规范化护理方案在甲状腺肿瘤术后低钙血症患者中的应用研究

目的评价规范化护理方案在甲状腺肿瘤行全甲状腺切除术后低钙血症患者中的应用效果。方法成立规范化护理管理小组,制定全甲状腺切除术后低钙血症的规范化护理方案,并对所有在岗护士进行规范化护理方案培训。采取方便抽样法,选取方案实施前(对照组,2017年6月至11月收治)及方案实施后(观察组,2018年1月至7月收治)于江苏省肿瘤医院行全甲状腺切除且出现低钙血症的各50例患者,比较两组患者低钙症状发生情况及对护理质量满意度的差异。结果观察组患者的低钙症状发生率下降了38％,症状减轻,肢端麻木感发生率低于对照组(18％ vs. 44％),差异有统计学意义(P<005)。观察组患者对护理质量的总体满意度比对照组提升,差异有统计学意义(P<005)。结论规范化护理方案有利于降低全甲状腺切除术后低钙症状的发生率,减轻低钙症状,增强护理人员对低钙血症的预防意识,提高患者对护理质量的满意度。     

Effect of calcium replacement on the hemodynamic changes associated with high dose interleukin-2 therapy.

Administration of high-dose IL-2 results in hemodynamic changes that are similar to those seen in septic shock. These include a decrease in systemic vascular resistance (SVR) with a resultant drop in mean arterial pressure (MAP). Hypocalcemia is seen in septic shock and with IL-2 administration. Calcium replacement in septic shock has been reported to result in hemodynamic improvement; we therefore administered calcium to patients receiving high dose IL-2 to correct ionized hypocalcemia. Five consecutive patients underwent invasive hemodynamic monitoring before and during IL-2 administration. Calcium chloride was administered to correct ionized hypocalcemia, and hemodynamic parameters were monitored before and after calcium administration. Ionized hypocalcemia was associated with an elevation in parathyroid hormone levels. There was no toxicity related to the administration of calcium. An improvement in the MAP and SVR was seen early and late (after a dose of IL-2 was held) in the IL-2 treatment cycle; there were minimal effects at other points. Because of the potential hemodynamic benefit of calcium replacement, we recommend that ionized hypocalcemia be corrected in patients receiving high-dose IL-2.     

纳米炭在甲状腺癌手术中对甲状旁腺及喉返神经的保护作用

目的探讨纳米炭在甲状腺癌手术中对甲状旁腺及喉返神经保护的应用价值。方法 选取2016年10月至2018年8月于桂林医学院第二附属医院乳腺甲状腺外科行全甲状腺切除收治的甲状腺癌患者112例,随机均分为观察组和对照组。观察组注射纳米炭后行甲状腺全切及中央区淋巴结清扫,对照组未注射纳米炭,而直接手术。测量两组术前及术后第1、3和30天的血钙、甲状旁腺激素(PTH)水平,统计淋巴结清扫数量、淋巴结转移、甲状旁腺误切、暂时性低钙血症和永久性低钙血症及喉返神经损伤情况。结果两组患者术前及术后第30天的血钙、PTH水平比较差异均无统计学意义(P>005),观察组术后第1、3天的血钙、PTH水平均高于对照组(P<005)。观察组病理检出中央区淋巴结数量多于对照组(P<005),但两组淋巴结转移率差异无统计学意义(P>005)。观察组甲状旁腺误切率、术后暂时性低钙血症和永久性低钙血症的发生率以及喉返神经损伤率均低于对照组(P<005)。结论在甲状腺癌行全甲状腺切除及中央区淋巴结清扫术中应用纳米炭,可有效降低甲状旁腺误切及喉返神经损伤率,具有较高的临床应用价值。     

Early onset of tetany following thyroidectomy: report of two cases

The most common complication of total thyroidectomy is hypocalcemia. Following thyroidectomy, especially total thyroidectomy, the serum calcium usually falls gradually and patients do not usually require supplementary medication before 24 hours. Two cases of total thyroidectomy are presented in which the preoperative serum calcium levels were normal and hypocalcemic tetany developed in the recovery room immediately after the operation. The hypocalcemia was a temporary phenomenon, and neither patient requires supplementary calcium at the present time. There is no good explanation for this precipitous drop in the serum calcium levels in these two patients.     

丹参川芎制剂对治疗甲状腺癌术后甲状旁腺功能减退的临床研究

目的 探讨丹参川芎制剂对甲状腺癌术后低钙血症和甲状旁腺功能减退的疗效。 方法  选择2016年1月至2017年12月江苏省肿瘤医院头颈外科收治的30例甲状腺癌术后并发低钙血症和甲状旁腺功能减退患者。遵患者意愿，接受丹参川芎注射液治疗为观察组，共15例，在传统葡萄糖酸钙注射液和骨化三醇治疗基础上加用丹参川芎注射液；对照组予传统葡萄糖酸钙注射液和骨化三醇治疗，共15例。分析丹参川芎制剂对术后甲状旁腺功能减退的治疗效果。 结果  观察组和对照组术后第1天血钙水平相比，差异无统计学意义（P＞005）；观察组术后第3、7、30天血钙水平高于对照组，差异有统计学意义（P＜005）。观察组和对照组术后第1、3天血甲状旁腺激素（PTH）水平相比，差异无统计学意义（P＞005）；观察组术后第7、30天血钙水平高于对照组，差异有统计学意义（P＜005）。 结论  丹参川芎制剂对术后甲状旁腺功能减退及低钙血症治疗效果明显，且不良反应低，值得临床应用。     

甲状腺全切除术在分化型甲状腺癌外科治疗中的应用价值

目的 探讨甲状腺全切除术在甲状腺癌外科治疗中的应用价值.方法 对60例分化型甲状腺癌患者的临床资料进行回顾性分析和总结,其中采用甲状腺全切除术的患者48例,采用甲状腺次全切除术的患者12例.结果 48例进行甲状腺全切除术的患者术后发生低钙及声嘶5例(10.42％),1年间甲状腺癌复发1例(2.08％);12例采用甲状腺次全切除术的患者术后发生低钙及声嘶6例(50.00％),1年间甲状腺癌复发5例(41.67％).采用甲状腺次全切除术治疗的患者更易出现术后并发症(P =0.042),且1年间甲状腺癌的复发率更高.结论 甲状腺全切除术是治疗分化型甲状腺癌的一种有效方式,但采用甲状腺全切除术对患者进行治疗时要预防并发症的发生.     

Calcium-induced activation of a mutant G-protein-coupled receptor causes in vitro transformation of NIH/3T3 cells

The calcium-sensing receptor (CaR) is a G-protein-coupled receptor that is widely expressed, has tissue-specific functions, and regulates cell growth. Activating mutations of this receptor cause autosomal dominant hypocalcemia, a syndrome characterized by hypocalcemia and hypercalciuria. The identification of a family with an activating mutation of the CaR (Thr151Met) in which hypocalcemia cosegregates with several unusual neoplasms led us to examine the transforming effects of this mutant receptor. Transfection of NIH/3T3 cells with the mutant but not the normal receptor supported colony formation in soft agar at subphysiologic calcium concentrations. The mutant CaR causes a calcium-dependent activation of the extracellular signal-regulated protein kinase (ERK) 1/2 and Jun-N-terminal kinase/stress-activated (JNK/SAPK) pathways, but not P38 MAP kinase. These findings contribute to a growing body of information suggesting that this receptor plays a role in the regulation of cellular proliferation, and that aberrant activation of the mutant receptor in this family may play a role in the unusual neoplastic manifestations.     

A Case of Leiomyosarcoma Associated with Humoral Hypercalcemia of Malignancy: Demonstration of Biological and Immunological Activities of Parathyroid Hormone-related Protein in the Tumor Extract

Hypercalcemia occurred in a patient with leiomyosarcoma when multiple lung metastases developed. Despite normal plasma parathyroid hormone (PTH) levels and low 1,25-dihydroxyvitamin D, this hypercalcemic patient had a marked hypercakiuria and phosphatnria associated with an increased excretion of nephrogenous cyclic AMP (NcAMP). Administration of cisplatin ameliorated both the hypercalcemia and hypercalciuria without any reduction in tumor size or NcAMP excretion. Terminally, acute pancreatitis occurred producing a profound hypocalcemia. In the extract of tumor tissue obtained post mortem, bioactivity stimulating the generation of cyclic AMP in osteogenic cells was demonstrated along with the immunoreactive PTH-related protein (PTH-rP). This is the first report of a solid non-epithelial malignancy producing PTH-rP and associated with humoral hypercalcemia of malignancy. The hypercalcemia in this case caused acute pancreatitis, which led to a profound hypocalcemia     

Role of Postoperative Vitamin D and/or Calcium Routine Supplementation in Preventing Hypocalcemia After Thyroidectomy: A Systematic Review and Meta‐Analysis

Background.

Transient hypocalcemia is a frequent complication after total thyroidectomy. Routine postoperative administration of vitamin D and calcium can reduce the incidence of symptomatic postoperative hypocalcemia. We performed a systematic review to assess the effectiveness of this intervention. The primary aim was to evaluate the efficacy of routine postoperative oral calcium and vitamin D supplementation in preventing symptomatic post-thyroidectomy hypocalcemia. The second aim was to draw clear guidelines regarding prophylactic calcium and/or vitamin D therapy for patients after thyroidectomy.

Methods.

We identified randomized controlled trials comparing the administration of vitamin D or its metabolites to calcium or no treatment in adult patients after thyroidectomy. The search was performed in PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Google Scholar, and Web of Knowledge databases. Patients with a history of previous neck surgery, calcium supplementation, or renal impairment were excluded.

Results.

Nine studies with 2,285 patients were included: 22 in the vitamin D group, 580 in the calcium group, 792 in the vitamin D and calcium group, and 891 in the no intervention group, with symptomatic hypocalcemia incidences of 4.6%, 14%, 14%, and 20.5%, respectively. Subcomparisons demonstrated that the incidences of postoperative hypocalcemia were 10.1% versus 18.8% for calcium versus no intervention and 6.8% versus 25.9% for vitamin D and calcium versus no intervention. The studies showed a significant range of variability in patients'' characteristics.

Conclusions.

A significant decrease in postoperative hypocalcemia was identified in patients who received routine supplementation of oral calcium or vitamin D. The incidence decreased even more with the combined administration of both supplements. Based on this analysis, we recommend oral calcium for all patients following thyroidectomy, with the addition of vitamin D for high-risk individuals.     

Diagnostic and therapeutic aspects of iatrogenic hypoparathyroidism

Postsurgical hypoparathyroidism is the most common cause of chronic hypocalcemia. This condition may occur after removal of all parathyroid glands or after interruption of the blood supply to the parathyroid glands during thyroidectomy and radical neck dissection. The severity of the clinical presentation of hypocalcemia may vary from an asymptomatic laboratory finding to a severe life-threatening condition. Persistent hypoparathyroidism requires treatment that must be maintained throughout the patient's lifetime, and for this reason care is required to avoid complications. In this review the most relevant aspects of calcium homeostasis and its alteration in hypoparathyroidism are briefly discussed. In addition, the main approaches to treatment of the hypocalcemic state are presented.     

A case of leiomyosarcoma associated with humoral hypercalcemia of malignancy: demonstration of biological and immunological activities of parathyroid hormone-related protein in the tumor extract

Hypercalcemia occurred in a patient with leiomyosarcoma when multiple lung metastases developed. Despite normal plasma parathyroid hormone (PTH) levels and low 1,25-dihydroxyvitamin D, this hypercalcemic patient had a marked hypercalciuria and phosphaturia associated with an increased excretion of nephrogenous cyclic AMP (NcAMP). Administration of cisplatin ameliorated both the hypercalcemia and hypercalciuria without any reduction in tumor size of NcAMP excretion. Terminally, acute pancreatitis occurred producing a profound hypocalcemia. In the extract of tumor tissue obtained post mortem, bioactivity stimulating the generation of cyclic AMP in osteogenic cells was demonstrated along with the immunoreactive PTH-related protein (PTH-rP). the first report of a solid non-epithelial malignancy producing PTH-rP and associated with humoral hypercalcemia of malignancy. The hypercalcemia in this case caused acute pancreatitis, which led to a profound hypocalcemia.     

甲状腺多发良性结节术后并发症风险的比较—Meta分析

Objective

The aim of our study was to compare the risk of main postoperative complications of patients underwent total thyroidectomy (TT), near total thyroidectomy (NTT) and subtotal thyroidectomy (ST) for treating BMNG.

Methods

Electronic databases including Cochrane Controlled Trials Register, EMbase, Medline, SCI Expanded-ISI, NTIS, SIGLE and CNKI were searched. Eligible studies were randomized controlled trials which compared the incidence of postoperative complications of TT with ST/NTT for treating BMNG. Data extraction was using predefined data fields and assessment of methodological quality with the GRADE approach. A Mantel-Haenszel random-effects model was used and the effect sizes were expressed by using relative risks and 95% confidence intervals.

Results

Four studies including 881 participants that met inclusion criteria were analyzed. Compared with ST/NTT, TT was associated with increased risk of transient RLNI (recurrent laryngeal nerve injuries) (relative risk 2.18, 95% confidence interval 1.08 to 4.42; P < 0.05) and transient hypocalcemia (3.79, 1.64 to 8.77; P < 0.05), but there were no statistically significant differences in permanent RLNI (1.36, 0.31 to 6.02; P > 0.05) and permanent hypocalcemia (2.37, 0.35 to 15.97; P > 0.05). The quality of evidence for each individual outcome was ultimately rated as moderate (permanent RLNI and permanent hypocalcemia), low (transient RLNI and transient hypocalcemia).

Conclusion

For treating BMNG with thyroidectomy, there were no statistically significant differences in postoperative complications between TT and ST/NTT on a long view.     

Persistent hypocalcemia induced by zoledronic acid in a patient with androgen-independent prostate cancer and extensive bone metastases

Zoledronic acid is a highly potent bisphosphonate that has been shown to reduce skeletal-related events in patients with androgen-independent prostate cancer metastatic to bone. We report a patient with androgen-independent prostate cancer and extensive bone metastases. After receiving a single dose of zoledronic acid, the patient developed hypocalcemia that persisted for approximately 60 days despite intravenous and oral calcium supplementation, likely because of excess unopposed osteoblastic activity. This case underscores the need for calcium and vitamin D monitoring and supplementation to avoid bisphosphonate-induced secondary hyperparathyroidism and highlights the possibility that extensive osteoblastic metastasis alone might lead to hypocalcemia.     

Effects of prospidin on the development of pulmonary metastases of Lewis tumors in rats in regard to changes in the level of extracellular calcium

The effect of prospidin on Lewis lung carcinoma spreading under hyper- and hypocalcemia was studied. At early stages, increased extracellular calcium level was associated with inhibition of tumor dissemination to the lungs; however, later, colony growth was stimulated. Extracellular calcium level was shown to modulate the antitumor and antimetastatic effect of prospidin.     

Denosumab: Prevention and management of hypocalcemia,osteonecrosis of the jaw and atypical fractures

Denosumab, a bone‐modifying agent, reduces the risk of skeletal‐related events in patients with bone metastases from solid tumors and is generally well tolerated. However, hypocalcemia, osteonecrosis of the jaw (ONJ) and atypical fracture are potential and important toxicities of denosumab therapy that require attention. In pivotal phase III trials in patients with bone metastases from solid tumors, the incidence of hypocalcemia was 9.6% in denosumab‐treated patients, with most events being asymptomatic, grade 2 and resolving by week 4. Established hypocalcaemia requires additional short‐term calcium and vitamin D supplementation and, if severe, administration of intravenous calcium. ONJ was reported in 1.8% of patients receiving denosumab over 3 years in these trials. Involvement of an experienced oro‐maxillary surgeon is important if ONJ is suspected. Atypical fractures were rare in a large study of denosumab using the dose and scheduling approved for the treatment of osteoporosis. To prevent toxicities, patients should maintain calcium and vitamin D supplementation, good oral hygiene and regular dental reviews throughout treatment. This article presents case studies from our clinical practice and discusses the pathophysiology of these toxicities along with guidance on prevention, diagnosis and management.     

A case of advanced breast cancer associated with hypocalcemia

Although hypercalcemia is a well-known complication of malignantdiseases, hypocalcemia seems to be a rather rare one. A 34-yr-oldwoman with advanced breast cancer who presented hypocalcemiais described. She had generalized multiple osteolytic bone metastaseswhich were progressive in spite of chemo-endocrine and radiationtherapy. She was admitted because of severe bone pain and dyspneacaused by bilateral pleural effusion. Laboratory examinationon admission showed that the serum calcium was 9.6 mg/dl, serumtotal protein 5.9 g/dl, serum inorganic phosphorus 4.6 mg/dl,and serum alkaline phosphatase 29.6 King-Armstrong units. Theserum calcium gradually fell to 7.0 mg/dl on the 45th hospitalday when the serum total protein was 6.8 g/dl and she complainedof paresthesia in the extremities. On the 58th day, severe tachycardiaand hypotension developed and she died of congestive heart failureon the 67th hospital day. At that time the serum calcium was5.4 mg/dl. During her hospital course, the plasma parathyroidhormone levels were examined repeatedly and were 0.4, 0.6, 0.6and 0.7 ng/ml (normal; less than 0.5 ng/ml). Autopsy revealedthat cancer invaded the space between the thyroid and the tracheaand no parathyroid glands could be found even in the mediastinum.Microscopically the parathyroid glands were replaced completelyby the cancer cells. These observations indicate that metastasis of breast cancerto the parathyroid glands caused relative hypoparathyroidism,resulting in hypocalcemia. In addition, congestive heart failurewhich was refractory to digitalis and diuretics might have beencaused by impaired contractility of the myocardium associatedwith hypocalcemia.     

纳米碳示踪剂在30例甲状腺癌手术中的应用

目的:探讨纳米碳示踪剂在30例甲状腺癌手术中的应用效果。方法:将60例甲状腺癌患者随机均分为纳米炭组和对照组,行甲状腺全切及患侧Ⅵ区颈部淋巴结廓清术,纳米炭组在行淋巴结廓清术前应用纳米炭示踪剂,对照组不使用,比较2组患者的淋巴结清扫数目、术后血钙水平及甲状旁腺素（PTH）水平。结果:纳米炭组每例患者平均清扫淋巴结6.5枚,对照组3.2枚（P＜0.05）;纳米炭组术后发生一过性低钙血症患者1例,对照组12例（P＜0.05）;纳米炭组术后发生PTH暂时下降的患者2例,对照组9例（P＜0.05）。结论:纳米炭淋巴示踪剂的应用可明显提高甲状腺癌患者Ⅵ区淋巴结的清扫数目,术中有助于甲状旁腺的识别并保护甲状旁腺的功能。     

The management of tumor lysis syndrome

The manifestation of tumor lysis syndrome (TLS) occurs when the destruction of tumor cells releases breakdown products that overwhelm the excretory mechanisms of the body. A cardinal sign is hyperuricemia, leading to uric acid nephropathy. Other signs are hyperkalemia, hyperphosphatemia and secondary hypocalcemia. Conventional management of TLS consists of aggressive intravenous hydration, diuretic therapy, urinary alkalization, and inhibition of urate production by high-dose allopurinol. Urate oxidase has been used in the management of patients at risk for TLS and recently the recombinant urate oxidase rasburicase was developed. Several data indicate that rasburicase is effective and well tolerated in the prevention and treatment of chemotherapy-induced hyperuricemia. Treatment options of hyperkalemia include sodium polystyrene sulfonate, hypertonic glucose and insulin, loop diuretics, and bicarbonate. Treatment of hyperphosphatemia reduces dietary phosphate intake and includes phosphate binders such as aluminum hydroxide and aluminum carbonate. When recurrent hypocalcemia is present, a continuous intravenous infusion of calcium gluconate can be initiated. Hemodialysis should be considered for every patient with excessively elevated uric acid, phosphate and/or potassium and in those patients with acute renal failure to control urinary volume and manage uremia.     

Permanent hypocalcemia in patients operated for thyroid carcinoma

Aim and objective

The incidence and risk factors for permanent hypocalcemia in thyroid carcinoma were investigated.

Materials and methods

The records of 417 patients were reviewed retrospectively at tertiary oncology referral center. Total or subtotal thyroidectomy patients constituted group I (n = 225), reoperative thyroid surgery patients constituted group II (n = 106), and therapeutic neck dissection cases constituted group III (n = 86). Age, gender, thyroid functions, pathologically verified tumor type, differentiation, localization and size, multicentricity, thyroid capsule invasion, extrathyroidal soft tissue invasion, coexistence of lymphocytic thyroiditis, metastatic lymph nodes dissected, incidental parathyroidectomy, and the type of surgery were investigated.

Re sults

Permanent hypocalcemia was seen in 32 (7.7%) patients. The incidence of permanent hypocalcemia for each group was 1.7%, 10.3% and 19.7%, respectively. Related risk factors were hyperthyroidism for group I [adjusted relative risk (RR) = 21.1, 95% confidence interval (CI) = 2.6–165, p = 0.01] incidental parathyroidectomy for group II (RR = 7.8, 95% CI = 1.9–31.0, p = 0.004), and extrathyroidal soft tissue invasion (RR = 3.1, 95% CI = 1.1–9.5, p = 0.03) for group III.

Conclusion

Permanent hypocalcemia rate was increased with reoperative thyroid surgery and neck dissection added to total thyroidectomy. Hyperthyroidism, incidental parathyroidectomy and extrathyroidal extension were related risk factors.     

Extreme hyperphosphatemia with hypocalcemia within the scope of cell lysis syndrome in a child with T-ALL

In a 10 3/4-year-old girl suffering from a T-ALL with an extremely high leukocyte blood cell count (400,000/microliters) we observed a tumor-lysis syndrome with hyperphosphatemia and hypocalcemia accompanied by clinical signs of tetany. The therapeutic application of calcium gluconate resulted in vascular calcification by exceeding by far the calcium-phosphate solubility product. The fast lysis of T-lymphoblasts with their high phosphate concentration is etiologically involved in the hyperphosphatemia. Our patient died of multiorganic failure. Regular monitoring of phosphate in urine might be helpful in instituting early therapeutic procedures.