Serum levels of intact parathyroid hormone on the first day after total thyroidectomy as predictor of permanent hypoparathyroidism | Endocrinología, Diabetes y Nutrición (English ed.)

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Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Uso del valor de la hormona paratiroidea intacta en el primer día postoperatorio tras tiroidectomía total como predictor de hipoparatiroidismo permanente" ] ] "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" => 1235 "Ancho" => 2167 "Tamanyo" => 129344 ] ] "descripcion" => array:1 [ "en" => "Flow chart of patients included in the study." ] ] ] "textoCompleto" => "IntroductionHypocalcemia, recurrent laryngeal nerve palsy and repeat surgery due to bleeding are the three most common complications associated with thyroid surgery. Permanent hypoparathyroidism is the most prevalent long-term complication, and is responsible for significant morbidity and the need for long-term replacement therapy.Postoperative permanent hypoparathyroidism is caused by damage to the parathyroid glands when total thyroidectomy is performed, either by inadvertent excision, direct damage or devascularization.<a class="elsevierStyleCrossRef" href="#bib0085">1</a> The associated risk factors reported in the literature include lymphadenectomy associated with thyroidectomy due to malignant disease,<a class="elsevierStyleCrossRefs" href="#bib0090">2,6</a> a prolonged duration of surgery (>120min),<a class="elsevierStyleCrossRef" href="#bib0110">6</a> the volume of thyroid surgery performed by the surgeon,<a class="elsevierStyleCrossRef" href="#bib0095">3</a> Graves’ disease,<a class="elsevierStyleCrossRef" href="#bib0105">5</a> patients with thyroiditis,<a class="elsevierStyleCrossRef" href="#bib0125">9</a> repeat surgery due to bleeding, and the identification of less than two parathyroid glands.<a class="elsevierStyleCrossRef" href="#bib0130">10</a>According to the meta-analysis published by Edafe et al. in 2014, transient hypocalcemia has a prevalence of 19–38%, with a permanent hypoparathyroidism rate of 0–3%,<a class="elsevierStyleCrossRef" href="#bib0130">10</a> though these figures vary greatly in the literature due to the different criteria and limiting values used in determining such complications.Different studies have shown that a decrease in intact parathyroid hormone (iPTH) to below the normal range in the immediate postoperative period (<24h) following total thyroidectomy is a reliable indicator for predicting postoperative transient hypocalcemia.<a class="elsevierStyleCrossRefs" href="#bib0135">11–14</a> This is because iPTH has a short half-life (2–5min) with a rapid plasma turnover (through hepatic and renal metabolism), thus making it a good marker of parathyroid function.<a class="elsevierStyleCrossRef" href="#bib0120">8</a>In this regard, a number of protocols have been proposed for the early initiation of replacement therapy in transient hypocalcemia based on calcium and vitamin D, but few studies have analyzed the role of the postoperative measurement of iPTH in predicting the development of permanent hypoparathyroidism.<a class="elsevierStyleCrossRefs" href="#bib0085">1,7–9</a>The main objective of this study was to determine whether iPTH levels on the first postoperative day after total thyroidectomy may be useful in predicting which patients will experience permanent hypoparathyroidism, avoiding the risks associated with the development of hyper- or hypocalcemia, and individualizing therapy.Material and methodsPatients and methodsAll patients undergoing total thyroidectomy at Hospital Universitario Puerta de Hierro (Majadahonda, Madrid, Spain) between January 2009 and December 2014 were included in the study. The baseline data and follow-up data were recorded from the case history, including demographic characteristics, the preoperative diagnosis, and postoperative complications.Total thyroidectomy using the standard technique was performed in all cases, completed with central and/or lateral lymphadenectomy in patients with thyroid carcinoma, as indicated according to the medical criterion. The procedure was performed by surgeons who specialized in endocrine surgery, or by general surgical residents under the supervision of such surgeons.The following inclusion criteria were established: all patients in our center subjected to total thyroidectomy due to benign or malignant thyroid disease, or on a prophylactic basis due to RET oncogene mutation. Patients with prior hemithyroidectomy who completed total thyroidectomy in second surgery, or individuals subjected to any other previous neck surgery, were excluded from the study.Transient hypoparathyroidism was defined as serum iPTH below the normal range (<15pg/ml) at 24h postsurgery, while postoperative hypocalcemia was defined as serum calcium <8mg/dl at 24h postsurgery, and permanent hypoparathyroidism as the need for calcium and vitamin D supplementation more than 12 months after surgery. The serum calcium values used in the study were not corrected for albumin.Blood samples for calcium and iPTH determination were collected from the first day after surgery at 7:00a.m. (16–20h after surgery), while on the subsequent days only calcium was recorded during the hospitalization period.Calcium measurements were performed using the Arsenazo III colorimetric method (ADVIA® XPT – Siemens Healthineers), while iPTH was measured by chemiluminescent immunoassay (ADVIA® Centaur – Siemens Healthineers). The manufacturer-reported iPTH reference range was 4.4–1900pg/ml, with a test sensitivity <2.5pg/ml and functional sensitivity <6.4pg/ml.Initial monitoring and treatment during hospital admission were jointly conducted by the general surgery and endocrinology team, while outpatient monitoring was carried out in the endocrinology clinic.Study design and statistical analysisA retrospective observational study was carried out. Data are reported as the mean and standard deviation (SD), or as the median and interquartile range (IQR). Statistical significance was considered for p<0.05.The comparison of two independent continuous variables was based on the Student t-test for unpaired samples, or on the nonparametric Mann–Whitney U-test, depending on the characteristics of the variables. The chi-squared test with continuous correction was used to compare discrete variables.The receiver operating characteristic (ROC) curves and AUC (area under the curve) were used to assess the diagnostic accuracy of the iPTH value on the first postoperative day or of the differential serum calcium value between the first postoperative day and presurgery as predictors of permanent hypoparathyroidism.The statistical analysis was performed using the SPSS version 20.0 statistical package (SPSS Inc., Chicago, IL, USA).ResultsA total of 481 patients with a mean age of 53±14 years (82% women) were included in the study. In the analysis of transient hypoparathyroidism, 123 patients (26%) with no postoperative iPTH measurements were excluded, due to the impossibility of analyzing this parameter at our center at weekends. The number of patients studied in relation to this analysis was therefore restricted to 358 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the main baseline clinical and laboratory test characteristics, and the postoperative complications. To summarize the findings, the most common cause of thyroidectomy was multinodular goiter (75%), followed by papillary thyroid carcinoma (15%), Graves’ disease (6%) and follicular carcinoma (2%).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The most common complication in our series was transient postoperative hypocalcemia, observed in up to 49% of the patients (234 out of 473 cases, as postoperative calcemia was not determined in the remaining cases). Of these patients, 25% had symptoms associated with hypocalcemia such as perioral and limb paresthesias, muscle spasms, or positive Trousseau or Chvostek signs.Postoperative hypoparathyroidism was another associated complication, and proved transient in 123 patients (34%) and permanent in 28 (6%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).The patients who developed long-term permanent hypoparathyroidism were significantly younger, and the surgery time was longer, than in the group that did not develop hypoparathyroidism. However, no significant differences were observed between the different causes of thyroidectomy.In order to determine whether the incidence of postoperative permanent hypoparathyroidism could be related to the learning curve of the surgical team during the study period, we analyzed the number of procedures and complications in three periods, with no significant differences being observed (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the clinical characteristics of the patients with suppressed iPTH in the early postoperative period (<5pg/ml), according to whether they developed permanent hypoparathyroidism over the long term or not.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>A total of 287 patients (60%) required calcium supplementation with or without vitamin D supplements during admission, and of these 37 (8%) required intravenous calcium. In 53 patients (11%), prophylactic treatment with calcium supplements was started at the discretion of the treating medical team after surgery because the postoperative PTH levels were not available and the serum calcium levels were at the lower limit of normal.In the statistical analysis of iPTH after 24h as a predictor of permanent hypoparathyroidism, the ROC curves showed iPTH 5pg/ml to exhibit a sensitivity of 95.4% and a specificity of 77.4%, with an increase in the latter as the iPTH levels decreased (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The positive predictive value (PPV) was 21.6% and the negative predictive value (NPV) 99.6%.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Sensitivity did not reach 100% because one patient in the series had a normal iPTH value (15pg/ml) on the first postoperative day, though he subsequently developed permanent hypoparathyroidism.The differential serum calcium value (postoperative versus preoperative) was also evaluated. Based on the analysis of the ROC curves, a decrease of 1.8mEq/l exhibited a sensitivity of 92% and a specificity of 65% in predicting permanent hypoparathyroidism (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>DiscussionThe results of this study show permanent hypoparathyroidism after total thyroidectomy to be an uncommon complication when performed by an experienced surgical team, and that postoperative iPTH levels >5pg/ml may help predict which patients will not develop this complication.The development of postoperative permanent hypoparathyroidism is associated with increased morbidity and healthcare costs. In order to reduce this complication, the preservation of as many parathyroid glands as possible is important, in the same way as the prevention of direct gland damage and devascularization during surgery, since as demonstrated by Lorente-Poch et al., the prevalence of hypocalcemia, and of transient and permanent hypoparathyroidism is inversely correlated to the number of preserved parathyroid glands.<a class="elsevierStyleCrossRef" href="#bib0100">4</a>The permanent hypoparathyroidism rate reported in the literature is highly variable, one of the reasons for this being the lack of unified biochemical and time criteria. The permanent hypoparathyroidism rate ranges from 1 to 11%.<a class="elsevierStyleCrossRefs" href="#bib0085">1,4,6–8,15</a> In our series the prevalence was 6%.Intact PTH is an excellent marker of parathyroid function thanks to its short half-life. Its fundamental physiological role is based on calcium homeostasis through calcium resorption by the renal tubules, the stimulation of calcium absorption at intestinal level, and the stimulation of bone resorption.In our study, an iPTH level of 5pg/ml on the first postoperative day after total thyroidectomy exhibited a sensitivity of 95% and a specificity of 77% in predicting permanent hypoparathyroidism, with a PPV of 21.6% and an NPV of 99.6%. These results suggest that if the iPTH levels obtained on the first postoperative day are >5pg/ml, the likelihood of developing long-term permanent hypoparathyroidism is negligible, and that approximately one in every 5 individuals who develop iPTH<5pg/ml will suffer permanent hypoparathyroidism.As reported in the results, one patient developed permanent hypoparathyroidism with an iPTH value of 15pg/ml. Promberger et al.<a class="elsevierStyleCrossRef" href="#bib0160">16</a> described this phenomenon in a series of 8 patients, suggesting the probable existence of a minimum number of functioning parathyroid cells intensely stimulated by persistent hypocalcemia, but with insufficient iPTH production to restore normal serum calcium levels. Thus, the authors considered that in these cases it would be more appropriate to speak of parathyroid insufficiency rather than permanent hypoparathyroidism.Only a few previous studies have analyzed the same variable, and the results have been similar to our own. Almquist et al. reported a permanent hypoparathyroidism rate of 19% in patients with iPTH<6.6pg/ml on the first postoperative day.<a class="elsevierStyleCrossRef" href="#bib0085">1</a> Julian et al. in turn found iPTH≤5.8pg/ml recorded 24h after total thyroidectomy to exhibit 100% sensitivity and 82% specificity in predicting permanent hypoparathyroidism, with a PPV of 30% and an NPV of 100%.<a class="elsevierStyleCrossRef" href="#bib0115">7</a> Hermann et al. found that iPTH<6pg/ml recorded 3h after surgery exhibited a PPV of 15% and an NPV of 100% in predicting permanent hypoparathyroidism, and that iPTH>6pg/ml ruled out the presence of permanent hypoparathyroidism.<a class="elsevierStyleCrossRef" href="#bib0120">8</a> Lastly, Wang et al. found iPTH<7pg/ml on the first postoperative day to be predictive of permanent hypoparathyroidism, with a sensitivity of 100% but a specificity of 70%.<a class="elsevierStyleCrossRef" href="#bib0125">9</a>Another variable analyzed as a possible predictor of permanent hypoparathyroidism was the decrease in serum calcium recorded at 24h postsurgery versus the preoperative serum calcium value. The statistical study based on the ROC curves found a decrease of 1.8mEq/l to exhibit a sensitivity of 92% and a specificity of 65% in predicting permanent hypoparathyroidism, i.e., this variable is a comparatively poor indicator. Serum calcium as an indicator was also analyzed by Julian et al., who found a serum concentration ≤1.95mmol/l to exhibit a sensitivity of 60% and a specificity of 79% in predicting permanent hypoparathyroidism, with a PPV of 18% and an NPV of 96%.<a class="elsevierStyleCrossRef" href="#bib0115">7</a>Our study has limitations. Given the retrospective design involved, no firm causal relationships could be established, and since the study was carried out at a single center with concrete treatment criteria, generalization of the results might not be warranted. In addition, the percentage of parathyroid glands removed at surgery and/or autotransplanted was likewise not analyzed. Despite these limitations, however, and thanks to the large number of patients analyzed, our study provides relevant clinical information about the complications associated with total thyroidectomy.In conclusion, although there is no specific iPTH value after total thyroidectomy allowing for the highly reliable prediction of the development of permanent hypoparathyroidism, the measurement of this parameter is useful because of its high NPV. Thus, postoperative serum iPTH>5pg/ml means we can practically discard the development of permanent hypoparathyroidism over the long term, and this in turn can contribute to establishing both optimal treatment and individualized outpatient follow-up.Conflicts of interestThere are no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1181614" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1102466" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1181615" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1102465" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients and methods" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study design and statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-25" "fechaAceptado" => "2018-08-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1102466" "palabras" => array:4 [ 0 => "Hypocalcemia" 1 => "Hypoparathyroidism" 2 => "Parathormone" 3 => "Thyroidectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1102465" "palabras" => array:4 [ 0 => "Hipocalcemia" 1 => "Hipoparatiroidismo" 2 => "Paratohormona" 3 => "Tiroidectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundPermanent hypoparathyroidism is the most common long-term complication after total thyroidectomy, causing significant morbidity and requiring long-term replacement therapy. Our study objective was to assess whether intact parathyroid hormone (iPTH) levels on the first day after total thyroidectomy are a good predictor of permanent hypoparathyroidism. Patients and methodsA retrospective observational study of all patients undergoing total thyroidectomy between January 2009 and December 2014. iPTH and calcium levels were measured the first day after surgery. Patients were followed up for at least one year after surgery. ResultsThe study group consisted of 481 patients with a mean age of 53±14 years, 82% of them females. The most common reason for thyroidectomy was multinodular goiter (75%), followed by papillary thyroid cancer (15%). Transient hypocalcemia was the most common early complication after total thyroidectomy (49%), and permanent hypoparathyroidism was the most common long-term complication (6%). ROC curve analysis showed that iPTH level on the first postoperative day was a good predictor of permanent hypoparathyroidism (area under the curve 0.87; 95% CI: 0.84–0.91). Cut-off iPTH levels of 5pg/mL had 95% sensitivity, 77% specificity, 21.6% positive predictive value, and 99.6% negative predictive value. ConclusionsiPTH level on the first day after total thyroidectomy is a useful predictor of permanent hypoparathyroidism because of its high negative predictive value. Serum iPTH levels >5pg/mL virtually exclude presence of permanent hypoparathyroidism." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl hipoparatiroidismo permanente es la complicación a largo plazo más prevalente tras una tiroidectomía total, siendo responsable de una importante morbilidad y de necesidad de tratamiento sustitutivo a largo plazo. El objetivo de este estudio fue determinar si el valor de la hormona paratiroidea intacta (PTHi) en el primer día postoperatorio tras una tiroidectomía total es un buen predictor de hipoparatiroidismo permanente. Material y métodosEstudio retrospectivo de observación en el que se analizaron todos los pacientes intervenidos de tiroidectomía total entre enero de 2009 y diciembre de 2014. Se recogieron los valores de PTHi y calcio sérico en el primer día postoperatorio, y todos los pacientes tuvieron un seguimiento mínimo de un año. ResultadosSe incluyeron 481 pacientes con una edad media de 53±14 años, el 82% de los cuales eran mujeres. La causa más frecuente de tiroidectomía fue el bocio multinodular (75%), seguido del carcinoma papilar de tiroides (15%). La complicación precoz más frecuente fue la hipocalcemia transitoria (49%), y a largo plazo fue el hipoparatiroidismo permanente (6%). El estudio estadístico mediante curvas ROC mostró que la PTHi en el primer día postoperatorio es un buen predictor de hipoparatiroidismo permanente (área bajo la curva de 0,87; IC 95%: 0,84–0,91). Valores de 5pg/ml presentan una sensibilidad del 95%, una especificidad del 77%, un valor predictivo positivo del 21,6% y un valor predictivo negativo del 99,6%. ConclusionesLa PTHi en el primer día postoperatorio de la tiroidectomía total es un predictor útil de hipoparatiroidismo permanente gracias a su alto valor predictivo negativo. Valores de PTHi>5 pg/ml excluyen prácticamente la presencia de hipoparatiroidismo permanente." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Calvo Espino P, Rivera Bautista JÁ, Artés Caselles M, Serrano González J, García Pavía A, García-Oria MJ, et al. Uso del valor de la hormona paratiroidea intacta en el primer día postoperatorio tras tiroidectomía total como predictor de hipoparatiroidismo permanente. Endocrinol Diabetes Nutr. 2019;66:195–201." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This study was presented as an Oral Communication at the XXXI National Congress of Surgery, 7–10 November 2016, in Madrid (Spain)." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1235 "Ancho" => 2167 "Tamanyo" => 129344 ] ] "descripcion" => array:1 [ "en" => "Flow chart of patients included in the study." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1229 "Ancho" => 1257 "Tamanyo" => 50028 ] ] "descripcion" => array:1 [ "en" => "The receiver operating characteristic (ROC) curve shows the precision of the PTH concentration on the first postoperative day in predicting permanent hypoparathyroidism. Area under the curve 0.87 (0.91–0.84 with 95% confidence interval [95%CI])." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1222 "Ancho" => 1250 "Tamanyo" => 50398 ] ] "descripcion" => array:1 [ "en" => "Receiver operating characteristic (ROC) curve of differential serum calcium (preoperative versus the concentration recorded on the first postoperative day) as a predictor of permanent hypoparathyroidism. Area under the curve 0.83 (0.87–0.8 with 95% confidence interval [95%CI])." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "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"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total (n=481) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">With permanent hypoparathyroidism (n=28) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No permanent hypoparathyroidism (n=453) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53±14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54±14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender, females (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">393 (82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (93) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">367 (81) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.116 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Etiology, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multinodular goiter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">359 (75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (57) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">343 (76) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Papillary carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 (15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 (14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Follicular carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medullary carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neuroendocrine carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Graves’ disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Amyloid goiter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RET oncogene mutation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (0.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (0.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metastasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Amiodarone hyperthyroidism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgery time, minutes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">123±43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150±38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">120±40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Periods \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.927 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2009–2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">107 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2011–2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">190 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">179 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2013–2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">184 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">174 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Laboratory test values</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preoperative calcium, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.6±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.5±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.6±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.142 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative calcium, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.9±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative iPTH, pg/ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 [4–37] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 [2–4] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 [6–39] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days of admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypocalcemic symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">120 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97 (21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Supplementation during hospital admission, n (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral calcium and vitamin D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250 (52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">236 (52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.967 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intravenous calcium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No supplementation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">194 (40) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">194 (43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other complications, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transient recurrent laryngeal nerve damage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Permanent recurrent laryngeal nerve damage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Repeat surgery due to hematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2013742.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical, laboratory test and follow-up data of the patients according to whether permanent hypoparathyroidism developed or not." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "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"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total (n=92) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Transient hypoparathyroidism (n=70) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Permanent hypoparathyroidism (n=22) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.009 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender, females (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83 (90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 (89) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (96) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.343 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgery time, minutes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">131±38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">125±39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">148±32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.016 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypocalcemic symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 (67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 (66) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (72) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Laboratory test values, mg/dl</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcium before surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.5±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.6±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.5±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.398 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcium 24h after surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.3±0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.5±0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcium at 48h of intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.4±0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.4±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.1±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.037 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Supplementation during hospital admission, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral calcium and vitamin D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 (63) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 (70) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intravenous calcium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 (36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (59) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No supplementation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2013741.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics and laboratory test parameters of the patients with postoperative PTH under 5pg/ml according to the development of transient or permanent hypoparathyroidism over the long term." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prediction of permanent hypoparathyroidism after total thyroidectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. 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Serum levels of intact parathyroid hormone on the first day after total thyroidectomy as predictor of permanent hypoparathyroidism

Uso del valor de la hormona paratiroidea intacta en el primer día postoperatorio tras tiroidectomía total como predictor de hipoparatiroidismo permanente

Pablo Calvo Espinoa,

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pcalvoespino@gmail.com

Corresponding author.

, José Ángel Rivera Bautistaa, Mariano Artés Casellesa, Javier Serrano Gonzáleza, Arturo García Pavíaa, Miguel Juan García-Oriaa, Fernando Caravaca-Fontánb, José Luis Lucena de la Pozaa, Víctor Sánchez Turrióna

a Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain

b Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, Spain

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  "pii" => "S2530018019300393"
  "issn" => "25300180"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hypocalcemia&#44; recurrent laryngeal nerve palsy and repeat surgery due to bleeding are the three most common complications associated with thyroid surgery&#46; Permanent hypoparathyroidism is the most prevalent long-term complication&#44; and is responsible for significant morbidity and the need for long-term replacement therapy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Postoperative permanent hypoparathyroidism is caused by damage to the parathyroid glands when total thyroidectomy is performed&#44; either by inadvertent excision&#44; direct damage or devascularization&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> The associated risk factors reported in the literature include lymphadenectomy associated with thyroidectomy due to malignant disease&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;6</span></a> a prolonged duration of surgery &#40;&#62;120<span class="elsevierStyleHsp" style=""></span>min&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> the volume of thyroid surgery performed by the surgeon&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Graves&#8217; disease&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> patients with thyroiditis&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> repeat surgery due to bleeding&#44; and the identification of less than two parathyroid glands&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">According to the meta-analysis published by Edafe et al&#46; in 2014&#44; transient hypocalcemia has a prevalence of 19&#8211;38&#37;&#44; with a permanent hypoparathyroidism rate of 0&#8211;3&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> though these figures vary greatly in the literature due to the different criteria and limiting values used in determining such complications&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Different studies have shown that a decrease in intact parathyroid hormone &#40;iPTH&#41; to below the normal range in the immediate postoperative period &#40;&#60;24<span class="elsevierStyleHsp" style=""></span>h&#41; following total thyroidectomy is a reliable indicator for predicting postoperative transient hypocalcemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11&#8211;14</span></a> This is because iPTH has a short half-life &#40;2&#8211;5<span class="elsevierStyleHsp" style=""></span>min&#41; with a rapid plasma turnover &#40;through hepatic and renal metabolism&#41;&#44; thus making it a good marker of parathyroid function&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this regard&#44; a number of protocols have been proposed for the early initiation of replacement therapy in transient hypocalcemia based on calcium and vitamin D&#44; but few studies have analyzed the role of the postoperative measurement of iPTH in predicting the development of permanent hypoparathyroidism&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;7&#8211;9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The main objective of this study was to determine whether iPTH levels on the first postoperative day after total thyroidectomy may be useful in predicting which patients will experience permanent hypoparathyroidism&#44; avoiding the risks associated with the development of hyper- or hypocalcemia&#44; and individualizing therapy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">All patients undergoing total thyroidectomy at Hospital Universitario Puerta de Hierro &#40;Majadahonda&#44; Madrid&#44; Spain&#41; between January 2009 and December 2014 were included in the study&#46; The baseline data and follow-up data were recorded from the case history&#44; including demographic characteristics&#44; the preoperative diagnosis&#44; and postoperative complications&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Total thyroidectomy using the standard technique was performed in all cases&#44; completed with central and&#47;or lateral lymphadenectomy in patients with thyroid carcinoma&#44; as indicated according to the medical criterion&#46; The procedure was performed by surgeons who specialized in endocrine surgery&#44; or by general surgical residents under the supervision of such surgeons&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The following inclusion criteria were established&#58; all patients in our center subjected to total thyroidectomy due to benign or malignant thyroid disease&#44; or on a prophylactic basis due to RET oncogene mutation&#46; Patients with prior hemithyroidectomy who completed total thyroidectomy in second surgery&#44; or individuals subjected to any other previous neck surgery&#44; were excluded from the study&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Transient hypoparathyroidism was defined as serum iPTH below the normal range &#40;&#60;15<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41; at 24<span class="elsevierStyleHsp" style=""></span>h postsurgery&#44; while postoperative hypocalcemia was defined as serum calcium &#60;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl at 24<span class="elsevierStyleHsp" style=""></span>h postsurgery&#44; and permanent hypoparathyroidism as the need for calcium and vitamin D supplementation more than 12 months after surgery&#46; The serum calcium values used in the study were not corrected for albumin&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Blood samples for calcium and iPTH determination were collected from the first day after surgery at 7&#58;00<span class="elsevierStyleHsp" style=""></span>a&#46;m&#46; &#40;16&#8211;20<span class="elsevierStyleHsp" style=""></span>h after surgery&#41;&#44; while on the subsequent days only calcium was recorded during the hospitalization period&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Calcium measurements were performed using the Arsenazo III colorimetric method &#40;ADVIA<span class="elsevierStyleSup">&#174;</span> XPT &#8211; Siemens Healthineers&#41;&#44; while iPTH was measured by chemiluminescent immunoassay &#40;ADVIA<span class="elsevierStyleSup">&#174;</span> Centaur &#8211; Siemens Healthineers&#41;&#46; The manufacturer-reported iPTH reference range was 4&#46;4&#8211;1900<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#44; with a test sensitivity &#60;2&#46;5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml and functional sensitivity &#60;6&#46;4<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Initial monitoring and treatment during hospital admission were jointly conducted by the general surgery and endocrinology team&#44; while outpatient monitoring was carried out in the endocrinology clinic&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design and statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">A retrospective observational study was carried out&#46; Data are reported as the mean and standard deviation &#40;SD&#41;&#44; or as the median and interquartile range &#40;IQR&#41;&#46; Statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The comparison of two independent continuous variables was based on the Student <span class="elsevierStyleItalic">t</span>-test for unpaired samples&#44; or on the nonparametric Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test&#44; depending on the characteristics of the variables&#46; The chi-squared test with continuous correction was used to compare discrete variables&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The receiver operating characteristic &#40;ROC&#41; curves and AUC &#40;area under the curve&#41; were used to assess the diagnostic accuracy of the iPTH value on the first postoperative day or of the differential serum calcium value between the first postoperative day and presurgery as predictors of permanent hypoparathyroidism&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using the SPSS version 20&#46;0 statistical package &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 481 patients with a mean age of 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years &#40;82&#37; women&#41; were included in the study&#46; In the analysis of transient hypoparathyroidism&#44; 123 patients &#40;26&#37;&#41; with no postoperative iPTH measurements were excluded&#44; due to the impossibility of analyzing this parameter at our center at weekends&#46; The number of patients studied in relation to this analysis was therefore restricted to 358 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the main baseline clinical and laboratory test characteristics&#44; and the postoperative complications&#46; To summarize the findings&#44; the most common cause of thyroidectomy was multinodular goiter &#40;75&#37;&#41;&#44; followed by papillary thyroid carcinoma &#40;15&#37;&#41;&#44; Graves&#8217; disease &#40;6&#37;&#41; and follicular carcinoma &#40;2&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The most common complication in our series was transient postoperative hypocalcemia&#44; observed in up to 49&#37; of the patients &#40;234 out of 473 cases&#44; as postoperative calcemia was not determined in the remaining cases&#41;&#46; Of these patients&#44; 25&#37; had symptoms associated with hypocalcemia such as perioral and limb paresthesias&#44; muscle spasms&#44; or positive Trousseau or Chvostek signs&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Postoperative hypoparathyroidism was another associated complication&#44; and proved transient in 123 patients &#40;34&#37;&#41; and permanent in 28 &#40;6&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The patients who developed long-term permanent hypoparathyroidism were significantly younger&#44; and the surgery time was longer&#44; than in the group that did not develop hypoparathyroidism&#46; However&#44; no significant differences were observed between the different causes of thyroidectomy&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In order to determine whether the incidence of postoperative permanent hypoparathyroidism could be related to the learning curve of the surgical team during the study period&#44; we analyzed the number of procedures and complications in three periods&#44; with no significant differences being observed &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the clinical characteristics of the patients with suppressed iPTH in the early postoperative period &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41;&#44; according to whether they developed permanent hypoparathyroidism over the long term or not&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">A total of 287 patients &#40;60&#37;&#41; required calcium supplementation with or without vitamin D supplements during admission&#44; and of these 37 &#40;8&#37;&#41; required intravenous calcium&#46; In 53 patients &#40;11&#37;&#41;&#44; prophylactic treatment with calcium supplements was started at the discretion of the treating medical team after surgery because the postoperative PTH levels were not available and the serum calcium levels were at the lower limit of normal&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In the statistical analysis of iPTH after 24<span class="elsevierStyleHsp" style=""></span>h as a predictor of permanent hypoparathyroidism&#44; the ROC curves showed iPTH 5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml to exhibit a sensitivity of 95&#46;4&#37; and a specificity of 77&#46;4&#37;&#44; with an increase in the latter as the iPTH levels decreased &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The positive predictive value &#40;PPV&#41; was 21&#46;6&#37; and the negative predictive value &#40;NPV&#41; 99&#46;6&#37;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Sensitivity did not reach 100&#37; because one patient in the series had a normal iPTH value &#40;15<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41; on the first postoperative day&#44; though he subsequently developed permanent hypoparathyroidism&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The differential serum calcium value &#40;postoperative versus preoperative&#41; was also evaluated&#46; Based on the analysis of the ROC curves&#44; a decrease of 1&#46;8<span class="elsevierStyleHsp" style=""></span>mEq&#47;l exhibited a sensitivity of 92&#37; and a specificity of 65&#37; in predicting permanent hypoparathyroidism &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">The results of this study show permanent hypoparathyroidism after total thyroidectomy to be an uncommon complication when performed by an experienced surgical team&#44; and that postoperative iPTH levels &#62;5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml may help predict which patients will not develop this complication&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The development of postoperative permanent hypoparathyroidism is associated with increased morbidity and healthcare costs&#46; In order to reduce this complication&#44; the preservation of as many parathyroid glands as possible is important&#44; in the same way as the prevention of direct gland damage and devascularization during surgery&#44; since as demonstrated by Lorente-Poch et al&#46;&#44; the prevalence of hypocalcemia&#44; and of transient and permanent hypoparathyroidism is inversely correlated to the number of preserved parathyroid glands&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The permanent hypoparathyroidism rate reported in the literature is highly variable&#44; one of the reasons for this being the lack of unified biochemical and time criteria&#46; The permanent hypoparathyroidism rate ranges from 1 to 11&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;4&#44;6&#8211;8&#44;15</span></a> In our series the prevalence was 6&#37;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Intact PTH is an excellent marker of parathyroid function thanks to its short half-life&#46; Its fundamental physiological role is based on calcium homeostasis through calcium resorption by the renal tubules&#44; the stimulation of calcium absorption at intestinal level&#44; and the stimulation of bone resorption&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In our study&#44; an iPTH level of 5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml on the first postoperative day after total thyroidectomy exhibited a sensitivity of 95&#37; and a specificity of 77&#37; in predicting permanent hypoparathyroidism&#44; with a PPV of 21&#46;6&#37; and an NPV of 99&#46;6&#37;&#46; These results suggest that if the iPTH levels obtained on the first postoperative day are &#62;5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#44; the likelihood of developing long-term permanent hypoparathyroidism is negligible&#44; and that approximately one in every 5 individuals who develop iPTH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml will suffer permanent hypoparathyroidism&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">As reported in the results&#44; one patient developed permanent hypoparathyroidism with an iPTH value of 15<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46; Promberger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> described this phenomenon in a series of 8 patients&#44; suggesting the probable existence of a minimum number of functioning parathyroid cells intensely stimulated by persistent hypocalcemia&#44; but with insufficient iPTH production to restore normal serum calcium levels&#46; Thus&#44; the authors considered that in these cases it would be more appropriate to speak of parathyroid insufficiency rather than permanent hypoparathyroidism&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Only a few previous studies have analyzed the same variable&#44; and the results have been similar to our own&#46; Almquist et al&#46; reported a permanent hypoparathyroidism rate of 19&#37; in patients with iPTH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6&#46;6<span class="elsevierStyleHsp" style=""></span>pg&#47;ml on the first postoperative day&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Julian et al&#46; in turn found iPTH<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>5&#46;8<span class="elsevierStyleHsp" style=""></span>pg&#47;ml recorded 24<span class="elsevierStyleHsp" style=""></span>h after total thyroidectomy to exhibit 100&#37; sensitivity and 82&#37; specificity in predicting permanent hypoparathyroidism&#44; with a PPV of 30&#37; and an NPV of 100&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> Hermann et al&#46; found that iPTH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>pg&#47;ml recorded 3<span class="elsevierStyleHsp" style=""></span>h after surgery exhibited a PPV of 15&#37; and an NPV of 100&#37; in predicting permanent hypoparathyroidism&#44; and that iPTH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>pg&#47;ml ruled out the presence of permanent hypoparathyroidism&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> Lastly&#44; Wang et al&#46; found iPTH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>pg&#47;ml on the first postoperative day to be predictive of permanent hypoparathyroidism&#44; with a sensitivity of 100&#37; but a specificity of 70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Another variable analyzed as a possible predictor of permanent hypoparathyroidism was the decrease in serum calcium recorded at 24<span class="elsevierStyleHsp" style=""></span>h postsurgery versus the preoperative serum calcium value&#46; The statistical study based on the ROC curves found a decrease of 1&#46;8<span class="elsevierStyleHsp" style=""></span>mEq&#47;l to exhibit a sensitivity of 92&#37; and a specificity of 65&#37; in predicting permanent hypoparathyroidism&#44; i&#46;e&#46;&#44; this variable is a comparatively poor indicator&#46; Serum calcium as an indicator was also analyzed by Julian et al&#46;&#44; who found a serum concentration &#8804;1&#46;95<span class="elsevierStyleHsp" style=""></span>mmol&#47;l to exhibit a sensitivity of 60&#37; and a specificity of 79&#37; in predicting permanent hypoparathyroidism&#44; with a PPV of 18&#37; and an NPV of 96&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Our study has limitations&#46; Given the retrospective design involved&#44; no firm causal relationships could be established&#44; and since the study was carried out at a single center with concrete treatment criteria&#44; generalization of the results might not be warranted&#46; In addition&#44; the percentage of parathyroid glands removed at surgery and&#47;or autotransplanted was likewise not analyzed&#46; Despite these limitations&#44; however&#44; and thanks to the large number of patients analyzed&#44; our study provides relevant clinical information about the complications associated with total thyroidectomy&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In conclusion&#44; although there is no specific iPTH value after total thyroidectomy allowing for the highly reliable prediction of the development of permanent hypoparathyroidism&#44; the measurement of this parameter is useful because of its high NPV&#46; Thus&#44; postoperative serum iPTH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml means we can practically discard the development of permanent hypoparathyroidism over the long term&#44; and this in turn can contribute to establishing both optimal treatment and individualized outpatient follow-up&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">There are no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Permanent hypoparathyroidism is the most common long-term complication after total thyroidectomy&#44; causing significant morbidity and requiring long-term replacement therapy&#46; Our study objective was to assess whether intact parathyroid hormone &#40;iPTH&#41; levels on the first day after total thyroidectomy are a good predictor of permanent hypoparathyroidism&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective observational study of all patients undergoing total thyroidectomy between January 2009 and December 2014&#46; iPTH and calcium levels were measured the first day after surgery&#46; Patients were followed up for at least one year after surgery&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study group consisted of 481 patients with a mean age of 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years&#44; 82&#37; of them females&#46; The most common reason for thyroidectomy was multinodular goiter &#40;75&#37;&#41;&#44; followed by papillary thyroid cancer &#40;15&#37;&#41;&#46; Transient hypocalcemia was the most common early complication after total thyroidectomy &#40;49&#37;&#41;&#44; and permanent hypoparathyroidism was the most common long-term complication &#40;6&#37;&#41;&#46; ROC curve analysis showed that iPTH level on the first postoperative day was a good predictor of permanent hypoparathyroidism &#40;area under the curve 0&#46;87&#59; 95&#37; CI&#58; 0&#46;84&#8211;0&#46;91&#41;&#46; Cut-off iPTH levels of 5<span class="elsevierStyleHsp" style=""></span>pg&#47;mL had 95&#37; sensitivity&#44; 77&#37; specificity&#44; 21&#46;6&#37; positive predictive value&#44; and 99&#46;6&#37; negative predictive value&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">iPTH level on the first day after total thyroidectomy is a useful predictor of permanent hypoparathyroidism because of its high negative predictive value&#46; Serum iPTH levels &#62;5<span class="elsevierStyleHsp" style=""></span>pg&#47;mL virtually exclude presence of permanent hypoparathyroidism&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El hipoparatiroidismo permanente es la complicaci&#243;n a largo plazo m&#225;s prevalente tras una tiroidectom&#237;a total&#44; siendo responsable de una importante morbilidad y de necesidad de tratamiento sustitutivo a largo plazo&#46; El objetivo de este estudio fue determinar si el valor de la hormona paratiroidea intacta &#40;PTHi&#41; en el primer d&#237;a postoperatorio tras una tiroidectom&#237;a total es un buen predictor de hipoparatiroidismo permanente&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de observaci&#243;n en el que se analizaron todos los pacientes intervenidos de tiroidectom&#237;a total entre enero de 2009 y diciembre de 2014&#46; Se recogieron los valores de PTHi y calcio s&#233;rico en el primer d&#237;a postoperatorio&#44; y todos los pacientes tuvieron un seguimiento m&#237;nimo de un a&#241;o&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 481 pacientes con una edad media de 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 a&#241;os&#44; el 82&#37; de los cuales eran mujeres&#46; La causa m&#225;s frecuente de tiroidectom&#237;a fue el bocio multinodular &#40;75&#37;&#41;&#44; seguido del carcinoma papilar de tiroides &#40;15&#37;&#41;&#46; La complicaci&#243;n precoz m&#225;s frecuente fue la hipocalcemia transitoria &#40;49&#37;&#41;&#44; y a largo plazo fue el hipoparatiroidismo permanente &#40;6&#37;&#41;&#46; El estudio estad&#237;stico mediante curvas ROC mostr&#243; que la PTHi en el primer d&#237;a postoperatorio es un buen predictor de hipoparatiroidismo permanente &#40;&#225;rea bajo la curva de 0&#44;87&#59; IC 95&#37;&#58; 0&#44;84&#8211;0&#44;91&#41;&#46; Valores de 5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml presentan una sensibilidad del 95&#37;&#44; una especificidad del 77&#37;&#44; un valor predictivo positivo del 21&#44;6&#37; y un valor predictivo negativo del 99&#44;6&#37;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La PTHi en el primer d&#237;a postoperatorio de la tiroidectom&#237;a total es un predictor &#250;til de hipoparatiroidismo permanente gracias a su alto valor predictivo negativo&#46; Valores de PTHi<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5 pg&#47;ml excluyen pr&#225;cticamente la presencia de hipoparatiroidismo permanente&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Calvo Espino P&#44; Rivera Bautista J&#193;&#44; Art&#233;s Caselles M&#44; Serrano Gonz&#225;lez J&#44; Garc&#237;a Pav&#237;a A&#44; Garc&#237;a-Oria MJ&#44; et al&#46; Uso del valor de la hormona paratiroidea intacta en el primer d&#237;a postoperatorio tras tiroidectom&#237;a total como predictor de hipoparatiroidismo permanente&#46; Endocrinol Diabetes Nutr&#46; 2019&#59;66&#58;195&#8211;201&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This study was presented as an Oral Communication at the XXXI National Congress of Surgery&#44; 7&#8211;10 November 2016&#44; in Madrid &#40;Spain&#41;&#46;</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1235
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow chart of patients included in the study&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The receiver operating characteristic &#40;ROC&#41; curve shows the precision of the PTH concentration on the first postoperative day in predicting permanent hypoparathyroidism&#46; Area under the curve 0&#46;87 &#40;0&#46;91&#8211;0&#46;84 with 95&#37; confidence interval &#91;95&#37;CI&#93;&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1222
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Receiver operating characteristic &#40;ROC&#41; curve of differential serum calcium &#40;preoperative versus the concentration recorded on the first postoperative day&#41; as a predictor of permanent hypoparathyroidism&#46; Area under the curve 0&#46;83 &#40;0&#46;87&#8211;0&#46;8 with 95&#37; confidence interval &#91;95&#37;CI&#93;&#41;&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
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        "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"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>481&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">With permanent hypoparathyroidism &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No permanent hypoparathyroidism &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>453&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Gender&#44; females &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">393 &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;93&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">367 &#40;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Etiology&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Multinodular goiter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">359 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">343 &#40;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Papillary carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Follicular carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Medullary carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neuroendocrine carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Graves&#8217; disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Amyloid goiter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RET oncogene mutation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Amiodarone hyperthyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Surgery time&#44; minutes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">123<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">120<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Periods</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;927&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2009&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">107&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2011&#8211;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">190&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">179&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2013&#8211;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">184&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">174&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Laboratory test values</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Preoperative calcium&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;142&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Postoperative calcium&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Postoperative iPTH&#44; pg&#47;ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#91;4&#8211;37&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#91;2&#8211;4&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#91;6&#8211;39&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Days of admission</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hypocalcemic symptoms</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">120 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Supplementation during hospital admission&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Oral calcium and vitamin D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250 &#40;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">236 &#40;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;967&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intravenous calcium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No supplementation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">194 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">194 &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Other complications&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Transient recurrent laryngeal nerve damage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Permanent recurrent laryngeal nerve damage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Repeat surgery due to hematoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Gender&#44; females &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83 &#40;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62 &#40;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#40;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;343&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Surgery time&#44; minutes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">131<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">125<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">148<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hypocalcemic symptoms</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62 &#40;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46 &#40;66&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Laboratory test values&#44; mg&#47;dl</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calcium before surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;398&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calcium 24<span class="elsevierStyleHsp" style=""></span>h after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Calcium at 48<span class="elsevierStyleHsp" style=""></span>h of intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;037&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Supplementation during hospital admission&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Oral calcium and vitamin D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intravenous calcium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No supplementation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Characteristics and laboratory test parameters of the patients with postoperative PTH under 5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml according to the development of transient or permanent hypoparathyroidism over the long term&#46;</p>"
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                            0 => "A&#46;C&#46; Reddy"
                            1 => "G&#46; Chand"
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Article information

ISSN: 25300180
Original language: English

DOI:10.1016/j.endien.2018.08.006

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	11	0	11
2024 October	33	7	40
2024 September	51	9	60
2024 August	42	6	48
2024 July	45	9	54
2024 June	38	0	38
2024 May	36	6	42
2024 April	29	5	34
2024 March	52	5	57
2024 February	53	5	58
2024 January	58	3	61
2023 December	35	7	42
2023 November	47	6	53
2023 October	38	4	42
2023 September	33	5	38
2023 August	22	3	25
2023 July	24	3	27
2023 June	26	2	28
2023 May	42	5	47
2023 April	51	4	55
2023 March	33	11	44
2023 February	25	2	27
2023 January	24	12	36
2022 December	24	5	29
2022 November	22	8	30
2022 October	20	12	32
2022 September	20	10	30
2022 August	34	19	53
2022 July	17	10	27
2022 June	14	13	27
2022 May	13	9	22
2022 April	28	13	41
2022 March	26	13	39
2022 February	26	8	34
2022 January	49	6	55
2021 December	47	10	57
2021 November	47	11	58
2021 October	43	20	63
2021 September	32	14	46
2021 August	52	8	60
2021 July	15	12	27
2021 June	13	9	22
2021 May	23	14	37
2021 April	38	11	49
2021 March	41	9	50
2021 February	21	16	37
2021 January	15	12	27
2020 December	14	10	24
2020 November	16	7	23
2020 October	16	5	21
2020 September	9	11	20
2020 August	17	15	32
2020 July	13	9	22
2020 June	12	5	17
2020 May	9	12	21
2020 April	16	8	24
2020 March	4	1	5
2020 February	5	3	8
2020 January	8	2	10
2019 December	7	9	16
2019 November	5	2	7
2019 October	9	3	12
2019 September	8	6	14

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