Parathyroid Hormone as a Predictor of Post-Thyroidectomy Hypocalcemia

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"documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Acta Otorrinolaringol Esp. 2011;62:255-64" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4381 "formatos" => array:3 [ "EPUB" => 53 "HTML" => 3205 "PDF" => 1123 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Alterations in Voice, Speech and Swallowing in Patients With Sjögren's Syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "255" "paginaFinal" => "264" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alteraciones de la voz, el habla y la deglución en pacientes con síndrome de Sjögren" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4271 "Ancho" => 3014 "Tamanyo" => 949968 ] ] "descripcion" => array:1 [ "en" => "Spectrogram and oscillogram of patients with alterations in voice and speech. (a) 4 first formants of the vowel /a/, showing irregularity of the morphology with all formants. (b) Broadband spectrogram of the vowel /o/, showing the aperiodic segment. (c) Normal plot in the oscillogram of the trisyllable /pataka/. (d) Abnormal plot in the oscillogram of the trisyllable /pataka/, where the downwards arrows show the segments with rhythm alterations. (e) Broadband spectrogram of the trisyllable /pataka/ analysed in the upper oscillogram, indicating the aperiodic segments." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Laura Daniela Ruiz Allec, Xochiquetzal Hernández López, Juanita Beatriz Arreguín Porras, Regina Velasco Ramos, Julia Cristina Pacheco del Valle, Ángel Israel Pérez García" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Laura Daniela" "apellidos" => "Ruiz Allec" ] 1 => array:2 [ "nombre" => "Xochiquetzal" "apellidos" => "Hernández López" ] 2 => array:2 [ "nombre" => "Juanita Beatriz" "apellidos" => "Arreguín Porras" ] 3 => array:2 [ "nombre" => "Regina" "apellidos" => "Velasco Ramos" ] 4 => array:2 [ "nombre" => "Julia Cristina" "apellidos" => "Pacheco del Valle" ] 5 => array:2 [ "nombre" => "Ángel Israel" "apellidos" => "Pérez García" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001651911000082" "doi" => "10.1016/j.otorri.2010.12.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001651911000082?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173573511000305?idApp=UINPBA00004N" "url" => "/21735735/0000006200000004/v1_201304231458/S2173573511000305/v1_201304231458/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Parathyroid Hormone as a Predictor of Post-Thyroidectomy Hypocalcemia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "265" "paginaFinal" => "273" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Laura Del Río, Alejandro Castro, Ricardo Bernáldez, Antonio Del Palacio, Carolina V. Giráldez, Beatriz Lecumberri, Cristina Álvarez-Escolá, Alberto Fernández-Martínez" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Laura" "apellidos" => "Del Río" "email" => array:1 [ 0 => "lauradelrioarroyo@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Alejandro" "apellidos" => "Castro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Ricardo" "apellidos" => "Bernáldez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Antonio" "apellidos" => "Del Palacio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Carolina V." "apellidos" => "Giráldez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Beatriz" "apellidos" => "Lecumberri" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "Cristina" "apellidos" => "Álvarez-Escolá" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "Alberto" "apellidos" => "Fernández-Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Bioestadística, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Endocrinología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valor predictivo de la paratohormona en la hipocalcemia postiroidectomía" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1472 "Ancho" => 2917 "Tamanyo" => 249420 ] ] "descripcion" => array:1 [ "en" => "Protocol for treatment of hypocalcaemia after thyroidectomy." ] ] ] "textoCompleto" => "IntroductionHypocalcaemia is one of the most common complications of total thyroidectomy. Its incidence in the literature ranges between 1% and 50%. Most authors report an incidence of 20%–30%, with symptoms ranging from numbness to tetany. Postoperative hypocalcaemia is usually temporary, with an incidence of permanent hypocalcaemia of about 2%.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> Although its aetiology is often multifactorial, most cases of hypocalcaemia are due to hyperparathyroidism as a result of the accidental removal, injury or devascularization of the parathyroid glands during surgery. While other possible complications of thyroidectomy, such as recurrent paralysis, laryngeal oedema or cervical haematoma, usually appear within the first 24h after surgery, the nadir of hypocalcaemia typically occurs at 24–48h after surgery. Occasionally, it may be delayed until the fourth postoperative day. This delay in the manifestation of hypocalcaemia is the reason why hospital stay after total thyroidectomy lasts longer than 24h, to prevent possible complications of late-onset hypocalcaemia.Several strategies have been proposed in the literature to diagnose and treat hypocalcaemia. The traditional method, consisting of serializing serum calcium levels during a hospital stay of 48h, is still used in many hospitals around the world,<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> including ours. Some surgeons advocate routine administration of oral calcium and/or vitamin D to all patients<a class="elsevierStyleCrossRef" href="#bib0005">1</a> so as to shorten hospital stay with a minimal risk of hypocalcaemia upon discharge. In recent years, there have been several studies suggesting the determination of postoperative parathyroid hormone (PTH) for early prediction of the risk of hypocalcaemia.<a class="elsevierStyleCrossRefs" href="#bib0010">2,6–9</a>Although many authors advocate using of PTH to predict hypocalcaemia, others recommend abandoning its use.<a class="elsevierStyleCrossRefs" href="#bib0050">10–12</a> Attempting to clarify this controversy, Grodski et al.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> conducted a review of the English literature on the accuracy of PTH in predicting hypocalcaemia after thyroidectomy, the optimal time to determine postoperative PTH and the role of routine use of oral calcium supplements. They found that levels of PTH after thyroidectomy could predict the development of hypocalcaemia, but lacked 100% accuracy. They concluded that, since it is unlikely that patients with a normal postoperative level of PTH develop hypocalcaemia, PTH could be used with caution to plan discharge 24h after surgery in many cases. In addition, PTH determination could be used to assess the desirability of establishing early therapy with calcium and/or vitamin D for patients at risk of developing hypocalcaemia, to reduce its incidence and severity (grade C recommendation).The hypothesis of our study was that, using the determination of intact PTH, patients could be classified into 3 groups:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Patients at minimal risk of hypocalcaemia: could be discharged 24h after surgery, avoiding an unnecessary extension of hospital stay.</li><li class="elsevierStyleListItem" id="lsti0010">2.Patients at high risk of hypocalcaemia: would initiate treatment with calcium supplements before the onset of symptoms, thus preventing the development of a potentially deadly condition.</li><li class="elsevierStyleListItem" id="lsti0015">3.Patients at intermediate risk of hypocalcaemia: would be admitted for 48 h, following the standard procedure for the detection and treatment of hypocalcaemia.</li></ul>There is no consensus in the literature about the cut-off values of serum calcium, intact PTH, and decrease in PTH levels to predict hypocalcaemia. In fact, normal ranges vary depending on each laboratory and each institution must establish its own references for intact PTH and the predictive value of such determination before generalising its use in daily clinical practice. This is the reason why we designed, in collaboration with the Department of Endocrinology and Biochemistry and the Biostatistics Unit, a prospective study to validate the technique and calculate our own reference values.The main objective of this study was to establish the optimal time for sample extraction of intact PTH and the best cut-off points for the decline in PTH levels, to stratify patients according to their risk of developing hypocalcaemia, and act accordingly.MethodsWe recruited all patients who underwent total thyroidectomy in 1 or 2 stages at the ENT Department of our hospital between 1 February 2009 and 1 March 2010. The study was reviewed and approved by the Ethics Committee of the Centre. All participants signed a specific consent prior to their enrolment in the study.The exclusion criteria for patients were:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">1.Preoperative alterations in parathyroid gland function.</li><li class="elsevierStyleListItem" id="lsti0025">2.Severe chronic renal insufficiency (defined as serum creatinine >2mg/dl or creatinine clearance <40ml/min).</li><li class="elsevierStyleListItem" id="lsti0030">3.Diseases or treatments that interfered with calcium homeostasis (bisphosphonates, diuretics, lithium, anticonvulsants, etc.).</li><li class="elsevierStyleListItem" id="lsti0035">4.Lack of any analytical determination from those used in the study.</li></ul>We recorded age, gender, preoperative endocrine diagnosis, type of surgery (total thyroidectomy in 1 or 2 stages), the number of parathyroid glands preserved or transplanted in the operation, the presence of symptoms and signs of hypocalcaemia (Chvostek's and Trousseau's signs) in the postoperative period, the need for administration or not of parenteral or oral calcium supplements, the anatomical pathology and the presence of other complications (recurrent paralysis, seroma, haematoma, etc.).We extracted a sample of preoperative blood after induction of anaesthesia and before starting surgery, to determine baseline levels of total, ionic and corrected ionic calcium and intact PTH. After closing the surgical incision and before awakening the patient, an immediate postoperative sample of total, ionic and corrected ionic calcium and intact PTH was extracted (immediate postoperative measurements). Late postoperative levels of intact PTH were determined hours after surgery (at 8pm if the patient was operated in the morning, or at 8am if the patient was operated on the previous evening). Late postoperative levels of total, ionic and corrected ionic calcium were extracted 8, 12, 24, and 48h after surgery.Intact PTH levels were analysed through immunoassay in an Immulite® 2500 device (Siemens Healthcare Diagnostics) at the Department of Endocrine Biochemistry.We calculated the percentages of immediate and late postoperative decrease of PTH using the following formula:<elsevierMultimedia ident="eq0005"></elsevierMultimedia>Patients who presented hypocalcaemia were treated according to the protocol shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. To determine the onset of treatment with calcium or to plan hospital discharge, PTH levels were not taken into account.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Statistical analysis was performed using SPSS version 12.0 for Windows (Chicago, IL, USA), in collaboration with the biostatistics unit. The level of significance was established at P<.05. We estimated the areas under the corresponding receiver operating characteristic (ROC) curves to calculate and compare the predictive power of the absolute values and percentages of immediate and late postoperative decrease of PTH. The two cut-off points needed to stratify patients were established by analysing the ROC curves, estimating the sensitivity and specificity of each of them.ResultsPopulation StudiedThe population consisted of 108 patients who underwent total thyroidectomy in 1 or 2 stages between February 2009 and March 2010. The ages of the patients are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>. A total of 75.9% were female and 24.1% were male. Their preoperative diagnoses are summarised in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>A total of 91.7% of the patients underwent total thyroidectomy in one stage and 8.3% in two stages. Unilateral or bilateral recurrent dissections were performed in the same operation in 2.8% and 1.9% of cases, respectively; and unilateral or bilateral functional neck dissections were carried out in 3.7% and 0.9%, respectively.Four parathyroid glands were identified in 46.7% of cases, three in 31.8%, two in 19.6% and one in 1.9%. One parathyroid gland was autotransplanted in 7.4% of patients.The results of anatomical–pathological examination of the resected thyroid glands are presented in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.Mean hospital stay was 4.9 days (median 4 days, range 3–44 days). A total of 87 patients (80.6%) did not require calcium treatment, 12 (11.1%) received oral calcium supplements, and 8 (7.4%) received intravenous treatment. One patient developed hypocalcaemia of difficult treatment, requiring an endocrinology consultation.Up to 17 patients (15.9%) presented recurrent paralysis. In all these cases, the paralysis was temporary and vocal cord mobility was recovered between 1 and 4 months after surgery.Two patients (1.9%) presented postoperative haemorrhage that required surgical review and 7 (6.5%) patients presented serohaematoma.Predictive Analysis of HypocalcaemiaOut of the 108 total patients, 26 were not involved in the predictive analysis of hypocalcaemia because they met one of the exclusion criteria outlined above. Therefore, each analysis group (immediate PTH and late PTH) included 82 patients.Considering only the patients included, 83.3% did not require treatment for hypocalcaemia and 16.7% received calcium. This treatment was oral in 9.5% of cases and intravenous in 7.2%.The levels of preoperative total calcium and intact PTH, and the immediate and late postoperative levels of total calcium, intact PTH and decreased intact PTH are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The average time elapsed between surgery and obtaining the late PTH sample was 8.5h, with a range between 4.75 and 22.5h. The Pearson correlation coefficient for the time until determination of late PTH and late postoperative PTH decrease was r: −0.047 (P=.68) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>The area under the ROC curve for the immediate PTH was 0.874; for late PTH, it was 0.932; for immediate postoperative PTH decrease, it was 0.908; and for late PTH decrease, it was 0.961 (all with P<.001) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Consequently, we chose the percentage of late PTH decrease as a predictor of hypocalcaemia after thyroidectomy.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>The maximum specificity while maintaining 100% sensitivity was obtained with a late PTH decrease of 79.01% (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), so we chose a value of 80% as the cut-off point. The point with highest sensitivity while maintaining a specificity of 100% for the development of hypocalcaemia corresponded to a decrease of 98.77% (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), so we determined a cut-off point of 98%.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The contingency table for the stratification of patients using the cut-off points listed above is shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. With these data, we calculated the sensitivity, specificity, predictive values and accuracy of both points. That is to say, 80% to define candidates for early hospital discharge due to their low risk of hypocalcaemia, and 98% to establish which patients would benefit from early treatment with calcium due to for their high risk of developing hypocalcaemia (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). Using this test, 73.2% of patients could have been discharged within 24h after surgery.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionThere are many controversies and many differences in the design of studies on hypocalcaemia and PTH after thyroidectomy.Some series have used rapid determination (intraoperative) of PTH, and others have used intact PTH determination.Lindblom et al.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> reported that, since transient hypoparathyroidism is a major contributing factor for the development of hypocalcaemia after thyroidectomy, low intraoperative Turbo PTH assay levels could predict which patients are at risk of postoperative hypocalcaemia, and thus help to select candidates for early discharge. For those researchers, the capacity of PTH to predict hypocalcaemia was not significantly different from that of conventional monitoring of calcium levels. Other authors<a class="elsevierStyleCrossRefs" href="#bib0010">2,13–18</a> also concluded that intraoperative PTH could predict the risk of suffering hypocalcaemia and could, therefore, be used for early discharge of patients, although different cut-off points were established.Regarding intact PTH, Soon et al.,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Payne et al.,<a class="elsevierStyleCrossRefs" href="#bib0035">7,20,21</a> Lombardi et al.,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Vescan et al.,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> and Scurry et al.,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> concluded that intact PTH determined a number of hours after surgery could predict the development of hypocalcaemia before calcium levels. Again, the cut-off points varied between the different studies, as did the time between the operation and the determination of intact PTH.In our hospital, the determinations of both intraoperative and intact PTH are available. However, given that we do not intend to discharge patients within 24h after surgery due to the risk of developing other complications of thyroidectomy, we choose the determination of intact PTH for its higher efficiency.The timing of PTH sample collection varied among the studies cited. In their review, Grodski and Serpell<a class="elsevierStyleCrossRef" href="#bib0005">1</a> concluded that any time from 10min to several hours after surgery provided equally accurate results in predicting hypocalcaemia (grade C recommendation). Since we obtained a better area under the ROC curve for the late postoperative PTH than for the immediate, we chose the late determination. The time at which the late sample was taken in our study was variable, making it a real parameter, typical of everyday clinical practice. However, we worried that this variability might influence the late PTH decrease values obtained. Consequently, we decided to perform a Pearson correlation to analyse whether the time until the determination had any influence on the results of late PTH decrease. We found no relationship between both parameters.Some of the aforementioned authors used absolute PTH values, while others preferred the percentage decrease in PTH as a predictor of hypocalcaemia. In their review, Grodski and Serpell<a class="elsevierStyleCrossRef" href="#bib0005">1</a> referred that both absolute values and PTH decrease could be used with similar accuracy and that, although similar, the levels varied between institutions. For this reason, each centre must validate its own reference values before using the PTH determination selected, and this was the purpose of our study. We chose the percentage of late PTH decrease instead of the absolute late PTH value because capability of late PTH decrease to predict the development of hypocalcaemia was higher, according to our data. In addition, given the differences between the reference values depending on the analyzer used, a percentage difference between preoperative and postoperative values seemed easier to generalise for its use at other centres than an absolute value.We took an 80% decrease of late PTH as the cut-off point for the selection of candidates for early discharge, as it had the highest specificity with 100% sensitivity: patients with postoperative late PTH decrease less than 80% presented a minimum risk of hypocalcaemia, so they could be discharged within 24h after surgery.In their review, Grodski and Serpell<a class="elsevierStyleCrossRef" href="#bib0005">1</a> concluded that the routine use of oral calcium supplements could reduce the incidence and severity of hypocalcaemia after thyroidectomy (grade B recommendation). We only considered the administration of calcium before the onset of hypocalcaemia for those patients at high risk of developing it, given that we wanted to reduce this group of patients as much as possible, since the unnecessary administration of calcium may delay the recovery of transient parathyroid hypofunction, and this recovery is stimulated in the presence of hypocalcaemia. In order to select those patients who were candidates for early treatment with calcium, we determined the cut-off point for late decrease with the highest sensitivity, and a specificity of 100%. This cut-off point corresponded to a percentage of late PTH decrease greater than or equal to 98%.Using both cut-off points, we stratified our patients into the 3 risk groups outlined above, namely: (1) patients at minimal risk of hypocalcaemia, who could be discharged at 24h; (2) patients with increased risk of hypocalcaemia, who would initiate treatment with calcium supplements before the onset of symptoms; and (3) patients with intermediate risk of hypocalcaemia, who would be admitted for 48h, following the standard procedure for the detection and treatment of hypocalcaemia. We should note that, using these criteria, none of the patients who would have been discharged early would have developed hypocalcaemia. Furthermore, only in one case who would have been treated with calcium before the onset of symptoms would such treatment have been unnecessary, since the patient would have presented hypocalcaemia.The sensitivity and specificity of the cut-off points for late PTH decrease of 80% and 98% determined in our study suggest that it is possible to stratify patients into the 3 risk groups discussed, and act accordingly. A time validation of the model is currently being conducted in order to test its reliability. In the future, we intend to conduct an external validation which allows us to generalize it for other centres.ConclusionsThe decrease in PTH levels is a good predictor of hypocalcaemia, especially if the PTH determination is carried out some hours after surgery. A postoperative late PTH decrease of 80% or more predicts the development of hypocalcaemia with excellent sensitivity and specificity. A late decrease greater than or equal to 98% could be a reliable criterion for initiating treatment with calcium before the onset of symptoms of hypocalcaemia.FinancingGrants for Applied Clinical Research Projects of the Foundation for Biomedical Research, La Paz University Hospital, 2009.Conflict of InterestsThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres94745" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction and objective" 2 => "Material and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec81898" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres94744" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción y objetivos" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec81899" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Population Studied" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Predictive Analysis of Hypocalcaemia" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Financing" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of Interests" ] 11 => array:2 [ "identificador" => "xack35135" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-10-28" "fechaAceptado" => "2011-01-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec81898" "palabras" => array:4 [ 0 => "Parathyroid hormone (parathormone)" 1 => "Predictor" 2 => "Hypocalcemia" 3 => "Thyroidectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec81899" "palabras" => array:4 [ 0 => "Paratohormona" 1 => "Predictor" 2 => "Hipocalcemia" 3 => "Tiroidectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Introduction and objectiveThe 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 methodsEighty-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. ResultsTreatment 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 24h 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%). ConclusionsThe 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." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Introducción y objetivosEl riesgo de hipocalcemia es el motivo para prolongar la hospitalización de los pacientes intervenidos de tiroidectomía. Nos planteamos validar la determinación de paratohormona intacta para predecir el desarrollo de hipocalcemia. Material y métodosSe realizó un estudio prospectivo en 82 pacientes intervenidos de tiroidectomía total entre febrero de 2009 y marzo de 2010 para establecer el momento de la determinación y el punto de corte de paratohormona más predictivos de hipocalcemia. Los pacientes con condiciones que pudieran interferir con la homeostasis del calcio fueron excluidos. Se determinaron la paratohormona y los niveles de calcio séricos preoperatoriamente, en el postoperatorio inmediato y en el tardío. ResultadosEl 16,7% de los pacientes presentaron hipocalcemia. La disminución tardía de paratohormona demostró ser la prueba más precisa para detectar hipocalcemia. El punto de corte para seleccionar candidatos al alta precoz se estableció en una disminución del 80%, con una sensibilidad del 100% (IC95%: 77,2-100%) y una especificidad del 87% (IC95%: 77-93%). Empleando esta prueba, el 73,2% de los pacientes podrían haber recibido el alta a las 24h de la cirugía. Se tomó como punto de corte para establecer candidatos a tratamiento precoz con calcio una disminución de la paratohormona del 98%, la especificidad fue del 98,6% (IC95%: 92,2-99,7%). ConclusionesLa disminución tardía de paratohormona es un buen predictor de hipocalcemia postiroidectomía, que permite estratificar a los pacientes en tres grupos según su riesgo de hipocalcemia usando dos puntos de corte. El punto de corte del 80% presenta una sensibilidad y especificidad excelentes para seleccionar candidatos al alta hospitalaria precoz. El punto de corte del 98% presenta una alta especificidad para seleccionar candidatos a tratamiento precoz con calcio." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Del Río L, et al. Valor predictivo de la paratohormona en la hipocalcemia postiroidectomía. Acta Otorrinolaringol Esp. 2011;62:265-73." ] ] "multimedia" => array:10 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1472 "Ancho" => 2917 "Tamanyo" => 249420 ] ] "descripcion" => array:1 [ "en" => "Protocol for treatment of hypocalcaemia after thyroidectomy." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1979 "Ancho" => 2486 "Tamanyo" => 126578 ] ] "descripcion" => array:1 [ "en" => "Age histogram of the 108 patients operated on." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1465 "Ancho" => 2812 "Tamanyo" => 205645 ] ] "descripcion" => array:1 [ "en" => "Preoperative and anatomical–pathological diagnoses of the 108 patients undergoing surgery. Ca, carcinoma." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1625 "Ancho" => 2097 "Tamanyo" => 124091 ] ] "descripcion" => array:1 [ "en" => "Pearson's correlation for time until determination of late PTH and postoperative late PTH decline. iPTH, intact parathyroid hormone." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 3062 "Ancho" => 2882 "Tamanyo" => 323215 ] ] "descripcion" => array:1 [ "en" => "ROC curves for absolute values and percentages of postoperative immediate and late PTH decrease. ABC, area below the curve; iPTH, intact parathyroid hormone; GS5% glucose serum at 5%." ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Dec, decrease; iPTH, intact parathyroid hormone." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Preoperative</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Immediate Postoperative</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Late Postoperative</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Calcium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">iPTH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Calcium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">iPTH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">% Dec. iPTH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Calcium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">iPTH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">% Dec. iPTH \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−47.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−37.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−60.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−50.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Typical deviation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62.80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−99.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−99.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maximum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">222 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">117 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">157.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">267 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">307.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179572.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Preoperative and Postoperative Levels of Immediate and Late Calcium, Parathyroid Hormone and Parathyroid Hormone Decrease." ] ] 6 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Dec, decrease; iPTH, intact parathyroid hormone; Spe, specificity; Sen, sensitivity." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">% Dec. late iPTH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">1 Spe \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−100.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−98.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−98.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−98.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−97.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−97.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−97.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−96.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−96.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−96.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−94.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−92.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−91.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−90.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−89.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−86.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.07 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−84.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−83.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−83.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−82.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−81.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−79.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">−76.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179574.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Sensitivity and Specificity of Different Cut-Off Points of the Decline in Late Parathyroid Hormone." ] ] 7 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Hypocalcaemia Treated</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (73.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (73.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Observation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (9.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (12.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (22%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Early treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (3.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (4.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69 (84.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (15.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82 (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179573.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Contingency Table for Stratification of Patients Using the Cut-Off Points of 80% and 98% for Late Intact Parathyroid Hormone Decrease." ] ] 8 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "CI, confidence interval; NPV, negative predictive value; PPV, positive predictive value." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">80% Cut-Off (Discharge)</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">98% Cut-Off (Early Treatment)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sensitivity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77%–100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8%–50% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Specificity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77%–93% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92%–100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39%–77% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30%–95% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94%–100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78%–93% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Accuracy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80%–94% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78%–92% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179571.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Sensitivity, Specificity, Predictive Values and Accuracy of the Selected Cut-Off Points for Late Parathyroid Hormone Decrease." ] ] 9 => array:5 [ "identificador" => "eq0005" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "(PTHpostop−PTHproep)×100PTHproep" "Fichero" => "si1.jpeg" "Tamanyo" => 2748 "Alto" => 40 "Ancho" => 201 ] ] ] "bibliografia" => array:2 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Without their efforts and dedication, this work would not exist." ] ] ] "idiomaDefecto" => "en" "url" => "/21735735/0000006200000004/v1_201304231458/S2173573511000251/v1_201304231458/en/main.assets" "Apartado" => array:4 [ "identificador" => "5871" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735735/0000006200000004/v1_201304231458/S2173573511000251/v1_201304231458/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173573511000251?idApp=UINPBA00004N"]

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Original article

Parathyroid Hormone as a Predictor of Post-Thyroidectomy Hypocalcemia

Valor predictivo de la paratohormona en la hipocalcemia postiroidectomía

Laura Del Ríoa,

Corresponding author

lauradelrioarroyo@gmail.com

Corresponding author.

, Alejandro Castroa, Ricardo Bernáldeza, Antonio Del Palacioa, Carolina V. Giráldezb, Beatriz Lecumberric, Cristina Álvarez-Escolác, Alberto Fernández-Martínezc

a Servicio de Otorrinolaringología, Hospital Universitario La Paz, Madrid, Spain

b Departamento de Bioestadística, Hospital Universitario La Paz, Madrid, Spain

c Servicio de Endocrinología, Hospital Universitario La Paz, Madrid, Spain

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        "titulo" => "Valor predictivo de la paratohormona en la hipocalcemia postiroidectom&#237;a"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Protocol for treatment of hypocalcaemia after thyroidectomy&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hypocalcaemia is one of the most common complications of total thyroidectomy&#46; Its incidence in the literature ranges between 1&#37; and 50&#37;&#46; Most authors report an incidence of 20&#37;&#8211;30&#37;&#44; with symptoms ranging from numbness to tetany&#46; Postoperative hypocalcaemia is usually temporary&#44; with an incidence of permanent hypocalcaemia of about 2&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Although its aetiology is often multifactorial&#44; most cases of hypocalcaemia are due to hyperparathyroidism as a result of the accidental removal&#44; injury or devascularization of the parathyroid glands during surgery&#46; While other possible complications of thyroidectomy&#44; such as recurrent paralysis&#44; laryngeal oedema or cervical haematoma&#44; usually appear within the first 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#44; the nadir of hypocalcaemia typically occurs at 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h after surgery&#46; Occasionally&#44; it may be delayed until the fourth postoperative day&#46; This delay in the manifestation of hypocalcaemia is the reason why hospital stay after total thyroidectomy lasts longer than 24<span class="elsevierStyleHsp" style=""></span>h&#44; to prevent possible complications of late-onset hypocalcaemia&#46;Several strategies have been proposed in the literature to diagnose and treat hypocalcaemia&#46; The traditional method&#44; consisting of serializing serum calcium levels during a hospital stay of 48<span class="elsevierStyleHsp" style=""></span>h&#44; is still used in many hospitals around the world&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> including ours&#46; Some surgeons advocate routine administration of oral calcium and&#47;or vitamin D to all patients<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> so as to shorten hospital stay with a minimal risk of hypocalcaemia upon discharge&#46; In recent years&#44; there have been several studies suggesting the determination of postoperative parathyroid hormone &#40;PTH&#41; for early prediction of the risk of hypocalcaemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#8211;9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although many authors advocate using of PTH to predict hypocalcaemia&#44; others recommend abandoning its use&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> Attempting to clarify this controversy&#44; Grodski et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> conducted a review of the English literature on the accuracy of PTH in predicting hypocalcaemia after thyroidectomy&#44; the optimal time to determine postoperative PTH and the role of routine use of oral calcium supplements&#46; They found that levels of PTH after thyroidectomy could predict the development of hypocalcaemia&#44; but lacked 100&#37; accuracy&#46; They concluded that&#44; since it is unlikely that patients with a normal postoperative level of PTH develop hypocalcaemia&#44; PTH could be used with caution to plan discharge 24<span class="elsevierStyleHsp" style=""></span>h after surgery in many cases&#46; In addition&#44; PTH determination could be used to assess the desirability of establishing early therapy with calcium and&#47;or vitamin D for patients at risk of developing hypocalcaemia&#44; to reduce its incidence and severity &#40;grade C recommendation&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The hypothesis of our study was that&#44; using the determination of intact PTH&#44; patients could be classified into 3 groups&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patients at minimal risk of hypocalcaemia&#58;</span> could be discharged 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#44; avoiding an unnecessary extension of hospital stay&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patients at high risk of hypocalcaemia&#58;</span> would initiate treatment with calcium supplements before the onset of symptoms&#44; thus preventing the development of a potentially deadly condition&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patients at intermediate risk of hypocalcaemia&#58;</span> would be admitted for 48 h&#44; following the standard procedure for the detection and treatment of hypocalcaemia&#46;</p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">There is no consensus in the literature about the cut-off values of serum calcium&#44; intact PTH&#44; and decrease in PTH levels to predict hypocalcaemia&#46; In fact&#44; normal ranges vary depending on each laboratory and each institution must establish its own references for intact PTH and the predictive value of such determination before generalising its use in daily clinical practice&#46; This is the reason why we designed&#44; in collaboration with the Department of Endocrinology and Biochemistry and the Biostatistics Unit&#44; a prospective study to validate the technique and calculate our own reference values&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The main objective of this study was to establish the optimal time for sample extraction of intact PTH and the best cut-off points for the decline in PTH levels&#44; to stratify patients according to their risk of developing hypocalcaemia&#44; and act accordingly&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">We recruited all patients who underwent total thyroidectomy in 1 or 2 stages at the ENT Department of our hospital between 1 February 2009 and 1 March 2010&#46; The study was reviewed and approved by the Ethics Committee of the Centre&#46; All participants signed a specific consent prior to their enrolment in the study&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The exclusion criteria for patients were&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Preoperative alterations in parathyroid gland function&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Severe chronic renal insufficiency &#40;defined as serum creatinine &#62;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl or creatinine clearance &#60;40<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Diseases or treatments that interfered with calcium homeostasis &#40;bisphosphonates&#44; diuretics&#44; lithium&#44; anticonvulsants&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Lack of any analytical determination from those used in the study&#46;</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">We recorded age&#44; gender&#44; preoperative endocrine diagnosis&#44; type of surgery &#40;total thyroidectomy in 1 or 2 stages&#41;&#44; the number of parathyroid glands preserved or transplanted in the operation&#44; the presence of symptoms and signs of hypocalcaemia &#40;Chvostek&#39;s and Trousseau&#39;s signs&#41; in the postoperative period&#44; the need for administration or not of parenteral or oral calcium supplements&#44; the anatomical pathology and the presence of other complications &#40;recurrent paralysis&#44; seroma&#44; haematoma&#44; etc&#46;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We extracted a sample of preoperative blood after induction of anaesthesia and before starting surgery&#44; to determine baseline levels of total&#44; ionic and corrected ionic calcium and intact PTH&#46; After closing the surgical incision and before awakening the patient&#44; an immediate postoperative sample of total&#44; ionic and corrected ionic calcium and intact PTH was extracted &#40;immediate postoperative measurements&#41;&#46; Late postoperative levels of intact PTH were determined hours after surgery &#40;at 8<span class="elsevierStyleHsp" style=""></span>pm if the patient was operated in the morning&#44; or at 8<span class="elsevierStyleHsp" style=""></span>am if the patient was operated on the previous evening&#41;&#46; Late postoperative levels of total&#44; ionic and corrected ionic calcium were extracted 8&#44; 12&#44; 24&#44; and 48<span class="elsevierStyleHsp" style=""></span>h after surgery&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Intact PTH levels were analysed through immunoassay in an Immulite<span class="elsevierStyleSup">&#174;</span> 2500 device &#40;Siemens Healthcare Diagnostics&#41; at the Department of Endocrine Biochemistry&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">We calculated the percentages of immediate and late postoperative decrease of PTH using the following formula&#58;<elsevierMultimedia ident="eq0005"></elsevierMultimedia></p><p id="par0245" class="elsevierStylePara elsevierViewall">Patients who presented hypocalcaemia were treated according to the protocol shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; To determine the onset of treatment with calcium or to plan hospital discharge&#44; PTH levels were not taken into account&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using SPSS version 12&#46;0 for Windows &#40;Chicago&#44; IL&#44; USA&#41;&#44; in collaboration with the biostatistics unit&#46; The level of significance was established at <span class="elsevierStyleItalic">P</span>&#60;&#46;05&#46; We estimated the areas under the corresponding receiver operating characteristic &#40;ROC&#41; curves to calculate and compare the predictive power of the absolute values and percentages of immediate and late postoperative decrease of PTH&#46; The two cut-off points needed to stratify patients were established by analysing the ROC curves&#44; estimating the sensitivity and specificity of each of them&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Population Studied</span><p id="par0100" class="elsevierStylePara elsevierViewall">The population consisted of 108 patients who underwent total thyroidectomy in 1 or 2 stages between February 2009 and March 2010&#46; The ages of the patients are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; A total of 75&#46;9&#37; were female and 24&#46;1&#37; were male&#46; Their preoperative diagnoses are summarised in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">A total of 91&#46;7&#37; of the patients underwent total thyroidectomy in one stage and 8&#46;3&#37; in two stages&#46; Unilateral or bilateral recurrent dissections were performed in the same operation in 2&#46;8&#37; and 1&#46;9&#37; of cases&#44; respectively&#59; and unilateral or bilateral functional neck dissections were carried out in 3&#46;7&#37; and 0&#46;9&#37;&#44; respectively&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Four parathyroid glands were identified in 46&#46;7&#37; of cases&#44; three in 31&#46;8&#37;&#44; two in 19&#46;6&#37; and one in 1&#46;9&#37;&#46; One parathyroid gland was autotransplanted in 7&#46;4&#37; of patients&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The results of anatomical&#8211;pathological examination of the resected thyroid glands are presented in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Mean hospital stay was 4&#46;9 days &#40;median 4 days&#44; range 3&#8211;44 days&#41;&#46; A total of 87 patients &#40;80&#46;6&#37;&#41; did not require calcium treatment&#44; 12 &#40;11&#46;1&#37;&#41; received oral calcium supplements&#44; and 8 &#40;7&#46;4&#37;&#41; received intravenous treatment&#46; One patient developed hypocalcaemia of difficult treatment&#44; requiring an endocrinology consultation&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Up to 17 patients &#40;15&#46;9&#37;&#41; presented recurrent paralysis&#46; In all these cases&#44; the paralysis was temporary and vocal cord mobility was recovered between 1 and 4 months after surgery&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Two patients &#40;1&#46;9&#37;&#41; presented postoperative haemorrhage that required surgical review and 7 &#40;6&#46;5&#37;&#41; patients presented serohaematoma&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Predictive Analysis of Hypocalcaemia</span><p id="par0135" class="elsevierStylePara elsevierViewall">Out of the 108 total patients&#44; 26 were not involved in the predictive analysis of hypocalcaemia because they met one of the exclusion criteria outlined above&#46; Therefore&#44; each analysis group &#40;immediate PTH and late PTH&#41; included 82 patients&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Considering only the patients included&#44; 83&#46;3&#37; did not require treatment for hypocalcaemia and 16&#46;7&#37; received calcium&#46; This treatment was oral in 9&#46;5&#37; of cases and intravenous in 7&#46;2&#37;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The levels of preoperative total calcium and intact PTH&#44; and the immediate and late postoperative levels of total calcium&#44; intact PTH and decreased intact PTH are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">The average time elapsed between surgery and obtaining the late PTH sample was 8&#46;5<span class="elsevierStyleHsp" style=""></span>h&#44; with a range between 4&#46;75 and 22&#46;5<span class="elsevierStyleHsp" style=""></span>h&#46; The Pearson correlation coefficient for the time until determination of late PTH and late postoperative PTH decrease was <span class="elsevierStyleItalic">r</span>&#58; &#8722;0&#46;047 &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;68&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">The area under the ROC curve for the immediate PTH was 0&#46;874&#59; for late PTH&#44; it was 0&#46;932&#59; for immediate postoperative PTH decrease&#44; it was 0&#46;908&#59; and for late PTH decrease&#44; it was 0&#46;961 &#40;all with <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Consequently&#44; we chose the percentage of late PTH decrease as a predictor of hypocalcaemia after thyroidectomy&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">The maximum specificity while maintaining 100&#37; sensitivity was obtained with a late PTH decrease of 79&#46;01&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; so we chose a value of 80&#37; as the cut-off point&#46; The point with highest sensitivity while maintaining a specificity of 100&#37; for the development of hypocalcaemia corresponded to a decrease of 98&#46;77&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; so we determined a cut-off point of 98&#37;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The contingency table for the stratification of patients using the cut-off points listed above is shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; With these data&#44; we calculated the sensitivity&#44; specificity&#44; predictive values and accuracy of both points&#46; That is to say&#44; 80&#37; to define candidates for early hospital discharge due to their low risk of hypocalcaemia&#44; and 98&#37; to establish which patients would benefit from early treatment with calcium due to for their high risk of developing hypocalcaemia &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Using this test&#44; 73&#46;2&#37; of patients could have been discharged within 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0170" class="elsevierStylePara elsevierViewall">There are many controversies and many differences in the design of studies on hypocalcaemia and PTH after thyroidectomy&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Some series have used rapid determination &#40;intraoperative&#41; of PTH&#44; and others have used intact PTH determination&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Lindblom et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> reported that&#44; since transient hypoparathyroidism is a major contributing factor for the development of hypocalcaemia after thyroidectomy&#44; low intraoperative Turbo PTH assay levels could predict which patients are at risk of postoperative hypocalcaemia&#44; and thus help to select candidates for early discharge&#46; For those researchers&#44; the capacity of PTH to predict hypocalcaemia was not significantly different from that of conventional monitoring of calcium levels&#46; Other authors<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;13&#8211;18</span></a> also concluded that intraoperative PTH could predict the risk of suffering hypocalcaemia and could&#44; therefore&#44; be used for early discharge of patients&#44; although different cut-off points were established&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Regarding intact PTH&#44; Soon et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Payne et al&#46;&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;20&#44;21</span></a> Lombardi et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Vescan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and Scurry et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> concluded that intact PTH determined a number of hours after surgery could predict the development of hypocalcaemia before calcium levels&#46; Again&#44; the cut-off points varied between the different studies&#44; as did the time between the operation and the determination of intact PTH&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In our hospital&#44; the determinations of both intraoperative and intact PTH are available&#46; However&#44; given that we do not intend to discharge patients within 24<span class="elsevierStyleHsp" style=""></span>h after surgery due to the risk of developing other complications of thyroidectomy&#44; we choose the determination of intact PTH for its higher efficiency&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The timing of PTH sample collection varied among the studies cited&#46; In their review&#44; Grodski and Serpell<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> concluded that any time from 10<span class="elsevierStyleHsp" style=""></span>min to several hours after surgery provided equally accurate results in predicting hypocalcaemia &#40;grade C recommendation&#41;&#46; Since we obtained a better area under the ROC curve for the late postoperative PTH than for the immediate&#44; we chose the late determination&#46; The time at which the late sample was taken in our study was variable&#44; making it a real parameter&#44; typical of everyday clinical practice&#46; However&#44; we worried that this variability might influence the late PTH decrease values obtained&#46; Consequently&#44; we decided to perform a Pearson correlation to analyse whether the time until the determination had any influence on the results of late PTH decrease&#46; We found no relationship between both parameters&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Some of the aforementioned authors used absolute PTH values&#44; while others preferred the percentage decrease in PTH as a predictor of hypocalcaemia&#46; In their review&#44; Grodski and Serpell<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> referred that both absolute values and PTH decrease could be used with similar accuracy and that&#44; although similar&#44; the levels varied between institutions&#46; For this reason&#44; each centre must validate its own reference values before using the PTH determination selected&#44; and this was the purpose of our study&#46; We chose the percentage of late PTH decrease instead of the absolute late PTH value because capability of late PTH decrease to predict the development of hypocalcaemia was higher&#44; according to our data&#46; In addition&#44; given the differences between the reference values depending on the analyzer used&#44; a percentage difference between preoperative and postoperative values seemed easier to generalise for its use at other centres than an absolute value&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">We took an 80&#37; decrease of late PTH as the cut-off point for the selection of candidates for early discharge&#44; as it had the highest specificity with 100&#37; sensitivity&#58; patients with postoperative late PTH decrease less than 80&#37; presented a minimum risk of hypocalcaemia&#44; so they could be discharged within 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In their review&#44; Grodski and Serpell<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> concluded that the routine use of oral calcium supplements could reduce the incidence and severity of hypocalcaemia after thyroidectomy &#40;grade B recommendation&#41;&#46; We only considered the administration of calcium before the onset of hypocalcaemia for those patients at high risk of developing it&#44; given that we wanted to reduce this group of patients as much as possible&#44; since the unnecessary administration of calcium may delay the recovery of transient parathyroid hypofunction&#44; and this recovery is stimulated in the presence of hypocalcaemia&#46; In order to select those patients who were candidates for early treatment with calcium&#44; we determined the cut-off point for late decrease with the highest sensitivity&#44; and a specificity of 100&#37;&#46; This cut-off point corresponded to a percentage of late PTH decrease greater than or equal to 98&#37;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Using both cut-off points&#44; we stratified our patients into the 3 risk groups outlined above&#44; namely&#58; &#40;1&#41; patients at minimal risk of hypocalcaemia&#44; who could be discharged at 24<span class="elsevierStyleHsp" style=""></span>h&#59; &#40;2&#41; patients with increased risk of hypocalcaemia&#44; who would initiate treatment with calcium supplements before the onset of symptoms&#59; and &#40;3&#41; patients with intermediate risk of hypocalcaemia&#44; who would be admitted for 48<span class="elsevierStyleHsp" style=""></span>h&#44; following the standard procedure for the detection and treatment of hypocalcaemia&#46; We should note that&#44; using these criteria&#44; none of the patients who would have been discharged early would have developed hypocalcaemia&#46; Furthermore&#44; only in one case who would have been treated with calcium before the onset of symptoms would such treatment have been unnecessary&#44; since the patient would have presented hypocalcaemia&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The sensitivity and specificity of the cut-off points for late PTH decrease of 80&#37; and 98&#37; determined in our study suggest that it is possible to stratify patients into the 3 risk groups discussed&#44; and act accordingly&#46; A time validation of the model is currently being conducted in order to test its reliability&#46; In the future&#44; we intend to conduct an external validation which allows us to generalize it for other centres&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0225" class="elsevierStylePara elsevierViewall">The decrease in PTH levels is a good predictor of hypocalcaemia&#44; especially if the PTH determination is carried out some hours after surgery&#46; A postoperative late PTH decrease of 80&#37; or more predicts the development of hypocalcaemia with excellent sensitivity and specificity&#46; A late decrease greater than or equal to 98&#37; could be a reliable criterion for initiating treatment with calcium before the onset of symptoms of hypocalcaemia&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Financing</span><p id="par0230" class="elsevierStylePara elsevierViewall">Grants for Applied Clinical Research Projects of the Foundation for <span class="elsevierStyleGrantSponsor">Biomedical Research&#44; La Paz University Hospital</span>&#44; 2009&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interests</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => array:5 [
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            1 => "Introducci&#243;n y objetivos"
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              "titulo" => "Population Studied"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Predictive Analysis of Hypocalcaemia"
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          "titulo" => "Discussion"
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          "identificador" => "sec0040"
          "titulo" => "Financing"
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          "identificador" => "sec0045"
          "titulo" => "Conflict of Interests"
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          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2010-10-28"
    "fechaAceptado" => "2011-01-17"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec81898"
          "palabras" => array:4 [
            0 => "Parathyroid hormone &#40;parathormone&#41;"
            1 => "Predictor"
            2 => "Hypocalcemia"
            3 => "Thyroidectomy"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec81899"
          "palabras" => array:4 [
            0 => "Paratohormona"
            1 => "Predictor"
            2 => "Hipocalcemia"
            3 => "Tiroidectom&#237;a"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The risk of developing hypocalcemia is the reason for prolonged hospitalisation after total thyroidectomy&#46; The objective of this study was to validate parathyroid hormone measurement for predicting post-thyroidectomy hypocalcemia&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">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&#46; Patients with any condition that could interfere with calcium homeostasis were excluded from the survey&#46; Parathyroid hormone and serum calcium levels were determined preoperatively&#44; immediately after surgery and a number of hours later&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Treatment for hypocalcemia was required in 16&#46;7&#37; of patients&#46; A percent of delayed decrease in parathyroid hormone was chosen as the best measurement to predict hypocalcemia&#46; An 80&#37; or higher decrease in delayed parathyroid hormone levels had 100&#37; sensitivity &#40;95&#37; CI&#58; 77&#46;2&#37;&#8211;100&#37;&#41; and 87&#37; specificity &#40;95&#37; CI&#58; 77&#37;&#8211;93&#37;&#41; for selecting patients for early discharge&#46; Using this test&#44; 73&#46;2&#37; of the patients could have been discharged 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#46; A 98&#37; decrease in delayed parathyroid hormone levels could select candidates for early calcium replacement with 98&#46;6&#37; specificity &#40;95&#37; CI&#58; 92&#46;2&#37;&#8211;99&#46;7&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The decrease in postoperative delayed parathyroid hormone levels is a good predictor of post-thyroidectomy hypocalcemia&#46; A decrease of 80&#37; or more in delayed parathyroid hormone level is a test with excellent sensibility and specificity for selecting candidates for early discharge&#46; The 98&#37; cutoff point has high specificity for selecting patients for early calcium replacement&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El riesgo de hipocalcemia es el motivo para prolongar la hospitalizaci&#243;n de los pacientes intervenidos de tiroidectom&#237;a&#46; Nos planteamos validar la determinaci&#243;n de paratohormona intacta para predecir el desarrollo de hipocalcemia&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio prospectivo en 82 pacientes intervenidos de tiroidectom&#237;a total entre febrero de 2009 y marzo de 2010 para establecer el momento de la determinaci&#243;n y el punto de corte de paratohormona m&#225;s predictivos de hipocalcemia&#46; Los pacientes con condiciones que pudieran interferir con la homeostasis del calcio fueron excluidos&#46; Se determinaron la paratohormona y los niveles de calcio s&#233;ricos preoperatoriamente&#44; en el postoperatorio inmediato y en el tard&#237;o&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El 16&#44;7&#37; de los pacientes presentaron hipocalcemia&#46; La disminuci&#243;n tard&#237;a de paratohormona demostr&#243; ser la prueba m&#225;s precisa para detectar hipocalcemia&#46; El punto de corte para seleccionar candidatos al alta precoz se estableci&#243; en una disminuci&#243;n del 80&#37;&#44; con una sensibilidad del 100&#37; &#40;IC95&#37;&#58; 77&#44;2-100&#37;&#41; y una especificidad del 87&#37; &#40;IC95&#37;&#58; 77-93&#37;&#41;&#46; Empleando esta prueba&#44; el 73&#44;2&#37; de los pacientes podr&#237;an haber recibido el alta a las 24<span class="elsevierStyleHsp" style=""></span>h de la cirug&#237;a&#46; Se tom&#243; como punto de corte para establecer candidatos a tratamiento precoz con calcio una disminuci&#243;n de la paratohormona del 98&#37;&#44; la especificidad fue del 98&#44;6&#37; &#40;IC95&#37;&#58; 92&#44;2-99&#44;7&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La disminuci&#243;n tard&#237;a de paratohormona es un buen predictor de hipocalcemia postiroidectom&#237;a&#44; que permite estratificar a los pacientes en tres grupos seg&#250;n su riesgo de hipocalcemia usando dos puntos de corte&#46; El punto de corte del 80&#37; presenta una sensibilidad y especificidad excelentes para seleccionar candidatos al alta hospitalaria precoz&#46; El punto de corte del 98&#37; presenta una alta especificidad para seleccionar candidatos a tratamiento precoz con calcio&#46;</p>"
      ]
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Del R&#237;o L&#44; et al&#46; Valor predictivo de la paratohormona en la hipocalcemia postiroidectom&#237;a&#46; Acta Otorrinolaringol Esp&#46; 2011&#59;62&#58;265-73&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Preoperative and anatomical&#8211;pathological diagnoses of the 108 patients undergoing surgery&#46; Ca&#44; carcinoma&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Pearson&#39;s correlation for time until determination of late PTH and postoperative late PTH decline&#46; iPTH&#44; intact parathyroid hormone&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ROC curves for absolute values and percentages of postoperative immediate and late PTH decrease&#46; ABC&#44; area below the curve&#59; iPTH&#44; intact parathyroid hormone&#59; GS5&#37; glucose serum at 5&#37;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Preoperative</td><td class="td" title="\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Immediate Postoperative</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Late Postoperative</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Calcium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">iPTH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Calcium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">iPTH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#37; Dec&#46; iPTH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Calcium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">iPTH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#37; Dec&#46; iPTH&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t">60 &#40;73&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Early treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;1&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69 &#40;84&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Contingency Table for Stratification of Patients Using the Cut-Off Points of 80&#37; and 98&#37; for Late Intact Parathyroid Hormone Decrease&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">94&#37;&#8211;100&#37;&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0240" class="elsevierStylePara elsevierViewall">We thank the ENT residents at La Paz Hospital&#44; Javier Galindo&#44; Agueda Diaz-Anad&#243;n&#44; Isabel S&#225;nchez-Cuadrado and &#193;lvaro de Arriba&#44; for their invaluable assistance in collecting samples at the beginning and end of each operation&#46; Without their efforts and dedication&#44; this work would not exist&#46;</p>"
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Article information

ISSN: 21735735
Original language: English

DOI:10.1016/j.otoeng.2011.01.002

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Year/Month	Html	Pdf	Total

2023 March	4	0	4
2021 March	0	3	3
2021 January	0	2	2
2020 December	0	2	2
2020 November	0	3	3
2020 October	0	1	1
2020 July	0	1	1
2020 March	25	1	26
2020 February	48	13	61
2020 January	44	8	52
2019 December	54	14	68
2019 November	41	4	45
2019 October	40	15	55
2019 September	38	4	42
2019 August	35	9	44
2019 July	59	13	72
2019 June	75	22	97
2019 May	146	40	186
2019 April	41	27	68
2019 March	20	7	27
2019 February	37	10	47
2019 January	13	9	22
2018 December	19	6	25
2018 November	25	5	30
2018 October	27	3	30
2018 May	4	0	4
2018 April	31	8	39
2018 March	15	2	17
2018 February	22	1	23
2018 January	24	1	25
2017 December	31	2	33
2017 November	23	8	31
2017 October	23	4	27
2017 September	23	2	25
2017 August	22	6	28
2017 July	27	4	31
2017 June	94	30	124
2017 May	23	16	39
2017 April	28	26	54
2017 March	19	17	36
2017 February	21	21	42
2017 January	18	4	22
2016 December	41	7	48
2016 November	49	15	64
2016 October	60	19	79
2016 September	49	7	56
2016 August	48	5	53
2016 July	26	5	31
2016 June	37	17	54
2016 May	36	21	57
2016 April	39	15	54
2016 March	43	15	58
2016 February	41	23	64
2016 January	28	16	44
2015 December	34	18	52
2015 November	28	16	44
2015 October	32	17	49
2015 September	27	12	39
2015 August	41	11	52
2015 July	25	12	37
2015 June	13	9	22
2015 May	23	11	34
2015 April	21	38	59
2015 March	33	21	54
2015 February	29	15	44
2015 January	39	13	52
2014 December	53	14	67
2014 November	41	12	53
2014 October	52	13	65
2014 September	57	14	71
2014 August	46	15	61
2014 July	38	8	46
2014 June	48	10	58
2014 May	41	8	49
2014 April	33	9	42
2014 March	31	8	39
2014 February	28	7	35
2014 January	29	8	37
2013 December	36	7	43
2013 November	32	15	47
2013 October	66	18	84
2013 September	42	17	59
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