Confirmatory factor analysis of the thyroid-related quality of life questionnaire ThyPRO

Testing the Psychometric Properties of 9 Bolt-Ons for the EQ-5D-5L in a General Population Sample

OBJECTIVES

We aimed to assess the psychometric performance and added value of 9 existing bolt-ons (breathing problems, cognition, hearing, self-confidence, skin irritation, sleep, social relationships, tiredness, and vision) for the EQ-5D-5L in a general population sample.

METHODS

The EQ-5D-5L, 9 bolt-ons, SF-6Dv1, Patient-Reported Outcomes Measurement Information System (PROMIS)-29+2, PROMIS Global Health, and Satisfaction with Life Scale were completed in an online cross-sectional survey among a general adult population sample in Hungary (n = 1587). The following psychometric properties were tested for the EQ-5D-5L + bolt-on(s): ceiling, divergent and convergent validity, structural validity, known-group validity, and explanatory power.

RESULTS

Adding sleep (30%), tiredness (24%), or vision (21%) substantially reduced the ceiling of the EQ-5D-5L (41%). Cognition, sleep, social relationships, and tiredness correlated with corresponding PROMIS and SF-6D items (rs = ǀ0.32ǀ - ǀ0.73ǀ). All bolt-ons, except cognition and self-confidence, loaded on a different factor from the EQ-5D-5L dimensions. Breathing, hearing, skin irritation, and vision significantly improved known-group validity in relevant health condition groups. The sleep bolt-on improved known-group validity in 9 of 13 chronic health conditions. Tiredness had the largest impact on explaining EQ VAS score variance in 8 of 13 conditions. Hearing and vision improved the ability of the EQ-5D-5L to capture declining health with age, whereas self-confidence and social relationships were valuable for mental health assessment.

CONCLUSIONS

This study established the validity of multiple bolt-ons for the EQ-5D-5L and highlights the usefulness of including relevant bolt-ons in population-based and patient surveys. Our findings inform the further development of these bolt-ons and the bolt-on item selection for clinical studies.

Designing a combined liothyronine (LT3), L- thyroxine (LT4) trial in symptomatic hypothyroid subjects on LT4 - the importance of patient selection, choice of LT3 and trial design

Approximately 10%-15% of subjects with hypothyroidism on L-thyroxine (LT4) alone have persistent symptoms affecting their quality of life (QoL). Although the cause is unclear, there is evidence that "tissue T3 lack" may be responsible. If so, combining liothyronine (LT3) with LT4 would be helpful. However, randomized controlled trials (RCT), have not established greater efficacy for the LT3 + LT4 combination in these subjects than for LT4 alone. While the trial design may have been responsible, the use of unphysiological, short-acting LT3 preparations and non-thyroid-specific patient-reported outcome measures (PROMs) may have contributed. We recommend attention to the following aspects of trial design for future RCTs of LT3 + LT4 compared to LT4 alone: (a) Subject selection-(i) measurable symptoms (disadvantages should be recognized); (ii) using a validated thyroid specific PROM such as ThyPRO39 or the Composite scale derived from it; (iii) those taking over 1.2 μg/day or 100 μg/day (for pragmatic reasons) of LT4 defining a population likely without intrinsic thyroid activity who depend on exogenous LT4; (iv) recruiting a preponderance of subjects with autoimmune thyroiditis increasing generalisability; and (v) those with a high symptom load with a greater response to combination therapy e.g. those with the deiodinase 2 polymorphism. (b) The use of physiological LT3 preparations producing pharmacokinetic similarities to T3 profiles in unaffected subjects: two long-acting LT3 preparations are currently available and must be tested in phase 2b/3 RCTs. (c) The superiority of a crossover design in limiting numbers and costs while maintaining statistical power and ensuring that all subjects experienced the investigative medication.

When 'good' is not good enough: a retrospective Rasch analysis study of the Berg Balance Scale for persons with Multiple Sclerosis

Background

The Berg Balance Scale (BBS) is one of the most used tools to quantify balance in Persons with Multiple Sclerosis, a population at high risk of falling.

Aim

To evaluate the measurement characteristics of the BBS in Multiple Sclerosis through Rasch analysis.

Design

Retrospective study.

Setting

Outpatients in three Italian Rehabilitation centers.

Population

Eight hundred and fourteen persons with Multiple Sclerosis able to stand independently for more than 3 s.

Methods

The sample (N = 1,220) was split into one validating (B1) and three confirmatory subsamples. Following the Rasch analysis performed on B1, the item estimates were exported and anchored to the three confirmatory subsamples. After obtaining the same final solution across all samples, we studied the convergent and discriminant validity of the final BBS-MS using the EDSS, the ABC scale, and the number of falls.

Results

The base analysis on the B1 subsample failed the monotonicity, local independence, and unidimensionality requirements and did not fit the Rasch model. After grouping locally dependent items, the BBS-MS fitted the model (χ²₈ = 23.8; p = 0.003) and satisfied all requirements for adequate internal construct validity (ICV). However, it was mistargeted to the sample, given the striking prevalence of higher scores (targeting index 1.922) with a distribution-independent Person Separation Index sufficient for individual measurements (0.962). The B1 item estimates were anchored to the confirmatory samples with confirmation of adequate fit (χ² = [19.0, 22.8], value of ps = [0.015, 0.004]) and satisfaction of all ICV requirements for all subsamples. The final BBS-MS directly correlated with the ABC scale (rho = 0.523) and inversely with EDSS (rho = -0.573). The BBS-MS estimates significantly differed across groups according to the pre-specified hypotheses (between the three EDSS groups, between the ABC cut-offs, distinguishing 'fallers' vs. 'non-fallers', and between the 'low' vs. 'moderate' vs. 'high' levels of physical functioning; and, finally, between 'no falls' vs. 'one or more falls').

Conclusion

This study supports the internal construct validity and reliability of the BBS-MS in an Italian multicentre sample of persons with Multiple Sclerosis. However, as the scale is slightly mistargeted to the sample, it represents a candidate tool to assess balance, mainly in more disabled people with an advanced walking disability.

Development and Validation of the Chinese Family Resilience Scale in Families in Hong Kong

Family resilience is an important protective factor mitigating the negative impact of adversities on individuals and families. As there are very few validated measures of family resilience in the Chinese context, we have developed the Chinese Family Resilience Scale (C-FRS) based on the family resilience framework of Froma Walsh. In this paper, we outline the development and the validation of the C-FRS with reference to the socio-cultural context of Hong Kong. Based on content validation involving family experts, the initial 51 items were assessed in terms of their relevance, clarity, and representativeness. The results showed that these items possessed adequate content validity. In order to validate the 51-item measure, we examined its convergent validity, its factorial validity, and its internal consistency based on the responses of 1020 Chinese families (N = 2858 participants). After removing the items with unsatisfactory psychometric properties, we retained 35 items in the final scale. The results showed that the C-FRS scores were significantly related to family functioning, thus providing support for its convergent validity. This study also provided support for the conceptual model of Walsh (i.e., three high-order domains involving nine primary indicators). Most importantly, the measurement invariance tests showed that the dimensions of the C-FRS were invariant among fathers, mothers, and adolescent children. As the findings support the reliability and the validity of the 35-item C-FRS, we suggest that this measure can be objectively used to assess family resilience in Chinese communities.

Quality of life in thyroid cancer

To explore the impact of differentiated thyroid cancer (DTC) on quality of life (QoL) a clinical analytical framework was developed. Based on the clinical analytical framework, a systematic literature search was performed to identify studies applying patient-reported outcomes (PRO) instruments among patients with DTC. Subsequently, the scope was narrowed down to studies comparing scores on the Medical Outcomes Study (MOS) Short form 36 (SF-36) to a reference population (clinical interpretability criterion). Further, the currently available thyroid cancer (TC) specific QoL PROs were review in accordance with the standards of the International Society of Quality of Life Research. In the initial search, 213 studies were included. The additional 'clinical interpretability'-criteria, limited the final study sample to 16 studies, 13 cross-sectional and 3 longitudinal. QoL was impacted across all SF-36 scales. The impact was generally modest and the impact was impeded by time since diagnosis and treatment. Four TC specific instruments were identified. Generally, the documentation of their measurement properties, particularly content validity and clinical validity, including substantial quantitative validation, was scarce. As was the cross-cultural applicability of the currently available instruments. This restricted, focused, clinically founded review showed an impact on a broad range of QoL issues. There is a need for large-scale measurement of QoL outcome longitudinally, using well-validated PRO instruments in order to identify with certainty the impact on subgroups.

Where do measures of health, social care and wellbeing fit within a wider measurement framework? Implications for the measurement of quality of life and the identification of bolt-ons

BACKGROUND

There is variability across studies in the dimensionality i.e., set of latent variables to which health, social care and wellbeing measures relate. This variability may impact the development of new measures and the identification of bolt-on dimensions. We examine the dimensionality of commonly used measures and identify a set of potential bolt-ons for the EQ-5D-5L.

METHODS

We used the OMS dataset, an online survey of health, social care and wellbeing measures in patients and members of the general public. A content analysis provided a theoretical framework for results interpretation. Quantitative analyses were based on a pool of 79 items from 7 measures. Confirmatory factor analysis was used to assess health, social care and wellbeing measures dimensionality and their contribution to quality of life. The relationship between EQ-5D-5L items and the identified factors was used for bolt-ons identification.

RESULTS

The dimensionality comprised of seven factors, namely physical functioning, psychological symptoms, energy/sleep, physical pain, social functioning, needs and satisfaction. Health measures covered five of the seven factors identified, wellbeing measures three and the social care measure one. A list of candidate bolt-on items for the EQ-5D-5L was presented e.g., cognition, energy, dignity.

CONCLUSIONS

This study provides evidence on the dimensionality of health, social care and wellbeing measures and presents a list of candidate bolt-ons for the EQ-5D-5L.

Thyroid disease‐specific quality of life questionnaires ‐ A systematic review

Introduction

Thyroid diseases are very common and rarely life‐threatening. One of the main therapeutic goals is an improvement in quality of life, making it important to measure in clinical and research settings. The aim of this systematic review is to provide an overview of the currently available thyroid‐specific quality of life questionnaires with regard to their validation quality in order to make recommendations for clinical use with a special focus on German questionnaires.

Methods

A systematic literature search was performed in Pubmed, Google Scholar and the Cochrane Library. A total of 904 studies were identified. After excluding duplicates, non‐English‐ or German‐language texts, full texts that were not freely available and studies with irrelevant content, 64 studies reporting on 16 different questionnaires were included in the analysis.

Results

Four questionnaires concerned benign thyroid diseases (ThyPRO, ThyPRO‐39, Thy‐R‐HRQoL and Thy‐D‐QOL), six malignant thyroid diseases (THYCA‐QoL, ThyCa‐HRLQOL, EORTC‐Thy34, MADSI‐Thy, QOL‐Thyroid and ThyCAT), and six endocrine orbitopathy (GO‐QOL, GO‐QLS, TED‐QOL, STED‐QOL, TAO‐QoL and Ox‐TED). Only five questionnaires were at least developed, if not validated, in German, and five were developed in more than two languages.

Conclusions

ThyPRO and the ThyPRO‐39 are the best‐evaluated questionnaires for benign thyroid diseases. Alternatively, in hypothyroid patients, the adequately validated Thy‐D‐QoL can be used. For malignant thyroid diseases, the choice should be made individually, as all six questionnaires (THYCA‐QoL, ThyCA‐HRQOL, EORTC‐Thy34, MDASI‐Thy, QOL‐Thyroid and ThyCAT) have different strengths and weaknesses. The GO‐QOL is the best‐validated questionnaire in endocrine orbitopathy. However, the TED‐QOL is also suitable as a short‐screening questionnaire for these patients.

The Effect of Laser Thermal Ablation on Quality of Life: Improvements in Patients with Solid-Cystic Thyroid Nodules

Background: Evidence of the efficacy of laser thermal ablation (LTA) in benign thyroid nodules is abundant. However, little is known about the effect on quality of life (QoL) of this treatment. Methods: Prospective cohort study investigating the effect of LTA before, three, and six months after LTA on QoL using the thyroid-specific patient-reported outcome (ThyPRO) measure. Patients receiving LTA (laser group [LG]) was compared with a well-characterized control group (CG) from the Danish civil registry. Results: The LG comprised 54 patients, with no age or sex differences compared with the CG (n = 739). Sixty-nine percent of the patients had a recurrent cystic thyroid nodule, 6% had a solid nodule, while the remaining 25% were of mixed character. The median nodule volume was 6.8 mL (interquartile range [IQR]: 4.0-11.1) before LTA, and 1.8 mL (IQR: 0.6-4.1) at 6 months post-LTA (p < 0.001), corresponding to a median reduction of 78%. All cystic fluid (median: 6 mL; IQR: 2.0-9.0) was aspirated before LTA. Median treatment time was 400 seconds (IQR: 300-600), applying a median energy of 823 J (IQR: 600-1200). At baseline and according to the ThyPRO scales, the LG differed significantly from the CG by having more goiter symptoms, hyperthyroid symptoms, tiredness, and cognitive complaints (p < 0.05 for all variables), but only the difference in the goiter symptom scale was of a clinically important magnitude. At three months, the LG experienced a large improvement in goiter symptoms (effect size [ES] = 1.05), a moderate improvement in cosmetic complaints (ES = 0.50), and a moderate improvement in the overall QoL (ES = 0.64). Only the improvements in the goiter symptom and the cosmetic complaint scales were clinically important. Six months after LTA, the anxiety scale showed further improvement of moderate size (ES = 0.52). At 6 months, the results above were maintained, and 79% of patients experienced a large and clinically important improvement in the goiter symptom scale and no clinically important differences were found between the LG and the CG. Conclusions: In this unblinded, prospective observational study, measures of disease-specific QoL were significantly improved compared with preprocedure levels, in patients with solid-cystic nodules.

Validation of 'Care Of the Dying Evaluation' (CODETM) within an international study exploring bereaved relatives' perceptions about quality of care in the last days of life

CONTEXT

Assessing quality of care provided during the dying phase using validated tools aids quality assurance and recognizes unmet need.

OBJECTIVE

To assess construct validity and internal consistency of 'Care Of the Dying Evaluation' (CODE^TM) within an international context.

METHODS

Post-bereavement survey (August 2017 to September 2018) using CODE^TM. Respondents were next-of-kin to adult patients (≥ 18 years old) with cancer who had an 'expected' death within 22 study site hospitals in 7 countries: Argentina, Brazil, Germany, Norway, Poland, United Kingdom, Uruguay. Exploratory and Confirmatory Factor Analysis (EFA and CFA) were conducted, and internal reliability was assessed using Cronbach alpha (α). Known group validity was assessed by ability to discriminate quality of care based in place (Palliative Care Units (PCUs)) and country (Poland, where most deaths were in PCUs) of care. Differences were quantified using effect sizes (ES).

RESULTS

A 914 CODE^TM questionnaires completed (54% response rate). 527 (58%) male deceased patients; 610 (67%) next-of-kin female who were most commonly the 'spouse/partner' (411, 45%). EFA identified 4 factors: 'Overall care,' 'Communication and support,' 'Trust, respect and dignity,' and 'Symptom management' with good reliability scores (α = 0.628 - 0.862). CFA confirmed the 4-factor model; these were highly correlated and a bifactor model showed acceptable fit. The ES for quality of care in PCU's was 0.727; ES for Poland was 0.657, supporting the sensitivity of CODE^TM to detect differences.

CONCLUSION

Within an international context, good evidence supports the validity and reliability of CODE^TM for assessing the quality of care provided in the last days of life.

The Impact of Post-Thyroidectomy Neck Stretching Exercises on Neck Discomfort, Pressure Symptoms, Voice and Quality of Life: A Randomized Controlled Trial

Background

Methods

Results

Conclusions

Primary hypothyroidism and quality of life

In the 1970s, treatment with thyroid extract was superseded by levothyroxine, a synthetic L form of tetraiodothyronine. Since then, no major innovation has emerged for the treatment of hypothyroidism. The biochemical definition of subclinical hypothyroidism is a matter of debate. Indiscriminate screening for hypothyroidism has led to overdiagnosis and treatment initiation at lower serum levels of thyroid-stimulating hormone (TSH) than previously. Adverse health effects have been documented in individuals with hypothyroidism or hyperthyroidism, and these adverse effects can affect health-related quality of life (QOL). Levothyroxine substitution improves, but does not always normalize, QOL, especially for individuals with mild hypothyroidism. However, neither studies combining levothyroxine and liothyronine (the synthetic form of tri-iodothyronine) nor the use of desiccated thyroid extract have shown robust improvements in patient satisfaction. Future studies should focus not only on a better understanding of an individual's TSH set point (the innate narrow physiological range of serum concentration of TSH in an individual, before the onset of hypothyroidism) and alternative thyroid hormone combinations and formulations, but also on autoimmunity and comorbidities unrelated to hypothyroidism as drivers of patient dissatisfaction. Attention to the long-term health consequences of hypothyroidism, beyond QOL, and the risks of overtreatment is imperative.

Validity and reliability of the German version of the shortened thyroid-specific quality of life questionnaire (ThyPRO-39de)

OBJECTIVES

Validation of a German version of the ThyPRO-39 questionnaire for quality of life (QoL) in patients with benign thyroid diseases.

DESIGN

Internal consistency, retest reliability, and validity were to be assessed in a test-retest study.

METHODS

The ThyPRO-39 was translated based on standard methodology. A sample of 98 patients with benign thyroid diseases was tested with the ThyPRO-39de and the generic EuroQol 5D-5L. Forty-four patients with stable symptoms after 2 weeks formed the repeated measures sample. Cronbach's alpha was calculated for the ThyPRO-39de composite score and for each disease-specific scale. Intraclass correlations between the original and the repeated measures sample were calculated for each scale as well as Pearson correlations between various ThyPRO scales and the EuroQol. T-tests were used to test for differences in the goiter and hyperthyroid symptom scales between relevant patient groups and other patients.

RESULTS

Internal consistency was between satisfactory and good, except for two scales (tiredness and cosmetic complaints/appearance). The test-retest correlation was between 0.62 and 0.8 for most scales, but below 0.5 for two scales (tiredness and impaired social life). There were significant correlations between the EuroQol index score and most aspects of the ThyPRO-39de. Only the hyperthyroid symptoms scale was specific for the relevant patient group (Graves' disease).

CONCLUSION

The ThyPRO-39de may be recommended for use in clinical and research settings, especially with regards to the composite score. However, the underlying thyroid disease should always be kept in mind when interpreting the test results. A larger sample would be needed to implement further improvements.

Levothyroxine Therapy in Elderly Patients With Hypothyroidism

Levothyroxine (L-T4) treatment of overt hypothyroidism can be more challenging in elderly compared to young patients. The elderly population is growing, and increasing incidence and prevalence of hypothyroidism with age are observed globally. Elderly people have more comorbidities compared to young patients, complicating correct diagnosis and management of hypothyroidism. Most importantly, cardiovascular complications compromise the usual start dosage and upward titration of L-T4 due to higher risk of decompensating cardiac ischemia and -function. It therefore takes more effort and care from the clinician, and the maintenance dose may have to be lower in order to avoid a cardiac incidence. On the other hand, L-T4 has a beneficial effect on cardiac function by increasing performance. The clinical challenge should not prevent treating with L-T4 should the patient develop e.g., cardiac ischemia. The endocrinologist is obliged to collaborate with the cardiologist on prophylactic cardiac measures by invasive cardiac surgery or medical therapy against cardiac ischemic angina. This usually allows subsequent successful treatment. Management of mild (subclinical) hypothyroidism is even more complex. Prevalent comorbidities in the elderly complicate correct diagnosis, since many concomitant morbidities can result in non-thyroidal illness, resembling mild hypothyroidism both clinically and biochemically. The diagnosis is further complicated as methods for measuring thyroid function (thyrotropin and thyroxine) vary immensely according to methodology and background population. It is thus imperative to ensure a correct diagnosis by etiology (e.g., autoimmunity) before deciding to treat. Even then, there is controversy regarding whether or not treatment of such mild forms of hypothyroidism in elderly will improve mortality, morbidity, and quality of life. This should be studied in large cohorts of patients in long-term placebo-controlled trials with clinically relevant outcomes. Other cases of hypothyroidism, e.g., medications, iodine overload or hypothalamus-pituitary-hypothyroidism, each pose specific challenges to management of hypothyroidism; these cases are also more frequent in the elderly. Finally, adherence to treatment is generally challenging. This is also the case in elderly patients, which may necessitate measuring thyroid hormones at individually tailored intervals, which is important to avoid over-treatment with increased risk of cardiac morbidity and mortality, osteoporosis, cognitive dysfunction, and muscle deficiency.

Evidence-Based Use of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism: A Consensus Document

BACKGROUND

Fourteen clinical trials have not shown a consistent benefit of combination therapy with levothyroxine (LT4) and liothyronine (LT3). Despite the publication of these trials, combination therapy is widely used and patients reporting benefit continue to generate patient and physician interest in this area. Recent scientific developments may provide insight into this inconsistency and guide future studies.

METHODS

The American Thyroid Association (ATA), British Thyroid Association (BTA), and European Thyroid Association (ETA) held a joint conference on November 3, 2019 (live-streamed between Chicago and London) to review new basic science and clinical evidence regarding combination therapy with presentations and input from 12 content experts. After the presentations, the material was synthesized and used to develop Summary Statements of the current state of knowledge. After review and revision of the material and Summary Statements, there was agreement that there was equipoise for a new clinical trial of combination therapy. Consensus Statements encapsulating the implications of the material discussed with respect to the design of future clinical trials of LT4/LT3 combination therapy were generated. Authors voted upon the Consensus Statements. Iterative changes were made in several rounds of voting and after comments from ATA/BTA/ETA members.

RESULTS

Of 34 Consensus Statements available for voting, 28 received at least 75% agreement, with 13 receiving 100% agreement. Those with 100% agreement included studies being powered to study the effect of deiodinase and thyroid hormone transporter polymorphisms on study outcomes, inclusion of patients dissatisfied with their current therapy and requiring at least 1.2 µg/kg of LT4 daily, use of twice daily LT3 or preferably a slow-release preparation if available, use of patient-reported outcomes as a primary outcome (measured by a tool with both relevant content validity and responsiveness) and patient preference as a secondary outcome, and utilization of a randomized placebo-controlled adequately powered double-blinded parallel design. The remaining statements are presented as potential additional considerations.

DISCUSSION

This article summarizes the areas discussed and presents Consensus Statements to guide development of future clinical trials of LT4/LT3 combination therapy. The results of such redesigned trials are expected to be of benefit to patients and of value to inform future thyroid hormone replacement clinical practice guidelines treatment recommendations.

Determining minimal important change for the thyroid-related quality of life questionnaire ThyPRO

OBJECTIVE

ThyPRO is the standard thyroid patient-reported outcome (PRO). The change in scores that patients perceive as important remains to be ascertained. The purpose of this study was to determine values for minimal important change (MIC) for ThyPRO.

METHODS

A total of 435 patients treated for benign thyroid diseases completed ThyPRO at baseline and 6 weeks following treatment initiation. At 6 weeks follow-up, patients also completed Global Rating of Change items. For each 0-100 scale, two MIC values were identified: An MIC for groups, using the receiver operating characteristic (ROC) curve method and an MIC for individual patients, using the Reliable Change Index.

RESULTS

ROC analyses provided group-MIC estimates of 6.3-14.3 (score range 0-100). Evaluation of area under the curve (AUC) supported the robustness for 9 of 14 scales (AUC > 0.7). Reliable Change Index estimates of individual-MIC were 8.0-21.1. For all scales but two, the individual-MIC values were larger than the group-MIC values.

CONCLUSIONS

Interpretability of ThyPRO was improved by the establishment of MIC values, which was 6.3-14.3 for groups and 8.0-21.1 for individuals. Thus, estimates of which changes are clinically relevant, are now available for future studies. We recommend using MIC values found by ROC analyses to evaluate changes in groups of patients, whereas MIC values identified by a dual criterion, including the reliability of changes, should be used for individual patients, for example, to identify individual responders in clinical studies or practice.

Evidence-Based Use of Levothyroxine/Liothyronine Combinations in Treating Hypothyroidism: A Consensus Document

Background: Fourteen clinical trials have not shown a consistent benefit of combination therapy with levothyroxine (LT4) and liothyronine (LT3). Despite the publication of these trials, combination therapy is widely used and patients reporting benefit continue to generate patient and physician interest in this area. Recent scientific developments may provide insight into this inconsistency and guide future studies. Methods: The American Thyroid Association (ATA), British Thyroid Association (BTA), and European Thyroid Association (ETA) held a joint conference on November 3, 2019 (live-streamed between Chicago and London) to review new basic science and clinical evidence regarding combination therapy with presentations and input from 12 content experts. After the presentations, the material was synthesized and used to develop Summary Statements of the current state of knowledge. After review and revision of the material and Summary Statements, there was agreement that there was equipoise for a new clinical trial of combination therapy. Consensus Statements encapsulating the implications of the material discussed with respect to the design of future clinical trials of LT4/LT3 combination therapy were generated. Authors voted upon the Consensus Statements. Iterative changes were made in several rounds of voting and after comments from ATA/BTA/ETA members. Results: Of 34 Consensus Statements available for voting, 28 received at least 75% agreement, with 13 receiving 100% agreement. Those with 100% agreement included studies being powered to study the effect of deiodinase and thyroid hormone transporter polymorphisms on study outcomes, inclusion of patients dissatisfied with their current therapy and requiring at least 1.2 μg/kg of LT4 daily, use of twice daily LT3 or preferably a slow-release preparation if available, use of patient-reported outcomes as a primary outcome (measured by a tool with both relevant content validity and responsiveness) and patient preference as a secondary outcome, and utilization of a randomized placebo-controlled adequately powered double-blinded parallel design. The remaining statements are presented as potential additional considerations. Discussion: This article summarizes the areas discussed and presents Consensus Statements to guide development of future clinical trials of LT4/LT3 combination therapy. The results of such redesigned trials are expected to be of benefit to patients and of value to inform future thyroid hormone replacement clinical practice guidelines treatment recommendations.

Proposal for Standardization of Primary and Secondary Outcomes in Patients with Active, Moderate-to-Severe Graves' Orbitopathy

Standardization of treatment outcomes in randomized clinical trials (RCTs) for active, moderate-to-severe Graves' orbitopathy (GO) is needed to make results of different RCTs comparable and to draw sound conclusions on the efficacy of a given treatment. Both subjective patient-reported outcome (PRO) and objective clinician-reported outcome (CRO) are important in this regard. In this paper, it is proposed that primary PRO should be the evaluation of treatment-related changes in the quality of life by the use of a validated and disease-specific questionnaire (GO-QoL). The proposed primary CRO is a revised composite index, which includes only objective items and provides an overall assessment of the effects of treatment. Secondary outcomes should also be provided in RCTs to show the effects of treatment on individual features of GO, as well on persistence of activity (by the 7-item Clinical Activity Score), safety, relapses of GO, need for subsequent medical and/or surgical treatments, and other indicators (orbital volume, cytokines, TSH receptor antibody levels). Assessment of the overall response to treatment by primary and secondary outcomes should be made 3 months after treatment completion.

How does thyroidectomy for benign thyroid disease impact upon quality of life? A prospective study

BACKGROUND

Choosing which patients to recommend surgery for benign thyroid conditions can be difficult due to the subjective nature of compressive thyroid and hormonal symptoms. The aim of this prospective study was to analyse changes in quality of life (QOL) following thyroid surgery using a validated disease-specific assessment tool, the thyroid-related patient-reported outcome (ThyPRO) questionnaire.

METHODS

Participants undergoing elective thyroid surgery for benign conditions were recruited. Patient demographics and clinical data were collected. ThyPRO consists of 85 questions grouped into 13 physical, mental and social symptom domains. Patients completed a ThyPRO questionnaire pre-operatively and at 6 weeks and 6 months post-operatively. ThyPRO items were scored according to protocol to produce 13 subscales. Repeated measures linear models with no random effects were performed using data for each outcome.

RESULTS

Results were available for a total of 72 patients. The sample was predominately female (n = 63, 88%) with average age 49.8 years. The majority of patients underwent surgery for multi-nodular goitre. At 6 weeks post-operatively, significant improvement was demonstrated in the goitre, hypothyroid, hyperthyroid and anxiety symptom domains. At 6 months post-operatively, significant improvement was demonstrated in all but four domains. No domains demonstrated significant increase in impairment post-operatively.

CONCLUSION

Patients had significant improvement in nine of 13 symptom domains following surgery. Patients did not experience a negative impact on QOL following surgery. Further studies with larger patient cohorts may be able to identify potential pre-operative predictive factors for a post-operative improvement in QOL for benign thyroid disease.

The unidimensionality of the five Brain Injury Rehabilitation Trust Personality Questionnaires (BIRT-PQs) may be improved: preliminary evidence from classical psychometrics

Objective: To assess the internal construct validity (ICV) of the five Brain Injury Rehabilitation Trust Personality Questionnaires (BIRT-PQ) with Classical Test Theory methods.Methods: Multicenter cross-sectional study involving 11 Italian rehabilitation centers. BIRT-PQs were administered to patients with severe Acquired Brain Injury and their respective caregivers. ICV was assessed by the mean of an internal consistency analysis (ICA) and a Confirmatory Factor Analysis (CFA).Results: Data from 154 patients and their respective caregivers were pooled, giving a total sample of 308 subjects. Despite good overall values (alphas ranging from 0.811 to 0.937), the ICA revealed that several items within each scale did not contribute as expected to the total score. This result was confirmed by the CFA, which showed the misfit of the data to a unidimensional model (RMSEA ranging from 0.077 to 0.097). However, after accounting for local dependency found within the data, fitness to a unidimensional model improved significantly (RMSEA ranging from 0.050 to 0.062).Conclusion: Despite some limitations, our analyses demonstrated the lack of ICV for the BIRT-PQ total scores. It is envisaged that a more comprehensive ICV analysis will be performed with Rasch analysis, aiming to improve both the measurement properties and the administrative burden of each BIRT-PQ.

Psychometric properties of the Chinese Version of the Readiness for Hospital Discharge Scale for people living with HIV

Objective

The study was conducted to validate the reliability and factor structure of the Chinese version of the Readiness for Hospital Discharge Scale (RHDS-CH) for people living with HIV (PLWH).

Methods

From May 2017 to November 2017, a cross-sectional survey was performed in two AIDS inpatient departments located in two cities in Hunan, China. Reliability was evaluated by examining the internal consistency and split-half reliability of the items. A confirmatory factor analysis was performed to assess the factor structure of the RHDS-CH, and the model was revised according to the modification index.

Results

Cronbach’s α for the RHDS-CH was 0.912, and the split-half reliability of the total scale was 0.831. Initially, the results of the confirmatory factor analysis indicated that the sample did not fit this four-factor model and its 23 items well (χ²/df = 3, GFI =0.772, TLI = 0.823, CFI = 0.844, RMSEA = 0.100). To improve the model fit indices, we performed model modification with the guidance of modification indices. Finally, the model fit indices showed an acceptable fit to the data (χ²/df = 2.141, GFI = 0.844, TLI = 0.899, CFI = 0.915, RMSEA = 0.075). Coefficients of corrected item-total correlation of the RHDS-CH ranged from 0.435 to 0.726.

Conclusion

This study is the first to examine the psychometric properties of the RHDS-CH for PLWH. Our findings showed good reliability and confirmed the four-factor structure model for PLWH.

Design of the Optimal Trial of Combination Therapy

Patients who take levothyroxine monotherapy to treat hypothyroidism frequently experience residual symptoms despite TSH testing at target levels. Trials have been conducted to evaluate the potential benefit of combination therapy with levothyroxine and liothyronine, though results have not consistently demonstrated benefit. In addition to randomization, placebo-control, and masking, four additional design choices to consider include the study population, dosing strategy for levothyroxine and liothyronine, primary and secondary outcome selection, and statistical power. A thoughtful design that considers these features will increase the likelihood that a combination trial will be considered definitive and finally resolve the important question of whether combination therapy with levothyroxine and liothyronine is a better thyroid replacement strategy than levothyroxine monotherapy.

The Impact of Esophageal Compression on Goiter Symptoms before and after Thyroid Surgery

INTRODUCTION

Benign nodular goiter may be associated with swallowing difficulties, but insight into the associated pathophysiology is limited. The aim of this study was to investigate the effect of surgery on the degree of esophageal compression, and its correlation to swallowing difficulties.

METHODS

Esophageal compression and deviation were evaluated blindly on magnetic resonance imaging (MRI) of the neck, prior to and 6 months after thyroid surgery for symptomatic benign goiter. Goiter symptoms and swallowing difficulties were measured by the Goiter Symptom Scale of the Thyroid-Specific Patient-Reported Outcome (ThyPRO) questionnaire. Cohen's d was used for evaluating effect sizes (ES).

RESULTS

Sixty-four patients completed the study. Before surgery, median goiter volume was 57 (range 14-642) mL. The smallest cross-sectional area of the esophagus (SCAE) increased from a median of 95 (47-147) to 137 (72-286) mm² (ES = 1.31, p < 0.001). Median esophagus width increased from 15 (range 10-21) to 17 (range 12-24) mm (ES = 0.94, p < 0.001) after surgery, while no statistically significant change was observed for the sagittal dimension (anterior-to-posterior), thus reflecting an increasingly ellipsoid esophageal shape. Median esophageal deviation decreased moderately after surgery from 4 (0-23) to 3 (0-10) mm (ES = 0.54, p = 0.005). The goiter symptom score improved considerably from (mean ± SD) 40 ± 21 to 10 ± 10 points (ES = 1.5, p < 0.001) after surgery, and the improvements were associated with improvements in SCAE (p = 0.03).

CONCLUSIONS

In patients with goiter, thyroidectomy leads to substantial improvements in esophageal anatomy, as assessed by MRI, and this correlates with improved swallowing symptoms. This information is valuable in qualifying the dialogue with goiter patients, before deciding on the mode of therapy. Clinicaltrials.gov (NCT03072654).

Exploring the item sets of the Recovering Quality of Life (ReQoL) measures using factor analysis

Purpose

This paper presents two studies exploring the latent structure of item sets used in the development of the Recovering Quality of Life mental health outcome measures: ReQoL-10 and ReQoL-20.

Method

In study 1, 2262 participants completed an initial set of 61 items. In study 2, 4266 participants completed a reduced set of 40 items. Study 2 evaluated two formats of the questionnaires: one version where the items were intermingled and one where the positively worded and negatively worded items were presented as two separate blocks. Exploratory and confirmatory factor analyses were conducted on both datasets where models were specified using ordinal treatment of the item responses. Dimensionality based on the conceptual framework and methods effects reflecting the mixture of positively worded and negatively worded items were explored. Factor invariance was tested across the intermingled and block formats.

Results

In both studies, a bi-factor model (study 1: RMSEA = 0.061; CFI = 0.954; study 2: RMSEA = 0.066; CFI = 0.971) with one general factor and two local factors (positively worded questions and negatively worded questions) was preferred. The loadings on the general factor were higher than on the two local factors suggesting that the ReQoL scale scores can be understood in terms of a general factor. Insignificant differences were found between the intermingled and block formats.

Conclusions

The analyses confirmed that the ReQoL item sets are sufficiently unidimensional to proceed to item response theory analysis. The model was robust across different ordering of positive and negative items.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-2091-1) contains supplementary material, which is available to authorized users.

How Should Thyroid-Related Quality of Life Be Assessed? Recalled Patient-Reported Outcomes Compared to Here-and-Now Measures

BACKGROUND

The impact of thyroid disease on quality of life is an important disease aspect that is best investigated by patient-reported outcomes. Recent patient-reported outcomes research has raised concern about the validity of traditional retrospective questionnaires. Therefore, ecological momentary assessments of patients' subjective well-being have been introduced to avoid recall bias and improve contextual validity. Despite theoretical advantages, the measurement properties remain unsubstantiated. This study examines the relationship between the retrospective thyroid-related quality of life patient-reported outcome measure (ThyPRO) and a momentary (here-and-now) version of ThyPRO.

METHODS

Eighty-three newly diagnosed hyperthyroid patients expected to undergo treatment completed questions on their thyroid-related quality of life. Head-to-head comparison was performed between 12 momentary items from four multi-item ThyPRO scales administered three times daily via a smartphone application during 28 days and the original retrospective ThyPRO on day 28. The measurement difference between recalled and momentary ratings was quantified for all four scales. Furthermore, correlations between the measures were investigated, and their agreement was explored using Bland-Altman plots. Finally, the study examined whether retrospective ratings were influenced by two forms of recall bias (the peak effect and the end effect).

RESULTS

Retrospective and mean momentary ThyPRO ratings were highly correlated (Pearson's correlations: 0.74-0.88). However, retrospective ratings provided significantly higher scores (i.e., worse quality of life) on all scales. Bland-Altman plots showed a skewed distribution, indicating low levels of agreement. Results supported a peak effect for retrospective ratings on tiredness but not for the remaining scales. Further, results supported end effects for retrospective ratings of emotional susceptibility and anxiety.

CONCLUSIONS

Retrospective and mean momentary ThyPRO ratings correlated strongly, but retrospective ratings were higher, indicating more disease impact. The differences were of magnitudes normally deemed clinically relevant. Limited evidence supported peak and end effect bias for retrospective assessments. The two measurement modalities did not appear congruent and thus cannot be used interchangeably. When designing clinical studies, whether to use a momentary or retrospective measurement method may depend on the aim of measurement. Further prospective analyses are needed to compare any beneficial effects, for example in terms of higher precision or sensitivity to clinical change, of momentary assessments.

Patients with Benign Thyroid Diseases Experience an Impaired Sex Life

BACKGROUND

This study aimed to characterize the frequency of self-reported thyroid-related impaired sex life in patients with thyroid diseases, to examine its clinical correlates and relationship with overall quality of life (QOL), and to investigate the effect of treatment.

PATIENTS AND METHODS

Two separate patient samples with benign thyroid diseases were investigated: a cross-sectional sample (759 women and 118 men) treated at two Danish university hospital outpatient clinics, in 2007-2008, and a longitudinal sample (358 women and 74 men) undergoing treatment at the abovementioned centers, during 2008-2012, evaluated before and 6 months after therapy. The thyroid-specific QOL questionnaire ThyPRO was used to measure patient-evaluated thyroid-related sex life impairment. Biochemical and clinical variables were analyzed (i.e., age, education, degree of thyroid dysfunction, comorbidity, serum thyrotropin, total thyroxine, and triiodothyronine, as well as thyroperoxidase and thyrotropin receptor antibody concentrations). The SF-36 Health Survey was used to analyze the effect of impaired sex life on overall QOL.

RESULTS

In the cross-sectional sample, 36% of women and 31% of men reported what they perceived to be thyroid-attributable impaired sex life. Women with autoimmune thyroid diseases reported more impairment than those with non-autoimmune thyroid diseases. In patients with Graves' disease lower levels of educational attainment and in patients with toxic nodular goiter comorbidities were associated with impaired sex life. Overall QOL was lower in patients with thyroid-related sex life impairment. In the longitudinal sample, 42% of women and 33% of men had impaired sex life at baseline, which improved at 6 months follow-up only in women and, when analyzing individual diagnoses separately, statistically significantly among those with autoimmune hypothyroidism. Sexual impairment was associated with low education in patients with toxic nodular goiter and with high plasma triiodothyronine concentrations in patients with Graves' disease. In autoimmune hypothyroidism, a younger age was associated with sex life impairment.

CONCLUSION

We found a high frequency of self-reported, thyroid-related sex life impairment in patients with benign thyroid diseases, especially in young women with autoimmune thyroid diseases. Self-perceived impaired sex life persisted in women treated for Graves' disease, suggesting that normalization of thyroid function was not sufficient to restore sexual function.

Changes in Swallowing Symptoms and Esophageal Motility After Thyroid Surgery: A Prospective Cohort Study

INTRODUCTION

Swallowing difficulties, the pathophysiology behind which is incompletely understood, have been reported in 47-83% of goiter patients referred for thyroidectomy. We aimed at examining the influence of thyroid surgery on swallowing symptoms and esophageal motility.

METHODS

Thirty-three patients with benign nodular goiter undergoing thyroid surgery were included. All completed high-resolution esophageal manometry examinations and the goiter symptom scale score, assessed by the thyroid-specific patient-reported outcome measure. The evaluations were performed before and 6 months after surgery.

RESULTS

Before surgery, the goiter symptom score was median 39 points (range 2-61), which improved to median five points (range 1-52) after surgery (p < 0.001). The motility parameters were within the limits of normal swallowing physiology, both before and after surgery. Only the upper esophageal sphincter (UES) pressure increased significantly from 70.6 ± 27.7 to 87.7 ± 43.2 mmHg after surgery (p = 0.04). Using regression analyses, there was no significant correlation between change in goiter symptoms and weight of the removed goiter, motility parameters, or motility disturbances. However, patients undergoing total thyroidectomy experienced a larger reduction in pressure in the area of the UES and former thyroid gland after surgery in comparison with patients undergoing less extensive surgery.

CONCLUSIONS

Goiter symptoms improved significantly after thyroidectomy, but without correlation to esophageal motility disturbances. This information is essential when interpreting dysphagia in patients with nodular goiter, and when balancing patients' expectations to surgical goiter therapy.

REGISTRATION NUMBER

NCT03100357 ( www.clinicaltrials.org ).

Treatment choice, satisfaction and quality of life in patients with Graves' disease

BACKGROUND

Thyrotoxicosis, most often caused by Graves' disease (GD), when treated inadequately may result in premature mortality. There is little consensus as to which of the 3 treatment options available - antithyroid drugs (ATD), radioactive iodine (RAI) and surgery, is better.

AIMS

(i) To assess factors involved in treatment choice and treatment satisfaction in patients treated for Graves' disease; (ii) To assess quality of life (QoL) following treatment of Graves' disease.

METHOD

Participants were selected from a prospective study cohort assessing thyrotoxicosis incidence and severity. Of the 172 eligible patients with Graves' disease, 123 treated patients participated (64% had received ATD only, 11% RAI and 25% total thyroidectomy, the latter 2 usually after a period of ATD), along with 18 untreated patients with newly diagnosed Graves' disease (overall participation rate, 73%). Consented patients completed a questionnaire detailing factors involved in treatment choice, QoL and satisfaction with treatment.

RESULTS

Participants reported that the most important factors in choosing a treatment were the following: the effects on activities of daily living, concern about use of radioiodine, possibility of depression or anxiety, and doctor's recommendations. Satisfaction levels were high across all 3 treatment types. QoL 1-year following treatment was higher than in untreated patients, and comparable with other international studies.

CONCLUSIONS

Patient satisfaction with therapy and QoL does not differ by treatment type. Therefore, clinical and social factors, in combination with patient choice and resource availability, should determine which treatment modality patients with Graves' disease should receive.

THE ROMANIAN VERSION OF THE THYROID-RELATED PATIENT-REPORTED OUTCOMES THYPRO AND THYPRO-39. TRANSLATION AND ASSESSMENT OF RELIABILITY AND CROSS-CULTURAL VALIDITY

BACKGROUND

ThyPRO is a recently developed thyroid-specific quality of life (QoL) questionnaire applicable to patients with benign thyroid disorders(BTD). The aim of the present study was to translate ThyPRO and ThyPRO-39 into Romanian, and to evaluate reliability and cross-cultural validity.

METHODS

Standard methodology for translation and linguistic validation of patient-reported outcomes (PRO) was applied. The questionnaire was completed by 130 patients with benign thyroid diseases seen at Department of Endocrinology in the Emergency County Hospital, Tîrgu Mureş, Romania, between October 2015 and March 2016. Internal reliability of the Romanian version of the ThyPRO (ThyPROro) scales was assessed for multi-item scales using Cronbach's alpha coefficient. An efficient method for testing cross-cultural validity is analysis of differential item functioning (DIF). Uniform DIF between the Romanian and the original Danish sample was investigated using ordinal logistic regression. The translation process proceeded without difficulties, and any disagreements were revised by one of the developers and the language coordinator.

RESULTS

Internal reliability for ThyPRO was satisfactory. Cronbach`s alpha coefficients for the 13 scales ranged from 0.78 to 0.93 for the ThyPROro and 0.78 to 0.87 for the ThyPROro-39. In the 85-item ThyPRO, nine instances of DIF were found. Most were minor, explaining <3% of the variation in scale score, but DIF in positively worded items were larger, with explained variance (R2's) around 10-15%.

CONCLUSION

The ThyPROro questionnaire is ready for assessment of health-related quality of life in Romanian patients with benign thyroid diseases.

ThyPROgr: the Greek edition of the ThyPRO questionnaires for patients with benign thyroid diseases

The thyroid-related patient-reported outcome measure ThyPRO is currently the most reliable and valid instrument for the measurement of thyroid-related quality of life. The objective of the current study was to translate the original (85 items) and short (39 items) versions of ThyPRO into the Greek language as well as to validate and culturally adapt ThyPRO among the Greek population. Translation of patient-reported outcomes was done according to standard methodology. Following the translation process, the Greek version of ThyPRO (ThyPROgr) was validated in consecutive patients with thyroid diseases who visited the outpatient clinics of the Department of Endocrinology, "Hippokration" General Hospital, Thessaloniki, Greece, between September and December 2016. To test cross-cultural validity, analysis of differential item functioning (DIF) between the original Danish and the new Greek version, using ordinal logistic regression, was applied. Cross-cultural validity of the Greek translation was evaluated for both versions of ThyPRO. The ThyPRO questionnaire was validated in 143 consecutive patients (131 women and 12 men) with thyroid diseases, with a mean age of 62 ± 6 (SD) years. In the 85-item ThyPRO, 17 instances of DIF were detected, most of which were minor, this accounting for the ~ 5% of the variation in scale score. Two instances of DIF among positively worded items were larger, with 8-10% of variance explained. For ThyPRO-39, five minor instances of DIF were found. As judged by the linguistic validation as well as the DIF analyses, ThyPROgr has good cross-cultural validity when compared with the original Danish version. The two versions of ThyPROgr can now be used to assess thyroid-specific quality of life in the Greek population.

The compensatory enlargement of the remaining thyroid lobe following hemithyroidectomy is small and without impact on symptom relief

According to previous studies, hemithyroidectomy results in growth of the remaining thyroid lobe by up to 30% in first 12 months after surgery. However, this estimate is based on imprecise methods, high inter- and intra-observer variability, and lack of blinding of the measurements. Furthermore, it is unknown whether enlargement of the remaining hemi-thyroid interferes with the improvement in symptoms after surgery for goiter. We aimed to assess the impact of postoperative thyroid growth on goiter symptom relief following hemithyroidectomy in patients with benign nodular goiter. Outcomes were measured before and 6 months after hemithyroidectomy in 44 patients. Thyroid volumes were determined by two independent and blinded observers using magnetic resonance imaging (MRI). Inter- and intra-observer variability was visualized by Bland-Altman plots. Goiter symptoms were assessed by the Thyroid-Specific Patient-Reported-Outcome Questionnaire (ThyPRO) on a scale from 0 to 100 points. After hemithyroidectomy, the remaining thyroid lobe was 13.7 ± 6.4 mL, and enlarged by a mean of 1.8 mL over 6 months [95% confidence interval (CI) (1.6; 2.1), p < 0.001], corresponding to an increase of 17% [95% CI (12; 22)]. The Goiter Symptom score improved by 27 points [95% CI (21; 34), p < 0.0001] from median 39 points (range 2-86) at baseline, and was unaffected by the compensatory thyroid growth. Six months after hemithyroidectomy, using blinded MRI evaluations, we demonstrated a small but significant postoperative growth of the remaining hemi-thyroid, which did not significantly affect the considerable improvement in goiter symptoms.

Quality of life after thyroidectomy in patients with nontoxic nodular goiter: A prospective cohort study

BACKGROUND

Using the thoroughly validated Thyroid-Related Quality-of-Life Patient-Reported Outcome (ThyPRO) questionnaire, the purpose of this study was to investigate changes in disease-specific quality of life (QOL) after surgical treatment in patients with benign nontoxic multinodular goiters.

METHOD

Patients with goiters scheduled for thyroid surgery (n = 106) and individuals from the general population (n = 739) were studied. The ThyPRO data before, 3 months, and 6 months after surgery were compared with normative scores from the general population using a linear mixed model and t tests.

RESULTS

Before surgery, patients with goiters experienced poorer scores on all scales compared to the general population. After surgery, moderate to large improvements were seen in goiter symptoms, tiredness, anxiety, and overall QOL. After surgery, all scales returned to values equal to the general population. The degree of anxiety was, in fact, lower than in the general population.

CONCLUSION

Thyroid surgery leads to significant benefit among patients with benign nontoxic goiters by restoring QOL equal to that in the general population.

Laser, radiofrequency, and ethanol ablation for the management of thyroid nodules

PURPOSE OF REVIEW

The majority of benign thyroid nodules are nearly asymptomatic, remain stable in size, and do not require treatment. However, a minority of patients with growing nodules may complain of local symptoms or have cosmetic concerns, and thus seek surgical consultation.

RECENT FINDINGS

The timely use of ultrasound-guided minimally invasive procedures can change the natural history of benign enlarging thyroid nodules. The procedures produce persistent shrinkage of thyroid nodules and are associated with improvement of local symptoms. Among the various procedures, percutaneous ethanol injection represents the first-line treatment for relapsing thyroid cysts. In solid nonfunctioning nodules, laser and radiofrequency ablation produces a more than 50% reduction in nodular volume that remains persistent over several years. For hyperfunctioning nodules, thermal ablation techniques are not appropriate unless radioactive iodine is contraindicated or not accessible.

SUMMARY

MITs are best suited for the management of medium or large-sized nodules that are sonographically well visualized. Conversely, large nodules or nodular goiters that extend into the chest are difficult to treat. MITs are performed in outpatient clinics, are less expensive, and have a lower risk of complications, compared to surgery, and usually do not induce thyroid dysfunction. However, malignancy should be ruled out with a dedicated ultrasound neck assessment and repeat fine needle aspiration of the lesion before treatment.

Disease-Specific as Well as Generic Quality of Life Is Widely Impacted in Autoimmune Hypothyroidism and Improves during the First Six Months of Levothyroxine Therapy

BACKGROUND

Hypothyroidism is often diagnosed, and subsequently treated, due to health-related quality of life (HRQL) issues. However, HRQL following treatment has never previously been assessed in longitudinal descriptive studies using validated instruments.

OBJECTIVE

To investigate disease-specific (ThyPRO) and generic (SF-36) HRQL, following levothyroxine therapy in patients with hypothyroidism due to autoimmune thyroiditis.

METHODS

This prospective cohort study was set at endocrine outpatient clinics at two Danish university hospitals. Seventy-eight consecutive patients were enrolled and completed HRQL questionnaires before, six weeks, and six months after initiation of levothyroxine therapy. Normative ThyPRO (n = 739) and SF-36 (n = 6,638) data were available for comparison and changes in HRQL following treatment were estimated and quantified.

RESULTS

Prior to treatment, all ThyPRO scales were significantly impacted (p<0.0001), compared to the general population sample. The same was observed for seven of eight SF-36 scales, the exception being Bodily Pain. Tiredness (ThyPRO) and Vitality (SF-36) were the most markedly impacted scales. After six weeks of treatment, nine of thirteen ThyPRO scales had significantly improved. ThyPRO improvements were consistent at six months, where five of eight SF-36 scales had also significantly improved, but deficits persisted for a subset of both ThyPRO and SF-36 scales.

CONCLUSIONS

In this population of hypothyroid patients, HRQL was widely affected before treatment, with tiredness as the cardinal impairment according to both ThyPRO and SF-36. Many aspects of HRQL improved during the first six months of LT4 therapy, but full recovery was not obtained. Our results may help clinicians inform patients about expected clinical treatment effects.

A systematic review of quality of thyroid-specific health-related quality-of-life instruments recommends ThyPRO for patients with benign thyroid diseases

OBJECTIVES

To appraise the measurement properties of thyroid-specific health-related quality-of-life (HRQOL) instruments and to provide recommendations on the choice of HRQOL instruments.

STUDY DESIGN AND SETTING

Systematic review of English-language literature published between 1993 and 2015 identified psychometric studies involving patients with thyroid disease through a search of Pubmed, Web of Science, Embase, and OVID MEDLINE. HRQOL instruments were graded on methodological quality and overall levels of evidence using a COSMIN checklist.

RESULTS

After a review of 742 original studies, 23 studies reporting 14 standardized HRQOL instruments targeted for Graves' ophthalmopathy (n = 4), hypothyroidism (n = 3), thyroid cancer (n = 2), other thyroid disease (n = 3), and nonthyroid tumor sites (n = 2) were identified. Hypothesis testing was evaluated most frequently. The 84-item thyroid-specific patient-reported outcome measure (ThyPRO) and 16-item Graves' ophthalmopathy-specific Quality-of-Life (GO-QOL) instruments were the most extensively evaluated instrument. The highest number of positive ratings in overall level of psychometric evidence was found in ThyPRO, GO-QOL, and 11-item Thyroid Treatment Satisfaction Questionnaire (ThyTSQ) instruments.

CONCLUSION

The ThyPRO is recommended for the assessment of HRQOL in patients with benign thyroid diseases while measurement properties of GO-QOL and ThyTSQ are satisfactory in measuring HRQOL of patients with Graves' ophthalmopathy and hypothyroidism, respectively.

Development of a Short Version of the Thyroid-Related Patient-Reported Outcome ThyPRO

BACKGROUND

Thyroid diseases affect quality of life (QoL). The Thyroid-Related Patient-Reported Outcome (ThyPRO) is an international comprehensive well-validated patient-reported outcome, measuring thyroid-related QoL. The current version is rather long--85 items. The purpose of the present study was to develop an abbreviated version of the ThyPRO, with conserved good measurement properties.

METHODS

A cross-sectional (N = 907) and a longitudinal sample (N = 435) of thyroid patients were analyzed. A graded item response theory (IRT) model was fitted to the cross-sectional data. Short-form scales with three items were aimed for, by selecting items with best fit according to the IRT model, avoiding cross-culturally noninvariant items. Seven scales measuring mental and social well-being and function as well as one overall QoL impact item were analyzed in a bifactor model, to develop a supplementary composite score. Short-form scales were linked to original scales with IRT-based summed-score-linking. Agreement between the short and long form was estimated by agreement plots, intraclass correlations, and mean score levels. Responsiveness was compared by relative validity indices, clinical validity by ability to detect clinically relevant differences, and test-retest reliability by intra-class correlation.

RESULTS

One four-item scale was not abbreviated and one two-item scale was omitted from the short-form. For the 11 scales undergoing abbreviation, 10 with three and one with four items were developed. A bifactor model with good overall fit was fitted to the composite score, including the single QoL item. Responsiveness and clinical validity of the short-form scales were preserved, as were test-retest reliability (0.75-0.89). Short- versus long-form intraclass correlations were high (0.89-0.98), and the mean scale levels were similar.

CONCLUSIONS

A 39-item version of the ThyPRO, with good measurement properties, was developed and is recommended for clinical use.

HEALTH-RELATED QUALITY OF LIFE AFTER PERCUTANEOUS RADIOFREQUENCY ABLATION OF COLD, SOLID, BENIGN THYROID NODULES: A 2-YEAR FOLLOW-UP STUDY IN 40 PATIENTS

OBJECTIVE

We studied the impact of radiofrequency ablation (RFA) on health-related quality of life (HRQL) in patients with benign thyroid nodules (TN) in a 2-year follow-up.

METHODS

Forty patients (35 women and 5 men; age, 54.9 ± 14.3 years) with cold thyroid solitary nodules or a dominant nodule within a normofunctioning multi-nodular goiter (volume range, 6.5 to 90.0 mL) underwent RFA of thyroid nodular tissue under ultrasound real-time assistance.

RESULTS

Data are mean and standard deviation. Energy delivered was 37,154 ± 18,092 joules, with an output power of 37.4 ± 8.8 watts. Two years after RFA, nodule volume decreased from 30.0 ± 18.2 mL to 7.9 ± 9.8 mL (-80.1 ± 16.1% of initial volume; P<.0001). Thyroid-stimulating hormone, free triiodothyronine, and free thyroxine levels remained stable. Symptom score measured on a 0- to 10-cm visual analogue scale (VAS) declined from 5.6 ± 3.1 cm to 1.9 ± 1.3 cm (P<.0001). Cosmetic score (VAS 0-10 cm) declined from 5.7 ± 3.2 cm to 1.9 ± 1.5 cm (P<.0001). Two patients became anti-thyroglobulin antibody-positive. Physical Component Summary (PCS)-12 improved from 50.4 ± 8.9 to 54.5 ± 5.3, and the Mental Component Summary (MCS)-12 improved from 36.0 ± 13.3 to 50.3 ± 6.3 (P<.0001 for both score changes).

CONCLUSION

Our 2-year follow-up study confirms that RFA of benign TNs is effective in reducing nodular volume and compressive and cosmetic symptoms, without causing thyroid dysfunction or life-threatening complications. Our data indicate that the achievement of these secondary endpoints is associated with HRQL improvement, measured both as PCS and MCS.