Scunthorpe General Hospital,Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

Abstract Introduction Radioactive iodine (RAI) has been a cornerstone in management of hyperthyroidism since 1940s. Despite being effective therapy, a proportion of patients fail initial therapy and require repeat treatment. This study aims to identify clinical and biochemical predictors of RAI failure. Methods Retrospective cohort study of 764 patients treated with RAI for hyperthyroidism between 2007 and 2023 at a UK District Hospital. Univariable analyses followed by multivariable logistic regression were performed to identify independent predictors of treatment failure. Predictor variables were selected based on clinical relevance and published literature. Biochemical analysis of serial post-RAI TFTs up to 12 months were included. Categorical variables were analysed as factors with clinically relevant reference categories, and continuous variables were included as linear terms. Missing data were handled using random forest–based imputation. Results are reported as odds ratios (OR) with 95% confidence intervals (CI), with statistical significance defined as P < .05. Results Of the 764 patients included; 44 (5.76%) experienced treatment failure. Mean age was 56.6 ± 15.1 years, and 26.6% were male. On univariable analysis; male sex was associated with increased odds of treatment failure (OR 3.29, 95% CI 1.55-6.89, P = .001). Longer ATD treatment duration was protective, particularly ≥13 months (13-18 months: OR 0.06, 95% CI 0.006-0.57; >24 months: OR 0.10, 95% CI 0.02-0.48). Multinodular goitre was associated with higher failure risk compared with smooth texture (OR 4.85, 95% CI 2.06-11.44, P < .001). Six-week post-RAI TSH was significantly lower in patients who failed treatment (Mann-Whitney U = 1481, P < .001). On multivariable analysis; current smoking independently predicted treatment failure (OR 4.35, 95% CI 1.36-15.22, P = .016) whilst ex-smoking did not show the same relation (OR 1.62, 95% CI 0.33-7.15, P = .53) when compared with never smoking. Small goitre size was strongly protective compared with no goitre (OR 0.04, 95% CI 0.005-0.23, P < .001). Multinodular goitre texture remained independently associated with treatment failure (OR 11.48, 95% CI 2.58-62.12, P = .002). Autoimmune aetiology showed a borderline association with increased failure risk (OR 3.44, 95% CI 0.90-15.44). Six-week post-RAI TFTs were not independently predictive in the multivariable model, although raised TSH demonstrated a borderline protective trend. Conclusions This study confirms established clinical predictors of RAI treatment failure, including smoking status and multinodular goitre morphology. Importantly, suppressed 6-week post-RAI TSH emerged as a novel early biochemical marker of treatment failure, supporting its role in early risk stratification and optimisation of follow-up strategies.

Common variable immunodeficiency (CVID) is associated with immune dysregulation and an increased risk of gastric malignancy. The coexistence of CVID with autoimmune gastritis, pernicious anemia, and genetic defects such as cytotoxic T-lymphocyte antigen-4 (CTLA-4) haploinsufficiency may suggest a possible association with altered gastric adenocarcinoma risk. However, the clinical interplay remains incompletely understood and not well established. We present a case of a 54-year-old Caucasian woman with a high-grade intestinal tubulovillous adenoma in the stomach body, who developed gastric adenocarcinoma, which was subsequently resected, and had a recurrence of the tumor with a background of chronic lymphocytic gastritis almost four years later. She was later diagnosed with CVID and was found to have pernicious anemia and CTLA-4 haploinsufficiency. This case highlights the potential interplay between CVID, CTLA-4 haploinsufficiency, and autoimmune gastric pathology in the development of gastric adenocarcinoma. Early recurrence despite initial curative resection underscores the need for increased vigilance and consideration of structured surveillance strategies in high-risk patients with overlapping autoimmune gastric conditions. Further research is needed to guide screening and prevention in this population.

Abstract Combined Levothyroxine and Liothyronine (T4/T3) therapy in primary hypothyroidism remain a matter of debate, this study was designed to highlight the biochemical outcomes from real clinical practice. Methodology Retrospective observational audit of electronic records from secondary care endocrine clinic in UK. Participants All adults receiving liothyronine in combination with levothyroxine for primary hypothyroidism under clinic follow up during the audit period (n = 26). Most participants were female (24/26, 92.3%) and aged 36-80 years, with primary autoimmune, post-radioiodine and postsurgical hypothyroidism predominating. Interventions Existing combination therapy was reviewed. For each patient, prior levothyroxine dose, TSH and weight were extracted together with current T4 and T3 doses, TSH, weight and duration on a stable regimen. Main outcome measures Primary outcome was the proportion of patients with TSH within the reference range (0.4-4.5 mU/L) on combination therapy. Secondary outcomes included TSH <0.4 or >4.5 mU/L, change in TSH and weight from monotherapy to combination therapy, time to stable TSH, and prescribed T4:T3 dose ratios. Results Before combination therapy, 17/26 patients (65.4%) had TSH >4.5 mU/L despite levothyroxine doses most commonly between 100 and 150 mcg daily. On combination therapy, 18/26 (69.2%) had TSH 0.4-4.5 mU/L, 4/26 (15.4%) had TSH <0.4 mU/L, and 4/26 (15.4%) had TSH >4.5 mU/L. Stable TSH was documented in 14/26 patients (53.8%); in 12/26 (46.2%) TSH remained unstable, suppressed, recently altered or showed only minimal improvement. Mean T4:T3 ratio was approximately 4:1, with wide inter-individual variability. Conclusions In this cohort, combination therapy was used in a small, predominantly female group with persistent biochemical abnormalities on levothyroxine alone and led to normalisation of TSH in around two thirds of patients. However, almost half did not achieve sustained biochemical stability and a sizeable minority had suppressed or elevated TSH, raising concerns in the context of guidance that does not recommend routine combination therapy and emphasises cautious dosing and regular review. These findings support tighter local criteria, more structured monitoring and clearer documentation of indications when prescribing liothyronine.

The purpose of this study was to systematically evaluate the safety, clinical outcomes, and complications of EndoArt (EyeYon Medical, Nes Ziona, Israel) as an alternative to donor endothelial keratoplasty for chronic corneal oedema. MEDLINE/EMBASE, PubMed, Cochrane Library, and Google Scholar were searched for studies published between 1st Jan 2020 and 17th May 2025 reporting clinical outcomes following EndoArt implantation. A total of 12 studies were included. Eligible studies included case reports, case series, retrospective observational studies, and single-arm interventional studies. Overlapping cohorts were resolved by retaining the most complete datasets. Risk of bias was assessed by the Joanna Briggs Institute critical appraisal tools and the Methodological Index for Non-randomised Studies. Quantitative synthesis was pre-specified for outcomes with ≥2 studies; meta-analysis used standardised mean differences or pooled event rates with heterogeneity. Four studies (56 eyes) were included for quantitative analysis. Pooled visual acuity improved (SMD -0.728; 95% CI -1.277 to -0.180; p=0.009); mean visual acuity changed from 1.561 to 1.212 logMAR with low heterogeneity (I² = 20.428%, p = 0.285). Central corneal thickness decreased (SMD -1.420; 95% CI -1.867 to -0.974; p<0.001); mean central corneal thickness fell from 755.46 to 554.07 µm with low heterogeneity (I² = 0%). The pooled re-bubbling rate was 60.2% (95% CI 38.7 to 78.4%; I² = 52.88%). The most frequently reported adverse events included partial implant detachment and raised intraocular pressure. EndoArt achieves meaningful deturgescence and visual acuity gains, but at the cost of high detachment and rebubbling rates. Given current evidence, EndoArt is likely best suited as salvage therapy, offering independence from donor tissue. No immune response was reported. Larger cohort comparative studies are required to refine indications and technique.

Calcium channel blocker (CCB) overdose is a rare but potentially life-threatening presentation associated with profound bradycardia, shock, and metabolic disturbances. Management can be complex, often requiring advanced hemodynamic support and multimodal therapies. We report a case of severe CCB intoxication leading to refractory hypotension, illustrating the challenges encountered in critical care management. Current approaches involve multimodal pharmacological interventions, including high-dose insulin euglycemic therapy, IV calcium, glucagon, and lipid rescue. CCBs have widespread use; therefore, understanding the consequences of overdose is clinically important.