What are thyroid function tests?
Thyroid function tests are a series of blood tests used to measure how well your thyroid gland is working. Available tests include the T3, T3RU, T4, and TSH.

The thyroid is a small gland located in the lower-front part of your neck. It's responsible for helping to regulate many of the body's processes, such as metabolism, energy generation, and mood.

The thyroid produces two major hormones: triiodothyronine (T3) and thyroxine (T4). If your thyroid gland doesn't produce enough of these hormones, you may experience symptoms such as weight gain, lack of energy, and depression. This condition is called hypothyroidism.

If your thyroid gland produces too many hormones, you may experience weight loss, high levels of anxiety, tremors, and a sense of being on a high. This is called hyperthyroidism.

Typically, a doctor who is concerned about your thyroid hormone levels will order broad screening tests, such as the T4 or the thyroid-stimulating hormone (TSH) test. If those results come back abnormal, your doctor will order further tests to pinpoint the reason for the problem.

Drawing blood for thyroid function tests
Talk to your doctor about any medications you're taking, and tell your doctor if you're pregnant. Certain medications and being pregnant may influence your test results.

A blood draw, also known as venipuncture, is a procedure performed at a lab or a doctor's office. When you arrive for the test, you'll be asked to sit in a comfortable chair or lie down on a cot or gurney. If you're wearing long sleeves, you'll be asked to roll up one sleeve or to remove your arm from the sleeve.

A technician or nurse will tie a band of rubber tightly around your upper arm to make the veins swell with blood. Once the technician has found an appropriate vein, they'll insert a needle under the skin and into the vein. You may feel a sharp prick when the needle punctures your skin. The technician will collect your blood in test tubes and send it to a laboratory for analysis.

When the technician has gathered the amount of blood needed for the tests, they'll withdraw the needle and place pressure on the puncture wound until the bleeding stops. The technician will then place a small bandage over the wound.

You should be able to return to your normal daily activities immediately.

Side effects and aftercare
A blood draw is a routine, minimally invasive procedure. During the days immediately after the blood draw, you may notice slight bruising or soreness at the area where the needle was inserted. An ice pack or an over-the-counter pain reliever can help ease your discomfort.

If you experience a great deal of pain, or if the area around the puncture becomes red and swollen, follow up with your doctor immediately. These could be signs of an infection.

Understanding your test results
T4 and TSH results
The T4 test and the TSH test are the two most common thyroid function tests. They're usually ordered together.

The T4 test is known as the thyroxine test. A high level of T4 indicates an overactive thyroid (hyperthyroidism). Symptoms include anxiety, unplanned weight loss, tremors, and diarrhea. Most of the T4 in your body is bound to protein. A small portion of T4 is not and this is called free T4. Free T4 is the form that is readily available for your body to use. Sometimes a free T4 level is also checked along with the T4 test.

The TSH test measures the level of thyroid-stimulating hormone in your blood. The TSH has a normal test range between 0.4 and 4.0 milli-international units of hormone per liter of blood (mIU/L).

If you show signs of hypothyroidism and have a TSH reading above 2.0 mIU/L, you're at risk for progressing to hypothyroidism. Symptoms include weight gain, fatigue, depression, and brittle hair and fingernails. Your doctor will likely want to perform thyroid function tests at least every other year going forward. Your doctor may also decide to begin treating you with medications, such as levothyroxine, to ease your symptoms.

Both the T4 and TSH tests are routinely performed on newborn babies to identify a low-functioning thyroid gland. If left untreated, this condition, called congenital hypothyroidism, can lead to developmental disabilities.

T3 results
The T3 test checks for levels of the hormone triiodothyronine. It's usually ordered if T4 tests and TSH tests suggest hyperthyroidism. The T3 test may also be ordered if you're showing signs of an overactive thyroid gland and your T4 and TSH aren't elevated.

The normal range for the T3 is 100 200 nanograms of hormone per deciliter of blood (ng/dL). Abnormally high levels most commonly indicate a condition called Grave's disease. This is an autoimmune disorder associated with hyperthyroidism.

T3 resin uptake results
A T3 resin uptake, also known as a T3RU, is a blood test that measures the binding capacity of a hormone called thyroxin-binding globulin (TBG). If your T3 level is elevated, your TBG binding capacity should be low.

Abnormally low levels of TBG often indicate a problem with the kidneys or with the body not getting enough protein. Abnormally high levels of TBG suggest high levels of estrogen in the body. High estrogen levels may be caused by pregnancy, eating estrogen-rich foods, obesity, or hormone replacement therapy.

Follow-up
If your blood work suggests that your thyroid gland is overactive or underactive, your doctor may order a thyroid uptake test or an ultrasound test. These tests will check for structural problems with the thyroid gland, thyroid gland activity, and any tumors that may be causing problems. Based on these findings, your doctor may want to sample tissue from the thyroid to check for cancer.

If the scan is normal, your doctor will likely prescribe medication to regulate your thyroid activity. They will follow up with additional thyroid function tests to make sure the medication is working.

Thyroid Blood Tests

The thyroid is a gland located in the neck. It's job is to take iodine from the blood and combine it with an amino acid (one of the building blocks of protein) to form thyroid hormones. One of the hormones, thyroxine, is responsible for your metabolism. Thyroid function tests help to determine if your thyroid is not working correctly:

-hyperthyroid – an over-working thyroid
-hypothyroid – poor thyroid function

Abnormal thyroid function is common. It is seen in two to three percent of the entire population. When the thyroid is not working properly, it can cause changes in other blood tests as well.

#Thyroid Stimulating Hormone (TSH)
An indicator of thyroid function.
Normal range for an adult: 0.4 – 5.5 mU/mL
Preparation

-This test may be measured any time of the day without fasting.
-The brain regulates the amount of thyroid hormones in the blood.
-When the hormone levels are low, the brain sends a message to send out TSH. -This causes the thyroid gland to send out more hormones.
If blood levels of thyroid hormone are high, the brain senses this and sends a message to stop producing TSH. TSH is a very good test to check for hypothyroidism. TSH is increased with hypothyroid and decreased with hyperthyroid.
-Values may be lowered with use of aspirin, corticosteroids and heparin therapy.
-Values may be raised with use of lithium, potassium, iodide and TSH injections.

#Thyroxine (T4)
Normal range for an adult: 5 – 11 µg/dL
Preparation

-This test may be measured any time of the day without fasting.
-Thyroxine is a hormone produced by the thyroid. It is drawn to assess thyroid function. Low T4 is seen with hypothyroidism. High T4 is seen with hyperthyroidism.
-The T4 blood test can also be used to monitor the effectiveness of medications used to treat thyroid disease. Estrogen, anticonvulsants, aspirin use and anticoagulants may affect T4 levels. They are increased with pregnancy.

#Microsomal Thyroid Antibodies (TPO)
Desirable level for an adult: 0.0 - 5.0 IU/mL
Preparation

-This test may be measured any time of the day without fasting.
-Thyroid antibodies are present if hypothyroid is related to thyroiditis.
-Hypothyroid can be caused by primary thyroid disease. It also can be related to other health problems, such as glucocorticoid or amiodarone use, osteoporosis, pregnancy, insulin dependent diabetes and liver disease.

This information is about testing and procedures and may include instructions specific to Cleveland Clinic. Please consult your physician for information pertaining to your testing.

Thoracentesis uses imaging guidance and a needle to help diagnose and treat pleural effusions, a condition in which the space between the lungs and the inside of the chest wall contains excess fluid. It is performed to help determine the cause of the excess fluid and to ease any shortness of breath or pain by removing the fluid and relieving pressure on the lungs.

Your doctor will instruct you on how to prepare, including any changes to your medication schedule. Tell your doctor if there's a possibility you are pregnant and discuss any recent illnesses, medical conditions, allergies and medications you're taking, including herbal supplements and aspirin. You may be advised to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or blood thinners several days prior to your procedure. Leave jewelry at home and wear loose, comfortable clothing. You may be asked to wear a gown.

What is a Thoracentesis?
Thoracentesis is a minimally invasive procedure used to diagnose and treat pleural effusions, a condition in which there is excess fluid in the pleural space, also called the pleural cavity. This space exists between the outside of the lungs and the inside of the chest wall.

What are some common uses of the procedure?
Thoracentesis is performed to:

relieve pressure on the lungs
treat symptoms such as shortness of breath and pain
determine the cause of excess fluid in the pleural space.
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How should I prepare?
Prior to your procedure, your blood may be tested to determine how well your kidneys are functioning and whether your blood clots normally.

You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications, general anesthesia or to contrast materials containing iodine (sometimes referred to as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners for a specified period of time before your procedure.

Also inform your doctor about recent illnesses or other medical conditions.

You should tell your physician if you have:

bleeding problems or take blood thinners, such as aspirin, Lovenox®, Arixtra®, Fragmin®, Innohep®, Coumadin®, Pradaxa®, Xarelto®, or Eliquis®
had lung surgery
lung disease, such as emphysema.
Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays.

You will receive specific instructions on how to prepare, including any changes that need to be made to your regular medication schedule.

You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry, eye glasses and any metal objects or clothing that might interfere with the x-ray images.

If sedation is required, you will need to have a relative or friend accompany you and drive you home afterward.

What does the equipment look like?
In this procedure, ultrasound, CT, or x-ray equipment may be used to guide a needle into the fluid within the pleural space. Thoracentesis is typically performed with ultrasound guidance. Occasionally, CT-guidance will be used.

Ultrasound scanners consist of a console containing a computer and electronics, a video display screen and a transducer that is used to do the scanning. The transducer is a small hand-held device that resembles a microphone, attached to the scanner by a cord. Some exams may use different transducers (with different capabilities) during a single exam. The transducer sends out high-frequency sound waves (that the human ear cannot hear) into the body and then listens for the returning echoes from the tissues in the body. The principles are similar to sonar used by boats and submarines.

The ultrasound image is immediately visible on a video display screen that looks like a computer or television monitor. The image is created based on the amplitude (loudness), frequency (pitch) and time it takes for the ultrasound signal to return from the area within the patient that is being examined to the transducer (the device placed on the patient's skin to send and receive the returning sound waves), as well as the type of body structure and composition of body tissue through which the sound travels. A small amount of gel is put on the skin to allow the sound waves to travel from the transducer to the examined area within the body and then back again. Ultrasound is an excellent modality for some areas of the body while other areas, especially air-filled lungs, are poorly suited for ultrasound.

The CT scanner is typically a large, box-like machine with a hole, or short tunnel, in the center. You will lie on a narrow examination table that slides into and out of this tunnel. Rotating around you, the x-ray tube and electronic x-ray detectors are located opposite each other in a ring, called a gantry. The computer workstation that processes the imaging information is located in a separate control room, where the technologist operates the scanner and monitors your examination in direct visual contact and usually with the ability to hear and talk to you with the use of a speaker and microphone.

A thoracentesis needle is generally several inches long and the barrel is about as wide as a large paper clip. The needle is hollow so fluid can be aspirated (drawn by suction) through it. In some instances, a small tube is advanced over the needle, and the fluid is removed through the tube after removing the needle.


How is the procedure performed?
A chest x-ray may be performed before a thoracentesis.

This procedure is often done on an outpatient basis. However, some patients may require admission following the procedure. Please consult with your physician as to whether or not you will be admitted.

You will be positioned on the edge of a chair or bed with your head and arms resting on an examining table.

The area of your body where the needle is to be inserted will be sterilized and covered with a surgical drape.

Your physician will numb the area with a local anesthetic.

The needle is inserted through the skin between two ribs on your back. When the needle reaches the pleural space between the chest wall and lung, the pleural fluid is removed through a syringe or suction bottle.

Thoracentesis is usually completed within 15 minutes.

At the end of the procedure, the needle will be removed and pressure will be applied to stop any bleeding. The opening in the skin is then covered with a dressing. No sutures are needed.

A chest x-ray may be performed after thoracentesis to detect any complications.

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What will I experience during and after the procedure?
You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected. Most of the sensation is at the skin incision site, which is numbed using local anesthetic. You may feel pressure when the catheter is inserted into the vein or artery.

You will be asked to remain still during the procedure and not to cough or breathe deeply in order to avoid injury to the lung.

You may feel pressure when the needle is inserted into the pleural space.

When the pleural fluid is removed, you may feel a pulling sensation or pressure in your chest. It is common to have the urge to cough as the fluid is removed and the lung re-expands. Tell your doctor or nurse if you feel faint or if you have any shortness of breath or chest pain.

Who interprets the results and how do I get them?
The interventional radiologist or physician treating you will determine the results of the procedure and will send a report to your referring physician, who will share the results with you.

Your interventional radiologist may recommend a follow-up visit after your procedure or treatment is complete.

The visit may include a physical check-up, imaging procedure(s) and blood or other lab tests. During your follow-up visit, you may discuss with your doctor any changes or side effects you have experienced since your procedure or treatment.

The aim of therapeutic research is to find out
an effective medication against the disease without
any dangerous toxic action. The delicate problem
is that very often the dose of drug confines with
toxicity. Primary care physicians who understand
the complexities of drug dosing may be able to
provide their patients with more effective
pharmacologic therapy. Standard or empirical
methods of dosing are appropriate for most agents.
The evolution of pharmacokinetics and the recent
development of simple and reliable analytical
technology has led to pharmacokinetic dosing, a
more sophisticated and exact method of dosing
certain agents. When used properly,
measurements of plasma drug levels in the clinical
setting may provide valuable information. While
these drug levels often do allow more objective
monitoring and titration of therapy the information
also has the potential to be valueless or even
misleading 1. This article will review the reasons
why the dosage of most drugs should be
individualized, the conditions that must be satisfied
in order to make information about serum
concentration helpful for dosage individualization
and the many pitfalls and cautions encountered in
the use of this information.


While there may be specific individual
circumstances for TDM, most indications can be
summarized as follows2:
1. Low therapeutic index
2. Poorly defined clinical end point
3. Non compliance
4. Therapeutic failure
5. Drugs with saturable metabolism
6. Wide variation in the metabolism of drugs
7. Major organ failure
8. Prevention of adverse drug effects
TCM OF ESTABLISHED VALUES:
1. Cardio active drugs : amiodarone, digoxin,
digitoxin
disopyramide,
lignocaine,
procainamide,
propranolol and
quinidine
2. Antibiotics : gentamycin, amikacin
and tobramycin
3. Antidepressants : lithium and tricyclic
antidepressants
4. Antiepileptic drugs : Phenytoin,
phenobarbitone
benzodiazepines,
carbamazepine,
Valproic acid and
ethosuximide
5. Bronchodilators : theophylline
6. Cancer
chemotherapy : methotrexate
7. Immunosuppressives : cyclosporine

TDM will be useful if the following criteria are
met:
1) the drug in question has a narrow therapeutic
range,
2) a direct relationship exists between the drug
or drug metabolite levels in plasma and the
pharmacological or toxic effects,
3) the therapeutic effect can not be readily
assessed by the clinical observation,
4) large individual variability in steady state
plasma concentration exits at any given dose
and
5) appropriate analytic techniques are available
to determine the drug and metabolite levels.
TDM is unnecessary when
1) Clinical outcome is unrelated either to dose
or to plasma concentration
2) dosage need not be individualized
3) the pharmacological effects can be clinically
quantified
4) when concentration effect relationship remains
unestablished,
5) drugs with wide therapeutic range such as
beta blockers and calcium channel blockers.

Urinary incontinence - tension-free vaginal tape

Placement of tension-free vaginal tape is surgery to help control stress urinary incontinence. This is urine leakage that happens when you laugh, cough, sneeze, lift things, or exercise. The surgery helps close your urethra and bladder neck. The urethra is the tube that carries urine from the bladder to the outside. The bladder neck is the part of the bladder that connects to the urethra.

Description
You have either general anesthesia or spinal anesthesia before the surgery starts.

With general anesthesia, you are asleep and feel no pain.
With spinal anesthesia, you are awake, but from the waist down, you are numb and feel no pain.
A catheter (tube) is placed in your bladder to drain urine from your bladder.

A small surgical cut (incision) is made inside your vagina. Two small cuts are made in your belly just above the pubic hair line.

A special man-made (synthetic mesh) tape is passed through the cut inside the vagina. The tape is then positioned under your urethra. One end of the tape is passed through one of the belly incisions. The other end of the tape is passed through the other belly incision.

The doctor then adjusts the tightness (tension) of the tape just enough to support your urethra. This amount of support is why the surgery is called tension-free. If you do not receive general anesthesia, you may be asked to cough. This is to check the tension of the tape.

After the tension is adjusted, the ends of the tape are cut level with the skin at the incisions. The incisions are closed. As you heal, scar tissue that forms at the incisions will hold the tape ends in place so that your urethra is supported.

The surgery takes about 2 hours.

Why the Procedure is Performed
Tension-free vaginal tape is placed to treat stress incontinence.

Before discussing surgery, your doctor will have you try bladder retraining, Kegel exercises, medicines, or other options. If you tried these and are still having problems with urine leakage, surgery may be your best option.

Risks
Risks of any surgery are:

Bleeding
Breathing problems
Infection in the surgical cut or the cut opens up
Other infection
Risks of this surgery are:

Injury to nearby organs. Changes in the vagina (prolapsed vagina, in which the vagina is not in the proper place)
Damage to the urethra, bladder, or vagina
Erosion of the tape into surrounding normal tissues (urethra or vagina)
Fistula (abnormal passage) between the vagina and the skin
Irritable bladder, causing the need to urinate more often
It may become harder to empty your bladder, and you may need to use a catheter
Pubic bone pain
Urine leakage may get worse
You may have a reaction to the synthetic tape
Before the Procedure
Tell your health care provider what medicines you are taking. These include medicines, supplements, or herbs you bought without a prescription.

During the days before the surgery:

You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), warfarin (Coumadin), and any other medicines that make it hard for your blood to clot.
Arrange for a ride home and make sure you will have enough help when you get there.
On the day of the surgery:

You will likely be asked not to drink or eat anything for 6 to 12 hours before the procedure.
Take the medicines you were told to take with a small sip of water.
Your doctor or nurse will tell you when to arrive at the hospital. Be sure to arrive on time.
After the Procedure
You will be taken to a recovery room. The nurses will ask you to cough and take deep breaths to help clear your lungs. You may have a catheter in your bladder. This will be removed when you are able to empty your bladder on your own.

You may have gauze packing in the vagina after surgery to help stop bleeding. It is most often removed a few hours after surgery or the next morning if you stay overnight.

You may go home on the same day if there are no problems.

Follow instructions about how to care for yourself after you go home. Keep all follow-up appointments.

Outlook (Prognosis)
Urinary leakage decreases for most women who have this procedure. But you may still have some leakage. This may be because other problems are causing your incontinence. Over time, some or all of the leakage may come back.

Alternative Names
TVT; Urethral suspension