Background, Objectives, and Rationale. Subclinical Hypothyroidism. American College of Physicians. Tsuda S, Nakayama M, Matsukuma Y, et al. Nat Genet. American Academy of Family Physicians. Guidelines generally recommend thyroid hormones for adults with TSH levels above 10 mIU/L. Home » Patients Portal » Clinical Thyroidology for the Public » March 2019, Clinical Thyroidology for the Public summarizes selected research studies discussed in the previous month’s issue of Clinical Thyroidology, an official publication of the American Thyroid Association. Jeena M Varghese, MD is a member of the following medical societies: Endocrine Society, Harris County Medical Society, Texas Medical AssociationDisclosure: Nothing to disclose. 2009 Feb 12. Eur Thyroid J 2012;1(2):55–71. Thyroid. 42(5):379-89. Cooper DS, Biondi B. Subclinical thyroid disease. [Medline]. 2017 Mar 8. Hypothyroidism is defined by increased serum thyroid-stimulating hormone (TSH) values and reduced circulating free thyroid hormones, whereas subclinical hypothyroidism … Denny JC, Crawford DC, Ritchie MD, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. Other thyroid preparations such as T3 or desiccated thyroid should not be used in pregnancy. Postpartum thyroid dysfunction and the long-term risk of hypothyroidism: results from a 12-year follow-up study of women with and without postpartum thyroid dysfunction. Which factors predict the outcome of radioactive iodine therapy of Graves’ Disease? Hypothyroidism (underactive thyroid) 1.1.4 . Can J Cardiol. Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002). 11(6):e0156925. Bekkering GE, et al. 1995 Mar 8;273(10):808-12. quence, the Guidelines aim to cover a relatively wide range of recommenda-tions as opposed to the often more uniform national guidelines. [Medline]. [Medline]. The rapid communication, “Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline ” was published in the British Medical Journal on 14 May 2019. 1982 Nov. 57(11):877-8. Radioactive iodine dosing based on the radioiodine uptake and thyroglobulin levels is helpful in treating differentiated thyroid cancer. [Guideline] Jonklaas J, Bianco AC, Bauer AJ, et al. [Medline]. Radioactive iodine therapy has become less popular recently with more patients started on anti-thyroid drugs. [Medline]. thyroid disease in the NICE guideline on coeliac disease. Treatment of Hypothyroidism and sHT The fundamental clinical principle in the case of glandular deficiency is replacement therapy, while available; in the case of overt hypothyroidism, the treatment of choice is l -T4 replacement therapy, also in the elderly [ 56 ]. [Full Text]. This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice. 2017 Sep 26. N Engl J Med. The objective of this study was to determine if normalization of TSH in patients with hypothyroidism treated with L-T4 led to normalization of cholesterol levels. PMID: 30289349. Li D, Radulescu A, Shrestha RT, et al. Thyroid. [Medline]. George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine SocietyDisclosure: Nothing to disclose. [Medline]. ETA Guidelines 2020 ETA Clinical Practice Guideline for the Use of Image-Guided Ablation in Benign Thyroid Nodules 2011 Oct 7. [Medline]. Grozinsky-Glasberg S, Fraser A, Nahshoni E, Weizman A, Leibovici L. Thyroxine-triiodothyronine combination therapy versus thyroxine monotherapy for clinical hypothyroidism: meta-analysis of randomized controlled trials. Summary of recommendations for clinicians and policy-makers . LeBeau SO, Mandel SJ. 2011 Apr 28. Kajantie E, Phillips DI, Osmond C, Barker DJ, Forsen T, Eriksson JG. [Full Text]. J Clin Endocrinol Metab. (PDF File for saving and printing, 618 KB), HYPOTHYROIDISM Patients with hypothyroidism adequately treated with levothyroxine have higher levels of cholesterol compared to healthy controls. Endocr Connect. Medscape Education. PLoS One. Adequate levothyroxine doses for the treatment of hypothyroidism newly discovered during pregnancy. [Medline]. [Full Text]. Sponsors: American Association of Clinical Endocrinologists, American College of Endocrinology, The Obesity Society. Scenario: Subclinical hypothyroidism (non-pregnant): Covers the management of subclinical hypothyroidism and criteria for referral in primary care. J Clin Endocrinol Metab. Scenario: Preconception or pregnant: Covers the management of women … doi: 10.1159/000339444. We are dedicated to providing the field of endocrinology with timely, evidence-based recommendations for clinical care and practice. [Medline]. Sci Rep. 2018 Feb 1. [Medline]. Hypothyroidism results from low levels of thyroid hormone with varied etiology and manifestations. Subclinical Hypothyroidism Is Associated With Adverse Prognosis in Heart Failure Patients. For those planning a pregnancy and whose thyroid function tests (TFTs) are not within range, advise delaying conception until stabilised on levothyroxine sodium treatment. Refer all females with hypothyroidism who are planning a pregnancy or are pregnant, to an endocrinologist. … Thyroid. 919758-overview 2006 Dec. 35(4):687-98, vii-viii. 2009 Mar. Most read. Busko M. Optimal levothyroxine doses for hypothyroidism in pregnancy. Treatment Strong recommendation, low-quality evidence 95.2 R32 It is reasonable to target a TSH concentration in the lower half of the trimester-specific reference range. L evothyroxine (LT 4) has been considered the standard of care for treatment of hypothyroidism for many years. The interested reader is directed to the other sources for this information (4). Clinical Thyroidology for the Public (CTFP). [Medline]. This newly published guideline by Bekkering and team (3) is based on a 2018 research review article by Feller and team, who analyzed 21 previous studies of subclinical hypothyroidism. Niimi H, Inomata H, Sasaki N, Nakajima H. Congenital isolated thyrotrophin releasing hormone deficiency. The Society for Endocrinology is a UK-based membership organisation representing a global community of scientists, clinicians and nurses who work with hormones. Zamfirescu I, Carlson HE. JAMA. McAninch EA et al. J Clin Endocrinol Metab. 2005 Sep. 15(9):1021-33. Age ≥65 years, watch and wait. Learn about congenital hypothyroidism, symptoms, diagnosis and treatment options. 18 (9):[Medline]. Hollowell JG, Staehling NW, Flanders WD, et al. [Medline]. [Full Text]. overt hypothyroidism and to provide an updated view of the controversies and assertions in the field of subcli - nical hypothyroidism. [Medline]. Pregnancy and fertility in thyroid disorders. 8 (1):2031. The goal of this study was to assess the opinions of these doctors regarding the issue of treatment for hypothyroidism given the availability of the guidelines, reviews and other new publications on the topic of alternative thyroid hormone therapy. N Engl J Med. All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. Ann Intern Med. Macchia PE, Lapi P, Krude H, et al. Pendred syndrome is caused by mutations in a putative sulphate transporter gene (PDS). Endocrine. 2013 May-Jun. A joint position statement from the British Thyroid Association and Society for Endocrinology highlights important limitations of this study which may confound its conclusions and calls for caution in … 129(2):141-3. Hypothyroidism is a common condition of thyroid hormone deficiency, which is readily diagnosed and managed but potentially fatal in severe cases if untreated. Thyroid disease and coronavirus (Covid-19) Find information on thyroid disease and Covid-19. This study evaluated changes in HRQoL over time and the factors at diagnosis that may predict HRQoL at one-year follow up Abalovich M, Vazquez A, Alcaraz G, et al. Learn all of the updated information relating to hypothyroidism treatment and management in this guide with references to the newest scientific research and studies. Turner MR, Camacho X, Fischer HD, et al. New clinical practice guidelines strongly recommend against the routine use of thyroid hormones in adults with subclinical hypothyroidism, based on a systematic review published in the BMJ. Busko M. Subclinical hypothyroidism in pregnancy usually transient. Scenario: Overt hypothyroidism (non-pregnant): Covers the management of overt hypothyroidism and criteria for referral in primary care. The goal of this study is to assess the risk of hyperthyroidism in newborns of mothers who were treated with radioactive iodine within 2 years before their pregnancy. Pregnant patients: Levothyroxine should be dose titrated to … 2016 May 19. We are dedicated to providing the field of endocrinology with timely, evidence-based recommendations for clinical care and practice. 83(5):1762-5. Nat Clin Pract Endocrinol Metab. Pregnancy and fertility in thyroid disorders. In congenital and severe forms of CeH (eg, In patients with CeH, concomitant free T4 and TSH measurements should be used to check the adequacy of replacement therapy 6-8 weeks after the start of LT4 replacement, provided that blood is withdrawn before the morning replacement dose or at least 4 hours after LT4 administration; replacement therapy should be aimed at maintaining the free T4 level above the median value of the normal range, Once adequate thyroid replacement is achieved, pediatric patients with CeH should undergo monitoring of free T4 concentrations according to the age-related reference ranges, and follow-up should be conducted in the same way as in patients with primary hypothyroidism, Once adequate thyroid replacement is achieved, adult patients with CeH should undergo annual monitoring of free T4. Nebesio TD, McKenna MP, Nabhan ZM, Eugster EA. [Medline]. In congenital and severe forms of CeH (eg, TSHβ mutations), LT4 treatment should be started as soon as possible (optimally within 2 weeks after birth) at doses used also for primary congenital hypothyroidism (10-12 μg/kg body weight per day), in order to rapidly rescue serum free T4 levels to normal range and secure optimal neurodevelopment as quickly as … Lancet. This section covers recommendations regarding levothyroxine therapy. TSH >10mIU/L. 318 (12):1150-60. Most read. Anu Bhalla Davis, MD Assistant Professor, Department of Internal Medicine, Division of Diabetes, Endocrinology, and Metabolism, University of Texas Medical School at Houston, Shikha Bharaktiya, MD Physician in Endocrinology, Diabetes, and Metabolism, Endocrinology Clinics of Texas, PA, Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS Professor of Medicine (Endocrinology, Adj), Johns Hopkins School of Medicine; Affiliate Research Professor, Bioinformatics and Computational Biology Program, School of Computational Sciences, George Mason University; Principal, C/A Informatics, LLC, Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Nutrition, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Informatics Association, American Society for Bone and Mineral Research, Endocrine Society, and International Society for Clinical Densitometry, Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference, Walter R Woodhouse, MD, MSA Associate Clinical Professor, Department of Family Practice, Medical College of Ohio, Walter R Woodhouse, MD, MSA is a member of the following medical societies: American Academy of Family Physicians, American Academy of Pain Medicine, and Society of Teachers of Family Medicine, Frederick H Ziel, MD Associate Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Physician-In-Charge, Endocrinology/Diabetes Center, Director of Medical Education, Kaiser Permanente Woodland Hills; Chair of Endocrinology, Co-Chair of Diabetes Complete Care Program, Southern California Permanente Medical Group, Frederick H Ziel, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society for Bone and Mineral Research, California Medical Association, Endocrine Society, andInternational Society for Clinical Densitometry. 35(1):117-36, vii. 360(7):731-4. 2004 Jan 14. 129(2):144-58. Scenario: Overt hypothyroidism (non-pregnant): Covers the management of overt hypothyroidism and criteria for referral in primary care. A systematic review with meta-analysis on lipid profile. 1998 Jul 15. [Medline]. Aoki Y, Belin RM, Clickner R, et al. [Medline]. [Medline]. 91(7):2592-9. Treatment Strong recommendation, low-quality evidence 95.2 R32 It is reasonable to target a TSH concentration in the lower half of the trimester-specific reference range. This increase should be reversed during treatment with L-T4, with a goal of therapy decreasing TSH levels back to the normal range. 1991 Jan. 75(1):169-78. J Clin Endocrinol Metab. 2007 Dec. 17 (12):1211-23. TSH 4-10mIU/L. 2018 Oct 5. [Full Text]. Medscape Medical News from WebMD. 2018 Oct. 7 (5):225-37. What Are the Current Recommendations for Pediatric Dermatology in Primary Care? Untreated hypothyroidism increases morbidity and mortality. 2019 ETA Guidelines on the Management of Thyroid Dysfunction following Immune Reconstitution Therapy. 6(8):e22552. Screening for thyroid disease: recommendation statement. Bothra N, Shah N, Goroshi M, et al. 2012 Sep-Oct. 18(5):750-7. The following guidelines on the diagnosis and management of central hypothyroidism (CeH) were released in October 2018 by the European Thyroid Association The hypothalamic-pituitary-thyroid axis. Cinemre H, Bilir C, Gokosmanoglu F, Bahcebasi T. Hematologic effects of levothyroxine in iron-deficient subclinical hypothyroid patients: a randomized, double-blind, controlled study. American Thyroid Association Continues to Recommend Levothyroxine as First-Line Therapy for Hypothyroidism This article is Part I in a series covering the American Thyroid Association guidelines on the treatment of hypothyroidism. [Medline]. 1998 May. [Full Text]. Eur J Prev Cardiol. Am J Hum Genet. Hypothyroidism in pregnancy. Current practice: Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing. Endocr Pract. 1997 Dec 4. 2012 ETA guidelines: The use of L–T4 + L–T3 in the treatment of hypothyroidism. Clinical Practice Guidelines for Healthy Eating for the Prevention and Treatment of Metabolic and Endocrine Diseases in Adults. [Medline]. Thyroid hormone replacement for hypothyroidism can be achieved via several approaches utilizing different preparations of thyroid hormones, T3, and/or T4. [Medline]. [Medline]. Graves’ disease is the most common cause of hyperthyroidism in the United States. American Thyroid Association guidelines for detection of thyroid dysfunction. 2006 Jul. Endocrinol Metab Clin North Am. This website also contains material copyrighted by 3rd parties. Shields BM, Knight BA, Hill AV, Hattersley AT, Vaidya B. George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine Subclinical and overt hypothyroidism is associated with reduced glomerular filtration rate and proteinuria: a large cross-sectional population study. Jeena M Varghese, MD Assistant Professor, Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center 2002 Serum TSH as The Principal Diagnostic Marker of Systemic Thyroid Status (PDF File for saving and printing, 680 KB), ATA ALLIANCE FOR THYROID PATIENT EDUCATION, Change In Thyroid Nodule Volume Calculator, Find an Endocrinology – Thyroid Specialist, Clinical Thyroidology for the Public Volume 12 Issue 3, Fear of recurrence affects health-related quality of life in thyroid cancer patients, even a year after diagnosis, Symptoms strongly drive the consideration of alternative thyroid hormone-replacement options in patients with hypothyroidism. http://www.medscape.com/viewarticle/832682, http://www.medscape.com/viewarticle/817459, http://www.medscape.com/viewarticle/818195, American Association of Clinical Endocrinologists, American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, Central Society for Clinical and Translational Research, American College of Physicians-American Society of Internal Medicine, American Society for Bone and Mineral Research. J Med Genet. (PDF File for saving and printing, 618 KB), HYPERTHYROIDISM A mild risk of neonatal hyperthyroidism follows radioactive iodine therapy for Graves’ disease prior to pregnancy 2009 Jan. 94(1):151-6. Thvilum M, Brandt F, Lillevang-Johansen M, Folkestad L, Brix TH, Hegedus L. Increased risk of dementia in hypothyroidism: A Danish nationwide register-based study. [Medline]. We continually create new guidelines and update existing guidelines to reflect evolving clinical science … PLoS One. Clin Endocrinol (Oxf). (4). Park SM, Chatterjee VK. The goal of this study was to assess the opinions of these doctors regarding the issue of treatment for hypothyroidism given the availability of the guidelines, reviews and other new publications on the topic of alternative … doi: 10.1159/000339444. 1999 Aug 19. Peleg RK, Efrati S, Benbassat C, Fygenzo M, Golik A. Thyroid deficiency in the Framingham Study. 2010 Jun. Surks MI, Ortiz E, Daniels GH, et al. [68] : Garber JR, Cobin RH, Gharib H, et al. Clinical Review, You are being redirected to Although hypothyroidism, secondary to surgical and medical procedures (thyroidectomy or radioiodine treatment) with suboptimal L-T4 replacement therapy, should be not overlooked, chronic autoimmune thyroiditis (Hashimoto thyroiditis) is the most frequent cause of (subclinical) hypothyroidism in the elderly. The definition of hypothyroidism is based on statistical reference ranges of the relevant biochemical parameters and is increasingly a matter … Accessed: February 19, 2015. The guidelines are divided into four areas, addres-sing diagnosis, screening, treatment and a special sec-tion for hypothyroidism in pregnancy. The Society for Endocrinology is a UK-based membership organisation representing a global community of scientists, clinicians and nurses who work with hormones. Eur Thyroid J. 2007 Feb. 92(2):608-11. Thyroid. 2010 Sep. 73(3):389-95. The drug of choice for the treatment of hypothyroidism is thyroid hormone replacement. [Medline]. [Full Text]. Accessed: December 30, 2013. Melville NA. Systemic Thyroid Hormone Status During Levothyroxine Therapy In Hypothyroidism: A Systematic Review and Meta-Analysis. 2006 Dec. 91(12):4953-6. Hashimoto's thyroiditis: Relative recurrence risk ratio and implications for screening of first degree relatives. October 02, 2014. Diseases & Conditions, 2003 The 2019 version of the Guidelines introduces a new drug-drug interaction panel and now consists of six main sections, including a general over- 1st December 2019 Radioiodine has been used very effectively to treat thyroid overactivity since the 1940’s, but a recent study has cast doubt on its safety, causing considerable concern. Clinical guideline, part 2. Chang YC, Chang CH, Yeh YC, Chuang LM, Tu YK. This guideline was... | Find, read and cite all the research you need on ResearchGate Article PDF Available Thyroid hormones treatment for subclinical hypothyroidism: A clinical practice guideline Hoang TD, Olsen CH, Mai VQ, et al. Smit JW, Stokkel MP, Pereira AM, Romijn JA, Visser TJ. [Guideline] Jonklaas J, Bianco AC, Bauer AJ, et al. TRAB is detectable in the blood of most patients with Graves’ disease and can pass through to the baby and cause hyperthyroidism after delivery in mothers with Graves’ disease. 2000 Jun 12. StatPearls. JAMA. Clinical guideline, part 1. 2012 Dec. 22(12):1200-35. Everett LA, Glaser B, Beck JC, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. Eur Thyroid J 2012;1(2):55–71. Hum Reprod Update. Diseases & Conditions, encoded search term (Hypothyroidism) and Hypothyroidism, Primary Ovarian Insufficiency Requires Long-term Management of Sequelae, Some NP Thyroid Lots Recalled Due toReduced Potency, Superior Survival With Sintilimab in Squamous NSCLC, Myopathies: Muscling Your Way to the Diagnosis, Progesterone Eases Severe COVID-19 in Hospitalized Men, COVID-19 Can Cause Atypical Thyroid Inflammation, BMI, Age, and Sex Affect COVID-19 Vaccine Antibody Response, Older, Heavier People May Be 'Superspreaders' of COVID-19, More Published Data on 'Game-Changer' Drug for Obesity, Combo Thyroid Hormones as Good as Levothyroxine for Hypothyroidism. Overt hypothyroidism Offer levothyroxine sodium as first-line treatment and aim to maintain thyroid-stimulating hormone (TSH) levels within the reference range. Scenario: Preconception or pregnant: Covers the management of women planning a pregnancy or who … Disease-Specific as Well as Generic Quality of Life Is Widely Impacted in Autoimmune Hypothyroidism and Improves during the First Six Months of Levothyroxine Therapy. Newborn screening results in children with central hypothyroidism. 2011. Management. 156(6):990-3. Wolter P, Dumez H, Schoffski P. Sunitinib and hypothyroidism. Age ≥70 years, watch and wait. The guidelines are divided into four areas, addres-sing diagnosis, screening, treatment and a special sec-tion for hypothyroidism in pregnancy. [Medline]. 140(2):125-7. 2006 Mar. Gyamfi C, Wapner RJ, D'Alton ME. Primary aldosteronism and thyroid disorders in atrial fibrillation: A Swedish nationwide case-control study. [Medline]. Vono-Toniolo J, Rivolta CM, Targovnik HM, Medeiros-Neto G, Kopp P. Naturally occurring mutations in the thyroglobulin gene. This week, a BBC news article is circulating with the report that "Thyroid disease [is] being over-treated." Patients with hypothyroidism adequately treated with levothyroxine have higher levels of cholesterol compared to healthy controls. 2019;doi:10.1136/bmj.l2006. 2002 Feb. 87(2):489-99. [Medline]. 379(9821):1142-54. J Clin Endocrinol Metab. Piantanida E, Gallo D, Veronesi G, et al. [Medline]. Woeber KA. Endocrinol Metab Clin North Am. The recommended treatment of maternal hypothyroidism is administration of oral LT4. National status of testing for hypothyroidism during pregnancy and postpartum. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. If symptoms persist, even after achieving normal TSH levels, consider adjusting the dose to achieve optimal well-being whilst avoiding doses that cause TSH suppression or thyrotoxicosis. [Medline]. 2016 Jun 3. Treatment of subclinical hypothyroidism has long been controversial because of normal increases in TSH with age, variability between TSH measurements, and concerns for harm from treatment. 2004 Jan 20. Rosario PW, Bessa B, Valadao MM, Purisch S. Natural history of mild subclinical hypothyroidism: prognostic value of ultrasound. New ATA guidelines stick with levothyroxine for hypothyroidism. 2012 ETA guidelines: The use of L–T4 + L–T3 in the treatment of hypothyroidism. December 20, 2013. In the United States, autoimmune thyroid disease (Hashimoto thyroiditis) is the most common cause of hypothyroidism, but globally lack of iodine in the diet is the most common cause. [Medline]. Negro R, Formoso G, Mangieri T, Pezzarossa A, Dazzi D, Hassan H. Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical complications. This summary does not include information on: managing thyroid cancer or thyroid disease in pregnancy. This treatment is efficacious when administered orally, has a long serum half-life that permits daily administration, and results in resolution of the signs and symptoms of hypothyroid… (1) More specifically, it reported that newly published guidelines claim that "almost all adults with mild or "subclinical" hypothyroidism will not benefit from hormone treatment." Iodine and thyroid disease. [Medline]. (PDF File for saving and printing, 617 KB), THYROID CANCER Radioactive iodine dosing based on the radioiodine uptake and thyroglobulin levels is helpful in treating differentiated thyroid cancer [Guideline] Persani L, Brabant G, Dattani M, et al. Although hypothyroidism, secondary to surgical and medical procedures (thyroidectomy or radioiodine treatment) with suboptimal l-T4 replacement therapy, should be not overlooked, chronic autoimmune thyroiditis (Hashimoto thyroiditis) is the most frequent cause of (subclinical) hypothyroidism in the elderly …
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