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While hypothyroidism is common in lithium-treated patients, thyrotoxicosis is rarely reported. We present a female patient on lithium for maintenance therapy of bipolar affective disorder, who developed thyrotoxicosis for few months which was followed by hypothyroidism which continued. There was no further thyrotoxicosis episode during a five year follow up period. While she was treated for thyroid dysfunction, lithium was continued. There was no clinical impact on the maintenance of the bipolar affective disorder during the follow up period; she was maintained well in the community.

The case tells the story of Synthroid from its development in 1958 as the first synthetic thyroxine molecule to its competition against generic equivalents in 2004. The case introduces students to the pharmaceutical industry, its practices, and some of the complexities of pricing and drug choice, with drug manufacturers, insurance companies, physicians, pharmacists, and patients all playing a role. It also provides a primer on hypothyroidism, its symptoms, and its treatment.

Because Synthroid was developed and introduced before FDA regulations and drug standards of identity were fully established, it was difficult for competitors to get their drugs certified as identical to Synthroid. Through a series of efforts with physicians, especially endocrinologists, Synthroid's owners were able to maintain the perception for forty-six years that Synthroid was uniquely effective. In 2004, however, the FDA declared several competitive products to be bioequivalent to Synthroid, which posed a significant challenge to its owner, Abbott Laboratories. Students are challenged to consider options to maintain the drug's unit volume, revenue, and/or profit in these difficult circumstances.

The case is written in two parts. The (A) case provides background on the history of the drug, the pharmaceutical industry and its marketing practices, and hypothyroidism and its treatment, and it concludes in 2004 as Abbott's marketers face the impending challenge of defending the Synthroid business against generic competition. The (B) case describes what Abbott actually did to maintain its share in the United States and outlines its strategy in India, a market without patent protection for pharmaceuticals.

After analyzing the case students should be able to:

• Describe strategies that branded competitors can use to defend their business from lower-priced competition

• Understand the basics of pharmaceutical marketing and pricing, including the global challenge of defending branded drugs against generic equivalents

• Discuss ethical issues in the marketing of high-margin branded products that have lower-priced alternatives, especially in the healthcare industry

Describe strategies that branded competitors can use to defend their business from lower-priced competition

Understand the basics of pharmaceutical marketing and pricing, including the global challenge of defending branded drugs against generic equivalents

Discuss ethical issues in the marketing of high-margin branded products that have lower-priced alternatives, especially in the healthcare industry

The aim of this study is to assess healthcare workers' behavior on the congenital hypothyroidism screening program implementation based on a framework protocol and its associated factors.

A cross-sectional study was conducted using the multistage random sampling method in recruiting health clinic workers and purposive sampling techniques for hospital workers. The demographics, providers' characteristic, occupational profile, attitude, perceived behavior control (PBC), knowledge, behavioral intention and adherence to protocol were gathered using validated and reliable self-administered questionnaires.

Partial intention to adhere to protocol was 25.7%. Weak attitude (adjusted odds ratio [AOR]: 5.48, 95% confidence interval [CI]: 3.32–9.06), low PBC score (AOR: 0.91, 95% CI: 0.86–0.95) and low knowledge score (AOR: 0.85, 95% CI: 0.75–0.96) were associated with partial intention to adhere to protocol. In the self-rated adherence assessment, 92.6% of participants from health clinics, 79.1% from pediatric and 61.1% from pathology were found not adhering to protocol. There was a significant association between intention and adherence to protocol.

Documentations and observations in assessing program implementation were limited to perform in the present study. Using self-rated instruments and focusing on healthcare workers alone did not provide a comprehensive assessment.

Availability of a training module at site and regular refreshing course training should be made available to harness knowledge, attitude and behavioral perception in implementing the program activities.

Integrating the Logical Framework Approach in assessing program implementation and application of the Theory of Planned Behavior and Attitude, Subjective Norms, Self-Efficacy Model in this study were beneficial.

This article focuses on the assessment of thyroid hormones in 64 pregnant women in Mauritius. Our study revealed that serum thyroid‐stimulating hormone was significantly raised in four pregnant women with normal serum‐free tri‐iodothyronine and serum‐free thyroxine. It was also noted that mean serum‐free tri‐iodothyronine was non‐significantly much lower in the pregnant women. It is concluded that the four pregnant women with an abnormally elevated serum thyroid‐stimulating hormone together with normal free thyroid hormones probably have subclinical hypothyroidism.

The case tells the story of Synthroid from its development in 1958 as the first synthetic thyroxine molecule to its competition against generic equivalents in 2004. The case introduces students to the pharmaceutical industry, its practices, and some of the complexities of pricing and drug choice, with drug manufacturers, insurance companies, physicians, pharmacists, and patients all playing a role. It also provides a primer on hypothyroidism, its symptoms, and its treatment.

Because Synthroid was developed and introduced before FDA regulations and drug standards of identity were fully established, it was difficult for competitors to get their drugs certified as identical to Synthroid. Through a series of efforts with physicians, especially endocrinologists, Synthroid's owners were able to maintain the perception for forty-six years that Synthroid was uniquely effective. In 2004, however, the FDA declared several competitive products to be bioequivalent to Synthroid, which posed a significant challenge to its owner, Abbott Laboratories. Students are challenged to consider options to maintain the drug's unit volume, revenue, and/or profit in these difficult circumstances.

The case is written in two parts. The (A) case provides background on the history of the drug, the pharmaceutical industry and its marketing practices, and hypothyroidism and its treatment, and it concludes in 2004 as Abbott's marketers face the impending challenge of defending the Synthroid business against generic competition. The (B) case describes what Abbott actually did to maintain its share in the United States and outlines its strategy in India, a market without patent protection for pharmaceuticals.

After analyzing the case students should be able to:

• Describe strategies that branded competitors can use to defend their business from lower-priced competition

• Understand the basics of pharmaceutical marketing and pricing, including the global challenge of defending branded drugs against generic equivalents

• Discuss ethical issues in the marketing of high-margin branded products that have lower-priced alternatives, especially in the healthcare industry

Describe strategies that branded competitors can use to defend their business from lower-priced competition

Understand the basics of pharmaceutical marketing and pricing, including the global challenge of defending branded drugs against generic equivalents

Discuss ethical issues in the marketing of high-margin branded products that have lower-priced alternatives, especially in the healthcare industry

Research into the neurobiological origins of same-sex attraction is inconclusive. A recent theory of homosexuality posited that maternal thyroid dysfunction during pregnancy is associated with an increased rate of homosexual orientation in offspring. Relevant studies from the prenatal thyroid model perspective were reviewed, the major findings of which are as follows: i) An increased prevalence of Hashimoto's disease in lesbian women suggests a maternal and even familial presence of the same autoimmune thyroid disease. Female-to-male transsexuals and lesbian women were also reported to have higher rates of polycystic ovary syndrome (PCOS). Over the last several years, reports suggesting a strong link between PCOS and thyroid autoimmunity have accumulated. ii) The increased risk of autism spectrum disorders (ASD) in the offspring of mothers with thyroid autoimmunity in pregnancy and the association between ASD and gender dysphoria indicate a link between maternal thyroid dysfunction and gender dysphoria/same-sex attraction in the off-spring. iii) The high risk of miscarriage and retarded fetal growth in pregnancies of mothers who give birth to homosexual off-spring can be explained by the impact of maternal thyroid dysfunction during pregnancy. This perspective review highlights relevant research findings and integrates them into the prenatal thyroid model of homosexuality. A better understanding of the mechanisms involved in the generation of same-sex orientation will contribute to the betterment of individual lives, as well as of society.

Delirium, or acute confusional syndrome, is a set of symptoms whose care involves not only psychiatry, but also many other medical specialties. Being as how the syndrome is caused by multiple factors, it is important to recognize each risk factor affecting the patient in order to anticipate and prevent it. In case of diagnosis, identifying and treating the root cause that triggered is important, given that it has a high rate of comorbidity and an elevated cost of medical care. We describe a case where a patient with hypothyroidism began suffering from delirium due to an abrupt discontinuation of levothyroxine treatment. Previously, the patient was seemingly healthy. After the medical treatment was interrupted, sensory processing and behavior were altered, and symptoms fluctuated, for a short period of time, showing disorientation and memory and language impairment.

The prevalence of thyroid abnormalities among 831 sexual, violent, and non‐violent non‐sex offenders was found to be greater than found in the general population. Thyroid abnormalities were most common among violent offenders and among sex offenders who victimized children. Thyroid disorders were associated with psychotic diagnoses, delusions, mania, suicidal thoughts, and showed a trend to more suicide attempts. These disorders were undiagnosed in 49.1% of the cases prior to the present clinical assessment. Of these, 59.3% faced their first criminal charges, and the undiagnosed thyroid abnormalities may be important in the offenders’ treatment and may be possible legal mitigating factors in some offenses. Results indicate that a routine endocrine evaluation with blood tests would be a valuable addition to the assessment of violent and sexual offenders.

Both youngsters and adults with same-sex attraction are at greater risk for negative health outcomes. Despite mounting efforts to determine the biological background, a satisfactory conclusion has not been reached and there is a need to explore alternate factors like functioning of thyroid system during pregnancy. A retrospective chart review was undertaken of 790 eligible children and adolescents who had been admitted to child psychiatry between 2005 and 2013. This population consisted of 520 (65%) males and 270 (35%) females, aged 8 to 17 years. Fifteen mothers (1.8%) were found to have a history of thyroid dysfunction during pregnancy. Sixteen youngsters (2%) had a history of same-sex attraction. Twelve overlapping cases with both same-sex attraction and maternal thyroid dysfunction during pregnancy were identified, which was extremely significant (P<0.0001, by Fisher's exact test). The association was also significant for each sex (P<0.0001, by Fisher's exact test). There is evidence that thyroid gland plays a crucial and decisive role in determining sexual orientation in people. Maternal thyroid dysfunctions during pregnancy may result in homosexual orientation in the off-spring.

The purpose of this paper is to introduce and present the first findings of a new English performance indicator in the primary healthcare of adults with Down syndrome. This is a performance target, with associated bonus payment, requiring General Practitioners (GPs) to undertake annually a screening blood test for thyroid hormone deficiency.

Analysis and review of data collected from all GP practices and published by the National Health Service (NHS) Information Centre.

In total, 82 per cent of those identified as in the target group were screened and 10 per cent were identified as not wanting to be screened or screening inappropriate. The target group numbered just over 60 per cent of the number estimated from epidemiological and other studies. The numbers of cases involved is small (0, 1 or 2 cases in 75 per cent of GP practices), and whilst variation in coverage at local level appears important, numbers are too small for the variations seen in the first year's data to be statistically significant. The scope of the data precludes useful strategic analysis of the value of the intervention.

Data from several years need to be taken together. The NHS Information Centre should slightly increase the scope of the data to allow analysis of whether the programme is having useful public health benefits.

The paper examines a new data source and makes points applicable to a wider range of similar datasets in the same programme.