Incidence Of Hyperparathyroidism Research Articles

Retrospective study on the diagnosis, treatment, and follow-up of 85 cases of hypophosphatemic rickets in children

To study the diagnosis, treatment, and complications of hypophosphatemic rickets (HR) in children, explore effectiveness evaluation indicators for the disease, and understand the pattern in height growth among these patients. A retrospective analysis of the initial clinical data and five-year follow-up data of 85 children with HR treated at Children's Hospital of Nanjing Medical University from January 2008 to December 2022. Among the 85 children with HR, there were 46 males (54%) and 39 females (46%). The age at initial diagnosis ranged from 6 months to 13 years and 9 months, with a median age of 2.75 years. The average height standard deviation score was -2.0±1.1. At initial diagnosis, children exhibited reduced blood phosphate levels and elevated alkaline phosphatase (ALP), with 99% (84/85) presenting with lower limb deformities. The positive rate for PHEX gene mutations was 93% (55/59). One year post-treatment, there was a significant reduction in ALP levels and the gap between the lower limbs (P<0.05). The fastest height growth occurred in the first year after treatment, at 8.23 cm/year, with a peak height velocity (PHV) phase lasting about two years during puberty. The height increased by 9-20 cm in male children during the PHV stage and 10-15 cm in female children. Major complications included nephrocalcinosis and hyperparathyroidism. The incidence rate of nephrocalcinosis in the first year after treatment was 55% (22/40), which increased with the duration of the disease (P<0.001); an increased urinary phosphate/creatinine ratio was positively associated with a higher risk of nephrocalcinosis (OR=1.740, P<0.001). The incidence of hyperparathyroidism in the first year after treatment was 64% (27/42). For children presenting with lower limb deformities, short stature, and slow growth, early testing for blood levels of phosphate, calcium, and ALP, along with imaging examinations of the lower limbs, can aid in the early diagnosis of HR. Genetic testing may be utilized for definitive confirmation when necessary. ALP combined with improvements in skeletal deformities and annual height growth can serve as indicators of therapeutic effectiveness for HR. Compared to normal children, children with HR demonstrate a lower height increase during the PHV phase, necessitating close follow-up and timely adjustment of treatment plans Citation:Chinese Journal of Contemporary Pediatrics, 2024, 26(7): 677-682.

Obstetrical and neonatal outcomes among pregnancies complicated by hyperparathyroidism

Purpose Severe hypercalcemia resulting from hyperparathyroidism may result in adverse perinatal outcomes. The objective of this study was to evaluate maternal and neonatal outcomes among pregnant women with hyperparathyroidism using a population database. Methods A retrospective cohort study was conducted using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1999–2015. ICD-9 codes were used to identify women diagnosed with hyperparathyroidism during pregnancy. Perinatal outcomes between pregnant women with and without hyperparathyroidism were compared. Multivariate logistic regression, controlling for age, race, income, insurance type, hospital location, and comorbidities, evaluated the effect of hyperparathyroidism on perinatal outcomes. Results Of 13,792,544 deliveries included over the study period, 368 were to women with hyperparathyroidism. The overall incidence of hyperparathyroidism was 2.7/100,000 births, increasing from 1.6 to 5.2/100,000 births over the study period (p < 0.0001). Women with hyperparathyroidism were older and had more comorbidities, such as obesity, and pre-gestational hypertension and diabetes. Relative to the comparison group, women with hyperparathyroidism were more likely to deliver preterm, OR 1.69 (95% CI 1.24–2.29), to develop preeclampsia, 3.14 (2.30–4.28), and to deliver by cesarean, 1.69 (1.36–2.09). Infants born to mothers with hyperparathyroidism were more likely to be growth restricted, 1.83 (1.08–3.07), and to be diagnosed with a congenital anomaly, 4.21 (2.09–8.48). Conclusion Hyperparathyroidism during pregnancy is associated with a significant increase in adverse perinatal outcomes, including preeclampsia, preterm delivery, fetal growth restriction, and congenital anomalies. As such, pregnancies among women with hyperparathyroidism should be considered high-risk, and specialized care is recommended in order to minimize maternal and neonatal morbidity.

ODP115 Primary Hyperparathyroidism in Pregnancy

Abstract Introduction Primary hyperparathyroidism (HPT) is characterized by an overproduction of parathyroid hormone (PTH) by a parathyroid adenoma, parathyroid hyperplasia, or parathyroid carcinoma classically causing hypercalcemia. Incidence of this pathology during pregnancy is very low (1%), as the great majority of cases are diagnosed in adults &amp;gt;45 years old. When present,it can be associated with detrimental maternal and fetal outcomes. Complications may include maternal nephrolithiasis, hyperemesis, and pancreatitis, along with miscarriage, fetal demise, low birth weight, neonatal hypocalcemia, and tetany. Considering the incidence of HPT in pregnancy is uncommon, there is limited data regarding diagnostic and treatment options for these patients. Clinical Case This is the case of a 28-year-old pregnant female at 12 weeks gestational age (WGA) who had a history of Type 1 Diabetes Mellitus. She was evaluated regarding metabolic control during pregnancy, however, was incidentally found with hypercalcemia. She denied any history of fractures, abdominal discomfort, bone pains or nephrolithiasis; she also had no pertinent family history associated with hypercalcemia. Laboratories showed a calcium level of 14.9 md/dL (nl, 8.6-10.2) with a phosphorus level of 1.9 mg/dL (nl, 2.5-4.5), which raised the suspicion of HPT. Further workup demonstrated high parathyroid hormone (PTH) 245 pg/mL (nl, 18.4-80.1), vitamin D-25-OH 24.7 ng/mL (nl, 30-100) and 24hr urine calcium collection of 402.5 mg/24hr (nl, 100-300); the latter excluding the possibility of familial hypocalciuric hypercalcemia. Patient was managed conservatively with IV hydration resulting in mild improvement of calcium to 12.4 mg/dL. Thyroid/Neck ultrasound revealed a thyroid gland with normal homogeneous texture and no distinct focal vascularized structure to suggest parathyroid origin. Other diagnostic imaging for localization of parathyroid disease with technetium-99m methoxyisobutylisonitrile parathyroid scintigraphy or single-photon emission Computed Tomography are not recommended in pregnancy due to insufficient safety data and radiation risk. After discussion with a multidisciplinary team including endocrine surgeons, endocrinologists, and obstetricians, an exploratory neck surgery for possible parathyroidectomy was recommended. She underwent surgery at 13 WGA where a left superior adenoma was identified and completely removed without complications. Intraoperative PTH levels revealed a pre-excision PTH of 342 pg/mL (18.4-80.1), post-excision PTH at 5 minutes of 76 pg/mL, and at 10 minutes of 50 ng/mL, suggestive of successful surgical removal. Pathology report was consistent with left superior parathyroid adenoma. Both calcium and phosphorus levels normalized post-surgery [Ca 9.6 mg/dL (nl, 8.6-10.2) and 2.7 mg/dL (2.5-4.5)]. Conclusion This is an unusual case of a patient with asymptomatic severe hypercalcemia associated to HPT diagnosed during pregnancy. In this patient conservative medical treatment proved to be unsuccessful. Parathyroidectomy early on the 2 nd trimester was advantageous to avoid both maternal and fetal complications during pregnancy. Presentation: No date and time listed

Environmental Chemicals and their Association with Hyperparathyroidism.

The incidence of hyperparathyroidism has increased in the USA. The previous work from our institution detected environmental chemicals (EC) within hyperplastic parathyroid tumors. The National Health and Nutrition Examination Survey (NHANES) is a program designed to assess the health status of people in the USA and includes measurements of EC in serum. Our aim was to determine which EC are associated with elevated parathyroid hormone (PTH) and calcium levels within NHANES. NHANES was queried from 2003-2016 for our analysis with calcium. A separate subgroup was queried from 2003-2006 that included PTH levels. Subjects with elevated calcium, and elevated PTH and normal Vitamin D levels were identified. Wilcoxon rank sum tests were used to analyze levels of EC in those with elevated calcium, and those with elevated PTH in the subgroup. All EC with p < 0.05 were then included in separate multivariate models adjusting for serum vitamin D and creatinine for PTH and albumin for calcium. There were 51,395 subjects analyzed, and calcium was elevated in 2.1% (1080) of subjects. Our subgroup analysis analyzed 14,681 subjects, and PTH was elevated without deficient Vitamin D in 9.4% (1,377). Twenty-nine different polychlorinated biphenyls and the organochlorine pesticides hexachlorobenzene, transnonachlor, oxychlordane, and p,p'-dichlorodiphenyldichloroethylene (DDE) were found to be associated with elevated calcium and separately with elevated PTH (all p < 0.05). In NHANES, 33 ECs were found to be associated with elevated calcium as well as elevated PTH levels on our subgroup analysis. These chemicals may lead us toward a causal link between environmental factors and the development of hyperparathyroidism and should be the focus of future studies looking at chemical levels within specimens.

Evaluation of Micronutrient Status Post Laparoscopic Sleeve Gastrectomy: an Australian Perspective.

Laparoscopic sleeve gastrectomy (LSG) is a type of bariatric technique that has comparable outcomes to Roux-en-Y gastric bypass, the current gold standard. However, it can be associated with nutritional deficiencies postoperatively. The aim of this study was to evaluate micronutrient status post LSG. This is a retrospective study of 565 patients who underwent an LSG from January 2015 to September 2018. Patients lost to follow-up at 3, 6 and 12months were 6.3%, 18.6% and 32.4%, respectively. Follow-up of the patients included regular dietetic input and micronutrient supplementation. Data that was collected included both anthropometry and nutritional markers. The mean preoperative weight and body mass index (BMI) were 118.13 ± 25.36kg and 42.40 ± 7.66kg/m2, respectively. Statistically, significant reductions in anthropometric parameters including weight, BMI (30.50kg/m2), total weight loss (28.03%), excess weight loss (72.03%) and BMI loss (12.32kg/m2) were observed at all timepoints up to 12months follow-up. At 12months, there were significant increases in 25-OH vitamin D with the incidence of deficiency decreasing from 45.7 to 15.0% compared to baseline. The incidence of hyperparathyroidism also decreased from 32.2 to 18.9% compared to baseline, and incidence of folate deficiency increased from 7.7 to 19.2%. Other nutritional parameters including calcium, iron, ferritin, vitamin B12, holotranscobalamin (active B12) and haemoglobin did not significantly change. Modest effects on micronutrient status were observed in the 12-month postoperative period. Of clinically significant, de novo folate deficiencies increased, and vitamin D deficiency and hyperparathyroidism decreased. Thus, optimizing postoperative micronutrient status is imperative following LSG.

P1406A CASE-CONTROL STUDY ON RISK FACTORS OF CALCIPHYLAXIS: DATA FROM CHINESE HEMODIALYSIS PATIENTS

Abstract Background and Aims Calciphylaxis (CUA) is a rare but potentially fatal disease that is commonly occurred in dialysis patients. Since there is no data based on Chinese population, the study is aimed to investigate risk factors of CUA in Chinese hemodialysis patients. Method We retrospectively evaluated medical records of 20 hemodialysis patients who were newly diagnosed with CUA by skin biopsy admitted to Zhongda Hospital Southeast University from Oct.2017 to Dec.2018. Non-CUA dialysis patients with the same age and duration of dialysis were randomly selected as controls (Ratio=1:2). Results Most of CUA patients were male (80%) and elderly (55%), while 50% had a body mass index higher than 24. The mean time interval since start of dialysis to CUA diagnosis was 114.65±81.32 months, and the median time from appearance of skin lesion to diagnosis was 6 (2, 15) months. The incidence of hyperparathyroidism was higher in patients with CUA (80% vs 62.5%), but the differences of duration of elevated serum intact parathyroid hormone (iPTH) and its highest value were not significant compared with the controls. Warfarin therapy had no significant difference between two groups (15% vs 5%). Univariate logistic regression analysis indicated that male (OR 3.619, 95%CI 1.027-12.748), each 1 point increase in score of use of vitamin D and its analogues (OR 1.505, 1.029-2.201), each 1 mmol/L increase in corrected serum calcium level (OR 24.486, 1.570-381.873), each 1 mmol/L increase in serum phosphate level (OR 5.382, 1.767-16.389), each 1 pg/mL increase in iPTH level (OR 1.002, 1.000-1.003), each 1 g/L decline in serum albumin level (OR 1.181, 1.041-1.340), each 1 IU/L increase in serum alkaline phosphatase (ALP) level (OR 1.005, 1.000-1.009) and each 1 mg/L increase in hypersensitive c-reactive protein level (OR 1.029, 1.000-1.059) were significantly associated with CUA. Serum phosphate, albumin and ALP were still significant risk factors after multivariate analysis. Conclusion This is the first report of risk factors of CUA based on Chinese population. The results show that high levels of serum phosphate and ALP, low level of serum albumin are independent risk factors of CUA in Chinese hemodialysis patients. Unlike previous research from western countries, warfarin therapy didn’t show an increased risk in this study, propably because of the low exposure rate of it in China.

Parathyroidectomy is Safe in Elderly Patients: A National Surgical Quality Improvement Program Study.

With increasing age, the incidence of hyperparathyroidism is increased. This study evaluates parathyroidectomy outcomes in elderly patients. Primary hyperparathyroidism patients having parathyroidectomy as listed in the 2005-2017 ACS-NSQIP database were separated by age: ≤60, 61-79 and ≥80. Outcomes included complications, 30-day mortality, return to the OR, operating times, and hospital length of stay (LOS). Multivariable logistic regression was used to compare patients 61-79 and ≥80 to those ≤60. Patients ≤60 and ≥80 were propensity score matched using gender, race, BMI, smoking status, steroid use, modified frailty index (mFI), ASA class, procedure, setting, anesthesia, and wound class. Morbidity and mortality were compared to ACS-NSQIP database patients having elective inguinal hernia repair. Of 47,701 patients: 22,220 were ≤60, 22,683 were 61-79, and 2798 were ≥80. Patients ≥80 had more complications (2.3% vs. 1.5% for 61-79 and 1.0% for ≤60, p < 0.01), LOS > 1day (10.3% vs. 5.8% and 6.7%, p < 0.01), and mortality (0.21% vs. 0.11% and 0.03%, p < 0.01). On multivariable analysis of the overall population, older age, male gender, steroid use, high mFI, outpatient procedure, and general anesthesia increased the risk of complications. On propensity score matched analysis, there was no difference in complications (1.5% vs. 2.2%, p = 0.06) or mortality (0.04% vs. 0.23%, p = 0.12) between patients ≤60 and ≥80. Parathyroidectomy morbidity and mortality was lower than that for elective inguinal hernia repair in patients ≥80 (2.3% vs. 10% and 0.21% vs. 1.1%, p < 0.01). Parathyroidectomy is a safe operation, offering lower morbidity and mortality than elective hernia repair in all age groups including octogenarians.

Total Parathyroidectomy with Subcutaneous Parathyroid Forearm Autotransplantation in the Treatment of Secondary Hyperparathyroidism: A Single-Center Experience.

Introduction Secondary hyperparathyroidism is common in chronic kidney disease. Parathyroidectomy is indicated in refractory hyperparathyroidism when medical treatments and so the parathyroid hormone levels cannot be lowered to acceptable values without causing significant hyperphosphatemia or hypercalcemia. The aim of this study is to compare the efficacy and safety of total parathyroidectomy with subcutaneous forearm autotransplantation with total parathyroidectomy with intramuscular forearm autotransplantation. Materials and Methods A single-center retrospective cohort study of total parathyroidectomy with forearm autotransplantation from January 2002 to February 2013 was performed. According to the surgical technique, patients were divided into an intramuscular group (Group 1) and a subcutaneous group (Group 2). 38 patients with secondary hyperparathyroidism were enrolled; 23 patients were subjected to total parathyroidectomy with parathyroid tissue replanting in the subcutaneous forearm of the upper nondominant limb, while 15 patients were subjected to replanting in the intramuscular seat. Results A total of 38 patients (56 ± 13 years) were enrolled. In both groups, the preoperative iPTH value was markedly high, 1750 ± 619 pg/ml in the intramuscular autotransplantation group and 1527 ± 451 pg/ml in the subcutaneous autotransplantation group (p = 0.079). Transient hypoparathyroidism was shown in 7 patients, and 1 patient showed persistent hypoparathyroidism (p = 0.387). 2 patients showed persistent hyperparathyroidism (p = 0.816), and in 2 others was found recurrent hyperparathyroidism (p = 0.816); 3 of them underwent autograftectomy. The anterior compartment of the forearm nondominant limb was sacrificed in 1 case of intramuscular autotransplantation with functional arm deficit. Conclusions The efficacy and safety of parathyroid tissue autotransplantation in the subcutaneous forearm of the upper nondominant limb is confirmed with a good rate of tissue engraftment and with a comparable number of postsurgical transient and persistent hypoparathyroidism and hyperparathyroidism incidence in both techniques. Furthermore, this technique preserves arm functionality in the case of autograftectomy. Consequently, it is our opinion that total parathyroidectomy with subcutaneous forearm autotransplantation is currently the best choice.

Qu’attend le chirurgien de la scintigraphie au sestaMIBI ?

Nowadays, the incidence of hyperparathyroidism is increasing (about 3%). Its revealing aspect and its surgical treatment have changed these past few years. They evolved into mini-invasive approaches which lead to a more accurate gland resection, respecting the healthy ones. The interest of methoxy-isobutyl-isonitrile (MIBI) scintigraphy is now well established and contributes to this evolution. Different categories of hyperparathyroidism (primary, secondary, tertiary, sporadic vs. familial, adenoma vs. carcinoma) have been separated to evoke the consensual surgical indications. SestaMIBI scintigraphy always follows a cervical sonogram and can be associated, in some cases, with a scannography. It only has to be performed in case of a surgery treatment and exclusively helps in topographic diagnosis. However, it remains a lot of false positive errors (nodular goitre, nodular or carcinomatous thyroids, lymphadenopathies) and some rare false negative errors (encountered in early hyperparathyroidism). The major interest of MIBI scintigraphy is its help in the topographic diagnosis of surgical hyperparathyroidism. It can detect parathyroid ectopias, multiglandular diseases, underlining the most pathological ones. It has become the most necessary examination in hyperparathyroidism pre-operative check-up and, in association with sonography and scannography, can lead to an accurate and mini-invasive surgical treatment.

OSTEOPOROSIS IN CALCIUM PYROPHOSPHATE CRYSTAL DEPOSITION DISEASE

Objective: to study the incidence of osteoporosis (OP) in patients with calcium pyrophosphate crystal deposition disease (CPCDD). Subjects and methods. Eighty patients with CPCDD were examined. Bone mineral density (BMD) of the forearm, lumbar spine, and femoral neck was determined by dual-energy X-ray absorptiometry. Laboratory diagnosis involved determination of the blood levels of C-reactive protein, parathyroid hormone, calcium, magnesium, and phosphorus and the daily urinary excretion of calcium and phosphates. Results. The patients with OP were significantly older than those with normal BMD and osteopenia. Forearm bones were the most common isolated location of OP and osteopenia. Injuries in the history, traumatic fractures, and the intake of diuretics were somewhat more common in the patients diagnosed with OP. The incidence of hyperparathyroidism did not differ significantly in the groups.

A Case of Parathyroidectomy of Supernumerary Parathyroid Glands Using Intraoperative IPTH Monitoring

The incidence of hyperparathyroidism has slowly increased recently with routine measurement of serum calcium and increasing awareness of the disease by the public. Despite the availability of expert surgeons and preoperative imaging investigations, some patients are re-operated for persistent or recurrent hyperparathyroidism. The main cause of re-operation is the presence of ectopic parathyroid gland or supernumerary parathyroid gland. Supernumerary parathyroid glands are more frequently described in the secondary hyperparathyroidism than in the primary hyperparathyroidism cases, especially in surgery for renal hyperparathytroidism. The intraoperative measurement of intact parathyroid hormone (iPTH) provides the surgeon with a quantitative test that predicts the postoperative serum calcium level and can justify early closure or further exploration for hyperfunctioning parathyroid gland. We present a case of parathyroidectomy of supernumerary parathyroid glands by monitoring intraoperative iPTH in patients with secondary hyperparathyroidism. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:190-3 Key WordsZZParathyroid gland·Parathyroid hormone·Secondary hyperparathyroidism.

RET proto‐oncogene mutations are restricted to codons 634 and 918 in mainland Chinese families with MEN2A and MEN2B

Multiple endocrine neoplasia type 2 is caused by autosomal dominant gain-of-function mutations in the RET proto-oncogene, which includes multiple endocrine neoplasia type 2A (MEN2A), type 2B (MEN 2B), and familial medullary thyroid carcinoma (FMTC). In this paper we present the phenotype-genotype correlation of 20 unrelated Chinese families with 15 cases of MEN2A and five cases of MEN2B. Cross-sectional study. A total of 147 members from the 20 families were included. Among them, 119 family members were from MEN2A pedigrees (including 15 MEN2A probands) and 28 members from MEN2B pedigrees (including five MEN2B probands). Genomic DNA was isolated from peripheral blood leucocytes and was amplified using polymerase chain reaction (PCR). DNA analysis for RET mutations in exons 8, 10, 11, 13, 14, 15 and 16 was performed with specific primers. Thirty-seven MEN2A and five MEN2B patients were identified as having RET mutations. The incidence of medullary thyroid carcinoma (MTC), pheochromocytoma (PCC) and hyperparathyroidism (HPT) in the 37 MEN2A patients was 91.9, 56.8 and 10.8%, respectively; the onset of MTC in MEN2A patients was earlier than that of PCC and HPT. Five germline mutations, all located at codon 634 of exon11 in the RET proto-oncogene, were detected in all of the 37 MEN2A patients. The highest frequency of the five germline mutations was C634Y (46.7%), followed by C634R (26.7%), C634W (13.3%), C634F (6.7%) and C634S (6.7%). No statistical significance was found between the incidence of PCC and different genotypes of codon 634 in MEN2A patients, whereas the incidence of HPT was closely associated with C634R and C634Y. The gene mutation (M918T) at exon16 of the RET proto-oncogene was present in five MEN2B probands. RET proto-oncogene mutations were restricted to codon 634 and 918 in Chinese families with MEN2A and MEN2B. In general the genetic characteristics of these patients with MEN2A and MEN2B reflect the general pattern around the world and it remains to be determined with larger studies in China whether Chinese patients have a different genetic pattern of mutations.

Recent advances in the molecular pathology of hyperparathyroidism

Hyperparathyroidism represents a wide spectrum of parathyroid disorders from hyperplasia to adenoma and carcinoma. These disorders can be present as primary or secondary, and as sporadic or hereditary forms. Although the incidence of hyperparathyroidism has increased dramatically, the interpretation of the parathyroid pathology is still of considerable controversy and confusion. Over the past few years, multiple genetic abnormalities have been characterized in sporadic parathyroid tumors. A majority of secondary parathyroid hyperplasia have been shown to be of monoclonal origins by clonal analysis. The ret oncogene responsible for the pathogenesis of multiple endocrine neoplasia type 2 and multiple endocrine neoplasia (MEN) 1 gene for type 1 have been cloned in succession. Mutation of the calcium-sensing receptor gene has been identified to be thegenetic trigger of neonatal severe hyperparathyroidism and familial hypocalciuric hypercalcemia. HRPT 2 gene designated for the syndrome of hereditary hyperparathyroidism and jaw tumors has recently been localized on the 1q21-23, and linkage analysis has established the presence of familial hyperparathyroidism as a distinct entity. These advances provide new insights for understanding the molecular pathology of various types of hyperparathyroidisms and allow us a precise differentiation among them. Based on the results of our study and those reported in literature, this article reviews the recent advances in the molecular basis of various hyperparathyroidisms.

Parathyroidectomy in the elderly: do the benefits outweigh the risks?

Although the incidence of hyperparathyroidism (HPT) in the elderly exceeds 1.5%, limited resources and co-morbidity inhibit referral for parathyroidectomy. To determine the risks and benefits of surgery, we examined the outcomes of elderly patients who underwent exploration for primary HPT. Data from 211 consecutive patients who underwent parathyroidectomy by one surgeon at the Johns Hopkins Hospital between August 1990 and May 1996 were recorded prospectively. Of these patients, 184 had primary HPT. Demographic and outcome data of elderly patients (> 70 years of age) (n = 36) were compared to those from younger patients (< 70 years of age) (n = 148). Preoperative symptoms of mental impairment, bone disease, and fatigue were more common in elderly patients (p < 0.05), and nephrolithiasis was more frequent in younger patients (p < 0.025). Elderly patients presented with more advanced disease, manifested by higher preoperative parathyroid hormone levels (301.9 +/- 63.3 vs. 169.2 +/- 14.3 pg/ml, p < 0.05). The cure rate (94.4%), morbidity (5.5%), and mortality (0%) in the elderly were indistinguishable from those of their younger cohorts (98%, 1.4%, and 0%, respectively). In conclusion, the more advanced disease seen in the elderly suggests that they are referred for surgery with a higher threshold than younger patients. Although several series of parathyroidectomy in elderly patients have reported high morbidity rates, significant mortality, and long length of stay (LOS), we found that parathyroidectomy in these patients can be performed with high cures, low morbidity, no mortality, short LOS, and high patient satisfaction. These data suggest that the benefits of surgery outweigh its risks and argue for a lower threshold for referral of elderly patients with primary HPT for surgical treatment.

ALCOHOL AND BONE DISEASE

Alcohol is considered to be an important risk factor for various bone diseases but recent studies have shown that moderate alcohol intake can be beneficial to bone structure. Alcohol decreases osteoblastic activity, leading to decreased bone formation and defective mineralization. The changes reported in calciotropic hormones, mainly vitamin D and parathyroid hormone, are observed due in part to a deficient intestinal absorption of vitamin D and an inadequate synthesis of its hepatic metabolite, although greater emphasis has been given to dietary deficiencies or lack of exposure to sun. The changes in parathyroid hormone are not consistent and since there is no greater incidence of hyperparathyroidism in alcoholic patients, it suggests that alcohol does not have a long-term effect on the parathyroid glands. Alcohol increases calcitonin secretion acutely; calcitonin is an inhibitor of bone resorption and may be the mechanism by which moderate alcohol intake protects bone structure. Alcohol increases urinary calcium, magnesium and zinc excretion. Zinc deficiency has been postulated as a cause of oesteoporisis because it causes hypogonadism. The decrease in the levels of the gonadal hormones and the increase of cortisol, observed in chronic alcoholics, may indirectly cause osteopenia and aseptic necrosis. To these actions must be added the acidosis due to alcohol and the greater tendency of the alcoholic to fall, all of which influence bone changes and increase the incidence of bone fractures.

Hyperparathyroidism subsequent to neck irradiation. Risk factors.

A follow-up examination of 444 persons treated with x-rays for tuberculous cervical adenitis was performed to determine if the risk for hyperparathyroidism (HPT) following radiation exposure can be related to the age at treatment, the dose of x-rays, or the sex of the patient. The overall incidence of HPT was 14%. There was no definite age-dependent difference in susceptibility to the induction of HPT. The doses of radiation among the 63 subjects who developed HPT ranged from 0.6 to 45.7 Gy (60-4570 rad). There was a statistically significant positive correlation between the dose of radiation and the probability of developing HPT. After doses of 14 Gy (1400 rad) or more 29% of the subjects had developed HPT. After neck irradiation women had twice the relative risk of men of developing HPT. This sex ratio was lower than in the series of nonirradiated HPT patients treated at the same institution during the time of the follow-up study.

Hyperparathyroidism and thyroid disease. A study of their association.

The incidence of hyperparathyroidism was prospectively evaluated in a group of patients with thyroid disease, and the incidence of thyroid disease was retrospectively evaluated in a group of patients specifically referred for evaluation of hyperparathyroidism. Hyperparathyroidism was ten times more frequent in thyroid patients than expected in a general medical population and was especially prevalent in patients with nodular goiter. The incidence of thyroid disease in patients with hyperparathyroidism was 38.8%. Although radiation therapy was shown to be a factor in these associations, it alone could not explain the observed frequency.

Reduction of Incidence of Renal Osteodystrophy Associated with Low Protein Diet in Early Renal Failure

HE INCIDENCE of renal osteodystrophy in chronic renal failure in Israel is small less than 2 per cent of the patients having symptoms, or biochemical or radiological T criteria of osteodystrophy, whereas in Europe and North America it is 5 to 10 per cent (Reubi, 1971; Dossetor and Gault, 1971). Even in patients on regular haemodialysis, only 10 per cent have any radiological evidence of hyperparathyroidism. In the UK and the us the incidence of renal osteodystrophy is sufficiently high in frequency in dialysed patients to create a serious problem. We adduce evidence that the reason for the low incidence of hyperparathyroidism in renal failure in Israel is the normal Israeli diet which is low in phosphorus and normal in calcium, whereas the standard British and us diets contain 40 per cent more phosphorus. In this paper we show that in renal failure in Israel, there is at all stages a significantly lower plasma inorganic phosphorus than in comparable cases in the us and UK. We make the recommendation that anyone developing renal disease should reduce his intakes of meat, eggs and milk to approximately those found in a regular Israeli diet, so as to lessen the phosphate load. This will also reduce subsequent metastatic calcification, red eyes and all the accompanying problems caused by a high plasma calcium phosphorus product. Consequently there is a reduced stimulus to parathyroid secretion in Israeli patients, Reiss et al., (1971) having shown that hyperphosphataemia is associated with increased stimulation of parathyroid secretion.