Modification, validation and implementation of a protocol for post-thyroidectomy hypocalcaemia.

Introduction The management of post-thyroidectomy hypocalcaemia should facilitate early discharge, and reduce risks of hypocalcaemia, readmission and treatment related hypercalcaemia. This paper describes the implementation, evaluation and revision a protocol for the optimal management of this condition. Methods Day 1 parathyroid hormone (PTH) measurements in addition to calcium measurements were commenced following review of the unit's outcomes and literature on post-thyroidectomy hypocalcaemia. Outcomes from a three-year cohort of patients undergoing thyroid surgery helped amend this protocol (revision 1) to reduce biochemical tests, stipulate the need, nature and dose of vitamin D/calcium supplements, and encourage early discharge. This was further validated over seven months to assess compliance, episodes of hyper and/or hypocalcaemia after discharge, readmissions and need for treatment changes. Further revisions were made (revision 2) and implemented. Results The temporary and long-term postoperative hypocalcaemia rates were 29.1% and 3.2% respectively. Repeat calcium measurements on the first day altered management in only 1.4% of cases. The revised protocol was adhered to in 90% of cases. One patient had hypocalcaemia (due to non-compliance) and one had hypercalcaemia. Revision 2 involved reducing the dose of calcium. Conclusions This is a good example of a unit protocol for post-thyroidectomy hypocalcaemia being developed and modified on the basis of the literature and local experience. Day 1 PTH and calcium levels determine the need for treatment and frequency of follow-up visits, facilitate early discharge, reduce risk of over and/or undertreatment, and are good indicators of permanent hypocalcaemia.

Does using the WHO surgical checklist improve compliance to venous thromboembolism prophylaxis guidelines?

BACKGROUND: Using the World Health Organisation (WHO) surgical checklist has been shown to improve the safety of patients undergoing surgery. Its effect on the compliance to venous thromboembolism (VTE) guidelines has not been established before. Our objective was to assess if using the WHO checklist improved compliance to VTE prophylaxis guidelines. METHODS: Compliance to NICE VTE guidelines were prospectively assessed in all general surgery patients over two separate audit periods, before and after 6 months of the routine use of the WHO checklist. Correct completion of the checklist was verified. RESULTS: 370 patients (173 [47%] male, 197 [53%] female, mean age 61.6 yrs). Non compliance to NICE VTE guidelines was reduced form 16/233 (6.9%) to 3/137 (2.1%) after introduction of the checklist (p = 0.046 Fisher exact test). Non compliance was reduced in both emergency and elective procedures. CONCLUSIONS: Establishment of the WHO checklist for routine use in all general surgery patients may significantly improve VTE guideline compliance of all general surgery patients.

Transient increases in progesterone in daily and 2-hourly saliva specimens from adolescent girls.

Daily progesterone profiles obtained from saliva specimens from 101 peri- and postmenarcheal girls showed episodic 'spikes' which reached up to 600 pmol/l from baselines of approximately 40 pmol/l. The authenticity of progesterone in the 'spike' specimens was established using gas chromatography-mass spectrometry. 'Spikes' of progesterone occurred in 5.3% of premenarcheal saliva specimens but in only 1-2% of specimens from girls who were 4-6 years postmenarche. Two-hourly specimens from 53 pre- and postmenarcheal girls had 'spike' frequencies similar to those measured in daily specimens.

Quantification of progesterone in human saliva.

A procedure for the quantification of progesterone in saliva has been developed, using gas chromatography/mass spectrometry (GC/MS) with selected ion monitoring of the 3-enol heptafluorobutyrate derivative. (2H2)Progesterone is used as internal standard. The detection limit (c. 10 pg ml-1) is sufficiently low to permit the determination of the steroid in the saliva of adolescent girls. Assessment of the procedure indicated good assay linearity and excellent accuracy in the determination of progesterone added to saliva. Comparison of GC/MS and radioimmunoassay data showed good agreement, substantiating earlier immunoassay evidence for the occurrence of episodic increases in salivary progesterone concentrations in perimenarcheal girls.

Daily salivary progesterone levels in cyclical mastalgia patients and their controls.

Progesterone levels were measured in samples of saliva collected daily throughout the menstrual cycle in patients with pronounced cyclical mastalgia and breast nodularity. A control group matched for age, length of menstrual cycle and parity was also studied. No significant differences in progesterone levels were detected between the two groups for the luteal phase of the cycle. These data indicate that cyclical mastalgia is not associated with significant luteal phase progesterone insufficiency, as demonstrated by salivary levels and, by implication, serum levels of progesterone.

Sub-hourly variations in salivary estriol concentrations in the last trimester of pregnancy.

Sub-hourly variations in salivary estriol were measured in women in the last trimester of pregnancy. The mean and variation of salivary estriol concentrations in specimens collected at 5-min intervals for 30 min were greater on awakening in the morning (when subjects were recumbent and fasting) than in the afternoon. The differences in variation between morning and afternoon serial specimens were eliminated by the omission of the first two specimens collected in the morning. Significant differences between the mean concentrations obtained for morning and afternoon specimens were minimized by use of a recumbent posture for the afternoon specimen collection. The mean estriol concentration of four saliva samples collected at 5-min intervals for 15 min did not differ significantly from the concentration of saliva collected continuously over the subsequent 15 min. For routine estriol monitoring, therefore, samples should be collected over a 15-min period. This ought to be carried out at the same time of day, in the same posture on each occasion, but preferably not in the early morning.

Characterization of profiles of salivary progesterone concentrations during the luteal phase of fertile and subfertile women.

Salivary progesterone concentrations were measured in daily samples collected between 08.00 and 09.00 h throughout the menstrual cycle of women with a history of fertility. The luteal-phase salivary progesterone profiles in these normally menstruating, healthy women were characterized using a computer program based on a cumulative sum procedure. This method of statistical analysis led to the development of a 'progesterone boundary diagram', the inner and outer domains of which distinguished between the profiles of salivary progesterone considered compatible with fertility, and those observed in subfertile women attending an infertility clinic.

Salivary oestriol in normal and abnormal pregnancies.

Profiles of daily salivary oestriol concentrations throughout the third trimester of pregnancy have been constructed for 14 normal and 11 abnormal pregnancies. Day-to-day variations were significantly higher than those reported for unconjugated oestriol in plasma or serum. A sustained decline in salivary oestriol concentrations was observed in one pregnancy in which intrauterine death occurred. Sustained falls were also observed in two pregnancies in which a healthy infant was born at term. In all other patients a normal salivary oestriol profile correlated with a favourable outcome. Salivary oestriol measurements provide similar information to plasma unconjugated oestriol measurements while offering the advantages of a simple, non-invasive sample collection procedure.

Automated continuous-flow radioimmunoassay for salivary estriol.

We have automated a radioimmunoassay for salivary estriol by using the "Southmead" continuous-flow system. The assay, based on a well-validated manual assay, involves a Sepharose-coupled antiserum and an 125I-radioligand. The antibody-bound and free radioligand fractions are separated by on-line filtration. Performance of the automated assay has been reliable during six months of regular use, and compares favorably with that of the manual assay. Drift (0.5 nmol/L per 100 samples) and sample carryover (3%) are acceptable, and the throughput rate is 55 samples per hour. The system is suitable for the assay of the large numbers of samples generated by daily saliva specimen collection in the third trimester of pregnancy.

Influence of sampling time on salivary oestriol concentrations in pregnant women.

Saliva specimens were collected at weekly intervals during the third trimester of 61 uncomplicated pregnancies. Oestriol concentrations, measured in samples collected in the early morning from fasting, recumbent subjects, were used to construct a provisional normal range. This proved to be higher than the corresponding normal range reported from another laboratory applying the same method to samples obtained at random from a different population of ambulant subjects. Interlaboratory variation in the assay of salivary oestriol was not sufficient to account for the difference in normal range. It is concluded that consideration should be given to the timing of sample collection if salivary oestriol concentration is to be monitored as a possible means of assessing fetoplacental function. A normal range for salivary oestriol concentration versus gestational age obtained from women sampled randomly may not be appropriate for monitoring patients with 'at-risk' pregnancies who are normally bed-rested.

Radioimmunoassay for salivary estriol, with use of an 125I radioligand and a solid-phase separation technique.

This simple, rapid radioimmunoassay for salivary unconjugated estriol in the third trimester of pregnancy is based on use of a Sepharose-coupled antiserum and a radioiodinated tracer, and requires only a 15-min incubation. Estriol conjugates are shown not to be present in saliva in significant concentrations; therefore a preliminary extraction is unnecessary. Determinations of unconjugated estriol in matched specimens of plasma and saliva correlate well (r = 0.95). A provisional normal range for 30 weeks to term agrees closely with those reported by others. This assay can give results quickly for the large numbers of specimens generated by weekly or daily sampling regimes.