Normal Calcium Levels Research Articles

CENTRAL GRANULOMA OF GIANT CELLS IN THE MAXILLA: DIFFERENTIAL DIAGNOSIS AND SURGICAL PROCEDURE

Central giant cell granuloma (CGCG) is a rare benign tumor of unknown etiology. A 59-year-old female patient presented with a history of painful symptoms and mobility in teeth 12, 13, 14, and 15. The patient had an unsuccessful endodontic treatment associated with photodynamic therapy, evidenced by the presence of recurrent fistula with progressive bone reabsorption and swelling. The patient was forwarded to the maxillofacial surgeon under the hypothesis that there was a tumor in this region. For planning of the case, 3D reconstruction and lesion enucleation were performed after negative aspiration with the assistance of a fine needle. Microscopic images revealed proliferation of multinucleated giant cells in the stroma with spindle and osteoid cells, suggestive of CGCG. The biochemical examination reported normal parathyroid hormone parathormone levels, calcium, and phosphorus levels, ruling out the hypothesis of a brown tumor of hyperparathyroidism. The patient is currently on a 2-year follow-up, with no recurrences so far.

Beneficial effects of starting oral cysteamine treatment in the first 2 months of life on glomerular and tubular kidney function in infantile nephropathic cystinosis.

Nephropathic cystinosis is a rare lysosomal storage disease whose basic defect, impaired transport of cystine out of lysosomes, results in intracellular cystine storage. Affected individuals exhibit renal Fanconi Syndrome in infancy, end-stage kidney disease at approximately 10 years of age, and many other systemic complications. Oral cysteamine therapy mitigates the detrimental effects on glomerular function and prevents most of the late complications of the disease but has not shown benefit with respect to the early tubular damage of cystinosis. This is because cystinosis is generally diagnosed in the second year of life, after the damage to kidney tubular function has already occurred. We longitudinally evaluated 6 infants diagnosed and treated with cysteamine from before 2 months of age. The 4 infants with good compliance with cysteamine and consistently low leucocyte cystine levels maintained normal eGFR values, exhibited only minor degrees of renal Fanconi Syndrome, and maintained normal serum levels of potassium, bicarbonate, phosphate, and calcium without electrolyte or mineral supplementation through 2, 4, 10 and 16 years of age. Thus, renal Fanconi syndrome can be attenuated by early administration of cysteamine and renew the call for molecular-based newborn screening for cystinosis.

Role of Calcium in Development of Early Childhood Dental Caries

Objective: To deduce association of dental caries with hypocalcaemia. Study Design: Cross-sectional Place & Duration: Islamic Dental hospital Islamabad, from September 2020 to February 2021. Materials and Methods: Eighty children were carefully chosen for this study, their ages were between 2-8 years. They were eighty in number and were placed into two groups. In group 1 children with compromised dental health were placed and their number was sixty. In group 2 children with healthy dentition were included and they were twenty in number. The degree of caries was calculated by following the standards given by WHO. For finding the statistically significant association between dental caries and hypocalcaemia Chi-square test was used. Results: Results have established that dental caries is prevalent in children with hypocalcemia. Chi-square analysis has indicated that in children with hypocalcemia and with hypoplastic tooth surfaces, more non-cavitated and cavitated carious lesions, filled surfaces and missing teeth were found than in children with normal calcium levels and having sound enamel surfaces and well-formed teeth (p = 0.01). This cross-sectional study has showed that caries, hypoplastic tooth surfaces, poorly mineralized teeth and early childhood dental caries are strongly correlated. Conclusion: It can be established seen that caries, hypocalcaemia, hypoplastic tooth surfaces and poorly mineralized teeth are correlated. Keywords: Decayed, Missed, Filled Teeth (dmft), 25 Hydroxy Vitamin D (25OHD

Vitamin D and calcium, together and separately, play roles in female reproductive performance

Vitamin D (VD) deficiency reduces the chances of successful fertilization; however, it remains to be validated whether this effect is dependent or not on calcium. To address this question, we generated several situation using a mouse model in which VD content was either increased or decreased in a normo or hypocalcemia context. After the measurement of serum 25-hydroxyvitamin D2, calcium and phosphorus levels, an analysis was carried out in terms of oocytes maturation as well as reproductive performance. VD overdose, despite the fact that it resulted in an increased number of mature oocytes, reduced developmental competence and offspring survival. VD deficiency (VDD), on the contrary, reduced the number and percentage of mature oocytes, blastocyst rate, as well as fertility rate and offspring survival. Hypo-calcemia when VD levels were normal, had a similar effect than VDD. The effects of VDD were reversed by a diet that corrected calcium level. Therefore, both VD overdose (in a context of normal calcium level) VD deficiency as well as hypo-calcemia have an effect on female reproductive function. In conclusion, although closely related, VD and calcium act in part independently of each other in defining the “optimum” for female reproductive performance.

The effect of hypocalcemia on motor symptoms of Parkinson’s disease

BackgroundThe disabling nature of Parkinson’s disease (PD) impairs functional mobility and worsens quality of life. Calcium imbalances are thought to have a significant role in the progression of PD.ObjectiveTo evaluate the relation between calcium deficiency and deterioration of PD motor symptoms.MethodsA total of 28 idiopathic PD patients were subjected to motor symptoms evaluation using the modified Hoehn–Yahr scale (H–Y), Unified Parkinson’s Disease Rating Scale (UPDRS) Part II and III and Schwab and England Activities of Daily Living Scale (S–E ADL). Total and ionized serum calcium levels were measured for the PD patients and the 30 healthy control subjects.ResultsThe level of ionized calcium was significantly lower among PD patients (4.19 mg/dl ± 0.53) than in control subjects (4.8 mg/dl ± 0.35) (p < 0.0001). The PD patients with hypocalcemia showed marked deterioration of motor symptoms and significant impairment of daily life activities when compared to PD patients with normal calcium levels regarding their scores on the modified H–Y scale (p = 0.001), UPDRS-III (p = 0.001), UPDRS-II (p = 0.001), and S–E ADL scale (p = 0.001). Ionized calcium correlated significantly with PD patients’ scores on the modified H–Y scale (p = 0.019), UPDRS-Part II (p = 0.001), UPDRS-Part III (p = 0.001) and S–E ADL scale (p = 0.001). The significant cutoff point of the ionized calcium for detection of the deteriorated PD patients that presented with stages more than grade 2 of the modified H–Y scale was < 3.99 (p = 0.037) with a sensitivity of 80% and specificity of 95%.ConclusionsOur findings conclude that calcium deficiency could contribute to the deterioration of PD motor symptoms.

Vitamin D and Forearm Fractures in Children Preliminary Findings: Risk Factors and Correlation between Low-Energy and High-Energy Fractures.

Background: The forearm is the most common fracture site in childhood, accounting for every fourth pediatric fracture. It is well described that vitamin D is involved in the regulation of bone mineralization and skeletal homeostasis by the regulation of calcium absorption. The aim of our study was to determine the influence of 25-hydroxyvitamin D levels on forearm fracture falls in a pediatric population, depending on level of energy impact. Additionally, we also aimed to evaluate the correlation between 25-hydroxyvitamin D levels and other tested risk factors for pediatric fractures. Methods: We evaluated 50 eligible children aged 3 to 12 years with a forearm fracture. According to energy impact, patients were grouped into low-energy fractures (LEF) and high-energy fractures (HEF) groups. The general characteristics of the patients included age, gender, sport participation, and fractured bone and its localization. We analyzed 25-hydroxyvitamin D, parathyroid hormone (PTH), calcium, magnesium, phosphate, C-reactive protein (CRP) levels, and body mass index (BMI). Results: There is a significant difference in the 25-hydroxyvitamin D levels distribution between LEF and HEF (p < 0.001) and PTH levels (p = 0.002). For magnesium levels, calcium levels, phosphate levels, and CRP levels, there were no significant differences in their frequency distribution. For the group of patients with LEF, there is a significantly positive correlation between 25-hydroxyvitamin D and calcium levels (p = 0.019) and a borderline significantly positive correlation between 25-hydroxyvitamin D and magnesium levels (p = 0.050). For the group of patients with HEF, there was only a significantly positive correlation between 25-hydroxyvitamin D and PTH levels (p < 0.001). Conclusions: Children with LEF were more frequently insufficient in 25-hydroxyvitamin D levels but had normal calcium levels, compared to the ones with HEF. These findings suggest that LEF and HEF in children might to a certain degree have different pathophysiological mechanisms.

Abstract #1182278: Hyperthyroidism-induced hypercalcemia: Timing of response to treatment in the acute setting

Hyperthyroidism is an uncommon cause of hypercalcemia (HYPERCA). There is little information to guide the clinician on calcium (CA) response in relation to thyroid hormone control. This knowledge may be important when HYPERCA needs to be quickly treated due to its severity or to underlying patient co-morbidities. We describe a patient with HYPERCA of moderate severity due to Graves’ disease (GD) hyperthyroidism in whom normalization of CA level was a priority. Changes in CA levels in response to improvement in thyroid function and the role of anti-resorptive agents in this setting are discussed.

Abstract #1182064: Recurrent Hypercalcemia Following Calcium Sulfate Bead Placement

Stimulan® (Smith & Nephew) beads are antibiotic-loaded calcium sulfate beads (CSB) that are used to prevent and treat joint infections intraoperatively. They are used to prevent systemic toxicity of oral and intravenous (IV) antibiotics and can also be used as bone void fillers. We present a case of recurrent transient hypercalcemia due to calcium sulfate beads leading to prolonged hospitalization and IV bisphosphonate treatment. A 65-year-old female with chronic kidney disease (stage 3b) and no prior calcium disorder presented to her orthopedic surgeon with severe osteoarthritis in her left hip after having failed multiple non-surgical interventions. She subsequently underwent left total hip arthroplasty (THA) that was complicated by a prosthetic joint infection requiring THA revision for which she received 10 cc of CSB in the hip joint during the 1st stage revision surgery. On post-operative day 3, her calcium level rapidly increased from 8.3 to 12.6 mg/dL. She was treated with intravenous fluids for dehydration with resolution of hypercalcemia and discharged home. One month later, she was admitted for revision of left THA with insertion of CSB. On post-operative day 3, her calcium increased from 9.3 to 13.8 mg/dL requiring fluids and calcitonin with suspicion that CSB may be the etiology. Two months later, she was admitted with polymicrobial drug resistant infection of the left hip. She underwent another left THA revision with insertion of 20 cc of CSB beads instead of the 10 cc kits previously used. Once again, on post-operative day 3, her calcium levels increased from 8.2 to 14.5 mg/dL. At this time, she was treated with intravenous fluids, calcitonin and 60mg IV pamidronate. Hypercalcemia workup did not show another etiology for hypercalcemia with a suppressed PTH level and normal PTH-related peptide, 25-hydroxy and 1,25-dihydroxy vitamin D levels. Kidney function was at baseline during each admission. The patient endorsed fatigue and constipation. As highlighted above, each episode of hypercalcemia peaked on post-operative day three and resolved within one week. When 20 cc of CSB were used, the peak calcium was more severe necessitating IV bisphosphonate therapy. CSB were not used in subsequent surgical revisions resulting in normal calcium levels. While CSB-induced hypercalcemia has been reported, this case highlights the importance of recognizing this entity and being aware that susceptible patients may be more likely to have recurrence with re-use. Pre- and post-CSB calcium levels should be measured in patients who receive CSB and they should be used at the minimum effective dose. Treatment of CSB-induced hypercalcemia may be considered when hypercalcemia is severe.

Deficiency of Daily Calcium and Vitamin D in Primary School Children in Lviv, Ukraine.

This study was conducted to determine the prevalence of calcium and vitamin D deficiency in school children aged 6 to 11 years in Lviv (Ukraine). The aim of this study was also to assess the effect of nutritional intervention and supplementation on serum calcium and vitamin D levels in children diagnosed with calcium deficiency. A 3 day diet was analyzed in 172 children. In 56 children with a deficiency of calcium and/or vitamin D, the level of total calcium, ionized calcium, and 25-hydroxyvitamin D in blood, as well as the calcium content in hair samples, was determined. Thirty children with confirmed calcium and/or vitamin D deficiency underwent a dietary intervention to increase calcium and vitamin D intake for 3 months. The study group (n = 15) was provided with a nutritional correction by modifying their diet with supplementation of calcium and vitamin D. The control group (n = 15) received only a diet modification. Decreased daily calcium intake was observed in 50.68% of boys and 70.71% of girls. A decreased level of daily vitamin D consumption was found in 84.93% of boys and 96.97% of girls. Among 56 children with insufficient daily consumption of calcium and/or vitamin D, 26.8% had reduced levels of total calcium in the blood, 16.1% had reduced levels of ionized calcium in the blood, and 48.2% had reduced levels of vitamin D. After 3 months of correction, normal calcium level was found in the hair of 10 students (66.7%) from the study group and in three subjects (20.0%) from the control group. Modification of the diet along with supplementation of calcium and vitamin D seems to be a more effective method for increasing the level of calcium among children aged 6 to 11 years.

Prevalence and relevant factors of micronutrient deficiencies in hospitalized patients with inflammatory bowel disease

ObjectivesMicronutrient deficiencies are common in hospitalized patients with inflammatory bowel disease (IBD). We aimed to investigate the prevalence of micronutrient deficiencies, and explore relevant factors in hospitalized patients with IBD. MethodsA total of 52 hospitalized patients with IBD were included. Overall malnutrition and quality of life were evaluated with questionnaires, and micronutrient deficiencies were evaluated with serologic indices. Univariate and bivariate analyses were performed, and regression was applied to explore factors associated with micronutrient deficiencies. ResultsThe most common micronutrient deficiency was 25-hydroxyvitamin D3 (25[OH]D; 76.9%). Folate deficiency was more common in recently diagnosed than in previously diagnosed patients (37.0% vs. 8.0%; P = 0.013), but iron deficiency was the opposite (29.6% vs. 60.0%; P = 0.028). 25(OH)D interacted with folate (rs = 0.292; P = 0.036), vitamin B12 (rs = 0.292; P = 0.035), and calcium (rs = 0.415; P = 0.002), and ferritin interacted with folate (rs = –0.288; P = 0.038) and magnesium (rs = –0.333; P = 0.016). Calcium-deficient patients had longer hospital stays than those with normal calcium levels (P = 0.016). Low 25(OH)D levels increased the risk of overall malnutrition (odds ratio [OR]: 0.866; 95% confidence interval [CI], 0.744–0.982; P = 0.025), and low ferritin and calcium suggested a poorer quality of life (P = 0.043 and 0.011, respectively). In addition, hemoglobin (OR: 0.930; 95% CI, 0.870–0.993; P = 0.034) and folate (OR: 0.708; 95% CI, 0.545–0.922; P = 0.037) were independent protective factors against 25(OH)D deficiency. ConclusionsHospitalized patients with IBD were at risk of multiple micronutrient deficiencies, even those with a recent diagnosis or in remission. There were interactions between micronutrients and nutritional indices. Early identification and correction of micronutrient deficiency, as well as relevant factors, may improve clinical outcomes.

Zoledronic Acid Ameliorates the Bone Turnover Activity and Periprosthetic Bone Preservation in Cementless Total Hip Arthroplasty.

The administration of zoledronic acid (ZA) to patients who received cementless total hip arthroplasty (THA) has been reported to reduce bone turnover markers (BTMs) and increase bone mineral density (BMD). The effects of two-dose ZA versus placebo on cementless THA patients were analyzed in this five-year extension study. Alkaline phosphatase (ALP), osteocalcin (OC), procollagen 1 intact N-terminal propeptide (P1NP), serum calcium, renal function, radiological findings, and functional outcomes were compared in 49 patients, and the periprosthetic BMD of seven Gruen zones were compared in 19 patients. All the patients had normal renal function and calcium levels at their final follow-up. The mean ALP level in the ZA group was significantly lower at the fifth year, mean OC levels were significantly lower at the second and fifth year, and mean P1NP levels were significantly lower from 6 weeks to 5 years as compared with the control group. Fifth-year BMD levels were not found to be different between the ZA and control groups. The BMD Change Ratios in the ZA group were significantly increased in Gruen zone 6 at 1, 2, and 5 years. Our study results suggest that short-term ZA treatment with a subsequent 4-year drug holiday may inhibit serum BTMs and provide periprosthetic bone preservation at five years without adverse events.

Use of Parathyroid Function Index and Wisconsin Index to Differentiate Primary Hyperparathyroidism From Secondary Hyperparathyroidism: A Case-Control Study.

Introduction: Patients with primary hyperparathyroidism (PHPT) can be asymptomatic or have a normal calcium level (NHPT). Patients with 25(OH) vitamin D insufficiency, on the other hand, may present with a similar presentation. In regions where 25(OH) vitamin D deficiency is common, patients are usually diagnosed with secondary hyperparathyroidism (SHPT). Therefore, it is necessary to separate PHPT and NHPT from SHPT. Parathormone and calcium values are used for differentiation in the clinic. The predictive value of the newly developed parathyroid function test (PFindex), which previously had a high diagnostic value, was evaluated in this patient population in our investigation.Methods: The study comprised 163 PHPT and NHPT patients with pathological confirmation and 56 SHPT patients. The PHPT, NHPT, and SHPT properties were defined using PFindex. The diagnostic power of PFindex was investigated using a receiver operating characteristic (ROC) curve of the results assessed in three groups.Results: The PHPT group had the highest PFindex (1365.4±784.6) compared to the other two groups (NHPT: 723.5±509.4; SHPT:227.2±49.9, all p < 0.001). A PFindex threshold of 327.8 yielded 91.9% and 90.9% sensitivity and specificity rates for distinguishing PHPT and NHPT from SHPT, respectively.Conclusion: PFindex gave the outstanding diagnostic capacity to distinguish PHPT from SHPT due to our research. This straightforward tool can assist in making quick decisions about vitamin D therapy or surgery for PHPT.

Molecular Mechanisms of Parathyroid Disorders in Chronic Kidney Disease.

Secondary hyperparathyroidism (SHP) is a common complication of chronic kidney disease (CKD) that induces morbidity and mortality in patients. How CKD stimulates the parathyroid to increase parathyroid hormone (PTH) secretion, gene expression and cell proliferation remains an open question. In experimental SHP, the increased PTH gene expression is post-transcriptional and mediated by PTH mRNA–protein interactions that promote PTH mRNA stability. These interactions are orchestrated by the isomerase Pin1. Pin1 participates in conformational change-based regulation of target proteins, including mRNA-binding proteins. In SHP, Pin1 isomerase activity is decreased, and thus, the Pin1 target and PTH mRNA destabilizing protein KSRP fails to bind PTH mRNA, increasing PTH mRNA stability and levels. An additional level of post-transcriptional regulation is mediated by microRNA (miRNA). Mice with parathyroid-specific knockout of Dicer, which facilitates the final step in miRNA maturation, lack parathyroid miRNAs but have normal PTH and calcium levels. Surprisingly, these mice fail to increase serum PTH in response to hypocalcemia or uremia, indicating a role for miRNAs in parathyroid stimulation. SHP often leads to parathyroid hyperplasia. Reduced expressions of parathyroid regulating receptors, activation of transforming growth factor α-epidermal growth factor receptor, cyclooxygenase 2-prostaglandin E2 and mTOR signaling all contribute to the enhanced parathyroid cell proliferation. Inhibition of mTOR by rapamycin prevents and corrects the increased parathyroid cell proliferation of SHP. This review summarizes the current knowledge on the mechanisms that stimulate the parathyroid cell at multiple levels in SHP.

Free Papers Compiled

Human immunodeficiency virus HIV infected individuals on national AIDS control organization NACO India based highly active antiretroviral therapy (HAART) regimen often continue experiencing neurological complications referred to as HIV associated neurocognitive disorders (HAND).The cognitive impairment is attributed to HIV replication in the brain and liberation of inflammatory neurotoxins leading to neuronal dysfunction.The American academy of neurology task force on the acquired immune deficiency syndrome AIDS defined two level of neurological impairment in HIV patients: 1.HIV associated dementia(HAD)and 2.minor cognitive motor disorder (MCMD).A core difference between the two is the degree of functional impairment present . Patient with HAD have more impairment than those with MCMDTimely detection of Cognitive dysfunction in patients with HIV infection is very crucial as HAND could affect patient’s activities of daily living such as medication adherence, employment; driving and so on this worsens disease indirectly.Methods:A Cross sectional Study on Patients with immune compromised states infected by HIV/AIDS was the main aim. The study includes 75 HIV infected patients attending ART centre in Victoria hospital. Patients taken into study were aged above 18years, of both sexes, then MINI Screening for Psychiatric diagnosis will be applied to rule out Axis I Psychiatric illnessIHDS scale will be applied to know the neurocognitive severity (score less than <=10) patients will be considered.Results:More than half of the HIV patients had scored less in IHDS SCALE, reported.Conclusion:the results show that patients with HIV states have the high prevalence of prevalence of HIV associated neurocognitive impairment.Introduction:Electrolyte abnormalities are common in chronic alcoholics as a result of chronic alcohol consumption, acute alcohol intoxication. They are especially significant during alcohol withdrawal. We should be aware of these clinically important disturbances caused by alcohol abuse for their appropriate management.Material and methods:A cross-sectional observational study was conducted for a period of 18 months and 126 patients of alcohol dependence in withdrawal state were included. Diagnosis of alcohol withdrawal were confirmed using ICD-10 and patients were evaluated using CIWA-Ar. Venous blood was obtained for the determination of serum potassium, sodium and magnesium, calcium, phosphates, bicarbonates concentrations and LFT.Results:The prevalence of electrolyte imbalance was 71%. Hyponatraemia was noted in 28.6% and hypernatremia in 11.9% of individuals with alcohol dependence syndrome. Hypokalemia was noted in 42.1% and hyperkalemia was noted in 1.6% of individuals with alcohol dependence syndrome. 14.3% of the individuals have decreased magnesium levels and 15.1% have increased magnesium levels. 67.5% of individuals have normal calcium levels and hypocalcaemia was noted in 31.7%, while hypercalcaemia was noted in only one patient. Hypophosphatemia was present in 15.1% of individuals while in rest the serum phosphorous levels were normal. Metabolic acidosis was found in 19.8% and metabolic alkalosis in 3.2% patients.Conclusion:The prevalence of electrolyte imbalance in patients of alcohol dependance in alcohol withdrawal state was 71%. The most frequent electrolyte disturbances in these patients were hypokalemia (42.1%) followed by hypocalcemia (31.7%), hyponatremia (28.6%), and hypomagnesemia (14.3%). The metabolic disturbances ware present in 23% patients. The patients consuming 7/weeks were significantly more likely to have electrolyte imbalance and deaarranged liver function tests than in individuals consuming 4/weeks or less.

Impact of enhanced recovery after surgery program for hungry bone syndrome in patients on maintenance hemodialysis undergoing parathyroidectomy for secondary hyperparathyroidism.

Hungry bone syndrome after parathyroidectomy is an important clinical problem in patients on maintenance hemodialysis. We examined the effect of an enhanced recovery after surgery (ERAS) program on the incidence of hungry bone syndrome after parathyroidectomy in this population. This single-institution, retrospective study analyzed 108 patients on hemodialysis who underwent parathyroidectomy for secondary hyperparathyroidism. Patients were classified into the pre-ERAS (n = 52) and post-ERAS (n = 56) groups. The ERAS program identified high-risk patients and enforced aggressive measures to normalize calcium levels following parathyroidectomy. There was no significant difference in age, sex, body weight, presenting symptoms, preoperative calcium and alkaline phosphatase levels, postoperative intact parathyroid levels, postoperative calcium levels at 1 and 24 hours after parathyroidectomy, and 30-day readmission rates between the groups. The post-ERAS group had significantly higher levels of postoperative calcium at 48 and 72 hours after parathyroidectomy, but a lower incidence of hungry bone syndrome and shorter postoperative length of stay. Patients with hungry bone syndrome had higher preoperative levels of alkaline phosphatase and intact parathyroid, longer postoperative length of stay, and were less likely to have been part of the ERAS program. High preoperative alkaline phosphatase levels and absence of the ERAS program were independent risk factors for hungry bone syndrome after parathyroidectomy. The ERAS program reduced the incidence of hungry bone syndrome and shortened the postoperative length of stay in patients on maintenance hemodialysis who underwent parathyroidectomy for secondary hyperparathyroidism.

Hypercalcemia: A complicated puzzle

This is a mini-review concerning hypercalcemia of malignancy that represents a challenging condition requiring rapid management, not only in relationship with short term complications, but also with long term mortality concerning the originating tumor approach (if feasible). Hypercalcemia on a patient with previously known or unknown cancer may be caused by dehydration, concurrent medication causing increased serum calcium levels, concomitant primary or renal hyperparathyroidism, over production of vitamin D (which may be tumor-related) or by specific circumstances that induce suppression of parathormone (PTH), so called PTH-independent mechanisms. Specific circumstances related to an active cancer means an ectopic production of parathormone, metastasis causing osteolytic lesions, tumors that produce PTHrP (parathormone related peptide) and abnormal production of 1,25-dihydroxyvitamin D by a hematologic malignancy. Parathyroid carcinoma induces an excess of PTH which is caused by a malignancy but it is not a PTH independent entity. Once a malignancy-related hypercalcemia is identified based on biological panel (mostly blood assays), the investigations are essentially continued with different imaging techniques depending on signs (if any), accessibility, etc. The approach is based on a multidisciplinary panel, on one hand, in order to restore normal levels of calcium, on the other hand, to rapidly address the underlying cause. This is essential to contribute to the outcome which typically is poor.

Диференціальна діагностика первинного та вторинного гіперпаратиреозу, спричиненого дефіцитом вітаміну D

Причини вторинного підвищення рівня паратгормона, особливо дефіцит вітаміну D, можуть істотно перешкоджати діагностиці гіперпаратиреозу. Найбільш складна ситуація виникає, коли помірне підвищення рівня паратгормона збігається з дещо підвищеним або нормальним рівнем кальцію в сироватці крові. Ураховуючи переважно хірургічний шлях лікування пацієнтів із первинним гіперпаратиреозом, важливо розрізняти дефіцит вітаміну D і справді первинний гіперпаратиреоз.Мета: розробити метод для диференціації первинного гіперпаратиреозу та вторинного гіперпаратиреозу, пов’язаного з дефіцитом вітаміну D.Матеріали та методи. Ми пропонуємо надійний стандартизований протокол короткострокового лікування ергокальциферолом (3000 МО на добу протягом 45–50 днів) для усунення впливу недостатності вітаміну D на лабораторні критерії первинного гіперпаратиреозу. Зменшення більше ніж на 30 % і нормалізація рівня сироваткового паратгормона без підвищення рівня кальцію сироватки виключають первинний гіперпаратиреоз і необхідність хірургічного втручання.Результати. Було вивчено клінічну групу з 72 відібраних пацієнтів, які відповідають критеріям помірно підвищеного рівня паратгормона, нормального або дещо підвищеного рівня кальцію, із дефіцитом вітаміну D, відсутністю хронічних захворювань нирок або порушення всмоктування. Після 45–50 днів введення вітаміну D у 61 пацієнта (85 %) спостерігали нормалізацію рівня паратгормона без гіперкальціємії. Вони були виключені з клінічної групи первинного гіперпаратиреозу. Ми не спостерігали в подальшому в цій групі випадків прогресування первинного гіперпаратиреозу. Решта пацієнтів (10 із 72) були успішно прооперовані з приводу первинного гіперпаратиреозу, крім одного, який відмовився від операції і досі залишається під наглядом.Висновки. Короткострокове лікування ергокальциферолом може бути цінним і надійним клінічним методом, що дозволяє диференціювати ізольований дефіцит вітаміну D і безсимптомний первинний гіперпаратиреоз, який поєднується з недостатністю вітаміну D.

Tubular phosphate handling: references from child to adulthood in the era of standardized serum creatinine.

The assessment of phosphate homeostasis in clinical practice relies not only on circulating phosphate levels but also on phosphate tubular reabsorption, ideally assessed using the tubular maximum phosphate reabsorption per glomerular filtration rate (TmP/GFR). TmP/GFR reference values were established before the onset of isotope-dilution mass spectrometry-standardized (IDMS) creatinine assays and thus need to be updated. Our objective is to provide reference values for TmP/GFR from childhood to adulthood, using the gold-standard of GFR assessment and IDMS-standardized creatinine values. We retrospectively analysed all the inulin and iohexol clearances [measured glomerular filtration rate (mGFR)] performed in children and in adults screened for a living-donation in our unit since the beginning of IDMS-creatinine assays. TmP/GFR was calculated on a fasting sample, using the conventional formula without correction for tubular reabsorption of phosphate (TRP) in subjects below 19 years of age. A total of 2051 subjects (1711 children, 340 adults), aged from 1.9 to 73.4 years with normal GFR, normal phosphate and normal calcium levels, were included for TmP/GFR analysis. As expected, there was a progressive decrease along puberty in both genders of plasma phosphate and TmP/GFR, the decrease occurring earlier in girls. After the age of 19 years, there was a stabilization of plasma phosphate and TmP/GFR levels until the age of 55 years, phosphate levels and TmP/GFR being slightly lower in men than in women. We present the largest cohort describing TmP/GFR reference values in the era of IDMS-standardized creatinine assays. We believe that these data will help physicians to better diagnose and manage patients with abnormal phosphate metabolism in daily clinical routine.

Primary Hyperparathyroidism in the Common Orthopaedic Practice

An extensive review of the publications on primary hyperparathyroidism (pHPT) is presented in this report. It has strongly been emphasized in the literature that patients with pHPT may present either with the classical symptomatology or with asymptomatic disease, emerged due to biochemical screening. The clinical and epidemiological presentation of pHPT in western countries has changed profoundly during the past few decades, and bone disease is nowadays a distinct rarity. The introduction of serum calcium screening for osteoporosis and the technological advances in the laboratory assessment of parathyroid hormone have played important roles in early diagnosis. Subsequently, the disease is increasingly being detected as asymptomatic hypercalcaemia without guiding signs or symptoms. A third type of disease, the normocalcaemic variant, has been recently described in the literature. However, the potential diagnosis of pHPT should always be on the orthopaedics’ list of differential diagnoses in female or elderly patients with vertebral fractures and nephrolithiasis, either symptomatic or asymptomatic, as well as when solitary or multiple osteolytic lesions are encountered on the radiographs.Additionally, a middle aged woman with parathyroid adenoma and subsequent brown tumors detected on the pelvic radiographs is reported. Her initial laboratory findings indicated a minimal increase of the serum calcium, a mild increase of the erythrocyte sedimentation rate, and a significant increase in total serum alkaline phosphatase. Finally, the detection of elevated parathyroid hormone levels indicated the diagnosis of pHPT and necessitated imaging studies of the parathyroid glands, which indicated a parathyroid adenoma. Following successful excision of the parathyroid adenoma, the patient suffered from the hungry bone syndrome. After a follow-up of 20 years, the patient had normal calcium, vitamin D, and parathyroid hormone serum levels, while a pelvic radiograph indicated no significant changes in the appearance of the brown tumors.

Primary Hyperparathyroidism in the Common Orthopaedic Practice

An extensive review of the publications on primary hyperparathyroidism (pHPT) is presented in this report. It has strongly been emphasized in the literature that patients with pHPT may present either with the classical symptomatology or with asymptomatic disease, emerged due to biochemical screening. The clinical and epidemiological presentation of pHPT in western countries has changed profoundly during the past few decades, and bone disease is nowadays a distinct rarity. The introduction of serum calcium screening for osteoporosis and the technological advances in the laboratory assessment of parathyroid hormone have played important roles in early diagnosis. Subsequently, the disease is increasingly being detected as asymptomatic hypercalcaemia without guiding signs or symptoms. A third type of disease, the normocalcaemic variant, has been recently described in the literature. However, the potential diagnosis of pHPT should always be on the orthopaedics’ list of differential diagnoses in female or elderly patients with vertebral fractures and nephrolithiasis, either symptomatic or asymptomatic, as well as when solitary or multiple osteolytic lesions are encountered on the radiographs.Additionally, a middle aged woman with parathyroid adenoma and subsequent brown tumors detected on the pelvic radiographs is reported. Her initial laboratory findings indicated a minimal increase of the serum calcium, a mild increase of the erythrocyte sedimentation rate, and a significant increase in total serum alkaline phosphatase. Finally, the detection of elevated parathyroid hormone levels indicated the diagnosis of pHPT and necessitated imaging studies of the parathyroid glands, which indicated a parathyroid adenoma. Following successful excision of the parathyroid adenoma, the patient suffered from the hungry bone syndrome. After a follow-up of 20 years, the patient had normal calcium, vitamin D, and parathyroid hormone serum levels, while a pelvic radiograph indicated no significant changes in the appearance of the brown tumors.