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Annabelle's assignment and what her lecturer thought

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Introduction

What is a thyroid gland? How much do people understand about it? The organ is located at the base of the neck, surrounding the trachea. This seemingly insignificant body part plays a vital role in maintaining optimal development and ensuring the balance of an organism's central nervous system. In cases where it malfunctions, endocrine diseases may arise. This is reflected in Erica* who is a sufferer of grave's disease. This essay will first examine the effects of Erica's medical condition on her physical and psychological health and on her lifestyle. Secondly, Erica's personal perception of the disease and reaction to the diagnosis will be discussed. Next, environmental triggers and any other predictors that may have an impact on aspects of the disease will be addressed. Finally, emphasis will be given to Erica's expectations for the future. The author's own predictions will also be included strategically throughout the essay.

Basic information

Born and raised in Australia, Erica's parents were originally Vietnamese refugees who fled to Australia during the Vietnam War. At age 28, Erica is a female who holds the position of a sales and marketing manager. Erica is currently married and lives with her husband.

Grave's disease and the parameters in the prediction of its occurrence

Ando, Latif and Davies (2004) define Grave's disease as a prevalent autoimmune disorder resulting from the excess production of thyroid hormones. Hanna and Lafranchi (2002) suggest that this can be the effect of complicated interactions between external and internal factors. An example of this was that while Erica inherited the gene that caused Grave's disease from her mother, environmental stimulations such as a bacteria infection, stress or simply geographic variables such as her Asian background might have activated the onset of the disease. According to Erica, Asians are more prone to iodine-related diseases due to their low iodine diet.

Erica was first diagnosed with a thyroid condition at the tender age of 21. Hanna and Lafranchi (2002) contends that females are five times more likely to experience hyperthyroidism as compared to males and that in the initial stage of the disease, symptoms are covert despite it having fatal consequences later on. Statistically approximately 0.4% of adults suffer from Grave's disease. The severity of Erica's illness and persistent sanctioning from her parents prompted her to seek medical help immediately. After having had her blood test taken, antithyroid drugs were administered by the doctor based on the laboratory results. This was indicative of the amount of radioactive iodine that is absorbed by the thyroid gland. A high iodine uptake translates to Grave's disease (Isaacs and Ruggieri, 2004).

Various forms of treatment for thyroid disorders

There are three types of treatment for hyperthyroidism. They are antithyroid drugs (ATD), radioactive therapy (RAI) and surgery with the first type of treatment being the most common and the last being rare (Isaacs and Ruggieri, 2004).

Cooper (2005) explains that the use of such immunosuppressive drugs have an advantage over other more dangerous measures such as radiation therapy and surgery. This is largely because oral medication is more affordable and perceived as less life threatening. However, it is unknown to many that RAI can also be administered in medication form- as a radioactive pill ingested orally (Hanna and Lafranchi, 2002). Besides, surveys comparing the effectiveness of the three main treatments of hyperthyroidism have demonstrated up to 90% success rate for each. However, this form of treatment is more time consuming and requires long-term commitment in that frequent tests on the thyroid needs to be done at least once every month until the amount of thyroid hormones secreted appear to be of an acceptable level. If this data remains consistent for the next three months, the amount of drug administered could be lowered and eventually ceased within the span of 18 months (Cooper, 2005). According to Erica, her doctor had to monitor the development of her thyroid. This means that she was required to undergo blood tests on a monthly basis. Understandably, it was tricky to know the exact amount of medication to prescribe since her condition varied periodically, without adhering to a specific trend. Cooper (2005) asserts that an overdose may lead to hypothyroidism while insufficient administration will result in uncontrolled levels of hyperthyroidism. Personally, Erica felt that visits to the practitioner posed as an inconvenience because of her busy schedule at university. The late consultation hours added to her reluctance to seek treatment regularly. In other words, Erica felt that obligations to visit the physician frequently were an interference with her vocational and physical preoccupations (Jones, 2003).

Dilemma over the types of treatment to undertake

Erica's mom who was also a sufferer of Grave's disease could empathize with Erica's suffering perfectly. She advised Erica to undergo either RAI or surgery, as they are the permanent means of solving her thyroid problem. Monetary issues were not a problem for Erica, an Australian citizen who would be covered by the government's public health insurance policy completely. However, the fear of adverse effects from those treatments deterred Erica. In her view, the risks involved in them far outweighed the positive outcomes they could have attained given the bleakness of the situation at that point in time. Erica's primary concern was the effects of RAI on her fertility. However, her doctor assured her that this threat was minimized since the pill was focused solely on the thyroid gland and not on the consumer's reproductive organs. Erica's insecurities were not without reasons. Pauwels et al. (2000) hypothesized the link between RAI and cancer, although only to a small extent. This was illustrated by the research that points to increasing rate of cancer of the thyroid, stomach and other organs associated with digestion and excretion. Furthermore, in RAI, killing more of the thyroid gland than necessary may result in permanent hypothyroidism (Cooper, 2005). However, it was later acknowledged that the improvements brought about by RAI far surpassed its disadvantages. This view was challenged by Isaacs and Ruggieri (2004) who argued that the processes of RAI posed no threats of cancer.

Some experts have attested to the effectiveness of surgical methods of treatment but Isaacs and Ruggieri (2004) refuted this belief. Instead, they claimed that any undestroyed thyroid tissue might redevelop after the operation, causing another bout of hormonal attack on the victim. Hanna and Lafranchi (2002) further highlighted that almost half of the patients who had surgery became hyperthyroid; another 1.2 % reported to have lost their ability to speak and a small percentage of patients died as a result. Indeed, this verified how crucial it was to involve a veteran endocrine specialist in carrying out the thyroid removal surgery as any minor mistakes could result in irreversible damage to the patient's health or even death.

Environmental triggers

Even though iodine was alleged to reduce the adverse effects of hyperthyroidism, Erica did not intently increase her iodine intake, believing that it was too insignificant a source to be considered important. Her opinions were seconded by McLachlan (2005) who attested that iodine levels had no effects on the amount of thyroid hormone produced by the body. On the contrary, studies conducted by Cooper (2003) and Goodman (1994) underlined a correlation between iodine levels in the body and the occurrence of hyperthyroidism. An illustration was made when comparing the iodine intake of citizens of Iceland (normal) with that of Denmark (low) where the latter reported up to about 38% higher rates of the population infected with Grave's disease. Apart from this, stress, steroids and other poor lifestyle habits like smoking may also contribute to the development of Grave's disease, especially for those who may have genetic predispositions (Cooper, 2003; Cooper, 2005).

Physical impacts of the disease

Cooper (2003) and Isaacs and Ruggieri (2004) proposes that hormonal imbalances often result in patients experiencing heart palpitations. Physical manifestations of an over-worked heart and body include continuous perspiration although inactive, intolerance to even low degrees of heat, irregular pumping of the heart, breathlessness, trembling hands and in the worst scenario, death from a blocked artery in the heart. Erica reported experiencing similar physical symptoms, which were mild on some days but horrible on most occasions. For example, on certain days, she would not be able to muster the strength to walk up a mere flight of stairs because she had been exceedingly exhausted from her body's uncontrolled exertions. Hanna and Lafranchi (2002) and Cooper (2003) support the symptoms, explaining that this may be due to extreme weakness that results in temporal loss of muscular control or numbness. As a consequence, hyperthyroidism is often masked in clinical diagnosis and confused with hypothyroidism where lethargy is a common feature.

Erica claimed that her thyroid hormone level was four to five times more active as compared to a healthy individual, causing her thyroid gland to become tender and swollen. This was noted in Isaacs and Ruggieri (2004) and Hanna and Lafranchi (2002) who attribute the trait to an over stimulation of the thyroid gland. Subsequently, Erica commented that her eyes began to bulge, as experienced by 20-40% of patients suffering from Grave's disease (Hanna and Lafranchi, 2002). Eye abnormalities can result from the shortening of the muscles in the upper eyelids (Chang, Bernardino and Rubin, 2004; Hanna and Lafranchi, 2002; Isaacs and Ruggieri, 2004). Erica also lost hefty clumps of hair. Isaacs and Ruggieri (2004) identify similar problems in an individual suffering from the disease. The hair becomes thinner, drops easily and may even turn gray.

Psychological impacts of the disease

Neural alterations such as low concentration span and changed personality is being observed in individuals who suffer from this disease (Copper, 2003; Hanna and Lafranchi, 2002). Erica was under such great psychological strain that her state of mind became unstable. For instance, Erica often experienced outbursts and could not seem to control her emotions. Moreover, Erica admitted to experiencing several periods of depression following her diagnosis. Isaacs and Ruggieri (2004) maintain that hormonal stimulation of the brain is responsible for depressive and irritable moods. In addition, Erica's irritability could be attributed to factors such as the effects of hormones that influenced her ability to concentrate and the intense frustrations initiated by the distortions to her physical appearance. To worsen the situation, Erica claimed that the condition disrupted her normal sleeping patterns (Hanna and Lafranchi, 2002; Cooper, 2003). Despite this, Erica refused to submit to the use of sleeping pills in order to fall asleep, as she strongly believed in natural sleep instead of an artificially induced one. In Erica's opinion, society would not approve the use of sleeping tablets as a solution to insomnia in the long term. Clearly, side effects, the fear of social stigmatism and the fear of dependency on the drug served as reinforcements to prevent her from using sleeping pills. Erica's resistance to the use of those medications was in fact a wise decision. Pagel and Parnes (2001) establishes that ingesting tranquilizing pills to overcome chronic sleep disorders may adversely affect rapid eye movement (REM) sleep.

Behavioural changes in response to the disease

A significant change was determined in Erica whose appetite increased greatly. High levels of thyroid hormone in the bloodstream raised Erica's metabolic rate drastically (Goodman, 1994). For example, Erica could consume a ten course Chinese banquet and still feel unsatisfied. In spite of her large food intake, Erica's body was unable to absorb the vast amount of nutrients from these foods. Instead, most of it was lost in diarrhoea (Hanna and Lafranchi, 2002). Hence, frequent trips to the toilet after a meal was inevitable. More importantly, the loss of bodily fluids and nutrients drained Erica excessively, causing feelings of lethargic. At these times, Erica would appear withdrawn and disinterested in her surroundings. At other times, Erica tended to be tense, spoke rapidly, was restless and always fidgety. This was typically seen in hyperthyroid individuals who alternate between mania and exhaustion (Goodman, 1994; Isaacs and Ruggieri, 2004).

Attempts to revive any lost nutrients through vitamin supplements were futile given that it was excreted from the digestive system almost instantly (Isaacs and Ruggieri, 2004). This had an effect on Erica's outward appearance. She appeared disheveled and spindly as her metabolic mechanisms expended calories more rapidly than could be replaced in the diet. This implies that the Erica's body stores were deficient in essential vitamins and minerals which include calcium and vitamin D. Since these compounds are the precursor for healthy bone formation, Erica was warned of the possibility of developing osteoporosis if her condition was left untreated for prolonged periods (Cooper, 2003; Whitney and Rolfes, 2005). Luckily, the onset of her disease occurred following puberty years and hence her growth was not stunted as seen in cases of children who developed Grave's disease before maturity and thus failed to attain the full grown stature of an adult (Goodman, 1994; Hanna and Lafranchi, 2002).

Cognitive responses to the disease

Despite imposing the sick role on Erica, her parents' advice for her to remain indoors and eat a greater amount of nutritious foods was ignored. Erica rebelled against their instructions. Although Erica was intent on improving her condition, she was not prepared to sacrifice her social life. Being young and hot-blooded, she was eager to explore the world and refused to be restricted by the physical constraints of her illness. Looking back, she had naively thought that the problem was temporal and that the symptoms would disappear within a matter of months or even weeks. Moreover, Erica believed that there was no connection between her level of physical activity and the status of her disease.

Erica's optimistic appraisal of the situation prompted her to adopt effective ways of dealing with the personal crisis (Jones, 2003). Gradually, as Erica approached the 'acceptance stage', she began to see the 'funny side' of the disease and learnt to overlook the negative impacts. Unlike most girls who had to constantly watch their diet to stay slim, Erica had the freedom of eating whatever she fancied without worrying about obesity. Erica could eat four to five times more than most people. For instance, she consumes three times more than her husband in daily meals. Obviously, this feeling of blessing can only be achieved by disregarding the fact that her body was absorbing nil amounts of nutrients and could even be losing lean tissues in the form of muscles needed to keep the body fit (Isaacs and Ruggieri, 2004). An extra bonus lay in the surplus supply of energy Erica experienced continually. This enabled her to be more productive and proficient as compared to her peers. The conscious choice of adopting a positive attitude instead of dwelling in an eternal mode of self- pity promoted improvements in both her physical and mental strength. Likewise, Jones (2003) contends a link between optimism and good health.

Erica's assertiveness and uncompromising personality made her feel that the onus of finding out more information to assist in her self-awareness of the disease was ultimately on her.Jones (2003)allenging period of her life.

Side effects of antithyroid drugs

After consulting several reliable sources, she decided to undergo radioidodine therapy. This was largely because while antithyroid drugs could suppress the symptoms of her illness, it could not stem the problem of nutrient loss such as calcium from her body (Isaac and Ruggieri, 2004). This step of faith arrived only after seven years of antithyroid drug treatment. For almost a decade, Erica had had to put up with the discomforts and side effects brought about by the use of antithyroid drugs. Negative effects from the incorporation of thyroid medication range from those that are benign-rashes and other allergic reactions to those with malignant effects-liver failure and even death (Cooper, 2005). Fortunately, Erica noticed only mild symptoms. They were rapid weight gain, weariness and slow hand-eye coordination. Hanna and Lafranchi (2002) and Isaacs and Ruggieri (2004) recognize the necessity to decrease the amount of food use during treatment because while the drug returns the body's metabolic rate to its normal level, the individual's appetite remain heightened and may result in weight gain. She also experienced irregular menstrual cycles for a few years (Hanna and Lafranchi, 2002). This could be ascribed to the abnormal amount of estrogen and progesterone that circulated around the body at the initial stage of the disease as well as the sudden hormonal imbalance caused by the drugs (Cooper, 2003; Hanna and Lafranchi, 2002; Isaacs and Ruggieri, 2004).

Future expectations

Having started on the new form of treatment- RAI, Erica has observed marked improvements in her condition. Erica expects full recovery in the near future after which she and her husband hope to start a family.

Conclusion

Conceivably, Erica portrays herself as an independent and resilient individual who has learnt to cope and manage her illness with the support and counseling of her family and friends. At present, scarce information is available regarding the underlying mechanisms for the symptoms of the disease. Even though possible suggestions and speculations have been quoted, their inconsistency makes it difficult to discern between myths and the absolute truth. No one knows what the future will bring in terms of developments in treating thyroid disorders, much less the fate of Erica. However, with modern science and technology, a new invention or therapy for eliminating endocrine diseases could well be underway.

References

Ando, T, Latif, R and Davies, TF 2004, 'Concentration-dependent regulation of thyrotropin receptor function by thyroid-stimulating antibody', Journal of Clinical Investigation, vol. 113, no. 11, pp. 1589-1595.

Cooper, DS 2003, 'Hyperthyroidism', The Lancet London, vol. 362, no. 9382, pp. 459.

Cooper, DS 2005, 'Antithyroid drugs', The New England Journal of Medicine, vol. 352, no. 9, pp. 905-914.

Eli, LC, Bernardino, CR and Rubin, PAD 2004, 'Normalization of upper eyelid height and contour after bony decompression in thyroid-related ophthalmopathy: A digital image analysis', Archives of Ophthalmology, vol. 122, no. 12, pp. 1882-1885.

Goodman, HM 1994, Basic Medical Endocrinology, 2nd edn, Raven press, New York.

Hanna, CE and Lafranchi, SH 2002, 'Adolescent thyroid disorders', Adolescent Medicine, vol. 13, no. 1, pp. 13-36.

Isaacs, S and Ruggieri, P 2004, A simple guide to thyroid disorders: From treatment to diagnosis, Addicus Books, Nebraska.

Jones, K 2003, Health and human behaviour, Bookpac Production Services, Singapore.

McLachlan, SM, Braley-Mullen, H, Chen, C, Aliesky, H, Pichurin, PN and Rapoport, B 2005, ' Dissociation between iodide-induced thyroiditis and antibody-mediated hyperthyroidism in NOD.H-2h4 Mice', Endocrinology, vol. 146, no.1, pp.294.

Pagel, JF and Parnes, BL 2001, 'Medications for the treatment of sleep disorders: An overview', Pubmed, vol. 3, no. 3, pp.118-125.

Pauwels, EKJ, Smit, JWA, Slats, A, Bourguignon, M and Overbeek, F 2000, 'Health effects of therapeutic use of (131)I in hyperthyroidism', The Quarterly Journal of Nuclear Medicine, vol. 44, no. 4, pp. 333-339.

Whitney, E and Rolfes, SR 2005, Understanding Nutrition, Peter Marshall, United States of America.

[Lecturer's overall comments]

Comment

Starting your essay with rhetorical questions may be good for creating interest, but is not common in medical and scientific writing. Another, perhaps more appropriate way of expressing this idea would be as follows: The thyroid gland is a little-understood organ located at the base of the neck surrounding the trachea.

Comment

This introduction provides a thorough and clearly expressed outline of the intended essay structure.

Comment

This could be expressed more simply. For example:

Erica is female, 28 years old, and works as a sales and marketing manager.

Comment

When referring to sources, it is important to maintain subject-verb agreement. In this case it should be written as follows:

Hanna and Lafranchi (2002) contend that...

Comment

Note the range of sources referred to in outlining the medical details of the condition. Lecturers look to see an adequate range of references. They also look to see how current the sources are. In this essay, recent sources (2002, 2004) have been used. This is important to ensure that the information you provide about current knowledge and treatment is up-to-date.

Comment

Be careful not to have too many very short paragraphs (eg. consisting of only one or two sentences). In this essay the following three sentences could be combined to form the first paragraph of this section. The second paragraph would start as follows:

Surveys comparing the effectiveness of the three main treatments of hyperthyroidism demonstrate up to 90% success rate for each.

Comment

Is it clear which form of treatment the word 'this' is referring to? Be careful with your use of referents (eg. this, that) to ensure that the meaning is clear and unambiguous.

Comment

Although you could write 'posed a problem for her', this word is not used correctly in the text. Why not simply write:

Erica found the visits to the practitioner inconvenient...

Remember that the object of good writing in the medical and scientific fields is to express concepts simply, clearly and unambiguously.

Comment

Note that the student relates the medical information on the condition to Erica's specific case - there is good integration of the theoretical information obtained from academic sources and the information provided by the patient (in the interview).

Comment

Notice that the focus in this section is on the patient's perspective and concerns in terms of the choice of treatment. This is consistent with the requirements of the task, which is to view the condition and experience of illness through the patient's eyes.

Comment

When referring to something for the first time, the article 'a' or 'an' is usually used. Subsequent references then use 'the'. In this case, this is the first reference in the text to a link between RAI and cancer, and therefore 'a' is more correct. Although this may appear a minor error, it can often confuse the reader momentarily, and in that way cause a break in concentration on the essay content.

Comment

In this sentence is it clear to which treatment, and to whose views, the words 'this view' refers? This problem could be corrected by moving the sentence to directly after the 'view' in question - for example:

Pauwels et al. (2000) hypothesized a link between RAI and cancer. This was illustrated by the research that points to an increasing rate of cancer of the thyroid, stomach and other organs associated with digestion and excretion. However this view has been challenged by Isaacs and Ruggieri (2004), who argue that the processes of RAI pose no threat of cancer.

Another way of correcting this problem would be to provide a brief summary of the 'view' within the sentence. For example:

The view that RAI is linked to cancer has been challenged by Isaacs and Ruggieri (2004), who argue that the process poses no such threat.

Comment

Note that present verb tense is more appropriate in these sentences, due to the currency of the work being cited. Using reporting verbs in the present tense when appropriate gives your writing a greater sense of currency, something valued by lecturers and expected in academic writing in the medical and scientific fields.

Comment

If this finding continues to be relevant to current practice (as it does), then present tense would be more appropriate. For example:

Indeed, this verifies how crucial it is to involve a veteran endocrine specialist...

Comment

It is unclear whether this word expresses the writer's idea correctly. Perhaps she meant to write 'intentionally'. In fact, neither word is necessary in the sentence. For example:

Erica did not increase her iodine intake...

When proofreading your essay, check for words and phrases that are not necessary (redundant). Removing redundant language will make your ideas clearer to your reader, and also help you to avoid exceeding the word count.

Comment

Given the citation is very current, in fact within the same year in which the essay was written, present verb tense is more appropriate. For example:

H er opinions are seconded by McLachlan (2005), who attests that iodine levels have no effect on the amount of thyroid hormone produced by the body.

Comment

Subject-verb agreement error.

Comment

Is the word 'exceedingly' necessary in this sentence?

Comment

When referring to an action occurring both in the past and up to the present, the present perfect tense should be used. For example:

Neural alterations such as low concentration span and changed personality have been observed in individuals...

Comment

The following is an example of a cohesive, well-structured paragraph with excellent integration of theoretical and patient perspectives.

Comment

This is an error in word form. The adjective lethargic has been used instead of the noun lethargy. Note that these errors may not be identified using a spellchecker (as the word is correctly spelt), but may using a grammar check.

Comment

Verb tense.

Comment

In this section the writer displays a detailed knowledge of the patient's experiences of her condition. In order to provide this level of detail, it is important to:

  • (i) develop a good rapport with the patient during the interview
  • (ii) show consideration and ask questions with sensitivity
  • (iii) ask follow-up questions to elicit more detailed responses
  • (iv) record patient answers in a clear and systematic way

Comment

This is a word choice error. The writer has written the word temporal but she means temporary. This error will not show up through a grammar check, because there is no grammatical error. These are less serious errors, however care needs to be taken because they may significantly change the meaning of a sentence.

Comment

When starting a new section or paragraph it is preferable to use the patient's name rather than the pronoun 'he' or 'she'. For example:

After consulting several reliable sources Erica decided to…

Comment

Subject-verb agreement. For example:

…the individual's appetite remains heightened…

Comment

Based on your research of the condition, you could comment on whether this appears a realistic expectation.

Comment

Is the word conceivably correct here? What does it mean? Is it necessary? The sentence is clearer and reads better without this word — it is redundant.

Comment

In relation to this topic, and in the biomedical and health sciences generally, we are not dealing with either 'myth' or 'absolute truth'. The idea contained in this sentence could be expressed more simply and clearly. For example:

Even though suggestions and speculation regarding possible future treatments have been considered, no new treatments are available at present.

Comment

The conclusion provides a concise summary of the main points of the essay, along with a brief comment on possible future developments in the treatment of the condition. It should be consistent with the introduction.

Comment

References are arranged alphabetically by author's surname, using the Harvard style. Note the range and currency of references consulted. These include:

  • (i) general medical journals
  • (ii) specialist medical journals
  • (iii) textbooks

Overall Comments

This is a clear, well-structured and interesting essay. The introduction provides a thorough outline of the intended essay structure and clearly addresses the requirements of the assignment task. Information is organised in a clear and logical way, and this organization is made explicit by the use of headings.

Information of a general nature on the patient's condition is presented along with details of the patient's specific experience of the condition. As such, theoretical information and personal information regarding the patient are integrated. The medical information provided is generally relevant to the specific case, and a range of recent sources have been referred to. With the exception of the first sections, coverage of the various perspectives required in the assignment task is balanced, with the focus mostly on the patient's experiences and beliefs regarding her condition. Specific details of the patient's experiences and attitude are presented in a sensitive and non-judgmental manner.

The conclusion provides a concise summary of the main points of the essay, along with a brief comment on possible future developments in the treatment of the condition. The reference list indicates that the student consulted a range of sources, including general medical journals, specialist medical journals and textbooks, with several of her sources published within the last two years.

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