Graves' disease in children: long-term outcomes of medical therapy.

BACKGROUND AND OBJECTIVES: Management options are limited for the treatment of Graves' disease, and there is controversy regarding optimal treatment. We describe the demographic and biochemical characteristics of children with Graves' disease and the outcomes of its management. METHODS: This is a retrospective study reviewing medical records from 2001 to 2011 at a tertiary-care paediatric hospital. Diagnostic criteria included elevated free T4 and total T3, suppressed TSH, and either positive thyroid-stimulating immunoglobulin or thyroid receptor antibodies or clinical signs suggestive of Graves' disease, for example exophthalmos. Patients were treated with antithyroid drugs (ATD), radioactive iodine, or thyroidectomy. The main outcome measures were remission after medical therapy for at least 6 months and subsequent relapse. RESULTS: A total of 291 children met diagnostic criteria. A total of 62 were male (21%); 117 (40%) were Hispanic, 90 (31%) Caucasian, and 59 (20%) African American. Mean age (±standard deviation) at diagnosis was 12·3 ± 3·8 (range 3-18·5) years. At diagnosis, 268 patients were started on an antithyroid drug and 23 underwent thyroid ablation or thyroidectomy. Fifty-seven (21%) children achieved remission and 16 (28%) of these patients relapsed, almost all within 16 months. Gender and ethnicity did not affect rates of remission or relapse. Of 251 patients treated with methimazole, 53 (21%) had an adverse reaction, including rash, arthralgias, elevated transaminases, or neutropenia. CONCLUSIONS: Most children with Graves' disease treated with ATD do not experience remission, but most remissions do not end in relapse. Adverse reactions to methimazole are common but generally mild.

Evaluation of a workshop to improve residents' patient-centred obesity counselling skills.

BACKGROUND: Primary care physicians are being asked to counsel their patients on obesity and weight management. Few physicians conduct weight loss counselling citing barriers, among them a lack of training and confidence. Our objective was to pilot test the effectiveness of a 3-h interactive obesity-counselling workshop for resident physicians based on motivational interviewing (MI) techniques. DESIGN: This study used a pretest/post-test cross-sectional design. A convenience sample of resident physicians was invited to participate. Participating resident physicians completed a preintervention and postintervention questionnaire to assess their knowledge, beliefs and confidence in obesity counselling. MI techniques taught in the intervention were evaluated by audio recording interviews with a standardised patient (SP) pre intervention and post intervention. Audio recordings were transcribed and coded by two independent coders using a validated assessment tool. Paired t tests were used to assess preintervention and postintervention differences. RESULTS: Eight-six residents attended the workshop. At baseline, the majority (71%) felt that there is not enough time to counsel patients about obesity and only 24% felt that residency trained them to counsel. After the intervention, knowledge and confidence in counselling increased (p<0.001). Among the 55 residents with complete pre-post SP interview data, MI adherent statements increased from a mean of 2.88 to 5.42 while the MI non-adherent statements decreased from 6.73 to 2.33 (p<0.001). CONCLUSIONS: After a brief workshop to train physicians to counsel on obesity-related behaviours, residents improved their counselling skills and felt more confident on counselling patients. Future studies are needed to assess whether these gains are sustained over time.

Primary hyperparathyroidism with low intact PTH levels in a 14-year-old girl.

CONTEXT: Primary hyperparathyroidism (PHPT) is usually associated with hypercalcemia and inappropriately elevated serum PTH. OBJECTIVE: Our objective was to identify the reason(s) for a low serum intact PTH in a child with PHPT. SUBJECT AND METHODS: A 14-yr-old Caucasian girl presented with pancreatitis, nephrolithiasis, hypercalcemia ranging from 13.2 to 17.5 mg/dl, and a low serum intact PTH. She had an ultrasound and technetium-99m-sestamibi scintigraphy confirming the presence of a parathyroid adenoma. RESULTS: The preoperative serum intact PTH assays performed at Quest Diagnostics, Nichols Institute, were low even after serial dilutions, whereas the intraoperative turbo PTH assay was elevated at 3618 pg/ml. C-terminal and cyclase-activating PTH assays for PTH were also elevated. PTH gene sequence analysis performed from DNA extracted both from the parathyroid adenoma and the patient's peripheral blood leukocytes was negative for a mutation in the PTH gene sequence. CONCLUSIONS: The contrasting values on the intact PTH assay and the turbo PTH assay suggest that the adenoma was producing an aberrant PTH molecule that was not detected by the routine intact PTH assay. Because there was no change in PTH gene sequence, this could be indicative of a posttranslational change in the PTH molecule that would not be recognized solely by DNA sequencing. Therefore, a low or normal PTH measurement against the backdrop of clinical and biochemical hyperparathyroidism needs measurement with a variety of assays.

Training residents in obesity counseling: incorporating principles of motivational interviewing to enhance patient centeredness.

BACKGROUND: The US Preventive Services Task Force and the American Academy of Pediatrics recommend that physicians screen patients for obesity and practice counseling interventions to achieve modest (4%-8%) weight loss. Despite this, physicians frequently do not document obesity and/or counsel on weight loss. Our goal was to develop an innovative, easily disseminated workshop to improve resident physicians' skills and confidence in weight-loss counseling. METHODS: We developed a tailored 3-hour interactive Obesity Counseling Workshop. The approach incorporates principles of motivational interviewing, a set of listening and counseling skills designed to enhance patient centeredness and promote behavior change. Adult learning theory served as the foundation for program delivery. The half-day session is administered monthly to internal medicine and pediatric residents on outpatient rotations. KEY RESULTS: To date 77 residents (44 internal medicine and 33 pediatric) have completed the workshop, with approximately even distribution of postgraduate year (PGY)-1, PGY-2, and PGY-3 level residents. Forty-two were women and less than half planned to pursue a primary care-oriented career. Residents completed a 10-item workshop evaluation, with each category scoring an average of 3.5 or greater on a 4-point Likert scale. Residents reported the workshop was well organized and addressed an important topic; they enjoyed the role-playing with observation and feedback. CONCLUSIONS: Residents welcomed the opportunity to participate in an interactive workshop focused on obesity counseling and behavior change, and particularly liked putting new skills into practice with role-playing and receiving real-time feedback. Future analyses will determine the workshop's effect on knowledge, skills, and self-efficacy.