Normal Serum Calcium Levels Research Articles

Abstract #1183932: Management Challenge in Hyperphosphatemic Tumoral Calcinosis

Tumoral calcinosis (TC) is a rare metabolic disorder causing abnormal calcium salt deposition in different peri-articular soft tissue regions. The most common site is lateral hips. TC can be primary normo-phosphatemic or primary hyperphosphatemic. It can be secondary also, seen commonly in chronic renal failure. We describe a case report of 14 years old girl who presented with primary hyperphosphatemic tumoral calcinosis with recurrent swellings even after surgery and medical therapy. A 14-year-old girl presented to us with recurrent soft tissue mass and persistent hyperphosphtemia associated with pain and decreased movements. She was operated twice for this soft tissue. Her medical record stated that patient had undergone 6 surgeries till date for these periarticular swellings at multiple sites (right elbow, left hip, right hip and left knee) but it recurs after 3-4 months of surgery and progressively enlarges in size. Physical examination revealed firm tender 9 X 4 cm oval shaped swelling in the left greater trochanteric area with restriction in abduction, internal rotation and rotator movements at hip joint and 4 X 4 cm circular hard, non-sessile mass over medial aspect of left knee joint with slight difficulty in complete flexion of knee. Biochemical work up showed hyperphosphatemia with normal serum calcium and low iPTH levels, low serum 25 hydroxyvitamin-D and slightly high 1,25 vitamin D with calculated TmP/GfR of 5.7 mg/dl. C-terminal FGF23 level was grossly elevated to 1200 RU/ml. Histological evaluation of previously surgically excised soft tissue mass revealed fibrocollagenous stroma with clusters of crystalline and amorphous calcium enclosed by band of histiocytes and lymphocytes compatible with findings seen in tumoral calcinosis. Presently the patient is maintaining the near normal phosphate level with oral phosphate restricted diet and multiple phosphate binder and acetazolamide. Hyperphosphatemic Tumoral calcinosis is a disorder of dysregulated phosphate metabolism characterized by hyperphosphatemia and deposition of calcium salts in soft tissue regions of the body usually in the periarticular sites. FGF23 is a 251-amino acid peptide secreted by osteoblasts, osteocytes and erythroid precursor cells of the bone marrow that plays a critical role in phosphate regulation. In the proximal tubule of the kidney, FGF23 binds to the FGF receptor 1 (FGFR1) and its co-receptor KLOTHO, downregulating expression of the sodium-phosphate cotransporters NPT2a and NPT2c, which leads to phosphaturia. Additionally, FGF23 inhibits 1-alpha-hydroxylase and stimulates 25-vitamin D-24 hydroxylase, resulting in decreased 1,25-(OH)2-vitamin D (1,25D), the active form of vitamin D. Recently an entitity named autoimmune hyperphosphataemic tumoral calcinosis has been reported in which pathogenetic autoantibodies mediate FGF23 resistance.Treatment is to lower serum phosphorus by blocking dietary phosphate absorption and increasing renal phosphate excretion. Surgery is usually reserved for patients with significant pain or restricted movements of joint.

Metabolic Bone Disease of Prematurity.

Metabolic Bone Disease of Prematurity.

Abstract #1185089: Recognition of The Oral Calcium Loading Test in the Setting of Normocalcemic Hypercalcemia: A case series report

Context: Normocalcemic hyperparathyroidism is characterized by the persistence of normal serum calcium levels and elevated intact parathyroid hormone (PTH) values, after the exclusion of other secondary hyperparathyroidism causes. Patients with this condition can present with progressive complications, such as the conversion to primary hyperparathyroidism, as well as the development of osteoporosis and nephrolithiasis. The diagnosis can be challenging due to a vast number of issues including the differentiation between normocalcemic hypercalcemia and primary hyperparathyroidism, since both have similar biochemical findings.

Level of Serum Parathyroid, Calcium, Phosphate and Vitamin D and Their Correlation In Occurrence of Mineral Bone Disorder In Ckd Patient Admitted in Adult Medicine Ward Of a Tertiary Hospital in Bangladesh

Background: Chronic kidney disease (CKD) is a global health problem associated with increased risks of morbidity, premature mortality, and/or decreased quality of life. CKD is usually asymptomatic until progressive damage occurs and produce multiple symptoms and signs. Progressive loss of kidney function in CKD leads to reduced production of 1-á-(OH) 2-D3 (1, 25-dihydroxyvitamin D; calcitriol) and abnormal mineral homeostasis. The aim of the study was planned to assess the mineral and bone disorder in CKD patients admitted in a tertiary care hospital. Methods: A Cross sectional observational study was performed at a tertiary care centre. 100 cases of diagnosed Chronic Kidney Disease patients in indoor of department of Nephrology and Medicine of Sir Salimullah Medical College Mitford hospital from March 2018 to August 2018 were included in this study. Results: Majority of the patients (60%) were of age between 46 and 65 years. 31% of the study population were older than 65 years. 72% of the study population were male and 28% were female. Diabetic nephropathy was the leading cause of CKD, affecting 36% of the study population. Hypertension was the likely cause in 26% of the subjects. Obstructive uropathy and chronic glomerulonephritis affected 7% and 5% of the subjects respectively. There was one (1%) patient with ADPKD, and in 25% of the cases no causative factor was identified. Most (40%) of the study subjects were in the stage 3 of CKD. 34% & 26% of the patients were in the stage 5 & 4 respectively. We did not find any patient with normal vitamin D level. 10% of the patients were in the insufficient range and 90% of the study subjects were deficient in vitamin D. Hyperparathyroidism was prevalent in 75% of the study subjects. 79% of the patients had elevated serum phosphate levels. Hypocalcemia was found in 49% of the patients. 33% of the patients had hyperkalemia during admission. Hyperphosphatasia was prevalent in 39% of the study subjects. However, bone fraction of the ALP was not tested. Among stages 3B, 4 and 5 CKD patients, there were 2% patients in each group that were insufficient in vitamin D. Majority (32% in stage 5, 24% each in stages 3B and 4) were deficient in vitamin D. Deficiency was also prevalent in earlier stages of CKD (10% patients in stage 3A). The difference was statistically significant, that is, the later the stage of CKD the greater the prevalence of vitamin D deficiency was. All the patients in stage 5 and 4 (34% and 26% respectively) had hyperparathyroidism. 0% and 15% of the patients in stages 3A and 3B respectively had hyperparathyroidism. The difference between groups was statistically significant. Serum calcium level correlated well with the stage of CKD. Most of the patients in stage 5 were hypocalcemic (32 among 34). Among the 39% of the total study population with hyperphosphatasia, 24%, 9% and 6% were in stages 5, 4 & 3B respectively. Which were statistically significant. 49% pf the patients had hyperparathyroidism with hypocalcemia, 26% of the patients had hyperparathyroidism and normal serum calcium levels. None of the patients had hypocalcemia and normal PTH level. Among the 90 patients with deficient vitamin D levels, 46 had hypocalcemia also. 70 patients with deficient vitamin D level also had high PTH level. The difference between groups which was statistically significant. Conclusion: MBD is a common complication in our CKD patients. Raised PTH, low 25(OH) D, and raised phosphorus levels were the most prevalent markers. Majority of our patients presented, or were referred late. Clinical features of MBD in CKD were poor guides to the presence of MBD in our pre-dialysis patients. Bangladesh J Medicine 2022; 33: 145-153

X-linked Rickets with Inflammatory Sacroiliitis-like Presentation: A Case Report and Literature Review

Background: Hypophosphatemic rickets can cause a variety of bone and joint symptoms, one of its rare presentations is sacroiliac joint involvement, which may be mistaken for inflammatory spondylitis. Discussion: Here, we report the case of a 31-year-old African American woman who presented with a 2-year history of lower back pain and morning stiffness initially suspected to be due to inflammatory spondyloarthritis. Laboratory tests revealed negative inflammatory markers, normal serum calcium, vitamin D3, and parathyroid hormone level: - However, alkaline phosphatase levels were elevated and serum phosphorus level was low. MRI of the lumbosacral spine revealed mild widening of the sacroiliac joint with periarticular sclerosis. Her condition was attributed to a known diagnosis of X-linked hypophosphatemic rickets affecting her sacroiliac joints. Her symptoms gradually improved after conservative treatment with physical therapy, NSAIDs, phosphate and vitamin D supplementations. Based on our literature review, we have come across only five rickets cases with similar presentations. Two paints previously undiagnosed hypophosphatemic rickets at 14 and 35 years, respectively. One case was related to vitamin D-deficient rickets, and the final two cases were adult-onset vitamin D-resistant rickets misdiagnosed as ankylosing spondylitis. Radiological signs of sacroiliac joint involvement in these cases include narrowing of the sacroiliac joints, fusion of the sacroiliac joints, subchondral hypointense signal changes, and chondral surface irregularities. Conclusion: Vitamin D supplementation significantly reduce the incidence of rickets; however, there are still cases of familial rickets that can present with a variety of symptoms, including signs and symptoms consistent with inflammatory spondylitis, which can be easily misdiagnosed or mistreated if this presentation is not recognized.

A Retrospective Study of Serum Calcium Status in Tehran, Iran (105,128 Samples, from 2009-2018).

Background:Calcium is a necessary mineral for life to keep the body and bones healthy. Various factors including hormones, diet, age, and gender affect serum calcium status. The aim of this sturdy was to assess the serum calcium level (SCL) of Tehran population, which has about 10 million multi-Ethnic populations and represents from the whole country.Methods:In this retrospective study, the measured SCL of 105,128 individuals referred to different laboratories of Tehran, Iran were evaluated and its relationship with the age, gender, seasons, and different years during 2009–2018, were analyzed.Results:After excluding outliers, 91,257samples remained, which 61162 (58.64%) and 30,095 (41.36%) were female and male, respectively. The mean SCL was 9.36 (9.35, 9.37) mg/dl (95%CI). The highest and lowest SCLs were 3.1 and 18.2mg/dl, respectively. From the total study population, 74127 (81.23%) had normal SCLs, 14110 (15.46%) had hypocalcemia, and 3020 (3.31%) had hypercalcemia. SCLs were normal in 83.6% of men and 79.66% of women. Women had a significantly higher frequency of hypocalcemia compared to men (17.2% vs. 12.83%, p<0.0001).Conclusion:Normal and abnormal SCLs were significantly different in age groups and in both genders. It means that gender and age affect SCLs. Every year of increasing age, reduces the chance of hypercalcemia by 40%, significantly. Age seems to affect hypercalcemia more than hypocalcemia. Age in men increases the risk of hypocalcemia, and reduces the risk of hypocalcemia in women. Therefore, it is recommended to encourage dietary calcium intake among premenopausal women and older men.

IRON &amp; CALCIUM DEFICIENCY – POTENTIAL RISK FACTOR IN THE FORMATION OF BILIARY CALCULI – A PROSPECTIVE STUDY CONDUCTED IN A TERTIARY CARE HOSPITAL OF EASTERN INDIA.

Alteration in the serum level of trace elements may be an important causative factor in the formation of biliary calculi. Better understanding of the pathophysiology will help in prevention of this one of the commonest surgical problem in future. Deciency of the trace elements especially iron &amp; calcium interferes with the hepatic enzyme function that precipitates gall stone formation. This hypothesis is supported by few recent studies in animal &amp; human model in India and abroad. This prospective study was planned to evaluate serum concentration of iron &amp; calcium in 2 groups of patients, one group having cholelithiasis and another group undergoing other elective surgical procedures, named cases and controls respectively, over a period of one and half years. It was found that the level of serum iron of the patients with gallstone was signicantly lower than that of the patients without gallstone [p=0.04]. The risk of gallstone formation was also 5.44 times more among the patients with serum iron deciency as compared to the patients with normal level of serum iron and the risk was signicant [OR-5.44(1.61, 48.39);p=0.04]. Moreover, further analysis in the case group shows that the mean level of serum iron for Pigment stone was the highest and that for Cholesterol stone was the lowest and the 2 difference is statistically signicant. Corrected Chi-square (χ ) test showed that there was signicant association between level of serum calcium and patients of the two groups (p=0.026). The risk of gallstone was 7.97 times more among the patients with serum calcium deciency as compared to the patients with normal level of serum calcium and the risk was signicant [OR-7.97(1.04, 67.45);p=0.026]. Also, t-test showed that there was signicant difference in the level of serum calcium of the patients with gallstone than that of the patients without gallstone [t98 = 1.98; p=0.04] . Among the 3 stone groups in the Case arm the mean level of serum calcium for Pigment stone was the highest and that for Cholesterol stone was the lowest, but this difference is not statistically signicant (p=0.08).

The Importance of Vitamin D in Long-Term Care Residents

The Importance of Vitamin D in Long-Term Care Residents

Calcinosis Cutis of the Nasal Dorsum

Summary:Calcinosis cutis is a common dermatological problem in patients with systemic sclerosis, dermatomyositis, and systemic lupus erythematous; however, it is rare to occur outside of these diseases. It represents a multidisciplinary problem that involves primary care physicians, dermatologists, and surgeons. The pathophysiology is defined by deposition of calcium salts in the subcutaneous tissue as hydroxyapatite, but the underlying mechanism has yet to be determined. The most common locations of lesions are the scalp, scrotum, extremities, and joints. Rarely does calcinosis cutis occur on the face. We present a unique case of idiopathic calcinosis cutis that occurred in a healthy patient with normal serum calcium and phosphate levels on the nasal dorsum, which was managed surgically. The histology of the calcinosis showed normal morphology, dominated by large deposits of calcium and normal surrounding tissues. This case represents a rare but clinically relevant presentation of idiopathic calcinosis cutis in an otherwise healthy individual.

Risk factors influencing cure of ultrasound-guided microwave ablation for primary hyperparathyroidism

Objective To evaluate the potential risk factors influencing cure rate of ultrasound-guided microwave ablation (MWA) for primary hyperparathyroidism (PHPT). Materials and methods Seventy five patients (25 males and 50 females; mean age, 56.80 ± 12.34; age range, 26–85) with PHPT undergoing MWA under ultrasound guidance were enrolled between May 2017 and December 2020. The cure rate and complications were evaluated after treatment. The potential factors influencing cure rate of ultrasound-guided MWA for PHPT were analyzed by univariate and multivariate binary logistic regression. Results Fifty six of 75 patients had normal PTH and serum calcium levels after at least 6 months after one session MWA, and the cure rate was 74.7% (56/75). 6 uncured patients received the second session MWA during follow-up, and the cure rate achieved 81.3% (61/75) after the second session MWA. Voice changes occurred in 4 patients (5.33%) and recovered within 3 months after ablation without special treatment. Nodule volume was the independent risk factor associated with cure in PHPT patients undergoing MWA, whether after one session (p = 0.0224; odds ratio, 0.67) or the second session MWA (p = 0.0408; odds ratio, 0.74). The cutoff value for nodule volume in predicting the cure was 0.96 cm3 (one session: sensitivity, 76.8%; specificity, 73.7%; the second session: sensitivity, 72.1%; specificity, 71.4%). Conclusion In conclusion, parathyroid nodule volume was the independent risk factor associated with cure in PHPT patients undergoing MWA.

Vitamin D deficiency in proximal femur fractures: An observational, cross-sectional study

Introduction: A proximal femur fracture is the most serious complication of osteoporosis, due to the high mortality and morbidity associated with it. Its risk in the elderly is a function of multiple factors, including bone mineral density, muscle strength, and balance, all of which have been related to Vitamin D status and function. Materials and Methods: This was a prospective hospital-based study conducted over 2 years in the hilly state of Himachal Pradesh, India, to evaluate any correlation between Vitamin D levels and proximal femur fractures (PFFs). We also studied the influence of age and sex on Vitamin D levels in PFFs. Results: In our study, the female patients had lower Vitamin D levels (19.85 ± 5.28) as compared to males (20.436 ± 9.36), but this decrease was not found to be statistically significant (P = 0.2374). There was an average decrease of Vitamin D levels in patients of higher age group (20.770 ± 6.57 vs. 19.692 ± 8.40), but this was not statistically significant (P = 0.613). Thirty-four patients, i.e., 68%, had hypocalcemia, while 16 patients, i.e., 32%, had normal levels of serum calcium. Similarly, 30 patients, i.e., 70%, had hypomagnesemia, while 20 patients, i.e., 40%, had normal serum magnesium levels. The mean level of alkaline phosphatase in PFF was found to be 116.36 IU/L, i.e., within normal limits. The average Vitamin D level in our patients who were adequately exposed to sunlight was 22.5 ± 8.80 ng/ml, while the average Vitamin D level in patients who were inadequately exposed was 16.925 ± 5.98 ng/ml. The mean Vitamin D levels in vegetarian and nonvegetarian patients were 19.17 ± 6.05 ng/ml and 19.83 ± 9.56 ng/ml, respectively. We found that vitamin levels were relatively low (19.46 ng/dL) in patients from high altitudes as compared to patients from low altitudes (22.62 ng/dL), but the difference was insignificant (P = 0.3925). Conclusion: In our study, almost all patients (96%) were suffering from hypovitaminosis D (Vitamin D levels <30 ng/ml), and 38% of our patients had Vitamin D deficiency (Vitamin D levels <20 ng/ml). However, we were unable to find any significant difference in Vitamin D levels when patients of various ages, sex, and altitude were compared with each other.

IS CONFIRMATION OF PARATHYROID TISSUE BY FROZEN SECTION SUPERIOR TO LOCALIZATION OF SOLITARY PARATHYROID ADENOMA USING INTRAOPERATIVE GAMMA PROBE SURVEY? A RETROSPECTIVE COHORT STUDY.

In the surgical treatment of primary hyperparathyroidism, intraoperative localization of the diseased glands is an essential issue. We aimed to evaluate the impact of the intraoperative frozen section during radio-guided focused parathyroidectomy and compare its efficiency with intraoperative gamma probe survey and measurement of intraoperative quick parathyroid hormone. All consecutive patients underwent radio-guided focused parathyroidectomy for primary hyperparathyroidism due to solitary parathyroid adenoma. The outcomes of parathyroidectomy were evaluated by serum levels of calcium and parathyroid hormone. The primary outcome was the surgical cure diagnosed by normal serum calcium levels in the sixth postoperative month. A total of 55 patients with a mean age of 54.3±12.2 years were evaluated. The diagnostic accuracy of the preoperative localization tests was calculated as 92.7%. The intraoperative gamma probe survey impacted the operative plans of four patients (7.3%) by localizing the diseased gland in other positions. The accuracy of intraoperative quick parathyroid hormone and frozen section analysis was 100% for both. In all patients, serum calcium and PTH levels dropped to normal in the sixth postoperative month. There were no cases of the persistent or recurrent disease during the follow-up period. The results of the intraoperative gamma probe survey, intraoperative quick parathyroid hormone, and frozen section were concordant with the final pathology in all cases. In four patients (7.3%), intraoperative gamma probe survey impacted the operative plans. The intraoperative gamma probe survey may be used as the sole intraoperative method to locate the correct position of the solitary parathyroid adenoma.

Serum Calcium/Phosphorus Ratio in Biochemical Screening of Primary Hyperparathyroidism.

Primary hyperparathyroidism is a common endocrine disease and most cases are asymptomatic. Currently, in a hypercalcemic patient, the first laboratory investigation is serum primary hyperparathyroidism measurement. However, the primary hyperparathyroidism level cannot be measured in many primary healthcare centers in our country. In addition, serum calcium levels are normal in normocalcemic primary hyperparathyroidism patients, even if most centers have serum calcium levels measured. Therefore, a simple and inexpensive laboratory biochemical marker is required for the diagnosis of primary hyperparathyroidism. Recently, the calcium/phosphorus ratio has been proposed as a suitable tool for diagnosing primary hyperparathyroidism. This study aimed to investigate the diagnostic value of serum calcium/phosphorus ratio in primary hyperparathyroidism screening. A total of 462 patients followed in our clinic with a diagnosis of primary hyperparathyroidism were reviewed in this retrospective study. Out of these patients, 148 with normal levels of serum parathyroid hormone, calcium, and phosphorus were selected as the control group. Serum calcium, corrected calcium, phosphorus, albumin, parathyroid hormone, 25-hydroxyvitamin D, and creatinine were evaluated. The diagnostic accuracy of the calcium/phosphorus ratio was investigated using receiver operating characteristic curve analysis. There were 404 (87.4%) females and 58 (12.6%) males in the primary hyperparathyroidism group. Calcium, parathyroid hormone, and calcium/phosphorus ratio were significantly higher in primary hyperparathyroidism than in controls (p<0.001 for each). Receiver operating characteristic curve analyses identified a cutoff value of 2.59 (3.35 if calcium and phosphorus are measured in mg/dL) for the calcium/phosphorus ratio, with a sensitivity of 90.5% and specificity of 93.2% (p<0.001). The calcium/phosphorus ratio is a simple and inexpensive method for primary hyperparathyroidism screening when a cutoff value of 2.59 is used.

Analysis of the cause and management of persistent laboratory abnormalities occurring after the surgical treatment of primary hyperparathyroidism.

PurposeThe surgical success rate for primary hyperparathyroidism (PHPT) is currently 95%–98%. However, 3%–24% of patients show persistently elevated (Pe) parathyroid hormone (PTH) levels after parathyroidectomy (PTX). This single-center retrospective study aimed to compare the outcomes of patients with normal PTH and PePTH levels after successful PTX and to identify the factors associated with PePTH.MethodsThe normal group, defined as patients with normal serum calcium and PTH levels immediately after PTX, was compared with the PePTH group (patients with normal or low serum calcium and increased serum PTH levels up to 6 months postoperatively) to determine the causes of disease in the PePTH group.ResultsThere were no significant differences in age, sex, or preoperative estimated glomerular filtration rate between the normal PTH group (333 of 364, 91.5%) and the PePTH group (31 of 364, 8.5%). However, there were significant differences in preoperative 25-hydroxyvitamin D (17.9 and 11.8 ng/mL, respectively; P = 0.003) and PTH levels (125.5 and 212.4 pg/mL, respectively; P < 0.001) between the 2 groups. Among the 31 cases of the PePTH group, 18 were attributed to vitamin D deficiency.ConclusionPreoperative vitamin D deficiency is a predictive factor for PePTH. Therefore, preoperative administration of vitamin D supplements may reduce the probability of postoperative disease persistence. Patients with temporary laboratory abnormalities within 6 months after successful PTX should be monitored, and appropriate vitamin D and calcium supplementation may reduce the effort and cost of various examinations or reoperations.

Clinical Image: Calcinosis cutis universalis in a patient with polymyositis/scleroderma overlap syndrome.

The patient, a 32-year-old woman with a known history of polymyositis/scleroderma overlap, presented for a second opinion regarding subcutaneous nodules. On examination, the patient had extensive subcutaneous painful nodules over multiple areas of the body, including bilateral arms, thighs, and hands. There were no open or ulcerative lesions. Workup demonstrated normal creatine kinase, parathyroid hormone, serum calcium, and serum phosphate levels and normal bone mineral density. Electromyography showed no evidence of active myositis. A frontal projection radiograph demonstrated extensive sheetlike soft tissue calcinosis consistent with calcinosis cutis universalis. Calcinosis cutis describes the deposition of insoluble calcium salts in the cutaneous and subcutaneous tissue (1). Five subtypes of calcinosis cutis exist on the basis of the etiology: dystrophic, metastatic, idiopathic, iatrogenic, and calciphylaxis. The dystrophic subtype results from tissue trauma or chronic inflammation due to autoimmune connective tissue disorders. Dystrophic calcinosis cutis develops in approximately 25% of patients with systemic sclerosis and 11% to 20% of patients with dermatomyositis (2, 3). Calcinosis cutis universalis, as seen in this patient, is a rare presentation. Two types of calcinosis cutis universalis exist: diffuse deposits along myofascial planes and deep intramuscular tumoral deposits, as seen in this patient (4). Although multiple treatment modalities have been trialed, no effective treatment is known (5).

Evaluation of serum macronutrients level and depression among adolescents and its association with pre-hypertension: A cross sectional study

Introduction and Aim: Serum macronutrients measurement prove to be precedent values with regard to diagnose hypertension at an earlier age. Depression in any form could be ruinous to younger generation, also could precipitate hypertension. The aim of the study is to estimate serum calcium, magnesium levels, grade depression and to establish its association with prehypertension. Materials and Methods: A cross sectional study was conducted on 68 students aged 17-19 years over a two months period. Blood samples were drawn and serum magnesium and calcium were estimated. Depression was assessed by administering KADS – 6 questionnaires. Blood Pressure was measured by auscultatory method using mercury sphygmomanometer. All parameters were presented as mean ± SD. Chi square test was used to compare proportions for the groups. Unpaired t test was used to compare the groups. ANOVA was used to compare the groups for continuous variables. Statistical analysis was done using Epi info (version 6.04d) software package. Results: More than 44% of the study participants had elevated serum calcium levels, while about 10% of them had elevated serum magnesium levels. More than half (58.8%) of the participants were pre-hypertensive. One third of the study participants were depressed of which about 10% of them had severe depression. The prevalence of prehypertension was 2.1 times higher among participants having hypercalcemia when compared to participants who have normal serum calcium levels with 95% CI of 1.38 - 3.22 which is statistically significant (p-value &lt; 0.001). The study could not establish a statistical difference between different groups with regards to serum magnesium levels and depression. Conclusion: Our study portrays the widely prevalent depression and pre-hypertension in younger generation and exhibits firm evidence on measuring serum macronutrient levels to diagnose pre-hypertension before time that can prevent the disease load and help ineffective management.

Subcutaneous calcinosis: Is it different between systemic sclerosis and dermatomyositis?

Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It is a manifestation of several autoimmune connective tissue diseases, most frequently with systemic sclerosis and juvenile dermatomyositis, followed by adult dermatomyositis. Autoimmune connective tissue disease-associated calcinosis is of the dystrophic subtype, which occurs at sites of damaged tissue in the setting of normal serum calcium and phosphate levels. In juvenile dermatomyositis, calcinosis is considered a marker of ongoing disease activity and possibly inadequate treatment, while in adult dermatomyositis, it is a hallmark of skin damage due to chronic rather than active disease. Calcinosis is associated with long disease duration in systemic sclerosis and dermatomyositis, anti-polymyositis/sclerosis autoantibodies in systemic sclerosis and NXP-2 and melanoma differentiation-associated gene 5 in dermatomyositis. Calcinosis in systemic sclerosis occurs most frequently in the hands, particularly the fingers, whereas in dermatomyositis, it affects mainly the trunk and extremities. The primary mineral component of calcinosis is hydroxyapatite in systemic sclerosis and carbonate apatite in dermatomyositis. Calcinosis in dermatomyositis and systemic sclerosis share some pathogenic mechanisms, but vascular hypoxia seems to play a more important role in systemic sclerosis, whereas the release of calcium from mitochondria in muscle cells damaged by myopathy may be a primary mechanism contributing to dermatomyositis-related calcinosis. Multiple treatment strategies for dermatomyositis and systemic sclerosis-related calcinosis have been used with variable results. Early aggressive treatment of underlying myositis in patients with dermatomyositis may improve long-term outcomes of calcinosis. A better understanding of the pathogenesis of calcinosis is needed to improve treatment options.

Clinical and demographic aspects of Paget disease of bone: A multicentric study from Turkey.

Paget disease of bone (PDB) is a metabolic bone disease that has been rarely reported in the Eastern countries. This study aimed to evaluate the clinical and demographic characteristics of patients with PDB followed up at endocrinology clinics in Turkey. An invitation was sent to tertiary endocrinology clinics to complete a survey on the demographic, clinical, radiological, and laboratory parameters, as well as treatment modalities of patients with PDB. This study enrolled clinically and radiologically proven 185 patients with PDB from 18 endocrinology centers based in 10 cities of Turkey. This cohort of PDB had female preponderance (women/men: 105/80) with a mean age, during diagnosis, of 57±10 years. Most of the patients (59.6%) were symptomatic at diagnosis. Bone pain and headache were the predominant clinical symptoms. Polyostotic disease was observed in 67.5% (n=125) of patients. Frequently affected bones were skull (41.6%), pelvis (53.5%), spine (41%), and femur (25.4%). Moreover, 17 patients with skull involvement had hearing loss. Mean serum alkaline phosphatase (ALP) level (552±652 IU/L; range: 280-5762 IU/L) was over the normal reference cutoff with normal serum calcium levels. Intravenous bisphosphonates (zoledronic acid, 5 mg; pamidronate, 60-90 mg) were the most used drugs (75%) for the treatment of PDB. Most of the patients (87.1%) treated with intravenous bisphosphonates responded well, with a decrease in serum ALP level (117±114 IU/L) in the 12th month of therapy. Furthermore, 16 patients relapsed after the second year of therapy; 3 patients did not respond to the initial intravenous bisphosphonate treatment. The patients with PDB followed up by endocrinology clinics of Turkey exhibited polyostotic disease with classical clinical, radiological, and biochemical features and women's predominance with good response to intravenous bisphosphonate therapy.

18F-Fluorocholine-PET combined with contrast-enhanced CT for localizing hyperfunctioning parathyroid glands and optimizing surgical treatment in patients with hyperparathyroidism

Hyperparathyroidism (HPT) is a common disorder. A cure can only be achieved by removing all diseased glands. It is critical to localize the hyperfunctioning glands exactly to prevent extensive surgical exploration. The number of false negative/inconclusive results in standard imaging techniques is high. We aimed to evaluate the diagnostic accuracy of 18F-Fluorocholine-PET in combination with contrast-enhanced CT (FCH-PET/CT) and its sensitivity in patients with primary, secondary/tertiary, and familial HPT with negative and/or discordant findings in ultrasound and/or 99mTc-sestamibi scintigraphy/SPECT/CT. A total of 96 patients with HPT and negative/equivocal conventional imaging were referred for FCH-PET/CT. In this retrospective, single institution study, 69 patients, who have undergone surgery and histopathologic workup, were analyzed. Of the 69 patients included, 60 patients suffered from primary HPT, four from secondary or tertiary HPT, and five from familial HPT. Sensitivities, positive predictive values, and accuracies were calculated. Sensitivity/positive predictive value (PPV) per lesion was 87.5/98.3% for primary HPT, 75/100% for secondary/tertiary HPT and 25/66.7% for familial HPT. Sensitivity/PPV per patient was 91.5/98.2% for primary HPT, 100/100% for secondary/tertiary HPT and 50/100% for familial HPT. All patients showed normalized serum calcium levels in the postoperative period. The follow-up rate was 97%. Of the patients included in the study, 58 of 60 patients with primary HPT, and four of four patients with secondary/tertiary HPT showed normal calcium and parathyroid hormone (PTH) levels after six months and were cured. Of the patients with familial HPT, four of five patients were cured. Diagnostic accuracy of 18F-Fluorocholine-PET/CT for patients with pHPT is excellent. 18F-Fluorocholine-PET/CT is a valuable tool for endocrine surgeons to optimize the surgical treatment of patients with hyperparathyroidism.

Incidence of Hypocalcemia Post Thyroidectomy: Results from Dubai Hospital, Dubai, UAE

Introduction and Background: Thyroidectomy is one of the common endocrine surgery performed. Hypocalcemia is one of the most common complication post thyroidectomy. Incidence varies between 6.4-20.5% for transient and 1.5 to 2.69 for permanent hypocalcemia. Meticulous surgical technique is the key for preservation of blood supply to parathyroid gland and hence decreasing the incidence of post op hypocalcemia. Once identified should be treated with multidisciplinary approach with proper follow up. Objective: To determine the incidence of transient and perminant hypocalcemia in patients undergoing thyroidectomy in our institute for various reasons. Methods: Records of 120 patients who underwent thyroidectomy from Jan 2017 till July 2020 were retrospectively reviewed. Calcium levels were checked at 6 hours post operatively to find the incidence of transient hypocalcemia and at 6-8 months interval to calculate for permanent hypocalcemia. All patients were followed till 2 years post operatively and treatment started for those with hypocalcemia and repeated calcium levels were checked and treatment was tapered and gradually stopped once normal serum calcium levels reached normal. Results: The incidence of transient hypocalcemia in our study is 4.1 % while only 0.8 % patients had permanent hypocalcemia . Conclusion: Hypocalcemia being one of the most common complication of thyroidectomy, the incidence can be reduced by paying attention to meticulous surgical techniques. It is seen mostly in patients undergoing total thyroidectomy and advanced and prolonged surgery for malignancy.