useful because it's formalising and putting into the right language what we are always saying