Evaluation of Different Levels Thyroid Dysfunction in Patients having Diffuse Goiter from Rawalpindi and Islamabad

The enlargement of the thyroid gland is a common problem in clinical practice associated with iodine deficiency, increase in serum Thyroid-Stimulating Hormone (TSH) level, natural goitrogens, smoking, and lack of selenium and iron. Diffuse goiter is characterized by the enlargement of whole thyroid gland at the age of puberty. It is observed in the patients either having hypothyroidism or hyperthyroidism or have abnormal TSH concentrations. It has investigated that Diffuse goiter has been exhibiting equivalence with diffuse radioactive iodine uptake. The data comprised of 144 patients of diffuse goiter evaluated through various statistical techniques in order to investigate various thyroid dysfunctioning based on the normal concentration of thyroid function tests. Hypothyroidism and hyperthyroidism can be accurately diagnosed with laboratory tests performed at NORI. The data along with detailed history was collected with the help of clinicians in NORI and entered in the Performa. The diagnostic evaluation relating to functional and morphological characterization has examined through serum TSH concentration and imaging. The result shows non-significant difference between hypothyroid and hyperthyroid patients of diffuse goiter and control group individuals. The study has concluded that the prevalence of diffuse goiter is not dependent on the higher and lower concentration of TSH.


Introduction
Thyroid gland is a highly vascular endocrine gland that is placed anteriorly in the neck, extending from the fifth cervical to the first thoracic vertebrae [1] have investigated that in case of mild hypothyroidism serum TSH also have been observed high and the values of T3 and T4 have remained in normal range.
Diffuse goiter is characterized by the enlargement of whole thyroid gland is observed in the patients either having hypothyroidism or hyperthyroidism at the age of puberty while toxic diffuse goiter is also known as grave's disease is prevalent in hyperthyroid patients [2] have reported that Diffuse Goiter (Simple) or physiological goiter is the most common thyroid disorder among different thyroid diseases. They have further investigated that Diffuse goiter has been exhibiting equivalence with diffuse radioactive iodine uptake, while Multinodular goiter has not been exhibiting equivalence with irregularity in uptake

Evaluation of Different Levels Thyroid Dysfunction in Patients having Diffuse Goiter from Rawalpindi and Islamabad Abstract
The enlargement of the thyroid gland is a common problem in clinical practice associated with iodine deficiency, increase in serum Thyroid-Stimulating Hormone (TSH) level, natural goitrogens, smoking, and lack of selenium and iron. gland have produced about 7% Triiodothyronine (T3) and about 93% thyroxin (T4). Triiodothyronine (fT3) has 3-5 folds greater biological potency than thyroxin (fT4). Morreale de Escobar et al. [6] have reported that thyroid hormones as being critical regulatory molecules that played an important role in functioning and development of various organs of vertebrate body particularly normal brain functioning before and after birth and further it has been examined that these are Tyrosine based hormones that are partially composed of iodine and their deficiency enlarges the thyroid tissue which is known as simple goiter [7]. Suzuki et al. [8] have examined that alteration in TSH and free thyroid hormones have been observed in gender and during aging. They have further investigated that in males the process of aging have restrained the free thyroid hormones concentration but have not influenced on the concentration of TSH. While, in females the free thyroid hormones levels have not been changed with aging but TSH level have been increased in age-dependent areas of severe iodine deficiency can be as high as 80%. Khan et al. [9] have observed that two major ailments of thyroid gland, one is higher generation of thyroid hormones that is called hyperthyroidism and other is lower generation of thyroid hormones that is called hypothyroidism [9] also have examined that serum TSH level has been elevated in case of primary hypothyroidism but values of T3 and T4 have remained below the normal range. Caldwell et al. have been investigated that in case of mild hypothyroidism serum TSH also have been observed high and the values of T3 and T4 have remained in normal range [10] have been reported that in case of hyperthyroidism the values of triiodothyronine and Thyroxin have been observed above high level and TSH has subdued due to negative feedback mechanism. Current paper will explore various medical disorders and abnormalities in thyroid hormones in Pakistani population. Further, profile of thyroid hormones will be analyzed via level of different hormones and antibodies like TSH, FT4, T3 and ant thyroglobulin respectively will be analyzed from serum samples of patients. Analytical evaluation of the hormonal profile of patient will be carried out via electrochemical luminescent immunoassays (ECLIA).
The objective of study is to compare the hormonal profile of subclinical and clinical hypothyroid patients with normal healthy individuals and will be evaluated statistically.

Materials and Methods
The current study was carried out at Nuclear Medicine, Oncology and Radiotherapy Institute (NORI) in patients of diffuse goiter and control group individuals having no diffuse goiter. The population sample is comprised of 194 individuals. The whole population was categorized into two major groups, one is experimental group and other is control group.

Setting and Study Area
The present study was carried out in Nuclear Medicine, Oncology and Radiotherapy Institute (NORI). Study population: Total 194 patients that were referred for thyroid scan were included in the study. Inclusion Criteria: All patients having diffused goiter in any age group will be included in the study.
• Liver disease as evidenced by raised ALT level.

Study Group
The whole population sample constituting the patients of diffuse goiter was based on the incidence of Thyroid Functions Tests (TFTs).

Data Collection
After having informed consent (Annexure-I) from patients, the data along with detailed history was collected with the help of clinicians in NORI and entered in the Performa (Annexure-II).

Data Analysis
The data was analyzed using SPSS version 17.

Results
The current paper has investigated that 55% have abnormal TSH concentration, while 45%have normal TSH concentration in a whole sample of population having diffuse goiter. In abnormal patients, about 71% have low TSH levels, while 29% have high TSH levels. TSH levels ranging from 0.27-4.2 µIU/ml was considered as normal for the diagnosis in thyroid function tests (TFTs). When the abnormal patients of diffuse goiter having the clinical symptoms of hypothyroid or hyperthyroid were compared with control group individuals, statistically nonsignificant difference was observed in this case. Comparatively, similar results were obtained in the studies of nodular goiter and multinodular goiter. The study has worked out to determine the comparative evaluation of thyroid function tests between normal and abnormal, hyperthyroid and hypothyroid of diffuse goiter, Nodular Goiter (NG), Multinodular Goiter (MNG) and control group. The statistical evaluation of thyroid function tests in the group having diffused goiter has done in the statistical evaluation table (Tables 1 and 2).  [11][12][13]. The study has inconsistency with the findings of Evered et al. have been investigated that in case of mild hypothyroidism serum TSH also have been observed high and the values of T3 and T4 have remained in normal range. Such studies would be helpful to understand on the prevalence of diffuse goiter in different subjects and will also suggest the measures to minimize the goiter associated with its onset. It is further suggested that that the role of hormonal interactions in these patients may also be investigated with reference to their different metabolic disorders.

Conclusion
The present study concluded that prevalence of diffuse goiter may be dependent on the extent of hormonal dysfunctioning specifically normal and abnormal TSH levels.
In future comprehensive investigation is warrant covering the epidemiological profile of the patients having diffuse goiter.