Thymic Hyperplasia and Graves Disease: Management of Anterior Mediastinal Masses in Patients with Graves Disease

ObjectiveTo describe a case of an anterior mediastinal mass (AMM) in a patient with Graves disease.MethodsWe report the clinical presentation, diagnosis, management, and outcome of a 34-year-old man with dyspnea on exertion.ResultsInitial evaluation of the patient’s complaints revealed a large AMM on chest radiography and then chest computed tomography. After occurrence of additional symptoms, the patient was diagnosed as having Graves disease and treated with antithyroid medications. Despite an appropriate biochemical response, he continued to experience severe dyspnea on exertion. A repeated computed tomographic scan 8 weeks after initiation of therapy showed no appreciable decrease in size of the AMM. He elected to undergo thymectomy. An intraoperative phrenic nerve injury resulted in a paralyzed left hemidiaphragm, leaving the patient with considerable difficulties in his career and profoundly decreased exercise tolerance.ConclusionThe differential diagnosis of an AMM includes several malignant lesions with a risk often warranting early surgical excision. In light of the association of benign thymic hyperplasia with Graves disease, thymectomy may be delayed in expectation of thymic regression with medical therapy. The timing of regression is variable, and very few reports exist in the literature. In our current case, the patient opted for thymectomy relatively early and had an unfortunate complication. The lack of clinical evidence regarding management of an enlarged thymus in patients with Graves disease, however, makes management decisions more difficult. (Endocr Pract. 2009;15: 534-539)     

Medical Management of Extrathyroidai-Man I Festation of Graves Disease

ObjectiveTo review preventive measures and the current medical management of extrathyroidal manifestation of Graves disease and to provide an overview of potential immune therapies.MethodsA literature review of investigative trials of treatments for Graves disease and its extrathyroidal manifestations.ResultsGiven new knowledge of the stages of the autoimmune cascade responsible for the development of these extrathyroidal manifestations, the possibility has been raised of performing randomized trials of agents shown to provide benefits in other immune conditions. Two randomized trials on the efficacy of rituximab in moderate-to-severe Graves ophthalmopathy have reported conflicting results.ConclusionAdditional studies of rituximab and other agents are needed before they become routinely used in treating Graves disease. Meanwhile, the standard medical therapy for moderate-to-severe ophthalmopathy is intravenous (IV) or oral corticosteroids and, for dermopathy, local corticosteroid application with occlusive dressing. Because major adverse effects such as life-threatening hepatic failure can occur with very high doses of IV prednisolone, the cumulative total dose should not exceed 8 g. (Endocr Pract. 2014;20:1333-1344)     

Gender Influences the Clinical Presentation and Long-Term Outcome of Graves Disease

Objective: The outcome of antithyroid drug (ATD) treatment for Graves disease (GD) is difficult to predict. In this study, we investigated whether male gender, besides other factors usually associated with a poor outcome of ATD treatment, may affect disease presentation and predict the response to medical treatment in subjects with GD.Methods: We studied 294 patients with a first diagnosis of GD. In all patients, ATD treatment was started. Clinical features, thyroid volume, and eye involvement were recorded at baseline. Serum levels of free thyroxine (FT4), free triiodothyronine (FT3), thyroid-stimulating hormone (TSH), and TSH-receptor antibodies (TRAb) were measured at baseline and during the follow-up. Treatment outcome (FT4, FT3, and TSH serum levels and further treatments for GD after ATD withdrawal) was evaluated.Results: When compared to women, men showed a significantly larger thyroid volume and a higher family positivity for autoimmune diseases. During ATD, the mean serum levels of TSH, FT4, FT3, and TRAb did not differ between groups. Within 1 year after ATD discontinuation, relapse of hyperthyroidism was significantly more frequent in men than in women. Within the 5-year follow-up period, the prevalence of men suffering a late relapse was higher compared with that of women. The outcome at the end of the 5-year follow-up period was significantly associated with gender and TRAb levels at disease onset.Conclusion: Male patients with GD have a poorer prognosis when submitted to medical treatment with ATDs. A larger goiter at presentation and a stronger genetic autoimmune background might explain this gender difference in patients with GD.Abbreviations:ATD = antithyroid drugFT3 = free triiodothyronineFT4 = free thyroxineGD = Graves diseaseGO = Graves orbitopathyRAI = radioiodineTRAb = thyroid-stimulating hormone-receptor antibodyTSH = thyroid-stimulating hormone     

Atrial Fibrillation Management Strategies in Routine Clinical Practice: Insights from the International RealiseAF Survey

Background

Atrial fibrillation (AF) can be managed with rhythm- or rate-control strategies. There are few data from routine clinical practice on the frequency with which each strategy is used and their correlates in terms of patients’ clinical characteristics, AF control, and symptom burden.

Methods

RealiseAF was an international, cross-sectional, observational survey of 11,198 patients with AF. The aim of this analysis was to describe patient profiles and symptoms according to the AF management strategy used. A multivariate logistic regression identified factors associated with AF management strategy at the end of the visit.

Results

Among 10,497 eligible patients, 53.7% used a rate-control strategy, compared with 34.5% who used a rhythm-control strategy. In 11.8% of patients, no clear strategy was stated. The proportion of patients with AF-related symptoms (EHRA Class > = II) was 78.1% (n = 4396/5630) for those using a rate-control strategy vs. 67.8% for those using a rhythm-control strategy (p<0.001). Multivariate logistic regression analysis revealed that age <75 years or the paroxysmal or persistent form of AF favored the choice of a rhythm-control strategy. A change in strategy was infrequent, even in patients with European Heart Rhythm Association (EHRA) Class > = II.

Conclusions

In the RealiseAF routine clinical practice survey, rate control was more commonly used than rhythm control, and a change in strategy was uncommon, even in symptomatic patients. In almost 12% of patients, no clear strategy was stated. Physician awareness regarding optimal management strategies for AF may be improved.     

A Multi-Site Knowledge Attitude and Practice Survey of Ebola Virus Disease in Nigeria

Background

The 2014 Ebola Virus Disease (EVD) outbreak was characterised by fear, misconceptions and irrational behaviours. We conducted a knowledge attitude and practice survey of EVD in Nigeria to inform implementation of effective control measures.

Methods

Between July 30^th and September 30^th 2014, we undertook a cross sectional study on knowledge, attitude and practice (KAP) of Ebola Virus Disease (EVD) among adults of the general population and healthcare workers (HCW) in three states of Nigeria, namely Bayelsa, Cross River and Kano states. Demographic information and data on KAP were obtained using a self-administered standardized questionnaire. The percentage KAP scores were categorised as good and poor. Independent predictors of good knowledge of EVD were ascertained using a binary logistic regression model.

Results

Out of 1035 study participants with median age of 32 years, 648 (62.6%) were males, 846 (81.7%) had tertiary education and 441 (42.6%) were HCW. There were 218, 239 and 578 respondents from Bayelsa, Cross River and Kano states respectively. The overall median percentage KAP scores and interquartile ranges (IQR) were 79.46% (15.07%), 95.0% (33.33%) and 49.95% (37.50%) respectively. Out of the 1035 respondents, 470 (45.4%), 544(52.56%) and 252 (24.35%) had good KAP of EVD defined using 80%, 90% and 70% score cut-offs respectively. Independent predictors of good knowledge of EVD were being a HCW (Odds Ratio-OR-2.89, 95% Confidence interval-CI of 1.41–5.90), reporting ‘moderate to high fear of EVD’ (OR-2.15, 95% CI-(1.47–3.13) and ‘willingness to modify habit’ (OR-1.68, 95% CI-1.23–2.30).

Conclusion

Our results reveal suboptimal EVD-related knowledge, attitude and practice among adults in Nigeria. To effectively control future outbreaks of EVD in Nigeria, there is a need to implement public sensitization programmes that improve understanding of EVD and address EVD-related myths and misconceptions, especially among the general population.     

Frequency of Flame Sensor Activation in Public Places after Administration of Radioactive Iodine to Treat Graves Disease: A Recent Survey

Objective: Ultraviolet (UV)-perception-type flame sensors detect gamma rays emitted from iodine 131 (¹³¹I). Explaining the possibility of flame sensor activation to patients when they receive ¹³¹I to treat Graves disease or other ablative purposes is important. We investigate the current situation of flame sensor activation after radioactive iodine (RAI) therapy.Methods: A total of 318 patients (65 males and 253 females) with Graves disease who received RAI therapy at our clinic between November 2007 and June 2014 participated in this study. Patients were given both written and oral explanations regarding the possibility of flame sensor activation. Participants were surveyed with a questionnaire. The following question was asked: “Did the fire alarm (flame sensor) go off when you used a restroom in places like shopping centers within a few days after your isotope therapy?” To those who answered “yes,” we asked where the fire alarm had gone off.Results: Of the 318 patients, 19 (6.0%) answered “yes,” 2 of whom were male while 17 were female. Of the 299 (94.0%) patients who answered “no,” 63 were male and 236 were female. As to the place of restroom sensor activation, shopping centers were reported by 9 patients; supermarkets by 5; airports by 2; and a bookstore, the Kyushu Shinkansen (bullet train), and a hospital by 1 each.Conclusion: Explaining to patients the possibility of flame sensor activation after RAI therapy is important to avoid some complications, especially in security-sensitive areas.Abbreviations:¹³¹I = iodine 131RAI = radioactive iodineUV = ultra-violet     

专业护理硕士研究生临床实践模式指标初步构建

目的:了解护理专家对专业学位护理研究生临床实践的观点,旨在构建出一套合理的专业学位护理硕士研究生临床实践的问卷,为进一步调查专业学位护理硕士研究生临床实践奠定基础。方法:通过文献回顾,理论分析的方法自制问卷,自制问卷经专家函询后进行修正,各个条目经信度和效度检验。结果:回收的数据经SPSS17.0信度和效度检验后,每组专家的内容效度在0.741~1.000之间,问卷整体的内容效度(CVI)为0.951,问卷的信度为0.926。结论:最终形成的临床实践模式指标的问卷,可以用于专业学位护理研究生临床实践的现场发放。     

Modeling Relapsing Disease Dynamics in a Host-Vector Community

Vector-borne diseases represent a threat to human and wildlife populations and mathematical models provide a means to understand and control epidemics involved in complex host-vector systems. The disease model studied here is a host-vector system with a relapsing class of host individuals, used to investigate tick-borne relapsing fever (TBRF). Equilibrium analysis is performed for models with increasing numbers of relapses and multiple hosts and the disease reproduction number, R₀, is generalized to establish relationships with parameters that would result in the elimination of the disease. We show that host relapses in a single competent host-vector system is needed to maintain an endemic state. We show that the addition of an incompetent second host with no relapses increases the number of relapses needed for maintaining the pathogen in the first competent host system. Further, coupling of the system with hosts of differing competencies will always reduce R₀, making it more difficult for the system to reach an endemic state.     

提高医院传染病管理的实践

目的：总结解放军第302医院在防控传染病方面所践采取的措施,提高医院传染病管理相关工作。方法：完善传染病管理组织,明确责任;认真落实传染病管理相关制度;加强相关知识培训,强化医护人员责任意识,提高能动性、自觉性。总结分析以上相关措施实施后,2005年-2010年期间传染病报告情况。结果：2005年-2010年每年传染病疫情报告卡填写完整率逐渐提高,医院传染病报告漏报率呈逐年下降趋势,近两年呈现填写完整无漏报的情况。结论：提高医院传染病管理的相关措施的实施,使医护人员对的传染病防控意识有所提高,做到早发现、早报告、早隔离、早治疗,降低传染病传播风险,有效减少了医院交叉感染的发生,保障人们的生命健康和社会的发展稳定。     

Graves Hyperthyroidism and Pregnancy: A Clinical Update

ObjectiveTo provide a clinical update on Graves’ hyperthyroidism and pregnancy with a focus on treatment with antithyroid drugs.MethodsWe searched the English-language literature for studies published between 1929 and 2009 related to management of hyperthyroidism in pregnancy. In this review, we discuss differential diagnosis of hyperthyroidism, management, importance of early diagnosis, and importance of achieving proper control to avoid maternal and fetal complications.ResultsDiagnosing hyperthyroidism during pregnancy can be challenging because many of the signs and symptoms are similar to normal physiologic changes that occur in pregnancy. Patients with Graves disease require prompt treatment with antithyroid drugs and should undergo frequent monitoring for signs of fetal and maternal hyperthyroidism and hypothyroidism. Rates of maternal and perinatal complications are directly related to control of hyperthyroidism in the mother. Thyroid receptor antibodies should be assessed in all women with hyperthyroidism to help predict and reduce the risk of fetal or neonatal hyperthyroidism or hypothyroidism. The maternal thyroxine level should be kept in the upper third of the reference range or just above normal, using the lowest possible antithyroid drug dosage. Hyperthyroidism may recurin the postpartum period as Graves disease or postpartum thyroiditis; thus, it is prudent to evaluate thyroid function 6 weeks after delivery. Preconception counseling, a multidisciplinary approach to care, and patient education regarding potential maternal and fetal complications that can occur with different types of treatment are important.ConclusionPreconception counseling and a multifaceted approach to care by the endocrinologist and the obstetric team are imperative for a successful pregnancy in women with Graves hyperthyroidism. (Endocr Pract. 2010;16:118-129)     

Regional Enteritis: Disease Patterns and Medical Management

The clinical picture of regional enteritis was reviewed in 98 cases collected from five hospitals in the City of Edmonton. There was no apparent racial prevalence, although only one case was reported among Indians and Eskimos. More than one-half had their onset between the ages of 11 and 30 years. Men were more commonly affected than women. The onset in 44 patients was acute and closely mimicked acute appendicitis. Twenty-eight patients had had abdominal surgery prior to the onset of symptoms. Major symptoms were abdominal pain, diarrhea and weight loss. Abdominal tenderness, fever and abdominal mass were the most consistent physical signs. The most valuable diagnostic procedure was radiological examination of the bowel. Complications were largely confined to the gastrointestinal tract. In the majority of cases, surgery was the ultimate form of therapy.     

Characteristics of Graves Disease in HIV-Infected Patients on Antiretroviral Therapy

ObjectiveTo demonstrate clinical and laboratory characteristics of Graves disease in human immunodeficiency virus (HIV)-infected patients on antiretroviral therapy (ART).MethodsThis is a single-institution study. All HIV-infected Thai patients who were diagnosed with Graves disease following the initiation of ART between January, 2007, and June, 2018, were retrospectively enrolled.ResultsOf the 24 subjects, the mean age was 39.6 ± 10 years at the time of Graves disease diagnosis. The male to female ratio was 1:1.2. Palpitation and weight loss were the most common clinical manifestations. Of the 6 patients (25%) with evidence of Graves orbitopathy, 1 had sight-threatening orbitopathy. Two patients also had other autoimmune diseases (vitiligo and psoriatic arthritis). The median CD4 cell counts at HIV and Graves disease diagnosis were 73.5 (interquartile range &lsqb;IQR], 15.5 to 189.5) and 525 (IQR, 402.3 to 725) cells/μL, respectively. The median time from ART commencement of the last effective ART regimen to the development of Graves disease was 29.5 (IQR, 13.8 to 48) months with a mean CD4 cell count increment of 328.7 ± 174.9 cells/μL. The median duration of antithyroid therapy was 34.5 (IQR, 23.8 to 51.0) months. Thirteen patients (54.2%) received radioactive iodine ablation.ConclusionGraves disease should be suspected in HIV-infected patients who present with palpitations and weight loss despite good immunologic response to ART. Awareness of this condition can lead to diagnosis and appropriate management. Unlike immune reconstitution disease associated with infection, Graves disease may develop many years after ART initiation.