Repeated measure ANOVA showed that there external rotation and shoulder internal rotation over were statistically significant increase in degree of the 3-4 weeks after the operation (p-value < 0.001) shoulder flexion, shoulder abduction, shoulder

DISCUSSION early weeks and months after surgery are of intense 2002;73(5):479. 2002;75(1):51-64. ORIGINAL ARTICLE among Iranians 8.34 ± 2.37 ml 3 among Nigerians8.55 history, past history, medical and drug history which importance for females who must be provided with 11. Buragadda S, Alhusaini AA, Melam GR, Arora N. 15. Mondry TE, Riffenburgh RH, Johnstone PA. ± 1.82ml4, among Danish 11.9-13.6ml6 and among was noted in proforma. Physical examination of TG The findings of present study suggested that home optimal medical and physical therapy care 7. This Effect of complete decongestive therapy and a Prospective trial of complete decongestive therapy Turkish subjects was 12.98±2.53 mL.14 was performed and sign and symptoms of thyroid based decongestive lymphatic therapy following will reduce the occurrence of complications like home program for patients with post mastectomy for upper extremity lymphedema after breast QUANTITATIVE ASSESSMENT OF THYROID diseases were noted. axillary lymph node dissection had significant secondary lymphedema and decrease in range of lymphedema. J Phys Ther Sci 2015;27(9):2743-8. cancer therapy. Cancer J 2004;10(1):42-8. In our neighboring country Iran, Moghadam RN effects on range of motion of shoulder joint includ- motion of shoulder and arm17. 12. Fiets W, Van Helvoirt R, Nortier J, Van der Tweel I, 16. Kim S, Yi C, Kwon O. Effect of complex decon- GLAND VOLUME AMONG THE ETHNIC reported mean TGV of 8.34±2.37ml in 314 healthy The study included apparently healthy subject’s ing shoulder flexion, abduction, external rotation Struikmans H. Acute toxicity of concurrent adjuvant gestive therapy and the quality of life in breast euthyroid adults of Yzad Iran3, Abidi et al. in 2008 age 21 years and above. Euthyroid, subjects were and internal rotation among patients of breast Despite profuse amount of literature, effectiveness radiotherapy and chemotherapy (CMF or AC) in cancer patients with unilateral lymphedema. GROUPS OF KARACHI POPULATION reported mean TGV of 9.53 ± 3.68 ml among the 200 recruited with serum TSH level falling within the cancer surgery. The results of the present study are of lymphatic drainage is still under debate and breast cancer patients: a prospective, compara- Lymphology 2007;40(3):143-51. healthy adults of Isphan Iran15. Ahidjo et al. in 2002 normal range b/w 0.23 to 4.0 µlU/mL (as recom- consistent with a previous study which concluded further evaluations are needed18. Future studies are tive, non-randomised study. Eur J Cancer 17. Beurskens CH, van Uden CJ, Strobbe LJ, Oosten- Mahrukh Kamran1, Iffat Raza2, Maria Mohiuddin3, Nausheen Adnan4, Sadaf Saheen5 and Rabia Rehan6 reported mean TGV of about 8.55cm3 ±1.82 in mended by laboratory). that significant improvements were observed also recommended to evaluate the long term 2003;39(8):1081-8. dorp RA, Wobbes T. The efficacy of physiotherapy 1Department of Anatomy, Dow University of Health Sciences,2Karachi Institute of Medical Sciences,3Humdard Medical Maiduguri, North-Eastern Nigeria4 and Alazigha N in 4 5 among patients receiving home exercise plan. effects of home based decongestive therapy. 13. Clark B, Sitzia J, Harlow W. Incidence and risk of upon shoulder function following axillary dissection and Dental College, Karachi Institute of Medical Sciences, Mohtarma Benazir Bhutto Shaheed Medical College, 2015 reported The mean TGV 6.81+2.18cm3 in South Exclusion criteria of the study include subjects taking 6Dow University of Health Sciences. Decongestive therapy showed significant reduction arm oedema following treatment for breast cancer: in breast cancer, a randomized controlled study. geopolitical zone of Nigeria16. Ertan et al in 2015 drugs causing goiter especially lithium, carbamaze- in terms of pain and lymphedema11. a three-year follow-up study. QJM 2005;98(5):343-8. BMC Cancer 2007;7(1):166. reported mean TGV of 12.98±2.53 mL in subjects of pine, phenytoin and oral contraceptive, individual CONCLUSION 14. Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furni- 18. Feldman J, Stout N, Wanchai A, Stewart B, Corm- ABSTRACT Tekirdag city Turkey14. Seker et al. reported mean with palpable or visibly enlarged TG, palpable Previous literatures have identified that the provision val CM. Physiotherapy after breast cancer surgery: ier J, Armer J. Intermittent pneumatic compression TGV of 13±6.27 ml in Turkish population of Ankara17. thyroid nodules on physical examination. Exclusion of radiotherapy significantly increases the risk of Home based lymphatic decongestive therapy results of a randomised controlled study to minimise therapy: a systematic review. Lymphology Objectives: Thyroid gland volume varies from population to population. In this study mean thyroid gland Authors suggested the influence of genetic and criteria of the study also included previous or current edema. Multiple authors have reported the adverse proved to be effective in improving shoulder range lymphoedema. Breast Cancer Res Treat 2012;45(1):13. volume among the ethnic groups in Karachi population was determined. environmental factors especially daily iodine intake history of thyroid disease or thyroid surgery, preg- effect of breast edema as well as secondary lymph- of motion and reducing lymphedema post breast levels that accounts most for the regional variations nancy, lactation and females with history of delivery edema, fibrosis and dermatitis12. The literature also cancer surgery. Methods: A prospective cross-sectional study was carried out in the Radiology Department of Ziauddin in TGV. during the last 12 months as hormonal changes vary supported prevention of lymphedema through University Hospital Clifton Karachi, from January 2013 to in May 2014. Healthy subjects aged 21 years and TGV. Subjects in whom thyroid nodule, heterogene- particular techniques to decrease deterioration of above were recruited through convenient sampling. Serum thyroid stimulating hormone was evaluated in Karachi is largest cosmopolitan city of Pakistan. ity, agenesis or any other anomaly of thyroid gland 13 axillary system . No evidence is present which REFERENCES order to recruit euthyroid subjects. Ultrasonography of 416 euthyroid subjects was performed to determine People from all over the Pakistan reside here for was discovered during ultrasonography were also focuses on the home based management of better jobs and business opportunities, lifestyle mod- omitted from the study. the thyroid gland volume. lymphedema. Manual lymphatic drainage has 1. Kärki A, Simonen R, Mälkiä E, Selfe J. Impairments, ification, medical facilities, education facilities and been proved to be effective but the self manage- activity limitations and participation restrictions 6 so on18, 19. Reference range of normal TGV among Ultrasonography of thyroid was performed by single Results: Mean thyroid volumes reported were as follow: In Urdu speaking it was reported to be 5.47± 2.29 ml, ment at home has not been targeted yet. and 12 months after breast cancer operation. J euthyroids has been established worldwide. Region- sonologist. Length, width and depth of each lobe of Rehabilit Med 2005;37(3):180-8. in Sindhi 6.44 ± 3.23ml, in Pathan 6.52 ± 3.07ml, in Punjabi 7.02 ± 4.28ml, in Hazarah 7.05 ±3.91ml and in al variations in TGV within the same country are also thyroid gland were taken. Volume of TG was calcu- Box et al determined the treatment strategies to 2. Badger CM, Peacock JL, Mortimer PS. A random- Balochi7.56 ± 4.52ml. Mean thyroid volumes were significantly different among all the ethnic groups (P-Value a very well documented. lated by WHO recommended formula: Volume of reduce post operative lymphedema after removal ized, controlled, parallel‐group clinical trial compar- 0.015). each lobe (ml) = Length (cm) x Width (cm) x Depth of nodes resulting from breast cancer and highlight- ing multilayer bandaging followed by hosiery versus To the best of our knowledge so far no study (cm) x 0.479 (0.479 = correction factor) Total volume ed that rehabilitation plan focusing exercises and hosiery alone in the treatment of patients with Conclusion: Mean total thyroid gland volumes, right and left lobe volumes were found to be significantly conducted that determine the reference range of was the sum of two thyroid lobes. Isthmus dimen- counseling methods may decrease the complica- lymphedema of the limb. Cancer different among the ethnic groups that exist in Karachi population. Long term variations in the level of intake TGV among the different ethnic groups that exists in sions were not included in TGV as approved by tion of lymphedema almost 2 years post surgery14. In a multiethnic Karachi population. Objectives of this W.H.O20. Data was analyzed on SPSS version 21. 2000;88(12):2832-7. of iodine among the ethnic groups may have resulted alterations in genotype that probably has resulted in the current study girth measurement was not signifi- study were to determine mean TGV among the Means and standard deviations were derived by 3. Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn significant variation in the mean TGV among the ethnic groups. cantly improved after home based decongestive KL. Arm edema in breast cancer patients. J Natl different ethnic groups that exists in Karachi popula- descriptive stats. Kolmogorov–Smirnov test was lymphatic therapy. However previous study has Cancer Inst 2001;93(2):96-111. tion and to determine whether the changes in applied to check the normality. As the data fulfills shown that complete decongestive therapy plan 4. Ozaslan C, Kuru B. Lymphedema after treatment KEYWORDS: Ethnic Groups, Reference Values, Thyroid Gland, Thyrotropin, Ultrasonography. mean TGV among the ethnic groups are significant. the normality assumptions ANOVA was applied to along with home program had significant effects on of breast cancer. Am J Surg 2004;187(1):69-72. determine the difference of TGV among the differ- arm circumference. The results showed that circum- 5. Johansson K, Ohlsson K, Ingvar C, Albertsson M, Corresponding Author ent ethnic groups. ference of upper half of arm after intervention had Ekdahl C. Factors associated with the development Dr Mahrukh Kamran METHODS reduced significantly as compared to pre decon- of arm lymphedema following breast cancer treat- Department of Anatomy 15 gestive lymphatic therapy . Therefore, the current ment: a match pair case-control study. Lymphology Dow International Medical College This was a cross sectional study that was carried out RESULTS study highlights an important aspect that home 2002;35(2):59-71. Dow University of Health Sciences Karachi in the Radiology Department of Ziauddin University therapy alone had failed to produce significant Hospital, Karachi. This study was permitted by the Descriptive statistics for mean thyroid gland 6. Lacomba MT, Sánchez MJY, Goñi ÁZ, Merino DP, Email: [email protected] effects on arm volume. del Moral OM, Téllez EC, et al. Effectiveness of early ethical committee of Ziauddin University and was volumes is shown in Table 1 among the ethnic physiotherapy to prevent lymphoedema after started in January 2013 and completed in May groups and Table 2 representing the significance in In the current study the patient’s cooperation, surgery for breast cancer: randomised, single blind- 2014. Participants were gathered through the mean thyroid gland volume among the ethnic INTRODUCTION age, gender, anthropometric parameters, genetic adherence and compliance to rehabilitation plan ed, clinical trial. BMJ 2010;340:b5396. convenient sampling. Every participant was asked groups. makeup of population and environmental factors3-7. were high. This may be due to high literacy level of 7. Vignes S, Porcher R, Arrault M, Dupuy A. questions related to demographic profile, personal Anatomically Thyroid gland (TG) lies in the anterior After urinary iodine level evaluation, World Health participants. Hence this study targeting the home Long-term management of breast cancer-related triangle of neck. It is encapsulated and consists of Organization (WHO) suggests TGV as an important based remedial exercises and lymphatic drainage lymphedema after intensive decongestive physio- two lobes which extend from fifth cervical to first indicator for iodine status of a population8. Serum program highlights the importance of self tech- therapy. Breast Cancer Res Treat 2007;101(3):285. thoracic vertebrae. The two lobes of TG are thyroid stimulating hormones (TSH) and thyroid niques. 8. Zuther JE, Norton S, Armer JM. Lymphedema connected to each other by means of isthmus hormones level are also very well-known factor that management: the comprehensive guide for practi- anteriorly1. TG secretes thyroid and calcitonin regulates TGV9, 10. The study also focuses the reduction in volume of tioners: Thieme New York; 2009. hormones. Thyroid hormones maintain the ideal arm and forearm after home based intervention. 9. Szuba A, Cooke JP, Yousuf S, Rockson SG. Decon- However, there were no reduction in circumference level of metabolism in tissues and calcitonin Mean TGV reported in different regions of world is as gestive lymphatic therapy for patients with 2 at metacarpophalangeal and wrist circumference. hormone controls level of calcium in circulation . follow: In Karachi population mean TGV reported cancer-related or primary lymphedema. Am J Med 11 12 The results are in support with the previous literature was 6.29 ± 2.9 ml , among Sudanese 6.44 ± 2.44ml , 2000;109(4):296-300. 13 showing improved quality of life in relation to reduc- Mean thyroid gland volume (TGV) is highly variable. among Cubans 6.6 ± 0.26 ml , among Nepalese 10. LINFEDEMA PRPI, DELL’ARTO S. Rehabilitation l7 l5 16 Many factors are known to influence TGV such as 6.629 ± 2.5m , among Chinese 12.92 ± 3.9m , tion in arm volume after decongestive therapy The protocol in upper limb lymphedema. Ann Ital Chir

44 PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (01) Repeated measure ANOVA showed that there external rotation and shoulder internal rotation over were statistically significant increase in degree of the 3-4 weeks after the operation (p-value < 0.001) shoulder flexion, shoulder abduction, shoulder

MAHRUKH KAMRAN, IFFAT RAZA, MARIA MOHIUDDIN, NAUSHEEN ADNAN, SADAF SAHEEN AND RABIA REHAN

DISCUSSION early weeks and months after surgery are of intense 2002;73(5):479. 2002;75(1):51-64. among Iranians 8.34 ± 2.37 ml 3 among Nigerians8.55 history, past history, medical and drug history which importance for females who must be provided with 11. Buragadda S, Alhusaini AA, Melam GR, Arora N. 15. Mondry TE, Riffenburgh RH, Johnstone PA. ± 1.82ml4, among Danish 11.9-13.6ml6 and among was noted in proforma. Physical examination of TG The findings of present study suggested that home optimal medical and physical therapy care 7. This Effect of complete decongestive therapy and a Prospective trial of complete decongestive therapy Turkish subjects was 12.98±2.53 mL.14 was performed and sign and symptoms of thyroid based decongestive lymphatic therapy following will reduce the occurrence of complications like home program for patients with post mastectomy for upper extremity lymphedema after breast diseases were noted. axillary lymph node dissection had significant secondary lymphedema and decrease in range of lymphedema. J Phys Ther Sci 2015;27(9):2743-8. cancer therapy. Cancer J 2004;10(1):42-8. In our neighboring country Iran, Moghadam RN effects on range of motion of shoulder joint includ- motion of shoulder and arm17. 12. Fiets W, Van Helvoirt R, Nortier J, Van der Tweel I, 16. Kim S, Yi C, Kwon O. Effect of complex decon- reported mean TGV of 8.34±2.37ml in 314 healthy The study included apparently healthy subject’s ing shoulder flexion, abduction, external rotation Struikmans H. Acute toxicity of concurrent adjuvant gestive therapy and the quality of life in breast euthyroid adults of Yzad Iran3, Abidi et al. in 2008 age 21 years and above. Euthyroid, subjects were and internal rotation among patients of breast Despite profuse amount of literature, effectiveness radiotherapy and chemotherapy (CMF or AC) in cancer patients with unilateral lymphedema. reported mean TGV of 9.53 ± 3.68 ml among the 200 recruited with serum TSH level falling within the cancer surgery. The results of the present study are of lymphatic drainage is still under debate and breast cancer patients: a prospective, compara- Lymphology 2007;40(3):143-51. healthy adults of Isphan Iran15. Ahidjo et al. in 2002 normal range b/w 0.23 to 4.0 µlU/mL (as recom- consistent with a previous study which concluded further evaluations are needed18. Future studies are tive, non-randomised study. Eur J Cancer 17. Beurskens CH, van Uden CJ, Strobbe LJ, Oosten- reported mean TGV of about 8.55cm3 ±1.82 in mended by laboratory). that significant improvements were observed also recommended to evaluate the long term 2003;39(8):1081-8. dorp RA, Wobbes T. The efficacy of physiotherapy Maiduguri, North-Eastern Nigeria4 and Alazigha N in among patients receiving home exercise plan. effects of home based decongestive therapy. 13. Clark B, Sitzia J, Harlow W. Incidence and risk of upon shoulder function following axillary dissection 2015 reported The mean TGV 6.81+2.18cm3 in South Exclusion criteria of the study include subjects taking Decongestive therapy showed significant reduction arm oedema following treatment for breast cancer: in breast cancer, a randomized controlled study. geopolitical zone of Nigeria16. Ertan et al in 2015 drugs causing goiter especially lithium, carbamaze- in terms of pain and lymphedema11. a three-year follow-up study. QJM 2005;98(5):343-8. BMC Cancer 2007;7(1):166. reported mean TGV of 12.98±2.53 mL in subjects of pine, phenytoin and oral contraceptive, individual CONCLUSION 14. Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furni- 18. Feldman J, Stout N, Wanchai A, Stewart B, Corm- Tekirdag city Turkey14. Seker et al. reported mean with palpable or visibly enlarged TG, palpable Previous literatures have identified that the provision val CM. Physiotherapy after breast cancer surgery: ier J, Armer J. Intermittent pneumatic compression TGV of 13±6.27 ml in Turkish population of Ankara17. thyroid nodules on physical examination. Exclusion of radiotherapy significantly increases the risk of Home based lymphatic decongestive therapy results of a randomised controlled study to minimise therapy: a systematic review. Lymphology Authors suggested the influence of genetic and criteria of the study also included previous or current edema. Multiple authors have reported the adverse proved to be effective in improving shoulder range lymphoedema. Breast Cancer Res Treat 2012;45(1):13. environmental factors especially daily iodine intake history of thyroid disease or thyroid surgery, preg- effect of breast edema as well as secondary lymph- of motion and reducing lymphedema post breast levels that accounts most for the regional variations nancy, lactation and females with history of delivery edema, fibrosis and dermatitis12. The literature also cancer surgery. in TGV. during the last 12 months as hormonal changes vary supported prevention of lymphedema through TGV. Subjects in whom thyroid nodule, heterogene- particular techniques to decrease deterioration of Karachi is largest cosmopolitan city of Pakistan. ity, agenesis or any other anomaly of thyroid gland axillary system13. No evidence is present which REFERENCES People from all over the Pakistan reside here for was discovered during ultrasonography were also focuses on the home based management of better jobs and business opportunities, lifestyle mod- omitted from the study. lymphedema. Manual lymphatic drainage has 1. Kärki A, Simonen R, Mälkiä E, Selfe J. Impairments, ification, medical facilities, education facilities and been proved to be effective but the self manage- activity limitations and participation restrictions 6 so on18, 19. Reference range of normal TGV among Ultrasonography of thyroid was performed by single ment at home has not been targeted yet. and 12 months after breast cancer operation. J euthyroids has been established worldwide. Region- sonologist. Length, width and depth of each lobe of Rehabilit Med 2005;37(3):180-8. al variations in TGV within the same country are also thyroid gland were taken. Volume of TG was calcu- Box et al determined the treatment strategies to 2. Badger CM, Peacock JL, Mortimer PS. A random- a very well documented. lated by WHO recommended formula: Volume of reduce post operative lymphedema after removal ized, controlled, parallel‐group clinical trial compar- each lobe (ml) = Length (cm) x Width (cm) x Depth of nodes resulting from breast cancer and highlight- ing multilayer bandaging followed by hosiery versus To the best of our knowledge so far no study (cm) x 0.479 (0.479 = correction factor) Total volume ed that rehabilitation plan focusing exercises and hosiery alone in the treatment of patients with conducted that determine the reference range of was the sum of two thyroid lobes. Isthmus dimen- counseling methods may decrease the complica- lymphedema of the limb. Cancer TGV among the different ethnic groups that exists in sions were not included in TGV as approved by tion of lymphedema almost 2 years post surgery14. In 2000;88(12):2832-7. a multiethnic Karachi population. Objectives of this W.H.O20. Data was analyzed on SPSS version 21. the current study girth measurement was not signifi- 3. Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn study were to determine mean TGV among the Means and standard deviations were derived by cantly improved after home based decongestive KL. Arm edema in breast cancer patients. J Natl different ethnic groups that exists in Karachi popula- descriptive stats. Kolmogorov–Smirnov test was lymphatic therapy. However previous study has Cancer Inst 2001;93(2):96-111. tion and to determine whether the changes in applied to check the normality. As the data fulfills shown that complete decongestive therapy plan 4. Ozaslan C, Kuru B. Lymphedema after treatment mean TGV among the ethnic groups are significant. the normality assumptions ANOVA was applied to along with home program had significant effects on of breast cancer. Am J Surg 2004;187(1):69-72. determine the difference of TGV among the differ- arm circumference. The results showed that circum- 5. Johansson K, Ohlsson K, Ingvar C, Albertsson M, ent ethnic groups. ference of upper half of arm after intervention had Ekdahl C. Factors associated with the development METHODS reduced significantly as compared to pre decon- of arm lymphedema following breast cancer treat- gestive lymphatic therapy15. Therefore, the current ment: a match pair case-control study. Lymphology This was a cross sectional study that was carried out RESULTS study highlights an important aspect that home 2002;35(2):59-71. in the Radiology Department of Ziauddin University therapy alone had failed to produce significant 6. Lacomba MT, Sánchez MJY, Goñi ÁZ, Merino DP, Hospital, Karachi. This study was permitted by the Descriptive statistics for mean thyroid gland effects on arm volume. del Moral OM, Téllez EC, et al. Effectiveness of early ethical committee of Ziauddin University and was volumes is shown in Table 1 among the ethnic physiotherapy to prevent lymphoedema after started in January 2013 and completed in May groups and Table 2 representing the significance in In the current study the patient’s cooperation, surgery for breast cancer: randomised, single blind- 2014. Participants were gathered through the mean thyroid gland volume among the ethnic INTRODUCTION age, gender, anthropometric parameters, genetic adherence and compliance to rehabilitation plan ed, clinical trial. BMJ 2010;340:b5396. convenient sampling. Every participant was asked groups. makeup of population and environmental factors3-7. were high. This may be due to high literacy level of 7. Vignes S, Porcher R, Arrault M, Dupuy A. questions related to demographic profile, personal Anatomically Thyroid gland (TG) lies in the anterior After urinary iodine level evaluation, World Health participants. Hence this study targeting the home Long-term management of breast cancer-related triangle of neck. It is encapsulated and consists of Organization (WHO) suggests TGV as an important based remedial exercises and lymphatic drainage lymphedema after intensive decongestive physio- two lobes which extend from fifth cervical to first indicator for iodine status of a population8. Serum program highlights the importance of self tech- therapy. Breast Cancer Res Treat 2007;101(3):285. thoracic vertebrae. The two lobes of TG are thyroid stimulating hormones (TSH) and thyroid niques. 8. Zuther JE, Norton S, Armer JM. Lymphedema connected to each other by means of isthmus hormones level are also very well-known factor that management: the comprehensive guide for practi- anteriorly1. TG secretes thyroid and calcitonin regulates TGV9, 10. The study also focuses the reduction in volume of tioners: Thieme New York; 2009. hormones. Thyroid hormones maintain the ideal arm and forearm after home based intervention. 9. Szuba A, Cooke JP, Yousuf S, Rockson SG. Decon- However, there were no reduction in circumference level of metabolism in tissues and calcitonin Mean TGV reported in different regions of world is as gestive lymphatic therapy for patients with 2 at metacarpophalangeal and wrist circumference. hormone controls level of calcium in circulation . follow: In Karachi population mean TGV reported cancer-related or primary lymphedema. Am J Med 11 12 The results are in support with the previous literature was 6.29 ± 2.9 ml , among Sudanese 6.44 ± 2.44ml , 2000;109(4):296-300. 13 showing improved quality of life in relation to reduc- Mean thyroid gland volume (TGV) is highly variable. among Cubans 6.6 ± 0.26 ml , among Nepalese 10. LINFEDEMA PRPI, DELL’ARTO S. Rehabilitation l7 l5 16 Many factors are known to influence TGV such as 6.629 ± 2.5m , among Chinese 12.92 ± 3.9m , tion in arm volume after decongestive therapy The protocol in upper limb lymphedema. Ann Ital Chir

PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (01) 45 QUANTITATIVE ASSESSMENT OF THYROID GLAND VOLUME AMONG THE ETHNIC GROUPS OF KARACHI POPULATION

Table 1: Descriptive statistics for right Lobe volume, left Lobe volume and adverse health outcomes due to the of lack of 2. Hall JE. Guyton and Hall textbook of medical Med 2010;7(2). Evert M, et al. Genome-wide association study of blood. Moreover, there is a greater threat of toms within gastrointestinal tract for instance, total thyroid volume among different ethnic groups. iodization but uses iodized product as requisite 25. physiology e-Book: Elsevier Health Sciences; 2015. 18. Yusuf H. Conflict dynamics in Karachi: US Institute identifies four genetic loci associated with thyroid pulmonary embolism at the time of earthquakes diarrhea, dyspepsia, abdominal pain. Stress affects However, in the rural areas, intake of iodine was 3. Moghadam RN, Shajari A, Afkhami-Ardekani M. of Peace; 2012. volume and goiter risk. Am J Hum Gene and numbers of deaths per day owing to cardiovas- gut physiology by escalating intestinal permeability, Ethnicity Thyroid Mean Std. Deviation Minimum Maximum inadequate. According to NNS 2011, rural areas of Influence of physiological factors on thyroid size 19. Ali Budhani A, Gazdar H, Kaker SA, Bux Mallah H. 2011;88(5):664-73. cular disease increases histrionically on the day of gastrointestinal motility, alteration in abdominal N=416 volumes ml ± ml ml Punjab and Sindh provinces were the areas of mild determined by ultrasound. Acta Med Iran The Open City: social networks and violence in 23. Tarnoki AD, Tarnoki DL, Speer G, Littvay L, Bata P, earthquake4. Likewise, left ventricular dysfunction secretions, increase in visceral sensitivity and unde- Urdu Rt.lobe 2.84 1.29 0.717 6.75 to moderate iodine deficiency and the main cause 2011;49(5):302-4. Karachi. 2010. Garami Z, et al. Genetic and environmental has been reported owing to immensely raised sirable effects on enterobacteriaceae, regenera- Speaking Lt Lobe 2.63 1.159 0.367 7.84 of iodine deficiency was heavy rain fall and flood- 4. Tahir A, Ahidjo A, Yusuph H. Ultrasonic Assessment 20. Organization WH. Assessment of iodine deficien- influence on thyroid gland volume and thickness of interstitial infiltrates, plasma catecholamines and tive capacity of gastrointestinal mucosa and muco- 25 n=120 Total 5.47 2.29 1.153 13.79 ing, which washed away the iodine from soil . Of Thyroid Gland Size In Maiduguri, Nigeria. West Afri cy disorders and monitoring their elimination: a thyroid isthmus: a twin study. Arch Endocrinol contraction band abnormalitiesin patients with no sal blood flow. Gastrointestine receive signals from Volume J Ultrasound 2002;3(1). guide for programme managers. 2007. Metabol 2015;59(6):487-94. former cardiovascular disease historyin case of central nervous system via multiple parallel path- Sindhi Rt lobe 3.36 1.84 0.91 9.51 The study also reported increased mean TGV in 5. Ying M, Yung DM. Asymmetry of thyroid lobe 21. Hansen PS, Brix TH, Bennedbæk FN, Bonnema SJ, 24. Verkaaik O. Cosmopolistan. Gendering Urban intense emotional stress. Previously, analogous ways including autonomic nervous system, hypo- n=45 Lt lobe 3.08 1.99 1.18 10.65 Hazarah and largest mean TGV among Baloch. volume in normal Chinese subjects: association with Kyvik KO, Hegedüs L. Genetic and environmental Space in the Middle East, South Asia, and Africa: outcomes have been perceived in terms of critical thalamic pituitary-adrenal axis (HPA), brain-gut-axis These areas were previously known as the areas of handedness and position of esophagus. Anat Rec and reversible cardiomyopathy provoked by cata- (BGA) and stress dysregulate brain-gut-axis resulting TotalVolume 6.44 3.23 2.26 17.25 causes of individual differences in thyroid size: a Springer; 2008. p. 207-28. severe iodine deficiency. International Council for (Hoboken) 2009;292(2):169-74. study of healthy Danish twins. J Clin Endocrinol 25. https://www.unicef.org/pakistan/Annual_Re- strophic stress in patients with no past history of in various gut diseases2. Pathan Rt lobe 3.39 1.93 0.96 10.93 the Control of Iodine Deficiency Disorders (ICCIDD) 6. Rasmussen LB, Ovesen L, Bülow I, Jørgensen T, Metabol 2004;89(5):2071-7. port_2011.pdf. cardiovascular disease5. n=149 Lt lobe 3.13 1.41 0.403 7.03 and National Nutrition Survey(NNS) in 2011 reported Knudsen N, Laurberg P, et al. Relations between 22. Teumer A, Rawal R, Homuth G, Ernst F, Heier M, In response to stress various stressors are released TotalVolume 6.52 3.07 2.18 16.64 that there was severe iodine deficiency in mothers various measures of iodine intake and thyroid Work stressors like job insecurity and job strain like and central stressors prompt the release of Punjabi Rt lobe 3.71 2.67 0.49 14.55 as well as in the school going children of Baloch- volume, thyroid nodularity, and serum thyroglobulin. high job demands and long working hours increase corticotrophin releasing factor (CRF), adrenocorti- n=80 Lt lobe 3.31 2.92 0.39 11.29 istan, Azaad Jammu and Kashmir and Gilgit and Am J Clin Nutri 2002;76(5):1069-76. possibility of coronary heart disease and stroke cotropic hormone (ACTH) and glucocorticoids TotalVolume 7.02 4.28 1.03 24.75 Baltistan25. Adequate knowledge about the use of 7. Kayastha P, Paudel S, Shrestha D, Ghimire R, Prad- (10-40%). Moreover, increasedpsychosomatichas- which have anti-inflammatory roles. Corticotrophin Hazarah Rt lobe 3.76 2.22 1.78 9.20 iodized salt was present but the use of iodized salt han S. Study of thyroid volume by ultrasonography sles and low individual control over these demands releasing factor and urocortins (Ucns) (centrally n= 17 Lt lobe 3.29 1.79 1.15 6.75 was low because of price, availability and adverse in clinically euthyroid patients. J Instit Med leads to physiological strain and ultimatelyin- released stressors)stimulate parasympathetic TotalVolume 7.05 3.91 3.24 15.8 propaganda against the use of iodized products. It 2010;32(2):36-43. creased risk of cardiovascular disease. In line with nerves, which then innervate enteric neurons within Baloch Rt lobe 3.65 2.02 1.41 5.89 was also reported that mill owners in those areas 8. Disorders ICfCoID. Assessment of iodine deficien- this imbalance between extreme effort and little gut wall to stimulate or inhibit motility and increase n=5 Lt lobe 3.91 2.55 1.33 6.49 fooled people by supplying normal salt in the name cy disorders and monitoring their elimination: a reward is stressful. Earlier studies had inspected secretion. (Figure 1). Throughout stress, corticotropin 25 TotalVolume 7.56 4.52 2.74 12.37 of iodized salt . We suggest, that variations in level guide for programme managers. Geneva: World correlation amid job insecurity and coronary heart releasing factor from brain hypothalamus excites of intake of iodine among the ethnic groups may Health Organization. 2007. disease 6. High work load and low control are more adrenocorticotrophic hormone secretion from Rt lobe=right lobe, Lt lobe=left lobe, mL=milliliters have resulted alteration in their genotype that has 9. De Felice M, Postiglione MP, Di Lauro R. Minirev- likely to cause initial myocardial infarction while, pituitary gland that incites the discharge of gluco- ultimately resulted in significant variation in the iew: thyrotropin receptor signaling in development people suffering from permanent stress at work corticoids from adrenal gland thus mediate neuro- 14 Table 2: ANOVA analysis determining the significant difference in total thyroid volume, right and left lobe mean TGV among the ethnic groups. and differentiation of the thyroid gland: insights place or at home have more than 2.1 fold chance endocrine stress responses (Figure 1). 4 volume among the ethnic groups of Karachi population. * Correlation is significant at the 0.05 . from mouse models and human diseases. Endocri- for experiencing heart attack . Similarly, marital Unequal sample size and very small sample size nology 2004;145(9):4062-7. stress also influence on prevalence of coronary Stress may intensely disturb BGA through modula- Thyroid Volumes P-Value especially for Baloch group are the limitations of this 10. Panicker V, Wilson S, Spector T, Brown S, Falchi M, artery diseases. Marital stress is allied with 2.9 times tion of several imperative neuropeptides (like Right lobe volume 0.049* study. Large scale future studies with equal sample Richards J, et al. Heritability of serum TSH, free T4 and increased risk of cardiovascular events and in CGRP) that are concerned with alterations in diges- size from all the provinces of Pakistan would have free T3 concentrations: a study of a large UK twin accordance with astudy chronic work stress and tive fluids, protection and restoration of gastric given more appropriate results and better picture of cohort. Clin Endocrinol 2008;68(4):652-9. marital termination escalatethreat of cardiovascu- mucosal lining and mucosal blood flow15.Hence, 7 Left lobe volume 0.017* mean TGV among the ethnic groups of Pakistan. 11. Kamran M, NH, MA, FA, FR, NZ, et al. Correla- lar mortality in men . dysregulation of BGA ensues in generation of a tion of Thyroid Gland Volume with Ageand Gender wide range of gastrointestinal maladies. Stress 8 in a Subset of Karachi Population. Pak J Med Dent INTRODUCTION skeletal system and they become chronically Chronic stress presents with atherosclerosis . Athero- induced exacerbation of GERD symptoms is CONCLUSION 2014;3(2):26-32. over-activated or under-activated1. Hence, this sclerosis, comprising plaques development and ascribed to increased acid sensitivity and lower Total Thyroid Volume 0.015* 2 12. Yousef M, Sulieman A, Ahmed B, Abdella A, Stress is described as a social, environmental or review summarizes the impact of stress on various arterial walls thickening is a common pathology in esophageal sphincter inhibition . Moreover, devel- 6 Mean total thyroid gland volumes, right and left Eltom K. Local reference ranges of thyroid volume in internal demand, which ensues in a physiological, organ systems of body and informs therapeutic cardiovascular disease . Moreover, elevated opment of PUD upon exposure to stressful life events lobe volumes were found to be significantly differ- Sudanese normal subjects using ultrasound. J psychological or behavioral reaction which disturbs options to prevent stress-related disorders. ambulatory blood pressure (ABP) and greater is attributable to numerous factors involving modifi- ent among the ethnic groups that exist in Karachi Thyroid Res 2011;1-4. physical and psychological well-being1 affecting- intima-medial thickening (IMT) had been stated in cations in gastric acid secretion and gastric motility, 9 population. Long term variations in the level of 13. Turcios S, Lence-Anta JJ, Santana J-L, Pereda most of the people. According to a definition of H. STRESS AND ORGAN SYSTEMS carotid arteries of people in the course of highly reduction in mucosal blood flow and bicarbonate 10 intake of iodine among the ethnic groups may CM, Velasco M, Chappe M, et al. Thyroid volume Selye, stress is called an acute risk to organism’s 1. Stress and Cardiovascular system challenging and less manageable days . IMT is an secretion, acid back diffusion, diminished propaga- 16 DISCUSSION in 2011 in his genome wide association study report- have resulted alterations in genotype that probably and its relation to anthropometric measures in a homeostasis, which may be physical or psychologi- There is a colossal data on psychological stress and ultrasonographic marker of atherosclerosis that is tion and compensation of bruised mucosa . There 22 ed four loci associated with TGV and goiter risk . has resulted in significant variation in the mean TGV healthy Cuban population. Eur Thyroid J cal caused by events from within or in the outside cardiovascular disease. The acute stressors i.e., linked with greater risk for future heart attack and is a strong evidence that stress exposure triggers 11 Karachi is largest cosmopolitan city of Pakistan. Tarnoki AD in 2015 while studying on twins conclud- among the ethnic groups. 2015;4(1):55-61. world. Notably, stress arouses adaptive reactions disasters (earthquakes) and intense emotional stress stroke . According to a study among young adults, brain-gut axis and worsens IBD, thus leading to 18, 19 People from all over the Pakistan reside here . ed that genetic and environmental factors both are 14. Şahin E, Elboğa U, Kalender E. Regional refer- that assist to shield internal environment constancy while, chronic stressors such as job stress and marital job stress has been associated with increased release of gastrointestinal hormones and 23 12 Objectives of this study were to determine mean important in controlling TGV . We also suggest that ence values of thyroid gland volume in Turkish and organism’s survival2. Autonomic nervous unhappiness contribute to varied pathophysiologi- intimal medial thickening in carotid arteries . An neurotransmitters, changes in gastrointestinal motili- TGV among the different ethnic groups in Karachi variation in TGV among the ethnic groups in our ACKNOWLEDGEMENTS Adults. Srp Arh Celok Lek 2015;143(3-4):141-5. system, hypothalamic-pituitary-adrenal (HPA) axis cal changes comprising myocardial ischemia, arduous psychosocial environment may provoke ty, gut microbiota, endocrine functions and visceral population and to determine whether the changes study is probably due to genetic variation. 15. Adibi A, Sirous M, Aminorroaya A, Roohi E, and fight-or-flight response are conventional ways myocardial infarction, wall motion abnormalities persistent instigation of sympathetic nervous system sensitivity, increased manifestation and discharge in mean TGV among the ethnic groups are signifi- We would like to thank Ziauddin Laboratory and Mostafavi M, Fallah Z, et al. Normal values of thyroid of envisaging biological and behavioral response to and owing to fluctuations in hemostasis and sympa- pathways that may augment ABP along with some of pro-inflammatory cytokines, discharge of key cant. In this study, smallest mean TGV was found in Urdu Ziauddin Hospital Clifton Karachi campus for gland in Isfahan, an iodine replete area. J Res Med danger from a perilous situation, such as, a preda- thetic nervous system activity sudden death and pathophysiological alterations that contribute to neuropeptides and up-regulation of immune system 9,13 2 speaking population. This is probably due to exces- conducting this study. Sci 2008;13(2):55-60. tor, a mugger, an accident or natural disas- changes in cardiac regulation can result4. early signs of atherosclerosis . (low level inflammation) . The pathogenesis of IBS is In this study mean TGV varies significantly among sive intake of iodine rich food by this group. Urdu 16. Alazigha N, Ugboma E, Nwankwo C, Agi C. ter3.Stressors appear in 3 different forms i.e., numer- multifactorial and involves profound dysregulation the different ethnic groups that exists in Karachi speaking population is the pioneer of urban Karachi Sonographic Measurement Of The Volume Of The ous life happenings,enduringworries andeveryday- Earthquakes are allied with an increased cardiovas- 2. Stress and Gastrointestinal system of brain gut axis. Among the aforementioned gut population. Hensen et al. in 2004, while studying the population and relishes an easy excess to iodine Normal Thyroid Gland In Adults In Braithwaite disturbancesfrequently considered as trivial but can cular risk. The marked escalation in heart rate (160 Major systems of body (cardiovascular, muscular, disorders, most important is visceral hypersensitivi- 24 REFERENCES 17 genetics and environmental causes for the varia- rich sea food . 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46 PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (01)

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Symptoms of stress predict musculoskel- ating effect of social support.Military Med liberation of glucocorticoids, monoamine life-style3. thetic adrenal medullary axis, hypothalamic-pitu- comprise imbalances which excite development of ic kidney disorder is conceivable as kidney sympa- also been anticipated that stress incited hyperventi- influence on adult neurogenesis is very short lived, instigation of SNS and HPA axis contribute to after controlling for methodological confounds: etal disorders. J Epidemiol Community Health Res2014;1:3. thetic innervations and neuronal mechanisms regu- lation declines blood CO and upsurges blood pH with lessened cell proliferation resulting in anabolic state that upholds fat storage within neurotransmitters, growth hormone and prolactin to itary-adrenal axis and hypothalamic-pituitary-ovari- lithiasis22. Stress can also cause development and 2 Associations with carotid atherosclerosis in a 1989;43:293-300. 43. Altemus M, Rao B, Dhabhar FS, Ding W, late water and salt retention. It also has been levels, which adds to intensified neuronal excitabili- adapt the individual to its new circumstance. Stimu- Pharmacological interventions an system secrete adrenal as well as pituitary progress of chronic kidney diseases21. decreased immature neuron production followed visceral depots that upturns the risk of type 2 diabe- Effect on male reproductive system beings have to face intimidations to their stability in healthy sample. J Hypertens2002; 20: 1-7. 27. Chen WQ, Yu ITS, Wong TW. Impact of occupa- Granstein RD. Stress-Induced Changes in Skin Barrier submitted that stress may be allied with CKD ty, upraised muscular tension, and suppression of lation of corticotrophin releasing factor is mediated Many drugs, such as sedative/hypnotics, beta hormones and brain peptides which attach to by a period of enhanced cell survival, as the tes, cardiovascular disease, dyslipidemia and other Studies on male fertility have stated that psychologi- everyday life and our future as individuals and as a 11. O'Leary DH, Polak JF. Intima-medial thickness: A tional stress and other psychosocial factors on Function in Healthy Women. J invest Dermatol. through insulin resistance and diabetes. Environ- parasympathetic activity. The sympathetic ascen- mostly by norepinephrine, serotonin and acetylcho- blockers, tranquilizers and antidepressants that particular receptors on WBCs and execute several Many studies have established that chronic stress ultimate number of new mature neurons appears aspects of metabolic syndrome. Stress could cause cal pressure reduces paternity allied with anoma- species relies upon our capability to become tool for atherosclerosis imaging and event predic- musculoskeletal pain among Chinese offshore oil 2001;117:309-317. mental stressors have been instituted to be dency may augment responses to catecholamine 34 line. Incitement of pituitary-adrenal axis results in offset some of the problems allied to stress. More- regulatory actions. In addition, at times efforts of situations are allied with allostatic overload i.e., unchanged . overweight and fat build up through fluctuations in lous semen parameters. Psychological stress might accustomed to potent stressors affecting our tion. Am J Cardiol2002;90:18L-21L. installation workers. Occup Environ Med 44. Koelsch S, Boehlig A, Hohenadel M, Nitsche I, connected with decreased insulin sensitivity, obesity differentially, centered on qualitative interpretation increased cardiac output, sodium retention, skele- over, antioxidants, anti-inflammatory drugs, hypolip- people to cope with hassles of stressful experience body’s effort to gain stability through stressful eating manners. Long-term stress modifies food acutely impinge on spermatogenesis by affecting potentials. Therefore, it is indispensable to 12. Hintsanen M, Kivimäki M, Elovainio M, 2005;62:251–256. Bauer K, Sack U. The impact of acute stress on and metabolic disorder, eventually type 2 diabetes of exposure to stress25. tal muscle blood flow, cutaneous vasoconstriction, idemics and drugs that treat insulin insensitivity or prompt them to indulge in behaviors for example change, hence ensuing in modifications of cortisol Molecular mechanisms involved in inhibiting neuro- consumption behavior, dietetic tastes and less testosterone secretion in particular, hypothalam- treat/manage stress through various interventions Pulkki-Råback L, Keskivaara P, Juonala M, Raitakari 28. Lundberg U. Psychophysiology of work: stress, hormones and cytokines, and how theirrecovery is through modifications in neuroendocrine systems. In 36 reduced intestinal motility, increased glucose, bron- lasting ache also useful in managing metabolic and alcohol use or changes in sleeping patterns that and insulin levels in hypothalamo-hypophyseal axis genesis involve glucocorticoid signaling path- desire for craving . ic-pituitary-adrenal axis directly inhibits hypotha- like brain oriented/neurological approaches, phar- OT, Keltikangas-Järvinen L. Job strain and early gender, endocrine response, and work-related affected by music-evoked positive mood. Sci Rep CKD patients, level of release, a hormone that The muscle spindles possess a central role in muscles 33,35,31 chiolar dilatation and behavioral activation. More- neurological effects of stress. Although these medi- could also alter immune system processes. Hence, (HPA), kinins and other pro-inflammatory substanc- way .Dickkopf 1 (DKK1)alongwithinterleukin-1β lamic-pituitary-gonadal axis and Leydig cells in the macological interventions along with social support atherosclerosis: The Cardiovascular Risk in Young upper extremity disorders. Am J Indus Med 2016;6:23008. processes sympathetic nervous system products are by generating a viscous circle with sequentially over, there is suppression of circulating gonado- cations are valued to some degree, but have some these represent potentially important pathways es amid other homeostatic alterations. These varia- and NF-KB signaling routes. Moreover, Brain-derived Initial life anxiety transforms genetically NR3C1 testes. Both acute and chronic psychological stress to live a pleased and satisfied life full of achieve- Finns study. Psychosom Med 2005;67:740-7. 2002;41:383-392. 45. Prasad S, Tiwari M, Pandey AN, Shrivastav TG, reduced1. Hence, it is probable that long term increasing muscle stiffness and accretion of inflam- tropins and gonadal steroid hormones leading to side effects and limitations, thus affecting quality of associating stress with immune system20. tions have physiological implications, involving neurotrophic factor (BDNF) normally increase (receptor for cortisol and corticosteroid) expression can lead to erectile dysfunction as well46. ments. 13. Kamarck T, Shiffman S, Sutton-Tyrrell K, Muldoon 29. Johansson H, Sojka P. Pathophysiological mech- Chaube SK. Impact of stress on oocyte quality and disturbance of the normal menstrual cycle while life. changes in physiology of kidney. These conditions mental stressors bring about unimpeded increase in matory elements (arachidonic acid, bradykinin neurogenesis. Studies direct that crosstalk between in hypothalamus as well as hippocampus, arginine M, Tepper P. Daily psychological demands are anisms involved in genesis and spread of muscular reproductive outcome.J Biomed Sci2016;23:36. SNS tone that ensues a vicious reaction21. New etc.) that excite nociceptors and hence contribute prolonged exposure to stress condition can lead to Acute stress (examination stress or experimentally may result in renal repercussions, like high pressure GR and BDNF signaling follows and this might add to vasopressin and corticotrophin-releasing hormone THERAPEUTIC MANAGEMENT OF STRESS Brain oriented approaches tension in occupational muscle pain and in chronic 46. Nargund VH. Effects of psychological stress on researches revealed that exposure of discrimination to enlarged sensitivity of pain. Psychological stress 31 complete mutilation of reproductive function. induced stress) stimulates immune system18, where- level maintenance and association with incidence intricacy of interaction among stress and BDNF as in hypothalamus, resultant in inhibited glucocorti- For understanding the worth of life and its progress, Stress response is typically mediated by brain and musculoskeletal pain syndromes: a hypothesis. Med male fertility. Nat Rev Urol2015;12:373-82. and racism might be linked to chronic kidney and higher sympathetic provocation have been Figure 3: Diagrammatic illustration of stress influence as, chronic stress (work-related stress, bereavement, of renal calculi among other manifestations23. Previ- shown in Figure 2. coid receptor and amplified AVP and CRH activity stress is a censorious viewpoint now a day. All living remedial interventions must be projected to lessen Hypot1991;35:196-203. disease risk factors such as elevated blood pressure instituted to decrease or even abolish regulatory in reaction to stress later in life. Early life stress can on nervous system MAHRUKH KAMRAN, IFFAT RAZA, MARIA MOHIUDDIN, NAUSHEEN ADNAN, SADAF SAHEEN AND RABIA REHAN

adverse health outcomes due to the of lack of 2. Hall JE. Guyton and Hall textbook of medical Med 2010;7(2). Evert M, et al. Genome-wide association study of blood. Moreover, there is a greater threat of toms within gastrointestinal tract for instance, iodization but uses iodized product as requisite 25. physiology e-Book: Elsevier Health Sciences; 2015. 18. Yusuf H. Conflict dynamics in Karachi: US Institute identifies four genetic loci associated with thyroid pulmonary embolism at the time of earthquakes diarrhea, dyspepsia, abdominal pain. Stress affects However, in the rural areas, intake of iodine was 3. Moghadam RN, Shajari A, Afkhami-Ardekani M. of Peace; 2012. volume and goiter risk. Am J Hum Gene and numbers of deaths per day owing to cardiovas- gut physiology by escalating intestinal permeability, inadequate. According to NNS 2011, rural areas of Influence of physiological factors on thyroid size 19. Ali Budhani A, Gazdar H, Kaker SA, Bux Mallah H. 2011;88(5):664-73. cular disease increases histrionically on the day of gastrointestinal motility, alteration in abdominal Punjab and Sindh provinces were the areas of mild determined by ultrasound. Acta Med Iran The Open City: social networks and violence in 23. Tarnoki AD, Tarnoki DL, Speer G, Littvay L, Bata P, earthquake4. Likewise, left ventricular dysfunction secretions, increase in visceral sensitivity and unde- to moderate iodine deficiency and the main cause 2011;49(5):302-4. Karachi. 2010. Garami Z, et al. Genetic and environmental has been reported owing to immensely raised sirable effects on enterobacteriaceae, regenera- of iodine deficiency was heavy rain fall and flood- 4. Tahir A, Ahidjo A, Yusuph H. Ultrasonic Assessment 20. Organization WH. Assessment of iodine deficien- influence on thyroid gland volume and thickness of interstitial infiltrates, plasma catecholamines and tive capacity of gastrointestinal mucosa and muco- ing, which washed away the iodine from soil25. Of Thyroid Gland Size In Maiduguri, Nigeria. West Afri cy disorders and monitoring their elimination: a thyroid isthmus: a twin study. Arch Endocrinol contraction band abnormalitiesin patients with no sal blood flow. Gastrointestine receive signals from J Ultrasound 2002;3(1). guide for programme managers. 2007. Metabol 2015;59(6):487-94. former cardiovascular disease historyin case of central nervous system via multiple parallel path- The study also reported increased mean TGV in 5. Ying M, Yung DM. Asymmetry of thyroid lobe 21. Hansen PS, Brix TH, Bennedbæk FN, Bonnema SJ, 24. Verkaaik O. Cosmopolistan. Gendering Urban intense emotional stress. Previously, analogous ways including autonomic nervous system, hypo- Hazarah and largest mean TGV among Baloch. volume in normal Chinese subjects: association with Kyvik KO, Hegedüs L. Genetic and environmental Space in the Middle East, South Asia, and Africa: outcomes have been perceived in terms of critical thalamic pituitary-adrenal axis (HPA), brain-gut-axis These areas were previously known as the areas of handedness and position of esophagus. Anat Rec causes of individual differences in thyroid size: a Springer; 2008. p. 207-28. and reversible cardiomyopathy provoked by cata- (BGA) and stress dysregulate brain-gut-axis resulting severe iodine deficiency. International Council for (Hoboken) 2009;292(2):169-74. study of healthy Danish twins. J Clin Endocrinol 25. https://www.unicef.org/pakistan/Annual_Re- strophic stress in patients with no past history of in various gut diseases2. the Control of Iodine Deficiency Disorders (ICCIDD) 6. Rasmussen LB, Ovesen L, Bülow I, Jørgensen T, Metabol 2004;89(5):2071-7. port_2011.pdf. cardiovascular disease5. and National Nutrition Survey(NNS) in 2011 reported Knudsen N, Laurberg P, et al. Relations between 22. Teumer A, Rawal R, Homuth G, Ernst F, Heier M, In response to stress various stressors are released that there was severe iodine deficiency in mothers various measures of iodine intake and thyroid Work stressors like job insecurity and job strain like and central stressors prompt the release of as well as in the school going children of Baloch- volume, thyroid nodularity, and serum thyroglobulin. high job demands and long working hours increase corticotrophin releasing factor (CRF), adrenocorti- istan, Azaad Jammu and Kashmir and Gilgit and Am J Clin Nutri 2002;76(5):1069-76. possibility of coronary heart disease and stroke cotropic hormone (ACTH) and glucocorticoids Baltistan25. Adequate knowledge about the use of 7. Kayastha P, Paudel S, Shrestha D, Ghimire R, Prad- (10-40%). Moreover, increasedpsychosomatichas- which have anti-inflammatory roles. Corticotrophin iodized salt was present but the use of iodized salt han S. Study of thyroid volume by ultrasonography sles and low individual control over these demands releasing factor and urocortins (Ucns) (centrally was low because of price, availability and adverse in clinically euthyroid patients. J Instit Med leads to physiological strain and ultimatelyin- released stressors)stimulate parasympathetic propaganda against the use of iodized products. It 2010;32(2):36-43. creased risk of cardiovascular disease. In line with nerves, which then innervate enteric neurons within was also reported that mill owners in those areas 8. Disorders ICfCoID. Assessment of iodine deficien- this imbalance between extreme effort and little gut wall to stimulate or inhibit motility and increase fooled people by supplying normal salt in the name cy disorders and monitoring their elimination: a reward is stressful. Earlier studies had inspected secretion. (Figure 1). Throughout stress, corticotropin of iodized salt25. We suggest, that variations in level guide for programme managers. Geneva: World correlation amid job insecurity and coronary heart releasing factor from brain hypothalamus excites of intake of iodine among the ethnic groups may Health Organization. 2007. disease 6. High work load and low control are more adrenocorticotrophic hormone secretion from have resulted alteration in their genotype that has 9. De Felice M, Postiglione MP, Di Lauro R. Minirev- likely to cause initial myocardial infarction while, pituitary gland that incites the discharge of gluco- ultimately resulted in significant variation in the iew: thyrotropin receptor signaling in development people suffering from permanent stress at work corticoids from adrenal gland thus mediate neuro- mean TGV among the ethnic groups. and differentiation of the thyroid gland: insights place or at home have more than 2.1 fold chance endocrine stress responses14 (Figure 1). from mouse models and human diseases. Endocri- for experiencing heart attack4. Similarly, marital Unequal sample size and very small sample size nology 2004;145(9):4062-7. stress also influence on prevalence of coronary Stress may intensely disturb BGA through modula- especially for Baloch group are the limitations of this 10. Panicker V, Wilson S, Spector T, Brown S, Falchi M, artery diseases. Marital stress is allied with 2.9 times tion of several imperative neuropeptides (like study. Large scale future studies with equal sample Richards J, et al. Heritability of serum TSH, free T4 and increased risk of cardiovascular events and in CGRP) that are concerned with alterations in diges- size from all the provinces of Pakistan would have free T3 concentrations: a study of a large UK twin accordance with astudy chronic work stress and tive fluids, protection and restoration of gastric given more appropriate results and better picture of cohort. Clin Endocrinol 2008;68(4):652-9. marital termination escalatethreat of cardiovascu- mucosal lining and mucosal blood flow15.Hence, mean TGV among the ethnic groups of Pakistan. 11. Kamran M, NH, MA, FA, FR, NZ, et al. Correla- lar mortality in men7. dysregulation of BGA ensues in generation of a tion of Thyroid Gland Volume with Ageand Gender wide range of gastrointestinal maladies. Stress 8 in a Subset of Karachi Population. Pak J Med Dent INTRODUCTION skeletal system and they become chronically Chronic stress presents with atherosclerosis . Athero- induced exacerbation of GERD symptoms is CONCLUSION 2014;3(2):26-32. over-activated or under-activated1. Hence, this sclerosis, comprising plaques development and ascribed to increased acid sensitivity and lower 2 12. Yousef M, Sulieman A, Ahmed B, Abdella A, Stress is described as a social, environmental or review summarizes the impact of stress on various arterial walls thickening is a common pathology in esophageal sphincter inhibition . Moreover, devel- 6 Mean total thyroid gland volumes, right and left Eltom K. Local reference ranges of thyroid volume in internal demand, which ensues in a physiological, organ systems of body and informs therapeutic cardiovascular disease . Moreover, elevated opment of PUD upon exposure to stressful life events lobe volumes were found to be significantly differ- Sudanese normal subjects using ultrasound. J psychological or behavioral reaction which disturbs options to prevent stress-related disorders. ambulatory blood pressure (ABP) and greater is attributable to numerous factors involving modifi- ent among the ethnic groups that exist in Karachi Thyroid Res 2011;1-4. physical and psychological well-being1 affecting- intima-medial thickening (IMT) had been stated in cations in gastric acid secretion and gastric motility, 9 population. Long term variations in the level of 13. Turcios S, Lence-Anta JJ, Santana J-L, Pereda most of the people. According to a definition of H. STRESS AND ORGAN SYSTEMS carotid arteries of people in the course of highly reduction in mucosal blood flow and bicarbonate 10 intake of iodine among the ethnic groups may CM, Velasco M, Chappe M, et al. Thyroid volume Selye, stress is called an acute risk to organism’s 1. Stress and Cardiovascular system challenging and less manageable days . IMT is an secretion, acid back diffusion, diminished propaga- 16 DISCUSSION in 2011 in his genome wide association study report- have resulted alterations in genotype that probably and its relation to anthropometric measures in a homeostasis, which may be physical or psychologi- There is a colossal data on psychological stress and ultrasonographic marker of atherosclerosis that is tion and compensation of bruised mucosa . There 22 ed four loci associated with TGV and goiter risk . has resulted in significant variation in the mean TGV healthy Cuban population. Eur Thyroid J cal caused by events from within or in the outside cardiovascular disease. The acute stressors i.e., linked with greater risk for future heart attack and is a strong evidence that stress exposure triggers 11 Karachi is largest cosmopolitan city of Pakistan. Tarnoki AD in 2015 while studying on twins conclud- among the ethnic groups. 2015;4(1):55-61. world. Notably, stress arouses adaptive reactions disasters (earthquakes) and intense emotional stress stroke . According to a study among young adults, brain-gut axis and worsens IBD, thus leading to 18, 19 People from all over the Pakistan reside here . ed that genetic and environmental factors both are 14. Şahin E, Elboğa U, Kalender E. Regional refer- that assist to shield internal environment constancy while, chronic stressors such as job stress and marital job stress has been associated with increased release of gastrointestinal hormones and 23 12 Objectives of this study were to determine mean important in controlling TGV . We also suggest that ence values of thyroid gland volume in Turkish and organism’s survival2. Autonomic nervous unhappiness contribute to varied pathophysiologi- intimal medial thickening in carotid arteries . An neurotransmitters, changes in gastrointestinal motili- TGV among the different ethnic groups in Karachi variation in TGV among the ethnic groups in our ACKNOWLEDGEMENTS Adults. Srp Arh Celok Lek 2015;143(3-4):141-5. system, hypothalamic-pituitary-adrenal (HPA) axis cal changes comprising myocardial ischemia, arduous psychosocial environment may provoke ty, gut microbiota, endocrine functions and visceral population and to determine whether the changes study is probably due to genetic variation. 15. Adibi A, Sirous M, Aminorroaya A, Roohi E, and fight-or-flight response are conventional ways myocardial infarction, wall motion abnormalities persistent instigation of sympathetic nervous system sensitivity, increased manifestation and discharge in mean TGV among the ethnic groups are signifi- We would like to thank Ziauddin Laboratory and Mostafavi M, Fallah Z, et al. Normal values of thyroid of envisaging biological and behavioral response to and owing to fluctuations in hemostasis and sympa- pathways that may augment ABP along with some of pro-inflammatory cytokines, discharge of key cant. In this study, smallest mean TGV was found in Urdu Ziauddin Hospital Clifton Karachi campus for gland in Isfahan, an iodine replete area. J Res Med danger from a perilous situation, such as, a preda- thetic nervous system activity sudden death and pathophysiological alterations that contribute to neuropeptides and up-regulation of immune system 9,13 2 speaking population. This is probably due to exces- conducting this study. Sci 2008;13(2):55-60. tor, a mugger, an accident or natural disas- changes in cardiac regulation can result4. early signs of atherosclerosis . (low level inflammation) . The pathogenesis of IBS is In this study mean TGV varies significantly among sive intake of iodine rich food by this group. Urdu 16. Alazigha N, Ugboma E, Nwankwo C, Agi C. ter3.Stressors appear in 3 different forms i.e., numer- multifactorial and involves profound dysregulation the different ethnic groups that exists in Karachi speaking population is the pioneer of urban Karachi Sonographic Measurement Of The Volume Of The ous life happenings,enduringworries andeveryday- Earthquakes are allied with an increased cardiovas- 2. Stress and Gastrointestinal system of brain gut axis. Among the aforementioned gut population. Hensen et al. in 2004, while studying the population and relishes an easy excess to iodine Normal Thyroid Gland In Adults In Braithwaite disturbancesfrequently considered as trivial but can cular risk. The marked escalation in heart rate (160 Major systems of body (cardiovascular, muscular, disorders, most important is visceral hypersensitivi- 24 REFERENCES 17 genetics and environmental causes for the varia- rich sea food . 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It is revealed that both physical and worsening effects on heart and brain. Vitamin D long period) are described as psychosocial risk with developing and recollecting memories and neurotrophic factor: BDNF, Mitogen-activated appears to be helpful by decreasing their agony cular Disease.J Am CollCardiol2008; 51: 1237-1246. 2012;7:e43232 37. Sominsky L and Spencer SJ. Eating behavior initiate that inflammatory innate immune responses cancers are repressed. This suppression assembles thetic adreno-medullary system in company with psychologic stressors cause well defined neuroen- 19 deficiency is faced by more than 1/3 of stone factors that might ultimately reflect physical risks at spatial navigation and associated with stress regu- protein kinase: MAPK, Tropomyosin-related kinase B and professed pain as well as improve their physical 20. Segerstrom SC, Miller GE. Psychological stress and stress. Frontiers in Pharmacol2014;5: doi: in the body . Th2 cytokines, which initiate humoral immunity. This 38 5. Cebelin M, Hirsch C. Human stress cardiomyopa- 27 components of the parasympathetic system as docrine responses influencing several aspects of activity. These behavioral interventions also swing occurs via effects of stress hormones such as formers, which may contribute to hyperparathyroid- work . lation and mood possibly by modulating adult receptors: TRKB thy. Myocardial lesions in victims of homicidal and the human immune system: A meta analytic 10.3389/fpsyg.2014.00434 31 shown in Figure 3.During periods of acute stress skin physiology. As, systemic stress response is regu- decrease patients’ overuse of medications39. During psychological stress, as an effect of hypo- cortisol. Shift from Type 1 helper T cells to Type 2 ism. On the other hand, stressful life events are neurogenesis . Stress has been presented to assaults without internal injuries. Hum Pathol study of 30 years of inquiry. Psychol Bull 2004;130: 38. Zangeneh F.Z. Stress and female reproductive various physiological functions including ingestion, lated by two principal biologic effectors i.e., hypo- Moreover, a slothful way of living is a peril to many thalamic pituitary adrenal systemmobilizes glucose helper T cells varies immune response. Declined Th1 considerably more amongst persistent colic of renal It has been stated that not only ergonomic condi- impact memory and learning along with precipita- 7. Stress and Obesity 1980;11:123-32. 601-630. system: Disruption of corticotrophin- releasing 32 development and reproduction may be a detri- thalamic pituitary adrenal axis and sympathoadre- ailments such as diabetes, obesity, cardiovascular out of the cells that induces IL-6 production (pro-in- facilitated cellular immune response might increase lithiasis. Serum white blood cell count at acute tions, psychosocial factors and biomechanical load tion and exacerbation of mood disorders . A chief Obesity and its associated health risks have ascend- 6. Kivimäki M, Kawachi I. Work Stress as a Risk Factor 21. Bruce MA, Beech BM, Sims M, Brown TN, Wyatt hormone/opiate balance by sympathetic nerve ment to physical integrity and even survival. Subse- nal medullary system producing numerous chang- problems, depression and dementia. It has been flammatory cytokine) from monocytes. Resultant predisposition to infectious and cancerous diseases. phase of renal colic predicts stressful event and at work but also mental stress (general worry/psy- factor of ‘‘fight or flight’’ response implicates ed vividly. Deskbound social activities and for Cardiovascular Disease. CurrCardiol Rep SB, Taylor HA et al. Social environmental stressors, traffic.J FamReprod Health2009;3:69-76. 24 quent to the perception of stress, stress hormones es including reasoning stimulation, mobilization of found that adequate physical activity would be increased plasma glucose concentration beyond a Likewise, elevated Th2 mediated humoral immune spontaneous passage of stone . chological tension, general coping style, response activating energy stores for effectively evading stress-free accessibility of highly palatable nutrient 2015;17:74. psychological factors, and kidney disease. J Inves- 39. Schneiderman N, Ironson G, Siegel S.D. Stress are produced by the sympathetic nervous system fuel stores to meet metabolic requirements. Acute beneficial for the neural, vascular as well asmeta- certain limit, create a chronic stress situation. This response increase sensitivity to allergic and autoim- to pain and depression/anxiety) at work may immediate peril that comes at the expense of less rich foods encourages overweight and obesity. 7. Matthews K, Gump B. Chronic work stress and tig Med2009; 57:83-9. and health: Psychological, Behavioral, and Biologi- and hypothalamic-pituitary adrenocortical axis. psychosocial stress associated with sleep depriva- bolic disorders. Moreover, deliberate physical inflammatory condition then again cause compen- mune diseases because of loss of self-regulation20. Stress has also been presented to be linked with persuade muscle tension and raised stress levels energetic functions. The growth-inhibiting and Chronic societal stress frequently arising from marital dissolution increase risk of posttrial mortality 22. Diniz DHMP, Schor N, Blay SL. Stressful Life Events cal Determinants.Annu Rev ClinPsychol 1 Sympathetic nervous system along with the activa- tion cause disruption in skin barrier function and engagement has been shown to increase neurotro- satory phase response activation which would Henceforth, decreased effectiveness of immune hypertension, diabetes or obesity . Numerous inves- (catecholamines, cortisol, blood pressure, heart catabolic effects of stress hormones have long job/unemployment stress, low socioeconomic in men from the multiple risk factor intervention trial. and Painful Recurrent Colic of Renal Lithiasis. J 2005;1:607–628. tion of paraventricular nucleus of the hypothalamus homeostasis in women owing to cytokine secretion. phin expression in cortex and hippocampal regions expand beyond its normal range owing to repeat- system could result in enhanced functional impair- tigations exploring correlation amongst stress and rate) thus, generating increased risk for musculoskel- been documented. Glucocorticoids repress cell status, poor interpersonal relationships and poor Arch Intern Med 2002; 162:309-15 Urol2006;176:2483-2487 40. Sadeh A, Keinan G, Daon K. Effects of stress on producing corticotropin releasing factor, which in Previous studies have demonstrated that stress of the brain as well as to increase neurogenesis in ed induction consequently cause obesity and other ment and death18. CKD pathophysiology have concentrated on etal disorders. The extent of stress hormones secre- propagation and boost the cell death in many cell self-esteem have been allied with obesity and its 8. Strong P. Atherosclerotic lesions: Natural history, 23. Diniz DP, Marques DA, Blay SL, Schor N. Stressful sleep: The moderating role of coping style. Health 36 turn stimulates the pituitary to produce adrenocorti- augment some immune parameters including the dentate gyrus of young and aging animals. concomitant metabolic syndromes19. consequences for instance heart rate, vascular tion reflect work related stress intensity and concur- types, comprising myocytes, thymocytes and osteo- related complaints . Instantly after a stressful risk factors, and topography. Arch Pathol Lab Med life events and acute kidney injury in intensive and Psychology Copyright 2004 by the American 33 cotropin. Recurring stress can cause cognitive discharge of pro-inflammatory cytokines and Social support, another behavioral intervention, is 4. Stress and Renal system reactivity and blood pressure and specified that rently, catecholamines (epinephrine, and norepi- blasts .Latest studies in neurogenic cells direct that incident happens, there is a corticotrophin-releas- 1992;116:1268-1275. semi-intensive care unities. J Bras Nefrol2012;34:50-7. Psychological Association. 2004;23: 542–545. impairments and structural changes in the hippo- delayed-type hypersensitivity reactions. Moreover, composed of emotional and influential support. It is The psychosocial condition of a person can have Stress is a condition in which environmental factors both heart rate and blood pressure escalate and nephrine) and cortisol form a connection between molecular pathways triggered by glucocorticoids ing-hormone (CRH) interceded food intake subdu- 9. Kamarck TW, Muldoon M, Shiffman S, Sutton-Tyrrell 24. Kalaitzidis RG, Damigos D, Siamopoulos KC. 41. Klumpers UMH, Veltman DJ, van Tol M-J, Kloet endothelial sensitivity falls in many studies of acute psychosocial stress and health damage via their (main stress hormones) are controlled by crosstalk al. Subsequent to this, glucocorticoid induced campus, mainly through the actions of glucocorti- human study has revealed that wound healing is an interpersonal process characterized by mutual Environmental and stressful factors affecting the RW, Boellaard R, Lammertsma AA, et al. Neurophysi- direct impression on immune system. For instance, surpass adaptive capability of a person to a level 39 43 K, Gwaltney CJ. Experiences of demand and 28 coids . decreased by persistent stress . exchange of information that improved mental stress has diverse effects on immune system. First, where physiological as well as psychosomatic reac- stress. These connections among stress and patho- impact on various body functions and organs . with other stress pertinent mechanisms, containing offshoot of hunger and eating activities. During control in daily life as correlates of subclinical carot- occurrence of kidney stones and the kidney colic. ological effects of sleep deprivation in healthy health. Societal support involves regular social sympathetic nerves innervating both primary and tions increase the susceptibility of disease21. Further- physiology are assumed to be linked with variations neurotrophic factors, inflammatory mediators and constant mental stress, chronically raised glucocor- id atherosclerosis in a healthy older sample: the IntUrolNephrol 2014;46:1779-84. adults, a pilot study. PLoS ONE 2015;10:e0116906. 31 9. Stress and Endocrine system contacts with compassionate friends or relatives or secondary lymphoid tissues liberate variety of more, stress is not a single reaction but a process HPA, pro-inflammatory mediators, endothelin A and However, long-lasting instigation of motor units morphogen signaling pathways . Numerous studies ticoids ensue in chronically roused eating manners Pittsburgh Healthy Heart Project. Health 25. Lundberg ULF. Stress responses in low-status jobs 42. Zhang Q, Zhang Q, Sun X, Zhang L, Zhang S, Yao Stress alters the level of various hormones by eliciting health professionals, who offer emotive care and substances, affecting immune response by interact- because the moment a person experiences sympathetic autonomic nervous system activity. cause degenerative processes in company with have stated that both acute and chronic stress and undue weight increase. Expressly, stress can Psychol2004;23:24-32. and their relationship to health risks: musculoskeletal G et al. Relationship between acute stress and These alterations propose that pathologic connec- pain. Continuing psychological stress may also diminutes propagation of progenitor cells in augment proclivity to eat high calorie food through HPA axis hormones, sympathetic endocrine activity, delivered valuable information that reduce stress disorders. Ann N Y AcadSci1999;896:162-72. sleep disorder in grass-root military personnel: medi- ing the receptors on lymphocytes bearing adrener- tension; a biochemical process is instituted, leading 44 10. Kamarck TW, Polk DE, Sutton-Tyrrell K, Muldoon 28 33 37 inflammation and metabolism . Stress leads to the and improve mental health and results in healthy gic receptors. In line with this activation of sympa- to acute and chronic hormonal changes that may tion between stress, high blood pressure and chron- avert damaged muscle fibers repair . Besides, it has dentate gyrus (DG) of hippocampus . Stress its interface with central reward pathways .Chronic MF. The incremental value of ambulatory BP persists 26. Leino P. Symptoms of stress predict musculoskel- ating effect of social support.Military Med liberation of glucocorticoids, monoamine life-style3. thetic adrenal medullary axis, hypothalamic-pitu- comprise imbalances which excite development of ic kidney disorder is conceivable as kidney sympa- also been anticipated that stress incited hyperventi- influence on adult neurogenesis is very short lived, instigation of SNS and HPA axis contribute to after controlling for methodological confounds: etal disorders. J Epidemiol Community Health Res2014;1:3. thetic innervations and neuronal mechanisms regu- lation declines blood CO and upsurges blood pH with lessened cell proliferation resulting in anabolic state that upholds fat storage within neurotransmitters, growth hormone and prolactin to itary-adrenal axis and hypothalamic-pituitary-ovari- lithiasis22. Stress can also cause development and 2 Associations with carotid atherosclerosis in a 1989;43:293-300. 43. Altemus M, Rao B, Dhabhar FS, Ding W, late water and salt retention. It also has been levels, which adds to intensified neuronal excitabili- adapt the individual to its new circumstance. Stimu- Pharmacological interventions an system secrete adrenal as well as pituitary progress of chronic kidney diseases21. decreased immature neuron production followed visceral depots that upturns the risk of type 2 diabe- Effect on male reproductive system beings have to face intimidations to their stability in healthy sample. J Hypertens2002; 20: 1-7. 27. Chen WQ, Yu ITS, Wong TW. Impact of occupa- Granstein RD. Stress-Induced Changes in Skin Barrier submitted that stress may be allied with CKD ty, upraised muscular tension, and suppression of lation of corticotrophin releasing factor is mediated Many drugs, such as sedative/hypnotics, beta hormones and brain peptides which attach to by a period of enhanced cell survival, as the tes, cardiovascular disease, dyslipidemia and other Studies on male fertility have stated that psychologi- everyday life and our future as individuals and as a 11. O'Leary DH, Polak JF. Intima-medial thickness: A tional stress and other psychosocial factors on Function in Healthy Women. J invest Dermatol. through insulin resistance and diabetes. Environ- parasympathetic activity. The sympathetic ascen- mostly by norepinephrine, serotonin and acetylcho- blockers, tranquilizers and antidepressants that particular receptors on WBCs and execute several Many studies have established that chronic stress ultimate number of new mature neurons appears aspects of metabolic syndrome. Stress could cause cal pressure reduces paternity allied with anoma- species relies upon our capability to become tool for atherosclerosis imaging and event predic- musculoskeletal pain among Chinese offshore oil 2001;117:309-317. mental stressors have been instituted to be dency may augment responses to catecholamine 34 line. Incitement of pituitary-adrenal axis results in offset some of the problems allied to stress. More- regulatory actions. In addition, at times efforts of situations are allied with allostatic overload i.e., unchanged . overweight and fat build up through fluctuations in lous semen parameters. Psychological stress might accustomed to potent stressors affecting our tion. Am J Cardiol2002;90:18L-21L. installation workers. Occup Environ Med 44. Koelsch S, Boehlig A, Hohenadel M, Nitsche I, connected with decreased insulin sensitivity, obesity differentially, centered on qualitative interpretation increased cardiac output, sodium retention, skele- over, antioxidants, anti-inflammatory drugs, hypolip- people to cope with hassles of stressful experience body’s effort to gain stability through stressful eating manners. Long-term stress modifies food acutely impinge on spermatogenesis by affecting potentials. Therefore, it is indispensable to 12. Hintsanen M, Kivimäki M, Elovainio M, 2005;62:251–256. Bauer K, Sack U. The impact of acute stress on and metabolic disorder, eventually type 2 diabetes of exposure to stress25. tal muscle blood flow, cutaneous vasoconstriction, idemics and drugs that treat insulin insensitivity or prompt them to indulge in behaviors for example change, hence ensuing in modifications of cortisol Molecular mechanisms involved in inhibiting neuro- consumption behavior, dietetic tastes and less testosterone secretion in particular, hypothalam- treat/manage stress through various interventions Pulkki-Råback L, Keskivaara P, Juonala M, Raitakari 28. Lundberg U. Psychophysiology of work: stress, hormones and cytokines, and how theirrecovery is through modifications in neuroendocrine systems. In 36 reduced intestinal motility, increased glucose, bron- lasting ache also useful in managing metabolic and alcohol use or changes in sleeping patterns that and insulin levels in hypothalamo-hypophyseal axis genesis involve glucocorticoid signaling path- desire for craving . ic-pituitary-adrenal axis directly inhibits hypotha- like brain oriented/neurological approaches, phar- OT, Keltikangas-Järvinen L. Job strain and early gender, endocrine response, and work-related affected by music-evoked positive mood. Sci Rep CKD patients, level of release, a hormone that The muscle spindles possess a central role in muscles 33,35,31 chiolar dilatation and behavioral activation. More- neurological effects of stress. Although these medi- could also alter immune system processes. Hence, (HPA), kinins and other pro-inflammatory substanc- way .Dickkopf 1 (DKK1)alongwithinterleukin-1β lamic-pituitary-gonadal axis and Leydig cells in the macological interventions along with social support atherosclerosis: The Cardiovascular Risk in Young upper extremity disorders. Am J Indus Med 2016;6:23008. processes sympathetic nervous system products are by generating a viscous circle with sequentially over, there is suppression of circulating gonado- cations are valued to some degree, but have some these represent potentially important pathways es amid other homeostatic alterations. These varia- and NF-KB signaling routes. Moreover, Brain-derived Initial life anxiety transforms genetically NR3C1 testes. Both acute and chronic psychological stress to live a pleased and satisfied life full of achieve- Finns study. Psychosom Med 2005;67:740-7. 2002;41:383-392. 45. Prasad S, Tiwari M, Pandey AN, Shrivastav TG, reduced1. Hence, it is probable that long term increasing muscle stiffness and accretion of inflam- tropins and gonadal steroid hormones leading to side effects and limitations, thus affecting quality of associating stress with immune system20. tions have physiological implications, involving neurotrophic factor (BDNF) normally increase (receptor for cortisol and corticosteroid) expression can lead to erectile dysfunction as well46. ments. 13. Kamarck T, Shiffman S, Sutton-Tyrrell K, Muldoon 29. Johansson H, Sojka P. Pathophysiological mech- Chaube SK. Impact of stress on oocyte quality and disturbance of the normal menstrual cycle while life. changes in physiology of kidney. These conditions mental stressors bring about unimpeded increase in matory elements (arachidonic acid, bradykinin neurogenesis. Studies direct that crosstalk between in hypothalamus as well as hippocampus, arginine M, Tepper P. Daily psychological demands are anisms involved in genesis and spread of muscular reproductive outcome.J Biomed Sci2016;23:36. SNS tone that ensues a vicious reaction21. New etc.) that excite nociceptors and hence contribute prolonged exposure to stress condition can lead to Acute stress (examination stress or experimentally may result in renal repercussions, like high pressure GR and BDNF signaling follows and this might add to vasopressin and corticotrophin-releasing hormone THERAPEUTIC MANAGEMENT OF STRESS Brain oriented approaches tension in occupational muscle pain and in chronic 46. Nargund VH. Effects of psychological stress on researches revealed that exposure of discrimination to enlarged sensitivity of pain. Psychological stress 31 complete mutilation of reproductive function. induced stress) stimulates immune system18, where- level maintenance and association with incidence intricacy of interaction among stress and BDNF as in hypothalamus, resultant in inhibited glucocorti- For understanding the worth of life and its progress, Stress response is typically mediated by brain and musculoskeletal pain syndromes: a hypothesis. Med male fertility. Nat Rev Urol2015;12:373-82. and racism might be linked to chronic kidney and higher sympathetic provocation have been Figure 3: Diagrammatic illustration of stress influence as, chronic stress (work-related stress, bereavement, of renal calculi among other manifestations23. Previ- shown in Figure 2. coid receptor and amplified AVP and CRH activity stress is a censorious viewpoint now a day. All living remedial interventions must be projected to lessen Hypot1991;35:196-203. disease risk factors such as elevated blood pressure instituted to decrease or even abolish regulatory in reaction to stress later in life. Early life stress can on nervous system QUANTITATIVE ASSESSMENT OF THYROID GLAND VOLUME AMONG THE ETHNIC GROUPS OF KARACHI POPULATION

adverse health outcomes due to the of lack of 2. Hall JE. Guyton and Hall textbook of medical Med 2010;7(2). Evert M, et al. Genome-wide association study of blood. Moreover, there is a greater threat of toms within gastrointestinal tract for instance, iodization but uses iodized product as requisite 25. physiology e-Book: Elsevier Health Sciences; 2015. 18. Yusuf H. Conflict dynamics in Karachi: US Institute identifies four genetic loci associated with thyroid pulmonary embolism at the time of earthquakes diarrhea, dyspepsia, abdominal pain. Stress affects However, in the rural areas, intake of iodine was 3. Moghadam RN, Shajari A, Afkhami-Ardekani M. of Peace; 2012. volume and goiter risk. Am J Hum Gene and numbers of deaths per day owing to cardiovas- gut physiology by escalating intestinal permeability, inadequate. According to NNS 2011, rural areas of Influence of physiological factors on thyroid size 19. Ali Budhani A, Gazdar H, Kaker SA, Bux Mallah H. 2011;88(5):664-73. cular disease increases histrionically on the day of gastrointestinal motility, alteration in abdominal Punjab and Sindh provinces were the areas of mild determined by ultrasound. Acta Med Iran The Open City: social networks and violence in 23. Tarnoki AD, Tarnoki DL, Speer G, Littvay L, Bata P, earthquake4. Likewise, left ventricular dysfunction secretions, increase in visceral sensitivity and unde- to moderate iodine deficiency and the main cause 2011;49(5):302-4. Karachi. 2010. Garami Z, et al. Genetic and environmental has been reported owing to immensely raised sirable effects on enterobacteriaceae, regenera- of iodine deficiency was heavy rain fall and flood- 4. Tahir A, Ahidjo A, Yusuph H. Ultrasonic Assessment 20. Organization WH. Assessment of iodine deficien- influence on thyroid gland volume and thickness of interstitial infiltrates, plasma catecholamines and tive capacity of gastrointestinal mucosa and muco- ing, which washed away the iodine from soil25. Of Thyroid Gland Size In Maiduguri, Nigeria. West Afri cy disorders and monitoring their elimination: a thyroid isthmus: a twin study. Arch Endocrinol contraction band abnormalitiesin patients with no sal blood flow. Gastrointestine receive signals from J Ultrasound 2002;3(1). guide for programme managers. 2007. Metabol 2015;59(6):487-94. former cardiovascular disease historyin case of central nervous system via multiple parallel path- The study also reported increased mean TGV in 5. Ying M, Yung DM. Asymmetry of thyroid lobe 21. Hansen PS, Brix TH, Bennedbæk FN, Bonnema SJ, 24. Verkaaik O. Cosmopolistan. Gendering Urban intense emotional stress. Previously, analogous ways including autonomic nervous system, hypo- Hazarah and largest mean TGV among Baloch. volume in normal Chinese subjects: association with Kyvik KO, Hegedüs L. Genetic and environmental Space in the Middle East, South Asia, and Africa: outcomes have been perceived in terms of critical thalamic pituitary-adrenal axis (HPA), brain-gut-axis These areas were previously known as the areas of handedness and position of esophagus. Anat Rec causes of individual differences in thyroid size: a Springer; 2008. p. 207-28. and reversible cardiomyopathy provoked by cata- (BGA) and stress dysregulate brain-gut-axis resulting severe iodine deficiency. International Council for (Hoboken) 2009;292(2):169-74. study of healthy Danish twins. J Clin Endocrinol 25. https://www.unicef.org/pakistan/Annual_Re- strophic stress in patients with no past history of in various gut diseases2. the Control of Iodine Deficiency Disorders (ICCIDD) 6. Rasmussen LB, Ovesen L, Bülow I, Jørgensen T, Metabol 2004;89(5):2071-7. port_2011.pdf. cardiovascular disease5. and National Nutrition Survey(NNS) in 2011 reported Knudsen N, Laurberg P, et al. Relations between 22. Teumer A, Rawal R, Homuth G, Ernst F, Heier M, In response to stress various stressors are released that there was severe iodine deficiency in mothers various measures of iodine intake and thyroid Work stressors like job insecurity and job strain like and central stressors prompt the release of as well as in the school going children of Baloch- volume, thyroid nodularity, and serum thyroglobulin. high job demands and long working hours increase corticotrophin releasing factor (CRF), adrenocorti- istan, Azaad Jammu and Kashmir and Gilgit and Am J Clin Nutri 2002;76(5):1069-76. possibility of coronary heart disease and stroke cotropic hormone (ACTH) and glucocorticoids Baltistan25. Adequate knowledge about the use of 7. Kayastha P, Paudel S, Shrestha D, Ghimire R, Prad- (10-40%). Moreover, increasedpsychosomatichas- which have anti-inflammatory roles. Corticotrophin iodized salt was present but the use of iodized salt han S. Study of thyroid volume by ultrasonography sles and low individual control over these demands releasing factor and urocortins (Ucns) (centrally was low because of price, availability and adverse in clinically euthyroid patients. J Instit Med leads to physiological strain and ultimatelyin- released stressors)stimulate parasympathetic propaganda against the use of iodized products. It 2010;32(2):36-43. creased risk of cardiovascular disease. In line with nerves, which then innervate enteric neurons within was also reported that mill owners in those areas 8. Disorders ICfCoID. Assessment of iodine deficien- this imbalance between extreme effort and little gut wall to stimulate or inhibit motility and increase fooled people by supplying normal salt in the name cy disorders and monitoring their elimination: a reward is stressful. Earlier studies had inspected secretion. (Figure 1). Throughout stress, corticotropin of iodized salt25. We suggest, that variations in level guide for programme managers. Geneva: World correlation amid job insecurity and coronary heart releasing factor from brain hypothalamus excites of intake of iodine among the ethnic groups may Health Organization. 2007. disease 6. High work load and low control are more adrenocorticotrophic hormone secretion from have resulted alteration in their genotype that has 9. De Felice M, Postiglione MP, Di Lauro R. Minirev- likely to cause initial myocardial infarction while, pituitary gland that incites the discharge of gluco- ultimately resulted in significant variation in the iew: thyrotropin receptor signaling in development people suffering from permanent stress at work corticoids from adrenal gland thus mediate neuro- mean TGV among the ethnic groups. and differentiation of the thyroid gland: insights place or at home have more than 2.1 fold chance endocrine stress responses14 (Figure 1). from mouse models and human diseases. Endocri- for experiencing heart attack4. Similarly, marital Unequal sample size and very small sample size nology 2004;145(9):4062-7. stress also influence on prevalence of coronary Stress may intensely disturb BGA through modula- especially for Baloch group are the limitations of this 10. Panicker V, Wilson S, Spector T, Brown S, Falchi M, artery diseases. Marital stress is allied with 2.9 times tion of several imperative neuropeptides (like study. Large scale future studies with equal sample Richards J, et al. Heritability of serum TSH, free T4 and increased risk of cardiovascular events and in CGRP) that are concerned with alterations in diges- size from all the provinces of Pakistan would have free T3 concentrations: a study of a large UK twin accordance with astudy chronic work stress and tive fluids, protection and restoration of gastric given more appropriate results and better picture of cohort. Clin Endocrinol 2008;68(4):652-9. marital termination escalatethreat of cardiovascu- mucosal lining and mucosal blood flow15.Hence, mean TGV among the ethnic groups of Pakistan. 11. Kamran M, NH, MA, FA, FR, NZ, et al. Correla- lar mortality in men7. dysregulation of BGA ensues in generation of a tion of Thyroid Gland Volume with Ageand Gender wide range of gastrointestinal maladies. Stress 8 in a Subset of Karachi Population. Pak J Med Dent INTRODUCTION skeletal system and they become chronically Chronic stress presents with atherosclerosis . Athero- induced exacerbation of GERD symptoms is CONCLUSION 2014;3(2):26-32. over-activated or under-activated1. Hence, this sclerosis, comprising plaques development and ascribed to increased acid sensitivity and lower 2 12. Yousef M, Sulieman A, Ahmed B, Abdella A, Stress is described as a social, environmental or review summarizes the impact of stress on various arterial walls thickening is a common pathology in esophageal sphincter inhibition . Moreover, devel- 6 Mean total thyroid gland volumes, right and left Eltom K. Local reference ranges of thyroid volume in internal demand, which ensues in a physiological, organ systems of body and informs therapeutic cardiovascular disease . Moreover, elevated opment of PUD upon exposure to stressful life events lobe volumes were found to be significantly differ- Sudanese normal subjects using ultrasound. J psychological or behavioral reaction which disturbs options to prevent stress-related disorders. ambulatory blood pressure (ABP) and greater is attributable to numerous factors involving modifi- ent among the ethnic groups that exist in Karachi Thyroid Res 2011;1-4. physical and psychological well-being1 affecting- intima-medial thickening (IMT) had been stated in cations in gastric acid secretion and gastric motility, 9 population. Long term variations in the level of 13. Turcios S, Lence-Anta JJ, Santana J-L, Pereda most of the people. According to a definition of H. STRESS AND ORGAN SYSTEMS carotid arteries of people in the course of highly reduction in mucosal blood flow and bicarbonate 10 intake of iodine among the ethnic groups may CM, Velasco M, Chappe M, et al. Thyroid volume Selye, stress is called an acute risk to organism’s 1. Stress and Cardiovascular system challenging and less manageable days . IMT is an secretion, acid back diffusion, diminished propaga- 16 DISCUSSION in 2011 in his genome wide association study report- have resulted alterations in genotype that probably and its relation to anthropometric measures in a homeostasis, which may be physical or psychologi- There is a colossal data on psychological stress and ultrasonographic marker of atherosclerosis that is tion and compensation of bruised mucosa . There 22 ed four loci associated with TGV and goiter risk . has resulted in significant variation in the mean TGV healthy Cuban population. Eur Thyroid J cal caused by events from within or in the outside cardiovascular disease. The acute stressors i.e., linked with greater risk for future heart attack and is a strong evidence that stress exposure triggers 11 Karachi is largest cosmopolitan city of Pakistan. Tarnoki AD in 2015 while studying on twins conclud- among the ethnic groups. 2015;4(1):55-61. world. Notably, stress arouses adaptive reactions disasters (earthquakes) and intense emotional stress stroke . According to a study among young adults, brain-gut axis and worsens IBD, thus leading to 18, 19 People from all over the Pakistan reside here . ed that genetic and environmental factors both are 14. Şahin E, Elboğa U, Kalender E. Regional refer- that assist to shield internal environment constancy while, chronic stressors such as job stress and marital job stress has been associated with increased release of gastrointestinal hormones and 23 12 Objectives of this study were to determine mean important in controlling TGV . We also suggest that ence values of thyroid gland volume in Turkish and organism’s survival2. Autonomic nervous unhappiness contribute to varied pathophysiologi- intimal medial thickening in carotid arteries . An neurotransmitters, changes in gastrointestinal motili- TGV among the different ethnic groups in Karachi variation in TGV among the ethnic groups in our ACKNOWLEDGEMENTS Adults. Srp Arh Celok Lek 2015;143(3-4):141-5. system, hypothalamic-pituitary-adrenal (HPA) axis cal changes comprising myocardial ischemia, arduous psychosocial environment may provoke ty, gut microbiota, endocrine functions and visceral population and to determine whether the changes study is probably due to genetic variation. 15. Adibi A, Sirous M, Aminorroaya A, Roohi E, and fight-or-flight response are conventional ways myocardial infarction, wall motion abnormalities persistent instigation of sympathetic nervous system sensitivity, increased manifestation and discharge in mean TGV among the ethnic groups are signifi- We would like to thank Ziauddin Laboratory and Mostafavi M, Fallah Z, et al. Normal values of thyroid of envisaging biological and behavioral response to and owing to fluctuations in hemostasis and sympa- pathways that may augment ABP along with some of pro-inflammatory cytokines, discharge of key cant. In this study, smallest mean TGV was found in Urdu Ziauddin Hospital Clifton Karachi campus for gland in Isfahan, an iodine replete area. J Res Med danger from a perilous situation, such as, a preda- thetic nervous system activity sudden death and pathophysiological alterations that contribute to neuropeptides and up-regulation of immune system 9,13 2 speaking population. This is probably due to exces- conducting this study. Sci 2008;13(2):55-60. tor, a mugger, an accident or natural disas- changes in cardiac regulation can result4. early signs of atherosclerosis . (low level inflammation) . The pathogenesis of IBS is In this study mean TGV varies significantly among sive intake of iodine rich food by this group. Urdu 16. Alazigha N, Ugboma E, Nwankwo C, Agi C. ter3.Stressors appear in 3 different forms i.e., numer- multifactorial and involves profound dysregulation the different ethnic groups that exists in Karachi speaking population is the pioneer of urban Karachi Sonographic Measurement Of The Volume Of The ous life happenings,enduringworries andeveryday- Earthquakes are allied with an increased cardiovas- 2. Stress and Gastrointestinal system of brain gut axis. Among the aforementioned gut population. Hensen et al. in 2004, while studying the population and relishes an easy excess to iodine Normal Thyroid Gland In Adults In Braithwaite disturbancesfrequently considered as trivial but can cular risk. The marked escalation in heart rate (160 Major systems of body (cardiovascular, muscular, disorders, most important is visceral hypersensitivi- 24 REFERENCES 17 genetics and environmental causes for the varia- rich sea food . 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48 PAKISTAN JOURNAL OF MEDICINE AND DENTISTRY 2019, VOL. 8 (01)

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In 36 reduced intestinal motility, increased glucose, bron- lasting ache also useful in managing metabolic and alcohol use or changes in sleeping patterns that and insulin levels in hypothalamo-hypophyseal axis genesis involve glucocorticoid signaling path- desire for craving . ic-pituitary-adrenal axis directly inhibits hypotha- like brain oriented/neurological approaches, phar- OT, Keltikangas-Järvinen L. Job strain and early gender, endocrine response, and work-related affected by music-evoked positive mood. Sci Rep CKD patients, level of release, a hormone that The muscle spindles possess a central role in muscles 33,35,31 chiolar dilatation and behavioral activation. More- neurological effects of stress. Although these medi- could also alter immune system processes. Hence, (HPA), kinins and other pro-inflammatory substanc- way .Dickkopf 1 (DKK1)alongwithinterleukin-1β lamic-pituitary-gonadal axis and Leydig cells in the macological interventions along with social support atherosclerosis: The Cardiovascular Risk in Young upper extremity disorders. Am J Indus Med 2016;6:23008. processes sympathetic nervous system products are by generating a viscous circle with sequentially over, there is suppression of circulating gonado- cations are valued to some degree, but have some these represent potentially important pathways es amid other homeostatic alterations. These varia- and NF-KB signaling routes. Moreover, Brain-derived Initial life anxiety transforms genetically NR3C1 testes. Both acute and chronic psychological stress to live a pleased and satisfied life full of achieve- Finns study. Psychosom Med 2005;67:740-7. 2002;41:383-392. 45. Prasad S, Tiwari M, Pandey AN, Shrivastav TG, reduced1. Hence, it is probable that long term increasing muscle stiffness and accretion of inflam- tropins and gonadal steroid hormones leading to side effects and limitations, thus affecting quality of associating stress with immune system20. tions have physiological implications, involving neurotrophic factor (BDNF) normally increase (receptor for cortisol and corticosteroid) expression can lead to erectile dysfunction as well46. ments. 13. Kamarck T, Shiffman S, Sutton-Tyrrell K, Muldoon 29. Johansson H, Sojka P. Pathophysiological mech- Chaube SK. Impact of stress on oocyte quality and disturbance of the normal menstrual cycle while life. changes in physiology of kidney. These conditions mental stressors bring about unimpeded increase in matory elements (arachidonic acid, bradykinin neurogenesis. Studies direct that crosstalk between in hypothalamus as well as hippocampus, arginine M, Tepper P. Daily psychological demands are anisms involved in genesis and spread of muscular reproductive outcome.J Biomed Sci2016;23:36. SNS tone that ensues a vicious reaction21. New etc.) that excite nociceptors and hence contribute prolonged exposure to stress condition can lead to Acute stress (examination stress or experimentally may result in renal repercussions, like high pressure GR and BDNF signaling follows and this might add to vasopressin and corticotrophin-releasing hormone THERAPEUTIC MANAGEMENT OF STRESS Brain oriented approaches tension in occupational muscle pain and in chronic 46. Nargund VH. Effects of psychological stress on researches revealed that exposure of discrimination to enlarged sensitivity of pain. Psychological stress 31 complete mutilation of reproductive function. induced stress) stimulates immune system18, where- level maintenance and association with incidence intricacy of interaction among stress and BDNF as in hypothalamus, resultant in inhibited glucocorti- For understanding the worth of life and its progress, Stress response is typically mediated by brain and musculoskeletal pain syndromes: a hypothesis. Med male fertility. Nat Rev Urol2015;12:373-82. and racism might be linked to chronic kidney and higher sympathetic provocation have been Figure 3: Diagrammatic illustration of stress influence as, chronic stress (work-related stress, bereavement, of renal calculi among other manifestations23. Previ- shown in Figure 2. coid receptor and amplified AVP and CRH activity stress is a censorious viewpoint now a day. 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