Prognostic factors in short‐term disability due to musculoskeletal disorders

Objective

To identify factors associated with poor outcome in temporary work disability (TWD) due to musculoskeletal disorders (MSDs).

Methods

We conducted a secondary data analysis of a 2‐year randomized controlled trial in which all patients with TWD due to MSDs in 3 health districts of Madrid (Spain) were included. Analyses refer to the patients in the intervention group. Primary outcome variables were duration of TWD and recurrence. Diagnoses, sociodemographic, work‐related administrative, and occupational factors were analyzed by Cox proportional hazards models.

Results

We studied 3,311 patients with 4,424 TWD episodes. The following were independently associated with slower return to work: age (hazard ratio [HR] 0.99, 95% confidence interval [95% CI] 0.98–0.99), female sex (HR 0.84, 95% CI 0.78–0.90), married (HR 0.90, 95% CI 0.83–0.97), peripheral osteoarthritis (HR 0.77, 95% CI 0.6–0.9), sciatica (HR 0.59, 95% CI 0.54–0.65), self‐employment (HR 0.56, 95% CI 0.48–0.65), unemployment (HR 0.41, 95% CI 0.28–0.58), manual worker (HR 0.86, 95% CI 0.79–0.94), and work position covered during sick leave (HR 0.84, 95% CI 0.77–0.92). The factors that better predicted recurrence were peripheral osteoarthritis (HR 1.75, 95% CI 1.14–2.6), inflammatory diseases (HR 1.66, 95% CI 1.009–2.72), sciatica (HR 1.30, 95% CI 1.08–1.56), indefinite work contract (HR 1.43, 95% CI 1.14–1.75), frequent kneeling (HR 1.39, 95% CI 1.15–1.69), manual worker (HR 1.19, 95% CI 1.003–1.42), and duration of previous episodes (HR 1.003, 95% CI 1.001–1.005).

Conclusion

Sociodemographic, work‐related administrative factors, diagnosis, and, to a lesser extent, occupational factors may explain the duration and recurrence of TWD related to MSD.     

Measuring TSH receptor antibody to influence treatment choices in Graves’ disease

TSH receptor antibody (TRAb) plays a key role in the pathogenesis of Graves’ disease (GD), and its levels correlate with the clinical course. The second‐ and third‐generation TRAb assays have >95% sensitivity and specificity for the diagnosis of GD and have improved the utility of TRAb to predict relapse. TRAb levels decline with antithyroid drug (ATD) therapy and after thyroidectomy. Its level increases for a year following radioactive iodine (RAI) therapy, with a gradual fall thereafter. TRAb level >12 IU/l at diagnosis of GD is associated with 60% risk of relapse at 2 years and 84% at 4 years. The prediction of risk of relapse improves further to >90% with TRAb >7·5 IU/l at 12 months or >3·85 IU/l at cessation of ATD therapy. TRAb tests are not expensive, and hence, TRAb measurements at presentation, after 12 months and/or 18 months (at cessation) of ATD therapy, could potentially guide treatment choices in GD. Elevated TRAb favours definitive treatment in the form of RAI or thyroidectomy, depending on the presence or absence of moderate‐to‐severe Graves’ ophthalmopathy (GO) and the ability to comply with radiation protection requirements. Use of ATDs in early pregnancy is associated with increased risk of congenital anomalies; early ablative treatment (RAI/surgery) should be considered in women of childbearing age at higher risk of relapse of GD. TRAb ≥5 IU/l in pregnant women with current or previously treated GD is associated with increased risk of foetal and neonatal thyrotoxicosis, and hence needs close monitoring. TRAb levels parallel the course of GO, and elevated TRAb is an indication for steroid prophylaxis to prevent progression of GO with RAI therapy.     

Graves’ disease following successful treatment of severe aplastic anaemia with antilymphocyte globulin

This case report is only the third report of thyroid dysfunction following the administration of anti-lymphocyte globulin for severe aplastic anaemia. It is the first report of the development of Grave’s disease. We discuss a possible mechanism by which this may occur and highlight instances of other immune-mediated diseases occurring in ALG treated patients.     

The prevalence of transient thyrotoxicosis after antithyroid drug therapy in patients with Graves' disease.

BACKGROUND: Although transient thyrotoxicosis occurring after antithyroid drug (ATD) withdrawal in patients with Graves' hyperthyroidism has been reported, the prevalence of transient thyrotoxicosis after ATD therapy is as yet unknown. When patients with transient hyperthyroidism are mistakenly regarded as recurrences, they receive unnecessary therapy. The aim of this study was to investigate the prevalence of transient thyrotoxicosis after ATD withdrawal. METHODS: We selected 110 consecutive patients with Graves' disease whose ATD therapy was stopped from December 2002 to September 2004 prospectively. Patients were observed for more than 1 year after ATD withdrawal, and 12 patients dropped out. Serum levels of free thyroxine (FT(4)), thyrotropin, and thyrotropin-binding inhibitor immunoglobulin were measured at ATD withdrawal, and 3, 6, and 12 months after withdrawal. When the patients showed mild thyrotoxicosis (serum FT(4) level of less than 3.00 ng/dL), we followed them up for 1 month without medication. RESULTS: The remission rate of the study group was 61.8% (68/110). Twenty-eight patients became euthyroid after transient thyrotoxicosis, equivalent to 41.2% of the remission patients. Eight of 28 patients showed overt thyrotoxicosis, and the rest subclinical thyrotoxicosis. Transient thyrotoxicosis occurred mostly 3-6 months after ATD withdrawal. CONCLUSIONS: Transient thyrotoxicosis after ATD withdrawal in patients with Graves' disease is not a rare phenomenon. Clinicians should be aware that the recurrence of Graves' disease after the withdrawal of ATD may be transient.     

Valuable predictive features of relapse of Graves’ disease after antithyroid drug treatment

Purpose

Antithyroid drug treatment (ATDT) effectively achieves euthyroidism in patients with Graves’ disease (GD). However, apparently successful treatment may be followed by relapse. We investigated the outcome of ATDT in Chinese patients with GD to identify predictive features of relapse.

Methods

In total, 133 patients with mild to moderate goiter were included in this analysis. All patients received methimazole for 12 to 40 months and were subsequently followed up for at least 1 year. Lasting remission was defined as the presence of clinical and laboratory features of euthyroidism for ≥ 1 year after stopping methimazole.

Results

Most patients (118 of 133, 88.7%) remained in remission after the follow-up period; 15 patients (11.3%) developed relapse. A history of GD, larger goiter at the time of drug withdrawal, a positive thyroid-stimulating antibody titer and restauration of low thyroid-stimulating hormone levels during the maintenance period were related to a subsequent risk of relapse according to stepwise logistic regression analysis results. However, other clinical and biological features (age, sex, initial goiter, ophthalmopathy, thyroxine and triiodothyronine levels and thyroglobulin antibody and thyroid microsomal antibody titers) did not reach statistical significance.

Conclusion

Regular, individualized ATDT achieved an 88.7% remission rate in Chinese patients with GD. The features associated with probable relapse were a history of GD, larger goiter at the time of drug withdrawal, a positive thyroid-stimulating antibody titer at the time of drug withdrawal and redevelopment of low thyroid-stimulating hormone levels during the maintenance period.     

The insulin-like growth axis in patients with autoimmune thyrotoxicosis: effect of antithyroid drug treatment.

OBJECTIVE: Hyperthyroidism is associated with altered growth hormone (GH) secretion. Many patients with thyroid dysfunction experience several poorly described complications such as symptoms and signs also seen in patients with growth hormone deficiency (GHD). We have therefore prospectively evaluated a possible relationship between the thyroid function, body composition, leptin levels and insulin-like growth factor (IGF) related peptides in patients with Graves' disease. DESIGN, PATIENTS, AND MEASUREMENTS: In a prospective group of 24 fasting female patients with Graves' disease (mean age (CI 95%): 40 years (33-47)), we measured serum thyroxine, triiodothyronine, thyrotropine (TSH), TSH receptor antibodies, anti-thyroid peroxidase, leptin, body composition, body mass index (BMI) and IGF-related peptides at diagnosis and after 12 months of treatment with thiamazol (ATD). RESULTS: In thyrotoxic patients IGF-I plus IGF-II correlated positively with IGFBP-3 at baseline (r = 0.90, p < 0.1 x 10(16)) and after 12 months follow-up (r = 0.87, p < 0.1 x 10(-16)). In the thyrotoxic state total IGF-I, IGF-II, IGF binding protein 3 (IGFBP-3) and acid-labile subunit (ALS) but not free IGF-I decreased significantly from 223 microg/L (189-260) (mean (CI 95%), 877 microg/L (801-953), 4165 microg/L (3772-4577) and 22 mg/L (18-26)) to 198 microg/L (172-226), 788 microg/L (711-865), 3431 microg/L (3135-3741) and 19 mg/L (16-26) (p <0.006), respectively, after 12 months of ATD despite an increase in BMI from 22 (21-23) to 23 kg/m(2) (22-25) (p < 0.0004) but no significant changes in leptin. CONCLUSIONS: The complex IGF systems seemed intact in thyrotoxic patients but change in body composition and the regulation of leptin and insulin secretion during treatment of autoimmune thyroid disease influence IGF-related peptides leaving the patient in a state somewhat similar to partial GHD, but the mechanism behind these alterations remains unclear.     

Effects of adherence to treatment on short‐term outcomes in children with juvenile idiopathic arthritis

Objective

To determine the impact of adherence to treatment (medication and prescribed exercise) on outcomes in children with juvenile idiopathic arthritis (JIA).

Methods

In this longitudinal study, we studied parents of patients with JIA at the Montreal Children's Hospital and British Columbia Children's Hospital in Vancouver. Adherence was evaluated on a visual analog scale in the Parent Adherence Report Questionnaire. Outcomes of interest were active joint count, pain, child functional score on the Child Health Assessment Questionnaire, quality of life score on the Juvenile Arthritis Quality of Life Questionnaire, and parental global impression of overall well‐being. The association between adherence to treatment and subsequent outcomes was evaluated using generalized estimating equations and logistic regression.

Results

Mean age and disease duration of our sample of 175 children were 10.2 and 4.1 years, respectively. Moderate adherence to medication was associated with lower active joint count (odds ratio [OR] 0.47, 95% confidence interval [95% CI] 0.22–0.99). Moderate adherence to exercise was associated with better functional score (OR 0.13, 95% CI 0.03–0.54), and lower pain during the last week (OR 0.14, 95% CI 0.04–0.50). Both high and moderate adherence to exercise were associated with parental perception of global improvement.

Conclusion

Improved outcomes in patients who adhered to treatment underscores the need for clinicians to address adherence issues with their patients. Sustaining adherence, particularly to the more time‐consuming treatment of exercise, is a challenge.