Hypocalcaemia following thyroidectomy for treatment of Graves' disease: implications for patient management and cost-effectiveness.

BACKGROUND: No consensus exists on optimal treatment for Graves' disease once anti-thyroid medication fails to induce remission. Total thyroidectomy is a more cost-effective treatment than radioactive iodine or life-long anti-thyroid medication, but hypocalcaemia is an important complication, leading to longer hospital admissions and increased prescription costs. This study aimed to compare the relative risk of hypocalcaemia requiring medical treatment for patients with Graves' disease. METHODS: Prospective cohort study of patients undergoing total thyroidectomy for Graves' disease and for multinodular goitre, calculating serum calcium levels 24-hours post-operatively and prescription rates. RESULTS: Mean corrected calcium concentrations 24 hours post-operatively were 2.05 mmol/l for Graves' disease patients and 2.14 mmol/l for multinodular goitre patients (p = 0.003). Biochemical hypocalcaemia developed in 92 per cent (n = 34) of Graves' disease patients and 71 per cent (n = 43) of multinodular goitre patients (p = 0.012). Graves' disease patients were more likely to be prescribed calcium supplementation pre-discharge (p = 0.037). CONCLUSION: Total thyroidectomy for Graves' disease carries an increased risk of hypocalcaemia at 24 hours, and of calcium supplementation pre-discharge. Graves' disease patients should be informed of the increased risk of hypocalcaemia associated with total thyroidectomy, and this risk must be factored into future cost-effectiveness analysis.

Femoral neck fracture: a preventable phenomenon?

The purpose of this paper is to examine the problem of femoral neck fracture in the elderly New Zealand citizen, and to consider the prospects for prevention. Data are drawn chiefly from the Accident Compensation Corporation's claims data base, which has enabled identification of the mechanism of accident associated with such fractures. The data reveal a relative preponderance of femoral neck fracture in females of advanced age. In this group, the typical accident sequence is found to be mundane, 84% of victims falling to the ground without involvement of external agency. It is concluded that the resulting fractures are largely attributable to the heightened vulnerability of the subject as opposed to the magnitude of the blow. Hence, an appropriate intervention strategy should be aimed at strengthening the bone structure of individuals at risk. The practicability of this approach is discussed with particular reference to calcium and hormonal supplements. It is noted that cost and other factors make identification of a high risk sub-population desirable. Modern methods of bone density measurement have enhanced the feasibility of this procedure.