Intranasal Calcitonin Research Articles

Safety and Early Results for Off-Label Use of Intranasal Calcitonin for Treatment of Nondisplaced Acromial and Scapular Spine Stress Fractures After Reverse Total Shoulder Arthroplasty.

Immobilization for acromial and scapular spine stress AU4fractures (AF/SSF) after reverse total shoulder arthroplasty (RSA) is associated with patient dissatisfaction. Our study reports the effects and safety of intranasal calcitonin alongside sling immobilization on pain and function in the treatment of AF/SSF after RSA. The treatment was regimented calcitonin (salmon) 200 unit/actuation nasal spray (1 spray/day) for 6 weeks with sling immobilization for 4 weeks. Each patient was monitored through blood work. Visual analog scale, American Shoulder and Elbow Surgeons score, and active range of motion were collected preoperatively, postoperatively, at presentation of AF/SSF, and after completion of calcitonin treatment. Two hundred eighty-two RSAs were performed by two board-certified orthopaedic surgeons, of which 18 patients sustained AF/SSF (6.4%). Ten patients met inclusion criteria (nine AFs and one SSF). After calcitonin treatment, patients demonstrated an average improvement of visual analog scale of 5.8 points, active range of motion of 46_, and American Shoulder and Elbow Surgeons score of 43.6 points at average 7.53 months after RSA. No medical complications were reported at 6-month follow-up after calcitonin treatment. The use of intranasal calcitonin was not associated withadverse events including no aberrations/signs of cancer at 6-month follow-up after administration. Calcitonin with sling immobilization markedly improved clinical and functional outcomes of patients with nondisplaced AF/SSF and may be considered by orthopaedic surgeons for symptom management.

THU456 Beyond Guidelines: Treatment Of Concurrent Osteogenesis Imperfecta And Metastatic Bone Disease

Abstract Disclosure: M. Kanin: None. M. Lechner: None. Introduction: Osteogenesis imperfecta (OI) is a rare inherited skeletal dysplasia characterized by bone fragility and skeletal malformation predisposing patients to multiple, recurrent fractures. Treatment of OI is challenging and requires a multidisciplinary approach with emphasis on physical therapy and exercise in addition to medications. There is limited guidance on treatment in adults given truncated life expectancy. Furthermore, guidance on the treatment of OI in the setting of cancer bone metastases is lacking. We present the unique case of a woman with OI and new fracture in the setting of bone-metastatic endometrial cancer. Clinical Case: A 70 year old woman with Type I OI and endometrial adenocarcinoma initially presented to clinic with left hip and groin pain. Prior OI therapy included at least 10 years of bisphosphonate therapy and 3 years of intranasal calcitonin in her fifties. CT imaging revealed a lytic lesion in the L inferior pubic ramus with an associated pathologic fracture. She was treated with denosumab 120mg s.c. every 3 months for six total doses and palliative radiation to the pubic ramus. She developed osteonecrosis of the jaw and further treatment was terminated. She represented 2 years later with right hip pain and was found to have cancer involvement of her right iliac bone. Labs showed creatinine of 0.48 mg/dL, Calcium 9.8 mg/dl, bone specific alkaline phosphatase 17.9ug/L (7.0-22.4 ug/L), n-telopeptide 18.6 nM BCE (6.2-19.0 nM BCE), and vitamin D-25 48ng/ml. DEXA scan showed T scores at the AP spine of -3.2, LFN of -2.1, and RFN of -2.5. Our patient had a high functional status, minimal pain and acceptable quality of life. Given the presence of active bone metastases, we favored treatment with zolendronic acid 4mg i.v. monthly given her high fracture risk, combined with continued cancer therapy targeted to bone metastases. Clinical Lesson: To our knowledge, there are no guidelines or case reports for optimal treatment of patients with concurrent OI and bone metastases. While bisphosphonates are typically a first line treatment for OI, osteoporosis and metastatic bone disease, the duration and dosing of bisphosphonates varies for each condition. For example, zolendronic acid 4mg i.v. monthly is recommended for cancer patients with metastatic bone disease, while a dose of 5mg i.v. yearly is used for osteoporosis, depending on the severity. Additionally, no clear consensus exists for how often or how long bisphosphonates may be given in adults with OI and treatment durations vary markedly. Other agents that may be considered include denosumab, with indications across bone metastases, osteoporosis, and OI, though this was not available to our patient given her prior complication. Data for newer agents PTH analogs and romosuzumab are lacking. We present this case to highlight the need for an individualized treatment approach in these patients. Presentation: Thursday, June 15, 2023

Intranasal calcitonin gene-related peptide administration impairs fear memory retention in mice through the PKD/p-HDAC5/Npas4 pathway

The calcitonin gene-related peptide (CGRP) suppresses fear memory retention in mice. Although intracerebroventricular administration of CGRP alters the fear memory processes, making it a promising therapeutic strategy for post-traumatic stress disorder (PTSD), direct brain injection into patients is not practical. Therefore, we propose that intranasal application may be an effective way to deliver CGRP to the brain. This study tested whether CGRP nasal administration exerts the same effect as intracerebroventricular administration using C57BL6J mice. The amount of CGRP in the cerebrospinal fluid and hippocampus 30 min after nasal administration of CGRP was significantly higher when compared with saline. Intranasal CGRP also elicited photophobic behaviors similar to intracerebroventricular injection. Moreover, intranasal CGRP decreased fear memory retention but did not affect reactivation and extinction of fear memory. We found intranasal CGRP significantly increased the expression of protein kinase D (PKD), phosphorylated histone deacetylase 5 (p-HDAC5) and neuronal PAS domain protein 4 (Npas4) in the hippocampus. CGRP-mediated impairment of fear memory and Npas4 expression increases were attenuated significantly by the CGRP receptor antagonist BIBN4096. Together, our data demonstrate that intranasal CGRP delivery activates the PKD/p-HDAC5/Npas4 pathway, decreases fear memory retention.

Primary Hyperparathyroidism From Ectopic Parathyroid Adenoma in a Patient With Bilateral Slipped Capital Femoral Epiphysis

Background: Primary hyperparathyroidism has been reported in 13 pediatric patients presenting with slipped capital femoral epiphysis (SCFE), but never in patients with ectopic parathyroid adenoma [1]. Case report: A 12-year-old boy with obesity (BMI 99th percentile) and autism spectrum disorder presented with a limp and was found to have bilateral SCFE. Calcium was elevated to 12.3 mg/dL (reference range 8.0–10.5) with phosphorus of 3.2 mg/dL (3.0–5.7), alkaline phosphatase 775 units/L (40–360), tubular reabsorption of phosphorus 89% (> 95%), 25OH-vitamin D 12.1 ng/mL (30–80), 1,25OH-vitamin D 246.6 pg/mL (19.9–79.3), and PTH 1191 pg/mL (10–65). He had significant neuropsychiatric agitation but denied constipation, polyuria, and other symptoms of hypercalcemia. He had in situ pinning of the SCFE bilaterally and was hyperhydrated with minimal improvement in his calcium level. Neck ultrasound revealed no parathyroid adenoma. He was discharged on cholecalciferol 1000 IU daily with plans for outpatient Tc-99m Sestamibi scintigraphy. Following discharge, he developed significant nausea, did not tolerate the cholecalciferol, and was non-weight bearing. Repeat labs and imaging 5 days later demonstrated calcium had risen to 16.7 mg/dL with phosphorus of 2.2 mg/dL. He was admitted and calcium improved transiently to less than 12 mg/dL with intranasal calcitonin therapy. Sestamibi and subsequent CT scan revealed a 2.7x1.6x1.9 cm ectopic parathyroid adenoma in the upper anterior mediastinum. He had thoracoscopic resection of the mass, which was revealed to be intrathymic, and PTH levels fell from 1613 pg/mL pre-operatively to 76 pg/mL 30 minutes post-resection. Post-operatively, he developed hungry bone syndrome with a calcium nadir of 7.6 mg/dL and phosphorus nadir of 1.6 mg/dL, which required oral calcium and calcitriol for 10 days. With normalization of his calcium, his neuropsychiatric symptoms improved. Pathology revealed a parathyroid adenoma. Conclusion: Primary hyperparathyroidism can be associated with SCFE and should be considered even in patients with traditional risk factors for SCFE, especially with bilateral disease. Pediatric patients with primary hyperparathyroidism and negative neck imaging should be further evaluated for ectopic parathyroid adenomas.

Comparison of the effectiveness between epidural methylprednisolone injection and intranasal calcitonin in reduction of back pain due to osteoporosis in postmenopausal patients: a randomized controlled trial

<p class="abstract"><strong>Background:</strong> Back pain is a common symptom in osteoporotic patients due to spinal compression fracture. Conservative management like nonsteroidal anti-inflammatory drugs and spinal orthoses has not been able to produce early pain relief. Intranasal calcitonin spray is considered effective because of its analgesic effect and increase in bone density. Role of epidural steroid injection for the treatment of osteoporotic back pain has not been studied. This study was conducted to find out the efficacy of epidural methylprednisolone injection in management of osteoporotic back pain in postmenopausal patients.</p><p class="abstract"><strong>Methods:</strong> Hundred patients with osteoporotic back pain in postmenopausal subjects were allocated into two groups: epidural and calcitonin. Epidural group received a single dose of interlaminar epidural steroid injection with methylprednisolone 80 mg. Calcitonin group received one puff of 200 IU given through one nostril followed to the other nostril the next day. Visual analogue scale for pain was the outcome measurement used. Pain relief at rest within 7 days was taken as early pain relief and within 21days as late pain relief. Pain relief after 21<sup>st</sup> day was considered no response. Test of significance was done by Kaplan Meier, Chi square and Fisher exact tests.</p><p class="abstract"><strong>Results:</strong> Out of 50 patients, 38 patients in the epidural group got pain relief within 7 days and the finding was statistically significant.</p><p class="abstract"><strong>Conclusions: </strong>Epidural methylprednisolone gives faster pain relief as early as the first post-injection day with a median value of 2 days against 15 days in case of intranasal calcitonin spray.</p>

Idiopathic Hypercalcemia in Decompensated Cirrhosis: Reexploring an Entity in Oblivion

Hypercalcemia is a rare metabolic abnormality seen in patients with cirrhosis and is usually considered a paraneoplastic manifestation of hepatocellular carcinoma. Idiopathic hypercalcemia in cirrhosis is a diagnosis of exclusion, which is considered when all the causes of hypercalcemia have been ruled out. Here, we report a rare case of idiopathic hypercalcemia presenting as acute kidney injury in a case of decompensated cirrhosis, managed with adequate hydration and injection of ibandronate and intranasal calcitonin, leading to the normalization of serum calcium and resolution of acute kidney injury.

MON-357 Craniofacial Deformities with Hypercalcemia: A Rare Case of Co-Existing Primary Hyperparathyroidism and Paget’s Disease of the Bone Since Young Adulthood

Background:Primary Hyperparathyroidism (PHPT) and Paget’s Disease of the Bone (PDB) are two distinct bone mineral disorders which rarely co-exist. It has been very scarcely reported in the elderly but almost unheard of in young adults.Clinical caseA middle-aged Indian lady presents with multiple and recurrent facial and jaw bony swellings, since the age of 12. She had normal developmental as a child, without visual, auditory deficits or limb deformities. No family history of hypercalcemia or endocrine disorders was elicited. At initial diagnosis, biochemical parameters were consistent with PHPT, with mild to moderate hypercalcemia (2.6-3.0 mmol) and concomitant hypophosphatemia (0.6-0.8 mmol/L), elevated intact PTH 10.6pmol/L and ALP persistently more than 350 U/L. She had undergone multiple surgeries to remove the bony swellings, presumed to be brown tumours. She developed medullary nephrocalcinosis approximately 30 years after onset of illness. Over a span of three decades, numerous modalities were employed in attempt to localise the parathyroid lesion, including imaging (ultrasonography, sestamibi with SPECT CT, FDG PET),angiography, venous sampling and exploratory neck surgeries which were unsuccessful. Due to failure in localising the offending parathyroid lesion, it was conceded to maintain her on medical therapy.She was initially started on oral phosphate therapy, intranasal calcitonin and subsequently calcimimetics. Aside from rising ALP levels, her other biochemical parameters remained static. Her diagnosis was re-evaluated when she presented with osteomyelitis of the right mandible requiring surgery. Pre -operative CT imaging showed mixed lytic and sclerotic lesions at the mandible, maxilla, facial bones and skull. It also revealed diffuse thickening of the calvarium with narrowing of the posterior fossa resulting in hydrocephalus, requiring a ventriculoperitoneal shunt insertion. Histopathological examination of the mandible showed a background of osteosclerosis. These findings were inconsistent with PHPT and was most often described in PDB. On the other hand, a repeated skeletal survey showed generalised osteopenia in the small bones of the hand with subperiosteal and terminal phalanges reabsorption which was in keeping with PHPT. Her pelvis, spine and long bones remained normal and bone densitometry was preserved. It was concluded that this patient was suffering from dual pathology, PHPT and PDB and was commenced on bisphosphonates.Conclusion:This lady presented with two diseases which simulate each other despite not being etiologically linked. The aberrancy in the age of onset and the overlapping clinical features of the dual pathology imposed a significant challenge in making the correct diagnosis. Retrospectively, histopathological examination of the bone at an earlier stage of disease may have been the key to solving this perplexing case.

MON-335 Bisphosphonate and Denosumab Refractory Hypercalcemia of Malignancy: What Else Is at Play?

Hypercalcemia of Malignancy has been historically responsive to anti-resorptive agents. However, when multiple mechanisms contribute, it may be difficult to treat with one modality. This case highlights the importance of the work up in treatment of hypercalcemia in a low PTH state. A 44 yo M with h/o high grade metastatic spindle cell neoplasm with skeletal metastasis was admitted with hypercalcemia. He reported some constipation prior to presentation, however denied confusion. His vital signs were notable for HR of 86 bpm and BP of 112/75 mmHg. Labs at admission were remarkable for an uncorrected Ca of 16.1 (8.8-10.3 ng/mL), a phosphorus (Phos) level of 3.3 mg/dL (2.5-4.5 mg/dL), a PTH level of 11 pg/mL (15-65 pg/mL), PTHrP level of 134 pg/mL (14-27 pg/mL), a 25 OH vit D level of 11 ng/mL (30-100 ng/mL), and a BUN/Cr and GFR of 34/2.38 (8-22 mg/dL/0.5-1.3 mg/dL) and 32 ml/min/m2. He was given intranasal calcitonin and ergocalciferol, then received 2mg IV of zolendronic acid, which reduced the patient’s Ca level to a nadir of 6.6 ng/mL in 5 days. On the next admission serum Ca was elevated to 15.7 ng/dL, which did not respond to zolendronic acid. Given that patient’s Ca was refractory to zolendronic acid, denosumab was given but had no response. He then underwent surgery for cord compression and was given dexamethasone (dex) 4mg IV Q6h post-op. His Ca responded quickly to dex, with a nadir to 9.2 ng/dL, however his Ca became elevated after cessation. Given response to dex, vit D 1,25 OH level was sent and was elevated at 94 pg/mL (18-72 pg/mL). In addition, given his inappropriately normal Phos level in the setting of low PTH, FGF23 was sent and came back elevated at 473 RU/mL (<180 RU/mL). This was likely due to increased bone turnover and release of FGF23. He was discharged with a Ca level of 12.5 ng/mL, however was found to have an elevated Ca to 14.9 ng/mL on presentation to clinic. Given concern that Vit D 1,25 OH, PTHrP and direct bony involvement were all contributing to his hypercalcemia, patient was started on IVF and dex IV. His calcium responded 11.5 ng/mL and was then transitioned to PO dexamethasone and plaquenil. The most likely explanation for this phenomenon is malignancy induced cytokine/PAMP release, which stimulates 1-alpha hydroxylase in tumor macrophages to convert 25 OH D to 1,25 OH D. This was supported by his elevated 1,25 OH D level and a decreased 25 OH D, which suggests that 25 OH D was used as substrate by activated macrophages. This case highlights the importance of ancillary work up of hypercalcemia when a patient’s calcium is refractory to standard anti-resorptive therapy. Moreover, it shows the need for a systematic approach when treating hypercalcemia.

MON-336 Presumed Parathyroid Infarction Leading to Remission of Primary Hyperparathyroidism: A Rare Clinical Occurrence

Background: Infarction of a parathyroid adenoma, also known as ‘parathyroid auto-infarction’ or ‘parathyroid apoplexy,’ is a rare condition that can present and lead to acute and dramatic reduction of calcium (Ca2+) and parathyroid hormone (PTH) levels and spontaneous remission of primary hyperparathyroidism (PHPT). Some patients may experience neck pain, dysphagia, hoarseness, anterior neck swelling or ecchymoses, while others are asymptomatic. Ultrasound can show the lesion getting larger due to hemorrhage, but weeks to months later, there can be a size decrease of the adenoma due to loss of blood supply and necrosis. Sestamibi scans can also show non-localization on serial exams. Few case reports have evidence of infarction on pathology.Clinical Case: A 38 year old man with no significant past medical history presented after a pedestrian-motor vehicle accident with polytrauma, including a cervical spine injury requiring tracheostomy and immobilization of his neck. Over the first week of his hospitalization, his Ca2+ rose as high as 14.0 mg/dL (8.9-10.2 mg/dL). Concurrent PTH level was 233 pg/mL (12-88 pg/mL) and 25-OH vitamin D level was 14.8 ng/mL (20.1-50.0 ng/mL). A neck ultrasound showed a hypoechoic nodule measuring 1.4 x 1.2 x 1.6 cm posterior to the superior aspect right thyroid lobe. A sestamibi scan with SPECT-CT showed a persistent focal activity in the region of right thyroid bed. He was treated with aggressive intravenous (IV) hydration, 7 doses of intranasal calcitonin 500 units, multiple doses of furosemide 40-80 mg IV, pamidronic acid 90 mg IV, and eventually transitioned to cinacalcet 30 mg twice daily. Due to his C-spine injury, parathyroid surgery was deferred.Four months later, the patient developed acute muscle spasms. He denied anterior neck pain, dysphagia, bruising, or swelling. Ca2+ level was checked and found to be 7.0 mg/dL. Cinacalcet was decreased, and eventually had to be discontinued. His serial Ca2+ and PTH levels normalized to 9.8 mg/dL and 55 pg/mL, respectively. A repeat 25-OH vitamin D level was replete at 31.1 ng/mL. A follow up ultrasound redemonstrated a slightly ill-defined hypoechoic nodule, now only measuring 0.9 x 0.9 x 1.4 cm along the the right thyroid. A sestamibi scan was also obtained and did not localize any lesion.The biochemical and imaging findings were most consistent with a parathyroid infarction resulting in spontaneous remission of PHPT. Now one year following his initial presentation, he remains normocalcemic.Clinical Lesson: The differential diagnosis for a sudden remission of PTH-dependent hypercalcemia is limited. Parathyroid infarction is a rare condition with paucity of data regarding follow up, but these patients likely need to remain under close long term clinical and biochemical surveillance as recurrence has been documented in the literature.

Effect of Calcitonin on Healing Duration, Function and Pain Relief in Patients with Maxillofacial Fractures. A pilot study

Introduction: Calcitonin is a polypeptide hormone regulating the metabolism calcium in the body. Many studies showed that calcitonin had analgesic effect on several painful circumstances. The aim of this study was to determine the effects of intranasal calcitonin during the immediate postoperative period on postoperative pain in patients undergoing maxillofacial fracture surgery. Materials and Methods: In this clinical trial which was conducted in April 2019 in Imam Reza Hospital of Tabriz, 16 patients with maxillofacial fracture were divided randomly into two groups. The intervention group was given 200UI of intranasal calcitonin and the control group received nasal spray of NaCl. The severity of pain was then evaluated daily for up to seven days after the operation, with the severity of: no pain (0) to the most severe pain (10) using visual analog scale for pain. The daily dose of analgesic was also measured. The patients were allowed to request 250 mg of injectable acetaminophen each day up to a maximum daily dose of 4 g (maximum permissible dose) in the event of pain. Results: The results show that the pain intensity between two groups was not significantly different. However in the seventh day the total acetaminophen consumption was significantly lower in the intervention group. Conclusion: calcitonin may be a useful medication to help to control the post operative pain by reducing the required dose of routine painkillers.

A Curious Case of Acute Pancreatitis in Pregnancy

Hypercalcaemia is rare in pregnancy and is under diagnosed owing to its non-specific presentation which is frequently attributed to the pregnancy itself. Severe hypercalcaemia presents a therapeutic challenge, especially during pregnancy. The present case of a 26-year-old primigravida who presented with acute pancreatitis is described here. The pancreatitis was found to be secondary to parathyroid adenoma- induced hypercalcaemia. After initial conservative medical management with subcutaneous and intranasal calcitonin, she underwent a small-incision adenoma excision. This unusual cause and presentation of hypercalcaemia and its management is reviewed thereof.

Intranasal Calcitonin Gene-Related Peptide Protects Against Focal Cerebral Ischemic Injury in Rats Through the Wnt/β-Catenin Pathway.

BackgroundIntranasal calcitonin gene-related peptide (CGRP) delivery offers a noninvasive method of bypassing the blood-brain barrier for the delivery of CGRP to the brain. Here, we first reported the therapeutic benefits of intranasal CGRP delivery in rats following middle cerebral artery occlusion (MCAO).Material/MethodsReal-time quantitative polymerase chain reaction (RT-qPCR) assay, enzyme-linked immunosorbent assay (ELISA), rat MCAO model, TTC (2, 3, 5-triphenyltetrazolium chloride) staining, hematoxylin and eosin (H & E) staining, Morris water maze test, TUNEL assay, immunofluorescence, and western blot assay were used to investigate the role of CGRP in rats. Cell Counting Kit-8 assay, colony formation assay, cell cycle assay, apoptosis assay, western blot assay, and TOP/FOP assay were used to investigate the role of CGRP in normal human astrocytes (NHA) cells.ResultsThe CGRP-MCAO-NDDS (nasal drug delivery system) group showed a significant reduction in the infarct volume and improvement in neurologic deficit tests of motor, sensory, reflex and vestibulo-motor functions compared to those rats in the CGRP-MCAO-IV group. CGRP markedly inhibited apoptosis and increased the expression of vascular endothelial growth factor (VEGF) and bFGF and decreased the expression of GAP43 in the cortex of MCAO rats. CGRP promoted cell proliferation and cell cycle process and inhibited cell apoptosis through the Wnt/β-catenin pathway in NHA cells.ConclusionsThis noninvasive, simple, and cost-effective method is a potential treatment strategy for focal cerebral ischemic injury.

Calcitonin effects on shoulder adhesive capsulitis.

Adhesive capsulitis (frozen shoulder) is a relatively prevalent disease of shoulder and affects soft tissue of glenohumeral joint. Signs include painful restricted motion and disability of the patient in daily activities. Calcitonin is a thyroid hormone, and its effectiveness has been demonstrated in painful conditions. The presents study aims to evaluate theeffect of calcitonin in treating shoulder adhesive capsulitis. This double-blinded randomized clinical trial was conducted on 64 patients suffering from shoulder adhesive capsulitis. The intervention and control groups were given intranasal calcitonin and placebo for 6weeks, respectively. For both groups, physiotherapy and non-steroidal anti-inflammatory drugs were administered correspondingly. The patients were evaluated pre- and post-treatment for shoulder pain and shoulder range of motion (ROM). Shoulder functional outcome (secondary outcome) was evaluated using Disability of Arm, Shoulder, and Hand, Shoulder Pain and Disability Index, and Health Assessment Questionnaire disability criteria. The mean age of patients in calcitonin and control group was 52.4±4.6 and 53.2±4.9, respectively. Demographic characteristics and pre-treatment scores were similar in both groups (all P>0.05). In post-treatment follow-up, shoulder pain, ROM, and the patients' functional scores were significantly improved in both groups (P<0.001); however, the improvement in calcitonin group was more effective than that of placebo group. Intranasal calcitonin spray could be an additional safe alternative in shoulder adhesive capsulitis with regard to the efficiency in alleviating pain and improving functional outcome. II.

69-Year-Old Woman With Confusion and Fatigue

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN (H.M.K.); Advisor to resident and Consultant in Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN (A.E.K.). A 69-year-old woman presented to her primary care physicianwith a 4-day history of fatigue and dizziness. She was 45 minutes late for her appointment because she had trouble driving to the office. She reported no motor or sensory deficits but had difficulty with coordination. Review of systems was positive for dysuria and urinary frequency. She did not have fever, chills, weight or appetite changes, respiratory, cardiac, or gastrointestinal symptoms, or recent head trauma. The patient’s medical history was remarkable for hypertension, hyperlipidemia, type 2 diabetes mellitus, osteoporosis, and gastroesophageal reflux disease. Medications included metoprolol tartrate, lisinopril with hydrochlorothiazide, lovastatin, cholecalciferol, and as-needed calcium carbonate. She had smoked half a pack of cigarettes per day for 40 years but had quit smoking 6 years previously. She didnot use alcohol or illicit drugs. On examination, the patient was afebrile with a blood pressure of 104/67 mm Hg, heart rate of 76 beats/min, respiratory rate of 17 breaths/min, oxygen saturation of 94% while breathing room air, and body mass index (calculated as weight in kilograms divided by height inmeters squared) of 39 kg/m. Shewas alert and oriented to person, place, and time. Her speech was dysarthric, and she had difficulty following simple commands. Her coordination was impaired with symmetric dysmetria on finger-to-nose testing, heel-kneeshin testing, and rapid alternating movements. Cranial nerves II through XII were intact. Results of motor and sensory examinations were within normal limits. Reflexes were symmetric. Lymph node, thyroid, cardiac, respiratory, gastrointestinal, musculoskeletal, and skin examinations identified no abnormalities.

Current Clinical Practice Scenario of Osteoporosis Management in India

Various osteoporosis guidelines are available for practice. To understand the current clinical practice scenario from the perspective of Indian orthopaedicians, especially about the epidemiology, clinical manifestations, approach to diagnosis and management and patient compliance patterns to long term treatment. A pre-validated structured questionnaire containing questions (mostly objective, some open-ended) catering to various objectives of the study was circulated amongst orthopaedic surgeons across India by means of post/courier, after giving a brief overview of the study telephonically. Data was extracted from the completed questionnaires, and analysed using Microsoft Excel software. The questionnaire was filled by a total of 84 orthopaedicians throughout India. The prevalence of osteoporosis in India according to the orthopaedic surgeons was 38.4% and there was a female preponderance. Most of the respondents felt out of every 100 osteoporosis patients in India, less than 20 patients are actually diagnosed and treated for osteoporosis. The most common initial presenting feature of established osteoporosis cases was general symptoms. Most respondents preferred Dual-energy X-ray absorptiometry (DEXA) as the initial investigation for the diagnosis of osteoporosis in a patient presenting with typical features. While most respondents preferred once-a-month oral over intravenous (IV) bisphosphonates, they agreed that IV administration had advantages such as lower gastrointestinal side effects and improved compliance. The average duration of therapy of oral bisphosphonates was the longest (27.04 months) among the other anti- osteoporosis therapies that they used. On an average, the patient compliance rate in osteoporosis management was around 64%. IV Zoledronic acid (ZA) and intranasal calcitonin were infrequently used than other anti- osteoporosis therapies. While concerns about cost and availability deterred more frequent usage, there was an agreement that if used regularly these two agents may improve compliance rates among patients. Current clinical practice scenario of osteoporosis management in India largely adheres to various clinical practice guidelines for osteoporosis. Side effects and lengthy duration of therapy with bisphosphonates seem to be the main factors leading to a low patient compliance. Widespread popularization of once-yearly Zoledronic acid and intranasal calcitonin spray may improve patient compliance and reduce side effect incidence.

Localized hypertrichosis after index finger revascularization and complex regional pain syndrome.

Localized hypertrichosis after index finger revascularization and complex regional pain syndrome.

Coccyx Fractures Treated with Intranasal Calcitonin

Background: Treating pain associated with acute coccyx fractures can be challenging. Intranasal calcitonin has been used to treat acute pain after vertebral fracture, and may even accelerate fracture healing. However, intranasal calcitonin has never previously been published as part of the treatment of acute coccyx fractures. Objective: To examine a series of cases in which intranasal calcitonin was used to treat coccydynia related to coccyx fractures. Study Design: Case series and literature review. Setting: Outpatient university-based coccyx pain center. Results: After use of intranasal calcitonin, pain levels decreased, adverse events were minimal, and the medication was generally well tolerated. Limitations: As this is not a randomized control trial, the patients treated with intranasal calcitonin were not compared to a control group. Additionally, the sample size of 8 patients is relatively small. Conclusions: We propose that clinicians consider use of intranasal calcitonin for the treatment of pain due to acute coccyx fractures. Key words: Coccyx, fractures, calcitonin, pain

Central Giant Cell Reparative Granuloma of the Maxillary Sinus: Endoscopic Resection and Intranasal Calcitonin Therapy

Objectives: Central giant cell reparative granuloma (CGCRG) is an uncommon, nonneoplastic, osteolytic lesion that can display locally aggressive behavior. CGCRG most often involves the mandible. Lesions arising within the paranasal sinuses are far less common. Treatment has historically consisted of surgical excision, typically via open approaches. Recently, calcitonin has been proposed as therapy for CGCRG. We present the case of a young woman with an extensive, aggressive CGCRG of the maxillary sinus who underwent total endoscopic resection followed by adjuvant therapy with intranasal calcitonin. Methods: Case report. Results: A 19-year-old woman presented with a 3-month history of progressively worsening left-sided malar pain and hypesthesia. Physical exam revealed hyperglobus; loose maxillary dentition; a soft, compressible bulge in the left hard palate; and a large mass occupying the left nasal cavity. Computed tomography and magnetic resonance imaging showed a 4 x 4 x 4.8 cm mass within the left maxillary sinus which had eroded the hard palate and inferior orbital wall and displaced the orbital contents superiorly. Biopsy of the lesion was consistent with CGCRG. The patient underwent complete resection via a modified endoscopic, endonasal medial maxillectomy approach. Adjuvant therapy with intranasal calcitonin is underway, and the patient is doing well 3 months post-excision. Conclusions: In this report, we demonstrate a safe, effective, entirely endoscopic resection of an extensive CGCRG. We advocate prompt surgical management of these lesions given their potential for local destruction. Although evidence regarding the use of calcitonin is limited, we suggest considering its use as adjuvant therapy.

Intranasal calcitonin reducing bone pain in a patient with Camurati–Engelmann disease

Camurati–Engelmann disease (CED) is a rare autosomal dominant disease characterized by progressive bilateral symmetric sclerosis and thickening of long bone diaphyses (1). Diagnosis is based on phy...

Efficacy and Harms of Nasal Calcitonin in Improving Bone Density in Young Patients With Inflammatory Bowel Disease: A Randomized, Placebo-Controlled, Double-Blind Trial

There are very few published studies of agents having the potential to improve bone health in children with inflammatory bowel disease (IBD). The objective of this study was to establish the efficacy and safety of intranasal calcitonin in improving bone mineral density (BMD) in young patients with IBD and to define additional factors that impact bone mineral accrual. We conducted a randomized, placebo-controlled, double-blind clinical trial in 63 participants, ages 8-21 years, with a spinal BMD Z-score ≤ -1.0 s.d. measured by dual energy X-ray absorptiometry. Subjects were randomized to 200 IU intranasal calcitonin (n=31) or placebo (n=32) daily. All received age-appropriate calcium and vitamin D supplementation. Subsequent BMD measurements were obtained at 9 and 18 months. Intranasal calcitonin was well tolerated. Adverse event frequency was similar in both treatment groups, and such events were primarily minor, reversible, and limited to the upper respiratory tract. The BMD Z-score change documented at screening and 9 months and screening and 18 months did not differ between the two therapeutic arms. In participants with Crohn's disease, the spinal BMD Z-score improved between screening and 9 months (change in spine BMD Z-score (ΔZSBMD)(9-0)) in the calcitonin group (ΔZSBMD(9-0)(calcitonin)=0.21 (0.37), ΔZSBMD(9-0)(placebo)=-0.15 (0.5), P=0.02); however, this was only a secondary subgroup analysis. Bone mineral accrual rate during the trial did not lead to normalization of BMD Z-score in this cohort. Factors favoring higher bone mineral accrual rate were lower baseline BMD and higher baseline body mass index Z-score, improvement in height Z-score, higher serum albumin, hematocrit and iron concentration, and more hours of weekly weight-bearing activity. Factors associated with lower bone mineral accrual rate were more severe disease-as indicated by elevated inflammatory markers, need for surgery, hospitalization, and the use of immunomodulators-and higher daily caffeine intake. Intranasal calcitonin is well tolerated but does not offer a long-term advantage in youth with IBD and decreased BMD. Bone mineral accrual rate remains compromised in youth with IBD and low BMD raising concerns for long-term bone health outcomes. Improvement in nutritional status, catch-up linear growth, control of inflammation, increase in weight-bearing activity, and lower daily caffeine intake may be helpful in restoring bone density in children with IBD and low BMD.