[Essay] Help my paper get better please

[Narkises]

Hi
I have done my research, now time to write it in English. I appreciate your help and suggestions to improve my paper writing.

here is the title: "Evaluation of the Impact of Stopping Thyroid Hormone Replacement on Health-Related Quality of Life in Patients with Differentiated Thyroid Cancer"

 

[Narkises]

Introduction

In 1995 the worldwide Health Organisation (WHO) considered the importance of evaluation of the quality of life. Many theories and approaches define the concept of quality of life. The subjective quality of life is how good a life each individual feels he or she has. Each individual personally evaluates how he or she views things and his or her feelings and notions. Whether an individual is content with life and happy are aspects that reflect the subjective quality of life(Ventegodt, Merrick, & Andersen, 2003).


When we talk about the quality of life in the field of health and disease, we call it Health-Related Quality of Life (HRQOL) so that we can separate it from other domains of quality of life. As health is not only the absence of diseases and has multiple dimensions, health-related quality of life also has so many dimensions and it includes physical, mental, emotional, and social dimensions. It is known that HRQOL demonstrates the effects of a disease or its treatment on ones physical, emotional, and social well-being that is normal or is expected(Tan, Nan, Thumboo, Sundram, & Tan, 2007).


Thyroid cancer is the most common endocrine malignancy. It has two subtypes: differentiated and anaplastic. Thyroid cancer is the fifth commonest cancer among women. The worldwide incidence of thyroid cancer for women is 2.7 percent and for men is 0.7%(van Nagell et al., 2013). In recent decades, the incidence of thyroid cancer has increased worldwide. For instance, it is increased meaningfully from 2004 to 2010 in Iran(Safavi, Azizi, Jafari, Chaibakhsh, & Safavi, 2016).


Although the incidence of thyroid cancer has increased, the mortality rate of it has remained stable(Pellegriti, Frasca, Regalbuto, Squatrito, & Vigneri, 2013)...

 

[emsr2d2]

There's a mistake in the first five words. Can you see it?

 

[Narkises]

There's a mistake in the first five words. Can you see it?

"In 1995, the Worldwide Health Organization..."

You meant the capitalisation?

 

[Raymott]

In 1995 the World Health Organisation (WHO) considered the importance of evaluation of [STRIKE]the [/STRIKE]quality of life. Many theories and approaches define the concept of quality of life. [STRIKE]The [/STRIKE]Subjective quality of life is how good a life each individual feels he or she has. Each individual personally
. . .
demonstrates the effects of a disease or its treatment on one's physical, emotional, and social well-being that is normal or is expected (Tan, Nan, Thumboo, Sundram, & Tan, 2007).

Thyroid cancer is the most common endocrine malignancy. It has two subtypes: differentiated and anaplastic. Thyroid cancer is the fifth commonest cancer among women. The worldwide incidence of thyroid cancer for women is 2.7 percent and for men is 0.7% (van Nagell et al., 2013). In recent decades, the incidence of thyroid cancer has increased worldwide. For instance, it [STRIKE]is[/STRIKE] increased [STRIKE]meaningfully[/STRIKE] significantly from 2004 to 2010 in Iran(Safavi, Azizi, Jafari, Chaibakhsh, & Safavi, 2016).

Although the incidence of thyroid cancer has increased, the mortality rate [STRIKE]of it[/STRIKE] has remained stable(Pellegriti, Frasca, Regalbuto, Squatrito, & Vigneri, 2013)...

Just as HRQOL doesn't take an article, nor does "quality of life" in this context.
Consider "Every individual personally evaluates how they view things and their feelings and notions."
You need to put a space before the opening of a bracket (consistently).

 

[Narkises]

[FONT=&quot] Although the incidence of thyroid cancer has increased, the mortality rate of it has remained stable [/FONT][FONT=&quot](Pellegriti, Frasca, Regalbuto, Squatrito, & Vigneri, 2013)[/FONT][FONT=&quot]. As the result of the great progress in diagnostic and therapeutic methods, the number of survived patients from thyroid cancer has increased [/FONT][FONT=&quot](van Nagell et al., 2013)[/FONT][FONT=&quot]; so, with the rise of its incidence and decreasing in mortality, we now see the increase in the population of thyroid cancer survival. Differentiated thyroid cancer has a very good prognosis, specially when it is diagnosed and treated soon. The average rate of survival up to 5-years is up to 98% and it is really close to the healthy population [/FONT][FONT=&quot](SEER[FONT=&quot][1][/FONT], 2018)[/FONT][FONT=&quot]. Patients with thyroid cancer have a good prognosis. Thus, physicians assume that their quality of life is similar to healthy population. However, quality of life is not[/FONT][FONT=&quot] [/FONT][FONT=&quot]directly dependent to the severity of prognosis of cancer [/FONT][FONT=&quot](Singer et al., 2012)[/FONT][FONT=&quot].[/FONT]

---

[FONT=&quot][1][/FONT] https://seer.cancer.gov/statfacts/html/thyro.html

 

[Narkises]

Although the incidence of thyroid cancer has increased, the mortality rate of it has remained stable (Pellegriti, Frasca, Regalbuto, Squatrito, & Vigneri, 2013). As the result of the great progress in diagnostic and therapeutic methods, the number of survived patients from thyroid cancer has increased (van Nagell et al., 2013); so, with the rise of its incidence and decreasing in mortality, we now see the increase in the population of thyroid cancer survival. Differentiated thyroid cancer has a very good prognosis, specially when it is diagnosed and treated soon. The average rate of survival up to 5-years is up to 98% and it is really close to the healthy population (SEER[1], 2018). Patients with thyroid cancer have a good prognosis. Thus, physicians assume that their quality of life is similar to healthy population. However, quality of life is not directly dependent to the severity of prognosis of cancer (Singer et al., 2012).

The rapid increase in thyroid cancer’s incidence has made some worries and attention to health-related quality of life in thyroid cancer survivors (Lee et al., 2010). The importance of evaluation of health-related quality of life in the survivors is being known rapidly (Goldfarb & Casillas, 2016)and it is shown in new guidelines of the American Thyroid Association (Haugen et al., 2016). The therapeutic strategies should include evaluation of quality of life and also evaluation of long-term side effects of the treatments; so that we can choose the best treatment for this growing population of patients (Vega-Vázquez et al., 2015).

In sensitive periods of the course of DTC and its treatment, some research has shown that the quality of life had decreased: Time to diagnose cancer and inform the individual about having thyroid cancer (Bãrbuş, Peştean, Larg, & Piciu, 2017; Stanton, Rowland, & Ganz, 2015); surgery time and removing all or part of the thyroid gland (Thyroidectomy); timing and hospitalization; and temporary withdrawal of thyroid hormones (Chow et al., 2006; Dow, Ferrell, & Anello, 1997; Luster, Felbinger, Dietlein, & Reiners, 2005; Schroeder et al., 2006).

The aim of this study is to see whether the temporary withdrawal of levothyroxine affects the health-related quality of life in patients with DTC or not. In detail, we want to figure out which domains of HRQOL were affected more and why. Through considering the quality of life before and after the withdrawal of levothyroxine, we hope better therapeutic decisions and with our patients to improve their quality of life.

---

 

[Tarheel]

Say "dependent on" and not "dependent to".

 

[Narkises]

Methods

Study design: It was a semi experimental, pretest-posttest with one group design. The study was prospective and randomized controlled.

Setting: The study took place in nuclear medicine department of Educational, research and therapeutic center of Ghaem Hospital in Mashhad, Iran. From 6[SUP]th[/SUP] May to 12[SUP]th[/SUP] November 2017, DTC patients who visited the oncologists in Ghaem Hospital, and they had had thyroidectomy or hemi-thyroidectomy at least a year before, has been considered as the society. They should have stopped consuming levothyroxine temporarily for one month.

Participants: From 120 society individuals, we finally had a sample of 27 patients who freely took part in the study to the end (figure 1). It was an available-selected sample. The patients were both female and male and they were all adults (more than 18 years). The inclusion criteria were therapeutic planning to temporary withdrawal of iodine (LT3,4), or to undergo WBS; this criterion included patients who had stopped iodine from the last month and were ready for WBS. The exclusion criteria were either consuming iodine pills or other foods containing iodine salt. This could decrease TSH level less than 10 mm/l which was the hypothyroid index. Another exclusion criterion was operating WBS before filling the post-test questionnaire. WBS exclude participants because it might interfere with the aim of us. Ethical considerations involved. The participants freely filled out the questionnaires and their consent was obtained through their signatures. It is worth-noted that there were not any interventions except the ordinary, necessary therapeutic decisions.

Outcome measures: The following data were collected: socio-demographic information, TNM staging classification, clinical data (including size of tumor, metastases, response to treatment, comorbidity diseases, and consuming drugs), and HRQOL through Short Form 36 Health Survey (SF-36). The standard Persian version of SF-36 was used (Rafiei, Sani, Rafiey, Behnampour, & Foroozesh, 2014). Participants filled SF-36 index twice as pretest-posttest: Once when they were using levothyroxine and the other time was when they were in the state of hypothyroidism (TSH level=< 10 mm/l).

Statistics analyses: The software application used to analyze the data was IBM SPSS version 24. Paired sample t-test was used to assess the probable significant differences in quality of life and in its subtypes before and after withdrawal of levothyroxine. The level of statistical significance was 0.5 (P-value = 0.5). Independent samples t-tests were used to see whether the participants' sex, age, educational level, job, dosage of drugs, comorbidities, and other information had made difference in their QOL. In fact, the relationships of patients’ socio-demographic and clinical data with their QOL were assessed through independent samples t-test and one-way ANOVA (P-value= 0.5).

 

[Narkises]

Results
From 27 patients, 70.37% of subjects were younger than 55 years and 29.63% were 55 and older. The age cutoff used for staging was increased from 45 to 55 years of age at diagnosis in Eighth Edition Staging Systems (Tuttle, Haugen, & Perrier, 2017). There were 5 men and 22 women in the study so 81.5 percent of subjects were female. It was consistent with the incidence of differentiated thyroid cancer in population because generally DTC is more common in women. Most of patients (85.2%) were married; 85.2% had diploma or under regarding educational level. 3 out of 27 subjects were smoking cigarettes (11.1%).

Table 1 shows some clinical data including: Time from cancer diagnosis, TNM staging classification, size of tumor, regional lymph node metastases, response status to therapy, distant metastases, comorbidities including physical and psychological diseases, and some other. The table is revealing in several ways. First, a great majority of patients (81.48%) had been diagnosed with differentiated thyroid cancer in 5 recent years. Of the 27 patients took part in the study, only 5 patients (18.51%) were long-term cancer survivors; which means those who were living five years or more behind a DTC diagnosis. Second, the majority of participants (74.1%) were in stage Ⅰ differentiated thyroid cancer, which means the tumor is any size maybe in the thyroid or may have spread to nearby tissues and lymph node cancer has not spread to other parts of the body (Tuttle et al., 2017). Third, 33.3% of those questioned reported that they had not any diseases except thyroid cancer. 55.5% of them reported that they had one to three diseases and only 11.1% of them reported that they had more than 4 diseases. Table 1 also summarizes the data on levothyroxine, vitamin D, calcium, and another medicines which patients consumed.

The analysisrevealed that stopping using thyroid hormone affects quality of life inpatients with differentiated thyroid cancer (Figure 2). Quality of life(QOL) is a variable comprising 8 subtypes; 4 in physical health and the otherfour belongs to psychological health. Vitality (VT), social functioning(SF), role imitation caused by emotional problems (RE), and mental health (MH)are all in the psychological health domain. Role limitations causedby physical problems (RP), bodily pain (BP), physical functioning (PF),and general health (GH) comprise physical health. A significant difference wasfound in the QOL before and after levothyroxine withdrawal (P=0.010<0.05). Further analyses were done to identify any significant differencesin the subtypes (P-value=0.05). There was the greatest significant differencebetween the average scores of PF before and after levothyroxine withdrawal(P=0.00; t=4.341). Average scores of RP had changed significantly (P=0.028;t=2.323). Similar to RP, there was a significant difference betweenthe scores of VT (P=0.029; t=2.311). These results led to the remarkable, significantdifference between the average scores of the “physical domain” before andafter levothyroxine withdrawal (P=0.02; t=4.455). However, the analysis did notconfirm any significant differences in other physical subscales (BP and GH). RegardingMH, SF, RE, and generally “psychological health”, none of these differenceswere statically significant.

 

[Narkises]

Independent t-tests highlighted that there was no significant difference between QOL in women and men (P = 0.239> 0.05). Therefore, no relationship between sex and QOL was found. Also, there was no significant difference in QOL between patients under 55 and over 55 years old (P = 0.467> 0.05). Based on analyze of variance (ANOVA), no significant difference in QOL highlighted among marital status (P = 0.867> 0.05). Interestingly, there was a significant difference between the quality of life of people with different educational levels (P = 0.002 <0.05). The results of Bonferroni test showed that QOL was significantly higher in diploma graduates than those under the diploma (p = 0.008). Although the QOL was not significantly higher in BA and MA graduated patients in comparison to diplomas’. There was no significant difference in QOL between different job status in patients (P = 0.467). No significant correlation was found between smoking and QOL (P = 0.285). In sum, the analysis did not confirm any significant differences in QOL between demographic characteristics (age, sex, marital status, and smoking). The single marked observation to emerge from the data comparison was the relation between education and QOL.
There was no significant difference between QOL in short-term survivors and long-term survivors (P=0.93>0.05). There was no relation between TNM staging status and QOL. There was no significant difference between QOL of patients with different tumor size (P = 0.456> 0.05); nor with different developments of the lymph nodes (P = 0.954> 0.05). No significant relation was found between the status of metastatic disease and QOL (P = 0.936> 0.05). There was no significant relation between patient's response to treatment and QOL (P = 0.393> 0.05); nor between the number of other diseases and QOL (P = 0.068> 0.05). No significant difference was found in QOL of patients using some medicines with regard to number of them (P = 0.248> 0.05). There was no significant relation between the amount of levothyroxine, calcium and calcitriol daily and QOL. Totally, our study was unsuccessful in proving that DTC patients with different clinical situations are significantly different in QOL.

 

[emsr2d2]

I really think you need a medical professional to look through this. It's less a question of everyday language and more a question of medical terminology.

 

[Raymott]

Actually, a statistician would be more appropriate. Do you need to write all this out? If it were my paper, I wouldn't go to the bother of separate sentences for all the non-significant findings. I'd put them in a table, with their p values, or whatever. In the text, I'd say, "the following were not correlated significantly with QOL: factor 1, factor 2, etc." Or put that in a table too. The text needs to highlight what you've found that is correlated. I wouldn't bother to read through your densely-wrought analysis to find out.
You've already said in paragraph one, "The single marked observation to emerge from the data comparison was the relation between education and QOL." This would seem to render the entire second, and much of the first, paragraph pointless.

"Totally, our study was unsuccessful in proving that DTC patients with different clinical situations are significantly different in QOL."
You mean, "Our study was totally unsuccessful in proving ..."
Unless you have to pad out a certain number of words, you'd be better off using two or three simple tables, and a one or two sentence paragraph that summarises the results. Or write a non-repetitive Discussion section. Do people really write this way in the journal you hope to publish in? If so, I guess you should keep what you've got, if that's their preferred style. I wouldn't read that journal.

PS: I'm aware of the irony that my post is repetitive and too long, but I only spent 5 minutes on it.

 

[Narkises]

Wow! Thank you Raymott. Your suggestions are very useful and I should consider them in my paper.
Hahah! It is not the specific style of a journal, but my bothering style of writing! It could reject my paper!! Thank you so much. I should go and correct the faults.

 

[Narkises]

Discussion

In this study, the withdrawal of levothyroxine for a month lead to decreased quality of life. DTC patients need to monitor thyroglubulin level of serum, whole body scanning (WBS) with radioactive iodine, and other scanning methods in their whole lives. Although levothyroxine withdrawal is a suitable way to evaluate treatment response and WBS, it causes temporary hypothyroidism (Schroeder et al., 2006). Schroeder et al. concluded: “Short-term hypothyroidism after L-T4 withdrawal is associated with a significant decline in quality of life that is abrogated by rhTSH use.” The decreased quality of life which we found in this study is in good agreement with other studies (Dow, Ferrell, & Anello, 2009; Schroeder et al., 2006; Tagay et al., 2006; Chow et al., 2006).

To further investigate, the significant decrease in quality of life mostly happened in its physical subtypes. This finding shows that the temporary hypothyroidism affects the patients’ physical functions. Tiredness, fatigue, inability in doing hard works, difficulties in daily chores, etc. are common complaints of the patients undergoing levothyroxine withdrawal.

In sensitive points of treatment course, decrease in quality of life; depending on patients’ situation and the type of interventions; make differences in some subtypes of the total quality of life scale (Chow et al., 2006). In time of diagnosis, psychological health is mostly affected (Bãrbuş et al., 2017)and during the first year after diagnosis; vitality, Role physical limitation, mental health, Role emotional limitations decrease. Also social functioning impairments can be seen in the first year.
In time of consuming levothyroxine, patients have no quality of life problems or at least have a small decrease in QOL comparing to healthy population (Schroeder et al., 2006). However it is different in some studies (Giusti et al., 2011; Husson et al., 2013; Singer et al., 2012). In time of short-term hypothyroidism caused by withdrawal of levothyroxine, patients have the worst feeling ever, and they feel the most impairments in their QOL. Our experiments confirm that.

What we were surprised to find is that beside physiological problems, the vitality domain decreased in the patients. Although vitality is considered a psychological factor in SF-36, it refers to being energetic and absence of fatigue. So it is meaningful that when patients face temporary hypothyroidism, they have low energy, thus little scores of vitality domain.

 

[Narkises]

Limitations and suggestions
We aware that our research may have limitations: we didn't check weight changes and intolerance to cold and heat as these two are common insulting physical problems for patients after l-4 withdrawal. Some psychological variables such as anxiety, depression, and adaptation problems were ignored to assess due to the negative effect and discomfort of the therapeutic intervention. The restricted time and number of participants in this study suggest that longer evaluation with more patients would be needed. Thyroid cancer needs special considerations regarding QOL studies.

Acknowledgments
This work was carried out within the framework of Mashhad University of Medical Sciences. It was made possible by Educational, research, and therapeutic center of Ghaem; Nuclear Medicine Department. We gratefully acknowledge Dr. Alavi for her valuable statistical suggestions. We would like to thank the following people for their support, without whose help this work would never have been possible: Maryam Pourmahdi, Zeinab Barzgar. We are also grateful to constructive comments of the anonymous referees.

 

[tedmc]

Hi
I have done my research, now time to write it in English. I appreciate your help and suggestions to improve my paper writing.

here is the title: "Evaluation of the Impact of Stopping Thyroid Hormone Replacement on Health-Related Quality of Life in Patients with Differentiated Thyroid Cancer"

I suggest dropping "Health-Related" as it is understood.
I would add a definite article to "quality of life" and replace "in" with "of".
I would add an indefinite article to "evaluation" since it is a countable noun.