Low fertility and population replacement in Scotland

It has been argued that Scotland faces population ageing and decline that will have potentially serious economic and social consequences, and that the origin of these processes lie in its low and declining fertility rates. After considering alternatives to the total period rate measure of fertility, empirical evidence and theoretical argument about low fertility and its consequences is briefly reviewed. The paper argues that low fertility in general may not be the problem it is often purported to be, that Scotland has relatively high fertility, and that pro-natalist policies are neither desirable nor necessary. It suggests that low fertility and population ageing may be viewed as positive developments, and that within Europe, Scotland is distinguished more by its excess of early deaths than by any shortage of births.Peer reviewe

Calcium-stimulated calcitonin - The “new standard” in the diagnosis of thyroid C-cell disease - clinically relevant gender-specific cut-off levels for an “old test”

Introduction: Pentagastrin (Pg) stimulated calcitonin (sCT) was used to enhance accuracy in medullary thyroid cancer (MTC) diagnosis. As it is now unavailable, calcium (Ca) has been recommended as an alternative. The aim of this study was to define gender-specific cut-off values to predict MTC in patients with elevated basal CT (bCT) following Pg-sCT and Ca-sCT stimulation and to compare the time courses of CT release during stimulation. Materials and methods: The stimulation tests were applied in 62 consecutive patients with thyroid nodules. Basal calcitonin was measured by chemiluminescent immunometric assay. All patients underwent thyroidectomy and bilateral central neck dissection. C-cell pathology was confirmed by histological and immunohistochemical evaluation. Results: In 39 (0.63) patients MTC was documented while isolated C-cell hyperplasia (CCH) was identified in 23 (0.37) patients. Medullary thyroid cancer was predicted in males with bCT values > 43 pg/mL or sCT concentrations > 470 pg/mL (Pg-sCT) or > 1500 pg/mL (Ca-sCT), and in females with bCT concentrations > 23 pg/mL or sCT concentrations > 200 pg/mL (Pg-sCT) or > 780 pg/mL (Ca-sCT), respectively. Pg-sCT correctly predicted MTC in 16 (0.66) compared to 13 (0.54) after Ca-sCT in males and in 12 (0.80) compared to 11 (0.73) in females; without statistical significance. In patients with CCH or low tumor burden, there was a tendency of faster CT release after Ca stimulation (CT peak after 3min in > 60%) compared to patients with advanced MTC (CT peak after 3min in < 10%). Conclusions: Using gender-specific cut-off values, Ca could replace Pg to predict MTC with similar diagnostic power

Transoral Thyroidectomy: Initial Results of the European TOETVA Study Group

BackgroundThe aim of this study was to evaluate a new surgical technique by the European Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) Study Group.MethodsThis study included 391 patients (47 [(12%]) male and 344 [(88%)] female) who had undergone endoscopic thyroid or parathyroid surgery via the vestibular approach between February 2016 and May 2022 at nine centers. The data were analyzed with regard to complications, surgery time and specimen retrieval.ResultsOverall, 376 (96.2%) TOETVA and 15 (3.8%) transoral endoscopic parathyroidectomy vestibular approach interventions were performed with an average surgery time of 145 (+/- 61.2) minutes and 509 nerves at risk. The specimens were retrieved via a transoral vestibular and retroauricular approach in 66 (16.9%) patients and via a transaxillary approach in 8 (2%). Benign histology including Grave's disease was identified in 272 (69.6%) patients, 1 (0.3%) presented noninvasive follicular thyroid neoplasms with papillary-like nuclear features, and 103 (26.3%) showed differentiated thyroid carcinoma. Solitary parathyroid adenoma were removed in 15 (3.8%) patients. Conversion to open surgery was necessary in 13 (3.3%) and revision had to be performed in 2 (0.5%) patients. Transient recurrent laryngeal nerve palsy (RLNP) was present in 18 (4.6%) and permanent RLNP in 2 (0.5%) patients. Fifteen (3.8%) patients experienced transient hypoparathyroidism after thyroidectomy. No case of permanent hypoparathyroidism was observed. Postoperative surgical site infection occurred in 1 (0.3%) patient. Despite a higher rate of sensory and motor disorders and skin discoloration at discharge, permanent disorders were present in only 3 (0.8%) and 16 (4.1%) patients, respectively.ConclusionOur results show that transoral endoscopic surgery, performed by experienced endocrine surgeons, is a safe alternative to conventional thyroid surgery

Journal für Klinische Endokrinologie und Stoffwechsel / Neue Operationszugänge - Entwicklung und Anwendung der transoralen endoskopischen Schilddrüsenchirurgie (TOETVA)

Der konventionelle Kocher-Kragenschnitt in der Schilddrüsenchirurgie konnte in den letzten 15 Jahren so weit modifiziert werden, dass von einer minimal-invasiven offenen Chirurgie mit einer Operationsnarbe von 3–5 cm gesprochen werden kann. Dennoch besteht großes Interesse an einer Operationstechnik, bei welcher es zu keinen Narben im sichtbaren Bereich kommt. Die transoral-endoskopische Schilddrüsenchirurgie über den vestibulären Zugang (TOETVA) stellt ein solches Operationsverfahren dar, welches nach jahrelanger Erforschung alternativer Zugänge zur Entfernung der Schilddrüse und der Nebenschilddrüsen letztendlich 2015 im asiatischen Raum, in Thailand, etabliert werden konnte und vielversprechende Ergebnisse lieferte. Somit wird auch im europäischen Raum immer häufiger zu dieser Operationsmethode gegriffen. Zur Bergung größerer Präparate im Rahmen der endoskopischen Schilddrüsenchirurgie kann der transorale mit einem retroaurikulären Zugang kombiniert werden und umfasst somit ein größeres Indikationsspektrum. Nach Anlegen des transoralen Zugangs gestalten sich die restlichen Schritte der transoral-endoskopischen Thyreoidektomie ähnlich denen des offenen Eingriffs. Abgesehen von den auch in der offenen Schilddrüsenchirurgie bekannten Komplikationen, der Recurrensparese und dem Hypoparathyreoidismus, stellen die häufigsten postoperativen Komplikationen periorale, mandibuläre oder zervikale Dys- und Hypästhesien, Hämatome und Störungen des Nervus mentalis dar.The conventional Kocher’s incision in thyroid surgery has been modified in the last 15 years to such an extent that a minimally invasive open surgery with a scar of 3–5 cm can be performed. Nevertheless, there is great interest in a surgery technique with no visible scars. Transoral endoscopic thyroid surgery via vestibular approach (TOETVA) represents such a surgical procedure which was finally established 2015 in Thailand after years of research on alternative approaches for the removal of the thyroid and parathyroid glands and shows promising results. This surgical method is also being increasingly used in European countries. For the retrieval of larger specimens, the transoral access can be combined with a retroauricular approach, which covers a broader range of indications. Once the transoral approach has been positioned, the remaining steps are similar to those of open surgery. Apart from the known complications that can also occur in open thyroid surgery, paresis of the recurrent laryngeal nerve and hypoparathyroidism, the most frequent postoperative complications that appear are perioral, mandibular, or cervical dysesthesia and hypesthesia, hematomas and malfunction of the mental nerve

Journal für Klinische Endokrinologie und Stoffwechsel / Autofluoreszenz der Nebenschilddrüsen in der Schilddrüsenchirurgie

Eine Unterfunktion der Nebenschilddrüsen (postoperativer Hypoparathyreoidismus) ist die häufigste Komplikation in der Schilddrüsenchirurgie. Obwohl sie zumeist nur vorübergehend besteht, kann sie zu einer starken Einschränkung der Lebensqualität führen. Um die Rate an temporärem und permanentem Hypoparathyreoidismus zu vermindern, kann zur intraoperativen Erkennung der Nebenschilddrüsen die Nahinfrarot-Autofluoreszenz(NIRAF)-Bildgebung verwendet werden. Die Overlay-Ansicht stellt hierbei eine Weiterentwicklung der bisherigen NIRAF-Bildgebung dar, die durch die Überlappung von Nahinfrarot und Weißlicht entsteht und sich somit von der klassischen Schwarz-weiß-Ansicht unterscheidet.Malfunction of the parathyroid gland (postoperative hypoparathyroidism) is the most common complication in thyroid surgery. Although it is mostly temporary, it can lead to a severe reduction in life quality. To decrease the rate of temporary and permanent hypoparathyroidism, near-infrared autofluorescence (NIRAF) imaging can be used for intraoperative detection of the parathyroid glands. Overlay imaging represents a further development of the previous NIRAF imaging, which is created by overlapping of near-infrared and white light, thus differs from the classic black and white view