Oral Calcium Research Articles

SAT222 More Than Skin Deep: A Case Of Psoriasis Associated With Hypoparathyroidism

Abstract Disclosure: G. Sheth: None. M. Alsayed: None. Introduction: Primary hypoparathyroidism is commonly encountered post-surgically, however isolated cases are rarely seen without clear risk factors. Severely low calcium levels have been shown to correlate with flare ups and worsening of psoriasis. Treatment of hypocalcemia has been thought to improve and prevent the progression of this skin rash. This case highlights an interesting presentation of psoriasis in which the severity was likely related to hypocalcemia. Clinical Case: 25 y/o F with no prior past medical history presented to the emergency room with diffusely worsening skin rash and fever. She had bilateral erythematous plaques on her anterior legs for a few months that was progressively worsening. A few days prior, she started noticing erythema and scaling on her upper body and back. Her on arrival labs were remarkable for a calcium level of 4.5 mg/dL (8.8-10.4). Patient declined any symptoms at the time but did state she had noticed tingling in her face and hand/foot cramps occurring on and off over the last 6 months. Her EKG was remarkable for a mildly prolonged QT interval. She was treated with IV calcium gluconate 4 grams without improvement in her calcium. She ultimately was placed on a calcium gluconate drip and oral calcium carbonate 2 grams every 2 hours. Meanwhile, her work up revealed a PTH of <6 pg/mL, phosphate of 7 mg/dL, magnesium of 1.7 mg/dL, and vitamin D of 23 ng/mL. To elucidate the cause of her newly diagnosed primary hypoparathyroidism, iron studies were ordered to rule out hemochromatosis and ceruloplasmin to rule out Wilson’s disease, both of which returned negative. She had no history of radiation therapy or prior blood transfusions. She denied any family history of calcium disorders. Therefore, PTH antibody testing was sent to a send out lab and is currently pending. Patient was ultimately weaned off of the calcium drip with low normal calcium values around 7.5-8.5 mg/dL. She was placed on calcium carbonate 2 grams every 6 hours with plans for close outpatient labs and follow up. She was seen by dermatology in the hospital and was diagnosed with erythrodermic psoriasis. She was given an IL-17 inhibitor, Taltz, with significant improvement in her rash over her 2 day hospital stay. Conclusions: This case brings to light the importance of a thorough investigation of primary hypoparathyroidism and to recognize the rare genetic or autoimmune etiology as a possibility. Additionally, this case identifies the association of psoriasis with hypocalcemia. Studies have recognized a correlation of severity of psoriasis in patients with low calcium as was seen in this patient. Moreover, treatment with calcium supplementation may have a role in improving skin manifestations. Presentation: Saturday, June 17, 2023

OR23-04 Treatment Of Chronic Hypoparathyroidism With Eneboparatide (AZP-3601), A Novel PTH 1 Receptor Agonist: Results From A Phase 2 Trial

Abstract Disclosure: P. Kamenicky: Consulting Fee; Self; consultant. I. Takacs: Consulting Fee; Self; consultant. E. Mezosi: None. A. Soto: None. L. Figueres: None. S. Lemoine: None. F. Borson-Chazot: None. I. Capel: None. M.A. Galvez moreno: None. M. Ovize: Employee; Self; employee. T. OuldRouis: Employee; Self; employee. S. allas: Employee; Self; employee. M. Sumeray: Employee; Self; employee. M. Mannstadt: Consulting Fee; Self; consultant. Background: Conventional therapy for chronic hypoparathyroidism (cHP) is often unable to maintain normal serum calcium levels throughout the day, control symptoms, or prevent hypercalciuria and long-term renal complications. Eneboparatide is a novel 36-amino-acid peptide designed to activate the R0 conformation of the PTH 1 receptor, which produces a prolonged calcemic response despite a short half-life. We previously presented data from the first cohort (n=10) and report here the results of the second cohort of cHP patients enrolled in our phase 2 multi-center study. Methods: Before starting Eneboparatide treatment, all patients received oral calcium (Ca) and active vitamin D (vitD) adjusted to achieve albumin-adjusted serum Ca (sCa) levels within the target range of 7.8 mg/dL to 9.0 mg/dL. Starting Day 1, patients received a once-daily sc. injection of Eneboparatide, while simultaneously reducing their Ca and active vitD intake. The initial dose of 10 µg/day(d) could be titrated up to 80 µg/d. sCa, urinary excretion of calcium (24h-uCa) and serum bone biomarkers (s-CTX and P1NP) were assessed. DXA was performed at baseline and at D84. Results: Fourteen patients (10 women), with a mean (SD) age of 52 (11) years,79% post-surgical, were taking an average of 0.58 (0.25) µg/d calcitriol and 1786 (1800) mg/d oral Ca at baseline. Eneboparatide was well tolerated with no serious adverse event. At 3 months, over 90% of patients were off active vitD and oral Ca (≤500mg/d). In 13 of 14 patients, Eneboparatide was up-titrated early and the dose averaged 43(18) µg/d at D84 while sCa was 8.32 (0.72) mg/dL. Six of 14 patients displayed osteopenia or osteoporosis at least on one site at baseline. BMD, T and Z scores did not significantly change after 3 months. In 7 patients with hypercalciuria at baseline, mean 24h-uCa decreased by 49% at D14 and was normal in 6 of 7 patients at D84. Mean s-CTX and P1NP levels increased progressively from 217 (113) and 38 (13) at baseline to 477 (252) ng/L and 65 (31) ng/L at D84, respectively (all within the normal range). Conclusion: These results demonstrate that Eneboparatide treatment was safe and allowed independence from conventional therapy while maintaining mean sCa within the target range. Eneboparatide had a strong effect on renal reabsorption of calcium but limited effects on bone turnover. These data and the results from our first cohort support the advancement of Eneboparatide to Phase 3 and selection of 20 µg/d as a starting dose. Presentation: Saturday, June 17, 2023

SAT194 A Rare Case Of Untreated Primary Hyperparathyroidism With Extremely High PTH And Lytic Bone Lesions

Abstract Disclosure: M. Shah: None. K. Akinola: None. M. Bollineni: None. S.A. Milan: None. S. Challagulla: None. Background: Primary hyperparathyroidism (PHPT) typically presents with PTH levels two times above the upper limit of normal. Given the increase in routine calcium measurements, PHPT is usually diagnosed and treated early and skeletal complications are not frequent at presentation. We present a case of PHPT with severely elevated PTH levels and bone lesions mimicking metastatic disease. Clinical Case: A 30-year-old male with a history of untreated primary hyperparathyroidism presented with severe chest wall pain and abdominal pain. Initial laboratory tests revealed a calcium level of 13.3 mg/dL (normal 8.6 to 10.5 mg/dL), alkaline phosphatase (AP) of 747 IU/L (normal 24 to 130 IU/L), and PTH of 2485 pg/mL (normal 9-77 pg/mL). The patient was diagnosed with primary hyperparathyroidism years before this presentation, but was lost to follow up due to lack of insurance. His PTH was first noted to be elevated in 2013 at 266 pg/mL. CT of the chest, abdomen, pelvis showed a 2.8 x 3.0 x 3.3 cm anterior mediastinal mass and diffuse mixed lytic and sclerotic bone lesions consistent with metastatic disease. The patient underwent further imaging with CT 4D parathyroid which revealed a 1.1 cm left inferior thyroid nodule and an anterior mediastinal mass of unclear etiology. Given the high concern for malignancy, a biopsy of the mediastinal mass was performed and returned as hypercellular parathyroid tissue with no atypia. Bone biopsies of the sclerotic lesions of the iliac crest were consistent with osseous tissue with prominent bone remodeling and fibrous tissue; no neoplasm was seen. He was treated with IV fluids and zoledronic acid during this work up which only temporarily improved his high calcium levels. He was then placed on cinacalcet prior to surgery. He ultimately underwent resection of the anterior mediastinal mass and left inferior parathyroid gland via a cervical approach. The patient’s preoperative PTH level was 3455 pg/mL and decreased to 209 pg/mL immediately after resection. Resection of the other parathyroid glands was not done due to the high risk of postoperative hypocalcemia. Pathology of both lesions returned as intrathymic parathyroid adenoma with focal fibrosis. Postoperatively, the patient developed symptomatic hypocalcemia as low as 6.4 mg/dL. He required IV and oral calcium for approximately 3 weeks postoperatively, consistent with hungry bone syndrome. He was discharged on an oral regimen of calcium supplementation. Discussion: Long standing untreated PHPT can present with severely elevated PTH levels and skeletal manifestations commonly mistaken for metastatic lesions. As in this case, parathyroidectomy was the only effective treatment. However, it can be complicated by hungry bone syndrome, especially in a patient with significant bone remodeling as evidenced by high AP and lytic bone lesions. Presentation: Saturday, June 17, 2023

FRI676 Undiagnosed Celiac Disease: A Silent Offender Of Male Osteoporosis

Abstract Disclosure: I.E. Hernandez Castro: None. A.M. Ludeña De Freitas: None. M.S. Martinez Aguiar: None. G. Irizarry: None. Osteoporosis affects both genders, with higher incidence in women after menopause. In men, it's often overlooked, leading to significant morbidity and mortality, if not diagnosed and treated early. Hip fractures in men have higher mortality than in women.Celiac disease is an immune reaction to gluten, causing nutrient malabsorption and inflammation-mediated injury to the small intestine, in genetically predisposed patients. It can lead to severe osteoporosis, especially if the disease remains undiagnosed for a long time.A 64-year-old male patient who does not follow any regular medical care, was transported to the emergency department due to dizziness, blurry vision, and left arm numbness for one day evolution. Physical examination was unremarkable, no signs of tetany noted. Laboratories showed corrected calcium 4.4mg/dL, sodium 130 mEq/L, potassium 2.5 mmol/L, phosphorus 4.41. PTH intact level 465.3 pg/mL, and ionized calcium level 5.2 mg/dL, measured after supplementation. Further studies revealed 24 hours urine calcium, sodium, and creatinine 52mg/day, 107mmol/day, and 1118mg/day, respectively. DEXA scan reported low bone mineral density (BMD) at AP spine L1-L4 of 0.860 with T-score of -3.0, BMD at femur neck of 0.579 with T-score of -3.8, and BMD at femur total of 0.622 with T-score of -3.6. The latter findings indicated severe osteoporosis, a rare and unexpected finding in a male patient younger than 70 years of age. Tissue transglutaminase IgA was positive with value of 611 u/mL and serum IgA 242mg/dL. Pathology report from tissue of the duodenum reported small bowel mucosa with focal gastric foveolar metaplasia and acute duodenitis, negative for dysplasia or malignancy. Immunohistochemical study for Helicobacter Pylori was positive and biopsy findings taken from the stomach, antrum, and body revealed gastric mucosa with moderate chronic active inflammation without intestinal metaplasia. Patient was diagnosed with secondary hyperparathyroidism due to celiac disease, a well-known studied risk factor for osteoporosis. Celiac disease caused malabsorption of nutrients and electrolytes, including calcium, which is essential for bone health. A gluten-free diet and supplements of oral calcium and vitamin D were started. Antiresorptive medications for osteoporosis were not started at this moment due to hypocalcemia and vitamin D deficiency. This case highlights the importance of considering Celiac disease as an uncommon but important etiology of osteoporosis. This malabsorptive condition should always be included among the differential diagnosis in male patients presenting with unexplained electrolyte imbalance and secondary hyperparathyroidism. Approximately 20% of diagnosed osteoporosis cases are men, and early diagnosis and treatment are crucial in preventing associated morbidity and mortality, especially if complicated by a hip fracture. Presentation: Friday, June 16, 2023

SAT225 An Unexpected Case Of Hypocalcemia

Abstract Disclosure: M. Nogueira Cordeiro: None. Calcitriol and oral calcium supplementation remains the standard of care in the management of hypoparathyroidism. The targeted serum calcium level for this condition is quite narrow, typically at the lower end of the reference range to avoid hypercalciuria, but above the calcium level from which a patient may develop symptoms. Pharmacokinetic and pharmacodynamic properties vary among different over-the-counter (OTC) calcium salt preparations, therefore it is important for the provider and patient to understand the differences in calcium formulations to meet therapy goals. We present a case of symptomatic hypocalcemia related to a patient unknowingly switching from calcium carbonate to tricalcium phosphate supplementation. A 71 year-old woman with a history of thyroid cancer status post total thyroidectomy complicated by permanent hypoparathyroidism, CKD stage III, nephrolithiasis and hypercalciuria presented for a follow up visit complaining of perioral numbness for approximately one month. Laboratory evaluation revealed hypocalcemia, hyperphosphatemia, hypomagnesemia and a normal 25-OH-vitamin D level: Ca 7.3 mg/dL (8.5-10.5 mg/dL), Phos 5.6 mg/dL (2.5-4.5 mg/dL), Mg 1.1 mg/dL (1.7-2.8 mg/dL), 25-OH-vit D 45 ng/mL (30-60 ng/mL). Prior to this, her serum calcium had been well controlled, avoiding symptomatic hypocalcemia and hypercalciuria, for years. She had remained on her usual dose of calcitriol, but had changed her calcium supplement to 500 mg of tricalcium phosphate three times per day from calcium carbonate 650 mg three times a day. Rather than adjust her calcitriol, she was recommended to stop tricalcium phosphate and restart the previous regimen of calcium carbonate; serum calcium and phosphorus improved within 72 hours (Ca 7.7 mg/dL, Phos 3.8 mg/dL) and two weeks later her calcium level was back at goal (8.2 mg/dL), phosphate level had normalized (4.5 mg/dL) and she was no longer symptomatic. Tricalcium phosphate is not generally recommended for patients with hypoparathyroidism given they are less available and not as well tested. Previous studies have shown conflicting outcomes for serum calcium elevation after an oral load of tricalcium phosphate when compared with calcium carbonate. Elderly individuals might also experience an elevation in phosphate levels after a tricalcium phosphate load. Additionally, the elemental calcium in OTC tricalcium formulations is often less than what is available in similar appearing calcium carbonate or citrate supplements. Although calcium carbonate and citrate are the most commonly prescribed calcium supplements, other preparations are available OTC and it is difficult to tell these apart. Given the narrow goal of serum calcium for patients with hypoparathyroidism, providers should confirm the calcium formulation at each visit and counsel the patient to notify them if any changes are made in their oral calcium supplementation. Presentation: Saturday, June 17, 2023

SAT229 Symptomatic Hypocalcemia In The Setting Of Crohn’s Disease With Severe Hypomagnesemia

Abstract Disclosure: K. Cuan: None. T. Reisman: None. Introduction: People with Crohn’s Disease (CD) are at risk for various nutritional deficiencies due to decreased oral intake, malabsorption, and increased intestinal losses. CD often causes a negative calcium balance, which does not usually cause hypocalcemia because the bones serve as a reservoir for calcium. However, symptomatic hypocalcemia may occur if a concurrent severe hypomagnesemic state is present. The factors resulting in hypocalcemia in patients with magnesium deficiency are impaired PTH secretion, PTH resistance, and vitamin D deficiency. Clinical Case: A 33-year-old man with CD and rheumatoid arthritis presented following a seizure with additional symptoms of hand cramping and facial twitching. He had previously undergone three small bowel resections and had a history of hypocalcemia due to malabsorption. Although this patient had previously been admitted due to a hypocalcemic seizure, he did not start oral calcium supplements at that time. No issues with magnesium were identified previously. On this encounter, he was found to have a corrected calcium (cCa) of 5.3 mg/dL, undetectably low magnesium at <0.7 mg/dL, normal phosphorus, 25-hydroxyvitamin D at 3.5 ng/mL, and an elevated intact PTH (iPTH) at 169 pg/mL. Aggressive intravenous calcium and magnesium repletion improved cCa to 7.4 mg/dL and magnesium to 2 mg/dL with no further seizure activity. He was discharged on calcium carbonate, calcitriol, and ergocalciferol. A month later, he presented to our endocrinology clinic asymptomatic but with a cCa of 6 mg/dL and magnesium at <0.7 mg/dL. Further biochemical workup revealed normal phosphorus, 25-hydroxyvitamin D at 7.9 ng/mL, and an inappropriately normal iPTH at 49 pg/mL. He was readmitted to the hospital where intravenous repletion improved cCa to 8.1 mg/dL and magnesium to 1.9 mg/dL. His recurrent hypomagnesemia was attributed to malabsorption. An increased dose of calcitriol and oral magnesium were added to his discharge medication regimen, in addition to his ergocalciferol and calcium carbonate. Three days later, he had a cCa level of 7.1 mg/dL as an outpatient. Conclusion: Patients with CD often have nutrient deficiencies, especially if they have had surgical resection within the intestinal tract. Our patient initially developed hypocalcemia from malabsorption, which was then exacerbated by the severely hypomagnesemic state. During his initial hospital encounter, the elevated iPTH level indicated PTH resistance. On his second encounter, the normal iPTH level suggested hypoparathyroidism. Given the relationship between magnesium and calcium homeostasis, addressing the hypomagnesemia eventually aided in achieving stabilization of serum calcium levels. Thus, in patients who are at risk for malabsorption and have recurrent symptomatic hypocalcemia, it is prudent to check magnesium levels as it can affect long term management of hypocalcemia. Presentation: Saturday, June 17, 2023

SAT253 A Rare Case Of Osteolytic Hypercalcemia Of Malignancy In Acute Myeloid Leukemia

Abstract Disclosure: S. Elahi: None. S. Baim: None. Introduction: Acute myeloid leukemia (AML) and other leukemias do not commonly induce hypercalcemia of malignancy (HCM). Limited previous reports of AML-related HCM have largely attributed cases to inflammatory-cytokine-mediated osteoclast activation, with rare reports of calcitriol-mediated HCM and ectopic parathyroid hormone (PTH) production. We describe an unusual case of AML-induced HCM caused by direct leukemic bone invasion, which responded to bisphosphonate therapy. Case Presentation: A 59-year-old female presented with spontaneous bruising and severe leukocytosis concerning for AML. The diagnosis was confirmed by flow cytometry and bone marrow biopsy. Imaging did not reveal any gross destructive bone lesions, but showed soft tissue nodules in the lumbar region which biopsy revealed to be myeloid sarcoma. Prior to initiation of chemotherapy, the patient developed severe hypercalcemia that was treated with aggressive intravenous hydration and zoledronic acid. Intrathecal chemotherapy and high-dose glucocorticoid therapy were initiated thereafter with normalization of serum calcium levels. PTH levels were suppressed. Calcitriol and PTHrP were below normal and undetectable, respectively. Bone turnover markers (C-telopeptide and bone-specific alkaline phosphatase) were significantly elevated prior to administration of zoledronic acid and normalized post-therapy. Calcium levels did not rebound after several interruptions in chemotherapy. Bone marrow biopsy showed focal areas of erosion in trabecular bone consistent with diffuse microscopic osteolytic disease. The patient developed bisphosphonate-induced hypocalcemia following treatment with zoledronic acid, which normalized with treatment with oral calcium carbonate. Discussion: Hypercalcemia of malignancy is a very unusual consequence of AML. No currently-published reports of this phenomenon have described biopsy-proven diffuse microscopic bone erosion associated with AML. We attribute our patient’s severe HCM to large-scale focal bone erosion by AML, independent of and/or associated with concurrent bone resorption mediated by inflammatory cytokines. A single dose of zoledronic acid, a potent suppressor of bone remodeling, achieved long term control of calcium for our patient despite interruption of chemotherapy. Bisphosphonate therapy should be considered an early treatment of HCM in patients with AML due to several potential mechanisms that result in direct calcium release from the skeleton. Presentation: Saturday, June 17, 2023

The impact of HCV eradication using interferon-free direct acting antivirals on bone-mineral, anemia parameters and peripheral insulin resistance in hepatitis c-infected Egyptian hemodialysis cohort

BackgroundHepatitis C virus (HCV) infection is linked to a higher mortality rate in hemodialysis (HD) patients. We aimed to see if HCV eradication using interferon-free direct acting antivirals (DAAs) can affect bone-mineral and anemia biochemical parameters such as serum calcium (Ca++), phosphorus (PO4+), parathormone (PTH), fibroblast growth factor 23 (FGF23), hemoglobin (HB), and ferritin in HD patients and also peripheral insulin resistance by monitoring serum fasting insulin and HOMA insulin resistance (HOMA-IR).MethodsThree hundred and thirty-four adults on regular HD with positive HCV genotype 4 (191 male and 143 female) were included; 157 of them had seroconversion during HD. All were hepatitis B virus (HBV) negative and received treatment with DAAs. All cases were examined for body mass index (BMI), HB, ferritin level, transferrin saturation (TSAT), Ca++, PO4+, PTH, FGF23, serum albumin, alanine transaminase (ALT), fasting insulin level, and HOMA-IR at the beginning and then were measured after 6 and 12 months from a sustained virological response (SVR).ResultsAfter 6 and 12 months from SVR, there was a significant increase in serum Ca despite no change in oral calcium dose requirement over that period (p = 0001), a significant increase in HB, serum iron (p = 0001), and a significant reduction in serum ferritin, PO4, PTH, and FGF23 (p = 0001). Both fasting insulin level and HOMA-IR were statistically significantly dropped.ConclusionHCV eradication with interferon-free DAAs showed a statistically significant impact on hemodialysis patients regarding hemoglobin, ferritin level, bone-mineral parameters, and improvement in peripheral insulin resistance.

P01 An unusual case of pregnancy associated osteoporosis presenting with bilateral neck of femur fractures

P01 An unusual case of pregnancy associated osteoporosis presenting with bilateral neck of femur fractures

Perfil de seguridad de nirmatrelvir-ritonavir: evidencia de eventos adversos por interacciones farmacológicas

ObjectiveThe aim of the study was to evaluate the safety profile of nirmatrelvir-ritonavir (NMV-r) in real clinical practice and to analyze the clinical relevance of drug-drug interactions in the development of adverse events. MethodsObservational, retrospective study in which safety data of patients treated with NMV-r between April and July 2022 in an outpatient setting were evaluated. The duration of follow-up was 28 days and the number of adverse reactions reported, as well as whether they were managed on an outpatient basis or required health care, and the presence of renal and hepatic function impairment were assessed. Concomitant treatment was reviewed, identifying theoretical drug-drug interactions (TDDIs) whose severity was defined using the Lexi-interact classification. ResultsThe study included 146 patients, 82 (56,16%) were women, whose median age was 65 years (22-95). The number of TDDIs detected and maintained during treatment with NMV-r was 164, with the percentage of patients with at least one interaction being 62,33%. The median number of TDDIs per patient was 1 (0-5). At least 1 adverse event (AE) was reported in 18 patients (11,84%). Eleven AEs were potentially related to any TDDI. Seven patients required contact with hospital assistance for AE management. Eight patients had impaired renal function and 2 had impaired liver function at 28 days. The main groups of drugs implicated in the occurrence of an AE were oral anticoagulants and calcium antagonists. ConclusionsOur results show a high number of TDDIs detected were detected between NMV-r and other drugs. This study provides greater knowledge of the drugs involved in such interactions and their potential relationship with the occurrence of adverse events.

Oral calcium and vitamin D supplements differentially alter exploratory, anxiety-like behaviors and memory in male rats.

Oral calcium and calcium plus vitamin D supplements are commonly prescribed to several groups of patients, e.g., osteoporosis, fracture, and calcium deficiency. Adequate and steady extracellular calcium levels are essential for neuronal activity, whereas certain forms of calcium supplement (e.g., CaCO3) probably interfere with memory function. However, it was unclear whether a long-term use of ionized calcium (calcium chloride in drinking water ad libitum), vitamin D supplement (oral gavage) or the combination of both affected anxiety and memory, the latter of which was probably dependent on the hippocampal neurogenesis. Here, we aimed to determine the effects of calcium and/or vitamin D supplement on the anxiety- and memory-related behaviors and the expression of doublecortin (DCX), an indirect proxy indicator of hippocampal neurogenesis. Eight-week-old male Wistar rats were divided into 4 groups, i.e., control, calcium chloride-, 400 UI/kg vitamin D3-, and calcium chloride plus vitamin D-treated groups. After 4 weeks of treatment, anxiety-, exploration- and recognition memory-related behaviors were evaluated by elevated pulse-maze (EPM), open field test (OFT), and novel object recognition (NOR), respectively. The hippocampi were investigated for the expression of DCX protein by Western blot analysis. We found that oral calcium supplement increased exploratory behavior as evaluated by OFT and the recognition index in NOR test without any effect on anxiety behavior in EPM. On the other hand, vitamin D supplement was found to reduce anxiety-like behaviors. Significant upregulation of DCX protein expression was observed in the hippocampus of both calcium- and vitamin D-treated rats, suggesting their positive effects on neurogenesis. In conclusion, oral calcium and vitamin D supplements positively affected exploratory, anxiety-like behaviors and/or memory in male rats. Thus, they potentially benefit on mood and memory in osteoporotic patients beyond bone metabolism.

Incidence and risk factors of hypoparathyroidism and hypocalcemia after hemithyroidectomy.

The incidence and risk factors for hypoparathyroidism after total thyroidectomy is well-known. However, the characteristics of hypoparathyroidism and hypocalcemia after hemithyroidectomy have not been investigated well. In this study, we aimed to evaluate the incidence, characteristics, and risk factors of hypoparathyroidism and hypocalcemia after hemithyroidectomy. We retrospectively analyzed the medical data of 321 patients who underwent hemithyroidectomy, with or without central neck dissection, from January 2012 to April 2019. We analyzed the serum intact parathyroid hormone (iPTH), calcium, and ionized calcium (iCa) levels serially (preoperatively and postoperatively on the operation day; days 1 and 3; and months 1, 3, 6, and 12) and evaluated risk factors for postoperative hypoparathyroidism and hypocalcemia. The mean iPTH and calcium levels decreased significantly after hemithyroidectomy on the operation day and postoperative days 1 and 3, and returned to the preoperative level at the postoperative 1-month follow-up. The mean iCa level decreased significantly on the operation day and postoperative day 1. Transient hypoparathyroidism and transient hypocalcemia occurred in 16 (5%) and 250 (78%) participants, and they recovered to normal levels postoperatively by 1month. Eight (2.5%) patients had mild symptoms of hypocalcemia necessitating oral calcium supplementation. No permanent hypoparathyroidism or hypocalcemia was observed. Preoperatively low serum iPTH and calcium levels were associated with transient hypoparathyroidism and hypocalcemia after hemithyroidectomy. Approximately 5% and 2.5% of participants showed transient hypoparathyroidism and mild symptomatic hypocalcemia after hemithyroidectomy. The risk factors for transient hypoparathyroidism and hypocalcemia include preoperative low serum iPTH and calcium levels.

Fahr's syndrome with hypoparathyroidism, thrombocytopenia, and seizure: a rare case report.

A 32-year-old male was brought with a repeated history of twitching of hands, tingling sensation, and uncontrolled seizure despite medications. Computed tomography findings showed bilateral basal ganglia, cerebellar dentate nuclei, and subcortical cerebral white matter calcifications. Laboratory studies revealed reduced levels of calcium, parathyroid hormone, and thrombocyte count. Based on these investigations Fahr's syndrome probably due to hypoparathyroidism with thrombocytopenia was diagnosed. The patient was initially treated with intravenous calcium gluconate and platelet transfusion followed by oral calcium supplementation. Fahr's syndrome due to hypoparathyroidism should be suspected in any patient with neurological symptoms and hypocalcemia. Seizures in the patient of Fahr's syndrome with thrombocytopenia could be very detrimental due to the risk of intracranial hemorrhage. Hence, treatment should be started as early as possible.

Assessment of systemic inflammation following oral calcium supplementation in postpartum dairy cows – a pilot-scale randomized controlled trial

A new line of thinking is emerging to link inflammation with calcium metabolism. Around parturition, dairy cows inevitably and perhaps necessarily experience some degree of systemic inflammation, but excessive or dysregulated inflammation likely contributes to inflammatory disease. Immune activa­tion decreases blood Ca, so greater extracellular Ca availability may potentiate or sustain inflammation. Hypocalcemia may be an adaptive response to inflammation. The objective of this study was to investigate a possible role of supplemental calcium (Ca) in postpartum systemic inflammation in dairy cows. We hypothesized that in clinically healthy multiparous cows, post­partum administration of supplemental Ca may increase serum concentrations of markers of inflammation.

Impact of oral calcium bolus timing on milk production and health events in early lactation Holstein cows

Treatment of subclinical hypocalcemia by administration of an oral Ca bolus at 0 and 24 h post calving has shown limited suc­cess in increasing production and minimizing adverse health events. Our objective was to explore the effect of delayed oral Ca bolus supplementation on milk production and disease inci­dence and the impact of delayed oral Ca bolus supplementation on postpartum blood Ca dynamics. We conducted a random­ized controlled trial on multiparous Holstein cows (n = 998) from 4 herds in New York. At calving, cows were randomly assigned to 1 of 3 treatment groups: 1) no supplemental Ca at or around parturition (CON; n = 343), 2) an oral Ca bolus con­taining 43 g Ca at calving and 24 h later (BOL-C; n = 330), or 3) an oral Ca bolus containing 43 g Ca at 48 and 72 h post-calving (BOL-D; n = 325). We created generalized linear mixed models to analyze differences in serum total Ca (tCa) at 1 and 4 DIM and milk yield for the first 10 wk of lactation between treatment groups and multivariable Poisson regression models to analyze adverse event outcomes (metritis, displaced abomasum, died or sold, or a combination of the above) in the first 30 DIM. Serum tCa was lower at 1 than 4 DIM (P < 0.001; 1.91 [95% CI = 1.90, 1.93] mmol/L and 2.26 [95% CI = 2.24, 2.28] mmol/L, respectively), and there was no difference in tCa between treatment groups (P = 0.16). Milk yield increased by week (P < 0.001) and was not af­fected by treatment (P = 0.18; CON: 48.9 [95% CI = 48.1, 49.8] kg, BOL-C: 48.3 [95% CI = 47.5, 49.1] kg, BOL-D: 49.3 [95% CI = 48.5, 50.1] kg). A treatment by parity group interaction for milk yield (P = 0.005) showed that BOL-D parity 3 cows produced more milk than BOL-D cows in parity group 2 or 4+ as well as CON and BOL-C cows in parity groups 2, 3 or 4+. Incidence of adverse events did not differ between treatments (P = 0.39; CON: 9.5%, BOL-C: 8.1%, BOL-D: 11.5%). Our findings suggest that delaying oral Ca bolus supplementation has limited impact on blood Ca concentrations but may be beneficial to cohorts of cows as a tar­geted prophylactic supplement to support milk production.

Emerging Problem Evaluation of Hypocalcemia in Super Vasmol Hair Dye Poisoning Patients: Clinical Study in RIMS, Kadapa

Introduction: One of the most frequent method of suicide attempt in India is intentional super vasmol poisoning. If it is untreated, it leads to many complications such as, rhabdomyolysis, angioedema, acute kidney injury, and hypocalcemia. Of all above mentioned; hypocalcemia can cause pathologies of the neuromuscular, cardiovascular, and respiratory systems. Early detection and treatment of the issue can reduce the diseases and fatalities that are related to it.
 Aim: This study aims to assess the incidence, clinical manifestations, and management of hypocalcemia in super vasmol poisoning patients.
 Methods: A prospective observational study was undertaken on 50 super vasmol poisoning patients for about six months at the government general hospital, RIMS, Kadapa from November 2021 to April 2022. Only subjects who are willing to give their consent were included in the study. All trial participants were observed for the duration of their hospital stay to evaluate hypocalcemia.
 Results: Out of the 50 subjects, 22 (44%) were male, 28 (56%) were female, and the majority (40%) were in between the age group of 21 to 30 years. 15 patients (30%) out of the 50 subjects were developed with hypocalcemia, particularly those who consumed more than 50 ml of super vasmol. We observed that 66.5% of subjects received parenteral calcium gluconate while 33.5% subjects received oral calcium carbonate.
 Conclusion: Hypocalcemia is a hidden complication of super vasmol poisoning, and there is a need to raise awareness among the among medical professionals about the necessity of routinely checking serum calcium levels as well as public regarding the dangers of super vasmol.
 Keywords: Super vasmol, Toxicity, Hypocalcemia, Hospitalization, Counselling.

Evaluation of the safety and potential lipid-lowering effects of oral hydrogen-rich coral calcium (HRCC) capsules in patients with metabolic syndrome: a prospective case series study.

Metabolic syndrome is characterized by a cluster-like occurrence of conditions such as hypertension, hyperglycaemia, elevated low-density lipoprotein (LDL) cholesterol or triglycerides (TG) and high visceral fat. Metabolic syndrome is linked to the build-up of plaque within the artery, which leads to disorders of the circulatory, nervous and immune systems. A variety of treatments target the regulation of these conditions; nevertheless, they remain dominant risk factors for the development of type 2 diabetes (T2DM) and cardiovascular disease (CVD), which affect 26.9% of the US population. Management and intervention strategies for improving cholesterol and/or TG are worthwhile, and recent studies on hydrogen treatment are promising, particularly as molecular hydrogen is easily ingested. This study aimed to investigate the lipid-lowering effects and quality of life (QOL) improvement of hydrogen-rich coral calcium (HRCC) in patients with metabolic syndrome. The patients, all Taiwanese, were randomly assigned to 3 different doses (low, medium, and high) of HRCC capsules. The primary outcome was the adverse effects/symptoms during this 4-week use of HRCC capsules. The secondary outcome was lipid profile changes. Complete blood count, inflammatory biomarkers, and QOL were also measured before and after the course of HRCC. Sixteen patients with metabolic syndrome completed this study (7 males, 9 females; mean age: 62 years; range: 32-80). No obvious adverse effects were recorded. Only changes in blood TG reached significance. The baseline TG value was 193.19 μL (SD = 107.44), which decreased to 151.75 μL (SD = 45.27) after 4 weeks of HRCC (p = 0.04). QOL showed no significant changes. This study is the first human clinical trial evaluating HRCC capsules in patients with metabolic syndrome. Based on the safety and potential TG-lowering effects of short-term HRCC, further long-term investigations of HRCC are warranted. [ClinicalTrials.gov], identifier [NCT05196295].

Familial isolated hypoparathyroidism type 2: a case report with review of literature

Familial isolated hypoparathyroidism (FIH) is a rare group of genetic disorder associated with dysregulation of parathyroid hormonal axis characterized by refractory hypocalcaemia. Herein we report a 1 month 4 days old baby born out of consanguineous marriage presented with respiratory distress with single episode of convulsion, cause pointing towards hypocalcaemia. The hypocalcaemia symptoms were refractory despite repeated calcium gluconate. Laboratory parameters yielded evidence of hypoparathyroidism which was further strengthened by neuroimaging and skeletal imaging. The hypoparathyroidism was treated by oral calcitriol and calcium supplementation along with institution of phosphate binder. Whole genome exome sequencing revealed a novel nonsense mutation of glial cell missing transcription factor 2 (GCM2) gene variant c.109C>T (p.Gin37Ter) establishing the diagnosis as FIH type 2. The calcium and phosphate normalized in further follow up. The new found locus and the novel variation of GCM2 gene adds another feather to the ever-evolving genetic conundrum of the disease.

The additive effect of vitamin K supplementation and bisphosphonate on fracture risk in post-menopausal osteoporosis: a randomised placebo controlled trial

SummaryThis study assessed whether vitamin K, given with oral bisphosphonate, calcium and/or vitamin D has an additive effect on fracture risk in post-menopausal women with osteoporosis. No difference in bone density or bone turnover was observed although vitamin K1 supplementation led to a modest effect on parameters of hip geometry.PurposeSome clinical studies have suggested that vitamin K prevents bone loss and may improve fracture risk. The aim was to assess whether vitamin K supplementation has an additive effect on bone mineral density (BMD), hip geometry and bone turnover markers (BTMs) in post-menopausal women with osteoporosis (PMO) and sub-optimum vitamin K status receiving bisphosphonate, calcium and/or vitamin D treatment.MethodsWe conducted a trial in 105 women aged 68.7[12.3] years with PMO and serum vitamin K1 ≤ 0.4 µg/L. They were randomised to 3 treatment arms; vitamin K1 (1 mg/day) arm, vitamin K2 arm (MK-4; 45 mg/day) or placebo for 18 months. They were on oral bisphosphonate and calcium and/or vitamin D. We measured BMD by DXA, hip geometry parameters using hip structural analysis (HSA) software and BTMs. Vitamin K1 or MK-4 supplementation was each compared to placebo. Intention to treat (ITT) and per protocol (PP) analyses were performed.ResultsChanges in BMD at the total hip, femoral neck and lumbar spine and BTMs; CTX and P1NP did not differ significantly following either K1 or MK-4 supplementation compared to placebo. Following PP analysis and correction for covariates, there were significant differences in some of the HSA parameters at the intertrochanter (IT) and femoral shaft (FS): IT endocortical diameter (ED) (% change placebo:1.5 [4.1], K1 arm: -1.02 [5.07], p = 0.04), FS subperiosteal/outer diameter (OD) (placebo: 1.78 [5.3], K1 arm: 0.46 [2.23] p = 0.04), FS cross sectional area (CSA) (placebo:1.47 [4.09],K1 arm: -1.02[5.07], p = 0.03).ConclusionThe addition of vitamin K1 to oral bisphosphonate with calcium and/or vitamin D treatment in PMO has a modest effect on parameters of hip geometry. Further confirmatory studies are needed.Trial registrationThe study was registered at Clinicaltrial.gov:NCT01232647.

Early postoperative PTH level following total thyroidectomy as a predictor of hypocalcemia: a single center-based study in Bangladesh

Background: Assessment of parathyroid hormone (PTH) following thyroid surgery assists in the prediction of hypocalcemia and permits early intervention and therapy with oral calcium and/or vitamin D supplements.
 Methods: This retrospective analysis comprised 141 individuals who had undergone a total or completion thyroidectomy over the previous four years. The blood PTH level was measured 3 hours after surgery to determine its change and to predict hypocalcemia.
 Results: Patients were predominately female (75.2%), and the mean age was 48.73 ± 13.44 years. The main surgical procedure was total thyroidectomy (80.14%), and the main cause for surgery was a multinodular goiter (34.04%). A comparable number of patients with each type of thyroid disease (multinodular goiter, papillary thyroid cancer, thyroiditis, Graves’ disease or toxic multinodular goiter were enrolled. Three hours after surgery 93 patients (65.95%) had serum PTH levels of >10 pg/ml (mean 28.06) and 90 patients (68.38%) had normal serum calcium (mean 8.66). Most of these 93 patients (65.95%) didn't require postoperative supplementation, whereas 48 patients (34.05 %) with serum PTH levels less than 10 pg/ml required some form of supplementation; 39 (27.65 %) required both oral calcium and vitamin D supplements, and 9 (6.4 %) required only oral vitamin D supplementation. There was a significant correlation between the 3-h postoperative PTH level and hypocalcemia (P-value 0.000). The type of pathology had no significant association with low serum PTH level after surgery (P-value 0.166).
 Conclusion: Asymptotic individuals with PTH levels less than 10 pg/ml, who are regarded as being in the high-risk category, can start taking calcium and/or vitamin D supplements early if their PTH levels are measured at 3 hours following complete thyroidectomy. To predict hypocalcemia, more research is required to compare the outcome of early serum PTH level with the day one serum PTH level following complete thyroidectomy.
 Central Medical College Journal Vol 6 No 2 Jauly 2022 Page: 82-89