Category Archives: academic writing

hyroidectomy PTH in Predicting Hypocalcaemia

The Role of Post -Thyroidectomy  PTH in Predicting Hypocalcaemia



Correspondence: Dr.





Category: Case series











Running title:




 Hypocalcemia is the most common complication after total thyroidecto­my. It is also the leading cause for prolonged hospitalization after thyroidectomy. The purpose of this study is to determine the validity of PTH monitoring six and twelve hours after total thyroidectomy in predicting hypocalcaemia. Nineteen patients who underwent total thyroidectomy alone or with neck dissection were included. PTH levels and calcium levels were monitored for all patients at two major points: at 6 and 12 hours post-operatively. In all patients, corrected calcium level was calculated.

At 6 hours post-operatively, 47% of patients had calculated calcium level< 8, with normal PTH level in 5 of them. At 12 hour post-operatively 37% of patients had calculated calcium level< 8, with normal PTH level in 3 of them. The validity of low serum PTH in predicting the post-operative hypocalcaemia and of normal serum PTH in predicting the normocalcemia were calculated.

 We conculude that there is a strong correlation of postoperative PTH with post thyroidectomy hypocalcaemia. A single serum PTH level 12 hours post-operatively is an accurate predictor of normocalcaemia. Patients with normal PTH and normal calcium level 12 hours postoperatively can be considered for discharge.



Key Words: Thyroidectomy, hypocalcemia, parathyroid hormone, surgery







Running title:




Thyroid cancer is the most common endocrine malignancy accounting for approximately 1% of all human cancers and causing approximately 0.5% of all cancer deaths. Total thyroidectomy is the treatment of choice for clinically significant thyroid cancers. Transient hypocalcaemia after total thyroidectomy is reported at 20%-30% in most studies . The search for a blood test that identifies patients who will become hypocalcaemic after total thyroidectomy versus those who will remain normocalcaemic in the early postoperative period has evolved since the late 1980s (1-5) . Transient hypocalcaemia after total thyroidectomy is reported at 20-30% in most studies (2,7). Hypocalcaemia after total thyroidectomy is multi-factorial, but parathyroid dysfunction is the main cause.The incorporation of parathyroid hormone (PTH) levels as a monitor for hypoparathyroidism leading to hypocalcaemia has been the next step in the evolution of this field of research (2). Serum PTH has a half  life of 1 to 4 minutes. Any insult to parathyroid glands with impaired PTH secretion leads to an immediate decline in PTH levels.

Serum calcium homeostasis by PTH occurs through a variety of mechanisms:

  1. It promotes distal tubule calcium re-absorption.
  2. Bone re-absorption.
  3. 1,25(OH)2D mediated intestinal calcium absorption.

The nadir of serum calcium post total thyroidectomy is 24-48h postoperatively and it may be delayed as the 4th  postoperative day (6). Thus, monitoring calcium levels postoperatively, might lead to patients being hospitalized for longer time than otherwise necessary. The risk of hemorrhage and hematoma is mostly in the early postoperative  period, and warrant 24 h in hospital observation.

Inpatient stay beyond 24 h after Total thyroidectomy, in the absence of complications, is not warranted because patients suffer minimal pain (8).

Grodski found that postoperative PTH can be used to stratify the risk of patients developing    hypocalcaemia after thyroidectomy (1). In addition, the routine use of oral calcium supplements was shown to lead to decreased incidence and severity of post-thyroidectomy hypocalcaemia (1) .

In this work we aimed to investigate the role and best timing of PTH monitoring post total thyroidectomy in predicting hypocalcaemia.



In this study we included patients (men and women) that underwent different thyroidectomy procedures: total thyroidectomy  or total thyroidectomy with central neck dissection. PTH levels were monitored for all patients at two major points: at 6 and 12 hours postoperatively. Calcium levels were measured twice a day. Corrected calcium level was calculated using the next formula:

Corrected Ca. = serum calcium + 0.8 (4 – serum albumin)

We defined two different points for hypocalcaemia:

While the corrected calcium level was less than 8 mg/dl

While the PTH level was less than 1.6 Pcmoll/l (8).




Nineteen patients were included (13 women and 6 men). Age of patients ranged from 20 to 76, with a mean age of 45 years. Patients underwent total thyroidectomy and 4 patients underwent total thyroidectomy with central neck dissection.

Mean time of hospitalization for these patients was 5.05 days (SD 0.97). The PTH levels, and corrected calcium levels (calculated) at three measurements are shown in Table I.

At 6 hours post-operatively, 47% (9 from 19) of patients had calculated calcium level< 8, with normal PTH level in 5 of them. At 12 hours post-operatively 37% (7 from 19) of patients had calculated.

calcium level< 8, with normal PTH level in 3 of them. At 48 h post-operatively, 2 of those 3 patients, had a normal calculated calcium level and were asymptomatic without calcium supplementation.

Seven of our patients (36.8%) received intravenous calcium treatment after the operation. Six of them received also the calcium supplementation. Five from these patients were symptomatic. Furthermore, one patient who underwent thyroidectomy with central neck dissection required 5 month calcium supplementation.

We calculated the validity of  low serum PTH in predicting the post-operative hypocalcaemia and of  normal serum PTH in predicting the normocalcaemia. For low serum PTH, the sensitivity of this test was 55% at 6 hours after the operation, and 71% at 12 hours after the operation. The specificity of this test was 90% at 6 hours after the operation, and 100% at 12 hours after the operation.

The sensitivity of normal serum PTH level as a predictor of normocalcaemia was 91% at 6 hours after the operation and 100% at 12 hours after the operation. The specificity of this test was 44% at 6 hours after the operation and 75 % at 12 hours after the operation.




Hypocalcemia is the most frequent complication of total thyroidectomy. The reported incidence in the literature varies from 1-50% (1). The risk of hypoparathyroidism increases in reoperative thyroid surgery and when central neck is associated (11). Patients symptoms and serum calcium levels dictate the necessity for calcium and vitamin D supplementation. The need of monitoring hypocalcemia is the leading reason for patients’ hospitalizaion beyond 23 hours (7) . Within the last decade, numerous studies have been conducted to predict the factors involved in the early prediction of hypocalcemia following thyroidectomy. Parathyroid hormone assay was one of the most reliable tool to predict postoperative hypocalcemia within hours of total thyroidectomy or completion thyroidectomy ( 11-13).

Several published reports have demonstrated the marked utility of the PTH assay in predicting patients who will develop hypocalcemia after thyroidectomy. However, there is a substantial

variability among these reports about the sensitivity and specificity  of PTH in accurately predicting hypocalcemia. Lam and ker found that all patients with PTH values less than 8pg/mL measured one hour after surgery became hypocalcemic, and all patients with PTH level greater than 9pg/mole did not (14) . Higgins and his colleagues demonstrated that 64% of those patients who subsequently required calcium supplementation had more than 75%  decrease in PTH levels from baseline 20minutes post surgery. Another finding was that most of patients who did not  need calcium supplementation (74%) had  a decrease of less than 75% from baseline (15). For Lombardi and colleague. PTH less than 10 pg/mL measured four or six hours after surgery predicted hypocalcemia with an overall accuracy of 98% (3). Pattou and colleagues  reported that a postoperative PTH level of 12 pg/mL or less was a good predictor of hypocalcemia, but did not state how long after surgery PTH values were obtained (6). Payne and his colleagues found that 6 hours post-operation PTH level is the most accurate predictor for hypocalcaemia and accurately predicts also the normocalcaemia (7).

As we saw earlier, most of the studies are discussing the correct timing of taking the measurements of PTH levels post-operatively. In our study we performed the measurements at 6 and 12 hours after the operation. We saw that the sensitivity of  low PTH as a predictor of hypocalcaemia was higher at the 12 hours measurement. Despite this no absolute PTH levels or percentage decline has 100% sensitivity or specificity. Sensitivity of normal PTH levels predicting normocalcaemia was higher than sensitivity of  low PTH levels predicting hypocalcaemia.

There are a few limitations to the study. First, it is a retrospective non-random review, which may result in selection bias. Secondly, a small number of participants. Further randomised controlled are required.









In our study we saw that a single serum PTH level 12 hours postoperatively is an accurate predictor of normocalcaemia. Thus, patients with normal PTH and normal calcium level 12 hours post-operatively can be considered for discharge reducing unnecessary hospitalization and patients’ discomfort.




No acknowledgements













  1. Grodski, S., Serpell, J. Evidence for the Role of Perioperative PTH Measurement after Total Thyroidectomy as a Predictor of Hypocalcemia. World Journal of Surgery 2008; 32: 1367–1373.
  2. LoGerfo, P., Gates R., Gazetas, P. Outpatient and Short-stay Thyroid Surgery. Head and Neck;2006; 13 (2): 97 – 101.
  3. Lombardi, C.., Raffaelli, M., Princi, P. et al. Early prediction of postthyroidectomyhypocalcemia by one single iPTH measurement. Surgery;2006; 136: 1236-1241.
  4. Marohn M.R, LaCivita K.A. Evaluation of total/near-total thyroidectomy in a short-stay hospitalization: safe and cost-effective. Surgery;2006; 118:943–948.
  5. McHenry C. R. ‘‘Same-day’’ thyroid surgery: an analysisof safety, cost savings, and outcome. American Surgery:1997: 63:586–589.
  6. Pattou, F., Combemale, F., Fabre. et al. Hypocalcemia following Thyroid Surgery: Incidence and Prediction of Outcome. World Journal of Surgery:1998: 22, 718–724.
  7. Payne, R. J., Hier, M. P., Tamilia, M. et al. Same-Day Discharge After Total Thyroidectomy: The Value of 6-hour Serum Parathyroid Hormone and Calcium Levels. Head and Neck:2004; 27: 1 – 7.
  8. Kalmovich LM1, Cote V, Sands N, Thyroidectomy: Excatly how painful is it? J otology head and neck surgery; 2010:39(3),277-83.
  9. Payne, R. J., Tewfik, M. A., Hier, M. et al. Benefits Resulting from 1-and 6-Hour Parathyroid Hormone and Calcium Levels After Thyroidectomy. Otolaryngology — Head and Neck Surgery;2005; 133: 386-390.
  10. Sywak, M. S., Palazzo, F. F., Yeh, M. et al. Parathyroid hormone assay predicts hypocalcaemia after total thyroidectomy. ANZ Journal of Surgery;2007; 77: 667–670.
  11. McLeod IK, Arciero C, Noordzij JP, et al. The use of rapid parathyroid hor­mone assay in predicting postoperative hypocalcemia after total or comple­tion thyroidectomy. Thyroid. 2006;16:259–65
  12. Noordzij JP, Lee SL, Bernet VJ, et al. Early prediction of hypocalcemia after thyroidectomy using parathyroid hormone: an analysis of pooled individual patient data from nine observational studies. J Am Coll Surg. 2007;205:748–54
  13. Khafif A, Pivoarov A, Medina JE et al. Parathyroid hormone: A sensitive predictor of hypocalcemia following total Otolaryngol Head Neck Surg. 2006;134:907–10).
  14. Lam A, Kerr P. Parathyroid hormone: an early predictor of postthyroidectomy hypocalcemia. Laryngoscope. 2003;113(12):2196-200.
  15. Higgins KM, Mandell DL, Govindaraj S et al. The role of intraoperative rapid parathyroid hormone monitoring for predicting thyroidectomy-related hypocalcemia. Arch Otolaryngol Head Neck Surg. 2004;130(1):63-7






Table I. PTH and calcium level measurements at two different post-operation time points

  6 hours after the operation 12 hours after the operation
PTH level

(mean (SD))

3.36 (2.58) 3.27 (2.47)
Corrected calcium

(mean (SD))

8.04 (0.42) 8.04 (0.55)






System Quality Requirements Engineering (SQUARE)

  • Due to the growth and sophistication of cyber-attacks against organizations, the client and software developers need to agree on security definitions derived from the client’s business goals. As a software engineer, you have explored the concept of System Quality Requirements Engineering (SQUARE). Now you need to convince your team to build security and quality concepts into the early stages of the development life cycles. Your job is to discuss SQUARE methodology or SQUARE steps to show your team the advantages of using SQUARE methodology in the development stage. How will you accomplish this? What are some things you might do to get the team on board with your plan?
  • Note: The Security Quality Requirements Engineering (SQUARE) project is identifying and assessing processes and techniques to improve requirements identification, analysis, specification, and management. The project is also focusing on management issues associated with the development of good security requirements.
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Posted by on July 23, 2018 in academic writing



Elements of Reasoning and Intellectual Standards

For our assignment this week, you may choose either Option A or Option B. Regardless of the option you choose, be sure to read through the entire assignment directions before crafting your essay.

Additionally, use the Week Six Assignment Organization Guide to help you organize your paper.

HU260 W6 Assignment Organization Guide

Option A

Using the Eight Elements of Reasoning that were outlined in week two (purpose, problem, information, concepts, assumptions, inferences, points of view, implications, or consequences) choose a news article and break it down according to those elements. Make sure you address each of these elements. If one of these elements does not apply to your article (rare), address that in your essay and explain how the article could have been improved by including it or how the author is justified in leaving it out.

Option B

Describe how each of the Eight Intellectual Standards (clarity, accuracy, precision, relevance, depth, breadth, logic, and fairness) were used or not used in the article, supported by an example. If one of these standards does not apply to your article (rare), address that in your essay and explain how the article could have been improved by including it or how the author is justified in leaving it out.


For either option you choose:

Write an introduction identifying the reasons for choosing either Option A or Option B and justify your reasoning.

In the conclusion of your essay, describe how you feel the article is biased.

Keep in mind, for either option you are being asked to analyze the article/author itself/himself/herself, NOT the topic discussed. Do not include your own opinion/position on the topic being addressed.

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Posted by on July 23, 2018 in academic writing



Social Influences Presentation

Influences from people’s social environments have an effect on their beliefs and behaviors, but they may not understand that influence. This assignment asks you to examine different social influences and the effects they may have on offender behavior.

Imagine your team has been asked to create a training on the role of social influences in offender rehabilitation for new support services staff. The intent of this training is to provide a base knowledge of this information so the new support services staff can structure their program delivery with these concepts in mind.

Develop examples of conformity, obedience, group membership, group conflict, and group decision making occurring in a group session for support services to help with offender rehabilitation.

Create a 10- to 12-slide Microsoft® PowerPoint® presentation to utilize in the training. Include the following:

  • Describe the concepts of conformity, obedience, group membership, group conflict, and group decision making.
  • Describe examples of these concepts occurring during support services.
  • Explain how the group influenced individual decision making in your examples.
  • Describe how social relationships developed or changed because of the group interactions in your examples
  • Explain how to navigate address these situations when they may occur.

Include a minimum of three sources.

Include detailed speaker notes for each slide. Do NOT repeat slide information in speaker notes, different with citations.

Format any citations in your presentation according to APA guidelines.

Submit your presentation to the Assignment Files tab.

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Posted by on July 23, 2018 in academic writing



Points of View Essay

The instructions for this assignment is posted below. I have also uploaded week 1 assignment.

In Week 1, you selected a topic to work with throughout the course to practice your critical thinking skills.

This week, you identify and discuss alternative points of view about that topic.

Resource: Week 1 topic and the “Opposing Viewpoints in Context.”

Optional Resource: Writing Resources lab

  1. Locate the topic you chose in Week 1 using the “Opposing Viewpoints in Context.”
  2. Select two viewpoints from those listed on the page.
  3. Write a 200- to 300-word essay on your topic that includes responses to the following:
    1. Introduce the topic you selected and briefly discuss why people might think differently about the topic. (50 to 75 words)
    2. Explain the two different viewpoints you selected. The goal of your explanation is to help your reader understand the reasoning for each viewpoint. (100 to 150 words total)
    3. For each viewpoint, identify one intellectual standard of thinking that is used well and one that is lacking. Review the intellectual standards of thinking discussed on p. 91 and Exhibit 5.1 on p. 102 of Ch. 5 of your text. (50 to 75 words total)


Course Outcome

Course Outcomes – Find and list the official course outcomes for each of your other (non-externship) courses. This list should be broken down by course with the proper course prefix, number, and name.

Course 1. Information security System (BA63271G118).

Course 2. Project Management (BA63170H118).

My Job Description:


· Analyze, design, prototype, configure, test, document, and implement new or modify existing software to support various business processes.

· Develop an area of expertise within Sales, customer service, Order Entry/Order Management and Billing/Collections in due course of time.

· Learn overall business operations and help develop innovative solutions to improve productivity

· Assist key users in testing new functionality, documenting and retaining ERP knowledge

· Documented testing results and updated the same for verification to the management

· Involved in developing Test Plans and Test cases for the entire functionality of the portal.

· Understanding and analyzing the Business functionality of existing systems of Issue to Resolve

· Written Standard test scripts for Oracle Accounts Payable and Oracle accounts receivable Modules



Management Information Systems

Management Information Systems

Chapter 9 – Systems Development and Project Management

Denver International Airport

One good way to learn how to develop successful systems is to review past failures. One of the most infamous system failures is Denver International Airport’s (DIA) baggage system. When the automatic baggage system design for DIA was introduced, it was hailed as the savior of modern airport design. The design relied on a network of 300 computers to route bags and 4,000 card to carry luggage across 21 miles of track. Laser scanners were to read bar-coded luggage tags, while advanced scanners tracked the movement of toboggan-like baggage carts.

When DIA finally opened its doors for reporters to witness its revolutionary baggage handling system, the scene was rather unpleasant. Bags were chewed up, lost, and misrouted in what has since become a legendary systems nightmare.

One of the biggest mistakes made in the baggage handling system fiasco was that not enough time was allowed to properly develop the system. In the beginning of the project, DIA assumed it was the responsibility of individual airlines to find their own way of moving the baggage from the plane to the baggage claim area. The automated baggage system was not involved in the initial planning of the DIA project. By the time the DIA developers decided to create an integrated baggage system, the time frame for designing and implementing such a complex and huge system was not possible.

Another common mistake that occurred during the project was that the airlines kept changing their business requirements. This caused numerous issues, including the implementation of power supplies that were not properly updated for the revised system design, which caused overloaded motors and mechanical failures. Besides the power supply design problem, the optical sensors did not read bar codes correctly, causing issues with baggage routing.

Finally, BAE, the company that designed and implemented the automated baggage system for DIA, had never created a baggage system of this size before. BAE had created a similar system in an airport in Munich, Germany, where the scope was much smaller. Essentially, the baggage system has an inadequate IT infrastructure because it was designed for a much smaller system.

DIA simply could not open without a functional baggage system so the city had no choice but to delay the opening date for more than 16 months, costing taxpayers roughly $1 million per day, which totaled around $500 million.


  1. One problem with DIA’s baggage system was inadequate testing. Why is testing important to a project’s success? Why do so many projects decide to skip testing?
  2. How could more time spent in the analysis and design phase have saved Colorado taxpayers hundreds of millions of dollars?
  3. Why couldn’t BAE take existing IT infrastructure and simply increase its scale and expect it to work?