Thyroid problems revisited

View Large Image | Download PowerPoint SlideThe new, second edition of Diseases of the Thyroid edited by Lewis Braverman promises a great deal in the preface: an update on the progress that has been made in basic and clinical thyroidology over the past five years, and a fresh perspective on the pathophysiology, presentation and therapy of thyroid disease. In general, the book delivers on its promise in the area of basic research and molecular thyroidology. Chapters about nuclear and nongenomic actions of thyroid hormone are well written, nicely illustrated, and current, with references from 2000 and 2001. The chapter about autoimmune thyroid disease is an excellent overview of the basic and clinical aspects of humoral and cellular autoimmune mechanisms and their relationship to thyroid disease. The authors of the chapter expertly weave clinical considerations into the discussion, with well crafted sections on antithyroid drugs and remissions in Graves' disease, pregnancy-related autoimmune disease, ophthalmopathy and dermopathy. The chapter about thyroid hormone resistance (RTH) is timely and well written, and addresses the controversy of whether there are distinct mutations leading to ‘central’ versus ‘generalized’ resistance: the author believes that there are. There is also an excellent review of the sodium/iodine symporter, which is a new, welcome addition to this edition. Oddly, there is hardly a mention of the ‘other’ iodine transporter, pendrin. Perhaps this will be taken up in a third edition. The chapter about radiation and thyroid cancer is largely epidemiological; happily, the authors address a very common problem in my own practice about which little has been written: nasopharyngeal radium applicator therapy, for which current evidence suggests no increased risk for thyroid cancer.With the recent widespread publicity surrounding proposed new, more stringent EPA limits on perchlorate contamination of drinking water, I was interested in what the chapter about goitrogens in the environment had to say. In all likelihood, the chapter was being written when the EPA was beginning to reexamine this ‘hot button’ issue. The senior author has published extensively on the subject, and his widely quoted epidemiological studies have found no evidence for an effect of perchlorate on neonatal thyroid function at currently permissible concentrations. Nevertheless, in spite of these data, formerly permissible levels of perchlorate in drinking water (32 mcg l−1 in adults and 10 mcg l−1 in children) are now considered to be unsafe by several state health departments.In contrast to the chapters that cover ‘molecular’ and nonclinical aspects of thyroidology, I found the clinical chapters to be somewhat uneven. Some are quite ambitious, such as the one about thyroid cancer, whereas others, such as the chapters on thyrotoxicosis and pregnancy-related thyroid disease, are good, but not comprehensive reviews of the topic. Perhaps the authors were instructed to be brief, but I found the final product somewhat unsatisfying. For example, in the thyrotoxicosis chapter, there is a nice review of the therapy of Graves' disease, but only a cursory discussion of the management of the various forms of thyroiditis, toxic nodules, or toxic multinodular goiter. The chapter about pregnancy makes only brief note of the problem of ‘gestational thyrotoxicosis’ caused by hyperemesis gravidarum. Even the thyroid cancer chapter is, in spite of its breadth, not comprehensive: although the blurb on the back of the book promises ‘expanded coverage of thyroid cancer, including recombinant human TSH’, I was only able to find only a few lines devoted to this major clinical advance. I also found that not all sides of clinical controversies are presented to the reader. For example, the chapter about thyroid cancer does not describe the controversy surrounding routine ablation of thyroid remnants, and the discussion of low iodine diets does not mention recent data calling their efficacy into question.I liked a lot of this book. It would be a welcome addition to the library of an endocrinologist who wishes to be updated, in a user-friendly way, on the latest research advances in thyroidology. However, if I were a pure clinician or an endocrine fellow on a tight budget, I would be a bit disappointed in the way some important clinical topics are covered. Obviously, a book that is one-half the size of the classic thyroid tome The Thyroid, (also co-edited by Braverman) cannot possibly be all things to all people. The current book makes a good effort, and I know that I will refer to it often.