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Long-term outcome of hyperthyroidism diagnosed in childhood and adolescence: a single-centre experience.
Gill, DS, Greening, JE, Howlett, TA, Levy, MJ, Shenoy, SD
Journal of pediatric endocrinology & metabolism : JPEM. 2019;(2):151-157
Abstract
Background The objective of the study was to evaluate the long-term outcome of paediatric-onset hyperthyroidism with follow-up into adulthood and to identify any early predictors of a need for definitive therapy (DT). Methods In a retrospective analysis of patients diagnosed with hyperthyroidism under the age of 18 years and at follow-up, a comparison was made by categorising them into those who underwent definitive therapy (DT group), i.e. thyroidectomy/radioactive iodine (RAI), those who remained on antithyroid drugs (ATD) (CBZ group) and those who had complete remission (RE group). Results Sixty-one (49 females, 12 males) patients with a median age of 15.1 years (range: 3.6-18) at diagnosis were studied. The duration of the first course of ATD varied from <1 year (7%), 1-2 years (26%), >2 years (46%) and ATD never discontinued (21%). Disease relapsed in 69% of patients with <1 year of ATD vs. 79% with >2 years of ATD. At follow-up, the median duration since diagnosis was 8.75 years (range 2.0-20.7 years) and the median age at follow-up was 23.2 years (8-36 years). Thirty-three percent (20/61) had undergone DT (DT group) - with 16.5% (n=10) on RAI and 16.5% (n=10) on surgery, 36% (22/61) were on ATD (CBZ group), whilst 32% (19/61) had undergone full remission (RE group). The comparison did not identify any statistically significant difference for predictor factors at diagnosis including age, T4 and free T4 levels, thyroid peroxidise antibody levels (TPO) and the duration of the first course of carbimazole (CBZ) treatment. Conclusion Long-term complete remission of paediatric-onset hyperthyroidism in our study was 31%. There were no predictors identified that could help predict the long-term outcome, especially into adulthood.
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The timing of parathyroid hormone measurement defines the cut-off values to accurately predict postoperative hypocalcemia: a prospective study.
Filho, EBY, Machry, RV, Mesquita, R, Scheffel, RS, Maia, AL
Endocrine. 2018;(2):224-231
Abstract
PURPOSE Serum intact parathyroid hormone (iPTH) level is an early marker of post-thyroidectomy hypocalcemia. However, lack of methodological standardization to define timing and cut-off points of iPTH measurement limit its clinical applicability. Here, we evaluated the relationship between two distinct postoperative time sampling and iPTH accuracy on predicting hypocalcemia. METHODS iPTH was measured within 4 h after surgery (iPTH 4 h) and on the morning of the first postoperative day (iPTH 1st PO). Hypocalcemia was defined by levels of total calcium corrected by serum albumin ≤ 8.0 mg/dL and/or by the presence of symptoms. The most accurate iPTH cut-off point for hypocalcemia prediction was established from a ROC curve comparing both time-points. RESULTS The study included 101 patients. The mean age was 52.4 ± 12.9 years, 93 were women (92.1%) and 69 patients underwent total thyroidectomy (68.3%). Hypocalcemia occurred in 25 patients (24.8%), of whom 12 were symptomatic. Total thyroidectomy, longer duration of surgery, surgical complications related to parathyroid glands and lower levels of iPTH 4 h and iPTH 1st PO were associated with postoperative hypocalcaemia (all P < 0.05). Using the ROC curve, the optimal cut-off points were 19.55 pg/mL and 14.35 pg/mL for iPTH 4 h and iPTH 1st PO, respectively. The comparison of the AUC showed no significant difference between these two points of evaluation (0.935 vs. 0.940; P = 0.415). CONCLUSIONS Serum iPTH levels measured within 4 h or on the first morning after surgery are predictors of postoperative hypocalcemia. Notably, both time-points have the same accuracy to predict postoperative hypocalcemia (with different cutoff points).
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PTH(1-34) for the Primary Prevention of Postthyroidectomy Hypocalcemia: The THYPOS Trial.
Palermo, A, Mangiameli, G, Tabacco, G, Longo, F, Pedone, C, Briganti, SI, Maggi, D, Vescini, F, Naciu, A, Lauria Pantano, A, et al
The Journal of clinical endocrinology and metabolism. 2016;(11):4039-4045
Abstract
CONTEXT There are no studies evaluating teriparatide for prevention of post-thyroidectomy hypocalcemia. OBJECTIVE Our objective was to evaluate whether teriparatide can prevent postsurgical hypocalcemia and shorten the hospitalization in subjects at high risk of hypocalcemia following thyroid surgery. DESIGN This was a prospective phase II randomized open-label trial. SETTING This trial was set on a surgical ward. PATIENTS Twenty-six subjects (six males, 20 females) with intact PTH lower than10 pg/ml 4 hours after thyroidectomy were included. INTERVENTION Subjects were randomized (1:1) to receive SC administration of 20 mcg of teriparatide every 12 hours until the discharge (treatment group) or to follow standard clinical care (control group). MAIN OUTCOME MEASURE Adjusted serum calcium, duration of hospitalization, and calcium/calcitriol supplementation were measured. RESULTS Overall, the incidence of hypocalcemia was 3/13 in treatment group and 11/13 in the control group (P = .006). Treated patients had a lower risk of hypocalcemia than controls (relative risk, 0.26 [95% confidence interval, 0.09-0.723)]). The median duration of hospitalization was 3 days (interquartile range, 1) in control subjects and 2 days (interquartile range, 0) in treated subjects (P = .012). One month after discharge, 10/13 subjects in the treatment group had stopped calcium carbonate supplements, while only 5/13 in the control group had discontinued calcium. The ANOVA for repeated measures showed a significant difference in calcium supplements between groups at 1-month visit (P = .04) as well as a significant difference between discharge and 1-month visit in the treatment group (P for interaction time group = .04) Conclusions: Teriparatide may prevent postsurgical hypocalcemia, shorten the duration of hospitalization, and reduce the need for calcium and vitamin D supplementation after discharge in high risk subjects after thyroid surgery.
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Evaluating the prognostic factors associated with cancer-specific survival of differentiated thyroid carcinoma presenting with distant metastasis.
Lang, BH, Wong, KP, Cheung, CY, Wan, KY, Lo, CY
Annals of surgical oncology. 2013;(4):1329-35
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Abstract
BACKGROUND Because patients with differentiated thyroid carcinoma (DTC) presenting with distant metastasis (DM) have a particularly poor prognosis, examining the prognostic factors in this group is essential. We aimed to evaluate the prognostic factors affecting cancer-specific survival (CSS) in DTC patients presenting with DM. METHODS Of the 1227 DTC patients, 51 (4.2 %) presented with DM at diagnosis. All patients underwent a total thyroidectomy, followed by radioiodine (RAI) ablation and postablation whole body scan (WBS). Patients were considered to have an osseous metastasis if one of the metastatic sites involved a bone, while RAI avidity was determined by any visual uptake in a known metastatic site on the first WBS. Factors predictive of CSS were determined by univariate and multivariate analyses by the Cox proportional hazard model. RESULTS In univariate analysis, older age (relative risk [RR] 1.050, 95 % confidence interval [CI] 1.010-1.091, P = 0.014), DM discovered before WBS (RR 3.401, 95 % CI 1.127-10.309, P = 0.030), follicular thyroid carcinoma (RR 3.095, 95 % CI 1.168-8.205, P = 0.025), osseous metastasis (RR 4.695, 95 % CI 1.379-15.873, P = 0.013), non-RAI avidity (RR 3.355, 95 % CI 1.280-8.772, P = 0.014), and external beam radiotherapy to DM (RR 3.241, 95 % CI 1.093-9.614, P = 0.034) were significant poor prognostic factors for CSS. In the multivariate analysis, after adjusting for other factors, osseous metastasis (RR 6.849, 95 % CI 1.495-31.250, P = 0.013) and non-RAI avidity (RR 7.752, 95 % CI 2.198-27.027, P = 0.001) were the two independent poor prognostic factors for CSS. Older age almost reached statistically significance (RR 1.055, 95 % CI 0.996-1.117, P = 0.068). CONCLUSIONS DTC patients presenting with DM accounted for 4.2 % of all patients. Because osseous metastasis and RAI avidity were independent prognostic factors, future therapy should be directed at improving the treatment efficacy of osseous and/or non-RAI-avid metastases.
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[Parathyroid hormone as a predictor of post-thyroidectomy hypocalcemia].
Del Río, L, Castro, A, Bernáldez, R, Del Palacio, A, Giráldez, CV, Lecumberri, B, Alvarez-Escolá, C, Fernández-Martínez, A
Acta otorrinolaringologica espanola. 2011;(4):265-73
Abstract
INTRODUCTION AND OBJECTIVE The risk of developing hypocalcemia is the reason for prolonged hospitalisation after total thyroidectomy. The objective of this study was to validate parathyroid hormone measurement for predicting post-thyroidectomy hypocalcemia. MATERIAL AND METHODS Eighty-two patients who underwent total or completion thyroidectomy from February 2009 to March 2010 were enrolled in this prospective study to determine the best timing and cutoff point of parathyroid hormone to predict hypocalcemia. Patients with any condition that could interfere with calcium homeostasis were excluded from the survey. Parathyroid hormone and serum calcium levels were determined preoperatively, immediately after surgery and a number of hours later. RESULTS Treatment for hypocalcemia was required in 16.7% of patients. A percent of delayed decrease in parathyroid hormone was chosen as the best measurement to predict hypocalcemia. An 80% or higher decrease in delayed parathyroid hormone levels had 100% sensitivity (95% CI: 77.2-100%) and 87% specificity (95% CI: 77-93%) for selecting patients for early discharge. Using this test, 73.2% of the patients could have been discharged 24 hours after surgery. A 98% decrease in delayed parathyroid hormone levels could select candidates for early calcium replacement with 98.6% specificity (95% CI: 92.2-99.7%). CONCLUSIONS The decrease in postoperative delayed parathyroid hormone levels is a good predictor of post-thyroidectomy hypocalcemia. A decrease of 80% or more in delayed parathyroid hormone level is a test with excellent sensibility and specificity for selecting candidates for early discharge. The 98% cutoff point has high specificity for selecting patients for early calcium replacement.
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Predictors of hypocalcemia occurring after a total/near total thyroidectomy.
Kara, M, Tellioglu, G, Krand, O, Fersahoglu, T, Berber, I, Erdogdu, E, Ozel, L, Titiz, MI
Surgery today. 2009;(9):752-7
Abstract
PURPOSE The aim of this study was to identify the predictors of early postoperative hypocalcemia after a total/near total thyroidectomy in order to select patients for prompt treatment to prevent symptomatic hypocalcemia. METHODS Patients with hypocalcemia within 24 h of surgery were identified as Group I and normocalcemic patients as Group II. The perioperative serum total calcium (tCa, ionized calcium (iCa) and intact parathormone (iPTH) were measured perioperatively. Skin closure (SC) was accepted as the reference time point. Data are expressed as the mean +/- SEM. RESULTS The study included 73 patients. Hypocalcemia (Group I) was detected in 40 patients (54%) within the first 24 h postoperatively. Symptomatic hypocalcemia was detected in 40% of the patients in Group I. Intact parathormone values at 10 min of SC were significantly lower in Group I (P = 0.001). IPTH measurement at 10 min of SC showing a ≥30% decrease had a 92.3% sensitivity and 92.6% specificity in predicting hypocalcemia after a total/near total thyroidectomy. The postoperative day 15 mean tCa, iCa, and iPTH values were similar in both groups of patients. The mean iPTH level was 16.79 +/- 2.5 pg/dl at 10 min after SC in patients who developed symptomatic hypocalcemia. CONCLUSIONS Intact parathormone measurement 10 min after SC is helpful to predict early postoperative hypocalcemia. An IPTH decrease ≥30% at this time point estimates the risk of postoperative hypocalcemia.
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Diagnosis and prognosis of iatrogenic injury of the recurrent laryngeal nerve.
Hydman, J, Björck, G, Persson, JK, Zedenius, J, Mattsson, P
The Annals of otology, rhinology, and laryngology. 2009;(7):506-11
Abstract
OBJECTIVES Following perioperative injury to a macroscopically intact recurrent laryngeal nerve (RLN), there are two possible intraneural injury types: 1) axonal injury, including disruption of axons, and 2) conduction block, only affecting the Schwann cells and the nodes of Ranvier. In this study, it was hypothesized that the functional outcome after RLN injury may depend on the type of nerve injury. METHODS Fifteen patients with acute postoperative unilateral RLN paralysis were prospectively studied. Electrophysiological examination (laryngeal electromyography) was used to differentiate between the two types of nerve injury. Vocal fold motions were monitored by repeated laryngoscopy during the study period (up to 6 months). Three of the patients with axonal injury were treated with the regeneration-promoting agent nimodipine. RESULTS The patients with conduction block all recovered normal vocal fold motion, whereas patients with axonal injury within the nerve had a significantly worse outcome. The 3 patients who were treated with nimodipine all recovered normal or near-normal vocal fold mobility despite the more severe axonal injury. CONCLUSIONS In contrast to previous reports, our results show that laryngeal electromyography is a reliable tool for diagnosing the type of injury within the injured RLN, making it possible to predict the functional outcome in these patients. On the basis of the results, a future randomized study on nimodipine treatment for RLN axonal injury is suggested.
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Contribution of gamma probe-guided surgery to lateral approach completion thyroidectomy.
Uludag, M, Yetkin, G, Citgez, B, Isgor, A, Atay, M, Kebudi, A, Akgun, I
Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2009;(3):213-9
Abstract
OBJECTIVE To evaluate the effectiveness of gamma probe performed with technetium Tc 99m-labeled pertechnetate in patients who underwent completion thyroidectomy after pathologic detection of incidental thyroid cancer following subtotal thyroidectomy. METHODS In this prospective study, we evaluated findings from patients with multinodular goiter who underwent gamma probe-guided lateral approach completion thyroidectomy after the pathologic detection of incidental thyroid cancer following subtotal thyroidectomy where partial thyroid tissue was left unilaterally or bilaterally. Patients who underwent the procedure between January 2003 and January 2007 were included. Thyroid scintigraphy; thyroid and neck ultrasonography examinations; and concentrations of thyroid hormones, thyrotropin (TSH), thyroglobulin, and thyroglobulin antibodies were evaluated before the second operation. Patients were administered 3 mCi technetium Tc 99m pertechnetate during anaesthetic induction, and we extracted suspicious thyroid tissue and tissue with activity above background activity levels according to gamma probe. Extracted tissues were evaluated pathologically. RESULTS Completion thyroidectomy was performed in 23 patients. Seventy-nine tissue samples were extracted; 49 were thyroid tissue and 30 were nonthyroid tissue. Mean thyroid tissue to background activity ratio (T:B) was 6.4 +/- 3.9 (range, 2-14.3), and mean thyroid bed (after excision) to background activity ratio (Tbed:B) was 1.2 +/- 0.2 (range, 0.8-1.7) (P = .001). Mean T:B and Tbed:B ratios of the nonthyroid tissue were 1.2 +/- 0.3 (range, 0.2-1.7) and 1.1 +/- 0.2 (range, 0.4-1.4), respectively (P = .001). The thyroid tissue T:B ratio was significantly higher than that of non-thyroid tissue (P<.001). Gamma probe labeling contributed to extraction of small amounts of thyroid tissue that could not be viewed by scintigraphy in 43% of patients. CONCLUSIONS Using gamma labeling, thyroid tissue shows significantly more activity than nonthyroid tissue. Gamma probe helps detect small, residual thyroid tissue that is buried in the scar tissue that cannot be distinguished by scintigraphy; therefore, it assists in the extraction of the maximum amount of thyroid tissue.
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Intraoperative gamma probe guidance with 99mTc-pertechnetate in the completion thyroidectomy.
Aras, G, Gültekin, SS, Küçük, NO, Demirer, S, Tuğ, T
Annals of nuclear medicine. 2009;(5):421-6
Abstract
AIM: Intraoperative gamma probe (GP) guidance with (99m)Tc-pertechnetate in the completion total thyroidectomy after a first thyroidectomy was investigated in this prospective study. METHODS The study group comprises of fourteen consecutive patients (14 females, age mean 50.2 +/- 12.0 years, age range 29-73 years). All patients underwent a second thyroidectomy due to inadequate (5/14 patients) and complementary (9/14 patients) interventions. Serum-free three iodothyronine, free thyroxin and thyroid stimulating hormone measurements, a neck ultrasonography (USG) and thyroid scintigraphy (TS) were performed in the preoperative and postoperative period. After a 185 MBq (5 mCi) injection of (99m)Tc-pertechnetate, background (BG), left thyroid lobe (LTL), right thyroid lobe (RTL) and pyramidal tyroid lobe (PTL) regions were counted in time before and after resection of thyroid remnants by intraoperative GP. All resection materials were evaluated by histopathologic examination. RESULTS Preoperative TSH was less than 30 mIU/mL (mean 21 +/- 7) in all patients. Functioning thyroid remnants were shown in 13/14 patients on the preoperative TS and USG, which were diagnosed by USG in one but by TS in other one. We calculated that percentage median (minimum-maximum) values were 220.90% (56.00-411.11%) in LTL, 80.43% (11.54-471.05%) in RTL and 66.60% (-3.33 to 158.33%) in PTL for counts before resection, on the other hand, 15.96% (-20.55 to 47.62%) in LTL, 17.59% (-15.07 to 38.46%) in RTL and 17.59% (-1.96 to 57.14%) in PTL regions for counts after resection. There were statistically significant differences between these values belonging to before and after resection for LTL (p = 0.001), RTL (p = 0.001) and PTL (p = 0.008). Bilateral small foci in a patient and unilateral focus in other patient were observed in postoperative TS. Unilateral focus was detected on the RTL by GP, but not bilateral foci. Postoperative TSH levels increased to 30 mIU/mL (mean 69 +/- 26) at least. There was a statistically significant difference between preoperative and postoperative TSH values (p < 0.001). Histopathologic confirmation revealed that all removed materials were the thyroid tissues. CONCLUSIONS Gamma probe guidance with (99m)Tc-pertechnetate seemed to be a good option and easy available method in patients undergoing the completion total thyroidectomy.
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High-calcium mineral water as a calcium supplementing measure for post-thyroidectomy hypocalcemia.
Coiro, V, Zanardi, G, Saccani Jotti, G, Rubino, P, Manfredi, G, Chiodera, P
Minerva endocrinologica. 2008;(1):7-13
Abstract
AIM: The aim of this study was to test the possibility of enhancing blood calcium levels in totally thyroidectomized patients by supplementation with 1 L/d carbonate-bicarbonate-high-calcium mineral water. METHODS This study enrolled 95 outpatients, totally thyroidectomized four months earlier, and hence treated with oral calcium and vitamin-D. At recruitment, ionized blood calcium was either below (Group A; N. 55) or above (Group B; N. 40, randomly divided in Group B1 [N. 20] and Group B2 [N.20]) the lower limit of the normal range (1.12 mmol/L). For one month, Group A was treated with 1 L/d high-calcium (483 mg/L) mineral water and continued the usual therapy with Ca and vitamin-D. In contrast, Group B1 and Group B2 substituted their Ca and vitamin-D therapy with 1 L/d high-calcium mineral water (Group B1) or 1 L/d of placebo mineral water (Ca:80 mg/L) (Group B2). RESULTS After one month, a significant 7.5% increase in blood ionized-calcium levels was observed in Group A, no change in Group B1 and a significant drop below normality in Group B2 (Group B2 vs Group B1, P<0.001). Thereafter, 1 L/d of the high-calcium mineral water, given to Group B2 instead of placebo for an additional month, significantly enhanced ionized-calcium levels above the lower limit of normality (Group B2 vs Group B1, NS). CONCLUSION These experiments show that calcium supplementation as 1 L/d of a high-calcium mineral water may efficaciously enhance blood calcium levels in thyroidectomized patients. This complementary treatment might at least in part contribute to the prevention and/or treatment of hypocalcemia and substitute vitamin-D and calcium therapies after thyroidectomy.