This paper may be a bit too technical but I thought I had to publicize it. Its importance is that it takes our stance of the control of thyroid function, and discusses hypo and hyperthyroidism and change of treatment in this light. The main point is that our understanding in the field is also recognised by others independently and so gives some hope that people are listening and will take appropriate action. Its always a positive sign when this happens
Journal of Endocrinology, Metabolism and Diabetes of South Africa 2020; 25(1):28-34
ISSN1608-9677
REVIEW
Shifting the paradigm in the management of conditions affecting the thyroid gland
N Schellack, G Schellack and A Esterhuizen.
Written by
diogenes
Remembering
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nope... unless it's going straight into downloads and getting lost... i do have the IT skills of Fred Flinstone tho'........I'll look it up the old fashioned way
Thanks for posting. I must declare a prejudice, as someone with a computing background the word 'paradigm' always triggers all the alarm bells when we hear it! ('paradigm' and 'paradigm shift' always precedes computing articles that are full of waffle. This doesn't apply to this review, but it's hard to overcome my conditioning).
The review adopts an enlightened approach to the use of TSH for diagnosis of thyroid conditions which is most welcome. It does contain some statements which suggest the authors are confused or perhaps some sections were written by different people.
For example, it states 'About 90% of the secreted T4 is converted to T3 in peripheral target tissues outside of the thyroid gland. ' It's not clear what this means. Does it mean 90% of secreted T4 is converted to T3? I don't think this is so, T4 can be disposed of before it has chance to be converted. Does it mean that 90% of the T4 that is converted is done so outside the thyroid? i.e. the thyroid handles 10% of the conversion.
'This process of activation mainly takes place in the liver and kidneys.' It is generally thought that most T4 to T3 conversion is done by type-2 deiodinase (D2) although this is not certain. The liver and kidneys express type-1 deiodinase (D1). When thyroid hormone levels are low D2 takes over from D1 and so liver and kidney deiodinase becomes less important.
'Multiple epidemiological studies associated TSH serum concentrations with clinical outcomes'. They give no references for this and I know of no studies that show a link between TSH and clinical outcome - other than a very high TSH indicates primary hypothyroidism.
Finally, they recommend levothyroxine monotherapy titrated to TSH for treatment of hypothyroidism with no mention of liothyronine. Not sure where the 'Shifting the paradigm...' bit in the title comes from! I have a feeling that they have knocked up the review in order to get a publication on their CV as they don't seem to have a genuine desire to improve thyroid treatment.
It's inevitable that in discussing the problem from a rather naive viewpoint (the currently held ideas) the authors haven't fully grasped what it means. Remnants of the old ideas are mixed in with the new, sometimes with unfortunate results. But nevertheless, however plagiaristic the paper is, it largely consists of an endorsement of our ideas. And that dissemination of the concept is publicity I personally am enthusiastic about.
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