Hypocalcemia In Patients Research Articles

Zoledronate.

Zoledronate is the most potent and most long-acting bisphosphonate in clinical use, and is administered as an intravenous infusion. Its major uses are in osteoporosis, Paget's disease, and in myeloma and cancers to reduce adverse skeletal related events (SREs). In benign disease, it is a first- or second-line treatment for osteoporosis, achieving anti-fracture efficacy comparable to that of the RANKL blocker, denosumab, over 3years, and it reduces fracture risk in osteopenic older women. It is the preferred treatment for Paget's disease, achieving higher rates of remissions which are much more prolonged than with any other agent. Some trials have suggested that it reduces mortality, cardiovascular disease and cancer, but these findings are not consistent across all studies. It is nephrotoxic, so should not be given to those with significant renal impairment, and, like other potent anti-resorptive agents, can cause hypocalcemia in patients with severe vitamin D deficiency, which should be corrected before administration. Its most common adverse effect is the acute phase response, seen in 30-40% of patients after their first dose, and much less commonly subsequently. Clinical trials in osteoporosis have not demonstrated increases in osteonecrosis of the jaw or in atypical femoral fractures. Observational databases are currently inadequate to determine whether these problems are increased in zoledronate users. Now available as a generic, zoledronate is a cost-effective agent for fracture prevention and for management of Paget's disease, but wider provision of infusion facilities is important to increase patient access. There is a need to further explore its potential for reducing cancer, cardiovascular disease and mortality, since these effects could be substantially more important than its skeletal actions.

A comparative study of postoperative hypocalcaemia following total thyroidectomy in patients with Hashimoto’s thyroiditis and multinodular goitre in a rural tertiary care hospital

Background: Recurrent laryngeal nerve injury, hypothyroidism and hypocalcaemia have long been recognized as the three main sequalae of thyroidectomy. Persistent hypocalcaemia may cause intracranial lesions and cardiac arrhythmias. As the definitive diagnosis of Hashimoto’s thyroiditis was not always possible with clinical and cytological parameters when antibody testing was not done, surgery was planned with the diagnosis of multinodular goitre. This study was conducted to find out the incidence of post-operative hypocalcaemia following total thyroidectomy by skilled surgeons in patients with multinodular goitre and Hashimoto’s thyroiditis.Methods: This was a cross-sectional study to compare the incidence of hypocalcaemia in patients with biopsy-proven Hashimoto’s thyroiditis and multinodular goitre. After obtaining approval from the institutional review board and ethics committee, data was collected serially, from the surgical records of 123 patients who underwent total thyroidectomy in this tertiary care centre, during the past two years.Results: The incidence of post-operative hypocalcaemia (71.1%) in patients undergoing total thyroidectomy with Hashimoto’s thyroiditis was significantly higher than in patients with multinodular goitre (56.4%). Of the 45 patients who had a biopsy report of Hashimoto’s thyroiditis, 8 (17.8 %) developed permanent hypocalcaemia while only 8 (10.3%) of the 78 patients with histopathological diagnosis of multinodular goitre developed persistent hypocalcaemia needing supplementation following total thyroidectomy in this rural tertiary care hospital.Conclusions: The significant risk of post-operative hypocalcaemia should be kept in mind before opting for total thyroidectomy for benign lesions of the thyroid and pre-operative antibody studies must be done to diagnose Hashimoto’s thyroiditis.

Effect of Preoperative Vitamin D Deficiency on Hypocalcemia in Patients with Acute Hypoparathyroidism after Thyroidectomy.

Postoperative hypoparathyroidism is a common complication of total or completion thyroidectomy. The association between preoperative vitamin D deficiency (VDD) and the development of more severe postoperative hypocalcemia is still unclear. Objectives. To evaluate the effect of preoperative VDD on severity of hypocalcemia in patients with hypoparathyroidism following thyroidectomy. Methods. Patients who developed acute hypoparathyroidism after total or completion thyroidectomy, defined as postoperative parathyroid hormone (PTH) level <15 pg/mL and albumin-adjusted calcium level <8.6 mg/dL, were prospectively recruited. Patients were divided into two groups according to their preoperative vitamin D status (VDD group: 25-hydroxyvitamin D (25(OH)D) level <20 ng/mL; non-VDD group: 25(OH) level ≥20 ng/mL). The primary outcome was severity of hypocalcemia in postoperative hypoparathyroidism. Significant hypocalcemia was defined as calcium level ≤7.5 mg/dL. Results. Forty-three patients (21 VDD, 22 non-VDD) were enrolled. Serum total albumin-adjusted calcium level was significantly lower in the VDD group (7.71 ± 0.5 vs. 8.16 ± 0.4 mg/dL, p < 0.01), and the incidence of symptomatic hypocalcemia was significantly higher in the VDD group (43% vs. 9%, p=0.01). The median maximal daily supplementary dose of elemental calcium was significantly higher in the VDD group (2,400 vs. 1,500 mg/day, p=0.02). Length of hospital stay was nonsignificantly longer in the VDD group (p=0.06). Preoperative vitamin D level <19.6 ng/mL could predict significant and symptomatic hypocalcemia in postoperative hypoparathyroidism with sensitivity of 90% and 82% and specificity of 70% and 69%, respectively. Conclusion. VDD is an independent risk factor for both significant and symptomatic hypocalcemia in hypoparathyroidism patients after thyroid surgery.

Combined ionized calcium and PTH evaluation in the management of post-thyroidectomy hypocalcemia.

The aim of our study was to investigate the postoperative course of calcium and parathyroid hormone (PTH) levels after total thyroidectomy to define a proper and low cost protocol. We studied 144 patients who underwent total thyroidectomy between 2007 and 2010. Ionized calcium was determined preoperatively and on day 1 (POD1), day 2 (POD2) and day 7 (POD7) postoperatively; PTH preoperatively and on POD7. Patients with ionized calcium ≤1.11 mmol/L were considered hypocalcemic and treated only if symptoms, ≤1 mmol/L were treated in all cases. Ionized calcium and PTH declined postoperative in all patients compared to preoperative levels (P=0.000). Ionized calcium increased on POD7 compared to POD1 and POD2 (P=0.000). All hypocalcemic untreated 30 patients returned normocalcemic on POD7. Thirty-eight hypocalcemic patients were treated but 23 (61%) safely suspended therapy on POD7. We tested PTH and ionized calcium as independent factors of prolonged hypocalcemia (that required therapy beyond 7 days) with the following results (sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy): PTH ≤11 pg/mL (80%, 100%, 100%, 96% and 97%, respectively), ionized calcium ≤1.11 mmol/L (80%, 88%, 59%, 95%, and 87%, respectively) and ionized calcium ≤1 mmol/L (28%, 100%, 100%, 87% and 88%, respectively). Our data show that our protocol, including serum ionized calcium on 1st, 2nd, 7th days and PTH on 7th day after surgery, is safe and low cost and therefore may be useful in the post-surgical management of total thyroidectomy.

SAT-077 Two Cases of Hypoparathyroidism Due to Activating Calcium Sensing Receptor Mutation

IntroductionThe extracellular calcium-sensing receptor (CaSR) expressed mainly in the parathyroid gland and kidneys regulates calcium (Ca+2) homeostasis through parathyroid hormone (PTH) secretion. Activating mutations of CaSR can lead to autosomal dominant hypocalcemia and severe congenital hypoparathyroidism. Constitutively activated CaSR receptors blocks PTH release leading to hypocalcemia, hyperphosphatemia and decreased Ca+2 reabsorption from the kidney.Case 1:14 year old male presented for an evaluation of hypocalcemia and hyperphosphatemia found on routine blood work. He denied symptoms of hypocalcemia. He had normal vital signs, positive Chovstek sign but rest of exam was unremarkable. His lab results showed low Ca+2 8.1 mg/dl (8.6–10 mg/dl), high phosphorus 6 mg/dl (2.7–4.5 mg/dl) and inappropriately normal PTH 26.8 pg/ml (10–65 pg/ml). FISH was negative for DiGeorge. Genetic testing showed heterozygous CaSR gene mutation I822T, variant of uncertain significance. His father with primary hypoparathyroidism has the same CaSR gene mutation; mother is healthy and tested negative for this variant. Given the inheritance pattern of the mutation, it is likely a pathologic mutation. He is maintained on Calcium (1500 mg BID) and Calcitriol (0.5 mcg PO BID) and is doing well.Case 2:One day old premature 32-week old infant girl was found to have early onset neonatal hypocalcemia 6.1 mg/dl (6.2–11 mg/dl) during NICU admission for respiratory distress, inappropriately normal PTH 18.5 pg/ml and high phosphorus 8.8 mg/dl (4.6–7.9 mg/dl). She had no symptoms of hypocalcemia in the NICU or at home. She did not have any dysmorphic features. FISH was negative for DiGeorge. Genetic testing to sequence genes including AIRE, AP2S1, CASR, GNAS, HADHA, HADHB, PTH1R, SOX3, STX16, TBCE was done and revealed a novel heterozygous mutation in the CaSR gene for a missense variant c.2495T>C(p.lle832Thr) and STX16 c.644A>T, possibly benign variant. Unfortunately, the parents have not consented to testing yet. Further familial and functional characterization of this new variant is necessary to confirm its possible pathogenetic role in this hypocalcemic patient. Currently she is maintained on ergocalciferol 800 IU, calcitriol 0.25 mcg and sevelamer 3 packets daily and is doing well.Conclusion:In the workup for primary hypoparathyroidism without dysmorphic features and tests negative for DiGeorge, CaSR mutations should be investigated as part of the differential as we have identified variants in the CaSR gene in 2 children with asymptomatic hypocalcemia, one of which is a novel mutation which has never been reported before.

Vitamin D Status as a Predictor of Postoperative Hypocalcemia after Thyroidectomy.

To determine whether perioperative vitamin D levels are predictive of postoperative hypocalcemia in patients receiving thyroidectomy. Single center retrospective study. This study included all patients receiving total or completion thyroidectomy between January 2007 and March 2017 at a single tertiary care hospital. 25-Hydroxyvitamin D (25[OH]D) levels were measured within 42 days prior to surgery or 1 day postoperatively. Hypocalcemia was defined as an adjusted serum calcium <8.0 mg/dL (based on albumin levels) or symptomatic hypocalcemia. Univariate analysis was performed with a 2-sample t test and chi-square test, while multivariate analysis was performed with logistic regression analysis to determine whether perioperative 25(OH)D level is a predictor of postoperative hypocalcemia. A total of 517 subjects were included in the study, 15.7% (n = 81) of whom experienced postoperative hypocalcemia with a mean ± SD serum calcium level of 7.6 ± 0.5 mg/dL as compared with 8.9 ± 0.5 mg/dL in the normocalcemic population (P < .01). The mean 25(OH)D level for patients with hypocalcemia was 24.4 ± 12.0 ng/mL as compared with 27.5 ± 12.2 ng/mL in patients with normocalcemia (P = .038). Subjects who were hypocalcemic experienced a significantly longer hospital stay (2.9 ± 2.5 vs 1.4 ± 1.1 days, P < .01). After adjusting for preoperative calcium, age, and performance of a neck dissection, subjects with a 25(OH)D level <30 ng/mL were significantly associated with postoperative hypocalcemia (odds ratio, 1.9; P = .041; 95% CI, 1.0-3.3). Using a single-center retrospective study design, we demonstrated that 25(OH)D level is a significant predictor of postoperative hypocalcemia after thyroidectomy.

Causes of hypocalcemia after thyroid surgery

Aim. To identify the causes affecting hypocalcemia and its frequency of causing after thyroidectomy.&#x0D; Methods. The study included 402 patients after thyroidectomy, 361 (89.8%) women and 41 (10.2%) men, for the period 20152019. The patients were between the ages of 14 and 77 years (average 4527.2 years). Patients were tested for the presence of hyperthyroidism, the volume of tissue removed and type of thyroidectomy, presence of repeated thyroid operations and accidental parathyroidectomy, the results of parathyroid autotransplantation and pathohistological reports. To determine the effect of these factors on hypocalcemia, patients were divided into three groups. The first group included patients (n=51, 12.7%) were underwent surgery for Graves disease, the second (n=335, 83.3%) for nodular goiter, and the third (n=16, 4%) for recurrent goiter. Statistical data analysis was performed with IBM SPSS 16.0. The results were analyzed by one-way analysis of variance or KruskalWallis test and the median test. Results were considered statistically significant at p 0.05 (two-sided criterion).&#x0D; Results. In the early postoperative period, 20 (5%) of 402 patients had hypocalcemia, of which 12 (3%) had transient hypocalcemia, and 8 (2%) had permanent hypocalcemia. Postoperative hypocalcemia was detected in 9 (17.6%) patients the first group, 8 (2.4%) patients in the second group, and 3 (18.8%) patients of the third group. Patients hypocalcemia was characterized based on the types of underwent operations as follows: in 14 (5.3%; p 0.05) patients after total thyroidectomy, in 1 (3.2%) patient after close to total thyroidectomy, in 1 (16.7%) patient after total thyroidectomy with central lymphatic dissection, in 1 (20%) patient after total thyroidectomy with central and lateral lymphatic dissection, in 3 (18.8%) patients after repeated surgery. Postoperative hypocalcemia was identified in 5 of 44 patients of the second group with thyroid carcinoma, as well as in 1 patient of the third group with the same pathology (p=0.246).&#x0D; Conclusion. Incidence of hypocalcemia was more frequent after surgery for hyperthyroidism, especially after total thyroidectomy; in 40% of cases, transient hypocalcemia was identified in patients with autotransplantation of the parathyroid gland after an accidental parathyroidectomy.

Risk Factors for Development of Hypocalcemia in Patients With Cancer Treated With Bone-Modifying Agents.

This retrospective analysis describes the prevalence of and risk factors associated with the development of hypocalcemia in patients with cancer receiving bone-modifying agents (BMAs) as supportive care. Patients with cancer treated with an intravenous or subcutaneous BMA, including pamidronate, zoledronic acid, or denosumab, at a tertiary care/safety net hospital in 2005 through 2015 were included in this retrospective review. We reviewed the medical records for predictive clinical and laboratory parameters and for patient outcomes. A total of 835 patients with cancer received at least one dose of a BMA during the specified time frame; 205 patients (25%) developed hypocalcemia of CTCAE grade ≥1 within 8 weeks of BMA initiation, 18 of whom (8.8%) had grade ≥3, and 3 patients died as a result. Multivariate analysis showed that patients with hematologic malignancy (odds ratio [OR], 1.956; P=.025), bone metastases (OR, 2.443; P=.017), inpatient status (OR, 2.592; P<.001), and deficient baseline vitamin D levels (OR, 2.546; P<.023) were more likely to develop hypocalcemia. Hypercalcemia before BMA administration (OR, 0.474; P=.032) was protective. Certain patient populations, including those with hematologic malignancies and/or bone metastases, warrant closer monitoring of calcium levels while receiving BMAs because of the high rate of hypocalcemia. Low pretreatment vitamin D levels are associated with the development of hypocalcemia. These data support close monitoring of calcium levels in patients with cancer receiving BMAs, in addition to adequate repletion of vitamin D before initiation of BMAs when possible.

Effect of perioperative application of glucocorticoid on postoperative hypoparathyroidism and hypocalcemia in patients with total thyroidectomy plus central compartment dissection

Objective: To evaluate the effect of glucocorticoid used in perioperative period of total thyroidectomy (TT) plus central compartment lymph node dissection (CCLND) or combining with lateral neck dissection on postoperative hypoparathyroidism (HPT) and hypocalcemia (HPC). Methods: The data of 117 patients with papillary thyroid carcinoma (PTC) undergone the surgeries in Tongren Hospital between Nov 2015 and Mar 2017 were retrospectively analyzed. There were 36 males and 81 females, and their ages ranged from 21 to 74 years old, average age of 47.8±12.5. TT and CCLND were performed in 81 (69.2%) patients, and TT, CCLND and unilateral or bilateral lateral neck dissection were performed in 36 (30.8%) patients. The patients were divided into 4 groups: Group A (40 patients), no glucocorticoid was applied; Group B (36 patients), 5 mg dexmethasone sodium phosphate was sprayed on the surface of wound on both sides of trachea during operation; Group C (21 patients), 40 mg methylprednisolone was applied by intravenous injection after operation, one time per day for 3 days; Group D (20 patients), 5 mg dexmethasone sodium phosphate was sprayed on the surface of wound on both sides of trachea during operation and 40 mg methylprednisolone were applied by intravenous injection after operation, one time per day for 3 days. Serum parathyroid hormone and calcium were tested before operation and at the 1(st), 2(nd) and 3(rd) day after operation. Spss19.0 was used to analyze the data. Results: There were statistically significant differences in the incidences of both no HPT and no HPC and the incidence of HPT alone between Group A and B (35.0% vs 61.1%, 15.0% vs 2.8%, χ(2) were 5.182 and 3.885, respectively, P<0.05), but not in the incidence of HPC alone between the two groups. There were statistically significant difference in the incidences of both no HPT and no HPC between Group A and D (35% vs 70.0%, χ(2)=6.530, P<0.05), but not in the incidences of HPT or HPC between the two groups. There were not statistically significant differences in the individual incidences between Groups A and C (P>0.05). There were statistically significant differences in the incidence of both no HPT and no HPC and the incidence of HPT alone between Groups B and C (61.1% vs 23.8%, 2.8% vs 23.8%, χ(2) were 7.402 and 6.229, respectively, P<0.05), but not in the incidence of HPC between the two groups (P>0.05). HPT and HPC often occurred on the 1(st) or 2(nd) day after operation. Permanent hypocalcemia did not occur in all cases. Conclusions: Intraoperative especially plus post-operative application of glucocorticoid can decrease the incidence of HPT after operation.

C-terminal telopeptide of type I collagen, osteocalcin, alkaline phosphatase, and parathyroid hormone in healthy and hospitalized foals

Hypocalcemia is a common finding in critically ill equine patients. Parathyroid hormone (PTH) helps to maintain calcium homeostasis in hypocalcemic patients by promoting renal calcium reabsorption and bone resorption. Increased serum PTH concentrations have been reported in critically ill people and animals, including horses and foals. It is unknown whether increased secretion of PTH is associated with markers of bone turnover in hospitalized foals. The goals of this study were to measure markers of bone resorption (C-terminal telopeptide of type I collagen [CTX-I]) and bone formation (osteocalcin [OCN]; alkaline phosphatase [ALP]) and to determine their association with PTH concentrations, disease severity, and mortality in hospitalized foals. This prospective, multicenter, cross-sectional study was conducted on 75 newborn foals ≤3 d old divided into hospitalized (n = 65; 41 septic; 24 sick nonseptic) and healthy (n = 10) groups. Blood samples were collected on admission to measure serum CTX-I, OCN, and PTH concentrations and ALP activity. Data were analyzed by nonparametric methods and univariate logistic regression. Serum CTX-I and PTH concentrations were significantly higher, whereas OCN concentrations were lower, in septic compared with healthy foals (P < 0.05). Serum ALP activity was not different between groups; however, it was lower in hospitalized and septic foals with low OCN concentrations (P < 0.05). In hospitalized foals, PTH concentrations were positively correlated with CTX-I concentrations and inversely associated with ALP activity (P < 0.05). High CTX-I and low OCN concentrations were associated with disease severity (P < 0.05). Hospitalized nonsurviving foals had significantly lower OCN concentrations compared with survivors (P < 0.05), but CTX-I concentrations were not associated with survival. Hospitalized foals with PTH concentrations >12.4 pmol/L were more likely to die (OR = 1.5; 95% CI = 1.1–4.16; P < 0.05). Elevated PTH and CTX-I together with reduced OCN concentrations and ALP activity in sick foals indicates that bone resorption is increased during critical illness, which may be a compensatory mechanism to correct hypocalcemia or reflect a response to systemic inflammation and metabolic imbalances. Bone resorption could negatively impact skeletal development in the growing foal. Low OCN and high PTH concentrations were predictors of nonsurvival in hospitalized foals.

Preventative and management strategies of hypocalcemia after thyroidectomy among surgeons: An international survey study

To determine international surgeon practice patterns for transient postoperative hypocalcemia in patients undergoing total thyroidectomy. All member surgeons of the American Thyroid Association and the International Association of Thyroid Surgeons were contacted via email to complete a 20-question survey which included both questions about demographic information and preventing and managing postoperative hypocalcemia after thyroidectomy. Univariate analysis was performed to determine whether providers check preoperative vitamin D levels, postoperative calcium trends and/or PTH to assess for postoperative hypocalcemia. A total of 332 surgeons responded to the survey with 72.26% in practice for >10years and 82.18% performing >50 total thyroidectomies per year. 13.29% of surgeon's surveyed reported that they routinely check preoperative vitamin D levels. Surgeon case volume, type of practice (academic vs non-academic practice), and geographic location in the US were significant predictors of whether surgeons check preoperative Vitamin D levels. International surgeons were significantly more likely to check both postoperative serum Ca and PTH compared to US based surgeons (p<.01). There was no significance difference in practice patterns based on whether the surgeon was a General Surgeon or an Otolaryngologist. Using a questionnaire distributed to both General Surgeons and Otolaryngologists, we demonstrated that there is significant variation in practice patterns between surgeons practicing in the United States and surgeons practicing in other countries, and practice often differs from recommended guidelines.

Calcium and Vitamin D supplementation in the prevention of post-operative hypocalcaemia in thyroidectomy

Introduction: The incidence of transient hypocalcaemia after thyroidectomy varies in centres. It increases morbidity and delays discharge. This randomised controlled trial aimed to ascertain the usefulness of calcium and Vitamin D supplementation for 1 week pre-operatively in the prevention of hypocalcaemia in patients undergoing total thyroidectomy (TT) for multi-nodular goitre. Methodology: Patients undergoing TT for multi-nodular goitre from January 2019 to August 2019 were included in the study. They were randomly divided into two groups by block randomisation. Group A received oral calcium (500 mg every 6 h) and Vitamin D (calcitriol 0.25 mg every 6 h) 7 days before surgery and Group B did not receive supplementation. Symptoms and signs of hypocalcaemia were monitored. Calcium profile was measured pre-operatively and post-operatively at 6 h, 24 h, 72 h and 14th day. Serum calcium level ≤8.5 mg/dl was considered as hypocalcaemia. Results: 8/62 patients in Group A and 26/62 in Group B had symptoms of hypocalcaemia. 11/62 patients in Group A and 34/62 in Group B developed signs of hypocalcaemia. 15/62 patients in Group A and 36/62 in Group B had biochemical hypocalcaemia. 9/62 patients in Group A and 25/62 in Group B developed post-operative hypocalcaemia, which required post-operative oral supplementation. 3/62 patients in Group A and 16/62 in Group B needed post-operative intravenous calcium supplementation. Conclusions: It is concluded that post-operative hypocalcaemia which manifested as signs and symptoms and correlated with biochemical values was lower after receiving pre-operative oral calcium and Vitamin D3 supplement for 7 days. The need for post-operative supplementation was lower in this group.

Hypocalcemia After Completion Thyroidectomy for Papillary Thyroid Carcinoma.

SUMMARYSurgical management of papillary thyroid carcinoma (PTC) includes total thyroidectomy and lobectomy. After lobectomy, a reoperation called completion thyroidectomy is occasionally required. Postoperative hypocalcemia is the most common complication associated with thyroid surgery. Our main goal was to determine if there is a significant difference between the incidence rate of postoperative hypocalcemia in patients who underwent total thyroidectomy for PTC compared with patients who underwent completion thyroidectomy for PTC. Apart from that, we analyzed the following potential predictive factors for the occurrence of hypocalcemia: sex, age, size of tumor, side of tumor, maximum diameter of individual lobe, occult metastasis, and operating surgeon. The study involved 340 patients who underwent surgery for PTC at the Department of ENT and Head and Neck Surgery, Zagreb University Hospital Centre, between February 25, 2013 and January 3, 2016. Postoperative hypocalcemia incidence rates were higher in the total thyroidectomy group than in the completion thyroidectomy group (37.8% and 29.0%, respectively). However, these differences were not statistically significant. Every analyzed potential predictive factor was proven not to have any correlation with postoperative hypocalcemia. This study demonstrated that there was no significant difference between postoperative hypocalcemia rates in patients who underwent completion thyroidectomy compared with patients who underwent total thyroidectomy for PTC.

Predictors of Hypocalcemia in Patients Undergoing Parathyroidectomy with the Diagnosis of Primary Hyperparathyroidism

Predictors of Hypocalcemia in Patients Undergoing Parathyroidectomy with the Diagnosis of Primary Hyperparathyroidism

Prevalence of vitamin D deficiency and its relationship with epileptic severity in a pediatric department of tertiary care hospital

Aim To evaluate the prevalence of vitamin D deficiency in pediatric epileptic patients and to assess if there is any correlation between vitamin D level and disease severity in epileptic patients. Objective To estimate vitamin D deficiency and insufficiency as percentage of enrolled patients in pediatric department and to identify if there is any correlation between vitamin D deficiency and factors such as age, sex, BMI, total serum calcium levels, antiepileptic drugs, and types of seizures. Patients and methods A prospective interventional clinical study was carried out in a tertiary care hospital between September 2018 and February 2019. We included 30 pediatric epileptic patients of age group 1–14 years from whom the blood samples were withdrawn and were sent to the laboratory for the estimation of vitamin D levels. Results The data collected was analyzed using statistical method χ2 and analysis of variance in Prism 8.0 version. The prevalence of vitamin D deficiency and its correlation with epilepsy was determined. In this study, we found that there was a high prevalence of vitamin D deficiency in pediatric epileptic patients (23 patients out of 30–73%). The other risk factors for vitamin D deficiency found in this study are children of age group 5–10 years (43%), malnourished patients (40%), hypocalcemic patients (40%), and patients who use antiepileptic drugs for more than 2 years (57%). Conclusion Based on the aforementioned scientific analysis, it can be concluded that there is a high prevalence of vitamin D deficiency in pediatric patients with epilepsy. So, vitamin D3 supplements should be given for all epileptic children even before the initiation of antiepileptic therapy. Patients’ parents were educated on the importance of vitamin D.

Correlation of pre-operative vitamin D3 levels with post-operative hypocalcemia in patients undergoing total thyroidectomy

Background: Total thyroidectomy (TT) is a commonly performed procedure for various thyroid disorders, with parathyroid insufficiency manifesting as hypocalcaemia being a well-known complication. Albeit, vitamin D is well implicated in calcium homeostasis, the association between hypovitaminosis D and postoperative hypocalcaemia is yet to be concluded. The aim of our study is to evaluate the correlation of preoperative serum vitamin D3 levels with occurrence of post-operative hypocalcemia in patients undergoing TT.Methods: A prospective study was conducted on 50 patients undergoing TT for benign thyroid diseases from November 2016 to May 2018. Pre-operative vitamin D3 levels were estimated. Serum calcium levels was measured pre‑ and post‑operatively at 24hours, 1st week and 4th week. Serum calcium level ≤8.5 mg/dl was considered as biochemical hypocalcemia. A data of demographic, clinical, biochemical and intraoperative findings were documented and analysed.Results: Statically 14 (28%) patients developed symptomatic hypocalcemia. Out of these, 11 (78.5%) patients had preoperative vitamin D levels of &lt;30 ng/dl (p=0.034). 24 hours postoperative serum calcium level was significantly lesser in patients with lower preoperative vitamin D levels (p=0.015), suggesting that postoperative hypocalcemia (24 hr) is statistically related to pre-operative vitamin D3 levels.Conclusions: It could be concluded from our study that preoperative serum vitamin D3 levels can predict post-operative occurrence of symptomatic and/or biochemical hypocalcemia. Thus, it could be hypothesized that supplementing vitamin D preoperatively could curb the incidence of hypocalcaemia following TT. However, further relevant trials are needed to attest to this.

Hypocalcaemia and traumatic coagulopathy: an observational analysis.

Haemorrhage-associated calcium loss may lead to disruption of platelet function, intrinsic and extrinsic pathway-mediated haemostasis and cardiac contractility. Among shocked major trauma patients, we aimed to investigate the association between admission hypocalcaemia and adverse outcomes. Data were extracted from the Alfred Trauma Registry and the Alfred Applications and Knowledge Management Department for all adult major trauma patients presenting directly from the scene with a shock index ≥1 from 1 July 2014 to 30 June 2018. Patients with pre-hospital blood transfusion were excluded. Ionized hypocalcaemia was defined as <1·11mmol/l, and acute traumatic coagulopathy was defined as initial INR >1·5. Multivariable logistic regression analysis was used to assess the association between admission hypocalcaemia and acute traumatic coagulopathy that was adjusted for Injury Severity Score, initial GCS, bicarbonate and lactate. There were 226 patients included in final analysis with 113 (50%) patients recording ionized hypocalcaemia on presentation prior to any blood product transfusion. Ionized hypocalcaemia was associated with coagulopathy in patients with shock index ≥1 (adjusted OR 2·9; 95% CI: 1·01-8·3, P=0·048). Admission ionized hypocalcaemia was also associated with blood transfusion requirement in the first 24h post-admission in 62·5% of hypocalcaemic patients as compared to 37·5% of normocalcaemic patients (P<0·001). Admission ionized hypocalcaemia was associated with death at hospital discharge (25·6% among hypocalcaemic patients compared to 15·0% of normocalcaemic patients (P=0·047)). Hypocalcaemia was a common finding in shocked trauma patients and was independently associated with acute traumatic coagulopathy. The early, protocolized administration of calcium to trauma patients in haemorrhagic shock warrants further assessment in randomized controlled trials.

Denosumab-induced hypocalcemia in patients with osteoporosis: can you know who will get low?

RCTs have reported a 0.05-1.7% rate of hypocalcemia in denosumab-treated postmenopausal women with osteoporosis, but long-term real-life data are lacking. We assessed the rate of hypocalcemia in osteoporotic community-dwelling patients treated with denosumab. A retrospective analysis was conducted based on medical records (2010-2018) from a large HMO. An albumin-adjusted serum calcium concentration lower than 8.5mg/dL was defined as hypocalcemia. We included 2005 patients (93% women, mean age 76 ± 9years). Hypocalcemia developed during treatment in 149 patients (7.4%; 1% less than 8mg/dL): in 66 after 0.5-1years; 48 after 1-2years; 35 after > 2years. On comparison of the hypocalcemic and normocalcemic patients, the strongest predictors of hypocalcemia were pretreatment levels of albumin-adjusted serum calcium (9.1 ± 0.4 vs. 9.4 ± 0.5mg/dL, respectively; p < 0.05) and creatinine (0.9 ± 0.5 vs. 0.8 ± 0.3mg/dL, respectively; p < 0.05). The hypocalcemia rate increased in parallel to a decrease in eGFR (p = 0.032 for the difference between eGFR ranges). Baseline calcium level ≤ 9.31mg/dL predicted hypocalcemia with a sensitivity of 77% and specificity of 56%. A model of (- 2)*calcium + creatinine predicted hypocalcemia (3.7% when lower and 17.1% when higher than - 17.4). Gender, age, 25-hydroxyvitamin-D, parathyroid hormone, alkaline phosphatase, and whether denosumab was given as first or advanced line of osteoporotic therapy had no predictive value. Real-life rates of denosumab-induced hypocalcemia are higher than previously reported. Hypocalcemia might develop after each dose of denosumab in ongoing treatment. Adequate calcium and vitamin D supplementation are needed. Serum calcium monitoring is advised in high-risk patients for early detection of severe hypocalcemia.

Dilated cardiomyopathy with long QT secondary to hypothyroidism and hypocalcaemia in patient with post total thyroidectomy: A case report

The linkage between cardiac dysfunction and the lack of thyroid hormones has been well elucidated. A case involving a woman aged 44 years suffering a dilated cardiomyopathy (DCM) and long QT secondary to hypothyroidism and hypocalcaemia emerges. Thyroid hormone acts on the myocardium of the heart and peripheral blood vessels. There are two types of thyroid hormone effects, such as genomic and non-genomic. These effects are associated with cardiovascular and hemodynamic function. The prolongation of the QT interval is the most overlooked and well-documented sign in hypothyroidism. Ventricular fibrillation is usually the leading factor for the long QT syndrome. The incidence is characterized by an increased risk of sudden death and the abnormal QT-interval prolongation on the surface of ECG. The mechanism of hypothyroidism on the occurrence of the ventricular tachycardia and the OT prolongation is unrecognized, and although coexistent, the effects might be distinctive.

The most reliable time point for intact parathyroid hormone measurement to predict hypoparathyroidism after total thyroidectomy with central neck dissection to treat papillary thyroid carcinoma: a prospective cohort study.

We assessed the optimal time for intact parathyroid hormone (iPTH) measurement for early detection of post-total thyroidectomy (TT) hypocalcemia in patients with papillary thyroid carcinoma (PTC). In this single-center prospective cohort study, 143 patients who underwent TT with central neck dissection with or without lateral neck dissection for PTC were included. Biochemical profiles including iPTH, corrected total calcium, and ionized calcium within 24 h after surgery were analyzed. The 4-h postoperative iPTH was the most reliable predictor of post-TT transient or permanent hypoparathyroidism (cutoff for hypocalcemia was 3.75 pg/mL, AUC = 0.885, P < 0.001, sensitivity 81.6%, specificity 86.0%; cutoff for permanent hypocalcemia was 2.48 pg/mL, AUC = 0.819, P < 0.001, sensitivity 100%, specificity 57.8% calculated using ROC curves). The 4-h postoperative iPTH can most accurately predict hypoparathyroidism after TT with central neck dissection to treat PTC and facilitate the early discharge of low-risk postoperative hypoparathyroidism patients and decrease unnecessary overnight observation and calcium supplementation.