Regina Promberger

Risk factors for postoperative bleeding after thyroid surgery

Postoperative bleeding after thyroid surgery is a feared and life‐threatening complication. The aim of the study was to identify risk factors for postoperative bleeding, with special emphasis on the impact of the individual surgeon and the time to diagnosis of the complication.

Hashimoto's Thyroiditis Affects Symptom Load and Quality of Life Unrelated to Hypothyroidism: A Prospective Case–Control Study in Women Undergoing Thyroidectomy for Benign Goiter

BACKGROUND Hashimotos thyroiditis (HT) is a common disease, and is the most prevalent cause of hypothyroidism. Symptoms and diseases associated with HT are considered to be caused by hypothyroidism. We hypothesized that higher antithyroperoxidase (anti-TPO) antibody levels would be associated with an increased symptom load and a decreased quality of life in a female euthyroid patient collective. METHODS In a prospective cohort study 426 consecutive euthyroid female patients undergoing thyroid surgery for benign thyroid disease were included. Main outcome measures were preoperative anti-TPO levels, a symptom questionnaire and the SF-36 questionnaire, and lymphocytic infiltration of the thyroid tissue as evaluated by histology. RESULTS Histology revealed HT in 28/426 (6.6%) subjects. To maximize the sum of the predictive values, a cut-off point for anti-TPO of 121.0 IU/mL was calculated (sensitivity 93.3% [95% confidence interval: 77.9%-99.0%]; specificity 94.7% [95% confidence interval: 92.0%-96.7%]) to predict the presence of histological signs of HT. The mean number of reported symptoms was significantly higher in patients with anti-TPO levels >121.0 IU/mL than in the other group (6.7 ± 2.5 vs. 4.1 ± 2.8; p < 0.001). There were no differences in preoperative thyroid-stimulating hormone levels (1.7 ± 1.3 vs. 1.5 ± 1.4 μU/mL, respectively; p = 0.155). Chronic fatigue, dry hair, chronic irritability, chronic nervousness, a history of breast cancer and early miscarriage, and lower quality-of-life levels were significantly associated with anti-TPO levels exceeding the cut-off point (p < 0.05). CONCLUSIONS Women with HT suffer from a high symptom load. Hypothyroidism is only a contributing factor to the development of associated conditions.

Kinetics of serum parathyroid hormone during and after thyroid surgery.

Hypocalcaemia after thyroidectomy is thought to result from surgical damage to the parathyroid glands. This study analysed postoperative outcomes related to perioperative parathyroid hormone (PTH) levels.

Intra- and Postoperative Parathyroid Hormone-Kinetics Do Not Advocate for Autotransplantation of Discolored Parathyroid Glands During Thyroidectomy

BACKGROUND Thyroidectomy continues to pose the risk of typical complications, including postoperative hypocalcemia and permanent hypoparathyroidism. The strategic decision on how to preserve parathyroid hormone (PTH) secretion relies on assessing the viability of the parathyroid glands (PGs). The aim of this study was to assess parathyroid discoloration as an indicator for loss of parathyroid function. METHODS The prospective study included 29 patients (24 women, 5 men; age 53.2 ± 13.0 years) who underwent near-total or total thyroidectomy. An intra- and postoperative PTH and calcium monitoring was performed. The intraoperative situs of the PGs was documented by a study protocol. The patients were grouped in three categories: group A, 12 patients with four visualized and normally colored PGs; group B, 13 patients with four visualized and three or four discolored PGs; group C, 4 patients who had undergone autotransplantation of two PGs. RESULTS Compared to group A, groups B and C showed sharper intraoperative PTH declines. PTH values recovered more quickly in group B than in group C. However, no significant differences in PTH kinetics were found in the general linear model for repeated measures (p = 0.132). However, a significantly higher incidence of protracted hypocalcemia-related symptoms for more than 14 postoperative days was found for group C (50.0%) than for groups A (0%) and B (0%; p = 0.011). None of the patients developed permanent hypoparathyroidism. CONCLUSIONS The function of discolored PGs is only transiently impaired and recovers within a short time after surgery. Our observations do not support autotransplantation as a generally applicable first-line intervention for discolored PGs in the absence of other criteria for autotransplantation.

Laparoscopic ovarian tissue harvesting for cryopreservation: an effective and safe procedure for fertility preservation

OBJECTIVE To critically review our experience with the method of laparoscopic ovarian tissue harvesting for ovarian cryopreservation. STUDY DESIGN In a retrospective cohort study 85 patients undergoing surgery for cryopreservation of ovarian tissue were included. One random ovarian cortical slice was histologically examined in order to determine the presence of primordial follicles and to detect possible malignant cells. Selective microbiological culture techniques from swabs were taken from all slices immediately after excision. Intra- and postoperative courses, histological and microbiological findings were evaluated. RESULTS Eighty-five patients underwent cryopreservation of ovarian tissue, mostly for malignant diseases (78/85, 91.8%). Sixty patients (70.6%) underwent laparoscopy for ovarian tissue harvesting only, without any additional surgical procedure. The median operating time was 30 min (range 10-75 min). The intraoperative course was uneventful in these patients. In two patients slight postoperative increases in C-reactive protein levels were found. Microbiological examination revealed no contamination apart from one case revealing sporadic Propionibacterium acnes. Histological examination revealed intact ovarian tissue with primordial follicles in 81/85 patients (95.3%). CONCLUSION Laparoscopy is a safe and effective procedure for ovarian tissue harvesting. We suggest microbiological and histological testing of ovarian tissue as mandatory tools to guarantee safety regarding ovarian tissue transplantation.

An everyday phrase may harm your patients: the influence of negative words on pain during venous blood sampling.

Objective:Venous blood sampling is one of the most common diagnostic medical procedures performed in clinical practice. It has been shown that negatively loaded words may result in negative affective reactions and, consequently, in an increased perception of pain. We aimed to evaluate whether common warnings before venous blood sampling might induce unnecessary pain. Methods:We included 100 healthy participants (50 females, 50 males) who were randomized to one of the 2 study groups (“sting” vs. “beware”). Directly before insertion of the needle, the participants were warned with either the word “sting” or “beware.” Venous blood sampling was performed according to a standardized protocol. Preinterventional and postinterventional blood pressure and heart rate, as well as pain scores after venous blood sampling, were evaluated. Results:There were 98 participants, 26.2±3.2 years of age, who were included into the analysis. Participants experienced significantly more pain after having been warned with the word “sting” compared with the word “beware.” The numeric rating scale results were 2.7±1.2 versus 1.9±1.1, respectively (P=0.001). Discussion:Words associated with pain increase the perception of pain during venous blood sampling. Omitting these words may be a simple and essential method by which to avoid unnecessary pain.

Fertility awareness among medical and non-medical students: a case-control study.

BackgroundTo compare the understanding and perceptions of fertility issues among medical and non-medical University students.MethodsIn a prospective case-control study, using a 43 item questionnaire with 5 sections and 43 questions regarding personal data (8 questions), lifestyle factors (9 questions), plans on having children (5 questions), age and fertility (5 questions), and lifestyle and fertility (16 questions), knowledge of fertility and influencing factors, desired age at commencement and completion of childbearing, among male and female medical and non-medical students in their first academic year at Vienna University, Vienna, Austria were evaluated.Results340 students were included. 262/340 (77%) participants planned to have children in the future. Medical students (n = 170) planned to have fewer and later children and had a higher awareness of the impact of age on fertility than non-medical students (n = 170; estimated knowledge probability 0.55 [medical students] vs. 0.47 [non-medical students]; F (1, 336) = 5.18 and p = .024 (η p = .015). Gender did not independently affect estimated knowledge probability (F (1, 336) = 1.50 and p = .221). More female and male medical students had a positive attitude towards Assisted Reproductive Technology in case of infertility than non-medical students (47 and 55% vs. 23 and 29%, respectively; p = <.001). Medical students had a healthier lifestyle than non-medical students. A healthy lifestyle and female gender were associated with higher fertility awareness.ConclusionsMedical students have a higher awareness of fertility issues than non-medical students. Choice of academic study, gender, and personal life style are important factors affecting fertility awareness. These data may be helpful to address knowledge gaps among young non-medical Academics.

The impact of thyroid function on intrauterine insemination outcome - a retrospective analysis

BackgroundHashimoto’s thyroiditis is the most common endocrinopathy in premenopausal women, and is associated with various gynecological problems, including recurrent miscarriage and unexplained infertility. A possible influence of Hashimoto’s thyroiditis on the success of intrauterine insemination seems likely, but has not been evaluated as yet. Therefore, the aim of our study was to retrospectively analyze the impact on intrauterine insemination outcome of thyroid function and markers suggestive for Hashimoto’s thyroiditis.MethodsRetrospective cohort study in a tertiary care center of 540 women who underwent Intrauterine Insemination. The clinical pregnancy rate was the main outcome parameters. The following possible influencing factors were tested: thyroid-stimulating hormone (TSH); thyroid autoantibodies; age; body mass index; type of sterility (primary/secondary); parity; male factor; presence of PCO syndrome; ovulation induction; ovarian stimulation; and current thyroid medication.ResultsThe overall clinical pregnancy rate was 6.9% (37/540). Age, thyroid hormone supplementation for thyroid-stimulating hormone (TSH) levels > 2.5 micro-IU/ml, and ovulation induction with HCG were significantly predictive in the multivariate analysis (p < 0.05) as influencing factors for the pregnancy rate after intrauterine insemination.ConclusionsWomen undergoing intrauterine insemination seem to benefit from a strict thyroid hormone supplementation regimen in order to achieve lower TSH levels.

Protocol of a prospective study for parathyroid function monitoring during and after thyroidectomy

ZusammenfassungGRUNDLAGEN: Der Hypoparathyreoidismus ist eine unterschätzte Komplikation nach Schilddrüsenoperation. Die Erkennung der zugrundeliegenden Störung des Parathormon (PTH)- und Kalziummetabolismus erfordert prospektive Langzeitstudien. Es besteht die Annahme, dass die sorgfältige Präparation der Nebenschilddrüsen das Risiko der permanenten Hypokalzämie reduziert. Prospektive evidenzbasierte Daten zur Erstellung von Leitlinien fehlen. METHODIK: Wir stellen drei Studienprotokolle vor und erläutern sie anhand eines Fallbeispiels: (i) das Monitoring der perioperativen Parathormon- und Kalziumkinetik, (ii) die genaue Beschreibung des intraoperativ-topographischen Nebenschilddrüsensitus und (iii) die Erfassung der Hypokalzämie-typischen Symptome. ERGEBNISSE: Studienziel ist die Definition von prognostischen Parametern (PTH cut-off Wert) für die Vorhersage des permanenten Hypoparathyreoidismus anhand der intra- und postoperativen PTH-Kinetik. Bei unserem Indexpatienten fielen die intraoperativen Parathormonwerte von 36,1 pg/ml auf 8,3 pg/ml (23 %). Zwei Nebenschilddrüsen wurden vom Operateur gesehen und sorgfältig erhalten, zwei blieben unerkannt. Die Funktion der Nebenschilddrüsen erholte sich innerhalb von vierzehn Tagen. Am ersten postoperativen Tag fielen die Kalziumwerte im Serum von 2,21 mmol/l auf einen Tiefstwert von 1,98 mmol/l, ohne dass die Patientin Hypokalzämie-typische Symptome entwickelte. SCHLUSSFOLGERUNGEN: Trotz eines klinisch unauffälligen postoperativen Verlaufes kann eine beträchtliche Störung der Parathormonsekretion – bedingt durch die Schilddrüsenoperation – vorliegen. Unsere Protokolle stellen die Basis zur prospektiven Analyse des Mechanismus der postoperativen Nebenschilddrüseninsuffizienz dar.SummaryBACKGROUND: Hypoparathyroidism still remains an underestimated complication after thyroidectomy; the kinetics of parathyroid hormone (PTH) are poorly understood. It is generally assumed that careful surgical preparation reduces the risk for postoperative persistent hypocalcaemia, but the standard of surgical care is illdefined. METHODS: We designed three protocols in order to (i) define the perioperative PTH- and Ca2+-kinetics, (ii) delineate intraoperatively the anatomic location of the parathyroid glands, (iii) correlate the temporal evolution of clinical symptoms of hypocalcaemia with the plasma levels of Ca2+ and PTH. RESULTS: The objective is to define perioperative parameters that may be predictive of persistent hypocalcemia. We tested the feasibility of our approach in a patient undergoing thyroidectomy for multinodular goitre: during surgery, PTH declined from 36.1 pg/ml to only 8.3 pg/ml (i.e. 23%). Two parathyroid glands were detected by the surgeon and carefully preserved, 2 glands remained invisible. However, parathyroid function recovered within 14 days. Calcium-levels fell from 2.21 mmol/l to a minimum of 1.98 mmol/l on the first postoperative day, but hypocalcaemia-related symptoms were not observed. CONCLUSIONS: Parathyroid gland function can be markedly impaired by surgical manipulation during thyroidectomy but this does not necessarily translate into postoperative clinical symptoms. Our protocols are suitable for collection of large prospective data series to better understand the mechanism of long-lasting or persistent hypocalcaemia.

Severe haematoperitoneum caused by ovarian bleeding after transvaginal oocyte retrieval: A retrospective analysis and systematic literature review

A case series of haematoperitoneum caused by ovarian bleeding after transvaginal oocyte retrieval (TVOR) is presented and all published cases summarized. In a retrospective case series, four patients with ovarian bleeding after TVOR were included. In addition, a pooled analysis of all published cases (n = 32) who underwent surgical intervention for severe haematoperitoneum caused by ovarian bleeding after TVOR was carried out. Main outcome measures were incidence, risk factors, course and intraoperative findings. In the pooled analysis, the incidence was 0.08%. The first sign of haematoperitoneum was evident in 33.3% within the first postoperative hour, and, cumulatively, in 93.3% within 24 h. The median time between TVOR and surgical intervention was 10 h. In four patients, the ovary could not be preserved, which was associated with a longer time interval between TVOR and the onset of symptoms (median 18 h versus 2.5 h; P = 0.004) as well as between TVOR and surgical intervention (median 21.5 h versus 8.5 h; 0.004). In conclusion, severe haematoperitoneum occurs in 0.08% after TVOR. Late-onset bleeding is common. A longer time interval between TVOR and surgical intervention might put a patient at risk of ovariectomy.