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MANAGEMENT OF ENDOCRINE DISEASE: Postsurgical hypoparathyroidism: current treatments and future prospects for parathyroid allotransplantation.
Mihai, R, Thakker, RV
European journal of endocrinology. 2021;(5):R165-R175
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Abstract
BACKGROUND Permanent postsurgical hypoparathyroidism (POSH) is a major complication of anterior neck surgery in general and of thyroid surgery in particular. Depending on diagnostic criteria, up to 10% of patients undergoing bilateral thyroid surgery develop POSH. This leads to a multitude of symptoms that decrease the quality of life and burden the healthcare provision through complex needs for medication and treatment of specific complications, such as seizures and laryngospasm. METHODS Narrative review of current medical treatments for POSH and of the experience accumulated with parathyroid allotransplantation. RESULTS In most patients, POSH is controlled with regular use of calcium supplements and active vitamin D analogues but a significant proportion of patients continue to experience severe symptoms requiring repeated emergency admissions. Replacement therapy with synthetic PTH compounds (PTH1-34, Natpara® and PTH1-84, teriparatide, Forsteo®) has been assessed in multicentre trials, but the use of this medication is restricted by costs and concerns related to the risk of development of osteosarcoma. Based on recent case reports of successful allotransplantation of parathyroid tissue between siblings, there is renewed interest in this technique. Data on selection of donors, parathyroid cell preparation before allotransplantation, site and timing of transplantation, need for immunosuppression and long-term outcomes are reviewed. CONCLUSION A prospective trial to assess the efficacy of parathyroid allotransplantation in patients with severely symptomatic protracted post-surgical hypoparathyroidism is warranted.
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The Afirma Xpression Atlas for thyroid nodules and thyroid cancer metastases: Insights to inform clinical decision-making from a fine-needle aspiration sample.
Krane, JF, Cibas, ES, Endo, M, Marqusee, E, Hu, MI, Nasr, CE, Waguespack, SG, Wirth, LJ, Kloos, RT
Cancer cytopathology. 2020;(7):452-459
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Recent analytical and clinical validation of the Afirma Xpression Atlas (XA) demonstrates test reliability and the identification of genomic alterations that may inform patient management. The updated Afirma Genomic Sequencing Classifier and XA reports aim to optimize the understanding of these contributions, including decisions about observation versus surgery, the need for disease‐specific preoperative testing, associated neoplasm types, prognostics, the identification of molecular targets for systemic therapy, and the recognition of potential hereditary syndromes.
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Role of oral calcium supplementation alone or with vitamin D in preventing post-thyroidectomy hypocalcaemia: A meta-analysis.
Xing, T, Hu, Y, Wang, B, Zhu, J
Medicine. 2019;(8):e14455
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BACKGROUND Thyroidectomy is the main intervention for thyroid malignancies and some benign thyroid diseases. Its most common complication is hypocalcaemia, which requires oral or intravenous calcium therapy. The aim of this meta-analysis was to assess the efficacy of routine calcium supplementation with or without vitamin D in preventing hypocalcaemia post-thyroidectomy. METHODS Systematic searches of the PubMed, EMBASE, and Cochrane Library databases were performed. The qualities of the included articles were assessed using the Cochrane risk of bias tool. The studies' qualities of outcomes and strengths of evidence were evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Data analysis was performed using Review Manager 5.3, and odds ratio (ORs) with their 95% confidence intervals (CIs) were computed for dichotomous data. RESULTS Ten randomized controlled trials (RCTs) were included. The combined study recruited 1620 patients (343 men and 1277 women) who underwent total thyroidectomy alone or with neck dissection. Calcium supplementation decreased the risk of transient postoperative hypocalcaemia (OR 0.48 [95% CI, 0.31-0.74]; P < .001) but did not decrease the demand for intravenous supplementation or the rate of permanent hypocalcaemia compared to no treatment. Calcium and vitamin D supplementation significantly reduced the rate of transient hypocalcaemia and the demand for intravenous supplementation compared to either no treatment (OR 0.21 [95% CI, 0.11-0.40]; P < .001 and OR 0.26 [95% CI, 0.10-0.69]; P = .007, respectively) or calcium alone (OR 0.39 [95% CI, 0.18-0.84]; P = .02 and OR 0.18 [95% CI, 0.07-0.47]; P < .001, respectively), but did not decrease the rate of permanent hypocalcaemia. GRADE-based confidence was moderate. CONCLUSION Postoperative calcium supplementation is effective for preventing post-thyroidectomy hypocalcaemia. Calcium plus vitamin D was more effective than calcium alone in preventing postoperative hypocalcaemia and decreasing the demand for intravenous calcium supplementation. Further, well-designed RCTs with larger sample sizes are required to validate our findings.
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American Head and Neck Society Endocrine Section clinical consensus statement: North American quality statements and evidence-based multidisciplinary workflow algorithms for the evaluation and management of thyroid nodules.
Meltzer, CJ, Irish, J, Angelos, P, Busaidy, NL, Davies, L, Dwojak, S, Ferris, RL, Haugen, BR, Harrell, RM, Haymart, MR, et al
Head & neck. 2019;(4):843-856
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BACKGROUND Care for patients with thyroid nodules is complex and multidisciplinary, and research demonstrates variation in care. The objective was to develop clinical guidelines and quality metrics to reduce unwarranted variation and improve quality. METHODS Multidisciplinary expert consensus and modified Delphi approach. Source documents were workflow algorithms from Kaiser Permanente Northern California and Cancer Care of Ontario based on the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. RESULTS A consensus-based, unified preoperative, perioperative, and postoperative workflow was developed for North American use. Twenty-one panelists achieved consensus on 16 statements about workflow-embedded process and outcomes metrics addressing safety, access, appropriateness, efficiency, effectiveness, and patient centeredness of care. CONCLUSION A panel of Canadian and United States experts achieved consensus on workflows and quality metric statements to help reduce unwarranted variation in care, improving overall quality of care for patients diagnosed with thyroid nodules.
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Post-thyroidectomy Hypocalcemia - Risk Factors and Management.
Păduraru, DN, Ion, D, Carsote, M, Andronic, O, Bolocan, A
Chirurgia (Bucharest, Romania : 1990). 2019;(5):564-570
Abstract
The complications of thyroidectomy vary from hypocalcemia and recurrent laryngeal nerve lesions to injury of vocal folds, local hematoma, cysts, granuloma. Post-operative hypocalcemia has an incidence of 1.2-40%. Permanent hyoparathyroidism is registered in 3% of cases. This is a brief narrative review focusing on the levels of calcium after performing a thyroidectomy and the need of calcium supplements under these circumstances. This complication, even it seems rather harmless at first, in fact it represents an important contributor to hospitalization delay and, especially for severe forms, to poor quality of life, including the risk of life threatening episodes. Devascularisation of parathyroid glands in addition to injury or dissection causes hypoparathyroidism. Hypocalcemia risk differs with sex (females have a higher risk), lymph node dissection (it increases the risk), it differs with type of thyroidectomy (larger dissections have a higher risk; also the intervention for recurrent goitre and second intervention for post-operatory bleeding increase the risk of hypocalcemia; while Basedow disease is probably at higher risk than multinodular goitre among benign conditions) and the duration of procedure. Pre-operatory low calcium, parathormon (PTH), 25-hydroxivitamin D increases the risk. The calcium drop rate matters as well: a decrease of 1 mg/dL calcium over 12 hours after surgery is independently correlated with the risk of symptomatic hypocalcemia. Early post-operatory PTH and calcium are best predictors for the need of oral calcium supplements. Routine post-operatory calcium and vitamin D supplementation statistically significant decreases the risk of developing transitory hypocalcemia and acute complications compare to calcium alone supplements or no supplements. In cases of hypoparathyroidism calcitriol is preferred.
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[Risk factors' analysis of transient and permanent hypoparathyroidism after thyroidectomy].
Cocchiara, G, Cajozzo, M, Fazzotta, S, Palumbo, VD, Geraci, G, Maione, C, Buscemi, S, Romano, G, Fatica, F, Spinelli, G, et al
La Clinica terapeutica. 2017;(4):e271-e277
Abstract
AIMS: This review evaluates those main risk factors that can affect patients undergoing thyroidectomy, to reach a better pre- and post-operative management of transient and permanent hypoparathyroidism. DISCUSSION The transient hypoparathyroidism is a potentially severe complication of thyroidectomy, including a wide range of signs and symptoms that persists for a few weeks. The definitive hypoparathyroidism occurs when a medical treatment is necessary over 12 months. Risk factors that may influence the onset of this condition after thyroidectomy include: pre- and post-operative biochemical factors, such as serum calcium levels, vitamin D blood concentrations and intact PTH. Other involved factors could be summarized as follow: female sex, Graves' or thyroid neoplastic diseases, surgeon's dexterity and surgical technique. The medical treatment includes the administration of calcium, vitamin D and magnesium sometimes. CONCLUSIONS Although biological and biochemical factors could be related to iatrogenic hypoparathyroidism, the surgeon's experience and the used surgical technique still maintain a crucial role in the aetiology of this important complication.
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Hyperthyroidism: Diagnosis and Treatment.
Kravets, I
American family physician. 2016;(5):363-70
Abstract
Hyperthyroidism is an excessive concentration of thyroid hormones in tissues caused by increased synthesis of thyroid hormones, excessive release of preformed thyroid hormones, or an endogenous or exogenous extrathyroidal source. The most common causes of an excessive production of thyroid hormones are Graves disease, toxic multinodular goiter, and toxic adenoma. The most common cause of an excessive passive release of thyroid hormones is painless (silent) thyroiditis, although its clinical presentation is the same as with other causes. Hyperthyroidism caused by overproduction of thyroid hormones can be treated with antithyroid medications (methimazole and propylthiouracil), radioactive iodine ablation of the thyroid gland, or surgical thyroidectomy. Radioactive iodine ablation is the most widely used treatment in the United States. The choice of treatment depends on the underlying diagnosis, the presence of contraindications to a particular treatment modality, the severity of hyperthyroidism, and the patient's preference.
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Calcium maelstrom: recalcitrant hypocalcaemia following rapid correction of thyrotoxicosis, exacerbated by pregnancy.
Shin, T, Guerrero, AF
BMJ case reports. 2015
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A 29-year-old pregnant woman with Graves' disease presented with severe persistent hypocalcaemia after thyroidectomy. Six months prior to presentation she was diagnosed with Graves' disease and remained uncontrolled with methimazole. She was confirmed pregnant prior to radioactive iodine ablation (RAI), and underwent total thyroidectomy during her second trimester. After surgery, continuous intravenous calcium infusion was required until delivery of the fetus allowed discontinuation at postoperative day 18, despite oral calcium and calcitriol administration. A total of 38 g of oral and 7.5 g of intravenous elemental calcium was administered. We report an unusual case of recalcitrant hypocalcaemia thought to be due to a combination of postoperative hypoparathyroidism, combined with thyrotoxic osteodystrophy and pregnancy, after surgical correction of Graves' disease. Increased vigilance and early calcium supplementation should be a priority in the management of these patients.
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The Treatment of Well-Differentiated Thyroid Carcinoma.
Paschke, R, Lincke, T, Müller, SP, Kreissl, MC, Dralle, H, Fassnacht, M
Deutsches Arzteblatt international. 2015;(26):452-8
Abstract
BACKGROUND Recent decades have seen a rise in the incidence of well-differentiated (mainly papillary) thyroid carcinoma around the world. In Germany, the age-adjusted incidence of well-differentiated thyroid carcinoma in 2010 was 3.5 per 100 000 men and 8.7 per 100 000 women per year. METHODS This review is based on randomized, controlled trials and multicenter trials on the treatment of well-differentiated thyroid carcinoma that were retrieved by a selective literature search, as well as on three updated guidelines issued in the past two years. RESULTS The recommended extent of surgical resection depends on whether the tumor is classified as low-risk or high-risk, so that papillary microcarcinomas, which carry a highly favorable prognosis, will not be overtreated. More than 90% of localized, well-differentiated thyroid carcinomas can be cured with a combination of surgery and radioactive iodine therapy. Radioactive iodine therapy is also effective in the treatment of well-differentiated thyroid carcinomas with distant metastases, yielding a 10-year survival rate of 90%, as long as there is good iodine uptake and the tumor goes into remission after treatment; otherwise, the 10-year survival rate is only 10%. In the past two years, better treatment options have become available for radioactive-iodine-resistant thyroid carcinoma. Phase 3 studies of two different tyrosine kinase inhibitors have shown that either one can markedly prolong progression-free survival, but not overall survival. Their more common clinically significant side effects are hand-foot syndrome, hypertension, diarrhea, proteinuria, and weight loss. CONCLUSION Slow tumor growth, good resectability, and susceptibility to radioactive iodine therapy lend a favorable prognosis to most cases of well-differentiated thyroid carcinoma. The treatment should be risk-adjusted and interdisciplinary, in accordance with the current treatment guidelines. Even metastatic thyroid carcinoma has a favorable prognosis as long as there is good iodine uptake. The newly available medical treatment options for radioactive-iodine-resistant disease need to be further studied.
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Hypocalcaemia following thyroidectomy unresponsive to oral therapy.
Etheridge, ZC, Schofield, C, Prinsloo, PJ, Sturrock, ND
Hormones (Athens, Greece). 2014;(2):286-9
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Hypocalcaemia due to hypoparathyroidism following thyroidectomy is a relatively common occurrence. Standard treatment is with oral calcium and vitamin D replacement therapy; lack of response to oral therapy is rare. Herein we describe a case of hypoparathyroidism following thyroidectomy unresponsive to oral therapy in a patient with a complex medical history. We consider the potential causes in the context of calcium metabolism including: poor adherence, hungry bone syndrome, malabsorption, vitamin D resistance, bisphosphonate use and functional hypoparathyroidism secondary to magnesium deficiency. Malabsorption due to intestinal hurry was likely to be a contributory factor in this case and very large doses of oral therapy were required to avoid symptomatic hypocalcaemia.