Antithyroid drug treatment for graves' disease in children: a long-term retrospective study at a single institution.

BACKGROUND: The management of Graves' disease (GD) in children is associated with a dilemma. Although the established initial treatment for GD in children is antithyroid drug (ATD) treatment, the remission rate in children is said to be lower than in adults, and severe propylthiouracil-induced adverse events (AEs) are an issue. Definitive treatments are effective, but they often result in permanent hypothyroidism and the need for lifelong T4 supplementation. OBJECTIVE: The objective of this study was to investigate the outcome of ATD treatment, identify significant predictors of a remission, and evaluate the AEs of ATDs in a large pediatric population of GD patients. METHODS: We retrospectively assessed the reports of 1138 children up to 18 years of age who had been newly diagnosed with GD at our institution between 1982 and 2006. Their median age at diagnosis was 16 years (range: 3-18 years), and there were 995 females and 143 males. All patients were initially treated with an ATD. Remission was defined as maintenance of euthyroidism for more than 12 months after discontinuing ATD treatment and the absence of any relapses during the follow-up period. RESULTS: Of the 1138 patients, 723 continued on ATD treatment, 271 underwent surgery or radioactive iodine therapy, and 144 dropped out. Of the 723 patients who continued on ATD treatment, ATD treatment was subsequently ongoing in 84 and was discontinued in 639 (median duration of treatment: 3.8 years; range: 0.3-24.8 years). Of the 639 patients who discontinued ATD treatment, 334 (46.2%) achieved a remission, 247 (34.2%) experienced a relapse, and 58 (8.0%) dropped out. The cumulative remission rate increased with the duration of ATD treatment up until five years. No significant predictors of a remission were identified. The overall incidences of AEs associated with methimazole and propylthiouracil were 21.4% and 18.8% respectively. There were no fatal AEs in our population. While most AEs (91.6%) occurred within the first three months of ATD treatment, 2.7% developed more than two years after the start of ATD treatment. Seven of the eight late-onset AEs were induced by propylthiouracil. CONCLUSION: Long-term ATD treatment is a useful treatment option for GD in children.

Long-term changes in parathyroid function after subtotal thyroidectomy for graves' disease.

BACKGROUND: Transient hypocalcemia is one of the postoperative complications of thyroidectomy for Graves' disease, and perioperative parathyroid hormone (PTH) assays are used to predict postoperative hypocalcemia. We evaluated long-term changes in parathyroid function after surgery for Graves' disease. METHODS: Serum PTH values were measured in Graves' patients with postoperative hypocalcemia, and those patients were followed postoperatively. RESULTS: Subtotal thyroidectomy was performed in 275 patients with Graves' disease. Their serum calcium levels were measured on postoperative day (POD) 1, and patients with transient postoperative hypocalcemia were treated with calcium and vitamin D supplementation and followed up. The amount of calcium and vitamin D supplementation was adjusted to keep the patient's serum calcium level within the normal range. Measurement of their serum intact PTH value on POD 1 revealed normal value in 18 patients, a below normal level in 22, and an above normal level in the other 2. During the follow-up period, the serum iPTH values remained normal in 12 patients, recovered to the normal level in 21 patients, and rose above the normal range in 9 patients. The serum iPTH values of all patients eventually reached the normal range during the follow-up period. A marked difference in preoperative serum alkaline phosphatase concentration was observed between the high-iPTH patients and the normocalcemic patients. CONCLUSIONS: The phenomenon of an elevated serum PTH level after surgery for Graves' disease was observed in 21% of the patients with postoperative hypocalcemia despite the achievement of normal serum calcium levels by calcium and vitamin D supplementation.

[Effectiveness of switch therapy for peritonitis].

The usefulness of switch therapy, from injection to oral medicine, for the treatment of peritonitis was evaluated. Thirty-five patients, who agreed to enroll the study, were randomly assigned to four treatment groups; one group treated with carbapenem antibacterial agent alone and three groups treated with switch therapy, in which injectable quinolone was switched to oral quinolone. For the intravenous administration group, if the patient showed the tendency of improvement by the third day, the intravenous injection was continued. However, if the patient did not show any improvement, the medication was changed to other medicine. For the switch therapy group, if the body temperature dropped to 37.5 degrees C or lower for at least 8 hours and if blood findings and clinical findings showed the tendency of improvement by the fourth day, the medication was switched to oral medicine. There was no difference in therapeutic effects among treatment groups. However, both duration of hospitalization and total medical costs were significantly reduced in the switch therapy groups comparing to those in the intravenous administration group. The results of this study showed that the switch therapy, from injection to oral medicine, was one of useful treatments in treating peritonitis.

[Miss-management in treatment failure of pulmonary tuberculosis].

PURPOSE: To investigate the risk factor of treatment failure of pulmonary tuberculosis excluding multi-drug resistant cases from the standpoint of both clinical management and tuberculosis control. OBJECT AND METHOD: Retrospective chart review of patients who admitted to Fukujuji Hospital for treatment failure of pulmonary tuberculosis excluding multi-drug resistant cases from Jan. 1993 to Dec. 2003. RESULTS: Out of 24 treatment failure cases available for analysis, 4 cases were associated with chronic tuberculous empyema with broncho-pleural fistula, and among them, chronic empyema was considered to be the main cause of treatment failure in one case. In 6 cases, poor adherence to medication was confirmed or suspected, and 2 of these 6 cases was also associated with miss-management. In 9 cases miss-management was found without poor adherence or chronic empyema, and in 8 out of these 9 cases, miss-management was considered to be the main cause of treatment failure. In 5 cases no apparent risk factor was found, but in 2 out of these 5 cases the ignorance of the results of drug sensitivity tests (and, therefore, miss-management) was strongly suspected. Summing up, in 10 out of 24 cases (41.7%), the miss-management was considered to be the main cause of treatment failure, and it was more frequently seen than poor adherence to medication. CONCLUSION: Clinicians should be aware of these risk factors of treatment failure such as chronic empyema, weak regimen in bacteriological negative cases, rifampicin+ethambutol regimen, and miss-management of drug adverse effect. From the standpoint of tuberculosis control in Japan we considered that, in addition to DOT, strategy to secure the quality of tuberculosis treatment is by all means needed.