A Prospective Study on Role of Supplemental Oral Calcium and Vitamin D in Prevention of Postthyroidectomy Hypocalcemia.

BACKGROUND: Postoperative transient hypocalcemia is sequelae of total thyroidectomy (TT), which is observed in up to 50% of patients. Routine oral calcium and Vitamin D supplementation have been proposed to prevent symptomatic hypocalcemia preventing morbidity and facilitating early discharge. PATIENTS AND METHODS: A total of 208 patients with nontoxic benign thyroid disorders, undergoing TT, were serially randomized into four groups: Group A (no supplements were given), Group B (oral calcium - 2 g/day given), Group C (calcium and calcitriol - 1 mcg/day are given), and Group D (calcium, calcitriol, and cholecalciferol - 60,000 IU/day are given). Patients were monitored for clinical and biochemical hypocalcemia (serum calcium, [Sr. Ca] <8 mg/dl), along with serum intact parathormone (Sr. PTH) and magnesium 6 h after surgery and Sr. Ca every 24 h. Intravenous (IV) calcium infusion was started, if any of the above four groups exhibit frank hypocalcemia. Patients are followed up with Sr. Ca and Sr. PTH at 3 and 6 months. RESULTS: All groups were age and sex matched. Hypocalcemia was observed in 72/208 (34.61%) cases. Incidence of hypocalcemia was higher in Group A (57.69%) and Group B (50%) compared to Group C (15.38%) and Group D (15.38%). Hypocalcemia necessitating IV calcium occurred in 31/208 (14.90%) patients. IV calcium requirement exceeded in Group A (26.92%) and Group B (23.07%) compared to Group C (5.76%) and Group D (3.84%). There was no statistical difference in basal levels of serum Vitamin D, calcium, magnesium, intact PTH, and 6 h after surgery. Permanent hypoparathyroidism developed in five patients on follow-up. CONCLUSION: Routine postoperative supplementation of oral calcium and Vitamin D will help in the prevention of postthyroidectomy transient hypocalcemia significantly. Preoperative Vitamin D levels do not predict postoperative hypocalcemia.

A Prospective Study on Cardiovascular Dysfunction in Patients with Hyperthyroidism and Its Reversal After Surgical Cure.

BACKGROUND: Cardiovascular dysfunction (CVD) is a major cause of mortality and morbidity in hyperthyroidism. CVD and its reversibility after total thyroidectomy (TT) are not adequately addressed. This prospective case-control study evaluates the effect of hyperthyroidism on myocardium and its reversibility after TT. MATERIALS AND METHODS: Surgical candidates of new onset hyperthyroidism, Group A (n = 41, age < 60 years) was evaluated with 2D Echocardiography, serum n-terminal probrain natriuretic peptide (NT-proBNP) at the time of diagnosis (Point A), after achieving euthyroidism (Point B) with antithyroid drugs, and 3 months after TT (Point C). 20 patients with nontoxic benign thyroid nodules undergoing TT served as controls (Group B). RESULTS: Both groups were age and sex matched. Group A (n = 41) comprises Graves disease (n = 22) and Toxic Multinodular goiter (n = 19). At point A, CVD was evident in 26/41(63.4%), pulmonary hypertension (PHT) in 24/41(58.5%)--mild in 17/41(41.4%) and moderate in 7/41(17%)--dilated cardiomyopathy (DCM) in 8/41(19.5%), heart failure in 4/41(9.7%), and NT-proBNP elevated in 28/41(68.3%). At point B, recovery was observed in PHT 19/26(73.1%), DCM 4/8(50%), heart failure 4/4(100%), NT-proBNP in 3/28(10.7%). At Point C, further improvement occurred in PHT 23/24(95.8%), DCM 7/8(87.5%), heart failure 4/4(100%), and NT-proBNP in 24/28(85.7%). CONCLUSION: Pulmonary hypertension is completely reversible at 3 months after TT and is the most common cardiac event in Hyperthyroidism. Various parameters of CVD improved consistently after surgical cure. NT-proBNP levels correlated well with the severity and duration of CVD and hence can be an objective tool in monitoring of hyperthyroid cardiac dysfunction.

EBSLN and Factors Influencing its Identification and its Safety in Patients Undergoing Total Thyroidectomy: A Study of 456 Cases.

BACKGROUND: The external branch of the superior laryngeal nerve (EBSLN) is at surgical risk during superior thyroid pole ligation during thyroidectomy. Majority of studies have addressed the identification of these nerves and its reported incidence. Very few studies have addressed the relationship of these nerves with the volume of the thyroid gland and presence of toxicity. MATERIALS AND METHODS: A retrospective evaluation of 456 patients who underwent total thyroidectomy were analysed from the prospectively maintained database. The EBSLN was diligently identified and preserved before individual ligation of the superior thyroid pedicle. The nerve was graded as per the Cernea classification (type I, IIa and IIb). Goitres are classified into toxic & non-toxic based on hyperthyroidism, further sub classified as large (>50 cc) and small (≤50 cc) based on volume of each lobe. The grading of EBSLN was correlated with hyperthyroidism and volume of each lobe. RESULTS: In 456 patients (912 nerves), EBSLN was identified in 849/912(93.09%), type I in 156/912(17.1%), type IIa in 522/912(57.23%) and type IIb in 171/912(18.75%). The prevalence of large goitres was 180/912(19.73%).Type IIb nerve was predominantly seen in 161/180(89.4%) of large goitres. Type IIb nerves was more common in toxic 141/372(37.9%) than non-toxic lobes 25/540(5.46%). CONCLUSION: Large goitres are not uncommon in toxic cases. The EBSLN is at highest risk of injury in this subgroup of patients and surgical expertise is essential to identify this entity of EBSLN to perform a safe thyroidectomy.

Evaluation of bone mineral density in thyrotoxicosis.

INTRODUCTION: This project aimed to study the incidence and profile of bone involvement in thyrotoxicosis patients by dual energy X-ray absorptiometry (DEXA) scan and the effect of treatment on the bone mineral density (BMD). METHODS: A total of 50 young patients with a mean age of 29.4 years, diagnosed to have thyrotoxicosis clinically and proven by thyroid function tests, were included in this prospective three-year study conducted at the Madras Medical College and Government General Hospital in Chennai, India. Patients were enrolled if they had bone pain or had elevation of serum alkaline phosphatase. All these patients had a baseline BMD measurement by DEXA scans in the region of the lumbar vertebrae before treatment and the T-score was computed. All other secondary causes of low BMD, like primary hyperparathyroidism, long-term steroid intake, vitamin D deficiency, was ruled out. After definitive management of hyperthyroidism by anti-thyroid drugs and surgery, all the patients with bone involvement had a repeat DEXA scan after one year and the T-score was computed. RESULTS: Out of 50 patients, 46 had bone involvement (92 percent). Based on the World Health Organisation classification, 16 (32 percent) had osteopenia and 30 patients (60 percent) had osteoporosis. After control of thyrotoxicosis, the mean bone mass increased from 0.729 g/sq cm to 0.773 g/sq cm, a statistically significant increase of 0.044 g/sq cm (p-value is less than 0.001) after one year, compared to age- and sex-matched controls. The mean percentage of the bone mass compared to the peak BMD increased from 70.2 percent to 74.2 percent after treatment, an increase of four percent (p-value is less than 0.001). The mean percentage of the bone mass compared to the age-matched BMD increased from 71.2 percent to 75.2 percent after treatment, an increase of four percent (p-value is less than 0.001), all of which were statistically significant. CONCLUSION: Metabolic bone disease should be looked for in all thyrotoxic patients, especially patients complaining of bone pain and those with elevated bone enzymes. DEXA scans offer a convenient, reliable and noninvasive modality for diagnosis and monitoring therapy.