Category: Calcium/Bone Disorders
Objective : Post-operative hypoparathyroidism is the most frequent complication following thyroidectomy (TT) resulting in significant morbidity and higher healthcare cost. Incidence varies from 5-75%. We aim to develop and implement a standardized practice for monitoring and supplementation of calcium (Ca)/vit D after TT to promote early identification/treatment of hypoparathyroidism while minimizing frequency of labs and length of stay (LOS).
Methods : A multidisciplinary team (endocrinology & thyroid focused surgeons) developed a post-TT management protocol as part of an institutional quality board approved project. Algorithm incorporating PTH and Ca to stratify need for Ca/calcitriol therapy was implemented. 45 TT cases analyzed pre-intervention (Jan-Feb 2018) and 16 TT after cycle 1 (Oct 2018). For every inpatient encounter, the frequency and timing of PTH, Ca and other relevant labs (Albumin, Magnesium, Phosphorus & preoperative Vit D) were collected pre and post-intervention. Timing of discharge (AM vs PM) and LOS were also recorded.
Results : Rate of hypoparathyroidism (PTH less than10) was similar in pre and post intervention (approx. 30 %); 1 case of symptomatic hypocalcemia was seen per group. In the pre-intervention cohort, most common frequency of phlebotomies was 3(range 2-8); 42% in hypoparathyroid vs 74 % in normal PTH. Post-cycle 1 phlebotomies decreased (range 2-5) with 3 labs per admission still being the predominant frequency (40 % in hypoparathyroidism vs 45% in normal PTH). Initial set of labs in the pre-intervention group were usually drawn within 4 hours post-TT (range 1-8 hours) whereas post-intervention 100% had labs within 2 hours of surgery. LOS between hypoparathyroid vs normal PTH was similar pre and post intervention, however AM discharge in normal PTH patients improved from 54% to 72%. Vit D screening pre-operatively improved pre- and post-intervention (47 to 68%).
Discussion : Initiation of standardized protocol resulted in notable improvement of frequency and timing labs thus decreasing phlebotomies and increasing AM discharge in patients with normal PTH. Outcomes like LOS post-TT are affected by multiple variables including pain control, airway/swallow status and presence of drainage etc. This is an ongoing strong prospective study analyzing the use of a standardized algorithm for post-TT selective calcium treatment rather than empiric therapy in tertiary referral center.
Conclusion : A standardized protocol can properly recognize and treat hypoparathyroidism with selective calcium supplementation while minimizing costs, facilitating early discharge and avoiding unnecessary treatment related complications like hypercalcemia.
Sarimar Agosto Salgado– Oncologic Endocrinology Fellow, University of Texas MD Anderson Cancer Center, Texas
Mimi Hu– Professor, Deputy Chair of Clinical Affairs, The University of Texas MD Anderson Cancer Center
Sonali Thosani– Assistant Professor, UT-MD Anderson Cancer Center
Anita Ying– Associate Professor, UT MD Anderson Cancer Center
Robert Gagel– Professor, M.D. Anderson Cancer Center, Houston, Texas
Mark Zafereo– Associate Professor, The University of Texas MD Anderson Cancer Center, Houston, Texas
Nancy Perrier– Professor, MD Anderson Cancer Center, Houston, Texas
Paul Graham– Assistant Professor of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
Jeena Varghese– Assistant Professor, UT MD Anderson Cancer Center
Oncologic Endocrinology Fellow
University of Texas MD Anderson Cancer Center, Texas
Sarimar Agosto, M.D currently is the Oncologic Endocrinology fellow at University of Texas MD Anderson Cancer Center 2018-2019. Dr. Agosto completed her medical school training at University of Puerto Rico School of Medicine and Internal Medicine Residency training at Dr. Ramon Ruiz Arnau University Hospital. After graduating in June 2016 from Endocrinology fellowship training at The University of Texas Health Science Center in San Antonio, she continued practicing in San Antonio Texas at University Medicine Associates Clinics. As part of her practice at University Health System she served as adjunct assistant medicine professor at UT San Antonio. Caring for thyroid cancer & diseases of thyroid, pituitary, adrenal, parathyroid and neuroendocrine tumors among common cases of general endocrinology like osteoporosis and diabetes, she earned recognition among both San Antonio’s Top Rising Stars Doctor’s 2018 and San Antonio’s Best Doctor’s 2018. As active member of the University Health System Commission on Cancer Committee until June 2018 she worked on a quality improvement project to raise awareness on thyroid cancer and expedite referrals for thyroid cancer & thyroid nodules. Her main clinical and research interest is the management of patients with advanced thyroid cancer & endocrine neoplasia.
Professor, Deputy Chair of Clinical Affairs
The University of Texas MD Anderson Cancer Center
Dr. Mimi I. Hu graduated from Rice University with a degree in mechanical engineering. She obtained her medical degree from the University of Texas - Houston Health Sciences Center and completed her residency and endocrine fellowship at the Baylor College of Medicine, where she also served as chief medical resident. After completing her research fellowship at MD Anderson, she joined the faculty in 2007 in the Department of Endocrine Neoplasia and Hormonal Disorders. Dr. Hu's clinical expertise is in the evaluation and treatment of patients with thyroid carcinoma (differentiated and medullary), hereditary endocrine neoplasia disorders and metabolic bone and mineral disorders. She is the primary investigator and collaborator on multiple clinical trials evaluating various targeted therapies for advanced thyroid carcinoma. She has published articles and book chapters evaluating the management of medullary thyroid carcinoma, multiple endocrine neoplasia, bone health in cancer patients, endocrine complications of head and neck surgery, and paraneoplastic endocrine disorders.
UT-MD Anderson Cancer Center
UT MD Anderson Cancer Center
Dr. Anita Ying is the Medical Director for the MD Anderson Endocrine Center, which cares for patients with endocrine tumors or endocrine complications from other cancers. Over 35 faculty and staff from Endocrinology, Endocrine Surgery, and Head and Neck Surgery provide multidisciplinary care in the center. Dr. Ying provides clinical care for children and adults with endocrine tumors and oversees the clinical operations of the center.
Dr. Ying is also an Executive Medical Director in Ambulatory Operations. In that role, she oversees the clinical operations of multiple ambulatory centers and reports directly to the Physician-in-Chief and SVP of Clinical Operations. Dr. Ying is also one of the physician executives leading optimization of MD Anderson’s newly installed electronic medical record and reorganization of patient access and financial clearance to improve the patient experience and MD Anderson’s financial sustainability. Dr. Ying also serves on the board for the San Jose Clinic, a safety net clinic that provides medical, dental, and pharmacy care for the uninsured, and on the Rice Jones Partners, an organization that brings together the Rice Business School and the local business community.
Dr. Ying is a faculty advisor for the Institute for Cancer Care Innovation (ICCI). ICCI builds on the work of Michael Porter’s principles of value-based health care delivery, focusing on defining the outcomes for cancer patients and costs of care. She also instructs in Professor Porter’s Value Based Healthcare Delivery executive course sponsored by the Texas Medical Center. Dr. Ying is also the Quality Officer for her department and instructs in MD Anderson’s Clinical and Safety Effectiveness Course.
She received her B.A. in Sociology from Rice University and her M.D. from Duke University, completed a residency in Internal Medicine/Pediatrics at Duke and a fellowship in Adult and Pediatric Endocrinology at Baylor College of Medicine and MD Anderson Cancer Center. She joined MD Anderson as faculty in 2008. She has written numerous book chapters, articles, and clinical reviews on the care for adults and children with inherited endocrine tumor syndromes and thyroid cancer. She completed her Executive MBA with Healthcare specialization at Rice University in May 2013, and received the Jones Scholar Award.
M.D. Anderson Cancer Center
Dr. Gagel is a Professor of Endocrine Neoplasia and Hormonal Disorders. His major interests are: 1. Multiple Endocrine Neoplasia type 2 and; 2. Metabolic bone disease and osteoporosis.
The University of Texas MD Anderson Cancer Center
Dr. Mark Zafereo is an Associate Professor of Head and Neck Surgery at MD Anderson Cancer Center in Houston, Texas. He is Section Chief of Head and Neck Endocrine Surgery and Associate Medical Director of the Endocrine Center at MD Anderson Cancer Center. Dr. Zafereo holds national committee appointments for the American Head and Neck Society, American Academy of Otolaryngology-Head and Neck Surgery, and American Board of Otolaryngology-Head and Neck Surgery, and he is a Past President of the Houston Society of Otolaryngology-Head and Neck Surgery. He has published extensively on Thyroid and other Head & Neck cancers, speaking nationally and internationally. His clinical practice focuses on patients afflicted with thyroid cancer and parathyroid neoplasms
MD Anderson Cancer Center
Nancy Perrier, MD, FACS is a Surgical Oncologist and tenured and endowed Professor in the Department of Surgical Oncology at MD Anderson Cancer Center. She completed her surgical training at Mayo Clinic in Rochester, Minnesota and fellowship training in both Endocrine Surgical Oncology and Outcomes Based Research in Epidemiology and Biostatistics at the University of California, San Francisco. She was a National Institute of Health funded T32 research fellow. She is a graduate of the Jesse H. Jones Graduate School of Business at Rice University, with a certificate in Health Care Management as well as the Harvard Business School - Value Measurement for Health Care Executive Education program. Dr. Perrier has had a career interest in endocrine neoplasms. Her scholarly works, of more than 350 publications and 42 book chapters, range from safe implementation of new medical technology to value based cost of care. She currently serves as a Director on the American Board of Surgery which provides oversight of more than 30,000 surgeons with regard to training, certification and professionalism policies governing surgery in the United States. Regarded as an expert, Dr. Perrier serves in multiple capacities at MD Anderson including Director of Value for the Division of Surgery, section chief and medical director. Nationally her influence extends across multiple societies and organizations including senior authorship of guidelines for care and lead editing of the American Joint Commission on Cancer 8th Edition Manual for staging of cancers. She is highly regarded for her clinical excellence, integrity, initiative, effectiveness and as a consummate leader for her peers.
Assistant Professor of Surgery
University of Texas MD Anderson Cancer Center
Dr. Graham graduated from The University of Texas Medical School at Houston and completed his General Surgery residency at The University of Alabama at Birmingham. He then completed an Endocrine Surgery fellowship at Brigham and Women's Hospital in Boston. Dr. Graham is board certified by the American Board of Surgery. He is a member of the American College of Surgeons and the American Association of Endocrine Surgeons. Dr. Graham holds an academic appointment as an Assistant Professor in the Department of Surgical Oncology at MD Anderson Cancer Center. His interests include the management of both benign and malignant thyroid, parathyroid, adrenal, and neuroendocrine diseases as well as the use of minimally-invasive techniques in the surgical management of endocrine disorders.