Kaupapa Māori methodological approach and kaupapa Māori methodolog

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Radioactive iodine therapy for thyrotoxicosis

Radioactive iodine was first used in the treatment of thyrotoxicosis in 1941(64, 65) and remains an important, common definitive treatment for thyrotoxicosis. International guidelines recommend RAI as a valid primary treatment of thyrotoxicosis, as are ATD and surgery.(385-387) These guidelines advise RAI as the favoured treatment in the elderly or patients with comorbidities and those in whom ATD are contraindicated, including young women who are planning a future pregnancy (within six months of treatment).(385, 386) Resource availability also influences decision-making, including for example, easy access to RAI or limited access to a high-volume thyroid surgeon.(385, 386) In addition, RAI is recommended for treatment in hyperthyroidism, particularly GD, when ATD therapy has failed to achieve control or remission.(385, 387) Patients placing importance on the
potential to be euthyroid off medication, or the desire to avoid hospitalisation/surgery, may also choose RAI.(385)
RAI is contraindicated in: individuals who are not able to follow the required safety guidelines; in pregnant or lactating mothers; and it is recommended that women do not become pregnant for four to six months after therapy.(385, 386, 439) RAI is generally very well tolerated, but patients can develop transient neck pain from a radiation thyroiditis and/or an initial transient worsening of thyrotoxicosis can occur.(440) Deterioration in TED is well-documented with RAI and needs to be taken into consideration when deciding on treatment modalities for GD.(69, 441)
Use of RAI for treatment of thyrotoxicosis differs markedly across the continents. RAI remains the most common principal treatment of thyrotoxicosis in the United States.(55, 400) The greater use of RAI in the USA, when compared to other parts of the world, has been attributed to: ease of access to the therapy; this treatment’s originated within North America; and the ‘social norm’ of acceptance of radiation within the USA population.(442) The view of the general public with regards to radiation, heavily influenced by historical events, is thought to play a role in the acceptability of RAI. In USSR, where the Chernobyl nuclear disaster occurred in 1986, only 3% of physicians caring for patients with GD would recommend RAI(398) and Japan’s low recommendation rates (11%) are likely influenced by the impact of historical events such as the 1945 Hiroshima or Nagasaki bombing or the more recent, 2011 Fukushima nuclear disaster.(56, 442) It has been suggested, that in Aotearoa/NZ our nuclear-free history may influence use of RAI for thyrotoxicosis.(59) In a 2015 survey, only 5% of Aotearoa/NZ physicians recommended RAI as a first-line treatment for GD,(59) despite that rate of recommendation being higher in 1991 (41%).(399) While pre-treatment with ATD prior to RAI is rare in USA, it is commonplace in Aotearoa/NZ(59) and is the standard within the unit in which this study was undertaken.(443)
One major consideration with RAI use is the efficacy of the treatment. The aim of RAI is to cure hyperthyroidism, with failure of therapy being persistent or recurrent thyrotoxicosis. This means that a euthyroid or hypothyroid state (with the aim of treating with thyroid hormone replacement to reach a euthyroidism) are both considered a cure. Depending on the study reported, success rates following RAI range from 50-90%.(66) A summary of the literature of failure rates is presented in Table-5.3. The largest and most comprehensive retrospective observational studies of RAI success have been in GD patients in Finland, 1965-2002 (n=2043),(444) in hyperthyroid patients in the UK, 1984-2006 (n=1278)(445) and nodular goitre (TMNG/STA) in Poland 1998-2010 (n=4140).(446) Both the Finnish and UK studies showed that treatment failed in approximately a quarter of patients.(444, 445) Within the cohort with nodular disease (TMNG and STA), RAI therapy failed in only 3-7% of patients.(446) Therapy failure requires a management plan for ongoing thyrotoxicosis, either a further dose/s of RAI, surgery or long-term ATD. While resolution of hyperthyroidism typically occurs within the first three to six months following RAI, hypothyroidism can occur much later, with an annual conversion rate of 3-5% per year (after a high prevalence of post-treatment hypothyroidism (up to 50%) in the first year after RAI for patients with GD).(444) The rates of hypothyroidism following RAI treatment of patients with TMNG(447) or STA(448) are much lower, hypothesised to be due to reduced RAI uptake by ‘normal’ thyroid tissue, which is suppressed in the presence of hyperthyroidism.(449)
A number of factors have been associated with an increased failure rate following the use of RAI for treatment of thyrotoxicosis, but as most literature is retrospective with only the occasional prospective, uncontrolled observational study, causation links are challenging to make (Table-5.3). Bonnema and Hegedüs’ comprehensive review has detailed the factors noted to influence RAI efficacy.
(450) Following treatment with RAI, TMNG(451- 453) and STA(446, 448, 454) have much higher success rates than GD. Biochemically severe thyrotoxicosis has frequently been a factor associated with RAI treatment failure.(418, 445, 455-462) In addition, young age,(443, 460) male gender,(418, 445, 453, 455, 456, 461) large goitre,(446, 455, 459-465) even when controlled for severity, have been shown by some to be linked with failed response to RAI. Debate continues about the effect of ATD medication prior to RAI on overall success.(444, 457, 458, 460, 462, 466)

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1. TE WHAKATAKATŪ – INTRODUCTION
1.0 Introduction
2.0 Thyroid
2.1 Thyroid anatomy and thyroid hormone production
2.2 Iodine and the thyroid
3.0 Thyrotoxicosis
3.1 Definition of thyrotoxicosis
3.2 Aetiology of thyrotoxicosis
3.3 Investigations of thyrotoxicosis
4.0 Ethnicity
4.1 History of official ethnicity measures in Aotearoa/New Zealand
4.2 Ethnicity measurements in health equity research
5.0 Māori health inequities
5.1 Māori health and healthcare inequities
5.2 Inequity and its determinants
6.0 Te Whakangungu Rākau
6.1 Te Whakangungu Rākau framework
6.2 Te Whakangungu Rākau study components
6.3 Hypothesis and aims
7.0 Summary
2. TE KOHIKOHIA – METHODOLOGICAL APPROACHES & METHODS
1.0 Introduction
2.0 Dual approach
2.1 Kaupapa Māori methodological approach and kaupapa Māori methodolog
2.2 Social epidemiology
3.0 Implications for this research
1.0 Pae Taumata / Foundation
1.1 Consultation
1.2 Ethics
1.3 Hui
2.0 Definitions
2.1 Ethnicity
2.2 Thyrotoxicosis
2.3 Study locale
3.0 Patient factor variables
3.1 Age
3.2 Gender
3.3 Co-morbidity
4.0 Social factor variables
4.1 New Zealand index of deprivation for individuals (NZiDep)
4.2 New Zealand Deprivation Index (NZDep)
4.3 Occupation
4.4 Smoking
4.5 Alcohol consumption
5.0 System factor variables
5.1 Delays in healthcare
5.2 Interactions with healthcare
5.3 Ease of healthcare system
6.0 Clinical measures
6.1 Symptoms
6.2 Hospital admissions
6.3 Family history
6.4 Examination measures
7.0 Investigation measures
7.1 Thyroid function tests
7.2 TSH receptor antibodies
7.3 Ultrasound
8.0 Follow-up measures
8.1 Primary treatment modality
8.2 Definitive therapy
8.3 Remission/relapse
8.4 Complications
8.5 Treatment satisfaction
9.0 Data management
9.2 Database
9.3 Data cleaning and storge
9.4 Statistical analysis
10.0 Summary
3. ŌWEHE – INCIDENCE OF THYROTOXICOSIS AMONG MĀORI
1.0 Introduction
2.0 Literature review
2.1 Systematic review of the literature
2.2 International incidence of thyrotoxicosis
2.3 Ethnicity and incidence of thyrotoxicosis
2.4 Other social situations and incidence of thyrotoxicosis
2.5 New Zealand incidence of thyrotoxicosis
3.0 Methods
3.1 Recruitment
3.2 Data collection
3.3 Census data
3.4 Statistical analysis
3.5 Post-hoc analysis
4.0 Results
4.1 Difference according to ethnicity, Māori and non-Māori
4.2 Difference according to ethnicity, Māori and Pākehā
5.0 Discussion
5.1 Incidence rates of thyrotoxicosis
5.2 Factors influencing thyrotoxicosis rates
6.0 Summary
4. TE ARA HAUORA – MĀORI JOURNEY TO DIAGNOSIS OF
THYROTOXICOSIS
1.0 Introduction
2.0 Literature review 1
3.0 Methods
4.0 Results
5.0 Discussion
6.0 Summary
5. NGĀ HUA O NGĀ MAHI ORA – TREATMENT OUTCOMES OF
THYROTOXICOSIS AMONG MĀORI
1.0 Introduction
2.0 Literature review
3.0 Methods
4.0 Results
5.0 Discussion
6. POROPOROAKI – DISCUSSION