Twice daily application to lesional skin for two weeks followed by a two week rest period is recommended in order to minimize the risk of steroid atrophy and telangiectasia purchase zoloft with visa depression symptoms diabetes. Topical tacrolimus may be of some beneft especially on the face and on skin lesions with less hyperkeratosis (Bohm et al zoloft 50 mg mastercard depression symptoms hypothyroidism. Unfortunately, the majority of patients do not respond ade- quately to local therapy, and systemic therapy is usually required. Up to 75 percent of patients have responded to one or a combination of drugs within this class (Furner, 1990a). Initial treatment should begin with hydroxychlo- roquine sulfate not to exceed a dose of 6 mg / kg lean body mass/day. If an adequate clinical response is achieved, the dose can be decreased to 3 mg / kg lean body mass/day for maintenance for at least one year in order to minimize recurrence. If there is no signifcant improvement by 2 months, quina- crine hydrochloride 100mg/day can be added (Feldman et al. If there is an inad- equate response to this combination regimen afer 46 weeks, chloroquine diphosphate 3mg/kg lean body mass/day can be substituted for hydroxychloroquine while continu- ing quinacrine. When using either hydroxychloroquine or chloroquine, ophthalmologic evaluation is required. The current surveillance guidelines recommend follow-up ophthalmologic examination 5 years afer an initial baseline exam in uncomplicated individuals on hydroxychloroquine. The use of an Amsler grid at home may allow early self-detection of visual feld defects. This is important since retinal changes may become irreversible if not found early. The risk of retinal toxicity may be minimized if certain daily doses of hydroxy- chloroquine (6mg/kg/day) and chloroquine (3mg/kg/day) are not exceeded (Lanham and Hughes, 1982). Hydroxychloroquine and chloroquine should not be used together be- cause of an enhanced risk of retinal toxicity. Blue-black pigmentation of sun- exposed skin, the palatal mucosa and nails has been seen with these agents. Quinacrine can cause difuse reversible yellowing of the skin, espe- cially in fair-skinned individuals. Tese are less common than in the past, when higher daily dosage regimens of antima- larials were used. Periodic laboratory monitoring of hematological and hepatic function is helpful in identifying any patient who might sufer an idiosyncratic reaction. Johansen and Gran (1998) reported two cases of ototoxicity associated with hydroxychloroquine. Hear- ing loss has been associated with chloroquine and quinine in the past, but this was the frst report of such with hydroxychloroquine. Appropriate referrals should be made if counseling or drug therapy is needed to accomplish this goal. Because of the high rate (approximately 75 percent) of relapse afer withdrawal of the medication, it has been suggested that low maintenance doses for long periods of time may be necessary (Ordi-Ros et al. Alternatively, other forms of therapy such as antimalarials can be used to maintain thalidomide-induced remissions. Since thalidomide is a potent teratogen, special precautions must be taken when prescribing the drug. Other second-line drugs should be considered in females of child-bearing potential. Physicians and pharmacies are required to register with the manufacturer, the Celgene Corporation. Another important adverse efect of thalidomide is sensory neuropathy, which is some- times irreversible. Routine clinical assessment for neuropathy is the single most efective means to detect the early development of neuropathy (Duong et al. Nerve conduc- tion tests are recommended at baseline and periodically during treatment, but the role of 230 Donna M. Evidence of neuropathy, by either high clinical suspicion or by electrophysiologic data is an indication to withdraw the drug (Stevens et al. Some of these side efects are improved on lower daily doses and when the drug is given at bedtime. Tese agents are usu- ally reserved for those patients who have not responded to less toxic therapies. However, they may be needed before an adequate trial of less toxic drugs is completed in those pa- tients with severe disease. The side efects of steroids, especially when used over long periods of time are worrisome. Tey are more appropriately used as adjunctive treatment and tapered of if possible. In one patient this response was successfully maintained for over 24 months on a lower dose of at least 1 g /day. Mycophenolate ofers a lower toxicity profle than some of the other immunosuppressants. A thorough understanding of potentially harmful side ef- fects is imperative with all of these medications, and close monitoring is essential. According to McGrath (1997), this modality reduced the need for medication and attenuated autoimmune antibody levels. Most patients tend to have intermittent recurrent skin lesions without signifcant disease progression, while some may experience permanent remis- 232 Donna M. More recent studies addressing prognosis have revealed similar fndings (Chlebus, 1998). The most com- mon complaints other than skin lesions and photosensitivity were fatigue, arthralgias and Raynauds phenomenon. Facial involve- ment, hypopigmentation and telangiectasias were common, while true scarring rarely oc- curred. Summary Lupus erythematosus is a multi-organ autoimmune disease which presumably results from a complex interplay of genetic and environmental factors. Histopathological diferen- tiation between especially the frst two disorders can be difcult. Annular lesions can be confused with erythema annulare centrifugum, granuloma annulare, erythema gyra- tum repens, tinea corporis or erythema multiforme. The most common complaints other than skin lesions and photosensitivity were fatigue, arthralgias and Ray- 5 Lupus Erythematosus 233 nauds phenomenon. Pediatric Dermatol 20(1):314 Ashworth J (1992) Subacute cutaneous lupus erythematosus in a patient with Crohns disease. Journal of the American Academy of Dermatology 44:925931 Brenner S, Golan H, Gat A, Bialy-Golan A (1997) Paraneoplastic subacute cutaneous lupus erythe- matosus: report of a case associated with cancer of the lung. Sontheimer Buckley D and Barnes L (1995) Childhood subacute cutaneous lupus erythematosus associated with homozygous complement 2 defciency. Clinical, serologic, immunoge- netic, and therapeutic considerations in 72 patients. An efective, corticosteroid- sparing therapy for patients with recalcitrant cutaneous lupus erythematosus or with recalci- trant cutaneous leukocytoclastic vasculitis.

In some antinuclear antibody testing results; presence of digital pit- cases purchase zoloft 25mg amex mood disorder treatment in children, poor oxygen supply to the tissue can cause the tips of ting discount 25 mg zoloft overnight delivery depression scale, ulcerations, or gangrene; and evidence of other organ the digits to ulcerate which can become infected (11). With system involvement, including gastrointestinal, cardiopul- continued lack of oxygen, gangrene of the digits can occur. Therefore, it should be considered as the basic tool of investigation to distinguish primary from secondary Prognosis Raynaud phenomenon. These drugs decrease the frequency and severity of l Progressive systemic sclerosis (scleroderma) attacks in about two-thirds of patients who have pri- l Systemic lupus erythematosus l mary and secondary Raynaud phenomena. If adverse Carpal tunnel syndrome l Thoracic outlet syndrome effects occur, decrease dosage or use another agent l Hypothyroidism such as nicardipine, amlodipine, or diltiazem. On the other hand, some patients found relief with l Acrocyanosis l Polycythemia postsynaptic a1-adrenergic antagonist which has been l Occupational (e. Like- wise angiotensin-converting enzyme inhibitors and intravenous prostaglandins have been advocated, and suspected it is important to consider specialist consultation clinical trials have indicated some benefit. The selective serotonin uptake inhibi- Therapeutic Management tor fluoxetine has also been shown effective if the range dose is from 20 to 40 mg daily (19). Intravenous pros- The goals of treatment are to reduce the severity of taglandins have also been used with success, such as attacks and to prevent tissue damage and loss in the iloprost, which when given as a 5-day infusion was fingers and toes. Any zosin has been used with some success against primary wounds or infections should be treated early to prevent and secondary Raynaud phenomenon (11). Avoiding emotional stresses dies have shown a role for bosentan in the treatment of and tools that vibrate the hand may reduce the fre- severe Raynaud phenomenon associated with systemic quency of attacks. Learning relaxation techniques and sclerosis in which the use of intravenous prostaglandin taking time to relax will further help to end an attack. Diet is also very important and some daily for the first 4 weeks followed by 125 mg twice trials have showed that fish oils containing omega-3-fatty daily. This dose has shown an improvement in the acids may be beneficial to some patients with primary ischemic lesions with healing of digital ulcer patients Raynaud. In addition, aspirin or clopidogrel is prescribed during the first month of therapy. In addition, patients should be treated for In some cases, surgery should be considered; sym- any underlying disease or condition that causes secondary pathectomy is indicated for pure vasospastic disease Raynaud phenomenon (13). Digital sym- of some benefit in patients whose symptoms are not pathectomy has been gaining support for patients with adequately controlled with simpler measures which severe or tissue-threatening disease. Patients with secondary Raynaud patients with either primary or secondary disease, but is phenomenon are more likely than those with the pri- more commonly necessary with the secondary form. Lancet; tolerability of a selective alpha (2C)-adrenergic receptor 357(9273): 20428. On local asphyxia and symmetrical gangrene of (2004) Raynauds phenomenon and serotonin reuptake inhi- the extremities (1862). Prevalence and clinical characteristics in a series of microcirculation in the hands of patients with primary Ray- 320 patients. Although autoimmunity secondary to drugs has been recognized for more than 50 years, the introduction of new drugs has extended the spectrum and severity of clinical manifestations. The diagnosis of these conditions is not simple and requires careful elimination of other possible conditions. Although rare cases of life-threatening autoimmune conditions have been described, the majority of cases are mild and resolve after the offending drug is discontinued. Some of the postulated mechanisms have Antiinflammatory D-penicillamine, sulfasalazine been prospectively investigated in experimental models. The range of autoimmune manifestations, and their clinical incidence and prevalence of other drug-induced autoim- relevance. In an analysis of the French national database of pharmacovigilance in the years 19911994, only 0. Cross-Reactivity of T Cells Cross-reactivity of T cells with self-antigens is an alterna- Breakdown of Central Tolerance tive mechanism for interference with peripheral tolerance. Moreover, adoptive transfer of these chroma- cell receptors, which are able to react with multiple anti- tin-reactive T cells into nave mice resulted in a similar gens. In According to the hapten hypothesis, drugs or more this model, CsA appears to prevent thymic deletion by commonly their reactive metabolites bind to proteins, blocking signaling during negative selection in the thymus. Once a response is initiated, epitope spreading may occur, Breakdown of Peripheral Tolerance inducing autoimmunity to self-antigens. Interestingly, this reactivity can these autoreactive T cells into syngenic recipients, caused a be transferred by lymphocytes to syngenic animals (9). In further studies, they demonstrated Additional mechanisms by which drugs may facilitate the 11. Drug-Induced Autoimmunity 61 emergence of autoimmunity include molecular mimicry autoimmune conditions, they may be more susceptible to and superantigen stimulation. Interestingly nity did not exist in the patient prior to the drug exposure; antihistone antibodies are found at a low frequency (13). But among hepatitis C patients, a wide range not follow the discontinuation of the suspected offending of seroconversion for thyroid autoantibodies has been drug, as several immune processes may not be readily or reported during treatment (up to 40%) and even months rapidly reversed. In some of the patients, the immune diseases may present insidiously or atypically, autoantibodies disappeared months after termination of making their diagnosis a difficult task. Interestingly, induction of autoantibodies was higher among 1) Autoimmunity does not exist in the patient prior to the drug exposure. After 34 weeks of infliximab treatment, 2) Autoimmunity develops after the introduction of the offending drug. Arthritis Rheum 2004; 50: the development of autoantibodies, following drug expo- 185060. Environmentally induced autoim- many patients, only a small minority developed a lupus- mune diseases: Potential mechanisms. Propylthiouracil- Therapy induced autoimmune syndromes: Two distinct clinical pre- sentations with different course and management. Semin For the vast majority of patients with drug-induced auto- Arthritis Rheum 2006; 36: 49. Leukotriene antagonists: Bystanders offending drug is terminated, although in selected patients, or causes of Churg-Strauss syndrome. Nat Med 2000; 6: induction of autoimmune rheumatic manifestations by cyto- 298305. The clinical evidence supporting the common origin of autoimmune diseases corresponds to the kaleidoscope of autoimmunity, which is the co-occurrence of various autoimmune diseases within an individual or co-occurrence within members of a family. Keywords Autoimmune diseases familial autoimmune disease familial autoimmunity multiple autoimmune syndrome sporadic disease expressions of similar pathogenetical processes and thus Introduction raising taxonomic questions. The term kaleidoscope of autoimmunity is used to describe the possible shift of Autoimmune diseases are chronic conditions initiated by one disease to another or the fact that more than one the loss of immunological tolerance to self-antigens and autoimmune disease may coexist in a single patient or which make up a heterogeneous group of disorders where in the same family (2, 3). Although their etiology remains multiple alterations in the immune system result in a spec- poorly understood, the common features they share and a trum of syndromes that either target specific organs or plausible common background for autoimmunity are affect the body systematically (1). Almost all autoimmune diseases dispro- expected on the basis of chance may offer new insights portionately affect middle-aged women and are among into their shared pathophysiological mechanisms.

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Rheumatic diseases are among the most common chronic illnesses generic zoloft 50mg amex depression glass for sale, yet only now has Nutrition and Rheumatic Diseasethe first volume dedicated to the interplay of nutrition and the rheumatic diseasesbeen published generic zoloft 25mg with mastercard depression symptoms yahoo. Actually, it was Sir James Paget who first described rheumatoid cachexia in the 1870s in a paper describing the muscle wasting he observed around tuberculous joints, especially the hip and shoulder. Shortly thereafterfrom the 1890s to the 1940scame the golden age of nutrition, when the vitamins were discovered and nutrient requirements were worked out, with Nobel prizes awarded for many of these discoveries. Ironically, by the late 20th century, patients often were much more concerned about their nutritional status than were their physicians, and often more knowledgeable due to the Internet. Today, there is clear evidence in both directionschronic inflammation alters macro- and micro-nutrient status, and diet can have important effects on immune function. This book is an important advance because it allows both patients and doctors to find in one place a detailed and thorough review of the state of the art in nutrition and the rheumatic diseases. The relationship between patient and doctor in chronic diseases differs from that in acute illness. In acute illness, there is not much time to make decisions, and both knowledge and the need to act give nearly all the power to the physician. However, in chronic illness, both the effects of the disease and the pace of treatment are slower, allowing more time for reflection and joint decision-making between patient and doctor. In this more transactional setting, the patients opinion, attitudes, and knowledge matter much more. Nutrition, being an area where patients claim both knowledgewhether correct or notand interest, often becomes a battleground between doctor and patient. Laura Coleman that this book has appeared, and those of us in both the nutrition and the rheumatology communities owe her a debt of gratitude for her efforts. Although historically, nutrition therapy for rheumatic diseases has been viewed with a fair amount of skepticism by the medical community, it has always been a topic of great interest to patients. Medical practitioners need information on how best to respond to patients questions about what they should be eating in an attempt to control their disease symptoms. The goal in editing this work, therefore, is to provide a comprehensive review of current knowledge regarding nutrition and dietary management for this complex set of conditions, from experts in each of the various rheumatic conditions. Unike many other chronic diseases, there is no definitive diet to prescribe for patients with rheumatic disease. There is no lupus diet, for example, the way there are diets for diabetes or cardiovascular disease, although there is more research for some conditions (e. This is not only a challenge for medical providers, but also a frustration for patients who are vulnerable to influence from much of the misinformation that exists related to diet and disease. Arguably, nowhere is this more the case than in the field of complementary and alternative medicine, which is the focus of one of the general chapters in this volume. With Internet access and search engines nearly universal, and patients having the ability to obtain information but not necessarily having the skills or the knowledge to critically evaluate either the source of the information or the data itself, confusion results. Health care providers are in the position of having to clarify and simplify much of the seemingly conflicting information that patients obtain. Nutrition and Rheumatic Disease is intended to be this reliable source of sound advice that providers can pass along to their patients. The field of rheumatic diseases includes a wide variety of pathological processes, although there are common features to a number of conditions. Inflammation is a central mechanism whereby much of the organ and tissue damage occurs, and pain is the most common manifestation of rheumatic disease. As a result, dietary interventions aimed at reducing inflammatory mediators in the body, such as the use of omega-3 fatty acids found in fish oils, are attractive to patients wanting to exert some control over their illness. Comprehensive reviews of the scientific literature by experts on each of the rheumatic diseases included in this work will help, we hope, to alleviate some of the inherent confusion surrounding the risks and benefits of various dietary therapies. Also common to most of the rheumatic diseases is their episodic nature, making it difficult to attribute improvement in symptoms to any one intervention. The natural xiii xiv Preface history of relapses and remissions in rheumatoid arthritis, for example, confounds studies attempting to examine the effect of diet alone on clinical symptoms. The goal in including these chapters is to provide a better understanding of a variety of topics that are applicable to the discussion of the specific rheumatic diseases that follow. One distinction that we have made is to include separate discussions on nutritional status versus dietary therapy for individuals with each rheumatic condition. Not only do these chapters include a critical evaluation of the literature, but they also are based on extensive clinical experience from each of the chapter authors; it is this combination that provides a unique perspective from which to address the role of nutrition in rheumatic diseases. Many of the chapters could be the focus of entire books themselves, and as a result, we have tried to limit discussion to the most practical and commonly misunderstood aspects of each topic. These organizations are often the first place where patients turn when they are in need of information. I thank Adrianne Bendich, Series Editor, and the staff at Humana Press for their guidance and patient assistance in helping to complete this work. I extend my deep gratitude to each of the authors for their hard work to complete these comprehensive chapters in the midst of maintaining busy clinical practices and research careers. Massarotti Summary The immune system is centrally involved in the pathogenesis of many rheumatic diseases, although the precise mechanisms by which the immune system becomes diseased remain undefined for most illnesses. Key Words: Autoimmunity; immunology; major histocompatibility complex; rheumatic illnesses 1. Multiple organ systems may also be involved in a single disease and different pathogenetic processes contribute to the clinical manifestations of each illness. Furthermore, although scleroderma may share some pathogenetic features with other rheumatic diseases, its pathogenesis is really quite unique from that seen in other systemic inflammatory rheumatic diseases From: Nutrition and Health: Nutrition and Rheumatic Disease Edited by: L. Osteoarthritis is also a rheumatic disease but does not have any systemic features, is primarily a degenerative disease of cartilage, and is not a disease characterized by defects in the immune system. Thus, grouping the rheumatic diseases into distinct pathogenetic modules can be challenging and no one organ system is uniformly involved in the manifestations of a particular disease. The immune system plays a direct role in the pathogenesis of many rheumatic diseases. No unifying theory of immunopathogenesis governs the pathophysiology of immune-mediated rheumatic diseases. Although many of the specific cells and pathways involved in various rheumatic diseases have been defined, much remains unknown regarding the precise mechanism by which pathological events are triggered and developed within the human body. Autoimmunity can result from several processes, including altered antigen presentation, increased T-cell help, and molecular mimicry. Autoimmunity has been shown to occur in normal individuals where antibodies or T cells react with self-antigen, resulting in self-reactivity without evidence of pathology. Autoantibody Formation The formation of antibodies against self-antigens, or autoantibodies, is character- istic of many autoimmune diseases. Polyclonal activation of B cells is found in lupus and has been demonstrated with lipopolysaccharide, which can stimulate autoantibody formation against self-antigens (2). Molecular mimicry refers to the generation of autoantibodies when an immune response to a foreign antigen cross-reacts with an epitope found on self-antigens (3). Apoptosis, or programmed cell death, may contribute to autoantibody formation by the production of autoantigens in apoptotic blebs (1). Altered self is said to occur with the binding of foreign and self-antigen, or with immunization of a foreign protein that then leads to autoimmunity to a homologous self-protein (1). Autoantibody formation occurs in some autoimmune diseases, and these diseases are not confined to rheumatology, per se.

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Approximately 1/2 of patients have stated total deterioration of the health status buy zoloft 50 mg on-line depression getting worse, alternatively quality of life generic zoloft 25mg mastercard depression test for disability, limitation in usual activities, as well as social and emotional problems. Two thirds feel tiredness and approximately one third is anxious, they have cognitive and sexual problems. Moreover, the patients with earlier hyperthyroidism very often suffer from classic symptoms of hypothyroidism and, vice versa, symptoms of hyperthyroidism persist approximately in one third. Patients with eufunctional goitre have been examined the least, there does not exist a study which would indicate that such patients suffer from cognitive ailments (Watt et al. A lot of works confuse the evaluation of the quality of life for the measurement of symptoms non/presence, health status, psychical status, eventually mental well-being are often incorrectly described as the quality of life. People, whose health is bad, do not have to necessarily feel worsen quality of life. Incorrect understanding of the notions leads to the fact that the results of these studies can be incorrect or misleading, because a method for evaluation of one variable is used for measurement of something else. A disadvantage of the tools is that they only focus on a specific Psychosocial Factors in Patients with Thyroid Disease 283 type of thyroid disease therefore they are not applicable across different thyreopathies. For a long time there has not been created a questionnaire that would cover all the relevant aspects of thyreopathies in longitudinal studies, when there can happen changes of hormonal status based on the character of the disease or treatment. According to available data we were the first who tried to create such method (Janekov 2001, 2006). Researches of alternative therapy treatment with hormone T4 and T3 combined substitution have been carried out. Whereas first works signalled differences in favour of combined T4 and T3 (Buneviius et al. Hormonal therapy is considered as a very successful for reduction of morbidity and mortality. On the other hand, there are also real deficiencies that we have to be aware of it is always dealt with imitation of normal hormone secretion. Additionally, it is difficult to quantify the effect of hormones on the level of tissues. Being aware of hormonal therapy deficiencies we can avoid incorrect marking of patients complaints. In fact, it is probable that deficiencies of biological therapy partially participate in the complaints. There are several proofs that patients do not follow sufficient treatment that can be indicative of their dissatisfaction with the treatment (McMillan et al. There are a lot of organisations abroad associating patients with thyroid disease, especially those dissatisfied patients create a big stress on professional public, they have reservations about the diagnostics and therapy (they criticise laboratory testing as a diagnostic criteria, or they prefer dried pork thyroid to synthetic hormone substitution). Persistence of worsened health status even after the hyperthyroidism treatment has been proved by Fahrenfort, Wilterdink and Van-der-Veen (2000). Orbitopathy (even in a moderate form) significantly influences patients quality of life (Egle et al. An interesting qualitative study in patients with orbitopathy has been carried out (Estcourt et al. Available studies are identical that there is a significant deterioration of patients health status with short T4 discontinuation (Botella-Carretero et al. Due to the fact that T4 discontinuation is of a significant effect on patients health status, other methods or preparation for diagnostics or radioiodine therapy have been sought. Concerning the patients undergoing long-term usage of supra-physiological doses of T4, the research findings with mentioned above methods application are inconsistent the results of some studies signal deterioration of the health status, even if less significant than in patients after T4 discontinuation (Botella-Carretero et al. The first studies in general methods of quality of life have been carried out in China. Psychosocial Factors in Patients with Thyroid Disease 285 Recently, the research has especially focused on follow up of patients with differentiated thyroid cancer. Impaired health status and quality of life have been surveyed in them (Hoftijzer et al. Quality-of-life and health status parameters were inversely affected by duration of cure and consequently may be restored after prolonged follow-up (Giusti et al. Special attention should be paid in patients with more severe staging on diagnosis (Almeida et al. Some patients may suffer from clinical symptoms resembling hypothyroidism or hyperthyroidism, and others do not. There is not a consensus concerning the fact whether these diseases should be treated (Strka, Zamrazil et al. A lot of studies observing patients with non-treated subclinical hypothyroidism proved deterioration in some aspects of the health status (Appolinario et al. However, the results of works observing if the therapy with T4 hormone is beneficial are disputable. The results of the studies in non-treated and treated patients signal deteriorated health status in some aspects (Bianchi et al. It is supposed that just a regular monitoring of patients euthyroid status with nodules in thyroid reduces the quality of his life; on the other hand, more significant deterioration of the quality of life would occur if the patient was not dispensarized within his course of life (Dietlein & Schicha, 2003; Vidal-Trcan et al. Aims and background The aim of our research was to map psychosocial aspects of thyroid disease (thyreopathy). We have especially focused on patients quality of life, role of stress and coping with it, including protective factors (resilience and social support); at the same time we tried to 286 Thyroid and Parathyroid Diseases New Insights into Some Old and Some New Issues compare the results with the healthy population. It dealt with comparing the patients in thyroid disease who have undergone an operation, including their follow up after surgery. We have looked into this topic from the viewpoint of two relatively young disciplines, namely health psychology and, at the same time, we are inspired by positive psychology. Health psychology represents one of the fastest developing spheres of present psychology; it is a relatively young discipline. Mostly there is a consensus that it is dealt with a discipline that applies psychological knowledge into the sphere of health, diseases and the healthcare system (comp. Many psychologists are aware of the necessity of a change, but not in a radical diversion from existing negative topics in psychology (basically given by the historic development), but rather in the sense of the whole picture completion with positive topics. It is due to the fact that absence of negative aspects is not the same as presence of the positive ones. Design of the research In correspondence with our research aim we have chosen non-experimental research plan (Hendl, 2006), where its core does not consist in an invasion or in a deliberate manipulation with the observed variables. We understand our study as a descriptive research focused on exploration, description and orientation, or confirmation of carried out research, eventually prediction. We have used differentiation overview where we have compared patients in thyreopathy to health population, or patients with different types of thyreopathies among each other. We have presumed to compare health population with the ills in thyreopathy as a whole, because it is known from literature that within the course of this disease there can occur changes of hormonal status based on the disease or treatment character. We have used a development overview (a specific type of a differentiation overview) in the sense of longitudinal follow up of patients after 3 and 6 months since surgery where we try to capture a change of observed variables in time in patients with thyreopathy overall, or in the patients with different types of thyreopathies. With respect to the research problem, the choice of a mixed research strategy has been considered as the most suitable one (quantitatively-qualitative). The patients have almost always been asked by the doctor, who operated them on, to take part in this research. At first, he described him simply the aim and character of the research, then there was the dialogue Psychosocial Factors in Patients with Thyroid Disease 287 itself and in the end, the patients were given questionnaires and instructions to them.

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