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Jansen HI, Heuveling van Beek C, Bisschop PH, Heijboer AC, Bruinstroop E, Boelen A. The need for the GREAT+ score to predict relapse in Graves' disease: a questionnaire among patients and internal medicine specialists. J Endocrinol Invest 2024; 47:2499-2505. [PMID: 38526836 PMCID: PMC11393202 DOI: 10.1007/s40618-024-02358-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/05/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE Graves' disease (GD) is an auto-immune cause of hyperthyroidism. First-line treatment often consists of a 12-18 month course of antithyroid drugs (ATD). After discontinuation of ATD, GD relapses in approximately 50% of patients. The 'Graves recurrent event after therapy+ ' (GREAT+) score may predict individual relapse chances after ATD discontinuation more accurately based on clinical and laboratory parameters at diagnosis. We investigated the need for the GREAT+ score through an online questionnaire among GD patients and physicians treating GD. METHODS An anonymous online questionnaire was distributed to patients and physicians between June 2022 and August 2023. RESULTS The questionnaire was completed by 532 patients and 44 physicians. Results showed that 94% of patients were interested in knowing their GREAT+ score at the start of treatment. 55% would consider definite treatment (radioiodine/thyroidectomy) as first-line treatment in case of a high relapse chance. 98% of the physicians indicated the GREAT + score would support patient counseling. 84% may change their advice for first-line treatment if a patient has a high relapse chance based on the score. CONCLUSION Patients and physicians considered the GREAT+ score as a valuable addition to the current available information which could change treatment decisions. Therefore, external validation of the GREAT+ score is justified to implement this score in clinical practice.
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Affiliation(s)
- H I Jansen
- Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam UMC Location University of Amsterdam, Academic Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - C Heuveling van Beek
- Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam UMC Location University of Amsterdam, Academic Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - P H Bisschop
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - A C Heijboer
- Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam UMC Location University of Amsterdam, Academic Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - E Bruinstroop
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - A Boelen
- Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam UMC Location University of Amsterdam, Academic Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, The Netherlands.
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands.
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Azizi F, Mehran L, Abdi H, Amouzegar A. Approach to the Patient Considering Long-term Antithyroid Drug Therapy for Graves' Disease. J Clin Endocrinol Metab 2024; 109:e1881-e1888. [PMID: 39018185 DOI: 10.1210/clinem/dgae456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Indexed: 07/19/2024]
Abstract
Antithyroid drugs (ATD) are the treatment of choice for the majority of patients with Graves' hyperthyroidism worldwide. However, relapse of hyperthyroidism after withdrawal of arbitrarily chosen conventional 12 to 18 months of therapy is very common. In the last 2 decades, many studies have shown that treatment with long-term ATD (LT-ATD) is effective and safe in the maintenance of euthyroidism. In addition, it has been reported that serum TSH receptor antibody may not decrease permanently before 5 to 6 years of ATD treatment, and clinical trials have shown that ≥5 years of ATD treatment is accompanied by remission in the majority of patients with Graves' hyperthyroidism. The objective of this article is to discuss the optimal time to withdraw of conventional ATD therapy, to illustrate the decision-making of the management of recurrent hyperthyroidism, to review the proper management of LT-ATD, and to generate suggestions for lifelong ATD treatment by discussing 4 scenarios of decision-making in patients with Graves' disease.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, I.R.Iran
| | - Ladan Mehran
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, I.R.Iran
| | - Hengameh Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, I.R.Iran
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, I.R.Iran
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3
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Larisch R, Midgley JEM, Dietrich JW, Hoermann R. Effect of Radioiodine Treatment on Quality of Life in Patients with Subclinical Hyperthyroidism: A Prospective Controlled Study. Nuklearmedizin 2024; 63:176-187. [PMID: 38262472 DOI: 10.1055/a-2240-8087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Radioiodine treatment (RIT) has a high success rate in both the treatment of hyperthyroidism and improving the quality of life (QoL) of symptomatic patients. In asymptomatic patients with subclinical hyperthyroidism thyroid related QoL outcomes are less well known. METHODS Study aim was to evaluate thyroid-related QoL in patients with subclinical hyperthyroidism mostly due to toxic nodular goitre undergoing RIT, compared to a control group of euthyroid subjects. Study design was monocentric, prospective, controlled. Fifty control subjects were enrolled and 51 RIT patients. Most subjects were examined at least twice at an interval of 6 months, with visits immediately before and 6 months after treatment in the RIT group. QoL was estimated with the ThyPRO questionnaire, using its composite scale as primary outcome. Treatment effect was the mean adjusted difference (MAD) between groups over time, using repeated? measures mixed? effects models. RESULTS TSH concentrations were lower in the RIT group prior to treatment and recovered thereafter slightly above the level of the control group. Correspondingly, QoL improved significantly after 6 months from a worse level in the RIT group, compared to controls (MAD -10.3 [95% CI -14.9, -5.7], p<0.001). QoL improvements were strong for general items, but less pronounced for the hyperthyroid domain. Compared to controls, thyroid volume, thyroid functional capacity (SPINA-GT) and deiodinase activity (SPINA-GD) were significantly reduced in the RIT group. CONCLUSION Patients with subclinical hyperthyroidism improve both biochemically and in their QoL after RIT, compared to controls. QoL assessment should have a wider role in clinical practice to complement biochemical tests and help with treatment decisions.
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Affiliation(s)
- Rolf Larisch
- Clinic of Nuclear Medicine, Klinikum Lüdenscheid, Lüdenscheid, Germany
| | - John E M Midgley
- North Lakes Clinical, Ilkley LS29 8PT, United Kingdom of Great Britain and Northern Ireland
| | - Johannes W Dietrich
- Medical Hospital I, Endocrinology and Diabetes Department, Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Bochum, Germany
| | - Rudolf Hoermann
- Clinic of Nuclear Medicine, Klinikum Lüdenscheid, Lüdenscheid, Germany
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4
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Blunschi F, Schofield I, Muthmann S, Bauer NB, Hazuchova K. Development and validation of a questionnaire to assess health-related quality-of-life in cats with hyperthyroidism. J Vet Intern Med 2024; 38:1384-1407. [PMID: 38647174 PMCID: PMC11099792 DOI: 10.1111/jvim.17083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/05/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Health-related quality-of-life (HRQoL) assessment tools are becoming increasingly important for the assessment of diseases in veterinary medicine. OBJECTIVES To develop a tool to assess the HRQoL of hyperthyroid cats and their owners. ANIMALS Cats with hyperthyroidism (n = 229) and without hyperthyroidism (n = 322). METHODS Cross-sectional study design. A preliminary list of 28 questions relating to the HRQoL of hyperthyroid cats and the influence their cat's disease might have on owners was created. Each question consisted of 2 subquestions: (1) "how often does the item apply"; (2) "how strongly does the item affect HRQoL." The questionnaire was refined based on statistical analysis, including Mann-Whitney-U tests on each item, comparing the results from cats with and without hyperthyroidism. Internal consistency and reliability of the questions were measured by Cronbach's alpha (α). P < .05 was considered significant. RESULTS Overall, 25/28 questions were retained within the final HRQoL tool, which had an excellent internal consistency (α = .92). The tool produced a score between 0 and 382 (lower scores meaning better HRQoL). The median HRQoL score was 87.5 (range, 2-348) for cats with hyperthyroidism, and 27 (range, 0-249) for cats without (P < .001), suggesting the HRQoL was poorer in hyperthyroid cats. CONCLUSIONS AND CLINICAL IMPORTANCE This validated HRQoL tool is useful to reliably quantify the influence of hyperthyroidism on the quality-of-life of affected cats and their owners. In the future, it could be considered of assistance in the clinical assessment of cats with hyperthyroidism.
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Affiliation(s)
- Fabienne Blunschi
- Department of Veterinary Clinical Sciences, Small Animal ClinicJustus‐Liebig‐UniversityGiessenGermany
| | | | - Sofie Muthmann
- Department of Veterinary Clinical Sciences, Small Animal ClinicJustus‐Liebig‐UniversityGiessenGermany
| | - Natali B. Bauer
- Department of Veterinary Clinical Sciences, Small Animal ClinicJustus‐Liebig‐UniversityGiessenGermany
| | - Katarina Hazuchova
- Department of Veterinary Clinical Sciences, Small Animal ClinicJustus‐Liebig‐UniversityGiessenGermany
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Chaker L, Cooper DS, Walsh JP, Peeters RP. Hyperthyroidism. Lancet 2024; 403:768-780. [PMID: 38278171 DOI: 10.1016/s0140-6736(23)02016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/07/2023] [Accepted: 09/16/2023] [Indexed: 01/28/2024]
Abstract
Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from Graves' disease or toxic nodular goitre, whereas thyroiditis (typically autoimmune, viral, or drug induced) causes thyrotoxicosis without hyperthyroidism. The diagnosis is based on suppressed serum concentrations of thyroid-stimulating hormone (TSH), accompanied by free thyroxine and total or free tri-iodothyronine concentrations, which are raised (overt hyperthyroidism) or within range (subclinical hyperthyroidism). The underlying cause is determined by clinical assessment, detection of TSH-receptor antibodies and, if necessary, radionuclide thyroid scintigraphy. Treatment options for hyperthyroidism include antithyroid drugs, radioactive iodine, and thyroidectomy, whereas thyroiditis is managed symptomatically or with glucocorticoid therapy. In Graves' disease, first-line treatment is a 12-18-month course of antithyroid drugs, whereas for goitre, radioactive iodine or surgery are preferred for toxic nodules or goitres. Evidence also supports long-term treatment with antithyroid drugs as an option for patients with Graves' disease and toxic nodular goitre.
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Affiliation(s)
- Layal Chaker
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - David S Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Walsh
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
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Meling Stokland AE, Austdal M, Nedrebø BG, Carlsen S, Hetland HB, Breivik L, Ueland HO, Watt T, Cramon PK, Løvås K, Husebye ES, Ueland GÅ. Outcomes of Patients With Graves Disease 25 Years After Initiating Antithyroid Drug Therapy. J Clin Endocrinol Metab 2024; 109:827-836. [PMID: 37747433 PMCID: PMC10876387 DOI: 10.1210/clinem/dgad538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Indexed: 09/26/2023]
Abstract
CONTEXT Graves disease (GD) is a leading cause of hyperthyroidism. Detailed investigations and predictors of long-term outcomes are missing. OBJECTIVE This work aimed to investigate the outcomes in GD 25 years after initiating antithyroid drug treatment, including disease course, clinical and biochemical predictors of relapse, and quality of life. METHODS A retrospective follow-up was conducted of GD patients that participated in a randomized trial from 1997 to 2001. Demographic and clinical data were obtained from medical records and questionnaires. Biobank samples were analyzed for inflammatory biomarkers and compared with age- and sex-matched healthy individuals. RESULTS We included 83% (182/218) of the patients from the original study. At the end of follow-up, normal thyroid function was achieved in 34%. The remaining had either active disease (1%), spontaneous hypothyroidism (13%), or had undergone ablative treatment with radioiodine (40%) or thyroidectomy (13%). Age younger than or equal to 40 years, thyroid eye disease (TED), smoking, and elevated levels of interleukin 6 and tumor necrosis factor receptor superfamily member 9 (TNFRS9) increased the risk of relapsing disease (odds ratio 3.22; 2.26; 2.21; 1.99; 2.36). At the end of treatment, CD40 was lower in patients who maintained normal thyroid function (P = .04). At the end of follow-up, 47% had one or more autoimmune diseases, including vitamin B12 deficiency (26%) and rheumatoid arthritis (5%). GD patients who developed hypothyroidism had reduced quality of life. CONCLUSION Careful lifelong monitoring is indicated to detect recurrence, hypothyroidism, and other autoimmune diseases. Long-term ATD treatment emerges as a beneficial first-line treatment option, especially in patients with young age at onset or presence of TED.
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Affiliation(s)
- Ann-Elin Meling Stokland
- Department of Endocrinology, Stavanger University Hospital, 4011 Stavanger, Norway
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
| | - Marie Austdal
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway
| | | | - Siri Carlsen
- Department of Endocrinology, Stavanger University Hospital, 4011 Stavanger, Norway
| | - Hanne Brit Hetland
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway
| | - Lars Breivik
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
| | - Hans Olav Ueland
- Department of Ophthalmology, Haukeland University Hospital, 5021 Bergen, Norway
| | - Torquil Watt
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Per Karkov Cramon
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen, Denmark
| | - Kristian Løvås
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
| | - Eystein Sverre Husebye
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
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7
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Li Y, Yang T, Ju L, Feng Y, Chen Z, Xiang X, Zhu T, Pang H, Wang Z. Quality of life and decision regret in patients with late-hypothyroidism after radioiodine treatment for Graves' disease. Clin Endocrinol (Oxf) 2024; 100:87-95. [PMID: 37964632 DOI: 10.1111/cen.14986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/22/2023] [Accepted: 10/25/2023] [Indexed: 11/16/2023]
Abstract
OBJECTIVE Patients with Graves' disease often engage in shared decision-making to select an individualised treatment regimen from multiple options. Radioactive iodine (RAI) is one of the treatment choices for their condition, aims to improve quality of life and well-being. Likewise, dissatisfaction with treatment outcomes can result in decision regret. We employed validated questionnaires to assess the prospective quality of life, decision regret and relative factors involved in decision-making of patients with late hypothyroidism after RAI therapy. METHODS A questionnaire survey was conducted among patients in hypothyroidism status for more than 1 year after RAI therapy. Disease-specific and generic QoL were assessed using the short form of thyroid-related patient-reported outcome (ThyPRO-39) questionnaire. Patient satisfaction regarding their decision to undergo RAI was assessed using the Decision Regret Scale (DRS) and patients were asked about the importance of relative factors in decision-making. RESULTS Of 254 patients who responded to the survey, the mean age of patients was 45.3 years (range: 18-78 years) and the median time from RAI therapy to survey was 4 years (range: 1-30 years). Patients' median and mean DRS score were 34.4 and 38.8 (range: 0-100), respectively. A total of 100 (39.4%) patients express absent-to-mild regret (score: 0-25), 154 (60.6%) patients express moderate-to-severe regret (score: >25). The mean score of the absent-to-mild regret group were significantly higher than those of the moderate-to-severe regret group on most ThyPRO-39 scales. A statistically significant positive correlation was observed between DRS score and most ThyPRO-39 scale score. There was a significant positive association between higher DRS score and longer time intervals after RAI treatment, a brief duration of hyperthyroidism, and the significance of long-time outpatient follow-up. More decision regret was negatively associated Iodine-free diet, ineffectiveness of ATD, fear of surgery. CONCLUSION Impairment of quality of life was positively correlated with decision regret in patients with late-hypothyroidism after radioiodine therapy. Patients with insufficient information support before decision-making are more likely to have higher decision regret after treatment. Our findings suggest that health providers should fully communicate with patients and provide information support in multiple dimensions during the shared-decision-making process.
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Affiliation(s)
- Yue Li
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tianyu Yang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Linjun Ju
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuyue Feng
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng Chen
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xing Xiang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Zhu
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Pang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengjie Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Quintanilla-Dieck L. The management of pediatric Graves' disease. Curr Opin Otolaryngol Head Neck Surg 2023; 31:419-423. [PMID: 37820281 DOI: 10.1097/moo.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW Graves' disease (GD) constitutes a significant proportion of thyroid disorders seen during childhood. Several specialties may be closely involved in the management of pediatric patients with GD and emerging research in each field contributes to variations in the approach over time. Here we review the recent literature on the management of the disease, with the hope that this can be a valuable resource for treating specialists who need to be continuously updated on new data obtained in relevant fields. RECENT FINDINGS Genetic, postinfectious and environmental factors may play a role in the immunological pathophysiology of GD. Research performed during the COVID-19 pandemic supports that viral-induced immune dysregulation may be a possible trigger for the disease. The various current treatment options all have positive and negative factors to consider. Antithyroidal drug therapy (ATD) is generally recommended as the initial treatment, although remission rates are only 20-30% at 2 years and 75% at 9 years. Unfortunately, about half of patients will relapse within 1 year of discontinuing therapy. Radioactive iodine therapy (RAI) is an effective treatment option and can be considered in certain pediatric patients. There continues to be no definitive evidence that the doses used for GD lead to a higher risk of cancer. Surgical treatment via thyroidectomy is effective and safe when performed by a high-volume surgeon. Recent studies show improvement in quality-of-life after surgery in adolescents and young adults. Future medical treatment options for GD currently being studied include antigen-specific immunotherapy and monoclonal antibodies. SUMMARY Although the future holds promising new therapeutic options for autoimmune diseases including GD, the current choices continue to be ATD, usually first-line, and definitive treatments including RAI and surgery. While all three offer the possibility of remission or cure, drug therapy and RAI have a possibility of relapse. Risks of each approach should be broached in detail with patients and their families, and the nuances of treating this disease specifically in children should be familiar to all treating providers.
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Affiliation(s)
- Lourdes Quintanilla-Dieck
- Department of Otolaryngology Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
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9
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Calissendorff J, Cramon PK, Hallengren B, Khamisi S, Lantz M, Planck T, Sjölin G, Wallin G, Holmberg M. Long-Term Outcome of Graves' Disease: A Gender Perspective. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2023; 4:487-496. [PMID: 37818181 PMCID: PMC10561747 DOI: 10.1089/whr.2023.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 10/12/2023]
Abstract
Introduction In gender-skewed conditions such as Graves' disease (GD), the outcome naturally becomes dominated by the majority. This may lead to gender-biased misunderstandings regarding treatment outcomes. This especially holds true when complications, such as depression, are unevenly distributed. We have, therefore, studied the long-term outcome of GD from a gender perspective. Materials and Methods A cohort of 1186 patients with GD was included in a follow-up 6-10 years after inclusion. Choice of treatment, the feeling of recovery, long-term treatment, comorbidity, and quality of life were investigated with questionnaires. All results were studied sex-divided. Results We included 973 women and 213 men. There was no difference between men and women in the choice of treatment. At follow-up, women scored significantly worse in the general questionnaire 36-item Short-Form Health Status (SF-36) domain bodily pain and in the thyroid-specific Thyroid-Related Patient-Reported Outcome (ThyPRO) domains depression, impaired sex life, and cosmetic complaints, all p < 0.05. Women were twice as likely (29.5%) to be treated with levothyroxine after successful treatment with antithyroid drugs (ATD) compared with men (14.9%, p < 0.05). Conclusion After treatment for GD, women were more affected by depression, impaired sex life, cosmetic issues, and bodily pain despite successful cure of hyperthyroidism. The prevalence of hypothyroidism was also doubled in women. Whether these observed gender differences reflect a worse outcome of GD in women or a natural consequence of a higher prevalence of these symptoms and autoimmunity in the female population is difficult to disentangle. Nevertheless, several years after GD, women reveal more persistent symptoms.
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Affiliation(s)
- Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Per Karkov Cramon
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Bengt Hallengren
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Selwan Khamisi
- Department of Endocrinology, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Tereza Planck
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Gabriel Sjölin
- Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden
| | - Göran Wallin
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden
| | - Mats Holmberg
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
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10
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Ma W, Zhang X, Zhao R, Tang Y, Zhu X, Liu L, Xu M, Wang G, Peng P, Liu J, Liu Z. Effectiveness and potential mechanism of Jiawei-Xiaoyao-San for hyperthyroidism: a systematic review. Front Endocrinol (Lausanne) 2023; 14:1241962. [PMID: 37780612 PMCID: PMC10534980 DOI: 10.3389/fendo.2023.1241962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023] Open
Abstract
Objectives To evaluate the effectiveness and potential mechanism of traditional Chinese medicine Jiawei-Xiaoyao-San (JWXYS) as an adjunct or mono- therapy for antithyroid drugs (ATDs) in the treatment of hyperthyroidism. Methods Eight databases and three trial registries were searched from inception until May 2023. Randomized controlled trials (RCTs) were included and meta-analysis was conducted using RevMan 5.4 and Stata 14.0. The Cochrane risk of bias (ROB) tool 1.0 and GRADE tool was used for quality appraisal. The findings from case reports using mono-JWXYS and pharmacological studies were summarized in tables. Results Thirteen RCTs with 979 participants were included. The majority of the included studies were assessed as high risk of bias in one ROB domain. Compared with ATDs, JWXYS plus ATDs resulted in lower free triiodothyronine (FT3) (MD = -1.31 pmol/L, 95% CI [-1.85, -0.76]; low-certainty), lower free thyroxine (MD = -3.24 pmol/L, 95% CI [-5.06, -1.42]; low-certainty), higher thyroid stimulating hormone (MD = 0.42 mIU/L, 95% CI [0.26, 0.59]; low-certainty), higher effectiveness rate of traditional Chinese medicine syndrome (RR = 1.28, 95% CI [1.08, 1.52]; low-certainty), lower goiter score (MD = -0.66, 95% CI [-1.04, -0.29]; very low-certainty), lower thyrotrophin receptor antibody (SMD = -0.44, 95% CI [-0.73, -0.16]; low-certainty) and fewer adverse events (AEs) (RR = 0.34, 95% CI [0.18, 0.67]; moderate-certainty). Compared with regular dosage of ATDs, JWXYS plus half-dose ATDs resulted in fewer AEs (RR = 0.24, 95% CI [0.10, 0.59]; low-certainty). Compared with ATDs in 1 trial, JWXYS resulted in higher FT3, lower goiter score and fewer AEs. Three case reports showed that the reasons patients sought TCM-only treatment include severe AEs and multiple relapses. Three pharmacological studies demonstrated that JWXYS restored Th17/Treg balance, lowered deiodinases activity, regulated thyroid cell proliferation and apoptosis, and alleviated liver oxidative stress in mouse or rat models. Conclusion JWXYS may enhance the effectiveness of ATDs for hyperthyroidism, particularly in relieving symptoms and reducing AEs. Mono-JWXYS is not recommended except in patients intolerant to ATDs. The findings should be interpreted with caution due to overall high risk of bias. Further pharmacological studies with more reliable models are needed. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023394923.
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Affiliation(s)
- Wenxin Ma
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaowen Zhang
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Ruotong Zhao
- Beijing University of Chinese Medicine, Beijing, China
| | - Yang Tang
- Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoyun Zhu
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Longkun Liu
- Beijing University of Chinese Medicine, Beijing, China
| | - Mingyuan Xu
- Beijing University of Chinese Medicine, Beijing, China
| | - Ge Wang
- Guang’anmen Hospital South Campus, China Academy of Chinese Medical Sciences, Beijing, China
| | - Peiyue Peng
- Beijing University of Chinese Medicine, Beijing, China
| | - Jianping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
- Department of Community Medicine, Faculty of Health Science, UiT The Arctic University of Norway, Tromsø, Norway
| | - Zhaolan Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
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11
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Liu X, Chan WW, Tang EH, Suen AH, Fung MM, Woo YC, Liu SY, Lam CL, Luo N, Wong CK, Lang BH. Psychometric properties of EQ-5D-5L for use in patients with Graves' disease. Health Qual Life Outcomes 2023; 21:90. [PMID: 37580816 PMCID: PMC10426177 DOI: 10.1186/s12955-023-02177-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND The EQ-5D-5 L is a commonly used generic measure of health. This study aimed to evaluate the psychometric properties of the EQ-5D-5 L in patients with Graves' disease (GD). METHODS A prospective cohort of patients with GD recruited at three public hospitals in Hong Kong completed the EQ-5D-5 L and ThyPRO-39 questionnaires at baseline, 1-month, and 6-month follow-ups. Convergent validity was tested by examining the Spearman correlation between EQ-5D-5 L and ThyPRO-39 scores at baseline. 1-month test-retest reliability was assessed by Intraclass Correlation Coefficient (ICC), Gwet's Agreement Coefficient 2 (AC2), and percentage agreement. Responsiveness of EQ-5D-5 L index and EQ-VAS scores was assessed using effect size statistics (standardized effect size [SES] and standardized response mean [SRM]). RESULTS Of 125 recruited patients, 101 (80.8%) and 100 (80.0%) patients were followed up at 1- and 6-month, respectively. For convergent validity, there was a moderate negative correlation between EQ-5D-5 L index or EQ-VAS score and ThyPRO-39 overall QoL-impact score (-0.350, -0.451), between EQ-VAS score and composite score (-0.483), and strong negative correlation between EQ-5D-5 L index score and composite score (-0.567). The Gwet's AC2 and percentage agreement were the highest in self-care (0.964 and 0.967), followed by mobility (0.952 and 0.962), usual activities (0.934 and 0.948), pain/discomfort (0.801 and 0.887), and anxiety/depression (0.788 and 0.882). The ICC for the EQ-5D-5 L index and the EQ-VAS was 0.707 and 0.700. For patients who reported having 'worsened' health at 6-month follow-up, the SES and SRM were - 0.66 and - 0.42 for EQ-5D-5 L index and - 1.15 and - 1.00 for EQ-VAS, respectively. CONCLUSIONS The EQ-5D-5 L demonstrated convergent validity, test-retest reliability, and responsiveness to worsened health status among patients with GD.
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Affiliation(s)
- Xiaodong Liu
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Wendy Wl Chan
- Department of Clinical Oncology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Eric Hm Tang
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Alex Hy Suen
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Matrix Mh Fung
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Yu Cho Woo
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Shirley Yw Liu
- Division of Endocrine Surgery, Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Cindy Lk Lam
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Nan Luo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Carlos Kh Wong
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China.
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China.
- Laboratory of Data Discovery for Health (D²4H), Hong Kong SAR, China.
| | - Brian Hh Lang
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China.
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12
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Wiersinga WM, Poppe KG, Effraimidis G. Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis. Lancet Diabetes Endocrinol 2023; 11:282-298. [PMID: 36848916 DOI: 10.1016/s2213-8587(23)00005-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 02/26/2023]
Abstract
Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT4], or high free tri-iodothyonine [FT3]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT4 concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (131I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands
| | - Kris G Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Grigoris Effraimidis
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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13
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Salman MA, Assal MM, Salman A, Elsherbiney M. Outcomes of Radioactive Iodine Versus Surgery for the Treatment of Graves’ Disease: a Systematic Review and Meta-analysis. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03692-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Abstract
Graves’ disease (GD) is a systemic autoimmune disorder mainly affecting the thyroid gland. During GD management, the principal target is to control the hyperthyroid state. There have been three rather similarly effective modalities: medical therapy with antithyroid drugs (ATD), radioactive iodine (RAI), or surgical excision of the thyroid tissue (thyroidectomy). Defining the relative risks and benefits of each of the two potential definitive treatment options (RAI or thyroidectomy) is crucial for creating evidence-based therapy algorithms. This systematic review and meta-analysis aimed to compare the outcomes of these two treatment options. This is a systematic review and meta-analysis that analyzed the studies comparing RAI and thyroidectomy to treat GD. Studies were obtained by searching on Scopus, the Cochrane Central Register of Controlled Trials, and PubMed central database. The surgically treated group showed significantly lower failure rates, non-significantly lower cardiovascular morbidities, non-significantly higher complication rates, and significantly lower mortality rates. The RAI-related complications were mostly the development or worsening of Graves’ ophthalmopathy. This review and meta-analysis comparing surgery and radioactive iodine for the treatment of Grave’s disease from 16 well-conducted trials has shown that although surgery viz., total thyroidectomy was less frequently utilized for the treatment of Grave’s disease, it controlled the symptoms with greater success and without any worsening of Grave’s ophthalmopathy.
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14
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Azizi F, Abdi H, Amouzegar A, Habibi Moeini AS. Long-term thionamide antithyroid treatment of Graves' disease. Best Pract Res Clin Endocrinol Metab 2023; 37:101631. [PMID: 35440398 DOI: 10.1016/j.beem.2022.101631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Thionamide antithyroid drugs (ATD) are the treatment of choice for Graves' hyperthyroidism. The major drawback of ATD treatment for 1-2 years is the relapse of hyperthyroidism in about 50% of patients. Recently, it has been shown that ATD treatment for more than five years is accompanied by long-term remission in majority of patients without additional major side effects in both adults and children. Compared to radioactive iodine therapy, long-term ATD results in more favorable outcomes. This review summarizes the evidence on long-term ATD therapy regarding the remission rate of hyperthyroidism, efficacy and safety, indications and mode of therapy in patients with hyperthyroidism.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hengameh Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Siamak Habibi Moeini
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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15
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Gillis A, Obiarinze R, McLeod MC, Zmijewski P, Chen H, Fazendin J, Lindeman B. Time to Symptom Resolution After Total Thyroidectomy for Graves' Disease. J Surg Res 2023; 281:185-191. [PMID: 36179596 PMCID: PMC10496743 DOI: 10.1016/j.jss.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/21/2022] [Accepted: 07/28/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Total thyroidectomy (TT) has been shown to be a safe and effective treatment for Graves' disease. However, the time course for improvement of symptoms has not been defined. METHODS With an institutional review board approval, we prospectively gathered survey data of all patients (n = 79) undergoing TT for Graves' disease at a single institution from 2019 to 2021. After informed consent was obtained, patients completed surveys preoperatively and at 2 wk followed by monthly postoperative visits/phone calls. Patient demographics and survey results were collected and analyzed. Symptom recovery time was evaluated using Kaplan-Meier analysis. RESULTS A total of 50 patients completed the survey on postoperative follow-up (response rate 63%). Average age was 38 y (range 12-80 y) and 88% of patients were female. The most common preoperative symptoms were fatigue (90%) and heat/cold intolerance (88%). Tremor (median time to resolution: 1 wk; interquartile range [IQR] 1-3), diarrhea (median 1 wk [IQR 1-3]), and palpitations (median 1 wk [IQR 1-3]) resolved the most rapidly followed by eye symptoms (median 3 wk [IQR 1-6]), heat/cold intolerance (median 3 wk [IQR 3-30]), memory deficits (median 3 wk [IQR 1-undefined]), and fatigue (median: 3 wk [IQR 1-14]). There were no significant differences in time to resolution of symptoms by gender or age (less than versus 40 y and older). Those with uncontrolled Graves' had more severe symptoms but no difference in time to resolution from the euthyroid Graves' patients. CONCLUSIONS Many Graves' disease symptoms improve rapidly following TT, with a median time to improvement of less than 1 mo.
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Affiliation(s)
- Andrea Gillis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Ruth Obiarinze
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - M Chandler McLeod
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Polina Zmijewski
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jessica Fazendin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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16
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Total thyroidectomy is more cost-effective than radioactive iodine as an alternative to antithyroid medication for Graves' disease. Surgery 2023; 173:193-200. [PMID: 36208983 DOI: 10.1016/j.surg.2022.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with Graves' disease treated with radioactive iodine report worse quality of life than those treated by thyroidectomy. However, radioactive iodine is often selected due to lower risk of complications and lower cost. The objective of this study was to estimate the cost-effectiveness of radioactive iodine versus total thyroidectomy for treatment of Graves' disease. METHODS A Markov decision-analytic model was created to simulate clinical outcomes and costs of medication-refractory Graves' disease treated with radioactive iodine or total thyroidectomy. Complication rates and utilities were derived from published data. Costs were extracted from national Medicare reimbursement rates. We conducted 1-way, 2-way, and probabilistic sensitivity analyses to identify factors that influence cost-effectiveness and reflect uncertainty in model parameters. The willingness-to-pay threshold was set at $100,000/quality-adjusted life-years. RESULTS Total thyroidectomy yielded 23.6 quality-adjusted life-years versus 20.9 quality-adjusted life-years for radioactive iodine. The incremental cost-effectiveness ratio was $2,982 per quality-adjusted life-years, indicating that surgery is highly cost-effective relative to radioactive iodine. Surgery was more cost effective than radioactive iodine in 88.2% of model simulations. Sensitivity analyses indicate that the model outcomes are driven predominantly by posttreatment quality of life, with contributing effects from rates of treatment complications and the impact of these complications on quality of life. CONCLUSION For patients with Graves' disease who either cannot tolerate or are refractory to antithyroid drugs, thyroidectomy is more cost-effective than radioactive iodine. Future research should validate reported differences in quality of life between these 2 treatment modalities.
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17
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Kuo EJ, Oh A, Hu Y, McManus CM, Lee JA, Kuo JH. If the price is right: Cost-effectiveness of radiofrequency ablation versus thyroidectomy in the treatment of benign thyroid nodules. Surgery 2023; 173:201-206. [PMID: 36334980 DOI: 10.1016/j.surg.2022.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/21/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Radiofrequency ablation is an emerging technology in the United States to treat benign thyroid nodules. The cost-effectiveness of radiofrequency ablation in comparison with traditional thyroidectomy is unknown. METHODS A patient-level state transition microsimulation decision model was constructed comparing radiofrequency ablation with lobectomy in the management of benign thyroid nodules. Our base case was a 45-year-old woman with a solitary 30-cm3 nodule. Estimates of health utilities, complications, and mortality were obtained from the literature, and costs were estimated using Medicare reimbursement data. The primary outcomes of interest included total cost, quality-adjusted life years, and incremental cost-effectiveness ratios. All model estimates were subjected to 1-way sensitivity analyses to identify factors that strongly influence cost-effectiveness. A probabilistic sensitivity analysis was run across 1 million simulations to gauge outcome confidence with a willingness-to-pay threshold set at $100,000/quality-adjusted life year. RESULTS Radiofrequency ablation was assumed to cost $5,000, with an initial success rate of 78%. Patients with volume reduction ratio <50% underwent a second treatment of radiofrequency ablation. Radiofrequency ablation represented the dominant strategy, yielding 21.31 quality-adjusted life years for a total cost of $16,563 in comparison to lobectomy, which yielded 21.13 quality-adjusted life years for a total cost of $19,262. In a 1-way sensitivity analysis varying the cost of radiofrequency ablation across of range of values, the radiofrequency ablation strategy remained cost-effective until the cost of radiofrequency ablation exceeded $12,330 at willingness-to-pay $50,000 or $17,950 at willingness-to-pay $100,000. CONCLUSION Radiofrequency ablation is a cost-effective strategy in the treatment of benign thyroid nodules but is most sensitive to the cost of radiofrequency ablation.
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Affiliation(s)
- Eric J Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY.
| | - Aaron Oh
- Albert Einstein College of Medicine, New York, NY
| | - Yinin Hu
- Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - James A Lee
- Section of Endocrine Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY
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18
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Kyriacou A, Syed AA, Sawicka-Gutaj N, Picolos M, Economides P, Kyriacou A. Body weight change trajectories following the treatment of hyperthyroidism: A prospective cohort study. Clin Endocrinol (Oxf) 2022; 98:738-740. [PMID: 36574980 DOI: 10.1111/cen.14873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022]
Affiliation(s)
- Angelos Kyriacou
- Department of Endocrinology & Diabetes, CEDM Centre of Endocrinology, Diabetes & Metabolism, Limassol, Cyprus
- Department of Endocrinology & Diabetes, Medical School, European University Cyprus, Nicosia, Cyprus
- Department of Diabetes, Endocrinology & Obesity Medicine, Salford Royal NHS Foundation & University Teaching Trust, Salford, UK
| | - Akheel A Syed
- Department of Diabetes, Endocrinology & Obesity Medicine, Salford Royal NHS Foundation & University Teaching Trust, Salford, UK
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Nadia Sawicka-Gutaj
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Michalis Picolos
- Dpeartment of Endocrinology, Diabetes & General Internal Medicine, Alithias Endocrinology Center, Nicosia, Cyprus
| | - Panayiotis Economides
- Department of Endocrinology & Diabetes, Medical School, European University Cyprus, Nicosia, Cyprus
| | - Alexis Kyriacou
- Department of Endocrinology & Diabetes, CEDM Centre of Endocrinology, Diabetes & Metabolism, Limassol, Cyprus
- Faculty of Health Sciences, University of Stirling, Stirling, UK
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Halada S, Baran JA, Isaza A, Patel T, Sisko L, Kazahaya K, Adzick NS, Katowitz WR, Magee L, Bauer AJ. Impact of Definitive Surgery for Graves' Disease on Adolescent Disease-Specific Quality of Life and Psychosocial Functioning. Thyroid 2022; 32:1519-1528. [PMID: 36254382 DOI: 10.1089/thy.2022.0334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Introduction: Pediatric Graves' disease (GD) is associated with hyperthyroid symptoms that impact psychosocial and physical functioning. Total thyroidectomy (TT) is a definitive treatment option that replaces antithyroid medication. While studies have examined health-related quality of life (QOL) in adults, there are no data describing impacts of TT in pediatrics. In this prospective longitudinal study, we explored the impact of TT on disease-specific QOL and satisfaction with TT and scar appearance in adolescent patients with GD undergoing TT. Methods: Patients 12-19 years old pursuing TT for GD and their parents were recruited to complete surveys before and at least 6 months after TT. Surveys assessed motivations for pursuing TT, QOL, perceived stigmatization, self-esteem, scar appearance, and surgery satisfaction. Paired scores were compared using Wilcoxon signed-rank tests, and subscore associations were assessed using Spearman association tests. Results: Thirty-seven patient-parent dyads completed baseline surveys, including 20 patient-parent dyads completing pre- and post-TT surveys. At baseline, patients reported physical and cognitive symptomology, including tiredness, anxiety, and emotional susceptibility through ThyPRO. Psychosocial functioning at school was low through PedsQL. Disease-specific QOL significantly improved after TT, with notable improvements associated with resolution of goiter (median change = -26.14, p = 0.003), hyperthyroid symptoms (median change = -43.75, p = 0.002), tiredness (median change = -26.79, p = 0.017), cognitive impairment (median change = -14.58, p = 0.035), anxiety (median change = -33.33, p = 0.010), and emotional susceptibility (median change = -28.99, p = 0.035). Physical (median change = 18.75, p = 0.005) and school-related functioning (median change = 30.00, p = 0.002) also significantly improved post-TT. Reported GD-associated eye symptomology (thyroid eye disease) was the second lowest scoring ThyPRO subscore at baseline and improved after surgery (median change = 14.06, p = 0.03). Families reported median recovery by two months, high satisfaction with the outcomes of TT, and minimal concerns over scar appearance. No permanent surgical complications (i.e., recurrent laryngeal nerve damage or hypoparathyroidism) were sustained. Conclusions: In the setting of a high-volume surgeon with low complication rates, TT for GD in pediatric populations may have substantial beneficial effects on disease-specific QOL and psychosocial functioning, with minimal adverse complaints about scar appearance.
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Affiliation(s)
- Stephen Halada
- Division of Endocrinology and Diabetes, The Thyroid Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia A Baran
- Division of Endocrinology and Diabetes, The Thyroid Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amber Isaza
- Division of Endocrinology and Diabetes, The Thyroid Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tasleema Patel
- Division of Endocrinology and Diabetes, The Thyroid Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lindsay Sisko
- Division of Endocrinology and Diabetes, The Thyroid Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - William R Katowitz
- Department of Ophthalmology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leanne Magee
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania , USA
| | - Andrew J Bauer
- Division of Endocrinology and Diabetes, The Thyroid Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kim HJ. Long-term management of Graves disease: a narrative review. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2022; 40:12-22. [PMID: 36329661 PMCID: PMC9946914 DOI: 10.12701/jyms.2022.00444] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/10/2022] [Indexed: 11/06/2022]
Abstract
Graves disease (GD) is the most common cause of hyperthyroidism, accounting for more than 90% of cases in Korea. Patients with GD are treated with any of the following: antithyroid drugs (ATDs), radioactive iodine (RAI) therapy, or thyroidectomy. Most patients begin treatment with ATDs, and clinical guidelines suggest that the appropriate treatment period is 12 to 18 months. While RAI treatment and surgery manage thyrotoxicosis by destroying or removing thyroid tissue, ATDs control thyrotoxicosis by inhibiting thyroid hormone synthesis and preserving the thyroid gland. Although ATDs efficiently control thyrotoxicosis symptoms, they do not correct the main etiology of GD; therefore, frequent relapses can follow. Recently, a large amount of data has been collected on long-term ATDs for GD, and low-dose methimazole (MMZ) is expected to be a good option for remission. For the long-term management of recurrent GD, it is important to induce remission by evaluating the patient's drug response, stopping ATDs at an appropriate time, and actively switching to surgery or RAI therapy, if indicated. Continuing drug treatment for an extended time is now encouraged in patients with a high possibility of remission with low-dose MMZ. It is also important to pay attention to the quality of life of the patients. This review aimed to summarize the appropriate treatment methods and timing of treatment transition in patients who relapsed several times while receiving treatment for GD.
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Affiliation(s)
- Hyo-Jeong Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Nowon Eulji University Hospital, Eulji University School of Medicine, Seoul, Korea,Corresponding author: Hyo-Jeong Kim, MD, PhD Thyroid-Endocrine Center, Nowon Eulji University Hospital, Annex, 1st floor, 68 Hangeulbiseok-ro, Nowon-gu, Seoul 01830, Korea Tel: +82-2-970-8558 • Fax: +82-2-970-8878 • E-mail:
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Sjölin G, Watt T, Byström K, Calissendorff J, Cramon PK, Nyström HF, Hallengren B, Holmberg M, Khamisi S, Lantz M, Planck T, Törring O, Wallin G. Long term outcome after toxic nodular goitre. Thyroid Res 2022; 15:20. [PMID: 36316779 PMCID: PMC9624053 DOI: 10.1186/s13044-022-00138-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The purpose of treating toxic nodular goitre (TNG) is to reverse hyperthyroidism, prevent recurrent disease, relieve symptoms and preserve thyroid function. Treatment efficacies and long-term outcomes of antithyroid drugs (ATD), radioactive iodine (RAI) or surgery vary in the literature. Symptoms often persist for a long time following euthyroidism, and previous studies have demonstrated long-term cognitive and quality of life (QoL) impairments. We report the outcome of treatment, rate of cure (euthyroidism and hypothyroidism), and QoL in an unselected TNG cohort. METHODS TNG patients (n = 638) de novo diagnosed between 2003-2005 were invited to engage in a 6-10-year follow-up study. 237 patients responded to questionnaires about therapies, demographics, comorbidities, and quality of life (ThyPRO). Patients received ATD, RAI, or surgery according clinical guidelines. RESULTS The fraction of patients cured with one RAI treatment was 89%, and 93% in patients treated with surgery. The rate of levothyroxine supplementation for RAI and surgery, at the end of the study period, was 58% respectively 64%. Approximately 5% of the patients needed three or more RAI treatments to be cured. The patients had worse thyroid-related QoL scores, in a broad spectrum, than the general population. CONCLUSION One advantage of treating TNG with RAI over surgery might be lost due to the seemingly similar incidence of hypothyroidism. The need for up to five treatments is rarely described and indicates that the treatment of TNG can be more complex than expected. This circumstance and the long-term QoL impairments are reminders of the chronic nature of hyperthyroidism from TNG.
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Affiliation(s)
- Gabriel Sjölin
- grid.412367.50000 0001 0123 6208Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden ,grid.15895.300000 0001 0738 8966Dept. of Surgery, Örebro University and University Hospital, 701 85 Örebro, Sweden
| | - Torquil Watt
- grid.475435.4Department of Medical Endocrinology Rigshospitalet, Copenhagen, Denmark ,grid.4973.90000 0004 0646 7373Internal Medicine Herlev Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kristina Byström
- grid.15895.300000 0001 0738 8966Dept. of Medicine, Örebro University and University Hospital, Örebro, Sweden
| | - Jan Calissendorff
- grid.4714.60000 0004 1937 0626Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Dept. of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Per Karkov Cramon
- grid.475435.4Department of Medical Endocrinology Rigshospitalet, Copenhagen, Denmark ,grid.4973.90000 0004 0646 7373Internal Medicine Herlev Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helena Filipsson Nyström
- grid.8761.80000 0000 9919 9582Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden ,grid.1649.a000000009445082XDept. of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden ,Wallenberg Center for Molecular and Translational Medicine, Göteborg, Sweden
| | - Bengt Hallengren
- grid.411843.b0000 0004 0623 9987Dept. of Endocrinology, Skåne University Hospital, Malmö, Sweden ,grid.4514.40000 0001 0930 2361Dept. of Clinical Sciences, Lund University, Lund, Sweden
| | - Mats Holmberg
- grid.8761.80000 0000 9919 9582Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden ,grid.24381.3c0000 0000 9241 5705ANOVA, Karolinska University Hospital, Stockholm, Sweden
| | - Selwan Khamisi
- grid.412354.50000 0001 2351 3333Dept. of Endocrinology, Uppsala University Hospital, Uppsala, Sweden ,grid.8993.b0000 0004 1936 9457Dept. of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Mikael Lantz
- grid.411843.b0000 0004 0623 9987Dept. of Endocrinology, Skåne University Hospital, Malmö, Sweden ,grid.4514.40000 0001 0930 2361Dept. of Clinical Sciences, Lund University, Lund, Sweden
| | - Tereza Planck
- grid.411843.b0000 0004 0623 9987Dept. of Endocrinology, Skåne University Hospital, Malmö, Sweden ,grid.4514.40000 0001 0930 2361Dept. of Clinical Sciences, Lund University, Lund, Sweden
| | - Ove Törring
- grid.4714.60000 0004 1937 0626Institution for Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Göran Wallin
- grid.412367.50000 0001 0123 6208Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden ,grid.15895.300000 0001 0738 8966Dept. of Surgery, Örebro University and University Hospital, 701 85 Örebro, Sweden
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22
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Sorensen JR, Døssing H, Watt T, Cramon P, Hegedüs L, Bonnema SJ, Folkestad L. The Effect of Laser Thermal Ablation on Quality of Life: Improvements in Patients with Solid-Cystic Thyroid Nodules. Thyroid 2022; 32:917-925. [PMID: 35570722 DOI: 10.1089/thy.2021.0665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Evidence of the efficacy of laser thermal ablation (LTA) in benign thyroid nodules is abundant. However, little is known about the effect on quality of life (QoL) of this treatment. Methods: Prospective cohort study investigating the effect of LTA before, three, and six months after LTA on QoL using the thyroid-specific patient-reported outcome (ThyPRO) measure. Patients receiving LTA (laser group [LG]) was compared with a well-characterized control group (CG) from the Danish civil registry. Results: The LG comprised 54 patients, with no age or sex differences compared with the CG (n = 739). Sixty-nine percent of the patients had a recurrent cystic thyroid nodule, 6% had a solid nodule, while the remaining 25% were of mixed character. The median nodule volume was 6.8 mL (interquartile range [IQR]: 4.0-11.1) before LTA, and 1.8 mL (IQR: 0.6-4.1) at 6 months post-LTA (p < 0.001), corresponding to a median reduction of 78%. All cystic fluid (median: 6 mL; IQR: 2.0-9.0) was aspirated before LTA. Median treatment time was 400 seconds (IQR: 300-600), applying a median energy of 823 J (IQR: 600-1200). At baseline and according to the ThyPRO scales, the LG differed significantly from the CG by having more goiter symptoms, hyperthyroid symptoms, tiredness, and cognitive complaints (p < 0.05 for all variables), but only the difference in the goiter symptom scale was of a clinically important magnitude. At three months, the LG experienced a large improvement in goiter symptoms (effect size [ES] = 1.05), a moderate improvement in cosmetic complaints (ES = 0.50), and a moderate improvement in the overall QoL (ES = 0.64). Only the improvements in the goiter symptom and the cosmetic complaint scales were clinically important. Six months after LTA, the anxiety scale showed further improvement of moderate size (ES = 0.52). At 6 months, the results above were maintained, and 79% of patients experienced a large and clinically important improvement in the goiter symptom scale and no clinically important differences were found between the LG and the CG. Conclusions: In this unblinded, prospective observational study, measures of disease-specific QoL were significantly improved compared with preprocedure levels, in patients with solid-cystic nodules.
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Affiliation(s)
- Jesper Roed Sorensen
- Department of ORL-Head & Neck Surgery and Audiology and Odense University Hospital, Odense C, Denmark
| | - Helle Døssing
- Department of ORL-Head & Neck Surgery and Audiology and Odense University Hospital, Odense C, Denmark
| | - Torquil Watt
- Department of Endocrinology, Copenhagen University Hospital, Herlev, Denmark
| | - Per Cramon
- Department of Endocrinology, Copenhagen University Hospital, Herlev, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense C, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, Odense C, Denmark
| | - Lars Folkestad
- Department of Endocrinology, Odense University Hospital, Odense C, Denmark
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23
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Cohen O, Ronen O, Khafif A, Rodrigo JP, Simo R, Pace-Asciak P, Randolph G, Mikkelsen LH, Kowalski LP, Olsen KD, Sanabria A, Tufano RP, Babighian S, Shaha AR, Zafereo M, Ferlito A. Revisiting the role of surgery in the treatment of Graves' disease. Clin Endocrinol (Oxf) 2022; 96:747-757. [PMID: 34954838 DOI: 10.1111/cen.14653] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 01/06/2023]
Abstract
Graves' disease (GD) can be managed by antithyroid drugs (ATD), radioactive iodine (RAI) and surgery. Thyroidectomy offers the highest success rates for both primary and persistent disease, yet it is the least recommended or utilized option reaching <1% for primary disease and <25% for persistent disease. Several surveys have found surgery to be the least recommended by endocrinologists worldwide. With the development of remote access thyroidectomies and intraoperative nerve monitoring of the recurrent laryngeal nerve, combined with current knowledge of possible risks associated with RAI or failure of ATDs, revaluation of the benefit to harm ratio of surgery in the treatment of GD is warranted. The aim of this review is to discuss possible reasons for the low proportion of surgery in the treatment of GD, emphasizing an evidence-based approach to the clinicians' preferences for surgical referrals, surgical indications and confronting traditional reasons and concerns relating to the low referral rate with up-to-date data.
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Affiliation(s)
- Oded Cohen
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ohad Ronen
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Avi Khafif
- A.R.M. Center of Otolaryngology-Head and Neck Surgery, Assuta Medical Center, Affiliated with Ben-Gurion University of the Negev, Tel Aviv, Israel
| | - Juan P Rodrigo
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospital Universitario Central de Asturias, University of Oviedo, ISPA, Oviedo, Spain
| | - Ricard Simo
- Department of Otorhinolaryngology, Head and Neck Surgery, Head and Neck and Thyroid Oncology Unit, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
| | - Pia Pace-Asciak
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gregory Randolph
- Division of Otolaryngology-Endocrine Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts, USA
| | - Lauge H Mikkelsen
- Department of Pathology, Eye Pathology Section, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Luiz P Kowalski
- Department of Head and Neck Surgery, University of Sao Paulo Medical School, AC Camargo Cancer Center, Sao Paulo, Brazil
- Department of Head and Neck Surgery and Otorhinolaryngology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - Kerry D Olsen
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia-Ips Universitaria, Medellín, Colombia
- CEXCA Centro de Excelencia en Enfermedades de Cabeza y Cuello-Clínica Las Vegas-Quirón, Medellín, Colombia
| | - Ralph P Tufano
- Multidisciplinary Thyroid and Parathyroid Center, Head and Neck Endocrine Surgery, Sarasota Memorial Health Care System, Sarasota, Florida, USA
- Division of Otolaryngology-Endocrine Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Madison, USA
| | - Silvia Babighian
- Department of Ophthalmology, Ospedale Sant'Antonio, Azienda Ospedaliera, Padova, Italy
| | - Ashok R Shaha
- Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Mark Zafereo
- Department of Head & Neck Surgery, Anderson Cancer Center, Houston, Texas, USA
| | - Alfio Ferlito
- International Head and Neck Scientific Group, Padua, Italy
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24
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The Impact of Post-Thyroidectomy Neck Stretching Exercises on Neck Discomfort, Pressure Symptoms, Voice and Quality of Life: A Randomized Controlled Trial. World J Surg 2022; 46:2212-2222. [PMID: 35637354 PMCID: PMC9150879 DOI: 10.1007/s00268-022-06610-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 11/01/2022]
Abstract
Background Methods Results Conclusions
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25
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Holmberg M, Malmgren H, Heckemann RA, Johansson B, Klasson N, Olsson E, Skau S, Starck G, Filipsson Nyström H. A Longitudinal Study of Medial Temporal Lobe Volumes in Graves Disease. J Clin Endocrinol Metab 2022; 107:1040-1052. [PMID: 34752624 PMCID: PMC8947220 DOI: 10.1210/clinem/dgab808] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Indexed: 11/23/2022]
Abstract
CONTEXT Neuropsychiatric symptoms are common features of Graves disease (GD) in hyperthyroidism and after treatment. The mechanism behind these symptoms is unknown, but reduced hippocampal volumes have been observed in association with increased thyroid hormone levels. OBJECTIVE This work aimed at investigating GD influence on regional medial temporal lobe (MTL) volumes. METHODS Sixty-two women with newly diagnosed GD underwent assessment including magnetic resonance (MR) imaging in hyperthyroidism and 48 of them were followed up after a mean of 16.4 ± 4.2 SD months of treatment. Matched thyroid-healthy controls were also assessed twice at a 15-month interval. MR images were automatically segmented using multiatlas propagation with enhanced registration. Regional medial temporal lobe (MTL) volumes for amygdalae and hippocampi were compared with clinical data and data from symptom questionnaires and neuropsychological tests. RESULTS Patients had smaller MTL regions than controls at inclusion. At follow-up, all 4 MTL regions had increased volumes and only the volume of the left amygdala remained reduced compared to controls. There were significant correlations between the level of thyrotropin receptor antibodies (TRAb) and MTL volumes at inclusion and also between the longitudinal difference in the levels of free 3,5,3'-triiodothyronine and TRAb and the difference in MTL volumes. There were no significant correlations between symptoms or test scores and any of the 4 MTL volumes. CONCLUSION Dynamic alterations in the amygdalae and hippocampi in GD reflect a previously unknown level of brain involvement both in the hyperthyroid state of the condition and after treatment. The clinical significance, as well as the mechanisms behind these novel findings, warrant further study of the neurological consequences of GD.
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Affiliation(s)
- Mats Holmberg
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Correspondence: Mats Holmberg, PhD, ANOVA, Karolinska University Hospital, Norra Stationsgatan 69, SE-17176 Stockholm, Sweden.
| | - Helge Malmgren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- MedTech West at University of Gothenburg and Sahlgrenska University Hospital, Göteborg, Sweden
| | - Rolf A Heckemann
- MedTech West at University of Gothenburg and Sahlgrenska University Hospital, Göteborg, Sweden
- Institute of Clinical Sciences, Department of Medical Radiation Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Birgitta Johansson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Niklas Klasson
- MedTech West at University of Gothenburg and Sahlgrenska University Hospital, Göteborg, Sweden
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Erik Olsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Simon Skau
- MedTech West at University of Gothenburg and Sahlgrenska University Hospital, Göteborg, Sweden
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Göran Starck
- Institute of Clinical Sciences, Department of Medical Radiation Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Helena Filipsson Nyström
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
- Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Göteborg, Sweden
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26
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Bartalena L, Piantanida E, Gallo D, Ippolito S, Tanda ML. Management of Graves' hyperthyroidism: present and future. Expert Rev Endocrinol Metab 2022; 17:153-166. [PMID: 35287535 DOI: 10.1080/17446651.2022.2052044] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Graves' disease (GD) is an autoimmune disorder due to loss of tolerance to the thyrotropin receptor (TSHR) and ultimately caused by stimulatory TSHR antibodies (TSHR-Ab). GD may be associated with extrathyroidal manifestations, mainly Graves' orbitopathy. Treatment of GD relies on antithyroid drugs (ATDs), radioactive iodine (RAI), thyroidectomy. The major ATD limitation is the high recurrence rate after treatment. The major drawback of RAI and thyroidectomy is the inevitable development of permanent hypothyroidism. AREAS COVERED Original articles, clinical trials, systematic reviews, meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, management of Graves' disease, antithyroid drugs, radioactive iodine, thyroidectomy, Graves' orbitopathy, thyroid-eye disease. EXPERT OPINION ATDs are the first-line treatment worldwide, are overall safe and usually given for 18-24 months, long-term treatment may decrease relapses. RAI is safe, although associated with a low risk of GO progression, particularly in smokers. Thyroidectomy requires skilled and high-volume surgeons. Patients play a central role in the choice of treatment within a shared decision-making process. Results from targeted therapies acting on different steps of the autoimmune process, including iscalimab, ATX-GD-59, rituximab, blocking TSHR-Ab, small molecules acting as antagonists of the TSHR, are preliminary or preclinical, but promising in medium-to-long perspective.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Daniela Gallo
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Silvia Ippolito
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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27
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Ihre-Lundgren C. Quality of Life in Patients with Benign Non-toxic Goiter after Surgical Intervention: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:1105-1106. [PMID: 35190874 PMCID: PMC8971169 DOI: 10.1007/s00268-022-06489-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 12/05/2022]
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28
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Cheetham TD, Cole M, Abinun M, Allahabadia A, Barratt T, Davies JH, Dimitri P, Drake A, Mohamed Z, Murray RD, Steele CA, Zammitt N, Carnell S, Prichard J, Watson G, Hambleton S, Matthews JNS, Pearce SHS. Adjuvant Rituximab-Exploratory Trial in Young People With Graves Disease. J Clin Endocrinol Metab 2022; 107:743-754. [PMID: 34687316 PMCID: PMC8851941 DOI: 10.1210/clinem/dgab763] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Remission rates in young people with Graves hyperthyroidism are less than 25% after 2 years of thionamide antithyroid drug (ATD). OBJECTIVE We explored whether rituximab (RTX), a B-lymphocyte-depleting agent, would increase remission rates when administered with a short course of ATD. METHODS This was an open-label, multicenter, single-arm, phase 2 trial in young people (ages, 12-20 years) with Graves hyperthyroidism. An A'Hern design was used to distinguish an encouraging remission rate (40%) from an unacceptable rate (20%). Participants presenting with Graves hyperthyroidism received 500 mg RTX and 12 months of ATD titrated according to thyroid function. ATDs were stopped after 12 months and primary outcome assessed at 24 months. Participants had relapsed at 24 months if thyrotropin was suppressed and free 3,5,3'-triiodothyronine was raised; they had received ATD between months 12 and 24; or they had thyroid surgery/radioiodine. RESULTS A total of 27 participants were recruited and completed the trial with no serious side effects linked to treatment. Daily carbimazole dose at 12 months was less than 5 mg in 21 of 27 participants. Thirteen of 27 participants were in remission at 24 months (48%, 90% one-sided CI, 35%-100%); this exceeded the critical value (9) for the A'Hern design and provided evidence of a promising remission rate. B-lymphocyte count at 28 weeks, expressed as a percentage of baseline, was related to likelihood of remission. CONCLUSION Adjuvant RTX, administered with a 12-month course of ATD, may increase the likelihood of remission in young people with Graves hyperthyroidism. A randomized trial of adjuvant RTX in young people with Graves hyperthyroidism is warranted.
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Affiliation(s)
- Tim D Cheetham
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, International Centre for Life, Newcastle upon Tyne, NE1 3BZ, UK
- Department of Paediatric Endocrinology, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE1 4LP, UK
- Correspondence: Tim D. Cheetham, MD, Newcastle University, c/o Department of Paediatric Endocrinology, Office Block 1, Level 3, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK.
| | - Michael Cole
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Mario Abinun
- Immunity & Inflammation Theme, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Department of Paediatric Immunology, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - Amit Allahabadia
- Academic Directorate of Diabetes and Endocrinology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Tim Barratt
- University of Birmingham, Diabetes Unit, Birmingham Children’s Hospital, Birmingham, B4 6NH, UK
- Birmingham Children’s Hospital, Birmingham, B46NH, UK
| | - Justin H Davies
- Department of Paediatric Endocrinology, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Paul Dimitri
- The Department of Paediatric Endocrinology, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - Amanda Drake
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, Edinburgh, EH16 4TJ, UK
| | | | - Robert D Murray
- Leeds Centre for Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, LS97TF, UK
| | - Caroline A Steele
- Children and Adolescent services, Leeds Teaching Hospitals NHS Trust, UK
| | - Nicola Zammitt
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Jonathan Prichard
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Gillian Watson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Sophie Hambleton
- Immunity & Inflammation Theme, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Department of Paediatric Immunology, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - John N S Matthews
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
- School of Mathematics, Statistics & Physics, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
| | - Simon H S Pearce
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, International Centre for Life, Newcastle upon Tyne, NE1 3BZ, UK
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
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29
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Cramon PK, Bjorner JB, Groenvold M, Boesen VB, Bonnema SJ, Hegedüs L, Feldt-Rasmussen U, Rasmussen ÅK, Watt T. Implementation of thyroid-related patient-reported outcomes in routine clinical practice. Front Endocrinol (Lausanne) 2022; 13:1000682. [PMID: 36246917 PMCID: PMC9554589 DOI: 10.3389/fendo.2022.1000682] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/09/2022] [Indexed: 11/26/2022] Open
Abstract
Patient-reported outcomes (PROs) are increasingly used in clinical practice to improve clinical care. Multiple studies show that systematic use of PROs can enhance communication with patients and improve patient satisfaction, symptom management and quality of life. Further, such data can be aggregated to examine health levels for patient groups, improve quality of care, and compare patient outcomes at the institutional, regional or national level. However, there are barriers and challenges that should be handled appropriately to achieve successful implementation of PROs in routine clinical practice. This paper briefly overviews thyroid-related PROs, describes unsolved quality of life issues in benign thyroid diseases, provides examples of routine collection of PROs, and summarizes key points facilitating successful implementation of thyroid-related PROs in routine clinical practice. Finally, the paper touches upon future directions of PRO research.
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Affiliation(s)
- Per Karkov Cramon
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Bue Bjorner
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- QualityMetric Incorporated, LLC, Johnston, RI, United States
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Palliative Care Research Unit, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Victor Brun Boesen
- Department of Internal Medicine, Copenhagen University Hospital Herlev Gentofte, Copenhagen, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Åse Krogh Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Torquil Watt
- Department of Internal Medicine, Copenhagen University Hospital Herlev Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Clinical Sciences, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Torquil Watt,
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Gunn AH, Frisco N, Thomas SM, Stang MT, Scheri RP, Kazaure HS. Patient-Reported Outcomes Following Total Thyroidectomy for Graves' Disease. Thyroid 2022; 32:54-64. [PMID: 34663089 PMCID: PMC8917896 DOI: 10.1089/thy.2021.0285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Graves' disease accounts for ∼80% of all cases of hyperthyroidism and is associated with significant morbidity and decreased quality of life. Understanding the association of total thyroidectomy with patient-reported quality-of-life and thyroid-specific symptoms is critical to shared decision-making and high-quality care. We estimate the change in patient-reported outcomes (PROs) before and after surgery for patients with Graves' disease to inform the expectations of patients and their physicians. Methods: PROs using the MD Anderson Symptom Inventory (MDASI) validated questionnaire were collected prospectively from adult patients with Graves' disease from January 1, 2015, to November 20, 2020, on a longitudinal basis. Survey responses were categorized as before surgery (≤120 days), short term after surgery (<30 days; ST), and long term after surgery (≥30 days; LT). Negative binomial regression was used to estimate the association of select covariates with PROs. Results: Eighty-five patients with Graves' disease were included. The majority were female (83.5%); 47.1% were non-Hispanic white and 35.3% were non-Hispanic black. The median thyrotropin (TSH) value before surgery was 0.05, which increased to 0.82 in ST and 1.57 in LT. In bivariate analysis, the Total Symptom Burden Score, a composite of all patient-reported burden, significantly reduced shortly after surgery (before surgery mean of 56.88 vs. ST 39.60, p < 0.001), demonstrating improvement in PROs. Furthermore, both the Thyroid Symptoms Score, including patient-reported thermoregulation, palpitations, and dysphagia, and the Quality-of-Life Symptom Score improved in ST and LT (thyroid symptoms, before surgery 13.88 vs. ST 8.62 and LT 7.29; quality of life, before surgery 16.16 vs. ST 9.14 and LT 10.04, all p < 0.05). After multivariate adjustment, the patient-reported burden in the Thyroid Symptom Score and the Quality-of-Life Symptom Score exhibited reduction in ST (thyroid symptoms, rate ratio [RR] 0.55, confidence interval [CI]: 0.42-0.72; quality of life, RR 0.57, CI: 0.40-0.81) and LT (thyroid symptoms, RR 0.59, CI: 0.44-0.79; quality of Life, RR 0.43, CI: 0.28-0.65). Conclusions: Quality of life and thyroid-specific symptoms of Graves' patients improved significantly from their baseline before surgery to both shortly after and longer after surgery. This work can be used to guide clinicians and patients with Graves' disease on the expected outcomes following total thyroidectomy.
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Affiliation(s)
- Alexander H. Gunn
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Durham, North Carolina, USA
| | - Nicholas Frisco
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Samantha M. Thomas
- Duke University Cancer Institute, Durham, North Carolina, USA
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Michael T. Stang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Randall P. Scheri
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Hadiza S. Kazaure
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
- Address correspondence to: Hadiza S. Kazaure, MD, Department of Surgery, Duke University Medical Center, 466G Seeley Mudd Building, Durham, NC 27710, USA
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Abstract
PURPOSE OF REVIEW Over the last 1-2 decades, patients and physicians have preferred antithyroid drug therapy as the initial treatment of Graves' disease, rather than radioactive iodine or surgery. More recently, the concept of long-term antithyroid drug therapy (LTADT; >24 months of treatment) has also become increasingly popular. RECENT FINDINGS Data from cohort studies and a prospective randomized trial suggest that LTATD therapy is safe and is associated with a higher chance of remission from Graves' disease than is shorter-term therapy. Also, LTADT may be associated with better quality of life and other clinical outcomes compared to radioiodine and surgery. SUMMARY Long-term antithyroid drug therapy is appropriate for children and young adults. This approach is a reasonable option in those who are doing well on a stable low dose of antithyroid drug therapy, and especially those who wish to avoid definitive treatment with radioactive iodine or surgery, given their inherent risks and need for lifelong hormonal replacement therapy.
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Affiliation(s)
- David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, Maryland, USA
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Abstract
Thyroid diseases may cause a variety of functional and structural body changes, including eye and vision abnormalities, which can have a negative impact on a patient’s well-being. However, only a few studies on the impact of other benign thyroid diseases on the visual process are available in the literature. In this study, using the Polish version of the thyroid-specific quality of life (ThyPROpl) questionnaire, we aimed to determine the self-reported influence of benign thyroid diseases (e.g., nodular goiter, toxic nodular goiter, Graves’ disease, thyroid orbitopathy, Hashimoto’s thyroiditis, and surgical hypothyroidism) on patients’ eyes and vision. This was a prospective study. In total, 374 randomly selected euthyroid patients and 255 control subjects responded to the ThyPROpl questionnaire and the results were evaluated. Nearly 69% of the respondents reported that the most frequent condition was “reduced sight.” Men most often reported wet/tearing eyes (66%). The occurrence of eyelid sacks or swollen eyelids (64%), ophthalmalgia (62%), and eye dryness (61%) was marked almost as often. In total, 29% of the patients reported diplopia, and it was found to be most prevalent among those with thyroid orbitopathy. Other complaints were similarly prevalent among all the subgroups. A positive correlation was also observed between the scores of the “eye symptoms” and other ailments. Except for swelling around the lower eyelids, patients with thyroid diseases more frequently experienced all of the ocular complaints analyzed in this study compared with controls. This study showed that eye complaints are common in patients with benign thyroid diseases and ocular disturbances have a negative impact on the overall quality of life of patients.
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Yilmaz S, Habibi HA, Yildiz A, Altunbas H. Thyroid Embolization for Nonsurgical Treatment of Nodular Goiter: A Single-Center Experience in 56 Consecutive Patients. J Vasc Interv Radiol 2021; 32:1449-1456. [PMID: 34256121 DOI: 10.1016/j.jvir.2021.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 06/25/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To investigate the safety and efficacy of thyroid artery embolization (TAE) in the treatment of nodular goiter (NG). METHODS During a 5.5-year period, 56 consecutive patients with a NG underwent TAE. In Group A, there were 20 patients with a solitary/dominant 5-11-cm nodule, and in Group B, there were 36 patients with numerous nodules. Of the 56 patients, 47 (84%) had a retrosternal goiter and 25 had hyperthyroidism. In all patients, clinical and radiological evaluations were made at baseline and 6 months after TAE, and these parameters were statistically compared. RESULTS In 56 patients, 145 of the 146 thyroid arteries were successfully embolized. The 30-day mortality rate was 1.8%. Minor and major complications occurred in 25 and 2 patients, respectively. Six months after the TAE, the mean nodule volume was reduced from 80.2 mL to 25.0 mL, the mean thyroid volume was reduced from 147.0 mL to 62.6 mL, and the mean intrathoracic extension was reduced from 31.7 mm to 15.9 mm (P < .001). Of the 22 patients with non-Graves hyperthyroidism, 19 (86%) became euthyroid. The mean thyroid-related patient-reported outcome scores improved from 155.4 to 70.4 (P < .001). Of the 51 patients, 50 (98%) declared that they would recommend TAE to other patients with NG. CONCLUSIONS TAE is safe and effective for the treatment of NG, with a significant volume reduction of the nodule(s) and thyroid gland.
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Affiliation(s)
- Saim Yilmaz
- Varisson Radiology Center, Yeşilbahçe Mah, Metin Kasapoğlu Cad Nuri Mancar Apt, D:No:42/A, 07160 Muratpaşa/Antalya, Turkey.
| | - Hatice Arıöz Habibi
- Varisson Radiology Center, Yeşilbahçe Mah, Metin Kasapoğlu Cad Nuri Mancar Apt, D:No:42/A, 07160 Muratpaşa/Antalya, Turkey
| | - Akin Yildiz
- Department of Nuclear Medicine, Memorial Bahcelievler Hospital, Istanbul, Turkey
| | - Hasan Altunbas
- Department of Endocrinology, Akdeniz University School of Medicine, Antalya, Turkey
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El Kawkgi OM, Ross DS, Stan MN. Comparison of long-term antithyroid drugs versus radioactive iodine or surgery for Graves' disease: A review of the literature. Clin Endocrinol (Oxf) 2021; 95:3-12. [PMID: 33283314 DOI: 10.1111/cen.14374] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/30/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The management of Graves' disease (GD) in the US is shifting towards increased use of anti-thyroid drugs (ATD). If patients fail to achieve remission after a standard course of therapy of 12-18 months, long-term treatment with ATD (≥24 months) may be chosen over definitive therapy with radioiodine (RAI) or surgery. Clinicians will need to contrast this strategy to ablative therapies as they help patients in decision making. SUMMARY Review of the literature illustrates that long-term ATD delivers euthyroidism with minimal complications, low financial cost and with an advantageous profile regarding quality of life (QoL) and other biological outcomes. CONCLUSIONS Long-term ATD is a viable alternative to ablative therapies in the management of GD offering advantages across multiple patient centred outcomes. Decision making must factor differences in this approach compared to ablative therapies and ultimately be tailored to individualized patient situations.
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Affiliation(s)
- Omar M El Kawkgi
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Douglas S Ross
- Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Marius N Stan
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
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Shalaby M, Hadedeya D, Toraih EA, Razavi MA, Lee GS, Hussein MH, Weidenhaft MC, Serou MJ, Ibraheem K, Abdelgawad M, Kandil E. Predictive factors of radioiodine therapy failure in Graves' Disease: A meta-analysis. Am J Surg 2021; 223:287-296. [PMID: 33865565 DOI: 10.1016/j.amjsurg.2021.03.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/18/2021] [Accepted: 03/31/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND I-131 therapy is a common treatment modality for adults with Graves' Disease (GD). Utilizing meta-analysis, we examined patient specific factors that predict I-131 therapy failure. METHODS Literature search followed PRISMA. Comprehensive Meta-analysis (version 3.0) was used. Mantel-Haenszel test with accompanying risk ratio and confidence intervals evaluated categorical variables. Continuous data was analyzed using inverse variance testing yielding mean difference or standardized mean difference. Decision tree algorithms identified variables of high discriminative performance. RESULTS 4822 collective patients across 18 studies were included. Male sex (RR = 1.23, 95%CI = 1.08-1.41, p = 0.002), I-131 therapy 6 months after GD diagnosis (RR = 2.10, 95%CI = 1.45-3.04, p < 0.001) and history of anti-thyroid drugs (RR = 2.05, 95%CI = 1.49-2.81, p < 0.001) increased the risk of I-131 therapy failure. Elevated free thyroxine, 24-h radioactive iodine uptake scan ≥60.26% and thyroid volume ≥35.77 mL were also associated with failure. CONCLUSION Patient characteristics can predict the likelihood of I-131 therapy failure in GD. Definitive surgical treatment may be a reasonable option for those patients.
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Affiliation(s)
- Mahmoud Shalaby
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Deena Hadedeya
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Eman A Toraih
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Michael A Razavi
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Grace S Lee
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Mandy C Weidenhaft
- Department of Radiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Michael J Serou
- Department of Radiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Kareem Ibraheem
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mohamed Abdelgawad
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
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Thewjitcharoen Y, Karndumri K, Chatchomchuan W, Porramatikul S, Krittiyawong S, Wanathayanoroj E, Lekpittaya N, Kittipoom W, Anuntakulnatee T, Vongterapak S, Butadej S, Nakasatien S, Rajatanavin R, Himathongkam T. Practice patterns and outcomes in the management of Thai patients with Graves' disease. Thyroid Res 2021; 14:5. [PMID: 33658045 PMCID: PMC7927256 DOI: 10.1186/s13044-021-00097-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The treatment of hyperthyroid Graves' disease (GD) varies considerably among geographic areas. In this study, we aimed to evaluate practice patterns and treatment outcomes in Thai patients with hyperthyroid GD. METHODS A retrospective cohort study over 35 years (1985-2019) in patients with hyperthyroid GD was conducted. The trends of treatment options were compared periodically during the study period and the overall remission rate from each option was determined. RESULTS A total of 2736 hyperthyroid GD patients were treated and followed-up for at least 3 months over the study period (female 82.0%, mean age at diagnosis 36.3 ± 12.0 years, median duration of follow-up 74.5 months). Anti-thyroid drug (ATD) was the most commonly used treatment (78.0%), followed by RAI (21.0%), and surgery (1.0%). There was a significant downward trend for surgery, from 12.3% in the 1980s to only 0.2% in last phase of the study period. The preference for RAI therapy has also decreased in the last 5 years. Among ATD-treated patients, the remission rate was achieved only in 30.7 and 16.0% of all ATD-treated patients were eventually treated with RAI. Spontaneous hypothyroidism developed in 2.7% of the ATD-treated patients during a follow-up period. Almost all RAI-treated patients (97.1%) developed hypothyroidism. CONCLUSIONS Our present study highlighted the changing landscape of primary treatments for hyperthyroid GD toward ATD and the sharp downward trend in the surgical option. Even though ATD was associated with a low remission rate, it was preferred by many patients and physicians. The use of RAI as the primary treatment decreased in the last decade. However, RAI was a very effective treatment for Graves' hyperthyroidism but will inevitably induce hypothyroidism and a requirement for life-long replacement therapy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Siriwan Butadej
- Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, Thailand
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Nordqvist SF, Boesen VB, Rasmussen ÅK, Feldt-Rasmussen U, Hegedüs L, Bonnema SJ, Cramon PK, Watt T, Groenvold M, Bjorner JB. Determining minimal important change for the thyroid-related quality of life questionnaire ThyPRO. Endocr Connect 2021; 10:316-324. [PMID: 33617467 PMCID: PMC8052573 DOI: 10.1530/ec-21-0026] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/10/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE ThyPRO is the standard thyroid patient-reported outcome (PRO). The change in scores that patients perceive as important remains to be ascertained. The purpose of this study was to determine values for minimal important change (MIC) for ThyPRO. METHODS A total of 435 patients treated for benign thyroid diseases completed ThyPRO at baseline and 6 weeks following treatment initiation. At 6 weeks follow-up, patients also completed Global Rating of Change items. For each 0-100 scale, two MIC values were identified: An MIC for groups, using the receiver operating characteristic (ROC) curve method and an MIC for individual patients, using the Reliable Change Index. RESULTS ROC analyses provided group-MIC estimates of 6.3-14.3 (score range 0-100). Evaluation of area under the curve (AUC) supported the robustness for 9 of 14 scales (AUC > 0.7). Reliable Change Index estimates of individual-MIC were 8.0-21.1. For all scales but two, the individual-MIC values were larger than the group-MIC values. CONCLUSIONS Interpretability of ThyPRO was improved by the establishment of MIC values, which was 6.3-14.3 for groups and 8.0-21.1 for individuals. Thus, estimates of which changes are clinically relevant, are now available for future studies. We recommend using MIC values found by ROC analyses to evaluate changes in groups of patients, whereas MIC values identified by a dual criterion, including the reliability of changes, should be used for individual patients, for example, to identify individual responders in clinical studies or practice.
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Affiliation(s)
- Selma Flora Nordqvist
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Victor Brun Boesen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Åse Krogh Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Per Karkov Cramon
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Torquil Watt
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine, Herlev Gentofte Hospital, Copenhagen, Denmark
- Correspondence should be addressed to T Watt:
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Palliative Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Jakob Bue Bjorner
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- National Research Centre for the Working Environment, Copenhagen, Denmark
- QualityMetric Incorporated, LLC, Johnston, Rhode Island, USA
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Lane LC, Rankin J, Cheetham T. A survey of the young person's experience of Graves' disease and its management. Clin Endocrinol (Oxf) 2021; 94:330-340. [PMID: 33128233 DOI: 10.1111/cen.14359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/16/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE A suboptimal quality of life (QoL) has been reported in patients with Graves' disease treated in adult life, but long-term QoL in those treated in childhood and adolescence is unclear. We wanted to understand how Graves' disease and its management impact on the physical, psychological and social well-being of young people and their longer-term QoL. DESIGN, PATIENTS AND MEASUREMENTS Two questionnaires were used to assess QoL and patient experience of Graves' disease; PedsQL™ Generic Core Scales and a Graves' disease questionnaire devised for this project. The anonymized questionnaires were sent to young people (<30 years) diagnosed with Graves' disease in childhood and adolescence and managed at a tertiary paediatric endocrine unit in the North of England. Respondent QoL scores were compared with a healthy UK cohort. RESULTS Questionnaires were sent to 51 young people, and 26 responded (51%). Graves' patients reported a lower total QoL score compared with the healthy cohort (p = .003). This was particularly apparent in the psychosocial domain (p = .0016). No patient regretted having definitive treatment (surgery/radioiodine), and all said they would recommend it to others. Half of those who had received definitive treatment still did not feel recovered. There was no difference in the long-term QoL in those who did/did not receive definitive treatment (p = .40). CONCLUSIONS This study highlights short- and long-term impacts on the QoL and general well-being of young people with Graves' disease. There were no regrets regarding the choice of definitive treatment. This information will help inform the counselling of patients and their families.
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Affiliation(s)
- Laura Claire Lane
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, International Centre for Life, Newcastle University, Newcastle-upon-Tyne, UK
| | - Judith Rankin
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Tim Cheetham
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, International Centre for Life, Newcastle University, Newcastle-upon-Tyne, UK
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Cheng Y, Sun Z, Zhong D, Ren L, Yang H. Cross-sectional investigation of serum creatine kinase concentration in Graves disease patients treated with oral antithyroid drugs. Medicine (Baltimore) 2020; 99:e22898. [PMID: 33120839 PMCID: PMC7581051 DOI: 10.1097/md.0000000000022898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Elevated serum creatine kinase (CK) concentration was reported in some Graves disease patients during the treatment with oral antithyroid drugs (ATD). The pathogenesis of this abnormal biochemical value was considered to be related to the therapeutic drug. However, the relevant epidemiological investigation was absent.Overall, 416 patients with Graves disease treated with oral ATDs were recruited from December 2017 to October 2019. Clinical characteristics such as the patient's medical history and therapeutic regimen were collected. Serum CK concentration and thyroid function were measured. Statistical analysis was adopted to clarify the relationship between serum CK level and these clinical parameters.Elevation of serum CK concentration was emerged in 13.5% patients who were treated with oral ATDs. The proportion was significantly higher among men than among women (19.5% vs 10.8%). There was no correlation between increased serum CK concentration and age. More than 60% of serum CK elevations occurred within 6 months after taking oral ATDs. Free triiodothyronine and free thyroxine are negatively correlated with serum CK concentration. The correlation coefficients are respectively -0.222 (P < .05) and -0.234 (P < .05). There is positive correlation between thyroid stimulating hormone and serum CK concentration. The correlation coefficient is 0.405 (P < .05). There was no statistical correlation between drug dosage and increased serum CK level.Increased serum CK level is a common adverse reaction of oral ATDs. It generally develops early after starting treatment. The cause of this adverse reaction is not clear. It is speculated that elevation of serum CK level is related to the fluctuation of thyroid function.
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Affiliation(s)
| | - Zhiyong Sun
- Nuclear Medicine Department, The General Hospital of Western Theater Command PLA, No. 270 Rongdu Avenue, Jinniu District, Chengdu, Sichuan Province, People's Republic of China
| | | | - Li Ren
- Department of Endocrinology
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Abdi H, Zakavi SR, Azizi F. A Clinical Debate: What Is the Therapeutic Choice for Recurrent Graves' Hyperthyroidism? Int J Endocrinol Metab 2020; 18:e108876. [PMID: 33613682 PMCID: PMC7887460 DOI: 10.5812/ijem.108876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/26/2020] [Accepted: 09/29/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hengameh Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Rasoul Zakavi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Abstract
Context: There are three therapeutic modalities for the management of Graves’ disease (GD), including thyroid surgery, radioactive iodine (RAI), and antithyroid drugs (ATDs). We aimed to briefly review the history of these treatment strategies and their advantages and disadvantages. Evidence Acquisition: We searched PubMed for English language articles using pertinent search terms. Results: Each treatment modality for GD is accompanied by several advantages and disadvantages. Nowadays, ATDs are the most commonly prescribed therapy for GD worldwide. The lack of well-designed, large RCTs comparing three different treatments for hyperthyroidism concerning various short-term and long-term outcomes has led to remarkable uncertainty in the preference of each of these treatments, as is evident in relevant guidelines from different societies. Recently, the efficacy and safety of long-term use of ATDs have been documented. Conclusions: Pros and cons of each therapeutic modality for Graves’ hyperthyroidism should be taken into account during the physician-patient discussion to select the primary treatment. Considering recent data about the long-term efficacy and safety of ATDs, it seems that the appropriate selection of Graves’ patients for long-term ATD therapy can be a new avenue in the treatment and even cure of GD.
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Boesen VB, Bjorner JB, Groenvold M, Cramon PK, Rasmussen AK, Watt T, Feldt-Rasmussen U. Ecological momentary assessments (EMAs) did not improve responsiveness of patient-reported outcomes on quality of life. J Clin Epidemiol 2020; 125:138-147. [PMID: 32525086 DOI: 10.1016/j.jclinepi.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/05/2020] [Accepted: 06/05/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Clinical practice guidelines recommend questionnaires with short recall. We compare responsiveness of ecological momentary assessments (EMAs) and retrospective assessments of thyroid-related quality of life. STUDY DESIGN AND SETTING Patients with newly diagnosed thyrotoxicosis completed retrospective Thyroid-related Patient-Reported Outcome measures (ThyPROs) with 4-week and 1-week recall, respectively, and three daily EMAs for 4 weeks at time of inclusion and again after treatment (N = 115). Magnitude of change and statistical power (F-test statistics) were compared. Two designs were applied to the same data: Design 1 mimicked the practical realities of clinical trials by comparing 4-week recall ThyPRO administered at time of inclusion with EMA initiated at time of inclusion and collected prospectively for 1 week, thus not covering the same time frame or duration. Design 2 compared assessments covering the same 4 weeks after inclusion. RESULTS Design 1: the estimated change and statistical power were significantly larger for 4-week ThyPRO compared with EMAs. Design 2: retrospective assessments and EMAs had comparable change and power. Repeated 1-week ThyPRO administrations increased the statistical power. CONCLUSION Selecting the optimal time frame for evaluation proved crucial for responsiveness. EMAs did not provide higher responsiveness than retrospective measures in either design. Repeated 1-week ThyPRO administrations increased statistical power.
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Affiliation(s)
- Victor Brun Boesen
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen Denmark
| | - Jakob Bue Bjorner
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, Denmark; Optum Patient Insights, Johnston, RI, USA
| | - Morgens Groenvold
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, Denmark; Department of Palliative Medicine, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23B, Copenhagen, Denmark
| | - Per Karkov Cramon
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen Denmark
| | - Aase Krogh Rasmussen
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen Denmark
| | - Torquil Watt
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen Denmark; Department of Internal Medicine, Copenhagen University Hospital Herlev-Gentofte, Gentofte Hospitalsvej 1, Gentofte, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen, Denmark.
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Grove-Laugesen D, Cramon PK, Malmstroem S, Ebbehoj E, Watt T, Hansen KW, Rejnmark L. Effects of Supplemental Vitamin D on Muscle Performance and Quality of Life in Graves' Disease: A Randomized Clinical Trial. Thyroid 2020; 30:661-671. [PMID: 31910101 DOI: 10.1089/thy.2019.0634] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Vitamin D deficiency has been proposed to have a role in the development and course of Graves' disease (GD). Muscle weakness and quality of life (QoL) impairments are shared features of GD and vitamin D deficiency. We aimed at investigating whether vitamin D supplementation would improve restoration of muscle performance and thyroid-related QoL in GD and at describing the effect of anti-thyroid medication (ATD) on these outcomes. Methods: In a double-blinded clinical trial, hyperthyroid patients with a first-time diagnosis of GD were randomized to vitamin D 70 μg (2800 IU)/day or matching placebo as add-on to standard ATD. At baseline and after 3 and 9 months of intervention, we assessed isometric muscle strength, muscle function tests, postural stability, body composition, and QoL-impairment by using the ThyPRO questionnaire. Linear mixed modeling was used to analyze between-group differences. (The DAGMAR study clinicaltrials.gov ID NCT02384668). Results: Nine months of vitamin D supplementation caused an attenuation of muscle strength increment in all muscle measures investigated, significant at knee extension 60° where the increase was 24% lower (p = 0.04) in the vitamin D group compared with placebo. Compared with placebo, vitamin D supplementation tended to reduce gain of lean body mass (-24%, p = 0.08). Vitamin D supplementation significantly impeded alleviation of Composite QoL and the same trend was observed for the Overall QoL-Impact and Impaired Daily Life scales. In response to ATD, all measures improved significantly. The increase in muscle strength ranged from 25% to 40% (pall < 0.001), and increment of lean body mass was 10% (p < 0.001). Large changes were observed in all QoL scales. Conclusions: Nine months of vitamin D supplementation caused unfavorable effects on restoration of muscle performance. In contrast, ATD treatment was associated with marked improvement in all measures of muscle performance and thyroid-related QoL. In patients with newly diagnosed GD, high-dose vitamin D supplementation should not be recommended to improve muscle function, but ATD is of major importance to alleviate muscle impairment.
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Affiliation(s)
- Diana Grove-Laugesen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Sofie Malmstroem
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Eva Ebbehoj
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Torquil Watt
- Department of Internal Medicine, Gentofte and Herlev Hospital, Herlev, Denmark
| | | | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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Bednarczuk T, Schomburg L. Challenges and perspectives of selenium supplementation in Graves' disease and orbitopathy. Hormones (Athens) 2020; 19:31-39. [PMID: 31721133 PMCID: PMC7033064 DOI: 10.1007/s42000-019-00133-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/09/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE This review focuses on the results of prospective randomized clinical trials and the conclusions from respective meta-analyses in order to summarize experiences with adjuvant selenium (Se) supplementation in Graves' hyperthyroidism and orbitopathy, while identifying ambiguous findings and highlighting important open research issues. METHODS We searched the PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) through May 31, 2019, for relevant studies. RESULTS The available evidence concerning routine use of Se in the treatment of Graves' hyperthyroidism remains ambiguous. Results of meta-analyses, including ten RCTs, suggest that adjuvant Se supplementation can enhance the restoration of biochemical euthyroidism. Unfortunately, these results must be judged cautiously owing to several important limitations. Moreover, an in-depth analysis of relevant long-term clinical measures of therapeutic success (such as remission rate after antithyroid drug treatment), besides surrogate markers (for example, hormone or autoantibody concentrations), is generally missing. Based on a single study, Se supplementation is recommended in patients with mild orbitopathy of short duration because it may decrease inflammation and eye-specific symptoms while also achieving a marked improvement in disease-specific quality of life. The effects of Se supplementation on moderate-to-severe orbitopathy remain as yet unknown. CONCLUSIONS Additional randomized clinical trials with clinically relevant endpoints are urgently needed to further aid in clinical decision-making, including better stratification of Graves' disease patients, who are most likely to benefit from Se supplementation.
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Affiliation(s)
- Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland.
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, Suedring 10, 13353, Berlin, Germany.
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The success rate of radioactive iodine therapy for Graves' disease in iodine-replete area and affecting factors: a single-center study. Nucl Med Commun 2020; 41:212-218. [PMID: 31895759 DOI: 10.1097/mnm.0000000000001138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Initial treatment options for Graves' disease include antithyroid drugs, radioactive iodine (RAI), and surgery. Because of similar effects of three modalities, initial treatment preferences differ by country to country. In Korea, iodine-replete area, RAI was used as a second-line option. For these reasons, the RAI success rate in Korea might differ from other countries. METHODS A total of 247 patients were enrolled. The primary outcome was cumulative success rate in the first year, and the secondary outcome was factors that affected the success. Delayed response, which included patients who attained successful RAI during the follow-up, after the first year without further RAI, and factors that affected the delayed response were reviewed. RESULTS The cumulative success rate in the first year was 62.8%. Higher RAI activity [odds ratio (OR) 2.56, P = 0.02], longer disease duration (OR 0.43, P = 0.01), larger goiter (OR 0.31, P = 0.01), and higher post-RAI fT4 (fT4 between upper normal limit (UNL) to 1.5 × UNL; OR 0.24; P < 0.01, 1.5 × UNL<; OR 0.08; P < 0.01) were associated with RAI success. Twenty-seven patients showed delayed response, and goiter size (P < 0.05), pre-RAI TSH receptor Ab (TRAb) level (P < 0.01) and post-RAI fT4 (P < 0.01) were associated. CONCLUSION The success rate of the first RAI in Korea was lower than that in other countries. Delayed response was observed in patients with smaller goiter, low pre-RAI TRAb, and low post-RAI fT4. In these patients, clinical follow-up with monitoring could be an option, and decision of optimal timing of first RAI is crucial.
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Vannucchi G, Covelli D, Campi I, Currò N, Dazzi D, Rodari M, Pepe G, Chiti A, Guastella C, Lazzaroni E, Salvi M. Prevention of Orbitopathy by Oral or Intravenous Steroid Prophylaxis in Short Duration Graves' Disease Patients Undergoing Radioiodine Ablation: A Prospective Randomized Control Trial Study. Thyroid 2019; 29:1828-1833. [PMID: 31860407 DOI: 10.1089/thy.2019.0150] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Radioiodine (RAI) is a known risk factor for activation or de novo occurrence of Graves' orbitopathy (GO). Several studies demonstrated that GO can be prevented by glucocorticoids (GCs) in patients with pre-existing GO. We have previously shown that Graves' disease duration (GDd) <5 years is a risk factor for RAI-induced GO. We studied the effect of prophylaxis with either oral GCs (OGCs) or intravenous GCs (IVGCs) on GO activation in patients with GDd. Methods: In total, 99 hyperthyroid patients without GO or with pre-existing inactive GO with GDd <5 years were randomized to receive IVGCs (N = 49) or OGCs (N = 50) before RAI; 22 patients with GDd >5 did not receive steroids and were studied as controls. All patients underwent ophthalmological assessment before and 45, 90, 180 days and for a 5-year follow-up after RAI. Serum thyrotropin (TSH) receptor antibodies (TRAbs), thyroid hormones, and thyroid volume (TV) were also measured in response to RAI therapy and steroid prophylaxis. Results: No patient on prophylaxis developed GO after RAI. One woman of the control group, without steroid prophylaxis, and who had a marked elevation of her TSH, showed transient reactivation of GO, which spontaneously improved after restoring euthyroidism. On follow-up at 12 and 20 months after RAI, two patients developed overt optic neuropathy. A smaller TV was associated with a higher prevalence of RAI-induced hypothyroidism. Serum TRAbs increased significantly after RAI (p < 0.0001) but less in patients receiving steroids than in those without prophylaxis at 45 days (p < 0.01). Conclusions: The risk of RAI-induced GO can be prevented in all patients with GDd <5 years by steroids. Such treatment may not be necessary in patients with GDd >5 years. The blunting of TRAb elevation after RAI may be related to the prophylactic effect of steroids.
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Affiliation(s)
- Guia Vannucchi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Danila Covelli
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Campi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Nicola Currò
- Ophthalmology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Dazzi
- Division of Internal Medicine, Ospedale Vaio, Fidenza, Italy
| | - Marcello Rodari
- Department of Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy
| | - Giovanna Pepe
- Department of Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy
| | - Arturo Chiti
- Department of Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy
| | - Claudio Guastella
- Department of Otolaryngology, University of Milan and Fondazione IRCCS Cà Granda, Milan, Italy
| | - Elisa Lazzaroni
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Salvi
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Holmberg MO, Malmgren H, Berglund P, Bunketorp-Käll L, Heckemann RA, Johansson B, Klasson N, Olsson E, Skau S, Nystrom Filipsson H. Structural brain changes in hyperthyroid Graves' disease: protocol for an ongoing longitudinal, case-controlled study in Göteborg, Sweden-the CogThy project. BMJ Open 2019; 9:e031168. [PMID: 31685507 PMCID: PMC6858258 DOI: 10.1136/bmjopen-2019-031168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 10/06/2019] [Accepted: 10/08/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Cognitive impairment and reduced well-being are common manifestations of Graves' disease (GD). These symptoms are not only prevalent during the active phase of the disease but also often prevail for a long time after hyperthyroidism is considered cured. The pathogenic mechanisms involved in these brain-derived symptoms are currently unknown. The overall aim of the CogThy study is to identify the mechanism behind cognitive impairment to be able to recognise GD patients at risk. METHODS AND ANALYSIS The study is a longitudinal, single-centre, case-controlled study conducted in Göteborg, Sweden on premenopausal women with newly diagnosed GD. The subjects are examined: at referral, at inclusion and then every 3.25 months until 15 months. Examinations include: laboratory measurements; eye evaluation; neuropsychiatric and neuropsychological testing; structural MRI of the whole brain, orbits and medial temporal lobe structures; functional near-infrared spectroscopy of the cerebral prefrontal cortex and self-assessed quality of life questionnaires. The primary outcome measure is the change in medial temporal lobe structure volume. Secondary outcome measures include neuropsychological, neuropsychiatric, hormonal and autoantibody variables. The study opened for inclusion in September 2012 and close for inclusion in October 2019. It will provide novel information on the effect of GD on medial temporal lobe structures and cerebral cortex functionality as well as whether these changes are associated with cognitive and affective impairment, hormonal levels and/or autoantibody levels. It should lead to a broader understanding of the underlying pathogenesis and future treatment perspectives. ETHICS AND DISSEMINATION The study has been reviewed and approved by the Regional Ethical Review Board in Göteborg, Sweden. The results will be actively disseminated through peer-reviewed journals, national and international conference presentations and among patient organisations after an appropriate embargo time. TRIAL REGISTRATION NUMBER 44321 at the public project database for research and development in Västra Götaland County, Sweden (https://www.researchweb.org/is/vgr/project/44321).
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Affiliation(s)
- Mats Olof Holmberg
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Institute of Medicine, University of Gothenburg, Sahlgrenska Academy, Göteborg, Sweden
| | - Helge Malmgren
- Institute of Medicine, University of Gothenburg, Sahlgrenska Academy, Göteborg, Sweden
- MedTech West, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Peter Berglund
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Lina Bunketorp-Käll
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Rolf A Heckemann
- Division of Brain Sciences, Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy, Göteborg, Sweden
| | - Birgitta Johansson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Niklas Klasson
- MedTech West, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Erik Olsson
- Institute of Medicine, University of Gothenburg, Sahlgrenska Academy, Göteborg, Sweden
| | - Simon Skau
- MedTech West, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Helena Nystrom Filipsson
- Institute of Medicine, University of Gothenburg, Sahlgrenska Academy, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
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Sjölin G, Holmberg M, Törring O, Byström K, Khamisi S, de Laval D, Abraham-Nordling M, Calissendorff J, Lantz M, Hallengren B, Filipsson Nyström H, Wallin G. The Long-Term Outcome of Treatment for Graves' Hyperthyroidism. Thyroid 2019; 29:1545-1557. [PMID: 31482765 DOI: 10.1089/thy.2019.0085] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: The treatment efficacy of antithyroid drug (ATD) therapy, radioactive iodine (131I), or surgery for Graves' hyperthyroidism is well described. However, there are a few reports on the long-term total outcome of each treatment modality regarding how many require levothyroxine supplementation, the need of thyroid ablation, or the individual patient's estimation of their recovery. Methods: We conducted a pragmatic trial to determine the effectiveness and adverse outcome in a patient cohort newly diagnosed with Graves' hyperthyroidism between 2003 and 2005 (n = 2430). The patients were invited to participate in a longitudinal study spanning 8 ± 0.9 years (mean ± standard deviation) after diagnosis. We were able to follow 1186 (60%) patients who had been treated with ATD, 131I, or surgery. We determined the mode of treatment, remission rate, recurrence, quality of life, demographic data, comorbidities, and lifestyle factors through questionnaires and a review of the individual's medical history records. Results: At follow-up, the remission rate after first-line treatment choice with ATD was 45.3% (351/774), with 131I therapy 81.5% (324/264), and with surgery 96.3% (52/54). Among those patients who had a second course of ATD, 29.4% achieved remission (vs. the 45.3% after the first course of ATD). The total number of patients who had undergone ablative treatment was 64.3% (763/1186), of whom 23% (278/1186) had received surgery, 43% (505/1186) had received 131I therapy, including 2% (20/1186) who had received both surgery and 131I. Patients who received ATD as first-line treatment and possibly additional ATD had 49.7% risk (385/774) of having undergone ablative treatment at follow-up. Levothyroxine replacement was needed in 23% (81/351) of the initially ATD treated in remission, in 77.3% (204/264) of the 131I treated, and in 96.2% (50/52) of the surgically treated patients. Taken together after 6-10 years, and all treatment considered, normal thyroid hormone status without thyroxine supplementation was only achieved in 35.7% (423/1186) of all patients and in only 40.3% of those initially treated with ATD. The proportion of patients that did not feel fully recovered at follow-up was 25.3%. Conclusion: A patient selecting ATD therapy as the initial approach in the treatment of Graves' hyperthyroidism should be informed that they have only a 50.3% chance of ultimately avoiding ablative treatment and only a 40% chance of eventually being euthyroid without thyroid medication. Surprisingly, 1 in 4 patients did not feel fully recovered after 6-10 years. The treatment for Graves' hyperthyroidism, thus, has unexpected long-term consequences for many patients.
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Affiliation(s)
- Gabriel Sjölin
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mats Holmberg
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
| | - Ove Törring
- Institution for Clinical Science and Education, Karolinska Institutet and Division of Endocrinology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Kristina Byström
- Department of Medicine, Örebro University and University Hospital, Örebro, Sweden
| | - Selwan Khamisi
- Department of Endocrinology, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Dorota de Laval
- Department of Medicine, Blekinge Hospital, Karlskrona, Sweden
| | | | - Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Bengt Hallengren
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Helena Filipsson Nyström
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Göran Wallin
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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50
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McLachlan SM, Rapoport B. A transgenic mouse that spontaneously develops pathogenic TSH receptor antibodies will facilitate study of antigen-specific immunotherapy for human Graves' disease. Endocrine 2019; 66:137-148. [PMID: 31560118 DOI: 10.1007/s12020-019-02083-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 09/04/2019] [Indexed: 12/13/2022]
Abstract
Graves' hyperthyroidism can be treated but not cured. Antigen-specific immunotherapy would accomplish this goal, for which purpose an animal model is an invaluable tool. Two types of animal models are available. First, pathogenic TSHR antibodies (TSHRAb) can be induced by injecting mice with fibroblasts co-expressing the human TSHR (hTSHR) and MHC class II, or in mammals using plasmid or adenovirus vectors encoding the hTSHR or its A-subunit. Second, a mouse model that spontaneously develops pathogenic TSHRAb resembling those in human disease was recently described. This outcome was accomplished by transgenic intrathyroidal expression of the hTSHR A-subunit in NOD.H2h4 mice that are genetically predisposed to develop thyroiditis but, without the transgene, do not generate TSHRAb. Recently, novel approaches to antigen-specific immunotherapy have been tested, primarily in the induced model, by injecting TSHR A-subunit protein or cyclic TSHR peptides. T-cell tolerance has also been induced in "humanized" HLA-DR3 mice by injecting synthetic peptides predicted in silico to mimic naturally processed TSHR T-cell epitopes. Indeed, a phase 1 study based on the latter approach has been conducted in humans. In the spontaneous model (hTSHR/NOD.H2h mice), injection of soluble or nanoparticle-bearing hTSHR A-subunits had the unwanted effect of exacerbating pathogenic TSHRAb levels. A promising avenue for tolerance induction, successful in other conditions and yet to be tested with the TSHR, involves encapsulating the antigen. In conclusion, these studies provide insight into the potential outcome of immunotherapeutic approaches and emphasize the importance of a spontaneous model to test future novel, antigen-specific immunotherapies for Graves' disease.
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Affiliation(s)
- Sandra M McLachlan
- Department of Medicine, University of California Los Angeles, 100 Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Basil Rapoport
- Department of Medicine, University of California Los Angeles, 100 Medical Plaza Driveway, Los Angeles, CA, 90095, USA.
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