verbal-0rchid.com

Some Flowers Only Bloom in the Imagination

Few changes

Posted By on February 1, 2013

Over the next few weeks, I will be moving the blog over to a new site. It’s been past time for the change, and I feel this one has become too public. I’ll send out messages with the new link when it’s ready.

Correlation between PTSD and Adrenal Fatigue

Posted By on April 8, 2012

This is what the Mayo Clinic has to say about symptoms of PTSD and TBI. Below this I will list some (and by no means all inclusive) of the symptoms of Adrenal fatigue in its various stages, and Hypopituitarism. Several years ago I spent a few days down in Fayetteville, at a Starbucks no less, with print outs of the AF symptoms, and polled soldiers who came in about their experiences with PTSD. I didn’t even get into TBI because at that time it wasn’t broadcast too much. I feel I should probably do it again and ask about that too. The results I got were, quite frankly, astounding and not a little disturbing.

 

http://www.mayoclinic.com/health/post-traumatic-stress-disorder/DS00246/DSECTION=symptoms

 

  • Feeling emotionally numb
  • Avoiding activities you once enjoyed
  • Hopelessness about the future
  • Memory problems
  • Trouble concentrating
  • Difficulty maintaining close relationships

 

  • Irritability or anger
  • Overwhelming guilt or shame
  • Self-destructive behavior, such as drinking too much
  • Trouble sleeping
  • Being easily startled or frightened

From: http://www.helpguide.org/mental/post_traumatic_stress_disorder_symptoms_treatment.htm#signs

 

Symptoms of PTSD: Re-experiencing the traumatic event

  • Feelings of intense distress when reminded of the trauma
  • Intense physical reactions to reminders of the event (e.g. pounding heart, rapid breathing, nausea, muscle tension, sweating)

Symptoms of PTSD: Avoidance and numbing

  • Avoiding activities, places, thoughts, or feelings that remind you of the trauma
  • Inability to remember important aspects of the trauma
  • Loss of interest in activities and life in general
  • Feeling detached from others and emotionally numb
  • Sense of a limited future (you don’t expect to live a normal life span, get married, have a career)

Symptoms of PTSD: Increased anxiety and emotional arousal

  • Difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Hypervigilance (on constant “red alert”)
  • Feeling jumpy and easily startled
  • Anger and irritability
  • Guilt, shame, or self-blame
  • Substance abuse
  • Feelings of mistrust and betrayal
  • Depression and hopelessness
  • Suicidal thoughts and feelings
  • Feeling alienated and alone
  • Physical aches and pains
  • Aches and pains with no apparent cause
  • Irritability and aggression

For Traumatic Brain Injury:

 

http://www.traumaticbraininjury.com/content/symptoms/mildtbisymptoms.html

 

  • Fatigue
  • Headaches
  • Visual disturbances
  • Memory loss
  • Poor attention/concentration
  • Sleep disturbances
  • Dizziness/loss of balance
  • Irritability-emotional disturbances
  • Feelings of depression
  • Seizures

Other Symptoms Associated with Mild TBI

  • Nausea
  • Loss of smell
  • Sensitivity to light and sounds
  • Mood changes
  • Getting lost or confused
  • Slowness in thinking
  • Chronic pain
  • Control of bowel and bladder
  • Sleep disorders
  • Loss of stamina
  • Appetite changes
  • Regulation of body temperature
  • Menstrual difficulties

Social-Emotional

  • Dependent behaviors
  • Emotional ability
  • Lack of motivation
  • Irritability
  • Aggression
  • Depression
  • Disinhibition
  • Denial/lack of awareness
  • Attention
  • Concentration
  • Distractibility
  • Memory
  • Speed of Processing
  • Confusion
  • Perseveration
  • Impulsiveness
  • Language Processing
  • “Executive functions”

Speech and Language

  • not understanding the spoken word (receptive aphasia)
  • difficulty speaking and being understood (expressive aphasia)
  • slurred speech
  • speaking very fast or very slow
  • problems reading
  • problems writing

Sensory

  • difficulties with interpretation of touch, temperature, movement, limb position and fine discrimination

Perceptual

  • the integration or patterning of sensory impressions into psychologically meaningful data

 

 

 

This is a page from Janie Bowthorpe’s book, Stop the Thyroid Madness, which lists the most common adrenal symptoms. I don’t think I need to draw a map to detail the similarities.

 

http://www.stopthethyroidmadness.com/adrenal-info/symptoms-low-cortisol/

 

  • shaky hands; shakiness
  • diarrhea
  • bad palps
  • higher heart rate
  • pounding heart
  • feeling of panic
  • weakness
  • inability to handle stress
  • inability to handle interactions with others
  • inability to focus
  • rage or sudden angry outbursts
  • emotionally hyper sensitive
  • overreacting
  • highly defensive
  • feeling paranoid about people or things
  • exacerbated reactions to daily stress
  • no patience
  • easily irritated
  • mild to severe hypoglycemic episodes
  • nausea in the face of stress
  • taking days to recover from even minor stress
  • taking days to recover from a dental visit
  • flu-like symptoms
  • headache
  • all over body ache
  • super-sensitive skin
  • extreme fatigue
  • scalp ache
  • hyper feeling
  • jittery
  • clumsy (drop things, bump into things)
  • confusion
  • suddenly feel extremely hungry
  • low back pain
  • dull
  • cloud-filled head
  • jumpiness
  • muscle weakness
  • “air hunger”
  • dizziness
  • light headedness
  • motion sickness
  • coffee putting patient to sleep
  • vomiting even running up the slightest incline
  • almost passing out every time patient gets up
  • dark circles under my eyes
  • waking up in the middle of the night for several hours
  • difficulty falling asleep
  • frequent urination
  • IBS symptoms
  • worsening allergies

As I said, these symptoms are by no means all inclusive. One thing I want to point out. All of the above symptoms CAN have other causes. It’s very easy for one disorder or disease to mimic another when symptoms cross each other. People can be diabetic without being hypothyroid, they can have nightmares without PTSD, they can have ulcers and irritable bowel syndrome without having adrenal fatigue, or sleep apnea, menstrual problems, infertility. etc. They can even be grouchy and irritable, or just plain assholes without having PTSD or TBI.

 

However, when one patient experiences MULTIPLE symptoms all falling in line with the same category, not to mention when a doctor knows a patient has been in a heightened stressful situation such as war or another traumatic event, a responsible doctor should start playing “connect the dots” – to put it in TV terms, they should play Dr. House. They should start looking for the connection underlying, tying all the symptoms together and find the cause, not just treat each symptom separately.

Pretty in Pain

Posted By on August 3, 2011

 

So pretty in pain,
and in life not vain.
We are the tortured,
tormented by our own
torrid love affairs
brief and explosive,
strewn with discarded cares.
We achieve our inspiration
through such tempests
as to make men weep with
longing to love
so lingeringly.
We chart our course
through love’s choppy sea,
that poets may sing,
and the blind may see.
No love,
found or lost,
can be in vain,
when there exists we,
the pretty in pain.

Balancing the Tray

Posted By on December 13, 2010

BALANCING THE TRAY

by Lenore Gerould (1996), Carbon-Lehigh Right to Education Task Force,
Schnecksville, PA. Distributed by Autism Services Center, Huntington, WV by kind
permission of the author.

Those of us who have daily contact with children with autism sometimes have
trouble explaining to regular education teachers or administrators the ‘hooks’
of autism; especially the kinds of support they need. You’re always trying
to explain the basics, ‘no, moving the pencil sharpener’s location in the
classroom is not what upset him. You have to understand that…’. Then I came up
with this analogy. Perhaps it will help others to visualize the support
needed.

Try to imagine the child balancing a large serving tray on one upturned hand.
Every distress for that child is like a liquid-filled glass you are putting
on this tray. The ‘distress glasses’ are unique to each kid; but generally
include things like auditory or visual over-stimulation, social interaction,
‘surprises’ or unexpected changes in the schedule, lack of clear leadership,
the number of people in the room; whatever is sensitive for that child. (Don’t
forget the ability to read the body English and anxiety of the adults around
them!) The size and weight of the ‘glass’ for that child varies; just like
the ‘distress glasses’ vary for each kid. Some things are merely shot glass
size, while others can be a two liter jug. At some point the tray is going to
start to wobble – the liquid will start spilling out of the glasses on the
tray. The cues that this is happening will vary kid to kid: just as the cause and
size of a ‘glass’ varies kid to kid, but generally include regressive
behavior, avoidance or shutting down, giggling or minor acting out to get
attention.

Hopefully, someone will help the kid rebalance the tray, or remove some
glasses. Perhaps taking a break, or allowing time to refocus or process will
work; again, techniques are unique to each kid. If there’s no intervention, the
addition of one more glass will topple the tray to the floor. The cause is not
the most recent ‘glass’ you added, but the fact that the tray was full or too
heavy (the latter is why the child seems so unpredictable to some people.)
Our efforts should be that the kid learns to hold a bigger tray, or to do
minor correction of the tray’s balance somewhat independently, but they will
always carry that wobbling tray. Ignoring cues can be disastrous, from classroom
disruptions to a major regression.

When an autistic kids’s tray crashes to
the floor, it is always a major event. That’s why, if I hear my son got highly
upset over a moved pencil sharpener and acted out, I do not want to hear that
he has to learn to accept change. The sharpener is immaterial, if I learn
that day he’d dealt with a substitute teacher, a fire drill just as Reading was
starting, dead calculator batteries halfway through Math, a ‘crashed’
computer in the middle of English, a late bus so that he missed part of home room
and some florescent lights in the class are half out – his tray was already
full.

All of the distresses are unavoidable and he’d dealt with them without a
hitch; but each was another glass on this tray. Autistic kids need someone
around who is familiar with them; to sense how full the tray is getting and read
the cues, so there’s intervention before that wobbling tray topples to the
floor. That is why the type of support for these kids is critical, not just a
‘hot body’ nearby – but the ‘right hot body’ whom they can trust will help
balance and who knows the ‘hooks’.

For all of us, life is a balancing act, but for autistic kids the glasses
generally break when they hit the floor and it takes a whole lot longer to clean
up the mess and get a new tray.

Air Hunger to Death: Breathing Problems of Hypothyroid Patients

Posted By on March 9, 2010

Air Hunger to Death: Breathing Problems of Hypothyroid Patients
http://www.drlowe.com/jcl/comentry/breathingproblems.htm
Dr. John C. Lowe
February 25, 2005 (Updated January 30, 2006)

Send Comments & Questions to
DrJohnLowe@aol.com

Last week I consulted long distance with a young hypothyroid woman who had a distressing symptom—trouble getting a deep enough breath. She told me, “I just can’t seem to get in enough air.” She said her doctor doesn’t believe her hypothyroidism is the cause of her breathing problem.

I referred the patient to several sections of my book, The Metabolic Treatment of Fibromyalgia.[1] In those sections, I explain that labored breathing is a troubling symptom for which some hypothyroid patients seek medical care.[2, 11-13, 15-24] Medical journals contain many reports of some patients with hypothyroidism or thyroid hormone resistance having laboured breathing. The difficult breathing is called “air hunger” or “dyspnea.” Air hunger, however, isn’t the worst of the breathing troubles of some patients with too little thyroid hormone regulation.

In The Metabolic Treatment of Fibromyalgia,[1] I explain various mechanisms of these patients’ air hunger, all of which result from too little thyroid hormone regulation. One mechanism is weakness of their respiratory muscles, including the diaphragm.[22-23] Researchers call this weakness of respiratory muscles “hypothyroid myopathy.”

Another mechanism is impairment of the phrenic nerves that regulate contractions of the diaphragm. When impaired, these nerves send too few signals to the diaphragm for it to contract normally.[23]

A third mechanism is decreased “central drive of respiration.”[34] This means that the brain centers that regulate breathing are impaired by too little thyroid hormone regulation.

Still another mechanism is abnormal heart and lung function.[14-15,20]

Some patients suffer from air hunger only when they exert themselves; others do so even at rest.

The young hypothyroid woman I consulted with had been on T4-replacement for three months. She had been troubled with hypothyroid symptoms, including air hunger, for a year before her doctor diagnosed her hypothyroidism. The T4-replacement had slightly improved her fatigue and dry skin, but not her air hunger. Her dose of T4 was 100 mcg (0.1 mg) per day.

I was not surprised that this patient was still suffering from hypothyroid symptoms, including air hunger. To illustrate, consider the study data reported by a group of endocrinologists in 1997.[30] They measured nine hypothyroid patients’ TSH levels and their resting metabolic rates, and compared them to their doses of T4. I analyzed their data from a perspective different from theirs.

At one point in the study, six of the endocrinologists’ nine patients were using 100 mcg (0.1 mg) of T4. For three of these patients, this dose provided normal metabolic rates, although the rates of two of them were low normal. These two patients’ metabolic rates were 7% and 9% below the calculated average rate. (We consider a rate abnormally low only if it’s 10% or more below the calculated average rate). For the other three patients on 100 mcg of T4, the dose was woefully inadequate: One patient’s metabolic rate was 18% below normal, another’s was 23% below, and a third patient’s was 26% below normal.

The endocrinologists didn’t report this finding. I found it simply by looking at their data from a different perspective. From this vantage point, their own data show that some hypothyroid patients are kept hypometabolic on 100 mcg of T4. We find this regularly in our clinic when we measure the metabolic rates of patients on T4-replacement. And 100 mcg of T4 is obviously not working for this young woman, whose main troubling symptom is air hunger.

Doctor-Caused Lifelong Breathing Problem.

Yesterday I consulted long distance with a woman in her seventies who has had breathing troubles far worse than those of the young woman I mentioned above. In the early 1970s—before the Tyranny of the TSH [32] began—an endocrinologist treated her for hypothyroidism. Through trial-and-error, he found that her safe and effective dose of Armour Thyroid was 6 grains (360 mg).

She remained well on that dose until, years later, a second endocrinologist found her TSH level suppressed. The patient had no symptoms of overstimulation. Despite that, this endocrinologist insisted that she reduce her dose of Amour. She complied, lowering it to 4.5 grains (270 mg).

“Soon,” she told me, “I simply was not functional. I was gasping for air and coughing so bad that I felt like I was damaging my lungs.” To breathe, she had to sit upright on a sofa without leaning her head back to rest. This went on for eight weeks.

When her daughter, a nurse, phoned the endocrinologist, he denied that the patient’s breathing problem was related to her lower dose of Armour. He advised her to consult an ear, nose, and throat specialist. She saw a lung specialist instead, and he prescribed 40 mg of cortisone and an inhaler. The inhaler enabled her to get through her days. But even with the help of the inhaler, she couldn’t walk up a short flight of stairs without gasping for air. Her voice was so badly affected that she could no longer sing, which she had always enjoyed. “I could only croak,” she said.

In March of 2004, she located the original endocrinologist who had put her on 6 grains of Armour in the early 1970s. Her put her back on that dose. “It took me the rest of the year to get off the cortisone and get well,” she told me. “Before the second endocrinologist lowered my Armour dose, I’d never had any asthma or other breathing problems. Now I’m left with a lifelong breathing problem.” She’s largely over the breathing problems that began on the lower dose, but she still has to use an inhaler one or two times each day.

I admire this woman’s strength of character in wresting control of her health away from her doctors. Some of them have recently tried to persuade her to lower her dose again. “They simply don’t listen when I tell them what happened to me on the lower dose. I feel that I’m up against a wall of idiocy,” she said. “I don’t have too many years left to fool around with their book theories, and I’m not going to let them kill me.”

The tragic fact is, of course, that many doctors today would sacrifice her health and, indeed, even her life. Like most fanatics, to these doctors any price the patient might pay is worth achieving their obsessive goal—keeping the patient’s TSH “in range.”

Asthma.

Some inhalants patients use to relieve their asthmatic symptoms work by stimulating beta2-adrenergic receptors in the bronchial tubes.[28] Stimulating the receptors dilates the tubes and constricts blood vessels in their lining, which dries mucous secretions. These effects of the inhalants relieve shortness of breath, coughing, and wheezing respiration.[25,p.207]

An alternative to using the inhalers is to increase the number of beta2-adrenergic receptors in the bronchial tubes by taking an effective daily dose of thyroid hormone.[33] T3 is especially useful for this purpose.

In 1991, Egyptian researchers treated 23 asthmatic children with T3.[29] The children weren’t hypothyroid. During the 30 days of treatment, they continued to use their usual anti-asthma drugs as needed, but they reduced their doses as low as they could.

The researchers wrote, “They [the children] all reported at the end of the 30 days an obvious subjective improvement of their asthmatic conditions with a decrease in the number of exacerbations. Seven patients stopped their usual anti-asthmatic medicines, being maintained on T3 only and 3 have decreased the amount of bronchodilators needed. A significant improvement of pulmonary function tests was noted in all patients.”

According to the researchers, “All patients tolerated well the T3 regimen without any adverse effect.” They concluded that T3 induced beneficial effects: T3 “proves to be a useful adjuvant to classic anti-asthma therapy, and may reduce the amount of bronchodilators needed.”

Other researchers reported that patients with asthma became hypothyroid from using iodine-containing expectorants. After becoming hypothyroid, their asthma worsened. The worsening of the asthma was relieved, however, when the patients stopped using the expectorants and their thyroid function became normal again.[27]

Another group of researchers took hypothyroid children off thyroid hormone for a month. By the end of the month, the children’s bronchial tubes became more reactive to antigens. (Heightened reactivity of the bronchial tubes to antigens, of course, is the basis of allergy-induced asthma.) The children then resumed their thyroid hormone therapy. Their bronchial tubes, however, remained more reactive to antigens for two more months. Finally, after twenty more days, their bronchial tubes became normally reactive to antigens.[26]

Respiratory Failure and Other Breathing Problems.

In 2004, doctors described a 36-year-old male admitted to the hospital for progressive respiratory failure.[3] His chest X-ray and CT scan were normal, but he had a severely slow heart rate (bradycardia) and his cognitive function was slow. His TSH was over 150 microU/ml (in the US, the current upper limit for a “normal” TSH is 2.5 or 3.03, depending on which authority one consults). After the man began thyroid hormone treatment, his respiratory function steadily improved.

The doctors who reported this patient’s case listed five other respiratory disorders common among hypothyroid patients: dysfunction of the diaphragm, poor respiration from low central nervous system drive, obstruction of the airways, pleural effusion, and sleep apnea. They advised doctors to evaluate patients with respiratory problems for hypothyroidism.

Anesthesiologists reported the case of a 58-year old man who was severely hypothyroid. They wrote that his hypothyroidism was the cause of “ventilatory failure.” They described his 3-to-4 breaths per minute after surgery as an “exceedingly low” respiratory rate. The volume of air he took in each minute was low. Despite his low oxygen intake overall, he developed “primary acute respiratory alkalosis” (carbon dioxide loss from hyperventilation) and associated “hypocarbia” (abnormally low carbon dioxide in arteries).

The anesthesiologists cautioned that severely hypothyroid patients are at risk for adverse events around the time of surgery. They are more sensitive to anesthetics, have a higher incidence of surgery-related cardiovascular disease, and have an increased risk for ventilatory failure following surgery.[34]

Hypothyroidism doesn’t have to be severe to lead to weak breathing responses to increased carbon dioxide in the body. Researchers published a report on ten patients with hypothyroidism less severe than that of the patient in the above paragraph. Two of these patients had “blunted ventilatory responses to hypercapnea.” This means that high carbon dioxide levels didn’t provoke a normal increase in breathing to lower the carbon dioxide levels. The patients’ breathing responses to increased carbon dioxide improved when they underwent thyroid hormone therapy.[35]

Hypothyroidism and Obstructive Sleep Apnea.

Hudgel recommended thyroid hormone as a “ventilatory stimulant” for hypothyroid patients with sleep-disordered breathing.[5] He explained that in 1964, Massumi and Winnacker reported the association of sleep-disordered breathing with hypothyroidism.[6] Their report was about two hypothyroid patients who had obstructive sleep apnea. In 1981, Orr reported the results of polysomnograms (recordings of physiology during sleep) of three hypothyroid patients.[7] The tests showed repetitive obstructive apneas during sleep. Further testing by Rajagopal tightly linked hypothyroidism to obstructive sleep apnea.[8] Nine of his 11 consecutive hypothyroid patients had apnea.

Not all hypothyroid patients, of course, have obstructive sleep apnea. Lin found that among 25 hypothyroid patients, only 25% had sleep apnea.[9] The patients who had apnea were older and more obese than the patients without apnea. And not all patients with obstructive sleep apnea are hypothyroid. Lin found that only 3% of patients with apnea were hypothyroid.[9]

But for most hypothyroid patients who do have sleep apnea, the consequences can be troubling.[10] For example, because they don’t sleep deeply long enough, they can be severely fatigued throughout the day. And as the section below shows, for at least one hypothyroid patient, apnea wasn’t just troubling; it was fatal.

First Reported Death From Hypothyroidism and Sleep Apnea.

In 1999, doctors reported the first case of a hypothyroid patient who suddenly died from sleep apnea.[4] The patient was a 48-year-old man who was short and slightly overweight. He had never been treated for his hypothyroidism.

For several years, the patient suffered from air hunger at night. In the previous few weeks, his air hunger had worsened. In the hospital, doctors noted that he was lucid, but his mental and physical functions were slow. They found that he had a multinodular goiter that had moved his windpipe (trachea) from its normal position. His tongue was enlarged, and his pharynx (the cavity that connects the mouth and nasal passages to the esophagus) was swollen with edema. His blood was adequately saturated with oxygen at 97%.

Doctors treated the man with T3 and hydrocortisone. They doubted that he had sleep apnea syndrome (SAS), but they applied pulse oximetry. (Pulse oximetry is a monitor, usually with a finger sensor, used during anesthesia and critical care. It measures oxygen saturation of arterial blood.) The man suddenly died seven hours later.

The oximetry record showed that over the seven-hour period, the patient had prolonged episodes of sleep apnea. These episodes had caused deep drops in oxygen saturation of his blood. The doctors who reported the man’s death urged other doctors to promptly diagnose hypothyroidism that’s associated with obstructive sleep apnea. They noted that the condition can become serious and require intensive care with continuous nasal airway positive pressure. They wrote that some patients may need tracheal intubation with assisted ventilation. They cautioned, “Continuous cardiac monitoring should also be carried out, given the risk for acute coronary complications and ventricular arrhythmias in the early phases of substitutive therapy with thyroid hormone.”

Conclusion: The studies I’ve cited in this report show that too little thyroid hormone regulation can cause a variety of breathing problems. These range from mere frustrating air hunger to death from sleep apnea. If you have a breathing problem and your doctor can’t find the cause, ask him or her to evaluate you for hypothyroidism or thyroid hormone resistance. If you’re being treated for hypothyroidism with T4-replacement, ask your doctor to consider that this thyroid hormone therapy leaves almost 50% of patients suffering from chronic hypothyroid symptoms.[31] Ask your doctor to also consider that you may need to switch to a more effective therapy such as a T4/T3 combination product or T3 alone. At minimum, if your doctor isn’t aware that too little thyroid hormone regulation can cause breathing problems, share this special report with him or her. The doctor may use the information not only to relieve your breathing problem, but to help other patients, too.
———————————————————————————————————————————–
References

1. Lowe, J.C.: The Metabolic Treatment of Fibromyalgia. Boulder, McDowell Publishing Co., 2000.

2. Fujimoto, K., et al.: A case of myxedema heart with serial endomyocardial biopsy. Kokyu to Junkan: Respir. Circul., 40(10):1019-1023, 1992.

3. Novik, V., Perez, M.E., and Anwandter, G.: Global respiratory failure as the presentation form of hypothyroidism. Report of one case. Rev. Med. Chil., 132(1):81-84, 2004.

4. Pompeo A, et al.: Sudden death by sleep apnea syndrome associated with myxedema. A case report and a review of the literature. Minerva Endocrinol., 24(1):37-44, 1999.

5. Hudgel. D.W. and Thanakitcharu, S.: Pharmacologic treatment of sleep-disordered breathing. Am. J. Respir. Crit. Care Med., 158(3):691-699, 1998.

6. Massumi, R. A., and J. L. Winnacker.: Severe depression of the respiratory center in myxedema. Am. J. Med. 36: 876-882, 1964.

7. Orr, W. C., et al.: Myxedema and obstructive sleep apnea. Am. J. Med., 70: 1061-1066, 1981.

8. Rajagopal, K. R., et al.: Obstructive sleep apnea in hypothyroidism. Ann. Intern. Med., 101: 491-494, 1984.

9. Lin, C., K., et al.: The relationship between sleep apnea syndrome and hypothyroidism. Chest, 102: 1663-1667, 1992.

10. Grunstein, R. R., and C. E. Sullivan. Sleep apnea and hypothyroidism: mechanisms and management. Am. J. Med., 85: 775-779, 1988.

11. Garcia Martinez, et al.: Heart insufficiency as first manifestation of familial primary hypothyroidism. Rev. Esp. Cardiol., 50(9):670-672, 1997.

12. Fiorani, S., et al.: Hypothyroidism and megacolon. Minerva Anestesiol., 62(7-8):271-275, 1996.

13. Pincheram A., et al.: Multinodular goiter. Epidemiology and prevention. Ann. Ital. Chir., 67(3):317-325, 1996.

14. Hellermann, J. and Kahaly, G.: Cardiopulmonary involvement in thyroid gland diseases. Pneumologie, 50(5):375-380, 1996.

15. Ikeshita, M., et al.: A case report of simultaneous surgery for Wolff-Parkinson-White syndrome combined with hemolytic anemia and mitral stenosis. Jpn. Circ. J., 60(3):171-176, 1996.

16. Fujimoto, K., et al.: A case of myxedema heart with serial endomyocardial biopsy. Kokyu To Junkan, 40(10):1019-1023, 1992.

17. Smallridge, R.C.: Metabolic and anatomic thyroid emergencies: a review. Crit. Care Med., 20(2):276-291, 1992.

18. Nyrop, M., et al. Cardiovascular manifestations of hypothyroidism. Ugeskr Laeger, 153(26):1849-1851, 1991.

19. Okabe, M., Kubara, K., Kawaguchi, H., et al.: A case of myxedema with diffuse myocardial fibrosis proven by endomyocardial biopsy. Kokyu To Junkan, 38(11):1159-1163, 1990.

20. Brussel, T., et al.: Pulmonary manifestations of endocrine and metabolic disorders. Clin. Chest Med., 10(4):645-653, 1989.

21. Sebe, T., et al.: A case of myxedema heart showing the improvement of impaired alpha-hANP secretion by administration of ATP and dibutyryl cAMP. Kokyu To Junkan, 38(10):1045-1048, 1990.

22. Martinez, F.J., et al.: Hypothyroidism. A reversible cause of diaphragmatic dysfunction. Chest, 96(5):1059-1063, 1989.

23. Laroche, C.M., et al.: Hypothyroidism presenting with respiratory muscle weakness. Am. Rev. Respir. Dis., 138(2):472-474, 1988.

24. Szabo, L., et al.: Thyroiditis causing upper respiratory stenosis. Orv. Hetil. 110(24):1388-1390, 1969.

25. Harvey, R.A. and Champe, P.C.: Pharmacology. Philadelphia, J.B. Lippincott Co., 1992.

26. Villa, M.P., et al.: Modification of nonspecific bronchial reactivity in hypothyroid children under different regimens of substitutive opotherapy. Pediatr. Pulmonol., 2(6):353-357, 1986.

27. Korsager, S. and Ostergaard Kristensen, H.P.: Iodine-induced hypothyroidism and its effect on the severity of asthma. Acta Med. Scand., 205(1-2):115-117, 1979.

28. Ursu, H.I., et al.: Graves’-Basedow’s disease–asthma association. Presentation of five cases. Rom. J. Endocrinol., 1993;31(1-2):89-94.

29. Abdel Khalek, K., et al: Effect of triiodothyronine on cyclic AMP and pulmonary function tests in bronchial asthma. J. Asthma., 28(6):425-431, 1991.

30. Al-Adsani, H., et al.: Resting energy expenditure is sensitive to small dose changes in patients on chronic thyroid hormone replacement. Clin. Endocrin. Metab., 82(4):1118-1125, 1997.

31. Saravanan, P., et al.: Psychological well-being in patients on ‘adequate’ doses of L-thyroxine: results of a large, controlled community-based questionnaire study. Clin. Endocrinol. (Oxf.), 57(5):577-585, 2002.

32. Lowe, J.C.: Tyranny of the TSH. Boulder, McDowell Publishing Co, 2005.

33. Weglarz, L., et al.: Beta2-agonists: what does their chemical structure determine? Postepy. Hig. Med. Dosw., 2004 Nov 3;58:372-80.

34. Lee, H.T. and Levine, M.: Acute respiratory alkalosis associated with low minute ventilation in a patient with severe hypothyroidism. Can. J. Anaesth., 46(2):185-189, 1999.

35. Ladenson, P.W., et al.: Early peripheral responses to intravenous L-thyroxine in primary hypothyroidism. Am. J. Med., 73(4):467-474, 1982.