High Serum Alkaline Phosphatase Research Articles

A novel assessment method of serum alkaline phosphatase for the diagnosis of osteosarcoma in children and adolescents

Background A high serum alkaline phosphatase (ALP) level is valuable for the diagnosis of osteosarcoma in adults, but its use in teenagers is problematic because ALP levels are affected by age, gender, and pubertal stage. Because serum acid phosphatase (ACP) shows the same tetraphasic pattern as serum ALP in children and adolescents, we presumed that serum levels of ALP and ACP would have a strong correlation and that the ratio of ALP to ACP (ALP/ACP) would show little variation and would be useful for the diagnosis of osteosarcoma in teenagers. The purpose of this study was to evaluate the correlation between the serum levels of ALP and ACP and to investigate the validity of ALP/ACP in the differential diagnosis of osteosarcoma in children and adolescents.Methods We retrospectively examined 538 patients aged 1–18 years, including 24 with osteosarcomas, 8 with other malignant bone tumors, 56 with benign bone tumors, and with 450 non-tumor lesions (controls). We evaluated the serum levels of ALP and ACP, both obtained by preoperative examination.Results There were significant correlations between the serum ALP and ACP levels in the controls (r = 0.805 in males and r = 0.860 in females). The ratios of ALP to ACP in the controls showed little variation with age. In ROC curve analysis, to discriminate between the osteosarcomas and the controls, the cutoff levels of serum ALP and ALP/ACP were 956 (U/l) and 50.9 in males and 748 (U/l) and 43.3 in females, respectively. The sensitivity and specificity of serum ALP and ALP/ACP in the differential diagnosis of osteosarcoma were 50.0 and 89.0 %, and 60.0 and 94.1 %, respectively in males, and 61.5 and 72.7 %, and 69.2 and 84.2 %, respectively, in females.Conclusions The results suggest that ALP/ACP is more useful than the serum ALP level in diagnosing osteosarcoma because it is little affected by the age.

PO-0102 Transcutanous Intrahepatic Portosystemic Shunt (tipss) In Children

Background Variceal haemorrhage is a major cause of mortality and morbidity in patients with portal hypertension. Transcutaneous intrahepatic portosystemic shunt (TIPSS) is a procedure which is widely used in adults with limited experience in children. Objectives The aim of this study is to analyse the use of pre- and post-operative laboratory results as predictors for TIPSS failure in the given sample. Methods This is a retrospective study of children who underwent TIPSS from 1998 to 2013. Data were obtained within 1 month before TIPSS placement. The variables are shown in (Table 1). Failure of TIPSS was defined as requirement of revision within 36 months after the procedure. Patients were divided into two groups post-operatively according to the procedure success; those who did not require revision within 36 months after procedure were considered to have successful TIPSS, while those who needed revision within 36 months after procedure had a failed TIPSS procedure. Results A total of 10 children (7 females) underwent TIPSS. The primary indication was variceal haemorrhage in all the patients with different diagnoses (Table-1). Congenital Hepatic Fibrosis was the most common aetiology (50%). Three patients (30%) needed revision in a mean of 24.2 month post-procedure. 7 patients (70%) did not require revision 36 month post procedure, with a mean follow up of 60.5 month. Pre-operative high serum alkaline phosphatase (ALP) was associated with TIPSS failure (p value =0.027) and thus, can be used as a pre-operative predictor for failed TIPSS. Other variables did not show significant association with TIPSS procedure including patients age and weight. Conclusion This study involves the association of multiple variables with TIPSS outcomes in children. ALP showed a relative association as a predictor to TIPSS failure. Further studies are needed with a larger sample.

Pattern of Elevated Serum Alkaline Phosphatase (ALP) Levels in Hospitalized Patients: A Single Centre Study

Background: Persistent elevation of serum ALP is frequently encountered and can pose a diagnostic dilemma due to its association with a wide range of clinical conditions. However, the significance of ALP in these clinical conditions in routine practice is often underestimated or overrated. Objectives: This study was determined to assess the pattern of ALP with an aim to elucidate its clinical utility among hospitalized patients. Method & materials: The inpatients with high ALP level were enlisted & analysed between January to December 2012 excluding cases of (a) patients who have bone involvements with malignancies and (b) HIV-seropositive patients attending a tertiary care Hospital at Dhaka. Extremely high levels of ALP were defined as being more than 1000 U/L. These patients were divided into different groups according to their final diagnosis. Results: A total of 154 hospitalized patients with eligible medical records were identified (98 male and 56 female, mean age 36 years). Their ALP levels are ranging from 1,006 to 3,067 IU/L; very extreme values of > 3000 IU/L being rarely (only about 2%) documented. Patients with sepsis can have an extremely high alkaline phosphatase level (1,648.2 ± 328.4 IU/L) and a normal bilirubin. Conclusion: High serum ALP levels in hospitalized patients were commonly found in three major groups having obstructive biliary diseases, infiltrative liver disease and sepsis. A variety of other causes were also noted. This routine laboratory test should receive more attention in clinical decision-making than has previously been given. DOI: http://dx.doi.org/10.3329/pulse.v6i1-2.20329 Pulse Vol.6 January-December 2013 p.20-26

Factors affecting postoperative activities of daily living in patients with osteoporotic vertebral collapse with neurological deficits.

Surgical treatment of osteoporotic vertebral collapse (OVC) with neurological deficits presents significant clinical challenges because some patients have fragile bones and often have medical comorbidities, which affect the severity of osteoporosis. We hypothesized that clinical results of surgery in these patients depend on the extent of medical comorbidities that induce secondary osteoporosis. The aim of this study is to examine the effects of medical history and comorbidities on surgical outcomes for these patients, along with the factors that predict postoperative function in activities of daily living (ADL). We retrospectively reviewed data for 88 patients with OVC and neurological deficits who underwent surgery. We assessed clinical results regarding neurological deficits and function in ADL. The presence or absence of comorbidities responsible for secondary osteoporosis and treatments or medical events that affect bone metabolism were examined. We performed statistical analysis to examine prognostic factors for postoperative function in ADL. Of 88 patients, the distributions of comorbidities, treatment, and events in medical history were as follows: hypertension, 57 patients (64.8%); chronic kidney disease (CKD) stage 3 or 4, 32 (36.4%); diabetes mellitus, 16 (18.2%); liver dysfunction, 11 (12.5%); cardiovascular disease, 10 (11.4%); rheumatoid arthritis, 9 (10.2%); and glucocorticoid intake, 8 (9.1%). Twenty-five patients (28.4%) represented poor postoperative ADL (chair-bound or bed-bound), and 11 of 25 patients with poor postoperative ADL represented full neurological recovery. Multivariate analysis revealed decreased estimated glomerular filtration rate (odds ratio 0.96; 95% confidence interval 0.93-0.99; p = 0.005) and a high serum alkaline phosphatase (ALP) level (odds ratio 1.01; 95% CI 1.00-1.02; p = 0.01) were strong predictive factors for poor postoperative function in ADL. The majority of patients with poor postoperative function in ADL had advanced CKD with a disorder of bone metabolism as well as bone fragility.

AN EPIDEMIOLOGICAL, CLINICAL AND PATHOLOGICAL STUDY OF LYMPHOMAS OF THE BONE AND MUSCULOSKELETAL SYSTEM AMONG POPULATION FROM THE SOUTH OF IRAQ

Lymphomas of the bone and musculoskeletal tissue are uncommon. Yet, they constitute a certain frequency that they merit certain consideration. A study was conducted to clarify the behavior of such type of lymphomas in the South of Iraq, epidemiologically, clinically, pathologically, biochemically and immunologically. Results show that they form minority among total lymphoma cases, but they were the third common type among extranodal lymphomas with male gender, adult age and urban residency predominance. There was a predominance of low performance status, absence of B symptoms, neurological and musculo-skeletal manifestations, secondary bone, especially the spine, involvement. Non- Hodgkin lymphoma (NHL) was the most predominant, mainly the intermediate grade, with diffuse large cell lymphoma (DLCL) and Burkitt lymphoma (BL) as the main histological types encountered. Hematologically, there was mild anemia, rapid ESR (> 50 mm), normal platelets count in the majority, leucocytosis in < half and monocytopenia predominance. Biochemically they were characterized by normal liver function tests with the exception of high serum alkaline phosphatase, normal total serum proteins, hypoalbuminemia, normal serum urea, creatinine & uric acid, hypercalcemia, with serum LDH and B2MG elevation in the majority. Serum anti EB virus antibodies were seen in 1/4th of cases and the majority were of the higher IPI scores (both high intermediate & high). Those results were comparable to some and contradicting to other studies elsewhere.

A higher serum alkaline phosphatase is associated with the incidence of hip fracture and mortality among patients receiving hemodialysis in Japan

Monitoring of serum alkaline phosphatase (ALP) is recommended in the management of chronic kidney disease-mineral and bone disorder (CKD-MBD). However, unlike calcium, phosphate or parathyroid hormone, the relationship between serum ALP and patient outcome receiving hemodialysis (HD) in Japan is unknown. Baseline data of 185 277 HD patients with duration >90 days (66 ± 12 years, males 61.9%, and median HD duration of 5.8 years) were extracted from a nationwide dialysis registry at the end of 2009 in Japan. Outcomes were then evaluated using the registry at the end of 2010 using a multivariate logistic regression analysis. During 1-year follow-up, 14 230 (7.9%) patients died of all causes, including 6396 (3.6%) cardiovascular deaths. In addition, 1586 patients (1.0%) were newly diagnosed as hip fractures. All-cause and cardiovascular mortality and the incidence of hip fracture were higher in line with the increase in baseline serum ALP. On multivariate analysis, patients with the highest ALP quartile had higher all-cause and cardiovascular mortalities and a higher incidence of hip fracture than those with the lowest quartile [odds ratio (OR) 1.46, 95% confidence interval (CI) 1.33-1.60; OR 1.25, 95% CI 1.10-1.42; and OR 1.71, 95% CI 1.33-2.18, respectively]. In this large cohort study, higher serum ALP levels were independently associated not only with mortality but also with the incidence of hip fracture in Japanese HD patients. Further study is needed to test whether serum ALP measurements could improve the patient outcomes.

Frequency of Cholestatic Liver Diseases in Zagazig University Hospitals, with Special Emphasize on Extrahepatic Causes

Background and study aim : Extrahepatic cholestasis results from the mechanical obstruction of large bile ducts outside the liver or within the porta hepatis. The common etiologies of cholestasis have been reported to vary from one center to another. Our aim was to assess the frequency of cholestatic disorders in patients admitted to our department and try to identify the underlying extrahepatic causes aiming at improving the quality of management offered to this patients group. Patients and methods: In the present study, 506 cases admitted to our department were included. Sixty one of them met our inclusion criteria, of high serum alkaline phosphatase (ALP≥1.5 times the upper limit of normal), high gamma glutamyl transferase (GGT≥3 times the upper limit of normal) and ultrasonogrpahic (US) features of extrahepatic cholestasis (dilated intra and/or extra-hepatic ducts) of whatever etiology. The selected patients underwent the following: Full history taking and thorough physical examination, complete blood picture, liver and kidney function tests and abdominal CT. Also, ERCP was performed whenever needed and the tumor markers, alpha feto-protein & (CA 19-9) were assessed in selected cases when mass lesions were detected. Results : The frequency of cholestatic liver diseases presented with elevated both ALP & GGT as described above, was %19.7 (100 of 506 patients).While the frequency of extrahepatic cholestasis was 12.1% with females accounting for 54.1% and males were 45.9% with mean ages SD of 51.1 11.7 years. Benign causes of surgical obstructive jaundice were more frequent than malignant ones (57.4% VS 42.6%). The most common cause was choledocholithiasis in 25/61 (40.9%), followed by cancer head of pancreas 9/61 (14.8%), peri-ampullary carcinoma 8/61 (13.11%), cholangiocarcinoma 5/61 (8.2%) and pancreatitis 4/61 (6.6%). Dark urine, clay stool and itching were more common in patients with malignant obstructive jaundice. There was a highly positive agreement between ALP and GGT with P Conclusion : We concluded that, the frequency of cholestatic liver diseases in our department was %19.7. Among them, extrahepatic causes had a frequency of 12.1% with choledocholithiasis as the commonest benign etiology, while cancer head of pancreas was the most frequently met with malignancy. ERCP is considered the gold standard modality in diagnosis and management of extrahepatic cholestasis

Association of alkaline phosphatase with isolated coronary artery ectasia

Background. It has been shown that alkaline phosphatase (ALP) is a reliable marker for cardiovascular events and mortality. However, there is no data available regarding the association of ALP with isolated coronary artery ectasia (CAE). The aim of the present study was to assess the serum ALP activity in isolated CAE. Methods. Seventy-nine patients with isolated CAE (59 males; mean age, 52 ± 12 years) and 88 age- and gender-matched normal subjects (73 males; mean age, 52 ± 7 years) were enrolled. Baseline characteristics were recorded in both groups and serum ALP activity were compared between the two groups. Results. Patients with angiography-proved isolated CAE had significantly higher serum ALP activity compared with angiographic normal controls (72.41 ± 29.97 vs. 59.27 ± 14.46, p < 0.001). In the multivariate analysis, increased ALP (OR = 1.037, 95% CI 1.017–1.057, p < 0.001) were independent predictors for the presence of isolated CAE. A cut-off of ≥ 66.5 U/L of ALP activity measured on admission had a 60.8% sensitivity and 75.0% specificity in predicting isolated CAE by receiver operating characteristic (ROC) curve analysis. Conclusion. Our data firstly demonstrated that serum ALP activity, a readily available clinical laboratory value, was associated with the presence of isolated CAE.

Evidence for circulating tumor cell (CTC) alkaline phosphatase (AP) expression in men with bone-metastatic castration-resistant prostate cancer (CRPC) during abiraterone acetate treatment.

178 Background: Serum alkaline phosphatase (AP) changes in men with metastatic prostate cancer have been described since the Nobel Prize winning discovery of the hormonal dependence of PC. High serum AP is independently associated with mortality in men with castration-resistant prostate cancer (CRPC) and reductions in AP with treatment are favorably prognostic. Transient rises in AP may occur during treatment initiation and reflect bone remodeling/healing. The source of serum AP in men with metastatic prostate cancer, however, remains unclear. We hypothesize that cancer cell osteomimicry and epithelial plasticity may contribute to serum AP elevations in these men. Methods: We examined the expression of AP in the circulating tumor cells (CTCs) of men with metastice CRPC on abiraterone acetate who had elevated serum AP to determine if one possible source of serum AP may be tumor-derived rather than host/bone derived. CTCs were isolated using the CellSearch method and EpCAM ferromagnetic capture, and only CD45 negative cells were considered CTCs. AP was evaluated using immunofluorescence and real time positive and negative controls. Liver function was evaluated to ensure lack of confounding with liver-derived AP. Results: We identified AP to be commonly expressed in the CTCs of men with CRPC who had high serum AP, with no expression in patient leukocytes. One patient had a transient rise in serum AP with no change in other liver enzymes during a dramatic response to abiraterone acetate while his prostate-specific antigen and CTC declined. AP expression was evident and common in his CTCs during this serum AP flare. A second patient was found to have common CTC AP expression in both CK+ and CK- CTCs. This patient had evidence of AR amplification, PTEN loss, and TMPRSS2-ERG fusion in his CK- and CK+ CTCs, accompanied by a high number of OB-cadherin + CTCs, indicating likely osteomimicry and plasticity of these clonal epithelial tumor cells. Conclusions: We provide clinical evidence that PC CTCs express AP, supporting the hypothesis that AP expression is associated with osteomimicry as part of the biology of epithelial plasticity in prostate cancer. These findings support the existence of multiple CTC phenotypes, the clinical significance of which is unknown.

Effect of tamra bhasma (calcined copper) on ponderal and biochemical parameters.

Introduction:Tamra Bhasma (TB) and its forms like Somnathi Tamra Bhasma (STB), etc., are in vogue since centuries in Ayurveda. The present study is carried out to evaluate the effect of TB and STB in different dose levels on ponderal and biochemical parameters in wistar strain albino rats to provide scientific basis for its safety profile.Materials and Methods:TB and STB were prepared as per the classical guidelines and administered to wistar strain albino rats for 45 consecutive days. Blood was collected and rats were sacrificed on the 46th day. Ponderal and biochemical parameters were studied.Results:Results showed significant decrease in serum cholesterol, High Density Lipoprotein (HDL) cholesterol, triglycerides, total protein, and serum alkaline phosphatase levels. Comparatively, all the differences in between the groups are insignificant and no pathological changes at ponderal and biochemical levels were observed.Conclusion:Based on these observations, it can be said that these formulations can be safely used in cases of hyperlipidemia.

High serum alkaline phosphatase in relation to cerebral small vessel disease

ObjectivesVascular calcification is related with cerebral small vessel disease. We investigated whether alkaline phosphatase (ALP), a marker of vascular calcificiation, is related to cerebral small vessel disease. MethodsWe included 1082 neurologically healthy subjects who underwent brain magnetic resonance image for a routine health checkup. ALP levels were divided into quartiles. We used quantile regression and logistic regression to evaluate the associations of ALP with white matter hyperintensities (WMH), cerebral infarct and cerebral microbleeds. ResultsSubjects with higher ALP were more likely to have a large WMH volume. The adjusted difference of WMH volume between the highest and the lowest quartiles was 0.27 mL (95% confidence interval [CI]; 0.22–0.31 mL). In addition, cerebral infarct was more prevalent in subjects with higher ALP. Compared to the lowest quartile, adjusted odds ratios of having cerebral infarct for the highest quartile was 2.60 (95% CI, 1.10–6.10). No association was found between ALP and cerebral microbleeds. In addition, we found a conjoint effect of ALP and C-reactive protein(CRP) on cerebral small vessel disease. Compared with subjects with low ALP (≤63 IU/L) and low CRP (≤0.5 mg/dl), those with high ALP (>63 IU/L) and high CRP (>0.5 mg/dl) had larger WMH volume (adjusted difference 0.39 mL; 95% CI 0.37–0.42 mL) and a 3-fold (adjusted OR. 3.37; 95% CI, 1.61–7.03) risk of cerebral infarct. ConclusionWe found that higher serum levels of ALP are independently associated with WMH and cerebral infarct, but not with cerebral microbleeds.

Diffuse osteosclerosis in a patient with prostate cancer

A 61-year-old man was referred to our outpatient clinic because of severe bilateral upper leg pain for 1 year. On admission, the patient had anemia and a high serum alkaline phosphatase level. Lumbar and femoral neck T-scores were +10.5 and +9.6, respectively. His radius 33 % T-score was -2.8. Plain radiographs of the patient's pelvis, spine, and long bones revealed osteosclerosis. The patient had previously undergone a prostate biopsy, which showed prostate adenocarcinoma (Gleason score 3 + 4). The patient's total and free prostate-specific antigen were very high. According to previous records, the patient did not have anemia, and his serum alkaline phosphatase (ALP) level was normal. An abdominal radiograph taken 2 years earlier revealed a normal spine and pelvic bone. Bone scintigraphy yielded nontypical findings for prostate cancer metastasis. Computed tomography of the patient's thorax and abdomen showed heterogeneous sclerotic areas in all bones consistent with prostate cancer metastasis. A bone marrow biopsy disclosed disseminated carcinomatosis of bone marrow in association with prostate cancer. Clinicians should be aware of the possibility of prostate malignancy as a cause of high bone mineral density (BMD), even in the absence of typical localized findings on plain radiographs.

Updates on rickets and osteomalacia: etiology and pathophysiology of osteomalacia

Impairment of bone mineralization causes rickets and osteomalacia. Rickets develops with impaired mineralization of bone prior to epiphyseal closure, and so does osteomalacia after the closure of epiphyses. Pain in lower extremities and back and bone pain are usually observed in patients with osteomalacia. Chronic hypophosphatemia and/or impairment of vitamin D action are involved in the development of osteomalacia. It is of great importance to suspect osteomalacia from clinical symptoms and laboratory data, such as hypophosphatemia and/or high serum alkaline phosphatase level.

Clinical and laboratory features of temporary brittle bone disease

Temporary brittle bone disease has been described since 1990. It is a syndrome characterised by multiple unexplained fractures in early childhood. There is growing evidence that it has natural causes and does not represent inflicted trauma. We report the clinical and laboratory features of 104 patients investigated personally between 1985 and 2000. These patients had in aggregate 976 fractures or fracture-like lesions. Our patients included disproportionate numbers of infants born preterm or as a result of multiple pregnancy. The fractures were mainly identified in the first 6 months of life and entirely within the first year of life. Most fractures were asymptomatic, particularly the many rib fractures and metaphyseal lesions. Few patients had evidence of bruising at presentation; none had clinical evidence of inflicted injury commensurate with the fractures found. In 22 patients the fractures were found in the course of investigation for unrelated symptoms. In several cases fractures took place while the children were in hospital. Unexplained bruising and sub-conjunctival haemorrhages also occurred in hospital, suggesting collagen defects. Hernias were recorded; in most these resolved spontaneously, again suggesting transient collagen defects. Among the unexplained symptoms of the patients was a history of vomiting, often projectile vomiting. Some patients had unusually blue or grey sclerae for the child's age. Many patients had abnormally large anterior fontanelles. Laboratory findings included anaemia, neutropenia and an exceptionally high serum alkaline phosphatase. Our findings reinforce the view that children with temporary brittle bone disease have a distinctive and identifiable syndrome which probably includes osteopathy of prematurity. These patients do not have osteogenesis imperfecta and are not the victims of non-accidental injury. While the causes of this syndrome remain uncertain, its distinctive features should now be more readily recognised.

Haematological and biochemical reference intervals of four feline breeds.

Many feline breeds have been generated from a small number of ancestors. Thus, breed-specific peculiarities can be expected, which could include haematological and biochemical measurements. Despite this, there are only a few reports on breed-specific reference intervals (RI). This information is essential in routine practice where results from individual patients are usually compared with an RI. The aim was to compare haematological and biochemical data from clinically healthy Abyssinian, Holy Birman, Norwegian Forest and Siberian cats with published RIs to assess whether the published RIs are acceptable in these breeds. Comparison with established RIs using guidelines from the National Committee for Clinical Laboratory Standards and the American Society of Veterinary Clinical Pathology, revealed a number of breed-related clinicopathological differences. New RIs were established, but in most cases the new RIs overlapped with published RIs, and the use of the breed-specific data would minimally affect the clinical interpretation of laboratory results. Important differences that could result in misinterpretation of laboratory results were as follows: microcytosis and high α2-globulin concentrations in Abyssinian cats; high serum creatinine, α2-globulin and glucose concentrations in Holy Birman cats; high serum alkaline phosphatase activity and calcium and phosphate concentration in Norwegian Forest cats; low β2-globulin and γ-globulin concentrations in Norwegian Forest and Siberian cats. Breed-specific RIs should be used for these analytes. In addition, care should be taken in interpreting clinicopathological data in purebred cats for which specific RIs have not been established.

Paget's disease of maxilla: A case report

Paget disease of bone (PDB) is a metabolic bone disease characterized by increased and disorganized bone turnover. Its etiology is not clear, but includes endocrine, genetics and inflammatory factors. Some patients are asymptomatic, whereas others develop complications such as pain, osteoarthritis, fracture, deformity, deafness, and nerve compression syndromes. Diagnosis of PDB is usually made incidentally by radiographic examinations obtained for other reasons or during evaluation of high serum alkaline phosphatase levels. In this study, we present a case of a 57-year-old female patient with complaint of swelling in the maxilla. Panoramic radiography accompanied by laboratory studies confirmed the diagnosis which was very important for choosing the proper treatment.

Prognostic factors for teenage and adult patients with high-grade osteosarcoma: an analysis of 240 patients

The aim of this retrospective, multicenter study was to evaluate clinicopathological characteristics, prognostic factors and treatment outcomes of teenage and adult patients with high-grade osteosarcoma. A total of 240 osteosarcoma patients who were diagnosed and treated from March 1995 to September 2011 were analyzed. Median age was 20 years (range 13-74 years), and 153 patients (63.8%) were male. Primary tumor localization was extremity in 204 patients (85.4 %), trunk in 21 patients (8.8%) and head and neck region in 14 patients (5.9%). According to American Joint Committee on Cancer staging system, 186 patients (77.5%) were stage II, 3 (1.3%) were stage III and 48 (20.0%) were stage IV. Median overall survival (OS) was 55 months (95 % CI 36.8-73.1 months). OS after 2, 5 and 10 years were 67, 49 and 42%, respectively. Univariable analysis for OS showed that male gender (p = 0.032), high baseline lactate dehydrogenase (LDH) level (p < 0.001), high baseline serum alkaline phosphatase level (p = 0.002), telangiectatic subtype (p = 0.023), presence of metastasis at diagnosis (p < 0.001), presence of tumor positive margins after primary surgery (p = 0.015), poor pathological response to preoperative chemotherapy (p = 0.006) and presence of recurrent disease during follow-up period (p < 0.001) were significantly associated with poor survival. Patients who received postoperative methotrexate plus doxorubicin plus cisplatin (M + A + P) combination regimen (p = 0.019), underwent surgery for recurrent disease (p < 0.001) and received chemotherapy for recurrent disease (p < 0.001) had longer OS. In multivariable analysis for OS, only high LDH level (p = 0.002) and the presence of metastasis at diagnosis (p = 0.011) were associated with poor OS, whereas the patients who received chemotherapy for recurrent disease had a longer OS (p = 0.009).

The effect of cigarette smoke exposure on vitamin D level and biochemical parameters of mothers and neonates.

BackgroundExposure to cigarette smoke during pregnancy leads to several adverse effects on mother and child. The purpose of this study was to evaluate the effect of being a passive smoker during pregnancy on vitamin D level and related biochemical indices including parathyroid hormone, calcium, phosphorus and alkaline phosphatase in mothers and newborns.MethodsOne hundred eight pregnant women and their newborns participated in a historical cohort study in two equal groups (n = 54) with and without cigarette smoke exposure. Maternal blood and urine samples and blood samples of umbilical cord were obtained in the delivery room. Concentration of 25-hydroxy vitamin D and related biochemical indices in samples of maternal and cord blood were investigated. Exposure to cigarette smoke was evaluated through questionnaire and maternal urine and umbilical cord serum cotinine levels.ResultsThe mean level of 25-hydroxyvitamin D in maternal serum was 9.28 ± 5.19 ng/mlin exposed and 10.75 ± 5.26 ng/ml in non-exposed group(p > 0.05). The mean concentration of 25-hydroxy vitamin D in cord serum was 10.83 ± 6.68 ng/ml in the exposed and 11.05 ± 4.99 ng/ml in the non-exposed group(p > 0.05). The exposed mothers had significantly higher parathyroid hormone level (p = 0.013), lower serum calcium (p = 0.024) and higher serum alkaline phosphatase (p = 0.024). There was a significant correlation between maternal and umbilical cord serum 25-hydroxyvitamin D within both exposed and non-exposed groups (p < 0.001).ConclusionMaternal exposure to cigarette smoking during pregnancy negatively influences serum calcium level and increase parathyroid hormone and alkaline phosphatase in mothers.

Endoscopic Papillectomy for Benign Ampullary Neoplasms: How Can Treatment Outcome Be Predicted?

Background/AimsEndoscopic papillectomy is increasingly performed with curative intent for benign papillary tumors. This study was performed to identify factors that predict the presence of malignancy and affect endoscopic success.MethodsWe retrospectively analyzed the medical records of patients who received an endoscopic papillectomy for papillary adenoma from 2006 to 2009.ResultsA total of 43 patients received endoscopic papillectomy. The pathologic results after papillectomy revealed adenocarcinoma in five patients (12%), and the risk of malignancy was high in cases of large lesions, preprocedural pathology of high-grade dysplasia or high serum alkaline phosphatase. Endoscopic success was observed in 37 patients (86%) at the end of follow-up (mean duration, 10.4±9.6 months). The factor significantly affecting success was a complete resection at the initial papillectomy (p=0.007). Two patients experienced recurrence 10 and 32 months after the complete resection, but both achieved endoscopic success with repeated endoscopic treatment. Six patients with endoscopic failure received surgical resection.ConclusionsEndoscopic papillectomy is a safe and effective method for the curative resection of benign papillary tumors, especially when complete resection is achieved at the initial papillectomy. Follow-up with surveillance should be performed for at least 3 years because of the possible recurrence of tumors during these periods.

Correlates of parathyroid hormone concentration in hemodialysis patients

The implications of chemical hyperparathyroidism on bone and mineral metabolism measures in maintenance hemodialysis (MHD) are not well known. We hypothesized that a higher serum intact parathyroid hormone (iPTH) level is associated with the higher likelihood of hyperphosphatemia, hyperphosphatasemia [high serum alkaline phosphatase (ALP) levels] and hypercalcemia. Over an 8-year period (July 2001-June 2009), we identified 106 760 MHD patients with iPTH and calcium (Ca), phosphorous (P) and ALP data from a large dialysis clinic. Logistic regression models were examined to assess the association between serum iPTH increments and the likelihood of hyperphosphatemia (P ≥5.5 mg/dL), hypercalcemia (Ca ≥10.2 mg/dL) and hyperphosphatasemia (ALP ≥120 U/L). Patients were 61 ± 16 years old and included 45% women, 59% diabetics and 33% Blacks. Compared with an iPTH level of 100 to <200 pg/mL, patients with an iPTH level of 600-700, 700 to <800 and ≥800 pg/mL had 122% (OR: 2.22, 95% CI: 2.04-2.41), 153% (OR: 2.53, 95% CI: 2.29-2.80) and 243% (OR: 3.43, 95% CI: 3.22-3.66) higher risk of hyperphosphatemia, respectively, and had 109% (OR: 2.09, 95% CI: 1.93-2.26), 130% (OR: 2.30, 95% CI: 2.10-2.52) and 376% (OR: 4.76, 95% CI: 4.50-5.04) higher risk of hyperphosphatasemia, respectively. Compared with an iPTH level of 100 to <200 pg/mL, both the low iPTH (<100 pg/mL, OR: 2.45, 95% CI: 2.27-2.64) and the high iPTH (≥800 pg/mL: OR: 2.13, 95% CI: 1.95-2.33) levels were associated with hypercalcemia. Higher levels of iPTH are incremental correlates of hyperphosphatemia and hyperphosphatasemia, whereas both very low and high PTH levels are linked to hypercalcemia. If these associations are causal, correction of hyperparathyroidism may have overarching implications on bone and mineral disorders in MHD patients.