Required Calcium Supplementation Research Articles

Development and validation of an eight-item calcium screener to assess daily calcium intake of patients with osteoporosis in clinical practice.

To validate a short food frequency questionnaire (screener) estimating daily average calcium intake from dietary sources to guide calcium supplementation of patients with osteoporosis in clinical practice. An eight-item calcium screener was developed based on existing literature, food consumption data and expert opinion. Convergent validity was determined by comparison with 3-day food records using mean difference, Spearman's correlation coefficients (SCC) and Bland-Altman analysis. Test-retest reliability was assessed by SCC and intraclass correlation coefficients (ICC). We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to identify patients requiring calcium supplementation (<1200 mg dietary calcium intake/day). Fifty-two patients filled out the eight-item calcium screener and the 3-day Food record (mean age of 66.8 ± 12.9 (SD)) and 38 patients filled out the screener twice for reliability analysis (mean age of 65.8 ± 12.8 (SD)). Dietary calcium intake between the calcium screener and food records showed a strong correlation (N = 52 patients, SCC = 0.53, p ≤ 0.001) and mean difference of 21 mg (p = 0.70). Bland-Altman analysis showed agreement within 95% confidence intervals for 49/52 comparisons (94%). Test-retest reliability of the calcium screener was excellent (SCC = 0.96, p ≤ 0.001; ICC = 0.99, p ≤ 0.001). The calcium screener shows good convergent validity, reliability and feasibility to estimate daily calcium intake of patients with osteoporosis in routine clinical practice.

Serum PTH at 4h after total thyroidectomy as a predictor of hypocalcemia: a prospective time frame analysis in search of evidence.

There has not been a universal agreement about the timings and the threshold level of PTH that can accurately predict the risk of hypocalcemia. Our study aimed to investigate the changes in the serum PTH levels at various time intervals and correlate it with the development of subsequent hypocalcemia. All patients had a pre-operative serum PTH done and were again assessed intra-operatively, at 4h, 24h, 72h, and 1month after the thyroid surgery. Absolute serum PTH value at various time points, absolute change in serum PTH values compared to pre-operative level, and relative change (percentage change) in serum PTH values compared with pre-operative levels were used to predict post-operative Hypocalcemia. 49 patients were included in the study. The sensitivity and negative predictive value was 100% for serum PTH at 4h. There was a statistically significant difference between the groups that required calcium supplementation versus the group that did not require it. The maximum relative reduction in serum PTH value with respect to the pre-operative level occurred at 4h in the calcium supplement required group which was 82.5%. Use of combination of 4h serum PTH and relative change at 4h yielded the best results. A combination of absolute serum PTH level at 4h and the relative decline in serum PTH at 4h has the highest diagnostic accuracy. The use of this combined parameter helps to reliably predict patients who would require supplementation.

Postoperative Hypocalcemia in Hyperthyroid Patients: The Parathyroids Aren't Always to Blame

Hypocalcemia is commonly reported after thyroidectomy and has multiple possible etiologies including: parathyroid devascularization, reactive hypoparathyroidism from relative hypercalcemia in thyrotoxicosis, and abrupt reversal of thyrotoxic osteodystrophy. In patients that are actively hyperthyroid and undergoing thyroidectomy, it is not known how many experience hypocalcemia from nonhypoparathyroidism etiologies. Therefore, our aim was to examine the relationship among thyrotoxicosis, hypocalcemia, and hypoparathyroidism. A retrospective review was performed of prospectively-collected data from all patients undergoing thyroidectomy for hyperthyroidism by 4 surgeons from 2016 to 2020. All patients carried a diagnosis of Graves' disease or toxic multinodular goiter. Patient demographics, preoperative medications, laboratory reports, and postoperative medications were reviewed. Hypocalcemia within the first month of surgery despite a normal parathyroid hormone (PTH) level was the primary outcome of interest and was compared between patients with and without thyrotoxicosis. Secondary outcomes were duration of postoperative calcium use and the relationship between preoperative calcium supplementation and postoperative calcium supplementation. Descriptive statistics, Wilcoxon rank-sum, and chi-square tests were used for bivariate analysis, as appropriate. A total of 191 patients were identified, with mean age of 40.5y (range 6-86). Most patients were female (80%) and had Graves' disease (80%). At the time of surgery, 116 (61%) had uncontrolled hyperthyroidism (thyrotoxic group, Free Thyroxine >1.64ng/dL or Free Triiodothyronine>4.4ng/dL), with the remaining 75 (39%) considered euthyroid. Postoperative hypocalcemia (calcium < 8.4mg/dL) developed in 27 (14%), while hypoparathyroidism (PTH < 12 pg/mL) was observed in 39 (26%). Thyrotoxic patients comprised a majority of those with hypocalcemia (n=22, 81%, P=0.01) and hypoparathyroidism immediately following surgery (n=14, 77%, P=0.04). However, a majority of initially hypocalcemic, thyrotoxic patients had normal PTH values within the first month after surgery (n=17, 85%), pointing to a potential nonparathyroid etiology. On bivariate analysis, no significant relationship was found for thyrotoxic patients with initial postoperative hypocalcemia (18%) and hypoparathyroidism <1-month after surgery (29%, P=0.29) or between 1 and 6mo after surgery (2%, P=0.24). Of the 19 patients in the nonhypoparathyroidism group, 17 (89%) were off all calcium supplements by 6mo postop. In patients with hyperthyroidism, those in active thyrotoxicosis at time of surgery have a higher rate of postoperative hypocalcemia compared to euthyroid patients. When hypocalcemia lasts >1mo postoperatively, data from this study suggest that hypoparathyroidism may not be the primary etiology in many of these patients, who typically require calcium supplementation no more than 6mo postoperatively.

Effect of Microdissection of Inferior Thyroid Artery on Post-operative Hypocalcemia in Total Thyroidectomy.

Hypocalcemia is one of the most common complication after bilateral thyroid surgery. Reported rates range from 5 to 35% and 0.5 to 4.4% for transient and permanent hypocalcemia respectively. Various methods have been devised to reduce the post-operative hypocalcemia and range from modification of surgical techniques to use of loops and avoidance of inadverant neck dissections. We conducted a randomised control trial of 50 patients divided into two groups, to evaluate the effect of microdissection and ligation of distal branches of inferior thyroid artery (group B) on incidence of temporary and permanent hypocalcaemia in patients of total thyroidectomy versus its ligation distally close to the thyroid capsule(group A). Postoperative mean total serum calcium levels were lower in group A as compared to group B (9.13mg/dl vs. 9.33mg/dl at 24h; 8.77 vs. 9.10 at 3rd day and 8.58 vs. 8.96mg/dl on 10 th day) with p > 0.05. The value of ionized serum calcium as recorded on 3rd day was 4.39mg/dl for group A and 4.72mg/dl for group B with p value ≤ 0.001 (Table 2). 19 patients in group A required calcium supplementation for 6months with incidence of transient hypocalcemia at 76% while 11 patients in group B had calcium supplementation for 6months with incidence of 40% and difference was significant statistically. Microdissection technique is better for preventing the temporary hypocalcemia and hence decreasing the hospital visits of the patient when compared to the ligation of inferior thyroid artery distally close to the thyroid gland. The incidence of permanent hypocalcemia doesn't varies significantly between both techniques.

Enhancing Patient Literacy on Calcium Supplementation: A Quality Improvement Initiative

This study aims to assess patients' knowledge and identify barriers in interpreting calcium on supplement and nutrition labels and to determine whether education would be beneficial. Patients with conditions requiring calcium supplementation were included in this study. Participants were first given a 9-question pre-education survey. They were then taught how to read calcium on labels using the educational cards developed. This was followed by a 7-question posteducation survey. Endocrinologists were surveyed to assess their experience in treating patients who required calcium supplementation. Before education, 31 (33%)and37 (40%) of the participants felt that the supplement and nutrition labels, respectively, were confusing. After education, only 2 (2%) and 6 (6%) of the participants, respectively, still felt the same. There was a significant improvement in the interpretation of calcium citrate (Citracal) and calcium carbonate (TUMS) labels, with a trend of improvement in reading a milk label. Of the 47 endocrinologists surveyed, only 5 (11%) felt that their patients often or always knew the correct amount of calcium to be taken. Two-thirds 30 (64%) of the endocrinologists always or often explained to their patients how to interpret calcium labels. About half23 (49%) of the endocrinologists always or often needed to take time to look up the calcium content of supplements. For most endocrinologists 29 (62%), this took at least 2 to 4 minutes. Our patients had trouble interpreting calcium labels, and the use of educational cards was effective in improving calcium literacy.

How Long Does It Take to Regain Normocalcaemia in the Event of Postsurgical Hypoparathyroidism? A Detailed Time Course Analysis.

Background: Postsurgical hypoparathyroidism (PH) is the most common side effect of bilateral thyroid resections. Data regarding the time course of recovery from PH are currently unavailable. Therefore, a detailed analysis of the time course of PH recovery and conditions associated with rapid recovery was conducted. Methods: This is a retrospective analysis of prospectively documented data. Patients with biochemical signs of PH or need for calcium supplementation were followed-up for 12 months. Logistic regression analyses were used to identify covariates of early as opposed to late recovery from PH. Results: There were 1097 thyroid resections performed from 06/2015 to 07/2016 with n = 143 PH. Median recovery time was 8 weeks and six patients (1.1% of total thyroid resections) required calcium supplementation > 12 months. Recovery of PH within 4 and 12 weeks was characterized by high PTH levels on the first postoperative day (4 weeks: OR 1.13, 95% CI 1.06–1.20; 12 weeks: OR 1.08, 95%CI 1.01–1.16). Visualization of all PTGs emerged as an independent predictor of recovery within 12 months (OR 2.32, 95% CI 1.01–4.93) and 24 weeks (OR 2.69, 95% CI 1.08–6.69). Conclusion: In the setting of specialized high-volume endocrine surgery, permanent PH is rare. However, every second patient will require more than 2 months of continued medical surveillance. Early recovery was associated with only moderately decreased postsurgical PTH-levels. Successful late recovery appeared to be associated with the number of parathyroid glands visualized during surgery.

Challenging Thyroid Storm in Pregnancy, Case Report

Background: Thyroid storm is a rare complication of hyperthyroidism. It can lead to life-threatening complications such as Arrhythmias, multiorgan failure and disseminated intravascular coagulation (DIC) (1). In pregnant patients can cause spontaneous abortions, fetal demise (2). Aggressive treatment under critical care settings is needed. Clinical Case: We report a case of 24-year-old Indian female twelve weeks pregnant; background of Graves’ disease for five years, was on carbimazole but she discontinued since she became pregnant. Presented to Hamad general hospital with nausea, vomiting and altered mental status for one day. She was afebrile, normotensive, tachypneic, tachycardiac with heart rate of 150bpm, and confused. Investigations showed supraventricular tachycardia aborted by adenosine and amiodarone, TSH was < 0.01mIU/l(0.3-4.2) and FT4> 100 pmol/L(11.6-21.9),normal baseline liver function and complete blood counts. In the emergency department, she was managed for thyroid storm with hydrocortisone, propranolol, propylthiouracil (PTU), iodine solution and cholestyramine. Then suddenly she deteriorated requiring intubation and vasopressor support under care of Medical Intensive Care Unit (MICU) progressed to multiorgan failure; acute liver injury, acute kidney injury and DIC. So, PTU was stopped and started on plasma exchange followed by total thyroidectomy and tracheostomy. US pelvis showed nonviable fetus, so dilation and curettage were done by obstetric team. Afterwards, she markedly improved except her conscious level and kidney function which required Hemodialysis. MRI brain showed small subdural hematoma treated conservatively and Wernicke encephalopathy treated with thiamine with substantial response and spontaneously breathing. Post thyroidectomy she required calcium supplementation and levothyroxine, liver function and coagulation parameters back to baseline. Conclusion: Thyroid storm in pregnancy is a medical emergency with high mortality rate, it needs high index of suspicion and early aggressive management by a multidisciplinary team. Plasmapheresis may be considered for challenging cases as a bridge for definitive therapy. Thyroidectomy may be the only option in selected cases like our case.

Long-term hypocalcemia prediction post thyroidectomy

Introduction: Hypocalcemia is a common sequela of total thyroidectomy and is usually transient (30%), only a few develop permanent hypoparathyroidism. Till date, no effective risk stratification score to predict hypocalcemia is available that can predict postoperative hypocalcemia. Materials and Methods: This was a prospective observational study including all patients who underwent total or completion thyroidectomy with initial parathormone (PTH) within the normal range in our institution during a 1 year period. Postoperative 6th h PTH fall was noted in all patients and cutoff point for the prediction of long-term hypocalcemia (LTHP) was determined using a paired t-test. Results: Postoperatively, calcium supplementation was initiated in 52% of patients. In 7.6% of patients who had a fall in PTH to more than 80% of preoperative value, calcium supplementation could not be tapered even after 3 months postoperatively. About 66% of patients &lt;20 years of age developed hypocalcemia in the postoperative period. Patients who developed delayed hypocalcemia with initial normal calcium levels had fall in PTH of at least 45%. For individuals below 20 years, a PTH fall of 56% or more required calcium supplementation. The various variables studied failed to attain statistical significance. Conclusions: More than 82% fall in 6th h postoperative PTH predicts long-term hypocalcemia. Post total thyroidectomy, adolescent individuals are at a higher risk of developing hypocalcemia; hence, early calcium supplementation is recommended based on fall in PTH. Weighted score to predict LTHP could not be developed, as none of the risk factors evaluated were statistically significant.

Evaluation of Hypoparathyroidism following Total Thyroidectomy

The most common cause of hypoparathyroidism is damage to the glands during thyroid surgery. Parathyroid gland preservation during thyroidectomy is not only desirable, but essential for the effective management of surgical diseases of the thyroid gland&#x0D; Objective: To find out the incidence rate of hypoparathyroidism after total thyroidectomy.&#x0D; Methods: Study Period: 2 years from Jan 2017 to December 2018&#x0D; Place of Study : National Institute of ENT, Tejgaon, Dhaka&#x0D; Study Design: Prospective Observational Study&#x0D; Sample size: 107&#x0D; Sampling Technique: Convenient Sampling technique&#x0D; Results: Among the 107 cases 39 cases were malignant comprising 36.45% of the cases. toxic multinodular goitre were 6 cases among 107 cases (5.6%) and rest 62 cases were benign multinodular goitre with or without cystic change and follicular adenomas (57.94 %). 29 cases out of 39 malignant cases were papillary carcinoma of thyroid (74.36% of malignant lesions), 2 cases of medullary Ca thyroid (5.12 % of malignant lesions) rest 8 were follicular carcinoma (20.51% of malignant lesions). 26 out of 107 (24.30%) cases suffered from postoperative hypocalcaemic tetany within 1st-5th POD. Their parathyroid hormones were significantly reduced and serum calcium were also reduced and they required calcium supplementation. In 5 (4.67%) cases there was no sign and symptoms of tetany but their serum parathormone levels were little below normal level but serum calcium levels were normal and therefore no calcium supplementation were given. The rest 76 (71.03%) cases did not show any sign or symptoms of tetany and did not require calcium supplementation. Among the patients who suffered from tetany majority were cases of Carcinoma of thyroid (18 out of 26 patients of hypoparathyroidism) 69.23%, however lateral neck dissection did not seem to affect decline in parathyroid function as 10 out of 18 patients with thyroid malignancy who suffered from postoperative tetany undergone level II to level V neck dissection in addition to total thyroidectomy.&#x0D; Bangladesh J Otorhinolaryngol; October 2020; 26(2): 116-120

Medical Management of Primary Hyperparathyroidism in Pregnancy: A Case Report and Brief Literature Review

There is no established standard of care for the medical management of primary hyperparathyroidism in pregnancy for those patients who are not surgical candidates. We present a case of primary hyperparathyroidism in the third trimester that was managed with cinacalcet and a literature review on the various modalities for the medical management of primary hyperparathyroidism in pregnancy. The primary aim of this case report is to document a case of hyperparathyroidism in pregnancy that was managed medically and to perform a brief systematic review of the literature available on the medical management of primary hyperparathyroidism in pregnancy. The secondary aim is to contribute to the literature available on the use of cinacalcet in pregnancy. A 37-year-old woman with untreated primary hyperparathyroidism presented at 32 weeks of gestation with hypercalcemia that was not amenable to surgical intervention. We treated her with increasing doses of cinacalcet with improvement in her serum calcium until developing pre-eclampsia which prompted emergent cesarean delivery of the infant. The neonate developed respiratory distress after delivery but did not develop hypocalcemia after birth. The neonate became transiently hypercalcemic in the setting of calcium gluconate infusions given to prevent hypocalcemia. The patient underwent surgical removal of a parathyroid adenoma and required calcium supplementation for 1 month afterwards. Hypercalcemic crisis during pregnancy is associated with significant maternal and fetal morbidity. There is limited information regarding the medical management of primary hyperparathyroidism due to the lack of high-powered studies and prospective studies owing to the relative rarity of the condition. No serious adverse maternal events were reported for either bisphosphonate or cinacalcet use. Adverse neonatal events include transient hypocalcemia of the infant with cinacalcet use and possibly low birth weight, infantile hypocalcemia, and shortened gestational periods with bisphosphonate use. J Endocrinol Metab. 2020;10(2):49-53 doi: https://doi.org/10.14740/jem624

Persistent Hypocalcemia in a Premature Neonate Exposed to Topiramate In-Utero

Neonatal hypocalcemia can result from numerous etiologies and is commonly seen in premature neonates. We describe a late preterm neonate with asymptomatic hypocalcemia whose mother took topiramate throughout the entire pregnancy. Other factors that may contribute to hypocalcemia, including infant of a diabetic mother, were ruled out in our patient. The patient we are reporting on required calcium supplementation for persistent hypocalcemia most likely due to fetal topiramate exposure.

SAT-495 1-α-Hydroxylase Activity-Mediated Hypercalcemia Associated with Ovarian Dysgerminoma

Background: Humoral hypercalcemia of malignancy is classically associated with increased tumor production of parathyroid hormone-related peptide (PTHrP). While 1,25 dihydroxy vitamin D (1,25D) mediated hypercalcemia has been demonstrated with a range of granulomatous disorders and lymphomas, there have only been 11 cases reported in ovarian dysgerminomas, of which only 2 were in adults. Ovarian dysgerminoma is the most common ovarian malignancy in childhood but is much more infrequent in adults. We present a case of a rare ovarian malignancy in an adult woman with an even more rare presentation of 1,25D mediated hypercalcemia. Case: A 23 year old African American female with a history of intravenous drug abuse was admitted for dilation and curettage for suspected molar pregnancy. Her operative course was complicated by uterine perforation requiring diagnostic laparoscopy which revealed a large, firm, irregular left ovarian mass concerning for malignancy. Laboratory findings were pertinent for calcium 13.4mg/dl (8.5-10.5), albumin 3.5g/dl (3.5-5.0), creatinine 1.61mg/dl (0.6-1.2), phosphorus 4.0mg/dl (2.5-4.5), alkaline phosphatase elevated at 170 Units/L (25-125) and appropriately suppressed PTH of 4 pg/ml (10-65). Previous calcium levels were all normal. Additional work-up revealed normal PTHrP, 25-OH Vitamin D 14.2 mg/dl (20-50) and high-normal 1,25 dihydroxy vitamin D at 76pg/ml (19.9-79.3). Tumor markers β-hCG, LDH, α-fetoprotein, and CA 19-9 were all elevated. CT scan of the abdomen and pelvis characterized the lesion to be a heterogenous 16.5 x 10.0 x 18.3 cm pelvic mass. The patient was initially given intravenous isotonic fluids and 4mg of intravenous zoledronic acid which decreased calcium to 10mg/dl. Biopsy of the mass performed during initial laparoscopy confirmed the suspected diagnosis of ovarian dysgerminoma. A left salpingo-oophorectomy was performed and the patient developed mild hypocalcemia post-operatively to a nadir of 6.7mg/dl (adjusted for albumin: 7.7) requiring calcium supplementation. The 1,25D level on post-operative day 2 was low at 9.1 pg/ml. Surgical pathology demonstrated metastatic ovarian dysgerminoma with para-aortic lymph node involvement. Conclusion: Our case demonstrates an unusual case of humoral hypercalcemia of malignancy. Exogenous 1-α-hydroxylase expression has been reported exceedingly rarely in solid tumors other than lymphomas. While we were unable to stain the tumor for 1-α-hydroxylase, the abrupt drop in 1,25D and calcium levels post resection strongly support our diagnosis. To our knowledge, our patient is the second oldest patient reported in literature to have 1,25D mediated hypercalcemia associated with an ovarian dysgerminoma.

Are Routine Postoperative Laboratory Tests Really Necessary After Lumbar Spinal Surgery?

For patients undergoing lumbar spinal surgery, many surgeons routinely perform laboratory tests within 3 days after surgery. However, few studies have reported the necessity for routine laboratory tests for patients with uncomplicated cases within 3 days after surgery. We performed a retrospective study of patients with lumbar degenerative disease who had undergone lumbar spinal surgery from May 2014 to May 2017. The perioperative patient information was recorded. The abnormal postoperative laboratory tests were recorded. Finally, the incidence and risk factors for patients requiring postoperative clinical treatment were analyzed. A total of 1915 patients were included in the present study. Postoperative laboratory tests had been ordered for 870 patients (45.43%). Of these patients, only asmall proportion had required postoperative clinical intervention to treat abnormal serum hemoglobin (2.53%), albumin (1.95%), serum potassium (0.92%), or serum calcium (6.55%) levels. Multivariate logistic regression analysis showed that female gender and operative time were risk factors for the need for blood transfusion after lumbar spinal surgery. Age and operative time were risk factors for patients requiring albumin supplementation after lumbar spinal surgery. Finally, intraoperative bloodloss and operative time were independent risk factors for patients requiring calcium supplementation after surgery. Owing to the small number of postoperative clinical interventions for abnormal laboratory test results, we believe that the use of routine laboratory tests within 3 days after lumbar spinal surgery for patients with uncomplicated cases are unnecessary. Our results showed that operative time is a potential risk factor for the necessity for clinical treatment after lumbar spinal surgery.

Calcium supplementation in CVVH using regional citrate anticoagulation.

Calcium supplementation is one of the most important factors in maintaining the safety and efficacy of regional citrate anticoagulation (RCA) during continuous renal replacement therapy (CRRT). The aims of this study were to assess the determinants of calcium requirements in RCA-CVVH and to simplify the calcium supplementation approach. Our study consisted of two parts. The first part was a discovery phase to determine the key factors of calcium supplementation. Twenty critically ill patients who required RCA-CVVH were enrolled in this part. Systemic citrate, total calcium, protein-bound calcium, and ionized calcium concentrations were serially measured using the traditional RCA protocol. A two-phase calcium supplementation protocol was then proposed, and algorithms were developed for calcium supplementation. The second part of the study was the validation phase. Another 97 critically ill patients were enrolled and were treated with RCA-CVVH using the new version of the calcium supplementation protocol. The loss of calcium flux in the extracorporeal circuit and the increase in citrate-calcium complexes in vivo were the main determinants of the required calcium supplementation. In the CVVH mode, the rate of calcium infusion had to be reduced after systemic citrate level reached a steady state. With the aid of mathematical models, systemic calcium levels could be stably maintained in the normal range, and the frequencies of calcium monitoring were reduced. Calcium supplementation during RCA-CVVH undergoes two phases. We propose mathematical models to quantify the need for calcium supplementation, which enable individualization of the RCA prescription and simplify the management of RCA in the CVVH mode.

POST-OPERATIVE HYPOCALCEMIA AMONG ONGOING PATIENTS AFTER TOTAL AND SUBTOTAL THYROIDECTOMY

Background: Hypocalcemia is a major post-operative complication of total thyroidectomy, causing severe symptoms and increasing hospitalization time. The primary cause is secondary hypoparathyroidism following damage to or devascularization of one or more parathyroid gland during surgery. Objective: To identify the occurrence rate of post-operative hypocalcemia as an indicator of parathyroid gland function and its relation to the type of the surgical procedure of thyroidectomy whether it’s a subtotal or total thyroidectomy. Methods: One hundred and ninety patients with total and subtotal thyroidectomy were selected in this study (144 females and 46 males). The patients were divided into 2 groups, group 1 (95 patients) represent the patients with total thyroidectomy, and group 2 (95 patients) represent the patients with subtotal thyroidectomy. Serum calcium and parathyroid hormone were done pre-operatively and post-operatively for all patients with a follow-up for serum calcium for 6 months. Results: Of the total number serum calcium levels decreased from pre-operative levels in 156 patients (82%), but still within normal range (2.1-2.6 mmol/L). The overall incidence of transient hypocalcemia was 22 % (42 patients), 35 patients belong to group 1 and 7 patients to group 2, and that of permanent hypocalcemia (hypocalcemia persisted at the 6 months assessment) was 2.6 % (5 patients), 4 patients belong to group 1 and one patient to group 2. Most of the patients with hypocalcemia were asymptomatic 19.4% (n=37) and did not require calcium supplementation. Symptomatic hypocalcemia occurred in 5.2 % (n =10) patients. It was found that the overall incidence of hypocalcemia after thyroidectomy was 24.7 % (22% transient and 2.6% permanent). Conclusion: It could be concluded that, insuring the integrity of parathyroid glands is important to avoid post-thyroidectomy hypocalcemia. If incidental removal or devascularization of the parathyroid glands is noted, parathyroid auto-transplantation should be done. Keywords: Post-operative hypocalcemia, total thyroidectomy, subtotal thyroidectomy. Citation: Naji RE. Post-operative hypocalcemia among ongoing patients after total and subtotal thyroidectomy. Iraqi JMS. 2018; Vol. 16(1): 92-99. doi: 10.22578/IJMS.16.1.13

Parathyroid hormone assay following total thyroidectomy for early prediction of post-operative hypocalcemia

Background: Detecting post-operative hypocalcaemia following total thyroidectomy using serum parathyroid hormone levels would help in an earlier and a definitive treatment plan in treating hypocalcaemia.Methods: This was a prospective interventional study done in a tertiary care teaching hospital. This was mainly done to assess the post-operative hypocalcemia following total thyroidectomy using parathyroid hormone levels and to assess the correlation between the two. With a baseline levels recorded patients underwent a post-operative evaluation of parathyroid hormone 1 hour after total thyroidectomy and serum calcium levels on day 1, 2, 3 and 4 after surgery. The same was statically analyzed to find a correlation between parathyroid hormone levels and the degree of hypocalcemia and evaluated to see if parathyroid hormone was a reliable clinical indicator.Results: A total of 43 patients were included in the study and the parathyroid hormone levels were assessed following surgery, the same was plotted statistically. Sensitivity of parathyroid hormone drop by 75% in predicting hypocalcaemia was 95%. 50% drop in parathyroid hormone levels was a sensitive predictor of hypocalcaemia. A PTH value of less than 15.1pg/ml was highly specific and sensitive indicator of hypocalcaemia.Conclusions: Parathyroid hormone Assay following total thyroidectomy is reliable for early prediction of hypocalcaemia. Patients with a parathyroid hormone level &lt;9pg/ml or with 75% drop in parathyroid hormone level are at a high risk for hypocalcaemia and would require calcium supplementation.

Parathyroid score can predict the duration of required calcium supplementation after total thyroidectomy.

BackgroundPostoperative hypoparathyroidism is the most common complication after total thyroidectomy, owing to unintentional injury or decreased blood flow to the parathyroid glands. Prediction of postoperative hypoparathyroidism would be helpful for surgeons to manage postoperative hypocalcemia. In this study, we scored the discoloration of the parathyroid glands using a new parathyroid scoring system and evaluated the correlation between the parathyroid score and duration of required calcium supplementation after total thyroidectomy.MethodsA total of 316 patients undergoing total thyroidectomy between November 2009 and April 2010 were enrolled in this retrospective study. Parathyroid scoring was performed by one experienced surgeon. The status of each of the 4 parathyroid glands was classified as normal color (3 points), slightly discolored (2 points), dark discoloration (1 point), or loss of the gland (0 points), resulting in possible total scores of 0–12. Serum parathyroid hormone (PTH), serum calcium, and ionized calcium concentrations were measured at 2 hours, 2 weeks, 3 months, 6 months, and 1 year after surgery. Patients were also divided into three groups based on the duration of required calcium supplementation: no required supplementation (n = 260, 82.3%), required supplementation for <6 months (n = 38, 12%), and required supplementation for ≥6 months (n = 18, 5.75%).ResultsParathyroid scores were positively correlated with ionized PTH concentrations at 2 hours (r = 0.053, p < 0.001), 2 weeks (r = 0.056, p < 0.001), 3 months (r = 0.032, p<0.001), 6 months (r = 0.072, p < 0.001), and 1 year (r = 0.071, p < 0.001) after thyroidectomy. Parathyroid scores were significantly and inversely associated with the duration of required calcium supplementation (p = 0.001).ConclusionsParathyroid scores at the end of surgery might be helpful for predicting the degree of postoperative hypocalcemia after total thyroidetomy.

Assessment of calcium homeostasis after total thyroidectomy in differentiated thyroid carcinoma

Background: After total thyroidectomy, hypocalcaemia can be transient or permanent. Most of the patients are being prescribed long term calcium supplementation despite preserving parathyroid glands. We have tried to study the various calcium homeostatic factors to predict the long term calcium levels in differentiated thyroid carcinoma following total thyroidectomy. Method: Study was conducted in a tertiary care centre and a total number of 28 patients of differentiated thyroid carcinoma were retrospectively analysed who underwent surgery from 2013 - 2015. Post surgery patients were given thyroxine and calcium supplementation with regular monitoring of thyroid function test and serum calcium. Serum Parathormone(PTH) levels were recorded after minimum of one year of completion of surgery. Results: Out of 28 patients, 26 patients have serum parathormone within normal range (15-65 pg/ml). Only two patients have low serum PTH values ( Conclusion: Our study reveals optimum calcium homeostasis in patients undergoing total thyroidectomy. A long term follow up of these patients is required so that many patients with normal PTH levels may not require calcium supplementation.

The Preservation and Autotransplantation of the Parathyroid Glands in Total Thyroidectomy in Patients With Thyroid Cancer—A Strategy for Avoiding Permanent Hypoparathyroidism

Hypoparathyroidism is a complication that occurs after total thyroidectomy (TT) in patients with thyroid cancer. We tried to determine a strategy for avoiding permanent hypoparathyroidism. A total of 42 patients underwent TT for thyroid cancer between April 2009 and March 2014. One or more parathyroid glands (PGs) could be macroscopically preserved in all of the patients. First, we evaluated the association between the number of PGs that were macroscopically preserved and the postoperative course in 28 patients without autotransplantation. The number of preserved PGs was not associated with postoperative tetany or the serum levels of calcium or phosphorous on postoperative day 1, or the proportion of patients who needed to take calcium supplements or a vitamin D analog. However, only the patients with a single preserved PG required calcium supplementation for longer than 1 year (33.3%, P &amp;lt; 0.05). Next, we compared the clinical course with PG autotransplantation in 16 patients in whom a single PG was preserved. Although the result was not statistically significant, only the patients without autotransplantation required calcium supplementation for longer than 1 year. To avoid permanent hypoparathyroidism after TT, it should be essential to preserve at least 2 PGs or to preserve 1 PG and perform autotransplantation.

Preserving Parathyroid Gland Vasculature to Reduce Post-thyroidectomy Hypocalcemia.

The failure to preserve parathyroid function in patients who have undergone total thyroidectomy is of major concern, because hypocalcemia is difficult to prevent and remains a common postoperative complication. Here, we describe procedures designed to preserve the vasculature supplying the parathyroid glands and examine both recent outcomes and retrospective reports of results obtained prior to the application of these preservation techniques. Our technique for preserving parathyroid function during thyroidectomy was adopted in 2009 and involves separating a relatively long segment of a vessel distally from the thyroid gland. We reviewed the medical records of 1,411 patients who underwent total thyroidectomy, with or without lateral neck dissection, at the Samsung Medical Center from January 2006 through June 2014 to determine outcomes. Patients were divided into three groups according to the time period during which the surgery took place: Group A, 2006-2008 (before the vasculature-preserving technique was applied); Group B, 2009-2011 (the time when the technique was first adopted); and Group C, 2012-2014 (more recent results of the technique). We analyzed the incidence of hypoparathyroidism in the three groups, as well as risk factors that influenced its development. The rates of transient and permanent hypoparathyroidism in Group A were 25.4 and 4.3%, respectively. However, the incidence of hypoparathyroidism decreased significantly over time after the vasculature-preserving procedure was adopted. Transient hypoparathyroidism developed in 4.8% of Group C patients, and only four (0.7%) of the 565 patients in this group required calcium supplementation, despite the fact that a greater number of patients were included who underwent total thyroidectomy combined with lateral neck dissection. Although female sex and lateral neck dissection tended to increase the rate of transient hypoparathyroidism, multivariate analysis showed that the vasculature-preserving procedure was the only significant risk factor related to postoperative hypoparathyroidism. The blood flow of the final branch to the parathyroid gland is mostly in the lateral-to-medial direction; therefore, mobilization and preservation of the vessels lateral to the gland is essential to prevent devascularization of the parathyroid gland.