Oral Calcium Research Articles

Sex-Specific Association Patterns of Bone Microstructure and Lower Leg Arterial Calcification

In conversations about bone loss and the importance of calcium homeostasis, patients frequently inquire about the association with arterial calcifications. Although a relationship between bone loss and the occurrence of vascular calcifications is suspected, it is not yet fully investigated and understood. This study aims to analyze associations between bone mineralization, structure, and vascular calcification at the lower leg in patients with low bone mineral density in HR-pQCT. We retrospectively analyzed 774 high-resolution quantitative computed tomography (HR-pQCT) scans of the distal tibia for the presence of vascular calcifications. After sex-specific propensity score matching for age and BMI to account for confounders, 132 patients remained for quantification of bone microstructure, bone density, lower leg arterial calcification (LLAC), and laboratory parameters of bone turnover. The interactions between bone parameters and vascular calcification were quantified by regression analyses. The calcium metabolism was not different between individuals with and without LLAC, nor oral calcium supplementation. Female patients with LLAC had a higher cortical perimeter (p = 0.016) compared to female patients without LLAC, whereas male patients with LLAC had lower cortical pore diameter than male patients without LLAC (p = 0.027). The appearance of LLAC was sex specifically associated with bone parameters. In female patients, only plaque density was associated with HR-pQCT bone parameters and age, whereas in male patients, plaque volume was associated with HR-pQCT parameters of the distal tibia. Female patients exhibit an increasing plaque density depended on age and trabecular thinning. Decreasing cortical pore diameter and trabecular number along with increasing bone mineralization are linked to increasing plaque volume in male patients.

7193 Hypocalcemia: Pitfalls, Paradoxes, And Conundrums

Abstract Disclosure: K. Dash: None. P. Eswaran: None. K. Maharajan: None. S. Nangia: None. U. Ayyagari: None. 58 year old female with PV bleed was diagnosed as Carcinoma Cervix and recommended radical radiotherapy with 6 weeks of concurrent chemotherapy with Cisplatin and IV Magnesium premedication. Post 6th cycle of chemo, she presented with nausea, perioral and facial tingling, and lower limb cramps of one day duration. Investigations showed Serum Magnesium 0.4 mg/dl (range 1.6–2.5), Calcium 5.9 mg/dl (8.4-10.2), Potassium 3.3 mg/dl (3.5-5.5). She was treated with IV Calcium gluconate and discharged home post correction with serum Calcium 7.9, Magnesium 1.8, PTH 88.7. She was readmitted twice, 5 and 9 days later, with hypocalcemia, given IV Calcium Gluconate, and discharged post correction of serum calcium levels. She presented to Endocrine OP 2 days later, asymptomatic, serum Calcium 5.9, Magnesium 0.6, K 3.8. She was admitted and replacement commenced with IV Magnesium and Calcium. Over the next day her Calcium and Magnesium levels improved. She was stabilized on oral Calcium and Magnesium replacement and discharged. Calcium replacement was weaned over the next 2 weeks with stable serum Calcium levels on continuing oral Magnesium replacement to date. Cisplatin is a commonly used chemotherapeutic agent. It binds to the N7 reactive center on purine residues and causes DNA damage in cancer cells blocking cell division resulting in apoptotic cell death. This interaction with DNA and the formation of covalent adducts with purine DNA bases is the source of the cytotoxic effect of cisplatin. Therapy is associated with side effects including neuro-, nephro-, hepato-, and cardiotoxicity. Electrolyte disturbances including hypomagnesemia, hypocalcemia, hypokalemia, and hyponatremia are recognized in association with cisplatin therapy. The signs and symptoms of dyselectrolytemias may be nonspecific and a high index of suspicion is required to diagnose. Hypomagnesemia is described in up to 78% of patients on cisplatin due to magnesium wasting attributed to reduced magnesium reabsorption in the distal tubule and/or inadequate intestinal magnesium absorption. Magnesium is primarily an intracellular cation and stored in bone. Serum levels are a poor indicator of total body magnesium and serum concentrations <1.8 mg/dl indicate more severe underlying deficit. Hypocalcemia, possibly due to end organ unresponsiveness to PTH, frequently coexists with hypomagnesimia, and can be resistant to treatment unless hypomagnesimia is corrected. While hypomagnesimia stimulates PTH secretion, very low serum concentrations can induce a paradoxical block. Our case illustrates the importance of recognizing and correcting underlying hypomagnesimia to stabilize serum calcium levels. The normal PTH level, despite low serum Calcium, suggests hypomagnesimia impairing parathyroid gland function. Due to the acute presentation, and ongoing IV correction, we were unable to measure urinary magnesium excretion. Presentation: 6/1/2024

8025 Hypocalcemia Secondary To Relative Hypoparathyroidism After Parathyroidectomy For Tertiary Hyperparathyroidism

Abstract Disclosure: N.N. Solanki: None. M.A. Bahrou: None. W. Taha: None. Parathyroidectomy is one of the treatment options for patients with tertiary hyperparathyroidism. Hypocalcemia following parathyroidectomy is a well-known occurrence due to a sudden drop in parathyroid levels, commonly to normal levels. We describe a case of hypocalcemia following subtotal parathyroidectomy for tertiary hyperparathyroidism with elevated parathyroid hormone (PTH) levels but relatively low compared to baseline. A 56-year-old female with a history of end-stage renal disease status post renal graft rejection presents for elective parathyroidectomy for tertiary hyperparathyroidism. Pre-operative investigations showed serum calcium levels of 11.6 mg/dL, normal value (NV): 9-10.5 mg/dL, serum phosphorus levels of 5.6 mg/dL, NV: 2.7-4.5 mg/dL, very high levels of serum intact PTH of 1257 pg/mL, NV: 10-65pg/mL and high level of alkaline phosphatase of 376 U/L, NV: 40-150 U/L. The patient underwent right and left inferior parathyroidectomy. Postoperatively, the patient's intact PTH levels remained elevated [895 pg/mL]; however, they decreased compared to baseline, but she developed hypocalcemia requiring intravenous and oral calcium supplementation. On postoperative day seven, she was discharged on oral calcitriol and calcium carbonate. Hypocalcemia following parathyroidectomy is well-described in cases where the PTH levels drop to the normal range. This case highlights that hypocalcemia can also occur when there is a relatively lower PTH level while the absolute value remains elevated. Presentation: 6/1/2024

6871 Hungry Bone Syndrome After Parathyroidectomy in End-Stage Kidney Disease: A Case Report Analysis

Abstract Disclosure: R. Rani: None. C. Mullarkey-desapio: None. Introduction: Hungry Bone Syndrome (HBS) is a rare yet severe complication following parathyroidectomy, characterized by pronounced hypocalcemia subsequent to a rapid decline in parathyroid hormone (PTH) levels. Renal hyperparathyroidism (RHPT) carries a heightened risk of HBS compared to primary hyperparathyroidism (PHPT), with prevalence varying from 15% to 25% in PHPT to as high as 75-92% in RHPT. This elevated risk in RHPT is attributed to chronically elevated PTH levels, both in terms of duration and intensity as compared to PHPT. Preoperative predictors for HBS occurrence and severity include younger age, larger gland size, lower preoperative calcium levels, elevated bone turnover markers, and the magnitude of PTH elevation. Case Report: We present a case of a 36-year-old female with End-Stage Renal Disease (ESRD) requiring dialysis, complicated by renal osteodystrophy and a radial fracture, unresponsive to medical therapy, who was admitted for parathyroidectomy. Preoperative labs revealed calcium at 8.3 mg/dL, phosphate at 4.1 mg/dL, alkaline phosphatase (ALP) at 797 IU/L, and an extremely elevated parathyroid hormone (PTH) level at 4139 pg/ml. Within 24 hours of parathyroidectomy (three and a half glands were removed, the largest weighing 0.7gm), her PTH levels declined to the 130s, accompanied by symptomatic hypocalcemia (calcium 6.5mg/dL). Initial management involved intravenous calcium gluconate and subsequent high-dose oral calcium (up to 10-16gm daily) with Calcitriol 1 mcg twice daily. Despite repletion, her calcium levels remained low on postoperative day 4 (calcium 6.8mg/dL, phosphate 1.9 mg/dL, magnesium 1.7mg/dL) with PTH at 131 pg/ml, confirming Hungry Bone Syndrome. After seven days of aggressive intravenous and oral calcium supplementation with high-dose Calcitriol, she was discharged with a calcium level of 8.9mg/dL. Discussion: Management of HBS following renal hyperparathyroidism surgery presents significant challenges due to associated comorbidities and other electrolyte abnormalities, with limited literature providing guidance on prevention and management. Our case demonstrated that early suspicion and aggressive management improved patient outcomes. Suspecting HBS in high-risk individuals and initiating interventions pre and post-surgery, including pre-treatment with calcitriol, bisphosphonates, and early aggressive intravenous calcium supplementation post-surgery, could potentially reduce morbidity and length of hospital stay. Presentation: 6/1/2024

12372 A Rare Case Of Silicon Granulomatosis Induced Hypercalcemia In A Transgender Female

Abstract Disclosure: O.A. Aluko: None. I. Singh: None. Introduction: Hypercalcemia has been described in patients with most granulomatous disorders, of which sarcoidosis and tuberculosis are the most common. Granuloma formation is a rare, however well known complication of silicon implants and injections. We present a case of silicon granulomatosis induced hypercalcemia in a transgender female. Case Report 60-year-old transgender female, with past medical history of HIV on HAART was referred to Endocrinology for evaluation of hypercalcemia. She Bloodwork done a few weeks prior revealed elevated calcium 12.3 and low PTH of 9. Reported symptoms include worsening abdominal pain similar to prior gastritis flare, insomnia and significant weight loss. Denied any constipation, joint pain, mood changes, no history of bone fractures or kidney stones. Admitted to significant dairy intake - half a gallon of milk within 3 days and daily yogurt consumption. Endorsed inadequate daily fluid intake and she was not taking oral calcium or Vitamin D supplementation. Quit tobacco 9 years ago. Vitals were significant for tachycardia with HR 120/min, BP stable. Patient was referred to the ER for IV hydration and further evaluation with initial suspicion of malignancy. Repeat corrected calcium was 14.7, ionized calcium 6.8, PTHrP undetectable <2, borderline high 1,25 dihydroxyvitamin D 74.5, low vitamin D 17.9 and normal free T4 1.5. ACE, SPEP, UPEP levels within normal limits. Vitamin A low. CT chest/abdomen/pelvis revealed innumerable soft tissue foci in the subcutaneous adipose tissue of the flanks and lateral gluteal areas; nodular liver, suspected cirrhosis and portal hypertension. Imaging findings prompted further discussion regarding prior procedures. She endorsed history of silicone fillers in hips and breast implants 30 years ago. Images reviewed with radiology confirmed calcification around bilateral breast implants, with intracapsular rupture. Calcium improved with IV Fluids, bisphosphonates and steroids. The most probable cause of hypercalcemia was believed to be secondary to silicone granulomatosis. Innumerable granulomas were deemed irresectable, removal of the breast implants considered however not performed. She was later diagnosed with hepatitis B, cirrhosis and succumbed to sepsis and multiorgan failure. Conclusion Eliciting a detailed history, physical exam and correlating with imaging findings is imperative to establishing an uncommon diagnosis. PTHrP was low and there were no bony metastases making the possibility of malignancy related hypercalcemia less likely. FDG-PET if performed would reveal hypermetabolic nodules, often an initial indication to the underlying etiology. Presentation: 6/2/2024

8157 Hypercalcemia To Hypocalcemia In Three Days: The Importance Of Asking The Questions

Abstract Disclosure: P. Kachhadia: None. K. Patel: None. S. Khan: None. A. Abu Limon: None. S. Aldasouqi: None. F. Akanbi: None. Z. Ul Abideen: None. Introduction: Severe hypercalcemia needing inpatient hospitalization requires very thorough history taking in order to determine etiology and treatment plan. Causes differ drastically, and misdiagnosis or mistreatment can be life threatening. Here, we present a case of symptomatic hypercalcemia secondary to milk-alkali syndrome that was treated promptly after admission with IV zoledronic acid, leading to severe symptomatic hypocalcemia and prolonged hospitalization. Case presentation: Patient is a 68 year old female with a PMH of breast cancer, osteoporosis and hiatal hernia who presented to the emergency department for fatigue, constipation and lightheadedness. On evaluation, she was found to have a creatinine of 1.54 (0.6-1.1 mg/dL), eGFR 36 (>90 mL/min/1.73 m²), Ca 18.48 (8.6-10.2 mg/dL), albumin 4.7 (3.4-5.4 g/dL), Mg1.4 (1.7-2.2 mg/dL), 25-OHD 18 (30-100), 1,25-Dihydroxy Vitamin D 7.4 (18-78 pg/mL), PTH 11.2 (15-65 pg/mL), phosphorus level 2.4 (2.5-4.5mg/dL), TSH 2.01 (0.4-4.0 mIU/L). SPEP and PTHrP were unremarkable. Due to history of prior breast cancer, imaging was done and CT showed new possible RUL pancoast tumor with RUL spiculated opacity. Patient was started on IV fluids and subsequently received IV zoledronic acid due to concern for severe hypercalcemia secondary to malignancy. By day 3 of treatment, patient's calcium decreased severely, down to a corrected calcium level of 6.4 (8.6-10.2 mg/dL). It was upon further investigation and discussion with the patient that we discovered the patient had received subcutaneous denosumab for her osteoporosis three weeks prior to admission. In addition, she was taking six tums daily (total 1 month duration) for symptoms of dyspepsia secondary her hiatal hernia. The patient’s severe hypocalcemia was treated with high dose oral calcium carbonate and vitamin D along with IV calcium gluconate. Magnesium was replaced daily. Through daily replacement, patient was kept in the hospital for a total of 10 days duration before her calcium levels were deemed safe for return home. Discussion: Hypercalcemia is a common cause of hospitalization worldwide. Testing should be comprehensive and history taking should be thorough to help navigate treatment plans. Bisphosphonates are indicated for hypercalcemia of malignancy, and its use otherwise may be the cause of severe hypocalcemia if not used in the right setting. In our case, the patient’s hypocalcemia was multifactorial from prior denosumab use and then subsequent zoledronic acid use. Additional risk factors included low vitamin D counts and disruption of high amounts of over the counter tums after being admitted to the hospital. Anchoring bias also led clinicians to believe that the hypercalcemia was secondary to malignancy. Consequently, this led to a prolonged 10 day hospitalization for persistently low calcium levels. Presentation: 6/1/2024

7387 A Rare Case Of Concomitant Intrathyroidal Parathyroid Carcinoma With Osteitis Fibrosa Cystica, Masquerading As Oncocytic Thyroid Carcinoma - A Post-operative Diagnosis

Abstract Disclosure: Y. Koh: None. D.E. Chew: None. T.P. Quek: None. Introduction: Parathyroid carcinoma is a rare form of malignancy. An intrathyroidal location of parathyroid carcinoma further complicates the diagnosis as it may be mistakenly presumed to be of thyroid origin instead. We present a case report of an intrathyroidal parathyroid carcinoma which was diagnosed post-total thyroidectomy. Clinical case: A 72-year-old lady was found to have an intrathyroidal mass after presenting with unintentional weight loss and chronic constipation. Ultrasound of the neck showed a 4.0 x 2.9cm markedly hypoechoic solid mass in the mid-lower right thyroid lobe. Fine needle aspiration of the mass was suspicious for an oncocytic neoplasm. She underwent total thyroidectomy with central neck dissection for concerns of oncocytic thyroid carcinoma. Intraoperatively, a 4cm right hard intrathyroidal nodule invading into the right recurrent laryngeal nerve was observed. All 4 parathyroids were identified and preserved. Post-operatively, routine biochemistry to monitor for hypocalcemia showed hypercalcemia instead. This quickly transitioned into hypocalcemia on post-operative day 4, with biochemistry supportive of hungry bone syndrome [adjusted calcium 2.05mmol/L [normal range (NR) 2.15-2.5], phosphate 0.6mmol/L (NR 0.8-1.4), PTH 8.2pmol/L (NR 0.8-6.8), 25-OH vitamin D 18ug/L (NR 30-100)]. She was started on oral calcium carbonate, calcitriol and cholecalciferol aiming for normocalcemia. Evidence for underlying primary hyperparathyroidism were sought for, which showed osteitis fibrosa cystica, severe osteoporosis and an ossifying fibroma of the mandible, suggesting underlying hyperparathyroidism-jaw tumour-syndrome. The intra-operative histology was reported as oncocytic carcinoma with angio- and perineural invasion, presumed to be thyroid in origin. Given our suspicion of underlying primary hyperparathyroidism, we requested our pathology colleagues to perform additional immunochemical stains, which stained diffusely positive for parathyroid hormone, GATA3 but were negative for thyroglobulin, thyroid transcriptor factor-1, confirming its parathyroid origin. Her hungry bone syndrome resolved 22 weeks post-operatively. Till present (14 months post-operatively), her calcium and PTH levels remain normal and ultrasound of the neck did not reveal any evidence of recurrence. She declined genetic screening. Clinical Lesson: A high index of suspicion is required for the diagnosis of parathyroid carcinoma. In a patient who presents with constitutional symptoms and a neck mass, it is imperative to consider parathyroid disease as a differential diagnosis. A lesion with oncocytic morphology may be of parathyroid or thyroid origin, and the use of immunochemical stains can help differentiate them. Effective communication between clinicians and pathologists is essential in clinching the correct cytopathological diagnosis. Presentation: 6/3/2024

8690 Severe Hypocalcemia Following Treatment with Venetoclax for AML

Abstract Disclosure: K. Ruddiman: None. C. Price: None. Background: Venetoclax is a chemotherapeutic agent which has known side effects of tumor lysis syndrome, but few reports of isolated hypocalcemia. Clinical case: A 73 year old male with medical history pertinent for myeloproliferative and myelodysplastic disease was admitted for evaluation of failure to thrive. Workup revealed progression to acute myeloid leukemia. Following treatment with decitabine 34mg/day for 5 doses and initiation of venetoclax 100mg daily, he developed progressive, severe, symptomatic hypocalcemia with positive Trousseau and Chvostek sign. The patient was normocalcemic prior to admission with serum calcium ranging between 8.6-9.7mg/dL. Corrected calcium at admission was 8.8mg/dL. Serum calcium decreased steadily following venetoclax, requiring repletion with 3 doses of calcium chloride and gluconate 1gm IV and initiation of oral calcium carbonate 1900mg TID. At its nadir, corrected calcium was 6.1mg/dL on day 19 of treatment with venetoclax despite oral and IV repletion. Further workup showed undetectable 25 hydroxy vitamin D, PTH 62pg/mL, normal range uric acid, low phosphorus (lowest 2.2mg/dL), mild hypokalemia (lowest 3.2mg/dL), and mild hypomagnesemia of 1.8mg/dL. GFR was >90mL/min. Hypocalcemia improved after 3 infusions of calcium gluconate 10gm IV in 1 L normal saline to 7.2mg/dL. Oral repletion with calcium carbonate was transitioned to calcium citrate due to concomitant PPI use. PO calcium citrate titrated to 2850 mg TID to target corrected calcium 7.5 - 8.5 and limit further need for diuresis following calcium gluconate infusions. Ergocalciferol 50,000 IU was given thrice weekly in addition to daily cholecalciferol 5,000 IU with improvement in 25 hydroxy vitamin D to 17ng/mL. This patient was suspected to have multifactorial etiology for hypocalcemia, secondary to undetectable 25 hydroxy vitamin D as well as diuresis with furosemide during the admission, but the most strongly attributed factor was initiation of venetoclax prior to development of progressive hypocalcemia. FDA prescribing information reports hypocalcemia as a side effect of venetoclax when used in treatment for CML, but in phase 2 and 3 studies of venetoclax used alone and in combination with low dose cytarabine to treat AML, no significant episodes of hypocalcemia were reported. Tumor lysis syndrome (TLS) is a known adverse effect of venetoclax in which hypocalcemia is an expected feature, however, this patient did not have laboratory to support this diagnosis. His other electrolyte deficiencies were mild and transient. Conclusion: While electrolyte abnormalities associated with TLS are an expected side effect of venetoclax, isolated severe hypocalcemia is a rarely reported side effect. Calcium should be closely monitored during treatment. Presentation: 6/1/2024

Evaluation of efficacy of oral calcium phosphate as an adjunct to standard-of-care regular phototherapy in cases of neonatal jaundice: a hospital-based double-blind, randomised, placebo-controlled trial

ObjectiveNeonatal jaundice is the most common cause of neonatal morbidity and rehospitalisation in the first week of life, affecting approximately 60% of term and 80% of preterm neonates, with 10%...

Efficacy of oral calcium carbonate and vitamin D3 granules for the management of pains in growing limbs in children

Efficacy of oral calcium carbonate and vitamin D3 granules for the management of pains in growing limbs in children

The use of prophylactic infusion of calcium gluconate compared to placebo in reducing the rate of early hypocalcaemia after total thyroidectomy: a double-blinded, randomized controlled trial.

Hypocalcaemia as a common complication after total thyroidectomy [23-40% in University Malaya Medical Centre (UMMC)] and could result in prolonged hospital stay. We compared the early hypocalcaemia rate between prophylactic infusion of calcium and placebo among post total thyroidectomy patients and to establish whether prophylactic intravenous infusion of calcium reduces the rate of hypocalcaemia in the first 48 hours after surgery. Patients undergoing elective total thyroidectomy in UMMC between June 2020-May 2022, were recruited and randomized to receive placebo or prophylactic calcium infusion. Both groups of patients received same dosages of post-operative prophylactic vitamin D and oral calcium. Early hypocalcaemia (within 48 hours) rate after surgery was the primary outcome and duration of hospital stay was the secondary outcome. The data collected was analysed using per-protocol analysis. Thirty-four patients were randomized equally (1:1) into both arms. No differences in the early hypocalcaemia rate between the intervention and placebo arms (0% vs. 5.8%, P>0.05). The median serum calcium levels were comparable between the intervention and placebo arms at 6 hours (2.33 vs. 2.37 mmol/L, P=0.59) and 48 hours (2.26 vs. 2.23 mmol/L, P=0.19) post-surgery. However, the median serum calcium level at 24 hours was statistically significantly higher in the intervention arm than the placebo arm (2.31 vs. 2.22 mmol/L, P=0.02). Similar duration of hospital stay between the both groups (2 vs. 2 days, P=0.81). Routine prophylactic calcium infusion with oral calcium and vitamin D does not diminish the rate of early symptomatic hypocalcaemia post total thyroidectomy in a low-risk group. However, its usefulness needs to be further assessed in a large scale randomized controlled trial (RCT) incorporating more bigger population. Registered on ClinicalTrials.gov (NCT04491357).

Population pharmacokinetics of oral fosfomycin calcium in healthy women.

Fosfomycin is an antibiotic extensively used to treat uncomplicated urinary tract infections in women, and it is available in different salts and formulations. The European Medicines Agency (EMA) recommends further studies to characterize the pharmacokinetics of fosfomycin calcium for oral administration and to justify its dosage recommendation. A population pharmacokinetic model of fosfomycin calcium was developed after oral administration to healthy women. A clinical trial (a randomized, open-label, bioavailability study of single and multiple doses of 1000 mg capsules, single dose of 500 mg capsule and single dose of 250 mg/5 mL suspension of oral fosfomycin calcium under fasted conditions in healthy women volunteers, Code: PD7522.22, EudraCT: 2020-001664-28) was carried out at the Clinical Trial Unit, Araba University Hospital (Vitoria-Gasteiz, Spain). Twenty-four healthy women were included in the study, and plasma samples were collected at different times over a period of 24 h. The concentration-time data of fosfomycin in plasma were modelled by a population approach using a nonlinear mixed-effects modelling implemented by NONMEM 7.4 (ICON Clinical Research LLC, North Wales, PA, USA). The pharmacokinetics of fosfomycin was best described by a two-compartment model. Creatinine clearance and body weight were identified as covariates for fosfomycin clearance and volume of distribution, respectively. This study provides relevant information on the pharmacokinetic profile of fosfomycin in women after oral administration as calcium salt. This population model may be very useful for establishing dosage recommendations of fosfomycin calcium to treat urinary tract infections in women.

Phytate Effects on Incomplete Distal Renal Tubular Acidosis.

Background: Adults who have incomplete distal renal tubular acidosis (dRTA) may present with recurrent urolithiasis due to metabolic acidosis, leading to bone resorption, which in turn causes hypercalciuria and urine alkalinization (pH > 6.0). Oral potassium citrate is the most commonly used treatment for dRTA, but some patients cannot tolerate this treatment. The objective of this single-arm study was to evaluate the effect of phytate, an inhibitor of bone resorption, on calciuria of patients with incomplete dRTA. Methods: The calciuria levels of 16 patients who had incomplete dRTA with urolithiasis and could not tolerate potassium citrate treatment were recorded before (baseline) and after 6 months of treatment with oral calcium magnesium phytate (380 mg every 12 h). There were no dietary modifications or other treatments. Results: The baseline calciuria was 317 ± 81 mg/24 h and the level after 6 months was 221 ± 38 mg/24 h (p < 0.005). Conclusions: Our results suggest that calcium magnesium phytate should be considered as an alternative or adjunctive treatment for hypercalciuria in patients with incomplete dRTA.

Effectiveness of oral calcium to prevent citrate-related toxicity during peripheral blood hematopoietic stem cell collection – An experience from a tertiary care center

Abstract: BACKGROUND: Apheresis procedures use citrate as an anticoagulant to ensure the fluidity of extracorporeal blood. Citrate-related toxicities are common adverse effects in peripheral blood stem cell (PBSC) collections as they are lengthy procedures resulting in prolonged citrate exposure. Intravenous (IV) calcium administration during therapeutic apheresis procedures is commonly used to reduce the citrate-related toxicity in adults and pediatric population. Very few literature on the use of oral calcium for the prevention of citrate toxicity during PBSC collection are present. OBJECTIVE: The objective of this study was to evaluate the effect of prophylactic oral calcium in reducing citrate-related toxicities during PBSC collections. MATERIALS AND METHODS: A prospective cross-sectional study was carried out at a tertiary care hospital of Southern India. All participants received calcium carbonate – 1 g before and at each 100 ml of collection. Preprocedure, interim, and postprocedure serum calcium were measured. All procedures were done using Spectra Optia. The ACD (acid-citrate-dextrose) rate were between 1:8 to 1:14 and were adjusted for inlet draw rate. The total blood volume processed between 2.5 to 3 based on body weight. Reduction in calcium levels and adverse reactions due to hypocalcemia were observed. Data were analyzed using SPSS 23 software. RESULTS: The majority of the procedures were undisturbed and tolerable to oral calcium. A total of 97.3% of the study subjects did not experience any symptoms of hypocalcemia. Only 2.7% (One autologous and one allogenic donor) had symptoms attributable to hypocalcemia though they had preprocedure calcium &gt;9 mg/dl. Pre- and postprocedure calcium were compared using a paired t-test which was statistically significant. CONCLUSION: Prophylactic oral calcium in PBSC collection is an effective and easy way to the prevention of citrate-related adverse effects without affecting technical performance and product efficacy.

Daily versus fortnightly oral vitamin D3 in treatment of symptomatic vitamin D deficiency in children aged 1-10 years: An open labelled randomized controlled trial.

Compare the efficacy and safety of daily versus fortnightly oral vitamin D3 in treating symptomatic vitamin D deficiency in children aged 1-10 years. Open labelled randomized controlled trial. Eighty children with symptomatic vitamin D deficiency were randomized into group daily (D) and group bolus (B) [40 in each group] to receive oral vitamin D3, 4000 IU daily or 60,000 IU fortnightly for 12 weeks respectively. Both groups received daily oral calcium of 500 mg/day. Serum calcium (Ca), phosphate (P), alkaline phosphatase (ALP), 25-hydroxy cholecalciferol (25(OH)D), parathyroid hormone (PTH) levels, urine calcium: creatinine ratio and radiological score were assessed at baseline, 4 weeks and 12 weeks. At the end of 12 weeks, 74 children were available for evaluation of the efficacy and safety of both regimens. Both regimens led to a significant increase in Ca and P levels and a fall in ALP and PTH levels from baseline to 4 and 12 weeks of therapy, with no intergroup difference. At 4- and 12-week assessments, all children in both treatment arms achieved 25(OH)D level in sufficiency range,with no significant difference in their geometric mean. Both regimens were associated with asymptomatic transient hypercalcemia [group D-51.4% vs. group B-34.3%; p-0.14] and hypercalciuria (5.7%) in group D that resolved spontaneously on follow-up. Daily and fortnightly oral vitamin D3 in similar cumulative doses are efficacious for treating symptomatic vitamin D deficiency in children (1-10 years). Treated children should be monitored for serum 25(OH)D, Ca and urinary calcium creatinine ratio.

Endovascular Embolization and Atorvastatin Therapy for Recurrent Chronic Subdural Hematoma.

Recurrent chronic subdural hematoma poses a significant clinical challenge. While craniotomy effectively removes the hematoma membrane, it is an invasive procedure associated with significant trauma. Recently, endovascular embolization of the middle meningeal artery has emerged as a promising minimally invasive alternative, demonstrating efficacy and a low recurrence rate in treating chronic subdural hematoma. Furthermore, postoperative administration of oral atorvastatin calcium may enhance hematoma absorption, thereby improving patient outcomes during the early recovery phase.

Long-term kidney outcomes in patients with permanent hypoparathyroidism after total thyroidectomy for benign disease: A population-based study

BackgroundPermanent hypoparathyroidism is a significant complication after total thyroidectomy. This study aimed to evaluate the long-term impact of postoperative permanent hypoparathyroidism on kidney outcomes. MethodsData of patients undergoing total thyroidectomy from 1999 to 2014 were retrieved. The estimated glomerular filtration rate was determined from serum creatinine results. Permanent hypoparathyroidism was defined as requiring oral calcium and vitamin D supplements postoperatively for at least 6 months. The primary outcome was a sustained decline in the estimated glomerular filtration rate from baseline by ≥50%. Secondary outcomes were end-stage kidney disease (a composite of sustained estimated glomerular filtration rate <15 mL/min/1.73 m2, need for dialysis, and kidney transplantation) and rate of estimated glomerular filtration rate decline. Patients with and without permanent hypoparathyroidism were compared. Multivariable Cox regression analysis was performed to identify independent risk factors for sustained estimated glomerular filtration rate decline by ≥50%. ResultsIn total, 3,245 patients were eligible for analysis; 418 patients (12.9%) had permanent hypoparathyroidism. Upon median follow-up of 11.6 years, more patients with permanent hypoparathyroidism had a sustained decline in estimated glomerular filtration rate from baseline by ≥50% compared to those without (15.6% vs 6.9%, P < .001). Similar findings were obtained on Kaplan–Meier analysis (P < .001). Permanent hypoparathyroidism was an independent risk factor for sustained estimated glomerular filtration rate decline by ≥50% (adjusted hazard ratio 2.77, P < .001). Other risk factors included age, preoperative estimated glomerular filtration rate <60 mL/min/1.73m2, and diabetes mellitus. Patients with permanent hypoparathyroidism had a more rapid estimated glomerular filtration rate decline (–1.60 vs –0.70 mL/min/1.73 m2/year, difference –0.91 mL/min/1.73m2/year, P < .001). ConclusionPatients with postsurgical permanent hypoparathyroidism were at greater risk of renal impairment. Further research is warranted to improve the identification and preservation of parathyroid glands during thyroidectomy to minimize patient morbidity.

Efficacy of intraperitoneal calcium for hungry bone syndrome following parathyroidectomy: A case report

A man with hyperparathyroidism secondary to kidney failure on peritoneal dialysis underwent a parathyroidectomy with half-gland reimplantation complicated by severe hungry bone syndrome resulting in severe hypocalcaemia, hypotension and QT prolongation on ECG. He was initially managed with oral calcium and intravenous (IV) calcium chloride. Despite standard supportive treatment, attempts to wean IV therapy were unsuccessful. We report the novel use of intraperitoneal calcium to facilitate the weaning of IV calcium and discharge from hospital. A subsequent peritoneal membrane adequacy study did not demonstrate loss of peritoneal membrane adequacy.

Associations between caries experience and oral fluid mineral content among patients in Arctic Russia: a study in the Nenets Autonomous Area

The relationship between the intensity of caries and mineral composition of oral fluid in adolescents in the Arctic zone of Russia was investigated using the example of the Nenets Autonomous Okrug. This study included 171 healthy boys and girls aged 15–17 years. The intensity of caries was assessed using the index caries + fillings + extracted permanent teeth and its components. Unstimulated oral fluid was collected into sterile tubes. Sodium, potassium, magnesium, phosphorus, and total and ionized calcium content and pH were examined in the oral fluid. Considering the pronounced right-sided asymmetry of the components of the index caries + fillings + extracted permanent teeth, calculations were performed using Poisson regression models. Results were presented as relative risks with 95% confidence intervals and as tests for trend. The prevalence of caries in the sample population did not differ by sex and was 87.8% for boys and 93.3% for girls (p = 0.221). On average, 1.8 carious teeth per person were detected in boys and 1.4 in girls (p = 0.021). No differences were found in the number of filled (p = 0.167) and extracted (p = 0.981) teeth. Additionally, the total sodium content in oral fluid was directly proportional to the index of caries + fillings + extracted permanent teeth (p = 0.040) and number of carious teeth (p 0.001). The total oral fluid calcium was significantly associated with both the caries + fillings + extracted permanent teeth index (p = 0.019) and number of filled teeth (p = 0.001). Inverse relationships were found between the number of filled teeth and magnesium (p = 0.028) and phosphorus (p = 0.037) content. The study showed the presence of statistically significant relationships between the mineral composition of oral fluid and index of caries + fillings + extracted permanent teeth and its components. Thus, unfavorable living conditions in the Arctic zone provide additional risk factors for the occurrence of dental diseases. The results of the study, if confirmed in other populations, can be used to develop models for predicting the development and progression of caries in adolescents of the Far North. Further studies of the mineral composition of oral fluid are required to obtain more complete clinical and laboratory data, considering confounding factors such as nutrition and type of filling material.

Severe hypocalcemia in the emergency department: a retrospective cohort study of prevalence, etiology, treatment and outcome.

The aim of this study was to evaluate the prevalence of severe hypocalcemia in patients attending the emergency department. Symptoms, causes, treatment, and outcome of severe hypocalcemia as well as course of calcium concentrations were assessed. This retrospective case series included all adult patients with measurements of serum calcium concentrations presenting to the emergency department of the Bürgerspital Solothurn between January 01 in 2017 and December 31 in 2020. Medical record reviews were performed of all patients with severe hypocalcemia, defined by a serum calcium concentration < 1.9mmol/L, to assess clinical presentation and management. 1265 (3.95%) patients had a serum calcium concentration of < 2.1mmol/L of which 139 (11%) had severe hypocalcemia of < 1.9mmol/L. 113 patients had at least one measurement of albumin. Of these, 43 (3.4%) had an albumin-corrected serum calcium < 1.9mmol/L defining true, severe hypocalcemia. Hypocalcemia was identified and documented in 35% of all cases. The mean serum calcium concentration was 1.74 ± 0.14mmol/L. Calcium concentrations in malignancy-related hypocalcemia were similar to non-malignancy-related hypocalcemia. The main symptoms attributed to hypocalcemia were cardiac and neurologic. 12% of patients with severe hypocalcemia received intravenous and 23% oral calcium replacement. Active malignancy was the main cause of severe hypocalcemia in 28%, while in most cases, the main cause remained unclear. 41.9% of severely hypocalcemic patients reattended the emergency department for another episode of hypocalcemia within 1 year. Hypocalcemia is common in patients attending the emergency department, however, appears to be neglected frequently. The disorder is often a manifestation of severe disease, triggered by multiple causes. Calcium replacement was administered in less than half of the patients with severe hypocalcemia in this study. Due to frequent readmissions to the emergency department and a high mortality, increased awareness of the disorder and careful follow-up are desirable.