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Original article
Use of thyroid hormone in hypothyroid patients and euthyroid subjects in Spain: A THESIS* questionnaire survey
Uso de la hormona tiroidea en pacientes hipotiroideos y sujetos eutiroideos en España
Juan C. Galofréa,b,c,
Corresponding author
jcgalofre@unav.es

Corresponding author.
, Roberto Attanasiod, Laszlo Hegedüse, Endre Nagyf, Roberto Negrog, Enrico Papinih, Petros Perrosi, Juan J. Díezc,j,k,l
a Department of Endocrinology, Clínica Universidad de Navarra, Pamplona, Spain
b Instituto de Investigación Sanitaria de Navarra (IdiSNA), Spain
c Thyroid Task Force from the Sociedad Española de Endocrinología y Nutrición (SEEN), Madrid, Spain
d IRCCS Orthopedic Institute Galeazzi, Endocrine Unit, Milan, Italy
e Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
f Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
g Division of Endocrinology, V. Fazzi Hospital, Lecce, Italy
h Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy
i Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
j Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
k Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Madrid, Spain
l Department of Medicine, Universidad Autónoma de Madrid, Spain
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requirements&#46; In addition&#44; there are some non-conventional indications for LT4 therapy &#40;not supported by evidence&#41; in euthyroid subjects&#46; Among them are infertility&#44; hypercholesterolemia&#44; depression&#44; obesity and goitre&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In contrast with other European countries&#44; the only approved thyroid replacement formula in Spain is LT4 tablets&#44; aside from the seldom-prescribed intravenous solution used in emergencies&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> The Spanish public healthcare system&#44; or its regional counterpart in each of the country&#39;s 17 autonomous regions&#44; usually funds this treatment&#46; The Spanish market is almost entirely controlled by one of the three name brands of levothyroxine available&#46; Generic levothyroxine is seldom prescribed due to the low cost of its name brand&#46; In selected cases&#44; imported thyroid hormone preparations&#44; such as combination therapy with tablets with LT4 and liothyronine &#40;LT3&#41;&#44; may be approved after adequate justification to health authorities&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">There are no National hypothyroidism guidelines supported by the <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Endocrinolog&#237;a y Nutrici&#243;n</span> &#40;SEEN&#41;&#44; apart from management of subclinical hypothyroidism during pregnancy&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> Therefore&#44; current practice is based mainly on the recommendations of international scientific societies&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#44;4&#44;10</span></a> Although Spanish endocrinologists routinely see many patients with underactive thyroid conditions&#44; most hypothyroid patients are&#44; in fact&#44; identified and treated by a general practitioner&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In recent years&#44; new data have emerged&#44; leading to an increased interest in exploring innovative measures to improve the quality of life of hypothyroid patients&#44; especially that of patients dissatisfied with their treatment outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">12&#8211;15</span></a> However&#44; the physicians&#8217; perspective has not been explored extensively&#46; For this reason&#44; the THESIS &#40;Treatment of Hypothyroidism in Europe by Specialists&#58; an International Survey&#41; project was developed&#46; It is an ambitious pan-European survey aimed at identifying the current attitudes of specialists involved in the treatment of hypothyroidism&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This survey aimed to assess the current attitudes of Spanish members of the SEEN towards the conventional treatment of hypothyroid patients with LT4 and the non-conventional use of LT4 in euthyroid subjects in their daily clinical practice&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Survey design</span><p id="par0030" class="elsevierStylePara elsevierViewall">Each THESIS questionnaire was in both Spanish and English&#46; Two of the co-authors &#40;JJD and JCG&#41; translated the original English text into Spanish &#40;Supplementary Material&#44; Table S1&#41;&#46; Questions B3 and B6-B9 of the initial survey were not included because they have to do with thyroid hormone preparations commercially unavailable under the Spanish healthcare system&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical issues</span><p id="par0035" class="elsevierStylePara elsevierViewall">The SEEN board of directors and its Thyroid Task Force Steering Committee approved the study&#46; The participants were not asked for any personal data that could make possible their identification to ensure anonymity&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Dissemination</span><p id="par0040" class="elsevierStylePara elsevierViewall">The survey was posted on the SEEN webpage&#44; available to all members &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1956&#41; from September 10 to November 18&#44; 2020&#46; Invitation e-mails were sent to members immediately before initiating the survey &#40;September 10&#44; 2020&#41;&#46; Two monthly reminders mailings were subsequently sent&#44; one in October and another in November&#46; Participant responses were electronically compiled&#44; saved and hosted on an open-access form creation website &#40;<a href="https://www.google.com/forms/">https&#58;&#47;&#47;www&#46;google&#46;com&#47;forms&#47;</a>&#41;&#46; Only the authors had access to the survey database&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Categorical variables are described as absolute values and percentages&#46; As not every participant answered every question&#44; the percentage of respondents providing a given answer was calculated individually for each question&#44; using the number of respondents to that question as the denominator&#46; Responses to the only question in which respondents were asked to give their opinion on a scale of 1&#8211;8 to reflect the possible cause of symptoms persistence in those patients with normal serum TSH are expressed as median and interquartile range&#46; Chi-square tests and Fisher&#39;s exact tests were used to compare proportions&#46; Differences were considered significant when <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Surveyed physicians</span><p id="par0050" class="elsevierStylePara elsevierViewall">We obtained 512 responses&#44; representing approximately a quarter of the 1956 SEEN members&#44; of whom 90&#37; are physicians and the remainder 10&#37; basic investigators&#46; After the exclusion of 7 incomplete questionnaires&#44; 505 valid responses were analysed&#46; Two-thirds &#40;66&#37;&#59; 333&#47;505&#41; of those who responded were female&#44; and 57&#37; &#40;288&#47;505&#41; of the participants have been practising for less than 20 years&#46; Almost all were endocrinologists who performed a large proportion of their work at university hospitals&#46; Most participants deal with thyroid patients daily&#44; with 70&#37; treating more than 100 hypothyroid patients per year &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Indication of thyroid hormones in euthyroid subjects &#40;non-conventional use of LT4&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">The respondents&#8217; main indication for LT4 treatment in biochemically euthyroid subjects &#40;non-conventional use of LT4&#41; was female infertility with a high level of thyroid antibodies &#40;48&#46;5&#37;&#41;&#44; followed by the presence of a slow-growing simple goitre &#40;21&#46;2&#37;&#41;&#46; In contrast&#44; 44&#46;2&#37; stated that thyroid hormone is never indicated for biochemically euthyroid subjects &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Treatment hypothyroid patients with thyroid hormones &#40;conventional&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Most respondents &#40;97&#46;0&#37;&#59; 490&#47;505&#41;&#59; stated that LT4 was the first-line replacement therapy for hypothyroid patients &#40;conventional use&#41;&#46; Only 13 respondents &#40;2&#46;6&#37;&#41; were in favour of combination therapy &#40;LT4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LT3&#41;&#46; Four hundred and sixty-six &#40;92&#46;5&#37;&#41; answered that most of their patients took the LT4 brand they had prescribed&#44; while general practitioners changed the brand in 4&#37; of cases&#44; with the remaining 3&#37; stating that they had no control over the specific brand of LT4 eventually taken by patients&#46; Only 0&#46;4&#37; acknowledge that they had to justify the brand of LT4 to the regulatory authorities&#46; Almost half of the sample &#40;238&#47;491&#59; 48&#46;5&#37;&#41; considered LT4 tablet to be the preparation least likely to be subject to variable absorption &#40;among a selection of alternative formulations&#41; due to interference with other medications&#46; Only 6&#46;5&#37; and 3&#46;3&#37; believed that the preparations least at risk of a variable absorption are liquid solution and soft-gel capsules&#44; respectively&#46; Moreover&#44; 41&#46;8&#37; did not expect significant absorption changes between the different formulations&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Control of serum TSH during therapy</span><p id="par0065" class="elsevierStylePara elsevierViewall">Once treatment was initiated&#44; the preferred timing of first control of serum TSH was carried out at 4&#8211;6 weeks and 8 weeks by 40&#46;4&#37; and 59&#46;2&#37; of respondents&#44; respectively&#46; If the LT4 formula or brand was switched&#44; 47&#46;7&#37; of surveyed physicians recommended checking serum TSH at 8 weeks&#44; with 25&#46;7&#37; checking TSH levels at 4&#8211;6 weeks&#46; Only 10&#46;5&#37; relied on clinical evaluation&#44; and 16&#46;0&#37; indicated that there was no need to monitor TSH following a change in LT4 formulation or manufacturer&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Use of dietary supplements and a combination of LT4 and LT3</span><p id="par0070" class="elsevierStylePara elsevierViewall">More than a third of the participants &#40;188&#47;495&#59; 38&#46;0&#37;&#41; responded that dietary supplements could be used in addition to thyroid hormone replacement upon patient request or as a complementary treatment&#46; Subclinical hypothyroidism and the coexistence of autoimmune thyroiditis were conditions for which dietary supplements were prescribed in 16&#46;4&#37; and 14&#46;1&#37; of the cases&#44; respectively&#46; In contrast&#44; 31&#46;5&#37; of specialists stated that dietary supplements should never be prescribed&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Almost half of the respondents &#40;49&#37;&#41; believed that combination replacement therapy &#40;LT4 and LT3&#41;&#44; a formula not marketed in Spain&#44; should never be used&#44; whereas 40&#37; of participants answered that it could be an option for patients who continued to complain of hypothyroid symptoms despite being biochemically euthyroid&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Persistence of symptoms despite normal TSH</span><p id="par0080" class="elsevierStylePara elsevierViewall">Participants were surveyed about LT4-treated hypothyroid patients who continued to experience symptoms despite normal serum TSH levels&#46; According to more than two-thirds of respondents&#44; the frequency of this phenomenon was present in 10&#37; or less&#44; with a trend unchanged over time &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; More than 60&#37; of respondents agreed or strongly agreed that these persistent symptoms could be explained by psychosocial factors &#40;72&#46;6&#37;&#41;&#44; comorbidities &#40;66&#46;2&#37;&#41; or unrealistic patient expectations &#40;65&#46;8&#37;&#41;&#46; More than 40&#37; of participants were confident of the ability of LT4 to restore patients to their normal physiology &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Participants were asked to rank&#44; according to their experience&#44; the relevance of possible explanations for persistent symptoms in patients who achieve normal serum TSH&#46; The range was from 1 to 8&#44; where 1 was the most likely and 8 was the least likely reason &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; The explanations considered least likely by respondents were the inconvenience of taking medication&#44; followed by unrealistic patient expectations and the inability of LT4 to restore the patient to normal physiology&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Hypothyroid physicians&#8217; choice</span><p id="par0090" class="elsevierStylePara elsevierViewall">Fifty-one respondents &#40;10&#46;1&#37;&#41; acknowledged having hypothyroidism themselves&#44; of which 13 &#40;25&#46;5&#37;&#41; reported experiencing excessive tiredness or fatigue&#46; Five hypothyroid physicians &#40;9&#46;8&#37;&#41; had tried LT4 and LT3 combination therapy&#44; and one &#40;2&#46;0&#37;&#41; had tried desiccated thyroid treatment&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Lastly&#44; 76 out of 439 &#40;17&#46;3&#37;&#41; non-hypothyroid physicians stated that they would consider LT4 and LT3 combination therapy or desiccated thyroid for themselves if they developed hypothyroidism&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Subgroup analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall">We examined various items to explore associations between the respondents&#8217; baseline characteristics&#44; such as gender&#44; years in practice&#44; hospital affiliation &#40;academic or non-academic&#41; on the one hand&#44; and the volume of hypothyroid patients they dealt with on the other &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The most important factors of these were years in practice and the volume of patients per year&#46; The longer the respondents had been in practice&#44; the more likely they considered that there was no indication for treatment in biochemically euthyroid subjects and the more reluctant they were to prescribe dietary supplements&#46; Furthermore&#44; compared to younger physicians&#44; more experienced specialists &#40;with a practice longer than 20 years&#41; were predisposed to believe that comorbidities or psychosocial factors were the leading causes of persistent hypothyroidism-like symptoms in subjects with normal TSH&#46; Specialists who deal with more than 100 patients per year were more inclined to prescribe LT4 in female infertility cases and use combined treatment with LT4 and LT3 in patients with persistent symptoms&#46; The institution &#40;either university or non-academic hospital&#41; had no influence over the opinion of the respondents&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Around a quarter of the SEEN members completed the survey&#46; More than 90&#37; of they are practicing endocrinologists&#44; which suggests that the results reflect the real-life practice in Spain&#46; The typical respondent was a young female doctor working in an academic institution &#40;75&#37; from a university hospital&#41;&#46; Nevertheless&#44; no relationship was found between the type of hospital &#40;academic or otherwise&#41; of the respondent and the treatment prescribed for hypothyroidism&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The survey analysed respondents&#8217; opinions about LT4 treatment indications in conventional &#40;patients with an underactive thyroid or without a thyroid gland&#41; and non-conventional &#40;patients with hypothyroid-like symptoms with normal serum thyroid hormone levels&#41; conditions&#46; It also assessed Spanish physicians&#8217; attitude towards the &#40;apparently adequately&#41; supplemented hypothyroid patient &#40;with normal thyroid hormone levels&#41; who continued to complain about symptoms traditionally associated with hypothyroidism&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The only replacement therapy for hypothyroidism available in Spain is LT4 in tablets&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> The Spanish National Health Service &#40;NHS&#41;&#44; which covers the country&#39;s entire population&#44; provides funding for the drug&#46; As previously mentioned&#44; combination treatment &#40;LT4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LT3&#41; or liothyronine alone are not available on the national market&#44; although a request may be made to the national health service&#46; Other formulas such as LT4 in soft-gel capsules and liquid solutions or desiccated thyroid extracts are available via the Internet&#46; It is important to consider this fact when comparing the present outcomes with the THESIS survey results in other countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">16&#44;17</span></a> Hence&#44; given the limited alternatives available to them&#44; it is logical that Spanish physicians rely almost solely on LT4 as the first line of treatment for hypothyroidism&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Following the international guidelines&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#44;4</span></a> the specialists rarely considered the non-conventional use of LT4 for non-hypothyroid conditions &#40;such as hypercholesterolemia&#44; obesity&#44; fatigue&#44; obesity or depression&#41;&#46; However&#44; several respondents &#40;21&#46;2&#37;&#41; would consider LT4 treatment in euthyroid subjects with simple goitre&#44; even though such treatment is discouraged under current guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#44;4</span></a> This result parallels that found in the Italian study&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a> which indicates that this improper practice is deeply rooted in certain sectors&#46; Specific attention deserves the cases of euthyroid seropositive women &#40;with positive antithyroid antibodies&#41; with infertility problems&#46; Almost half of the respondents &#40;48&#46;5&#37;&#41; admitted that this situation warranted thyroid hormone therapy&#46; Interestingly&#44; female specialists&#44; as compared to their male counterparts&#44; were more willing to treat the woman&#39;s infertility with LT4 supplements than their male counterparts&#46; Similarly&#44; more experienced physicians &#40;doctors with a high volume of patients&#41; also favoured LT4 supplements in this clinical scenario&#46; This approach has been proposed by recent studies&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> although there is no clear evidence to substantiate such a claim&#44; and its usefulness remains unsettled&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Cases of persistent hypothyroid symptoms with normal TSH levels&#44; although well known&#44; were rare in the experience of Spanish endocrinologists&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">20&#44;21</span></a> More than two-thirds stated that such symptoms were reported in fewer than 10&#37; of their hypothyroid patients&#44; and this trend remained unchanged over time&#46; According to respondents&#44; the cause of persistent hypothyroid symptoms is not related to the inability of LT4 to restore normal thyroid physiology&#46; Although there was no evidence to justify their opinion&#44; respondents attributed the persistence of symptoms to psychosocial factors &#40;72&#37;&#41;&#44; comorbidities &#40;66&#37;&#41; or unrealistic patient expectations to treatment &#40;65&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">5&#8211;7</span></a> However&#44; a large proportion of hypothyroid physicians &#40;almost 25&#37;&#41; reckoned to experience fatigue despite treatment&#44; which was in contrast to what specialists stated about the proportion of their patients who were dissatisfied with thyroid hormone supplementation&#46; This may reflect a double standards policy or that there are two different yardsticks applied for the same situation&#46; Clearly&#44; more research is needed&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Despite the lack of experience in treating with combination therapy &#40;due to its unavailability in Spain&#41;&#44; many specialists &#40;49&#37;&#41; follow the recommendations of the American and European guidelines&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#44;4</span></a> and find no reason to recommend LT4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LT3 therapy as the first-line option for patients with underactive thyroid glands&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> As in the Italian and Bulgarian THESIS studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">16&#44;23</span></a> and despite the limited availability of combination therapy in Spain&#44; 40&#37; of respondents favoured its use in patients with normal TSH who continued to complain of hypothyroidism-like symptoms&#46; In Italy&#44; 43&#37; of the respondents expressed support for combination therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Although there are no official guidelines that recommend using iodine in Spain&#44; thanks to the constant efforts of the SEEN&#44; the nutritional status of iodine in the country has improved in recent years&#44; although the problem has not been entirsolved&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> The lack of an official recommendation is reflected because the participants stated that the first reason to prescribe dietary supplements with iodine or selenium is at the patient&#39;s request&#44; while a third considered that dietary supplements should never be prescribed&#46; This situation parallels what is happening in Denmark<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> and reflects the lack of evidence about the clinical benefit of selenium&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Almost a quarter of Spanish practising endocrinologists completed the questionnaire&#44; a relatively high number of participants&#46; There have been very few studies that have aimed to evaluate the real-life practice of specialists&#46; Remarkably&#44; a recent Spanish study conducted by one of the authors of this paper on the attitude of family doctors towards the management of hypothyroidism reveals a proactive attitude in the diagnosis and therapy of hypothyroidism by most respondents&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> However&#44; the study also noted a tendency of family doctors to perform unnecessary diagnostic tests and an excessive willingness to treat mild subclinical hypothyroidism&#46; This highlights the difference in treatment management between endocrinologists and general practitioners&#46; As stated earlier&#44; the limitations of our analysis are mainly related to the unavailability of combination therapy in Spain and the composition of our sample of respondents that resulted strongly skewed towards young specialists working in university hospitals&#46; For this reason&#44; our results cannot be readily extrapolated to other countries&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusion</span><p id="par0150" class="elsevierStylePara elsevierViewall">The standard of treatment of hypothyroidism in Spain is almost exclusively with LT4 tablets&#46; Availability of other formulations of LT4 or combination therapy for hypothyroidism management remains to be explored&#44; especially in patients with persistent symptoms&#46; Notably&#44; non-evidence-based use of LT4 is widely practised in Spain for euthyroid women with autoimmune thyroiditis and fertility issues&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Financial support</span><p id="par0155" class="elsevierStylePara elsevierViewall">The present investigation has not received any financial support from public sector agencies&#44; commercial sector&#44; or non-profit entities&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">PP&#44; LH&#44; EVN and EP are scientific board members of and have received consultancy fees from IBSA Biochemie&#46;</p></span></span>"
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              "titulo" => "Treatment hypothyroid patients with thyroid hormones &#40;conventional&#41;"
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              "titulo" => "Subgroup analysis"
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          "titulo" => "Discussion"
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          "identificador" => "sec0090"
          "titulo" => "Financial support"
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          "identificador" => "sec0095"
          "titulo" => "Conflicts of interest"
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        11 => array:2 [
          "identificador" => "xack624700"
          "titulo" => "Acknowledgements"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2021-05-18"
    "fechaAceptado" => "2021-07-08"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1553907"
          "palabras" => array:4 [
            0 => "Hypothyroidism"
            1 => "Thyroid hormone"
            2 => "Treatment"
            3 => "Survey"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1553906"
          "palabras" => array:4 [
            0 => "Hipotiroidismo"
            1 => "Hormona tiroidea"
            2 => "Tratamiento"
            3 => "Encuesta"
          ]
        ]
      ]
    ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hypothyroidism is one of the leading conditions in endocrinology&#46; Despite that fact&#44; clinical indications for treatment still vary among Spanish specialists&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Aims</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To identify attitudes of Spanish specialists relating to the use of levothyroxine &#40;LT4&#41; and the management of hypothyroidism&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The members of the <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Endocrinolog&#237;a y Nutrici&#243;n</span> &#40;Spanish Society of Endocrinology and Nutrition&#41; were invited to participate in a web-based survey&#46; The survey&#44; initially in English&#44; was modified to reflect in accordance with the availability of thyroid hormone formulations in Spain&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A total of 505 of 1956 &#40;25&#46;8&#37;&#41; members &#40;66&#37; female&#41; completed the survey&#59; 97&#46;4&#37; declared that LT4 is the first-line therapy for hypothyroidism&#46; The indications for LT4 therapy in euthyroidism were infertility in thyroid antibody-positive women &#40;48&#46;5&#37;&#41; and simple goitre &#40;21&#46;2&#37;&#41;&#46; However&#44; 44&#46;2&#37; of specialists reported that there was no indication for LT4 therapy in such patients&#46; Only a minority of respondents &#40;2&#46;6&#37;&#41; considered combining LT4 with liothyronine as the treatment of choice from inception&#44; whereas 49&#37; stated that it should never be used&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The standard of treatment of hypothyroidism in Spain is almost exclusively with LT4 tablets&#46; Availability of other formulations of LT4 or combination therapy for hypothyroidism management remains to be explored&#44; especially in patients with persistent symptoms&#46; Notably&#44; non-evidence-based use of LT4 is widely practiced in Spain for euthyroid women with autoimmune thyroiditis and fertility issues&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Aims"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Methods"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
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          4 => array:2 [
            "identificador" => "abst0025"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El hipotiroidismo es una de las principales afecciones en endocrinolog&#237;a&#46; No obstante&#44; las indicaciones de tratamiento var&#237;an entre los especialistas espa&#241;oles&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Identificar las actitudes de los especialistas espa&#241;oles en el manejo del hipotiroidismo y el empleo de la levotiroxina &#40;LT4&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se invit&#243; a los miembros de la Sociedad Espa&#241;ola de Endocrinolog&#237;a y Nutrici&#243;n a participar en una encuesta <span class="elsevierStyleItalic">on line</span>&#46; La encuesta&#44; originalmente en ingl&#233;s&#44; se modific&#243; para reflejar la disponibilidad de formulaciones de hormonas tiroideas en Espa&#241;a&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">De los 1&#46;956 socios&#44; 505 &#40;25&#44;8&#37;&#59; 66&#37; mujeres&#41; completaron la encuesta&#46; El 97&#44;4&#37; declar&#243; que LT4 es la terapia de primera l&#237;nea para el hipotiroidismo&#46; Las indicaciones del tratamiento con LT4 en el eutiroidismo fueron infertilidad en mujeres con anticuerpos antitiroideos positivos &#40;48&#44;5&#37;&#41; y bocio simple &#40;21&#44;2&#37;&#41;&#46; Sin embargo&#44; el 44&#44;2&#37; de los especialistas contest&#243; que no hab&#237;a indicaci&#243;n de tratamiento con LT4 en estos casos&#46; Solo una minor&#237;a &#40;2&#44;6&#37;&#41; consider&#243; que la combinaci&#243;n de LT4 con liotironina era el tratamiento de elecci&#243;n desde el inicio&#44; mientras que el 49&#37; afirm&#243; que nunca deber&#237;a usarse&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El tratamiento convencional del hipotiroidismo en Espa&#241;a es casi exclusivamente mediante comprimidos de LT4&#46; Actualmente no hay disponibilidad de otros preparados de LT4&#46; La terapia combinada&#44; especialmente para aquellos pacientes con s&#237;ntomas persistentes de hipotiroidismo&#44; no ha sido a&#250;n explorada&#46; Aunque su uso no est&#233; basado en la evidencia&#44; en Espa&#241;a se prescribe ampliamente LT4 en mujeres eutiroideas con tiroiditis autoinmune y problemas de fertilidad&#46;</p></span>"
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            "identificador" => "abst0030"
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            "identificador" => "abst0035"
            "titulo" => "Objetivos"
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            "titulo" => "Resultados"
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            "titulo" => "Conclusiones"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">THESIS&#58; <span class="elsevierStyleBold">T</span>reatment of <span class="elsevierStyleBold">H</span>ypothyroidism in <span class="elsevierStyleBold">E</span>urope by <span class="elsevierStyleBold">S</span>pecialists&#58; An <span class="elsevierStyleBold">I</span>nternational <span class="elsevierStyleBold">S</span>urvey&#46;</p>"
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    "apendice" => array:1 [
      0 => array:1 [
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            "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0105"
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    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Opinion of respondents on the causes of persistent symptoms in patients treated with LT4 who achieved normal serum TSH&#46; Physicians provided their opinion on the different requested issues &#40;strongly disagree&#44; disagree&#44; neutral&#44; agree and strongly agree&#41;&#46; &#40;B&#41; Experience of respondents with patients treated with LT4 who achieved normal serum TSH but continued to experience symptoms such as fatigue&#46; Respondents were asked to rank each factor from 1 to 8&#44; where 1 is the most likely and 8 the least likely explanation in their opinion&#46; The data are the median &#40;squares&#41; and the interquartile range &#40;horizontal lines&#41;&#46; Figures in brackets indicate the number of interviewees who responded to each of the items&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; SEEN&#44; Spanish Society of Endocrinology and Nutrition&#59; ETA&#44; European Thyroid Association&#59; ATA&#44; American Thyroid Association&#59; LATS&#44; Latin American Thyroid Society&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Regional hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90 &#40;17&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Private clinic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51 &#40;10&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>General practice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Specialist practice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64 &#40;12&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Membership</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SEEN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">449 &#40;88&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ETA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ATA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LATS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;9&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Frequency of management of patients with thyroid disease</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Daily&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">432 &#40;85&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Weekly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67 &#40;13&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rarely&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Frequency of management of patients with hypothyroidism</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>10&#8211;50 patients&#47;year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;8&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>51&#8211;100 patients&#47;year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">101 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;100 patients&#47;year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">357 &#40;70&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rarely&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unexplained fatigue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obesity resistant to life-style interventions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe hypercholesterolemia&#44; as a complementary treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Depression resistant to anti-depressant medications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;5&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Female infertility with high level of thyroid antibodies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">245 &#40;48&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Simple goitre growing over time<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107 &#40;21&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thyroid hormone is never indicated for these patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">223 &#40;44&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "etiqueta" => "b"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Frequency</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">175 &#40;34&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#8211;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">175 &#40;34&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>11&#8211;30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107 &#40;21&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>More than 30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Not sure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;6&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trends</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I am seeing more such cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136 &#40;26&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I am seeing fewer such cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No change&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">272 &#40;53&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Not sure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;11&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0020"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Number of valid responses in the question about frequency&#58; 504&#59; number of valid responses in the question about trends&#58; 505&#46;</p>"
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Perceptions about the occurrence of persistence of hypothyroid symptoms despite normal serum TSH&#46;</p>"
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The data are the number &#40;percentage&#41; of affirmative or favourable responses to each one of the questions indicated&#46; Statistically significant differences &#40;chi-square test&#41; have been highlighted in bold&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Abbreviations TSH&#44; thyrotropin&#59; LT4&#44; levothyroxine&#59; LT3&#44; liothyronine&#46;</p>"
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            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Question&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Gender</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Years in practice</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hospital type</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Annual hypothyroid volume</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Female&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>333&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Male&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>169&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#8804;20&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>288&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#62;20&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>204&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">University&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>381&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Other&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>124&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#8804;100&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>147&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#62;100&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>357&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thyroid hormone may be indicted in biochemically euthyroid females with infertility and thyroid antibodies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">174 &#40;52&#46;3&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">69 &#40;40&#46;8&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;018</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">162 &#40;56&#46;3&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">78 &#40;38&#46;2&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">185 &#40;48&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;48&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">56 &#40;38&#46;1&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">189 &#40;52&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Thyroid hormone is never indicated for biochemically euthyroid subjects&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Dietary supplements may be used at the patient&#8217; request or as a complementary treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Dietary supplements should never be used&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">The use of LT4 and LT3 combination may be considered in patients with normal TSH who still complain of symptoms&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Combined therapy should never be used&nbsp;\t\t\t\t\t\t\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos