Total thyroidectomy for Graves' disease-what do our patients think? A qualitative cohort study to evaluate the surgical management of Graves' disease.

INTRODUCTION: Total thyroidectomy for Grave's disease has been covered extensively in literature. There are established risks and side effects of the procedure, but in experienced hands, this is minimised. Studies show the physical complication rate of total thyroidectomy, but not a holistic view. The authors pose the question, "what do our patients really think"? Has there been a significant improvement in quality of life by doing this surgery? METHODS: A cohort of patients who underwent total thyroidectomy for Graves' disease between the dates 2015-2018. A total of 95 patients were identified. The Glasgow Benefit Inventory (GBI) was used to ascertain patient's opinions on their surgery. RESULTS: There were 54 responders, 46 female and 8 male. Average age was 41, with a range 20-81. Average GBI scores were 13.35 (SD 30.16). A general subset had an average score of 19.21 (SD = 32.59), a social subset average was 9.57 (SD = 25.61), and a physical subset was average -6.79 (SD = 37.40). Patients' feedback included positive and negative statements on their feelings surrounding pre-operative communication and post-operative side effects. CONCLUSION: Overall, the GBI scores are positive, thereby showing an improvement in quality of life since having total thyroidectomy for Graves. Pre-operative communication was of paramount importance. It should be made clear to patients that they will require medication after surgery. The majority of patients stated they would prefer to know about "minor" post -operative side effects like weight gain or mood change post op. This highlights the importance of the consenting process- Montgomery Ruling-that clinicians explain the risks involved with surgery according to what the patient would deem a risk. In addition, they must be informed of the non-surgical options available, therefore, surgeons should be able to discuss risks and benefits of radio-iodine and anti-thyroid drugs too.

Antipsychotics in Hyperthyroid-Related Psychosis: Case Report and Systematic Review.

OBJECTIVES: Hyperthyroidism has been associated with relatively rare presentations of psychotic symptoms. We report an example of the successful use of antipsychotics to manage psychotic symptoms in hyperthyroid-related psychosis. Furthermore, we systematically describe the available literature on the use of antipsychotics in this setting to determine the associated relative efficacies of the various antipsychotic agents. METHODS: Presentation of a case of hyperthyroid-related psychosis treated with an antipsychotic agent followed by a systematic review of all similar cases: PubMed, Ovid MEDLINE and PMC were searched for articles published between 1960 and 2017 that report on the use of specific antipsychotics in the management of hyperthyroid-related psychosis. RESULTS: An 81-year-old woman presented with hallucinations and delusions in the context of untreated Graves' Disease and was effectively treated with medical management of her thyroidopathy and psychopharmacologic management of psychotic symptoms. Systematic review revealed that typical and atypical antipsychotics have comparable efficacy in the management of psychotic symptoms in hyperthyroid-related psychosis. CONCLUSION: Choice of antipsychotic in hyperthyroid-related psychosis should be primarily based on side-effect profile and medical comorbidities. Risperidone is the optimal and seemingly effective choice for treating hyperthyroid-related psychosis in an elderly thyrotoxic patient.

Clinical and socioeconomic factors influence treatment decisions in Graves' disease.

BACKGROUND: Definitive treatment of Graves' disease includes radioactive iodine (RAI) and thyroidectomy, but utilization varies. We hypothesize that, in addition to clinical reasons, there are socioeconomic factors that influence whether a patient undergoes thyroidectomy or RAI. METHODS: Patients treated for Graves' disease between August 2007 and September 2013 at our university hospital were included. A comparative analysis of clinical and socioeconomic factors was completed. RESULTS: Of 427 patients, 300 (70 %) underwent RAI, whereas 127 (30 %) underwent surgery. Multiple factors were associated with surgery: younger age (mean 36 vs. 41 years, p < 0.01), female gender (33 vs. 19 % males, p = 0.01), black race (56 vs. 28 % nonblack, p < 0.01), Medicaid or uninsured (43 vs. 27 % private insurance or Medicare, p < 0.01), ophthalmopathy (38 vs. 26 %, p < 0.01), goiter (35 vs. 23 %, p < 0.01), and lowest quartile of median household income (38 vs. 27 % upper three quartiles, p = 0.03). Thyroidectomy increased annually, with 52 % undergoing surgery during the final year (p < 0.01). Adjusting for confounding, younger age (odds ratio [OR] 1.04; 95 % confidence interval [CI] 1.02, 1.05), female gender (OR 2.06; 95 % CI 1.06, 4.01), ophthalmopathy (OR 2.35; 95 % CI 1.40, 3.96), and later year of treatment (OR 1.66; 95 % CI 1.41, 1.95) remained significantly associated with surgery. CONCLUSIONS: Surgery has now become the primary treatment modality of choice for Graves' disease at our institution. Clinical factors are the main drivers behind treatment choice, but patients with lower SES are more likely to have clinical features best treated with surgery, underlying the importance of improving access to quality surgical care for all patients.

Exploring the experiences of people with hypo- and hyperthyroidism.

Thyroid diseases evoke a complex range of psychological and physical symptoms. The psychosocial aspects of living with diseases causing hypo- or hyperthyroidism are poorly understood. In this article, we report the findings of a qualitative interview study in which we explored the lived experiences of 16 people with hypo- or hyperthyroidism. We purposefully selected participants from Danish outpatient clinics according to their diagnosis (Hashimoto's thyroiditis or Graves' disease with or without orbitopathy), age (18 to 65 years), and duration of treatment (more than 6 months). We used interpretative phenomenological analysis (IPA) as a theoretical frame and analytical approach and identified three superordinate themes: losing control over mental and physical states, ambiguous signs of disease, and negotiating sickness. We discuss the findings in the context of the recent literature on chronic illness and argue that these themes play an important role in the conceptualization and management of thyroid diseases.

Examination of quality of life and psychiatric symptoms in childhood Graves' disease.

OBJECTIVES: The aim of our study is to examine the emotional, behavioral problems, and psychiatric symptoms of children diagnosed with Graves' disease (GD), to assess their quality of life, and to compare with control group. METHODS: The research was planned as a cross-sectional study and included 16 patients with GD (13 female and three male) and 29 healthy children for control group (19 female and 10 male). Sociodemographic form, Pediatric Quality of Life Inventory, Revised Child Anxiety and Depression Scale-Child Version (RCADS-CV), Strengths and Difficulties Questionnaire (SDQ), Turgay DSM-IV-Based Child and Adolescent Behavior Disorders Screening and Rating Scale (T-DSM-IV-S), and Affective Reactivity Index scale were applied to the children and their families. RESULTS: Eighty one percent of GD group (GG) (n=13, mean age 15.1 ± 2.2) and 66 % of control group (CG) (n=19, 14.6 ± 2.2) were girls. No significant difference was found between GG and CG in terms of quality of life, anxiety, and depression scores. GG had higher scores in affective reactivity index, SDQ-P total score, and T-DSM-IV-S total scores (p values 0.039; 0.009; 0.023, respectively). While no significant difference was detected in the T-DSM-IV-S-inattention and hyperactivity scores, significantly higher scores were detected in oppositional defiance and conduct disorder scores (p values 0.172; 0.294; 0.019; 0.027, respectively). CONCLUSIONS: In children with GD, irritability, oppositional defiant, and conduct disorder symptoms have been detected. Children with these mental health symptoms experience behavioral and emotional difficulties in their daily lives. It is important to follow up children with GD for possible comorbid psychiatric disorders.

Does thyroid surgery for Graves' disease improve health-related quality of life?

PURPOSE: Graves' disease can induce alterations of the psychosocial well-being that negatively influence the overall well-being of patients. Among the current treatments, surgery has limited indications, and its impact on the health-related quality of life has not been well clarified. The aim of this study was to assess the impact of surgery on the quality of life. METHODS: Fifty-seven patients who underwent total thyroidectomy for Graves' disease in our surgical unit between April 2002 and December 2009 were administered a questionnaire concerning four issues: organic alterations and clinical manifestations, neurovegetative system disturbances, impairment of daily activities, psychosocial problems. Patients were retrospectively questioned after thyroidectomy about the presence of these symptoms in both the pre and postoperative periods. RESULTS: There was a significant improvement after surgery in all four areas. Organic manifestations and psychosocial problems had higher average improvements, as did some aspects of the neurovegetative system and difficulties in undertaking daily activities. There were no reports of a worsening of symptoms. CONCLUSIONS: Surgery resolved the hyperthyroidism in 100 % of cases, and was associated with a quality of life improvement of about 70 % in the patients. Surgery can therefore provide an immediate and effective resolution of Graves' disease, with benefits in health-related quality of life.

Thyroxine, shape, and weight: interaction of Graves' disease and bulimia nervosa.

OBJECTIVE: A case of a 25-year-old woman with bulimia nervosa and Graves' disease is presented. Graves' disease is the cause of 50-80 % of hyperthyroidism. The disease is characterized by increases of thyroid hormone production, activation of the metabolism, and successive weight loss. Bulimia nervosa is characterized by purging behavior after binge eating episodes. METHOD AND RESULTS: We report a patient suffering from both entities. A pronounced non-compliance to the intake of antithyroid drugs (Carbimazole) correlated with eating disorder symptoms like negative evaluation of the body and fear of weight gain. Thus, elevated hyperthyroidism due to Graves' disease served as a purging method. During 8 weeks of inpatient psychotherapy, the patient adapted to a structured eating behavior. Self-esteem was less influenced by body shape and body weight, and compliance to endocrinological recommendations improved. CONCLUSION: Non-compliance to antithyroid drugs may be a symptom of an eating disorder. A careful and primarily non-confronting interdisciplinary diagnostic and treatment approach is required.

Effect of stressful life events on the initiation of graves' disease.

OBJECTIVE: The aim of this study was to investigate the relationship between stressful life events (LESs) and its effect on the initiation of Graves' disease (GD) and toxic nodular goitre (TNG). PATIENTS AND METHOD: Forty-five patients with GD, 24 patients with TNG and 36 healthy control (CG) were included to the study. Graves and TNG patients had diagnosed within the last 12 months, with clinical and biochemical confirmation in Endocrinology Metabolism Outpatient Clinic of Cerrahpasa Medical School. The Holmes-Rahe Stress Scale and the Life Experience Survey (LES) was the psychological evaluation instrument used in this study. RESULTS: There was no significant difference according to Holmes-Rahe scale (Graves & TNG P = 0.329, Graves & Control P = 0.115, TNG and control P = 0.571). According to LES scale when negative event number, positive event number, neutral events and their effects are considered, between Graves and TNG groups no statistically difference was observed (P = 0.139, P = 0.083, P = 0.167, P = 0.162, P = 0.861). The number and impact of negative SLEs were significantly higher in GD compared to CG (P = 0.015, P < 0.001). CONCLUSION: According to LES scale GD patients has significant difference with respect to CG when negative event number and impact are considered.

An assessment of psychiatric disturbances in Graves disease in a medical college in eastern India.

BACKGROUND: Graves' disease is a unique conglomeration of cardiovascular, neurological, ophthalmological, and other systemic manifestations. In this study we have tried to explore the psychiatric dimensions of this disease. AIMS: This study attempted to explore clinical features, types, and treatment outcome of psychiatric disturbances in Graves disease. STUDY DESIGN: This is a purposive study following the criteria of DSM IV. MATERIALS AND METHODS: A total of 36 adult patients of newly diagnosed Graves disease and 30 age- and sex-matched controls were included. Data enumerated were age, sex, date of admission, analysis of psychiatric signs, and symptoms by one independent observer, diagnostic categorization, effect of treatment, and outcome. Follow-up evaluation was done after 1 year. Statistical Analysis : Statistical analysis was done by the standard error of difference, the chi-square test, and paired Student's T-test. RESULTS: Among 36 patients 32 were female and 4 were male. Fifteen patients (41.67%) were diagnosed with generalized anxiety disorders (GAD), 6 (16.67%) with mood disorder, 6 (16.67%) with obsessive compulsive disorder (OCD), and 2 each with personality disorder and schizophreniform disorder. The common symptoms were insomnia, irritability, and anxiety. The frequency of GAD was statistically more significant in the Graves disease group in comparison to control. Fourteen patients agreed to take both antithyroid and antipsychotropic medications (group 1). The rest were treated with only antithyroid drug (group 2). There was significant improvement in both groups and no difference between the groups. CONCLUSION: The prevalence of certain psychiatric manifestations in Graves' disease was significantly higher than in the control group. There was no significant difference between therapy with antithyroid drugs and combination of antithyroid with psychotropic medications.

Behavioral assessment of children and adolescents with Graves' disease: A prospective study.

Previous studies have identified frequent comorbid neuropsychiatric disorders and conditions in adults with thyrotoxicosis. These studies are scarce or even lacking in pediatric population. This work aimed to study the behavior of children and adolescents with Graves' disease (GD). This study included 35 children with GD (boys = 15; girls = 25; mean age: 11.45±1.50yrs) and 40 healthy children (boys = 20; girls = 20; mean age: 12.54±1.62yrs). Behavior was assessed using Child Behavior Checklist (CBCL). Children with GD were assessed during periods of thyroid hormone elevation (active disease) and normalized thyroid hormones (with anti-thyroid drugs or ATDs). Compared to healthy children, patients during periods of thyroid hormone elevation (74.29%) and normalized thyroid hormones (31.43%) had higher frequencies of behavioral abnormalities and scorings of total CBCL scale (P = 0.01; P = 0.04, respectively) and its subscales' [Anxious/Depressed (P = 0.02; P = 0.04), Withdrawn/Depressed (P = 0.03; P = 0.04) and Somatic Complaints (P = 0.03; P = 0.127) and Social (P = 0.01; P = 0.225), Thought (P = 0.01; P = 0.128) and Attention (P = 0.01; P = 0.01) problems], indicating internalizing and externalizing problems. The majority of patients had at least two different behavioral problems. Marked improvement was found during period of normalized thyroid hormones (P = 0.001). Correlation analyses showed significant associations between total CBCL scoring and age at onset (P = 0.01; P = 0.001) and lower concentrations of thyroid stimulating hormone (TSH) (P = 0.001; P = 0.04) and higher concentrations of free thyroxine (fT4) (P = 0.01; P = 0.02), triiodothyronine (fT3) (P = 0.01; P = 0.03) and thyrotropin receptor antibodies (TRAbs) (P = 0.001; P = 0.01) during periods of thyroid hormone elevation and normalized thyroid hormones, respectively. Multiple linear regression analysis showed that "at presentation" lower concentrations of TSH (P = 0.001; P = 0.03) and higher concentrations of fT4 (P = 0.001, P = 0.01), fT3 (P = 0.01; P = 0.06) and TRAbs (P = 0.001; P = 0.001) were predictors of behavioral problems during periods of active disease and normalized thyroid hormones. We conclude that GD is associated with higher frequencies and severities of anxiety, depression and inattention during periods of thyroid hormone elevation as well as normalized thyroid hormones with ATDs. Therefore, early diagnosis and optimizing management are required to improve children's social life.

[Mood of individuals with Graves-Basedow's disease and Hashimoto's disease]. / Nastrój osób z choroba Gravesa-Basedowa i choroba Hashimoto.

INTRODUCTION: Mood can be characterized as subjective, relatively long lasting emotional state. The impact of the mood on health can be considered in two aspects: mood as an intermediary factor/cause of disease or as its result. The aim of following paper was to define the mood of individuals with Graves-Basedow's disease Hashimoto's disease in comparison to each other and in comparison to healthy individuals. MATERIAL AND METHODS: The study group consisted of 70 individuals with Graves-Basedow's disease (56 women and 14 men) and the same amount of healthy ones. The study group of Hashimoto's disease consisted of 54 individuals (46 women and 8 men) and the same amount of healthy ones. The patients filled out three psychological methods: Profile of Mood States (POMS), University of Wales Institute of Science and Technology Mood Adjective Check List (UMACL), a personal survey and an analysis of the medical documentation. RESULTS: Results indicate difference between individuals with Graves-Basedow's disease and healthy ones taking under consideration mood: anger and tension, dejection, embarrassment and vigor. There is no difference between individuals with Hashimoto's disease and healthy ones considering mood. There are differences between Graves-Basedow's disease and Hashimoto's disease regarding tension - anger. No differences have been claimed concerning criterions of health such as: time of duration of disease, complications, coexisting other diseases. Nevertheless the level of hormones is connected with the mood. CONCLUSIONS: In case of Graves-Basedow's disease has been claimed stronger anger, sadness, embarrassment and less vigor. Individuals with Hashimoto's disease are regarded as similar to the healthy ones, without features of forced depression, irritability or embarrassment. To sum up the mood of individuals among testing group is a result of disease.

The relationship between quality of life, cognition, and thyroid status in Graves' disease.

PURPOSE: To assess quality of life (QoL) and cognitive function among Graves' disease (GD) patients with different thyroid status, with and without ophthalmopathy. METHODS: This is a cross-sectional clinic-based study involving 154 patients with GD (81.27% were female, mean age 45.6 ± SD 11.2 years) and 54 (35.06%) had ophthalmopathy. Data were collected after an informed consent from all patients was obtained. All patients completed the 36-Item Short Form Health Survey and Mini-Mental State Examination. Patients with ophthalmopathy also completed the Graves' Orbitopathy Quality of Life Questionnaire. RESULTS: Patients with hyperthyroidism presented a greater impairment in QoL when compared to euthyroidism group. A lower score in physical role functioning was found in both subgroups with active disease (hyperthyroidism and euthyroidism using thionamides). A lower score was also seen in visual function, only in patients with hyperthyroidism, without difference in appearance. No difference was found in cognition between patients. Younger ages at diagnosis, male sex, euthyroidism and absence of ophthalmopathy were factors associated with better QoL, as well as a shorter disease duration was associated with better recall, attention and calculation. CONCLUSIONS: An impairment in QoL among patients with active GD was evidenced, even in those receiving thionamides and in euthyroidism. Ophthalmopathy was a factor associated with a poor QoL and no clear evidence of cognitive impairment was demonstrated.

Structural brain changes in hyperthyroid Graves' disease: protocol for an ongoing longitudinal, case-controlled study in Göteborg, Sweden-the CogThy project.

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).

[Inactive Graves' ophthalmopathy and self-esteem]. / Auto-estima na forma inativa da oftalmopatia de Graves.

PURPOSE: To assess the self-esteem of Graves' ophthalmopathy patients in the inactive phase. METHODS: Thirty euthyroid patients were evaluated in the inactive phase of disease with age ranging from 26 to 65 years, average of 43 +/- 11,0 years, called study group and 39 individuals without Graves' ophthalmopathy with age ranging from 18 to 67 years, average of 41 +/- 13,4 years, selected from the general population called control group. To evaluate the self-esteem the Rosenberg UNIFESP/EPM self-esteem scale, applied by means of an interview, was utilized. The self-esteem scores in the two studied groups were compared by means of the non-parametric Mann-Whitey test. The same test was applied to compare the obtained scores in the Graves' ophthalmopathy group considering disease severity. RESULTS: No alteration with statistical significance in Graves' ophthalmopathy patients' self-esteem was observed (P=0.057). The study group presented, on average, lower self-esteem values when compared with the control group. There was no difference of self-esteem mild and moderate-severe patients (P=0.2710). CONCLUSION: Graves' ophthalmopathy in the inactive phase did not affect the patients' self-esteem in the group studied.

[Working memory and executive functions in hyperthyroid patients with Graves' disease]. / Pamiec operacyjna i funkcje wykonawcze w nadczynnosci tarczycy w przebiegu choroby Gravesa i Basedowa.

AIM: The aim of the study was to assess working memory and executive dysfunctions, as well as the intensity of depressive symptoms in hyperthyroid patients with Graves' disease compared to healthy persons. METHOD: Thirty (30) patients with Graves' disease (20 female, 10 male), aged 18-55, participated in the study. The control group consisted of 31 healthy persons matched by age, gender and educational level with the examined group. The assessment of working memory and executive functions was estimated by the Wisconsin Card Sorting Test and the N-back test. The intensity of depressive symptoms was assessed by the Beck Depression Inventory. RESULTS AND CONCLUSIONS: In comparison to healthy subjects, significant disturbances of working memory and executive functions were noted in hyperthyroid patients with Graves' disease. Longer disease duration was associated with worse results in neuropsychological tests, while higher educational level of the patient resulted in better test outcomes. In the group of patients with Graves' disease, 1/3rd of them presented with a significant intensity of depression symptoms; additionally, the intensity of depression symptoms correlated with cognitive function impairments in the whole group of the patients studied.

[Dispositional optimism and acceptance of illness among a group of individuals with Graves-Basedow's disease]. / Dyspozycyjny optymizm a akceptacja choroby w grupie osób z choroba Gravesa-Basedowa.

INTRODUCTION: Dispositional optimism is a general tendency to positively perceive the world and one's own future. We can consider what kind of connection with ability to cope with difficulties. One situation which is very stressful for an individual is an illness, particularly a chronic one. The aim of the paper was to define the connection between dispositional optimism and acceptance of illness among the group with Graves-Basedow disease. This is autoimmunizational illness and diseases of this kind are particularly sensitive to the influence of psychological factors, as there are many connections between the immune system and the human psyche. MATERIAL AND METHODS: The study group consisted of 59 individuals with Graves-Basedow disease, 50 women and 9 men and 55 of healthy ones, 49 women and 6 men according to age, sex and a level of education. The patients filled out three psychological questionnaires: The Life Orientation Test-Revised (LOT-R), The Acceptance of Illness Scale (AIS) and The Personal Questionnaire. RESULTS: of the study in question indicate a lack of differences between individuals with Graves-Basedow disease and healthy ones concerning the level of dispositional optimism. There no differences in the level of dispositional optimism as regards of criterion of health: by the levels of hormones TSH, fT3 and fT4, complications and a time of duration of disease. Instead, if they suffer additionally from others diseases, they have a lower level of dispositional optimism. There exist a connection between intensification of level of dispositional optimism and acceptance of illness among testing group. CONCLUSIONS: The dispositional optimism as a supply of individual helps her or his in adaptation to difficulty situation, which is a chronic disease. It is a reason way it is worth to help of patients to grow it stronger.