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Predicción de hipocalcemia postiroidectomía mediante determinación de PTH rápida
Prediction of post-idroidectomy hypocalcemia through rapid PTH determination
Gonzalo Gutiérrez Fernándeza,
Autor para correspondencia
gonzalo.gutierrez@scsalud.es

Autor para correspondencia.
, Antonio López Userosa, Pedro Muñoz Cachob, Daniel Casanova Rituertoa
a Servicio Cirugía General. Unidad Cirugía Endocrino-Metabólica. Hospital Universitario Marques de Valdecilla, Santander, España
b Unidad Docente de Medicina Familiar y Comunitaria, Servicio Cántabro de Salud, Santander, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La hipocalcemia postiroidectom&#237;a&#44; fundamentalmente por lesi&#243;n paratiroidea durante la cirug&#237;a<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">1</span></a>&#44; condiciona el postoperatorio y estancia&#46; Encontrar un factor predictor seguro y fiable es fundamental para prevenir y controlar esta complicaci&#243;n&#46; La paratohormona &#40;PTH&#41; se ha utilizado para tal fin&#44; pero debido a la heterogeneidad de los estudios a&#250;n no existe un valor de corte de PTH con una sensibilidad del 100&#37; para detectar dicha complicaci&#243;n&#46; La determinaci&#243;n r&#225;pida de paratohormona &#40;PTHr&#41; empez&#243; a utilizarse por Irvin en 1991<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">2</span></a> en cirug&#237;a paratiroidea y tiroidea en la d&#233;cada del 2000<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El objetivo del presente trabajo es evaluar la relaci&#243;n entre la determinaci&#243;n de PTH r&#225;pida y calcemias postiroidectom&#237;a con la hipocalcemia postoperatoria&#46; Validar si las determinaciones bioqu&#237;micas disponibles en nuestro medio sirven para predecir qu&#233; pacientes pueden estar en riesgo&#44; estableciendo un algoritmo de tratamiento selectivo precoz&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">M&#233;todos</span><p id="par0015" class="elsevierStylePara elsevierViewall">Dise&#241;o general&#58; estudio de seguimiento con recogida de datos prospectiva para evaluar la utilidad diagn&#243;stica de la PTH r&#225;pida y las calcemias postiroidectom&#237;a &#40;variables predictoras&#41;&#44; con el prop&#243;sito de predecir la hipocalcemia postoperatoria que es considerada la variable resultado&#46; Se incluyeron todas las tiroidectom&#237;as totales consecutivas entre los a&#241;os 2010 a 2015&#46; Criterios de exclusi&#243;n&#58; insuficiencia renal&#44; enfermedad paratiroidea y tratamiento activo con calcio&#46; Un total de 310 casos se incluyeron finalmente en el estudio&#46; Adem&#225;s&#44; se compararon con un grupo control de 48 hemitiroidectom&#237;as para contrastar los mismos par&#225;metros&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La cirug&#237;a fue realizada por dos cirujanos de forma similar y estandarizada&#46; Se efectu&#243; linfadenectom&#237;a central &#40;uni- o bilateral&#41;&#44; seg&#250;n estadio tumoral o indicios de extensi&#243;n ganglionar&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Determinaciones bioqu&#237;micas</span><p id="par0025" class="elsevierStylePara elsevierViewall">Para el estudio se analizaron&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Calcemia s&#233;rica total preoperatoria &#40;basal&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">PTH r&#225;pida basal &#40;PTHrpre&#41; en la inducci&#243;n anest&#233;sica&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">PTH r&#225;pida postiroidectom&#237;a &#40;PTHrpost&#41; a los 10 minutos de la extirpaci&#243;n tiroidea&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Calcemia s&#233;rica total postoperatoria&#58; la primera entre 5-8 horas postiroidectom&#237;a &#40;Ca1&#41;&#59; posteriormente cada 12 h &#40;7&#58;00 y 19&#58;00 horas&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">La PTH analizada es intacta y su determinaci&#243;n r&#225;pida fue realizada mediante inmunoensayo quimioluminiscente espec&#237;fico automatizado &#40;PTH STAT&#41; en un Elipsis &#40;Roche diagnostics dm&#44; Manheim&#41;&#46; Obteniendo resultados en menos de una hora&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">La calcemia analizada es exclusivamente la s&#233;rica total&#44; debido a la imposibilidad de obtener de manera urgente una calcemia corregida o alb&#250;mina para su c&#225;lculo&#46; Se analiz&#243; mediante espectrofotometr&#237;a automatizada &#40;m&#233;todo-&#952;-cresolphtaleina&#41; en un Dimension &#40;Siemens Healthcare Diagnostics&#44; DE&#44; USA&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Definici&#243;n y tratamiento de hipocalcemia</span><p id="par0060" class="elsevierStylePara elsevierViewall">La hipocalcemia sintom&#225;tica se defini&#243; como la aparici&#243;n de parestesias y&#47;o tetania&#46; Hipocalcemia bioqu&#237;mica se defini&#243; por valores de calcio s&#233;rico inferior a 8&#160;mg&#47;dL e hipocalcemia mantenida si consecutivamente durante las primeras 48 horas no aumenta o disminuye&#46; Se considera hipocalcemia por debajo de 8&#160;mg&#47;dL por ser cl&#237;nicamente m&#225;s relevante<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a> y ser el modelo que adoptan la mayor&#237;a de las publicaciones<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">5-7</span></a>&#46; Los pacientes sintom&#225;ticos y&#47;o con hipocalcemia bioqu&#237;mica mantenida&#44; se trataron con calcio oral &#40;lactogluconato c&#225;lcico&#44; 1&#46;500&#160;mg&#47;d&#237;a&#41; junto con calcitriol 1&#160;&#956;gr&#47;d&#237;a&#46; Solo los casos con hipocalcemia severa con aparici&#243;n de tetania&#44; se trataron con calcio intravenoso&#46; Los pacientes permanecieron ingresados hasta que estuvieron asintom&#225;ticos y bioqu&#237;micamente estables &#40;calcemias en ascenso&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Grupos de pacientes</span><p id="par0065" class="elsevierStylePara elsevierViewall">Se analizaron tres grupos de pacientes&#58; Grupo A &#40;n&#160;&#61;&#160;202&#44; 65&#44;1&#37;&#41;&#44; normocalc&#233;micos&#44; se mantuvieron asintom&#225;ticos y con calcemias consecutivas en ascenso&#44; no precisaron tratamiento&#59; Grupo B &#40;n&#160;&#61;&#160;108&#44; 34&#44;9&#37;&#41;&#44; con hipocalcemia mantenida precisando calcio y calcitriol&#59; Grupo Control&#44; 48 hemitiroidectom&#237;as consecutivas en el mismo periodo&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lisis estad&#237;stico</span><p id="par0070" class="elsevierStylePara elsevierViewall">Se calcul&#243; la sensibilidad &#40;S&#41;&#44; la especificidad &#40;E&#41;&#44; el valor predictivo positivo &#40;VPP&#41; y negativo &#40;VPN&#41; de diferentes puntos de corte de los valores bioqu&#237;micos disponibles&#58; valor absoluto y gradiente de descenso PTHr y calcemias cada 12&#160;h&#46; Se utilizaron las curvas ROC &#40;caracter&#237;stica operativa del receptor&#41; para comparar el &#225;rea bajo la curva de dichos valores como factores predictores de hipocalcemia sintom&#225;tica&#44; empleando el test de DeLong&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas se analizaron con &#967;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">2</span></a>&#46; Las cuantitativas con <span class="elsevierStyleItalic">t</span> de Student o U-Mann-Whitney seg&#250;n la normalidad de la variable&#59; y el test de Anova o Kruskal Wallis si se compararon m&#225;s de dos grupos&#46; Las variables con una distribuci&#243;n normal se expresaron como media &#177; desviaci&#243;n t&#237;pica&#44; de lo contrario&#44; como mediana y rango intercuart&#237;lico &#40;RI&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">La f&#243;rmula para calcular el gradiente de descenso es la publicada en otros trabajos<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">8&#44;9</span></a> y en la V&#237;a Cl&#237;nica de Tiroidectom&#237;a de la Asociaci&#243;n Espa&#241;ola de Cirujanos&#58; &#40;PTHrpre-PTHrpost&#41;&#47;PTHrpre x 100&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico se llev&#243; a cabo con el paquete estad&#237;stico IBM SPSS 25 &#40;IBM Corp&#46; Released 2017&#46; IBM SPSS Statistics for Windows&#44; Version 25&#46;0&#46; Armonk&#44; NY&#58; IBM Corp&#46;&#41; y MedCalc Statistical Software version 19&#46;1 &#40;MedCalc Software bv&#44; Ostend&#44; Belgium&#59; <a href="https://www.medcalc.org;/">https&#58;&#47;&#47;www&#46;medcalc&#46;org&#59;</a> 2019&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0090" class="elsevierStylePara elsevierViewall">Se incluyeron 310 casos&#44; se recogen en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#44; 273 fueron mujeres&#44; &#40;83&#44;2&#37;&#41;&#44; la media de edad fue de 54&#44;5 &#177; 13&#44;1 a&#241;os&#46; El bocio multinodular fue el diagn&#243;stico m&#225;s frecuente &#40;n&#160;&#61;&#160;239&#44; 77&#44;1&#37;&#41; y enfermedad de Graves en 26 casos&#46; En 28 pacientes &#40;11 en grupo A y 17 en el B&#41; se practic&#243; linfadenectom&#237;a central &#40;por indicios de extensi&#243;n ganglionar&#41;&#46; La hiperplasia fue el resultado histol&#243;gico m&#225;s habitual &#40;n&#160;&#61;&#160;234&#44; 75&#44;5&#37;&#41;&#44; y en 64 casos &#40;20&#44;6&#37;&#41; fue patolog&#237;a maligna&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Los 202 pacientes del Grupo A se mantuvieron asintom&#225;ticos&#59; del Grupo B&#44; 108 &#40;34&#44;9&#37;&#41;&#44; 79 desarrollaron s&#237;ntomas en el ingreso &#40;25&#44;4&#37; del total&#41; y 29 casos permanecieron asintom&#225;ticos a pesar de la hipocalcemia bioqu&#237;mica &#40;aunque recibieron tratamiento durante la estancia&#41;&#46; Casi todos los pacientes empezaron tratamiento sustitutivo en el segundo d&#237;a de ingreso &#40;48&#160;&#177;&#160;12 horas&#41;&#46; En la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se resumen estos grupos y la estancia&#44; que como puede observarse aumenta de forma significativa en el grupo B vs&#46; A &#40;3&#44;1&#160;&#177;&#160;1&#44;5 vs&#46; 2 &#177; 0&#44;6&#44; p&#160;&#60;&#160;0&#44;001&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">En grupo control fueron 48 casos &#40;41 mujeres&#44; 7 hombres&#41; con una edad media de 47&#44;1&#160;&#177;&#160;13 a&#241;os&#44; con diagn&#243;stico de n&#243;dulo solitario en 45 pacientes&#44; siendo histol&#243;gicamente 31 adenomas y cuatro c&#225;ncer&#46; No hubo complicaciones postoperatorias y el ingreso fue de 24 horas&#46; Como se puede comprobar&#44; existe un descenso significativo tanto de la calcemia basal &#40;9&#44;4&#160;&#177;&#160;0&#44;2 mg&#47;dL&#41; vs&#46; Ca24 h &#40;8&#44;2 &#177; 0&#44;4&#160;mg&#47;dL&#41; como de la PTHrpre &#40;83&#160;&#177;&#160;37&#160;pg&#47;dL&#41; vs&#46; PTHrpost &#40;57&#160;&#177;&#160;25&#160;pg&#47;dL&#41;&#44; p&#160;&#60;&#160;0&#44;04&#46; El descenso de PTHr es poco relevante&#44; 29 &#177; 17&#37;&#46; Se recogen en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Comparativa entre grupos</span><p id="par0105" class="elsevierStylePara elsevierViewall">No hubo diferencias estad&#237;sticamente significativas en cuanto a sexo&#44; diagn&#243;stico o histolog&#237;a&#44; pero s&#237; en edad&#44; linfadenectom&#237;a y estancia entre los grupos A y B&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">En las determinaciones bioqu&#237;micas no encontramos diferencias estad&#237;sticamente significativas en los valores de PTHrpre &#40;82 vs&#46; 90 pg&#47;mL&#41; y calcemias basales 9&#44;4 vs&#46; 9&#44;4&#160;mg&#47;dL&#59; pero s&#237; las hubo en la PTHrpost &#40;41 vs&#46; 12 pg&#47;mL&#41;&#44; descenso de PTHr &#40;49 vs&#46; 83&#44;6&#37;&#41;&#44; primera calcemia&#44; Ca1 &#40;8&#44;1 vs&#46; 7&#44;7 mg&#47;dL&#41;&#44; calcemia a las 24&#160;h &#40;Ca 24 h&#41; &#40;8 vs&#46; 7&#44;1&#160;mg&#47;dL&#41;&#44; calcemia a las 48&#160;h &#40;8&#44;1 vs&#46; 7 mg&#47;dL&#41; y calcemia a las 72&#160;h &#40;8&#44;4 vs&#46; 7&#44;3&#160;mg&#47;dL&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Comparando con el grupo control&#44; se aprecia que tanto el grupo A como el grupo B&#44; las determinaciones de PTHrpost y descenso&#44; as&#237; como las calcemias postoperatorias presentaron unas diferencias estad&#237;sticamente significativas como tambi&#233;n lo fue la edad &#40;47&#44;1 &#177; 13&#41;&#44; <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> &#46;Con el grupo B las diferencias son m&#225;s llamativas&#58; PTHrpost 12 &#40;10-19&#41; vs&#46; 57&#44;7 &#40;&#177; 25&#44;5&#41;&#44; descenso PTHr 83&#44;6 &#40;76-87&#41; vs&#46; 29&#44;7 &#40;&#177; 17&#44;4&#41;&#44; Ca&#160;24&#160;h 7&#44;1 &#40;&#177; 0&#44;5&#41; vs&#46; 8&#44;25 &#40;&#177; 0&#44;4&#41;&#44; p&#160;&#60;&#160;0&#44;001&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Predicci&#243;n riesgo hipocalcemia sintom&#225;tica</span><p id="par0120" class="elsevierStylePara elsevierViewall">Para determinar cu&#225;l de estos par&#225;metros pueden predecir mejor el riesgo de hipocalcemia comparamos el &#225;rea bajo la curva &#40;ABC&#41;&#44; de las siguientes variables &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#58; 0&#44;89 &#40;IC&#160;95&#37;&#58; 0&#44;8-0&#44;9&#41; para el descenso PTHr&#59; 0&#44;89 &#40;IC&#160;95&#37;&#58; 0&#44;8-0&#44;9&#41; para la PTHrpost&#59; de 0&#44;7 &#40;IC&#160;95&#37;&#58; 0&#44;6-0&#44;9&#41; para la calcemia de la tarde y de 0&#44;87 &#40;IC&#160;95&#37;&#58; 0&#44;8-0&#44;9&#41; para la calcemia a las 24&#160;h&#46; Para buscar la m&#225;xima sensibilidad y el menor n&#250;mero de falsos negativos &#40;FN&#41;&#44; se comparan estas variables con mayor ABC y se analizan diferentes puntos de corte arbitrarios basados en la literatura<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">8&#44;10-12</span></a> y en las medias bioqu&#237;micas obtenidas &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Se resume en la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#58; descenso de PTHr de 60&#44; 70 y 80&#37;&#44; valor absoluto de PTHrpost de 10&#44; 12&#44; 15&#160;pg&#47;mL&#44; calcemias entre 7&#44;2 a 7&#44;4&#160;mg&#47;dL&#44; as&#237; como asociaci&#243;n de descenso de 60&#37; y calcemia inferior a 7&#44;4&#160;mg&#47;dL&#46; Ninguno de estos puntos de corte consigue una sensibilidad del 100&#37; existiendo&#44; adem&#225;s&#44; falsos negativos&#46; Solo al combinar los par&#225;metros con la sensibilidad m&#225;s alta&#44; descenso mayor del 60&#37; con Ca&#160;24&#160;h inferior a 7&#44;4&#160;mg&#47;dL&#44; se llega a este 100&#37; sin dejar falsos negativos te&#243;ricos&#44; pero a costa de 48&#37; de falsos positivos&#46; Es destacable que solo cuatro pacientes sintom&#225;ticos presentaron un descenso inferior al 60&#37; con calcemias a las 24 h inferiores a 7&#44;4&#160;mg&#47;dL&#44; es decir&#44; el descenso de PTHr fue m&#225;s sensible que la calcemia&#44; excepto en estos cuatro pacientes&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Complicaciones</span><p id="par0125" class="elsevierStylePara elsevierViewall">De los 310 pacientes&#44; los 108 &#40;34&#44;8&#37;&#41; que corresponden al grupo B precisaron tratamiento con calcio &#40;por s&#237;ntomas o por hipocalcemia mantenida como se ha explicado&#41;&#46; De estos&#44; los 29 casos que permanecieron asintom&#225;ticos recibieron calcio oral para as&#237; romper la tendencia descendente de calcemias&#44; es posible que por ello no desarrollaran cl&#237;nica&#46; De hecho&#44; hubo 11 casos &#40;3&#46;3&#37;&#41; de hipoparatiroidismo definitivo&#44; todos en este grupo B y de ellos uno del subgrupo asintom&#225;tico&#46; El tiempo medio de suspensi&#243;n del tratamiento tras el alta fue de 3&#44;4 meses&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discusi&#243;n</span><p id="par0130" class="elsevierStylePara elsevierViewall">La tiroidectom&#237;a supone un factor de riesgo para la viabilidad de las gl&#225;ndulas paratiroides&#44; aumentando dicho riesgo con cirug&#237;as m&#225;s complejas &#40;linfadenectom&#237;a&#44; bocios grandes&#44; etc&#46;&#41;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">12-14</span></a>&#46; Por ello pensamos que el par&#225;metro m&#225;s adecuado para predecir la hipocalcemia postiroidectom&#237;a es la determinaci&#243;n de los niveles de PTH&#44; incluyendo este tipo de cirug&#237;as que aumentan el riesgo de lesi&#243;n glandular y&#44; en consecuencia&#44; los niveles de PTH&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Sin embargo&#44; existe una gran variabilidad de par&#225;metros a estudiar &#40;momento&#44; tipo de PTH&#44; manera de obtenerla&#44; definiciones de hipoparatiroidismo&#44; etc&#46;&#41;&#44; lo que hace muy dif&#237;cil establecer un umbral&#44; una cifra o un punto de corte que determine el riesgo de desarrollar hipocalcemia postiroidectom&#237;a<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">15-17</span></a>&#44;aunque tambi&#233;n apoyan su utilidad para detectar ese riesgo y&#47;o estratificar pacientes<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">4&#44;18&#44;19</span></a>&#46; La propia definici&#243;n de hipocalcemia es tambi&#233;n confusa&#44; consider&#225;ndose en la pr&#225;ctica una cifra inferior a los intervalos normales de laboratorio&#44; habitualmente 8&#160;mg&#47;dL &#40;2 mmol&#47;L&#41;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">10&#44;20&#44;21</span></a>&#46; Se justifica por ser &#171;cl&#237;nicamente&#187; m&#225;s relevante<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La Asociaci&#243;n de Cirujanos Endocrinos Australianos&#44; en una revisi&#243;n de cuatro art&#237;culos&#44; establece que la normalidad en la PTH a las cuatro horas predice normocalcemia&#44; aunque cifras bajas de PTH no son sensibles para predecir hipocalcemia<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a>&#46;Por otro lado&#44; Marthur revisando 69 art&#237;culos&#44; concluye que la &#171;extrema heterogeneidad&#187; hace dif&#237;cil adoptar un &#250;nico valor de PTH como predictor de hipocalcemia&#46; A esto contribuye la amplia disponibilidad de sistemas de determinaci&#243;n de PTH y la propia variabilidad entre ellos<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">22-24</span></a>&#46; La v&#237;a cl&#237;nica de la AEC recomienda analizar m&#225;s que un valor absoluto<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">25</span></a> el porcentaje del descenso de PTH&#46; Otras revisiones&#44; aun sosteniendo la ausencia de sensibilidad del 100&#37;&#44; establecen que su determinaci&#243;n es el mejor m&#233;todo de estratificar el riesgo<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">18&#44;19</span></a>&#46; Tambi&#233;n las hay que desestiman su utilidad&#59; del Rio en una serie de 1006 casos con an&#225;lisis de PTH a las 24&#160;h<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">26</span></a> y Lombardi a las 4&#160;h<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">27</span></a> son ejemplos de ello&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Comparativa entre determinaciones de PTH</span><p id="par0145" class="elsevierStylePara elsevierViewall">Las determinaciones de PTH y su relaci&#243;n con la hipocalcemia se pueden agrupar seg&#250;n el tipo&#58; est&#225;ndar<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">9&#44;28-30</span></a> o r&#225;pida<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">8&#44;12&#44;13&#44;20&#44;31</span></a> momento de la extracci&#243;n&#58; basal&#44; minutos <a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">12&#44;31-33</span></a>&#44; horas o d&#237;as postiroidectom&#237;a<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">21&#44;29&#44;33-35</span></a>&#59; valor analizado&#58; gradiente de descenso<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">11&#44;31&#44;36&#44;37</span></a> o valor absoluto<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">21&#44;28&#44;32&#44;33</span></a>&#59; asociaci&#243;n entre diferentes determinaciones de PTH y&#47;o calcemias<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">8&#44;12&#44;38-40</span></a>&#46; Todos estos datos raramente coinciden&#46; La sensibilidad del 100&#37; no es la norma<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">11&#44;29&#44;31&#44;37&#44;38&#44;41</span></a> y&#44; por ello&#44; los falsos negativos son frecuentes e importantes<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">28&#44;42</span></a>&#46; Sin embargo&#44; no parece que esta circunstancia afecte a la toma de decisiones&#44; alegando una baja posibilidad de presentar s&#237;ntomas&#44; o que los puntos de corte seleccionen a los pacientes sin riesgo<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">32&#44;43&#44;44</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Las determinaciones r&#225;pidas permiten obtener los resultados en la misma sesi&#243;n quir&#250;rgica con lo que se puede predecir el riesgo precozmente&#44; sin depender de terceras personas posteriormente&#44; con menos molestias para el paciente&#44; en definitiva&#44; optimizando el m&#233;todo<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">42</span></a>&#46; Lee<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">45</span></a> compara la determinaci&#243;n r&#225;pida con la est&#225;ndar en el postoperatorio inmediato sin encontrar diferencias significativas&#46; Aunque este menor tiempo de las muestras con los anticuerpos puede dar cifras m&#225;s orientativas que reales de PTH&#44; encuentra que un descenso de 75&#37; tiene una sensibilidad y especificidad de 100&#37; y 72&#37; respectivamente&#44; concluyendo que es &#250;til para predecir la funci&#243;n paratiroidea e identificar los pacientes en riesgo<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">31</span></a>&#46; Di Fabio tiene en su serie 33&#37; de casos con hipocalcemia y 25&#44;9&#37; de sintom&#225;ticos&#44; para los primeros un descenso de PTH &#40;basal-10&#8217;&#41; de 75&#44;7&#37; tiene la mayor sensibilidad &#40;81&#44;5&#37;&#41; y para los segundos un corte de 79&#44;5&#37; &#40;sensibilidad 76&#44;2&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Roh determina que un descenso de 70&#37; &#40;basal-10&#8217;&#41; y un PTHpost &#62;&#160;15&#160;pg&#47;mL puede discriminar qu&#233; pacientes est&#225;n en riesgo&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Con objeto de mejorar sensibilidad y falsos negativos se combinan diferentes par&#225;metros&#59; as&#237; Alia emplea el descenso de PTHr de 62&#44;5&#37; y una PTHrpost &#60; 18&#160;pg&#47;mL&#44; para llegar a una sensibilidad de 90&#37; y 17&#37; falsos negativos<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">8</span></a>&#46; Pisanu combina un valor de PTH de 12 pg&#47;ml con un descenso de 60&#37; a las 6 h para llegar a 100&#37;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Galy-Bernadoy compara dos kits de PTH con una sola determinaci&#243;n a los 10 minutos postiroidectom&#237;a&#46; Obtiene puntos de corte diferentes con cada uno para conseguir una VPP y VPN del 100&#37;&#46; En su serie hay 24&#37; de hipocalcemias asintom&#225;ticas y 14-28&#37; de casos en una &#171;zona gris&#187; para monitorizaci&#243;n o tratamiento&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En este trabajo analizamos el efecto de la tiroidectom&#237;a total sobre la secreci&#243;n de paratohormona perioperatoria &#40;empleando una medici&#243;n r&#225;pida&#41; y sobre las calcemias s&#233;ricas totales&#44; en el postoperatorio inmediato y su correlaci&#243;n con hipocalcemia bioqu&#237;mica y cl&#237;nica&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Tiroidectom&#237;as totales y hemitiroidectom&#237;as presentan un descenso de calcemia y PTHr postoperatoria<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">8&#44;20</span></a>&#46; Para determinar qu&#233; variable anal&#237;tica tiene la mayor sensibilidad en relaci&#243;n con la hipocalcemia&#44; se comparan las ABC&#46; Ninguno de los puntos de corte utilizados consigue 100&#37; de sensibilidad y con falsos negativos&#46; Para intentar mejorar estos resultados&#44; asociamos dos variables como tambi&#233;n se refleja en otros art&#237;culos<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">8&#44;29&#44;35&#44;38&#44;41</span></a> &#40;descenso superior de 60&#37; o calcemias inferiores a 7&#44;4&#160;mg&#47;dL a las 24 h&#41;&#46; Con estos criterios&#44; a pesar de aumentar los falsos positivos &#40;tratar innecesariamente&#41;&#44; se evitar&#237;an los falsos negativos &#40;no tratar precis&#225;ndolo&#41;&#44; lo que es clave como factor predictor&#46; Sin duda&#44; es m&#225;s seguro tratar innecesariamente algunos casos que dar de alta sin tratamiento cuando es necesario<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">42</span></a>&#46; Gran parte de la cirug&#237;a tiroidea se realiza en hospitales comarcales con menor volumen y menos recursos&#44; teniendo que adecuar los medios y tiempos a sus posibilidades con la menor incomodidad posible a los pacientes<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">42</span></a>&#46; Dada la variabilidad mencionada&#44; cada centro deber&#237;a utilizar sus propios medios disponibles&#44; y elaborar su algoritmo de predicci&#243;n&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Las limitaciones de este estudio son varias&#58; las determinaciones bioqu&#237;micas disponibles&#59; los pacientes del grupo B asintom&#225;ticos &#40;29 casos&#41; se les administr&#243; calcio oral previo alta&#44; aunque probablemente se hubieran mantenido asintom&#225;ticos y con calcemias tendentes a la normalizaci&#243;n en pocos d&#237;as&#46; El criterio para ello fue el descenso paulatino de las calcemias<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">46</span></a> que imped&#237;a un alta segura&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">La conclusi&#243;n de nuestro estudio es que la determinaci&#243;n de PTH r&#225;pida refleja claramente el efecto de la cirug&#237;a sobre la funci&#243;n paratiroidea postiroidectom&#237;a&#44; y puede usarse como factor predictor de hipocalcemia&#46; La combinaci&#243;n del porcentaje de descenso de PTHr &#40;60&#37;&#41; con la calcemia a las 24 horas &#40;&#60;&#160;7&#44;4&#160;mg&#47;dL&#41; consigue una sensibilidad del 100&#37;&#46; Con los puntos de corte seleccionados&#44; podr&#237;an identificarse los pacientes sin riesgo&#44; evitando tratamientos generalizados y un alta m&#225;s temprana con criterios cient&#237;ficos&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Financiaci&#243;n</span><p id="par0190" class="elsevierStylePara elsevierViewall">La presente investigaci&#243;n no ha recibido ayudas espec&#237;ficas provenientes de agencias del sector p&#250;blico&#44; sector comercial o entidades sin &#225;nimo de lucro&#46;</p></span></span>"
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              "titulo" => "Definici&#243;n y tratamiento de hipocalcemia"
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              "titulo" => "Comparativa entre grupos"
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              "titulo" => "Predicci&#243;n riesgo hipocalcemia sintom&#225;tica"
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              "titulo" => "Complicaciones"
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              "titulo" => "Comparativa entre determinaciones de PTH"
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            2 => "Paratohormona"
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            1 => "Hypocalcemia"
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    "resumen" => array:2 [
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introducci&#243;n</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La hipocalcemia es la complicaci&#243;n que condiciona el postoperatorio de la tiroidectom&#237;a&#46; El objetivo de este trabajo es identificar criterios bioqu&#237;micos de riesgo de hipocalcemia analizando niveles de paratohormona r&#225;pida &#40;PTHir&#41; pre y postiroidectom&#237;a y de calcemias postoperatorias&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se recoge una serie consecutiva de 310 tiroidectom&#237;as totales&#44; obteniendo muestras de PTHr basal y tras 10 minutos postiroidectom&#237;a&#44; junto a calcemias s&#233;ricas cada 12 horas&#46; Se estudian dos grupos&#44; A normocalc&#233;micos&#44; B hipocalc&#233;micos&#46; Se calcula la sensibilidad&#44; especificidad&#44; valor predictivo positivo y negativo en relaci&#243;n con la hipocalcemia utilizando las curvas ROC y sus &#225;reas bajo la curva&#46; Se analiza un grupo control de 48 hemitiroidectom&#237;as para comparar los efectos de la cirug&#237;a sobre la secreci&#243;n de PTH&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">De los 310 pacientes&#44; 202 &#40;65&#44;1&#37;&#41; se mantuvieron normocalc&#233;micos y asintom&#225;ticos &#40;grupo A&#41;&#44; 108 &#40;34&#44;9&#37;&#41;&#160;presentaron hipocalcemia Grupo B&#44; precisando calcio oral &#40;79 sintom&#225;ticos&#41;&#46; Tras el an&#225;lisis de varios puntos de corte&#44; combinando un gradiente de descenso de PTHr del 60&#37; o una calcemia menor de 7&#44;4&#160;mg&#47;dL a las 24 horas se consigue una sensibilidad del 100&#37; sin dejar falsos negativos&#46; Comparando con el grupo de control existe una diferencia significativa respecto de las calcemias y la PTHr postoperatorias&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La tiroidectom&#237;a total afecta la funci&#243;n paratiroidea con descenso evidente de PTHr y riesgo de hipocalcemia&#46; La combinaci&#243;n de un descenso del 60&#37; o la calcemia inferior a 7&#44;4&#160;mg&#47;dL a las 24 horas obtiene una sensibilidad del 100&#37; para la predicci&#243;n de pacientes en riesgo de hipocalcemia&#46;</p></span>"
        "secciones" => array:4 [
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hypocalcemia is the most frequent complication after thyroidectomy&#46; The aim of this work is to identify biochemical risk factors of hypocalcemia using quick perioperative &#40;pre and post-thyroidectomy&#41; intact parathyroid hormone &#40;PTHi&#41; and postoperative calcemias&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">In a consecutive series of 310 total thyroidectomies&#44; samples of quick PTHi at the anaesthetic induction and 10 minutes after surgery&#44; together with serum calcemias every 12 hours were obtained&#46; The sensitivity&#44; specificity&#44; positive and negative predictive value are analyzed and related to hypocalcemia&#46; A control group of hemithyroidectomies is also analyzed to compare the effects of surgery on PTH secretion&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Of the 310 patients&#44; 202 &#40;65&#46;1&#37;&#41; remained normocalcemic and asymptomatic &#40;group A&#41;&#44; 108 &#40;34&#46;9&#37;&#41; presented hypocalcemia &#40;Group B&#41;&#44; requiring oral calcium &#40;79 symptomatic&#41;&#46; After analysis of several cut-off points&#44; combining a PTHr drop gradient of 60&#37; or calcemia inferior to 7&#46;4 mg&#47;dl at 24 hours&#44; a sensitivity of 100&#37; is achieved without leaving false negatives&#46; Compared to the control group&#44; there is a significant difference with respect to the post-operative calcemias and PTHr&#44; p&#160;&#60;&#160;0&#46;001&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Total thyroidectomy affects parathyroid function with evident decrease in rPTH and risk of hypocalcemia&#46; The combination of PTHr decrease of 60&#37; or less than 7&#46;4 mg&#47;dl calcemia at 24 hours gives a 100&#37; sensitivity for predicting patients at risk of hypocalcemia&#46;</p></span>"
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          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Curvas COR&#46; Se incluyen calcemias de la tarde de la operaci&#243;n &#40;Ca1&#41;&#44; calcemia a las 7&#58;00 am de la ma&#241;ana siguiente de la intervenci&#243;n Ca&#160;24&#160;h&#44; gradiente descenso de PTHr &#40;basal-post&#41; y valor absoluto de PTHrpost&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grupo A</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grupo B</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Control</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="9" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">G&#233;nero</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mujer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">167&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#46;s&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#46;s&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Var&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Edad&#46; Media &#40;DT&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;13&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;12&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="9" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diagn&#243;stico</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BMN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">149&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">63&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">n&#46;s&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#46;s&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BMN intrator&#225;cico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bocio nodular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enf&#46; Graves-Basedow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Met&#225;stasis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tiroiditis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Reoperaci&#243;n c&#225;ncer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Linfadenectom&#237;a central</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t  " colspan="9" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Benigno&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">n&#46;s&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hiperplasia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tiroiditis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#44;1-46&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">108&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#91;10-19&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14&#44;0-17&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">p &#60; 0&#44;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Descenso PTHr &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#91;27-68&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#44;7-54&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84 &#91;76-88&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#44;0-82&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p &#60; 0&#44;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio 1 &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;1 &#40;0&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;1-8&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;8 &#40;0&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;7-7&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p &#60; 0&#44;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio 24 h &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">202&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#44;0 &#40;0&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;8-8&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;2 &#40;0&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;1-7&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p &#60; 0&#44;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio 48 h &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">148&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;1 &#40;0&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#44;0-8&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;1 &#40;0&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;0-7&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">p &#60; 0&#44;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio 72 h &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&#44;4 &#40;0&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;7-9&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;3 &#40;0&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;2-7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">p &#60; 0&#44;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio 4&#46;&#176; d&#237;a &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;3-7&#44;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio 5&#46;&#176; d&#237;a &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">7&#44;7 &#40;0&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#44;2-8&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio 6&#176; d&#237;a &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;9 &#40;0&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcio 7&#46;&#176; d&#237;a &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;4 &#40;0&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;4 &#40;0&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#46;s&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#44;5 &#91;62&#44;8-110&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&#44;3 &#91;38&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#46;s&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PTHr post &#40;pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25&#44;4 &#91;13&#44;0-48&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">41 &#91;24-59&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">65&#44;7 &#91;40&#44;5-82&#44;9&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#91;27-68&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Calcio 1 &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;7 &#40;0&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;1 &#40;0&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#44;1 &#40;0&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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Información del artículo
ISSN: 0009739X
Idioma original: Español
DOI:10.1016/j.ciresp.2020.05.009
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