Introduction: Non-alcoholic fatty liver disease (NAFLD) is the hepatic component of the metabolic syndrome. Although the only proven treatments are weight loss, diet, exercise and consumption of coffee, many medications are being investigated for treatment of NAFLD. Aim:To present different aspects of NAFLD as part of the metabolic syndrome and to review some aspects of obeticholic acid (OCA) therapy. Methods:We comment on the REGENERATE trial of OCA for treating NAFLD.Results: This trial (1968 patients with F2-3 fibrosis or F1 fibrosis and ≥ 1 comorbidity) has several limitations. The incidence of pruritus in the OCA group is 22% in the 25 mg dose, 17% in the 10 mg dose and 14% in the placebo group. Pruritus was not rigidly defined and in a trial of elafibranor for NAFLD, only 1% had pruritus in the placebo group. OCA causes hyperlipidaemia; the placebo group had a decrease in cholesterol of 3 mg/dL in the first month vs an increase of 17.8 mg/dL in the 10 mg dose and 23.8 mg/dL in the 25 mg dose group. Since 56% of the patients had diabetes mellitus and 69% had hypertension, this is likely to be detrimental. The interim analysis showed a 'significant histological improvement' but there is no data regarding clinical end-points. The issue of changes in lipids was addressed in a separate publication 2 weeks later. Conclusion:The current trials of treatment for NAFLD need to have robust treatment in the placebo groups and address clinical outcomes. At present, it appears to be drugs in search of a disease.

Background: Subacute thyroiditis (SAT) is a relatively common cause of thyroid disease. However, only a few studies evaluating SAT have been published in recent years with varying diagnostic criteria. We evaluate the clinical presentation and long-term outcome of isotope scan-confirmed SAT. Methods: A retrospective study of 38 patients with isotope scan-confirmed SAT was performed at a single isotope department. All patients were contacted for long-term follow-up. Results: The female/male ratio was 1.4:1, and mean age was 47 ± 14 years and 62 ± 12 years in women and men, respectively (p = 0.002). Almost half of the cases (42%) occurred during the summer. The most common symptoms were neck pain (74%) and weakness (61%). Palpitations, weight loss, heat intolerance, and sweating appeared in 50%, 42%, 21%, and 21%, respectively. Only half of the patients reported fever. TSH level was low in all patients, and mean FT4 and FT3 level were about twice the upper limit of normal range. Elevated CRP and ESR occurred in the majority (88%) of patients. The mean time period between the first clinic visit and performing thyroid function tests was 8 ± 7 days. One-third of the patients initially received a diagnosis of upper respiratory tract infection (URI). NSAIDs and steroids were prescribed to 47% and 8% of patients, respectively. Long-term follow-up of 33.5 months (range 9–52) revealed that 25% remained with subclinical or overt hypothyroidism. Conclusions: These data demonstrate that although SAT is a common entity, there is still a significant delay in diagnosis, and in a third of our patients, the initial diagnosis was URI, with 25% developing long-term hypothyroidism.

Background:Subacute thyroiditis (SAT) is a common inflammatory condition. However, only a few studies evaluating SAT were published in recent years with varying diagnostic criteria. Although thyroid isotope-scan is an accurate non-invasive test for confirming SAT, it was not used as a mandatory diagnostic criteria in prior studies. Aim:To evaluate the clinical presentation and long-term outcome of patients in the community who were found to have SAT confirmed later by an isotope scan.Methods: A retrospective study of 38 consecutive patients with isotope scan-confirmed SAT performed at a single isotope department. All patients were contacted to assess long-term follow-up. Results: The female/male ratio was 1.4:1, mean age was 47±14 years and 62±12 years in women and men, respectively (p=0.002). Almost half of the cases (42%) occurred during the summer. The most common symptoms were neck pain (74%) and weakness (61%). Palpitations, weight loss, heat intolerance, and sweating, appeared in 50%, 42%, 21%, and 21% of patients, respectively. Only half of the patients reported fever. TSH level was low in all patients, mean FT4 and FT3 level were about twice the upper limit of normal range. Elevated CRP and ESR occurred in the majority (88%) of patients. The mean time period between the first family physician clinic-visit and performing thyroid function tests was 8±7 days. One third of the patients initially received a diagnosis of upper respiratory tract infection (URTI). NSAIDs and steroids were prescribed to 47% and 8% patients. Long-term follow-up (range 6-42 months) revealed that 25% remained with subclinical or overt hypothyroidism. Conclusions:These data demonstrate that although SAT is a common entity, there is still a significant delay in diagnosis due to variation in the clinical symptoms. This leads to initial incorrect diagnosis in many cases such as URTI in a third of our patients. A quarter of patients developed long-term hypothyroidism. These data imply that: 1. SAT can still be a diagnostic challenge; 2. Long-term follow-up of thyroid function tests is needed.

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