Diagnosis and management of hypocalcaemia

Plasma Levels of Magnesium, Calcium, Calcium to Magnesium Ratio, and Associations with Metabolic Syndrome and Cardiometabolic Risk Factors

Magnesium and calcium are elements that have been associated with cardiometabolic risk factors related to metabolic syndrome (MetS). However, there are gaps in the knowledge regarding the impact of the calcium to magnesium (Ca/Mg) ratio in plasma. Thus, we aim to evaluate the associations between magnesium and calcium levels in plasma, and the Ca/Mg ratio in plasma with MetS components and other cardiometabolic risk factors. This cross-sectional study was carried out with 112 adults and older people, distributed into groups with (n = 60) and without MetS (n = 52). We evaluated sociodemographic, anthropometric, and biochemical data. Magnesium and calcium levels in plasma were measured by inductively coupled plasma mass spectrometry technique (ICP-MS). There was a high frequency of MetS, with no significant differences in magnesium and calcium levels and Ca/Mg ratio in plasma observed between groups. There were no associations between magnesium and MetS components or other cardiometabolic risk factors (all p > 0.05). Calcium levels were associated with total cholesterol (β =  - 0.020; p = 0.000) and high-density lipoprotein cholesterol (HDL-c) (β =  - 0.046; p = 0.005). The total cholesterol (β =  - 0.025; p = 0.000) and low-density lipoprotein cholesterol (LDL-c) (β = 0.017; p = 0.020) were preditors of the Ca/Mg ratio. These results indicate important associations of calcium and the Ca/Mg ratio in plasma with cardiometabolic risk factors related to MetS.

Switching from acetate to citrate dialysate in a central concentrate delivery system for high-volume online hemodiafiltration: a retrospective cohort study

Interest in citrate-based dialysate (Cit-D) is growing due to its benefits, including anticoagulation and dialysis efficacy. However, research on safety and efficiency of Cit-D in high-volume hemodiafiltration (HDF) via central concentrate delivery system (CCDS) is scarce. This study aimed to investigate the safety and efficacy of Cit-D when switching from acetate-based dialysate (Acet-D) in high-volume HDF via CCDS. This is a retrospective analysis of 28 patients who underwent post-dilution online HDF via CCDS, who switched from Acet-D to Cit-D. The study period was divided into 3 periods for analysis: 12 weeks using Acet-D (AD period), the first 12 weeks using Cit-D (CD-1 period), and the second 12 weeks using Cit-D (CD-2 period). We collected the laboratory, dialysis, and safety parameters in each period from electrical medical records. After switching from Acet-D to Cit-D, heparin dosage decreased by 17%, whereas the incidence of complications did not increase. Kt/VBUN and urea reduction ratio increased by 4.6% and 2.1%, respectively. Pre-dialysis beta2-microglobulin concentration decreased after using Cit-D. The corrected calcium levels decreased in the CD-1 period compared to the AD period, but in CD-2, they subsequently increased to levels similar to those observed during the AD period. Symptomatic hypocalcemia did not occur, and there was no significant difference in the incidence of hyperparathyroidism. Endotoxin levels and the bacterial culture of ultrapure dialysate were unremarkable throughout all periods. These results might suggest that Cit-D could potentially offer advantages over Acet-D, such as reducing the heparin dose and increasing dialysis efficiency, in patients undergoing high-volume HDF using CCDS.

High intracellular calcium amounts inhibit activation-induced proliferation of mouse T cells: Tert-butyl hydroquinone as an additive enhancer of intracellular calcium

Optimal T cell activation is critical to orchestrate adaptive immune responses. Calcium is critical for T cell activation and integrates signaling pathways necessary to activate key transcription factors. In fact, patients with calcium channelopathies are immunodeficient. Here, we investigated the effects of different concentrations of intracellular calcium on activation of mouse T cells. High intracellular calcium amounts inhibited in vitro T cell proliferation as evidenced by a decreased cell cycling-to-hypodiploidy ratio in two models of activation: the combination of phorbol 12-myristate 13-acetate (PMA) and Ionomycin (an ionophore)/Thapsigargin (a SERCA inhibitor) or plate bound anti-CD3 and anti-CD28. High intracellular calcium amounts increased the production of reactive oxygen species (ROS) in T cells activated with PMA and Ionomycin and scavenging excess ROS using N-acetyl cysteine (NAC) rescued the decrease in cycling-to-hypodiploidy ratio. To test the universality of our observations, we studied the effects of tert-Butylhydroquinone (tBHQ), a SERCA inhibitor and Nrf2 activator. tBHQ alone did not increase intracellular calcium amounts but the intracellular calcium amounts increased when tBHQ was used in combination with PMA. Also, tBHQ inhibited T cell activation in a dose-dependent manner in both in vitro models of T cell activation. Importantly, intraperitoneal injection of tBHQ ameliorated Dextran Sodium Sulfate (DSS)-induced colitis in mice as evidenced by rescue of colon length shortening and lower disease activity index. Overall, this study identifies high calcium amounts as a potential target to lower T cell activation. The implications of these observations are discussed in the context of calcium modulating drugs that are used to treat various diseases.

Hypocalcemia Event Associated with Denosumab: A Real-World Study from FDA Adverse Event Reporting System (FAERS) Database

BACKGROUND AND OBJECTIVE

Denosumab is widely used for osteoporosis and cancer treatment. However, hypocalcemia induced by denosumab is a frequent adverse event. The objective of this study is to comprehensively investigate the safety signals and the occurrence of hypocalcemia in real-world patient cases reported through the Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS).

METHODS

Reports from January 1, 2017 to December 31, 2021 were extracted from the FAERS. Only cases of hypocalcemia suspected to denosumab were eligible in pharmacovigilance study. Denosumab-related hypocalcemia safety signal were identified to characterize their clinical features. A safety signal for hypocalcemia was evaluated using reporting odds ratios (ROR).

RESULTS

Among the 102,413 cases related to denosumab, 1042 cases were reported with denosumab-related hypocalcemia. The affected patients were mainly elderly (median age 70 years) and male (n = 568, 63.5%). In available data, the median onset time of 23 (range 0-1601) days. Most patients required drug interruption (n = 226, 72.9%) and can achieve a recovered-resolved state (n = 318, 62.1%). For the whole database, denosumab exhibited a safety signal for hypocalcemia (ROR = 14.09, 95% Cl 13.18, 15.06). In the sensitivity analyses, denosumab also showed a safety signal for hypocalcemia in cancer (ROR = 21.28, 95% Cl 18.79, 24.11) and osteoporosis (ROR = 9.29, 95% Cl 6.80, 12.59). Compared with bisphosphonates, denosumab still has safety signal for hypocalcemia (ROR = 1.88, 95% Cl 1.67, 2.11).

CONCLUSIONS

This pharmacovigilance database analysis indicates a high safety signal for hypocalcemia associated with denosumab, particularly in cancer patients.

Case report: Familial hypoparathyroidism with elevated parathyroid hormone due to an inactivating PTH mutation

Introduction

So far, only 11 PTH mutations have been described as causes of familial isolated hypoparathyroidism (FIH). In this report, we describe a family with FIH but with significant elevation of functionally inactive PTH due to a PTH mutation. We also show a positive therapeutic outcome of recombinant human PTH (teriparatide) therapy in one of the siblings who was not well controlled on large doses of calcitriol and calcium replacement therapy.

Case description

The proband is a 34-year-old woman who has a history of chronic severe hypocalcemia (HypoCa) since birth. She and her three brothers (33-year-old male twins, and a 21-year-old male) were diagnosed with pseudohypoparathyroidism type 1b (PHPT 1b) based on the presence of chronic HypoCa (serum Ca 1.6-1.85 mmol/l) since birth associated with significantly elevated plasma PTH levels in the range of 310-564 pg/dl (normal range 10-65) and absence of signs of Albright hereditary osteodystrophy.

Molecular studies

WES showed no pathogenic, likely pathogenic or variants of unknown significance in any known calcium-associated genetic disorder but a bi-allelic variant in the PTH itself ((NM_000315.4:c.128G>A, p.Gly43Glu). This was confirmed by Sanger sequencing in the patient and her affected brothers.

Management

Because the patient's HypoCa was not controlled on large doses of calcitriol and calcium carbonate, a trial of teriparatide 20 mcg SC daily was started and resulted in normalization of calcium, decline in PTH levels and significant improvement in her general wellbeing.

Conclusion

High PTH in the presence of congenital hypocalcemia is not always due to receptor or post-receptor defect and can be due to a biologically inactive mutated PTH. In such cases, treatment with teriparatide may result in stabilization of biochemical profile and improvement in quality of life.

Association Between Eyelid Twitching and Digital Screen Time, Uncorrected Refractive Error, Intraocular Pressure, and Blood Electrolyte Imbalances

INTRODUCTION

 Previous studies have shown that isolated eyelid myokymia (EM) is usually caused by stress, fatigue, and caffeine consumption. The purpose of this study was to evaluate the association between EM and digital screen time, uncorrected refractive error, intraocular pressure (IOP), and blood electrolyte levels.

METHODS

Between February 2023 and June 2024, 103 eyes of 103 patients who applied to the ophthalmology outpatient clinic with complaints of eyelid twitching lasting for more than two weeks and 103 eyes of 103 healthy individuals as a control group were included in the study. All participants were asked to record their daily time spent with digital screens for two weeks. Cycloplegic refractive error, IOP, optic nerve head cup/disc (C/D) ratio, and blood calcium, sodium, potassium, and magnesium levels were recorded and compared between the two groups.

RESULTS

Mean digital screen time was 4.84±1.74 hours in the control group and 6.88±2.01 hours in the EM group. It was found that digital screen time was significantly higher in the EM group compared to the control group (p<0.001). There was a strong positive correlation between the duration of eyelid twitching and the time spent in front of digital screens (p<0.001, r=0.670). There was no significant difference in cycloplegic refractive error, IOP, C/D ratio, and blood electrolyte levels between the two groups (p>0.05).

CONCLUSION

Prolonged digital screen time might play a role in the development of EM. On the other hand, no relationship was found between eyelid twitching and uncorrected refractive error, glaucoma, or blood electrolyte levels.

The relationship between Glasgow Prognostic Score and hospital duration in patients with inflammatory bowel diseases

BACKGROUND AND OBJECTIVES

Both hypoalbuminemia and inflammation were common in patients with inflammatory bowel diseases (IBD), however, the combination of the two parameters on hospital duration re-mained unknown.

METHODS AND STUDY DESIGN

This is a retrospective two-centre study performed in two tertiary hospitals in Shanghai, China. Serum levels of C-Reactive Protein (CRP) and albumin (ALB) were measured within 2 days of admission. Glasgow prognostic score (GPS), based on CRP and ALB, was calculated as follows: point "0" as CRP <10 mg/L and ALB ≥35 g/L; point "1" as either CRP ≥10 mg/L or ALB <35 g/L; point "2" as CRP ≥10 mg/L and ALB <35 g/L. Patients with point "0" were classified as low-risk while point "2" as high-risk. Length of hospital stay (LOS) was defined as the interval between admission and discharge.

RESULTS

The proportion of low-risk and high-risk was 69.3% and 10.5% respectively among 3,009 patients (65% men). GPS was associated with LOS [β=6.2 d; 95% CI (confidence interval): 4.0 d, 8.4 d] after adjustment of potential co-variates. Each point of GPS was associated with 2.9 days (95% CI: 1.9 d, 3.9 d; ptrend<0.001) longer in fully adjusted model. The association was stronger in patients with low prealbumin levels, hypocalcaemia, and hypokalaemia relative to their counterparts.

CONCLUSIONS

GPS was associated with LOS in IBD patients. Our results highlighted that GPS could serve as a convenient prognostic tool associated with nutritional status and clinical outcome.

Evaluation of Hypocalcemia Following Total Laryngectomy With and Without Thyroidectomy

OBJECTIVE

Hypoparathyroidism and associated hypocalcemia are well-established complications following laryngectomy. This study further characterizes the rates of hypocalcemia in patients undergoing total laryngectomy (TL) with and without thyroidectomy and hemithyroidectomy.

STUDY DESIGN

Retrospective cohort study.

SETTING

TriNetX.

METHODS

We queried TriNetX, a deidentified patient database, to identify patients who underwent TL with and without thyroidectomy and hemithyroidectomy. Rates of hypocalcemia, low parathyroid hormone (PTH), calcium, and calcitriol supplementation were compared between groups with multivariable repeated measures logistic regression.

RESULTS

We identified 870 patients in the TL without thyroidectomy cohort, 158 patients in the hemithyroidectomy cohort, and 123 in the total thyroidectomy cohort. Rates of hypocalcemia differed between patients receiving total thyroidectomy versus TL alone for 0 to 1 month (odds ratio [OR]: 2.88 [1.95-4.26]) 1 to 6 months (OR: 5.08 [2.29-11.3]), and 6 to 12 months (OR: 2.63 [1.003-6.88]) postoperatively, with adjustment for age at laryngectomy, race, ethnicity, and gender. Results were similar among those who received calcium supplementation. The rate of low PTH levels differed in these groups for 0 to 1 month (OR: 5.13 [3.10-8.51]), 1 to 6 months (OR: 3.47 [1.46-8.22]), and 6 to 12 months (OR: 3.63 [1.40-9.38]) following surgery. Rates of postoperative calcium supplementation were increased for patients receiving total thyroidectomy versus TL for 1 to 6 months (OR: 2.44 [1.62-3.68]), and 6 to 12 months following surgery (OR: 1.79 [1.18-2.72]).

CONCLUSION

Patients undergoing TL with total thyroidectomy have a higher risk of postoperative hypocalcemia compared to patients receiving TL alone. Risk of parathyroid injury in these patients may warrant further emphasis on PTH measurement after surgery and a multidisciplinary approach to management.

Calcium Disorders

This article provides a comprehensive overview of calcium physiology, clinical presentation with physical examination findings, laboratory assessment, differential diagnosis, and management of hypocalcemia and hypercalcemia for the primary care provider.

External Validation and Update of the Risk Prediction Model for Denosumab-Induced Hypocalcemia Developed From a Hospital-Based Administrative Database

PURPOSE

Denosumab is used to treat patients with bone metastasis from solid tumors, but sometimes causes severe hypocalcemia, so careful clinical management is important. This study aims to externally validate our previously developed risk prediction model for denosumab-induced hypocalcemia by using data from two facilities with different characteristics in Japan and to develop an updated model with improved performance and generalizability.

METHODS

In the external validation, retrospective data of Kameda General Hospital (KGH) and Miyagi Cancer Center (MCC) between June 2013 and June 2022 were used and receiver operating characteristic (ROC)-AUC was mainly evaluated. A scoring-based updated model was developed using the same data set from a hospital-based administrative database as previously employed. Selection of variables related to prediction of hypocalcemia was based on the results of external validation.

RESULTS

For the external validation, data from 235 KGH patients and 224 MCC patients were collected. ROC-AUC values in the original model were 0.879 and 0.774, respectively. The updated model consisting of clinical laboratory tests (calcium, albumin, and alkaline phosphatase) afforded similar ROC-AUC values in the two facilities (KGH, 0.837; MCC, 0.856).

CONCLUSION

We developed an updated risk prediction model for denosumab-induced hypocalcemia with small interfacility differences. Our results indicate the importance of using data from plural facilities with different characteristics in the external validation of generalized prediction models and may be generally relevant to the clinical application of risk prediction models. Our findings are expected to contribute to improved management of bone metastasis treatment.

Identification of novel risk factors for postoperative severe hypocalcemia in patients with primary hyperparathyroidism undergoing parathyroidectomy: a case control study

BACKGROUND

Patients with primary hyperparathyroidism (PHPT) are at risk for severe hypocalcemia (SH) following parathyroidectomy (PTX), but limited data exist on the predictors of SH. We aimed to identify risk factors for early postoperative SH after PTX in patients with PHPT and to evaluate the predictive value of clinical parameters.

METHODS

A retrospective review of patients with PHPT who underwent PTX between January 2010 and December 2022 was performed. A total of 46 patients were included in the study, with 15 (32.6%) experiencing postoperative SH, 19 (41.3%) having calculi in the ureter or kidney, and 37 (80.4%) having osteoporosis. Patients were divided into SH and non-SH groups based on postoperative serum calcium levels. Preoperative biochemical indicators, bone turnover markers, and renal function parameters were analyzed and correlated with postoperative SH.

RESULTS

Statistically significant (P < 0.05) differences were found in preoperative serum calcium (serum Ca), intact parathyroid hormone, serum phosphorus (serum P), serum Ca/P, percentage decrease of serum Ca, total procollagen type 1 intact N-terminal propeptide, osteocalcin (OC), and alkaline phosphatase levels between the two groups. Multivariate analysis showed that serum P (odds ratio [OR] = 0.989; 95% confidence interval [95% CI] = 0.981-0.996; P = 0.003), serum Ca (OR = 0.007; 95% CI = 0.001-0.415; P = 0.017), serum Ca/P (OR = 0.135; 95% CI = 0.019-0.947; P = 0.044) and OC levels (OR = 1.012; 95% CI = 1.001-1.024; P = 0.036) were predictors of early postoperative SH. The receiver operating characteristic curve analysis revealed that serum P (area under the curve [AUC] = 0.859, P < 0.001), serum Ca/P (AUC = 0.735, P = 0.010) and OC (AUC = 0.729, P = 0.013) had high sensitivity and specificity.

CONCLUSION

Preoperative serum P, serum Ca/P and osteocalcin levels may identify patients with PHPT at risk for early postoperative SH after PTX.

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 < 1.9 mmol/L, to assess clinical presentation and management. 1265 (3.95%) patients had a serum calcium concentration of < 2.1 mmol/L of which 139 (11%) had severe hypocalcemia of < 1.9 mmol/L. 113 patients had at least one measurement of albumin. Of these, 43 (3.4%) had an albumin-corrected serum calcium < 1.9 mmol/L defining true, severe hypocalcemia. Hypocalcemia was identified and documented in 35% of all cases. The mean serum calcium concentration was 1.74 ± 0.14 mmol/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.

Full-Mouth Rehabilitation of a 15-Year-Old Girl Affected by a Rare Hypoparathyroidism (Glial Cell Missing Homolog 2 Mutation): A 3-Year Follow-Up

OBJECTIVE

Familial isolated hypoparathyroidism is a rare genetic disorder due to no or low production of the parathyroid hormone, disturbing calcium and phosphate regulation. The resulting hypocalcemia may lead to dental abnormalities, such as enamel hypoplasia. The aim of this paper was to describe the full-mouth rehabilitation of a 15-year-old girl with chronic hypocalcemia due to a rare congenital hypoparathyroidism.

CLINICAL CONSIDERATIONS

In this patient, in the young adult dentition, conservative care was preferred. Onlays or stainless-steel crowns were performed on the posterior teeth, and direct or indirect (overlays and veneerlays) were performed on the maxillary premolars, canines, and incisors, using a digital wax-up. The mandibular incisors were bleached. The treatment clearly improved the patient's oral quality of life, with fewer sensitivities, better chewing, and aesthetic satisfaction. The difficulties were the regular monitoring and the limited compliance of the patient.

CONCLUSION

Despite no clinical feedback in the literature, generalized hypomineralized/hypoplastic teeth due to hypoparathyroidism in a young patient can be treated as amelogenesis imperfecta (generalized enamel defects) with a conservative approach for medium-term satisfactory results.

HIGHLIGHTS

This study provides new insights into the management of enamel hypoplasia caused by familial isolated hypoparathyroidism, helping to improve patient outcomes in similar cases.

The association between low serum calcium level and new-onset atrial fibrillation after coronary artery bypass grafting

OBJECTIVES

This study aims to investigate the relationship between serum calcium (SC) levels and the incidence of postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass graft surgery.

METHODS

This retrospective, observational cohort study consecutively enrolled patients undergoing isolated coronary artery bypass grafting in Beijing Anzhen Hospital from January 2018 to December 2021. Patients with a previous history of atrial fibrillation or atrial flutter or requiring concomitant cardiac surgery were excluded. A logistic regression model was used to determine predictors of POAF. Multivariable adjustment, inverse probability of treatment weighting and propensity score matching were used to adjust for confounders. Moreover, we conducted univariable and multivariable logistic regression analyses on preoperative and postoperative SC and ionized SC levels.

RESULTS

The analysis encompassed 12 293 patients. The POAF rate was significantly higher in patients with low SC level than those without (1379 [33.9%] vs 2375 [28.9%], P < 0.001). Low SC level was associated with an increased odds ratio of POAF (odds ratio [95% confidence interval]: 1.27 [1.18-1.37], P < 0.001). Inverse probability of treatment weighting and propensity score matching analyses confirmed the results. The increased POAF rate in low SC level group still existed among subgroup analysis based on different age, sex, body mass index, hypertension, hyperlipidaemia, CHA2DS2-VASc and magnesium.

CONCLUSIONS

Low SC level indicates elevated POAF risk in patients undergoing isolated coronary artery bypass graft surgery even after the adjustment for age, sex, cardiovascular risk factors, echocardiographic parameters and laboratory markers.

Recurrent severe hypocalcemia following chemotherapy regimen changes in advanced breast cancer: two case reports

BACKGROUND

As an oncologic emergency related to abnormalities in calcium metabolism, hypercalcemia associated with paraneoplastic syndrome and bone metastases is well known. Meanwhile, the incidence of hypocalcemia is low, except in cases associated with bone-modifying agents used for bone metastases. Hypocalcemia induced by bone-modifying agents typically occurs early after the initial administration, and its incidence can be significantly reduced by preventive administration of calcium and vitamin D3 supplements.

CASE REPORT

We report two cases of recurrent severe hypocalcemia occurring during chemotherapy for metastatic breast cancer with multiple bone metastases. Case 1: A 35-year-old Japanese woman developed metastases in the bone, liver, and ovaries during postoperative endocrine therapy for invasive lobular carcinoma of the breast. She underwent chemotherapy and treatment with denosumab. She experienced recurrent episodes of severe hypocalcemia subsequent to a change in the chemotherapy regimen. Case 2: A 65-year-old Japanese woman encountered multiple bone metastases after postoperative anti-human epidermal growth factor receptor 2 therapy and during endocrine therapy for invasive ductal carcinoma of the breast. She underwent anti-human epidermal growth factor receptor 2 therapy and treatment with denosumab. She experienced recurrent severe hypocalcemia subsequent to a change in the chemotherapy regimen to letrozole + lapatinib, trastuzumab emtansine, and lapatinib + capecitabine.

CONCLUSIONS

We observed two cases of recurrent severe hypocalcemia in patients with advanced breast cancer and bone metastases after modifications to their therapy regimens. These cases differed from the typical hypocalcemia induced by bone-modifying agents. It is possible that antitumor drugs affect calcium and bone metabolism associated with bone metastases. While these cases are rare, it is crucial for oncologists to be aware of hypocalcemia not only at the initiation of bone-modifying agents but also throughout the entire antitumor therapy, as hypocalcemia can lead to fatal outcomes.

History of Bariatric Surgery Before Thyroid Surgery: Recommendations for Prevention and Management of Postoperative Hypocalcemia

Hypocalcemia following thyroidectomy is a common and potentially life-threatening complication. It is caused by intraoperative injury to the parathyroid glands or their blood supply. Although several studies have shown that patients with a prior history of bariatric surgery may be at an increased risk for hypocalcemia after thyroidectomy, no clear recommendations exist for preventing and managing this condition in this population. This paper highlights the significance of understanding this risk and of obtaining a history of prior bariatric surgery before thyroidectomy. We propose concise recommendations for preventing and managing hypocalcemia following thyroidectomy in patients with a history of bariatric surgery.

Epileptic seizures and abnormal tooth development as primary presentation of pseudohypoparathyroidism type 1B

Pseudohypoparathyroidism (PHP) is a rare genetic disorder characterised by a non-functioning PTH. Usually, the diagnosis is made following (symptomatic) hypocalcaemia. We describe a case in which epileptic seizures and abnormalities in dental development were the main clinical manifestation of PHP type 1B. This case demonstrates the importance of screening for hypocalcaemia in patients with de novo epileptic seizures. In addition, antiepileptic medications themselves may interfere with calcium-phosphate metabolism, causing or aggravating a hypocalcaemia as well. By correcting the calcium level, a resolution of these symptoms could be obtained.

[Hyper- and hypocalcemia: what should you watch out for?]

Calcium is essential for numerous metabolic processes and is hormonally controlled. These hormonal mechanisms are surprisingly effective in regulating calcium levels very reliably within a narrow range - but deviations in serum calcium levels quite often cause clinical problems. Hypercalcemia predominantly occurs in primary hyperparathyroidism or is associated with tumors (especially osteolytic processes). Hypocalcemia is usually due to hypoparathyroidism (75% surgical, 25% primary) or vitamin D deficiency. Causal calcium management requires identification of the etiology of the disorder. Symptomatic therapy depends on the severity of the electrolyte imbalance. Calcium is lowered in hypercalcemia via forced diuresis, the administration of calcitonin and bisphosphonates or denosumab, if necessary, via dialysis. Severe hypocalcemia is corrected acutely with parenteral calcium administration and any further treatment decisions and prognosis depend on the underlying disease.

Nonfebrile Seizures in Pediatrics: Key Points to Remember

Seizures are the most common neurological disorder in pediatrics, and their initial approach aims at clinical stabilization. A thorough patient evaluation may provide important clues for the etiological diagnosis. A 12-month-old female child was observed in the emergency department after experiencing her first apyretic seizure. She had a history of congenital alopecia and, on physical examination, presented subtotal alopecia and milia. Initial investigation revealed hypocalcemia; therefore, intravenous calcium correction was started with a partial response. The analytical study was extended, revealing hypophosphatemia, elevated parathormone, and 1,25(OH)2 vitamin D with normal 25(OH) vitamin D. The genetic analysis confirmed hereditary vitamin D-resistant rickets (HVDRR). The integration of the findings was crucial to diagnostic reasoning and to guide further investigation. HVDRR is a rare disorder, with more severe clinical presentations associated with alopecia. Early diagnosis and treatment are fundamental to minimize the impact on growth and the development of other comorbidities.

PTH level might be associated with impaired quality of life in patients with nonsurgical hypoparathyroidism

OBJECTIVE

Nonsurgical hypoparathyroidism (ns-HP) is a rare disease. There are few studies on Quality of Life (QoL) among patients with ns-HP. This study aimed to investigate the QoL among ns-HP patients with regular conventional treatment, and explore the influence factors affecting QoL among these Chinese ns-HP patients.

METHODS

This is a cross-sectional study comparing 101 patients identified as ns-HP and 101 healthy controls. The questionnaires of Short Form 36 Health Survey questionnaire version 2(SF-36v2) were used to evaluate QoL.

RESULTS

Scores of all eight subdomains of SF-36v2 and physical component scores (PCS), mental component scores (MCS) were significantly lower in the ns-HP group compared with the healthy controls. The indices of all subdomains of SF-36v2 between Q1 (the lowest quartile) and Q4 (the highest quartile) groups were compared, suggesting higher percentages of detectable parathyroid hormone (PTH) before treatment in Q4 group among all QoL indices except two subdomains (physical function and body pain).

CONCLUSION

Both mental and physical QoL were impaired in the ns-HP patients even with regular conventional treatment for hypocalcemia, which were more severe in cases with lower baseline PTH levels.

A symptom-based algorithm for calcium management after thyroid surgery: a prospective multicenter study

Objective

Evidence-based treatment guidelines for the management of postthyroidectomy hypocalcemia are absent. The aim of this study was to evaluate a newly developed symptom-based treatment algorithm including a protocolized attempt to phase out supplementation.

Methods

In a prospective multicenter study, patients were treated according to the new algorithm and compared to a historical cohort of patients treated with a biochemically based approach. The primary outcome was the proportion of patients receiving calcium and/or alfacalcidol supplementation. Secondary outcomes were calcium-related complications and predictors for supplementation.

Results

One hundred thirty-four patients were included prospectively, and compared to 392 historical patients. The new algorithm significantly reduced the proportion of patients treated with calcium and/or alfacalcidol during the first postoperative year (odds ratio (OR): 0.36 (95% CI: 0.23-0.54), P < 0.001), and persistently at 12 months follow-up (OR: 0.51 (95% CI: 0.28-0.90), P < 0.05). No severe calcium-related complications occurred, even though calcium-related visits to the emergency department and readmissions increased (OR: 11.5 (95% CI: 4.51-29.3), P <0.001) and (OR: 3.46 (95% CI: 1.58-7.57), P < 0.05), respectively. The proportional change in pre- to postoperative parathyroid hormone (PTH) was an independent predictor for supplementation (OR: 1.04 (95% CI: 1.02-1.07), P < 0.05).

Conclusions

Symptom-based management of postthyroidectomy hypocalcemia and a protocolized attempt to phase out supplementation safely reduced the proportion of patients receiving supplementation, although the number of calcium-related hospital visits increased. For the future, we envision a more individualized treatment approach for patients at risk for delayed symptomatic hypocalcemia, including the proportional change in pre- to post- operative PTH.

Fahr's syndrome associated with hypoparathyroidism: A case report

Fahr's syndrome affects fewer than 1 in 100,000 people. It is an inherited neurological disorder, which is distinguished by atypical calcium deposition in the movement-controlling areas of brain, that is thalamus, dentate nucleus, basal ganglia, cerebellum, cerebral cortex, hippocampus and subcortical white matter. The majority of patients often experience extrapyramidal symptoms, cerebellar signs, speech difficulty, dementia and neuropsychiatric manifestations. This disease's molecular genetics have not been thoroughly investigated. Typically, young to middle-aged adults are affected though basal ganglia calcification in hypoparathyroidism is quite uncommon. Laboratory results and radiographic brain imaging helps in reaching the diagnosis. The treatment is mainly symptomatic. We present a case of Fahr's syndrome associated with hypoparathyroidism.

Associations Between Fatigue and Endocrine and Non-endocrine Health Problems in Turner Syndrome: Cohort Study and Review

CONTEXT

Turner syndrome (TS) is a rare chromosomal disorder characterized by gonadal dysfunction, short stature, and heart defects, among other features. Women with TS often suffer from severe fatigue, for which they are typically referred to endocrinologists. The diagnostic work-up is generally time-consuming and invasive, and it rarely solves the problem. To prevent the personal and financial burden of unnecessary diagnostic procedures, it is crucial to understand fatigue in TS.

OBJECTIVE

To explore the association between fatigue and endocrine and non-endocrine comorbidities in a-for rare disorders-large group of women with TS.

METHODS

170 genetically confirmed women with TS who attended the TS Reference Center underwent a systematic health screening, including a structured interview, complete physical examination, biochemical measurements, perceived stress and fatigue questionnaires, and additional tests when indicated.

RESULTS

Median (interquartile range) age was 32.6 (23.9-41.4) years. Severe fatigue was experienced by 1 in 3 women with TS. Liver enzyme disturbances and body mass index were significantly associated with higher fatigue scores. Perceived stress was highly correlated with fatigue.

CONCLUSION

There was no association between fatigue and most endocrine and non-endocrine disorders, which implies that fatigue is only partly explained by somatic disorders. The high correlation between perceived stress and fatigue suggests that TS-related neuropsychological processes may play an important role in the etiology of fatigue in women with TS. We provide a practical algorithm for the endocrine, non-endocrine, and psychological approach to fatigue in women with TS.

Disorders of Calcium and Magnesium

This review will discuss the importance and homeostasis of calcium and magnesium in the human body, as well as the implications and treatment of disordered calcium and magnesium. With calcium and magnesium often considered to be the "forgotten cations" in medicine, it is our hope that this review will lead providers to evaluate for and effectively manage these electrolyte disorders in the emergency department.

Relationship between vitamin D deficiency and neonatal hypocalcemia: a meta-analysis

We aimed to explore the associations of neonatal hypocalcemia with neonatal vitamin D deficiency and maternal vitamin D deficiency. A comprehensive systematic literature search using PubMed and web of science was performed for relevant articles from inception to February 17th, 2023. We used odds ratio (OR) and 95 % confidence interval (CI) as effect sizes for our meta-analysis. Publication bias was evaluated using funnel plot, Begg's test, and Egger regression test. All the statistical analyses were performed using Stata 14.0. A total of 11 studies were included and analyzed, including 452 newborns with hypocalcemia and 2,599 newborns with normal serum calcium level. Our research results revealed that vitamin D deficiency in newborns may be related to the higher prevalence of hypocalcemia (OR: 2.87, 95 % CI: 1.17-7.04). In addition, maternal vitamin D deficiency might also be a risk factor for neonatal hypocalcemia (OR: 7.83, 95 % CI: 3.62-16.92). There was a significant correlation between vitamin D deficiency and neonatal hypocalcemia.This meta-analysis indicates that newborns with vitamin D deficiency have a higher risk of hypocalcemia, and maternal vitamin D level play a crucial role in this association. Vitamin D supplementation may have a positive effect in reducing the prevalence of neonatal hypocalcemia.

Biochemical spectrum of parathyroid hormone disorders in patients attending Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Objectives

This study intends to determine the association of parathormone with vitamin D and other biochemical parameters (calcium and phosphate) and evaluate the relationship between low vitamin D and parathormone levels.

Methods

A hospital-based cross-sectional study was conducted among 310 study participants over the period of 1 year. Patients who underwent laboratory investigations for vitamin D, parathormone, calcium, and phosphate in the Clinical Biochemistry Laboratory at the Institute of Medicine, Tribhuvan University Teaching Hospital were included. Serum intact parathyroid hormone, vitamin D, calcium, and phosphate were measured in Abbott Architect (ci4100) integrated system autoanalyzer.

Results

Among the 310 study participants, 177 (57%) were males and 43% were females. The mean age of the patient was 47.09 ± 19.01 years. High intact parathyroid hormone (>68 pg/ml) was observed in 73% of the patients. Low vitamin D (<20 ng/ml) was present in 30.2% of the patients. The findings from our study depict that there is a negative significant correlation between intact parathyroid hormone levels, vitamin D, and calcium levels and a positive correlation between intact parathyroid hormone and phosphate levels (p < 0.001).

Conclusions

The findings from our study illustrate that there is a swapping drift in the profile of hyperparathyroidism in the Nepalese population. We report the presence of hyperparathyroidism in the middle age group than in the older age group contradictory to that reported in the literature.

Autosomal Dominant Hypocalcemia Type 1 and Neonatal Focal Seizures

Autosomal dominant hypocalcemia type 1 (ADH1) is a rare form of hypoparathyroidism that is characterized by gain-of-function mutations in the CASR gene, which provides instructions for producing the protein called calcium-sensing receptor (CaSR). Hypocalcemia in the neonatal period has a wide differential diagnosis. We present the case of a female newborn with genetic hypoparathyroidism (L125P mutation of CASR gene), hypocalcemia, and neonatal seizures due to the potential correlation between refractory neonatal seizures and ADH1. Neonatal seizures were previously described in patients with ADH1 but not in association with the L125P mutation of the CASR gene. Prompt diagnosis and management by a multidisciplinary and an appropriate therapeutic approach can prevent neurological and renal complications.

The role of preoperative vitamin D and calcium in preventing post-thyroidectomy hypocalcaemia: a systematic review

BACKGROUND

The thyroid gland plays an important endocrine function regulating metabolism, growth and development. A variety of benign and malignant conditions necessitate surgical removal of the thyroid gland, either in its entirety, or partially. Thyroidectomy is the most commonly undertaken endocrine surgery. Hypocalcaemia, occurring at a rate of approximately 25%, is the most common complication following total thyroidectomy. Hypocalcaemia can increase healthcare costs requiring further investigations, treatment and delaying discharge. Severe hypocalcaemia can be potentially life threatening. It has been demonstrated that routine post-operative supplementation with Vitamin D and calcium, can reduce post-operative hypocalcaemia, at present it is unclear whether preoperative supplementation has a similar effect.

METHODS

This systematic review includes randomised controlled trials on human adult subjects, who received preoperative Vitamin D and/or calcium, and which studied the effect on post-operative hypocalcaemia following total or near total thyroidectomy. There were no restrictions in respect of post-operative supplementation regimen. Studies were limited to those published in English.

RESULT

Seven of the eleven trials demonstrated a reduction in either laboratory or clinical hypocalcaemia with preoperative supplementation. This benefit was most likely to be seen when postoperative supplementation was performed on an as needed basis. IV calcium was required to treat resistant or severe hypocalcaemia, in five of the eleven trials, in each of these five trials, rates of IV replacement were lower in the preoperative supplementation group.

CONCLUSION

The use of preoperative Vitamin D, with or without calcium, may provide a modest reduction in the incidence of laboratory and clinic hypocalcaemia following total or near total thyroidectomy. There is a trend toward a reduced requirement for IV calcium with preoperative supplementation. Larger robust randomised trials are needed to provide a definitive answer. Preoperative supplementation can be considered in patients undergoing total or near total thyroidectomy.

Serum Nutritional Biomarkers and All-Cause and Cause-Specific Mortality in U.S. Adults with Metabolic Syndrome: The Results from National Health and Nutrition Examination Survey 2001-2006

BACKGROUND

There is limited research on the associations between serum nutritional biomarkers and mortality risk in patients with metabolic syndrome (MetS). Existing studies merely investigated the single-biomarker effect. Thus, this study aimed to investigate the combined effect of nutritional biomarker mixtures and mortality risk using the Bayesian kernel machine regression (BKMR) model in patients with MetS.

METHODS

We included the MetS patients, defined according to the 2018 Guideline on the Management of Blood Cholesterol from the National Health and Nutrition Examination Survey (NHANES) 2001-2006. A total of 20 serum nutritional biomarkers were measured and evaluated in this study. The Cox proportional hazard model and restricted cubic spline models were used to evaluate the individual linear and non-linear association of 20 nutritional biomarkers with mortality risk. Bayesian kernel machine regression (BKMR) was used to assess the associations between mixture of nutritional biomarkers and mortality risk.

RESULTS

A total of 1455 MetS patients had a median age of 50 years (range: 20-85). During a median of 17.1-year follow-up, 453 (24.72%) died: 146 (7.20%) caused by CVD and 87 (5.26%) by cancer. Non-linear and linear analyses indicated that, in total, eight individual biomarkers (α-carotene, β-carotene, bicarbonate, lutein/zeaxanthin, lycopene, potassium, protein, and vitamin A) were significantly associated with all-cause mortality (all p-values < 0.05). Results from BKMR showed an association between the low levels of the mixture of nutritional biomarkers and high risk of all-cause mortality with the estimated effects ranging from 0.04 to 0.14 (referent: medians). α-Carotene (PIP = 0.971) and potassium (PIP = 0.796) were the primary contributors to the combined effect of the biomarker mixture. The nutritional mixture levels were found to be negatively associated with the risk of cardiovascular disease (CVD) mortality and positively associated with the risk of cancer mortality. After it was stratified by nutrients, the mixture of vitamins showed a negative association with all-cause and CVD mortality, whereas the mixture of mineral-related biomarkers was positively associated with all-cause and cancer mortality.

CONCLUSION

Our findings support the evidence that nutritional status was associated with long-term health outcomes in MetS patients. It is necessary for MetS patients to be concerned with certain nutritional status (i.e., vitamins and mineral elements).

Lessons learned from long-term side effects after zoledronic acid infusion following denosumab treatment: a case report and review of the literature

BACKGROUND

Zoledronic acid is an intravenous, highly potent aminobisphosphonate for use in patients with primary or secondary osteoporosis. Zoledronic acid-induced prolonged side-effects are well known and quite common. However, severe side-effects can be a threat to life. We report a case of severe side-effects induced by zoledronic acid infusion, and its positive effect on long-term back pain.

CASE PRESENTATION

In 2012, a 62-year-old white native Finnish woman was operated on for an estrogen and progesterone receptor-positive breast cancer. After radiotherapy, an aromatase inhibitor (letrozole) was started. Nine months after the operation, the patient suffered a low-energy compression fracture of Th XII. She received denosumab to prevent fragility fractures and to improve bone mineral density. Letrozole was discontinued after 5.5 years, and the last denosumab injection was given after 7 years. Six months later, at the age of 71 years, the patient received a single intravenous zoledronic acid infusion. Suddenly, at 10 hours from the infusion, she complained of severe trismus, muscle twitching, spasms, and tingling, matching hypocalcemia and several other symptoms. Her serum 25-hydroxyvitamin D concentration was high (163 nmol/L), the concentration of serum calcium and calcium-ion was normal (2.32 mmol/L and 1.23 mmol/L, respectively). However, the neutrophil to lymphocyte ratio (NLR) was low (1.6). A complete recovery took 2 months. Zoledronic acid infusion also had a positive effect: for many years, the patient had suffered low back pain and strain, which came to an end after this single infusion.

CONCLUSION

It is important that the potential patients receive sufficient information about the possibility of side-effects following the administration of intravenous zoledronic acid. To ensure that a zoledronic acid infusion is given as safely as possible, the safety information should include that the patient should not be left without monitoring for a minimum 24 hours after the infusion. Being alone and experiencing serious side-effects may lead to acute cardiac problems. Furthermore, the chronic low back pain and strain that our patient suffered for many years has clearly reduced for 16 months after infusion, so far. We conclude that this is a positive effect of zoledronic acid.

Intact Parathyroid Hormone Levels in Predicting Postoperative Hypocalcaemia After Total Thyroidectomy in South Indian Population: Cross Sectional Study

Hypocalcaemia being one of the most common complications after total thyroidectomy may not be avoidable in all cases. This study evaluated the effectiveness of intact Parathyroid hormone (iPTH) measured at 1-h after total thyroidectomy in predicting postoperative hypocalcaemia in early postoperative period in South Indian population. Patients who underwent total thyroidectomy in our institute from 2016 to 2018 were included. Preoperative calcium and iPTH levels were measured. Patients' iPTH level was measured 1 h after surgery and serum calcium level was measured at 24 h after surgery. Patients were also monitored clinically for any symptoms and signs of hypocalcaemia. A total of 57 patients were studied. The malignant causes accounted for 75.4% with papillary carcinoma thyroid being the most common cause. 65.7% of patients who underwent total thyroidectomy and 100% of patients who underwent total thyroidectomy with neck dissection developed hypocalcaemia. 70% of patients with low iPTH developed hypocalcaemia and none of the patients who had normal iPTH developed hypocalcaemia. This relation was statistically significant with p value of 0.018 (< 0.05). The positive predictive value is 70% and negative predictive value is 100%. Though our study supports the hypothesis that iPTH is effective in predicting hypocalcaemia after total thyroidectomy in the early postoperative period, a larger sample study is needed to further support this. It can be used to consider patients for early discharge or to prophylactically start oral calcium and Vitamin D supplementation based on iPTH levels at 1 h after surgery.

Quality of Life in Post-Surgical Hypoparathyroidism (PoSH) in Thyroid and Parathyroid Surgery

BACKGROUND

Post-surgical hypoparathyroidism (PoSH) is often long term, with significant associated morbidity and ongoing treatment. A recent systematic review found impaired quality of life (QoL) in patients with PoSH, despite stable treatment. Most studies did not include an appropriate control arm and further studies were recommended, taking into account underlying disease and comorbidities. This study aims to compare QoL in patients with PoSH with appropriate control groups.

METHODS

This was a cross-sectional observational study using the general quality of life SF-36 tool and a hypocalcaemia symptom score (HcSS) to assess QoL in patients with PoSH and controls (who had similar surgery but without PoSH). Participants were identified from two patient groups (the Butterfly Thyroid Cancer Trust and the Association for Multiple Endocrine Neoplasia Disorders) and a single tertiary centre in the UK.

RESULTS

Four hundred and thirty-nine responses (female n = 379, PoSH n = 89) were included with a median (range) age of 52 (19-92) years. Reported dates of surgery ranged from 1973 to 2019. HcSS scores showed significantly more associated symptoms in patients with PoSH than those without (p < 0.001). Although there was no overall difference in QoL between groups, patients with PoSH consistently had lower scores (p = 0.008) in the energy/fatigue subdomain of the SF-36.

CONCLUSION

Patients with PoSH reported significantly more fatigue and loss of energy compared to appropriately matched controls, but overall QoL was not significantly different. Standardised QoL measures may not be sensitive enough to highlight the impact on QoL in these patients. A disease-specific tool may be required.

A new pattern of bilateral cataracts associated with hypocalcemia secondary to uncontrolled hypoparathyroidism

Hypoparathyroidism is a disorder characterized by hypocalcemia. Premature cataract is one of the signs of hypoparathyroidism, but it is very rare. The present text is a case report of a rare case of a new pattern of bilateral cataracts associated with hypocalcemia secondary to uncontrolled hypoparathyroidism. The patient is a 30-year-old male with a chief complaint of progressive, painless vision loss and tearing in both eyes and photophobia in the left eye for the past 10 months and paresthesia, muscle spasms, and tingling for 2 years before referral. He had a history of hypoparathyroidism disorder that was undertreated with medication. Central posterior subcapsular cataract in both the eyes had been diagnosed. He underwent cataract surgery of the left eye under topical anesthesia. The visual acuity improved from 20/40 to 20/20 postoperatively, and the patient did not have any visual symptoms. This case is the first report of cataract with feathery opacity pattern reported with high-quality imaging from a patient. This feathery opacity pattern may explain the difference in the morphology of this patient's cataracts from others.

Serum calcium levels are associated with cognitive function in hypoparathyroidism: a neuropsychological and biochemical study in an Italian cohort of patients with chronic post-surgical hypoparathyroidism

PURPOSE

Hypoparathyroidism (HypoPT) is a rare endocrine disease and conventional therapy is based on calcium and vitamin D analogues. Conventional therapy does not restore calcium homeostasis and patients complain with neuropsychological symptoms, which have been evaluated with nonspecific self-administered questionnaires. This study aims to evaluate cognitive functions of patients with chronic post-surgical (PS)-HypoPT compared to a control population, using a standardized neuropsychological approach and evaluating the relationship with serum calcium (Alb-Ca).

METHODS

Observational, monocentric study on 33 patients with PS-HypoPT and 24 controls, in whom biochemical testing and a standardized neuropsychological assessment by a trained psychologist were performed.

RESULTS

In patients with PS-HypoPT, low Alb-Ca correlated with a worse performance on semantic memory abilities and executive function, as suggested by a significant inverse correlation between Alb-Ca and Trail Making Test A (TMT-A) scores (r = - 0.423; p = 0.014) and by a positive correlation with Semantic Fluency Test scores (SF)(r = 0.510; p = 0.002). PS-HypoPT patients with Alb-Ca ≤ 8.9 mg/dl had a significantly lower test performance compared with PS-HypoPT patients with Alb-Ca > 8.9 mg/dl, both at the TMT-A test (mean score: 34.53-18.55; p < 0.0001) and at SF test (mean score: 41.94-48.68; p = 0.01) and also a significantly lower test performance compared with control patients' group at TMT-A (mean score: 34.53-25.5; p = 0.0057).

CONCLUSIONS

Patients with chronic PS-HypoPT in conventional therapy do not show a severe cognitive impairment; however, cognitive functions namely visuo-spatial attention, executive function and semantic memory appear to be modulated by Alb-Ca and impaired by its low levels.

Electrolytes disturbances in cancer patients

PURPOSE OF REVIEW

Hypernatremia, hyperphosphatemia, hypocalcaemia, hyperkalaemia and hypermagnesemia are electrolytes disturbances that can arise in cancer patients in relation to unique causes that are related to the cancer itself or its treatment and can lead to delay or interruption of cancer therapy. This article summarizes these main causes, the proposed pathophysiology and the recommended management for these disturbances.

RECENT FINDINGS

There have been many cancer drugs approved in the field of oncology over the past several years and a subset of these drugs have been associated with electrolytes disturbances. This includes, for example, immune checkpoint inhibitor related hyperkalemia, fibroblast growth factor 23 inhibitor associated hyperphosphatemia and epidermal growth factor receptor inhibitor associated hypomagnesemia and hypocalcaemia.

SUMMARY

This article provides an updated review of certain electrolytes disturbance in cancer patients and allows clinicians to have a greater awareness and knowledge of these electrolyte abnormalities in efforts to early recognition and timely management.

Electromyographic changes in a patient with hypocalcemia after thyroidectomy: A case report

Hypocalcemia is a rather uncommon condition that may be encountered in the outpatient setting. It may be associated with a wide range of clinical symptoms and signs. It is unclear that the primary cause of symptom is hypocalcemia, as these symptoms are usually discrete and ambiguous. Signs of muscle cramp and tetany are considered the expressions of overexcitability of peripheral nerves or central nervous system in case of hypocalcemia in the nerve. In this case, we present a 59-year-old female who presented with persistent muscle cramp and pain of both upper and lower extremities and underwent an investigation that revealed electromyographic changes due to hypocalcemia during an electromyographic study.

Serum protein and electrolyte imbalances are associated with chemotherapy induced neutropenia

Introduction

Cancer and its treatment using various chemotherapeutic agents can have many adverse side effects. These side effects often result in significant changes in haematological and biochemical composition of blood. As a result, the regular monitoring of serum biochemical and haematological changes plays an important role in management of disease. The present study aimed to determine the relationship between haematological and biochemical changes in neutropenic cancer patients following chemotherapy. Specifically we evaluated the association between neutrophil count and serum proteins and electrolytes.

Methods

For this purpose we analysed retrospectively collected laboratory results from two independent patient cohorts. Each cohort was divided into a control group consisting of patients with normal haematological parameters and a study group which included patients with reduced neutrophil counts. Neutropenic patients (study group) were cancer patients on chemotherapy.

Results and conclusion

Blood samples of cancer patients in study group showed reduction in haemoglobin, neutrophils and platelets. Neutropenic group showed a significant reduction in serum albumin, total protein, calcium, and potassium. Our results show that patients with severe neutropenia had pronounced changes in serum protein and electrolytes and increased incidence of abnormal serum protein and electrolyte level. The changes in the neutrophil counts showed a positive correlation with the changes in serum protein and electrolyte levels. A similar trend was seen in both the patient cohorts: the discovery set (176 patients) and the validation set (200 patients). Taken together our results suggest that chemotherapy-induced neutropenia is associated with dysregulation in haemoglobin, platelets, serum proteins and electrolytes.

[Not Available]

Armenia and Azerbaijan fought between September and November 2020 in Nagorno-Karabagh. Several surgical missions were scheduled by Assistance Publique- Hôpitaux de Paris to help care for the warinjured Armenians. These missions included the evaluation of Armenian soldiers suspected of having been injured by phosphorus. Facing, during these missions, such infrequent burns, we were interested in their pathophysiology, care and complications. Repeated up-to-date information is necessary in order to better take care of phosphorus burns. Therefore, we conducted a literature review, using PubMed and the Mesh Terms "phosphorus" and "burns", without setting any date limit. The review acknowledges that phosphorus burns are deep, tend to spread and may be the cause of systemic toxicity including hypocalcaemia, which can lead to heart rate disturbance and even death. In the acute phase, burns should be extensively washed with normal saline or water before a mechanical decontamination. One should not use oily dressings, given the liposolubility of phosphorus. Subsequently, one or many debridements are necessary before starting wound coverage, for which any kind of plastic surgery may be used. Phosphorus burns are infrequent but serious. They mainly occur in warfare and should be known by any caregiver acting in this context.

Efficacy of Oral vs. Intravenous Calcium Supplementation for Continuation Therapy in Hypocalcemic Seizures: A Randomized, Controlled Trial

OBJECTIVE

To evaluate efficacy of oral vs. intravenous calcium supplementation for continuation therapy in hypocalcemic seizures.

METHODS

Sixty children between 1 mo and 5 y presenting with hypocalcemic seizures without any other underlying febrile, chronic systemic disease, or acute neurological illness were included. Participants were randomized to receive either intravenous (IV) 10% calcium gluconate (n = 30) or oral elemental calcium (n = 30) for 48 h following initial seizure control with intravenous calcium.

RESULTS

Seizures recurred in 3 (10%) children in IV group as compared to 4 (13.3%) in oral calcium group (p = 0.278) within 48 h. Serum calcium levels achieved in the two treatment groups at 24 h [7.96 (1.32) vs. 8.23 (1.58) mg/dL; p = 0.476] and 48 h [8.5 (1.01) vs. 8.63 (1.39) mg/dL; p = 0.681] were comparable.

CONCLUSION

Oral calcium may be as efficacious as intravenous calcium during continuation phase of treating hypocalcemic seizures; however, further studies are needed for definite recommendations.

TRIAL REGISTRATION

Trial Registration number: CTRI/2017/12/011042.

Late maternal diagnosis of DiGeorge syndrome with congenital hypoparathyroidism following antenatal detection of the same 22q11.2 microdeletion syndrome in the fetus

Genetic causes of hypocalcaemia can be overlooked in patients who present without apparent syndromic features. One relatively common but under-recognised genetic disorder is DiGeorge syndrome, which is often diagnosed in childhood but rarely in adulthood. Its enigmatic diagnosis can be attributed to its broad heterogeneous clinical presentation, such as the absence of cardiac abnormalities with only subtly abnormal facies. The presence of hypoparathyroidism-related hypocalcaemia may be the first early sign. We describe a young female adult with childhood-onset hypocalcaemia who was diagnosed with DiGeorge syndrome during her pregnancy when the fetus was found to have the same condition on antenatal screening and autopsy. This case reminds clinicians to consider the genetic causes of hypoparathyroidism-induced hypocalcaemia early on in childhood, while acknowledging the possibility of a late diagnosis in adulthood. We also highlight the risks of severe hypocalcaemia in pregnancy and outline a systematic approach to the evaluation of chronic hypocalcaemia.

Hypocalcemia as the Initial Presentation of Type 2 Bartter Syndrome: A Family Report

CONTEXT

Bartter syndrome (BS) is a group of rare autosomal-recessive tubulopathies characterized by hypokalemic, hypochloremic metabolic alkalosis in which the primary defect is a deficiency of transporters involved in sodium chloride reabsorption. Type 2 BS results from a defect in the renal outer medullary potassium channel encoded by the KCNJ1 gene. Type 2 BS presents with polyhydramnios, intrauterine growth retardation, prematurity, failure to thrive, polyuria, hypercalciuria, and life-threatening episodes of dehydration. Hypocalcemia is a very rare presenting symptom of BS, with only a few published cases reporting it as the initial manifestation of type 2 BS.

OBJECTIVE

To describe a child who presented with hypocalcemic seizure at the age of 2.3 years that was first related to vitamin D deficiency and high-phosphate soft drink consumption.

METHODS

Whole exome sequencing (WES) was used to evaluate the biochemical abnormalities of the proband.

RESULTS

We identified a previously described homozygous missense mutation c.212C>T, p.T71M in the KCNJ1 gene associated with type 2 BS. Six additional family members with the same mutation and diagnosed clinically with BS are also reported, 2 presenting with hypocalcemia associated with vitamin D deficiency.

CONCLUSION

This report expands the clinical spectrum associated with KCNJ1 mutations and emphasizes the role of WES in unsolved cases of hypocalcemia when genetic disease is suspected. It also highlights the hazardous effects of phosphate-containing soft drinks on calcium metabolism.

Validation of an equation for free calcium estimation: accuracy improves after adjustment for phosphate and CO2

PURPOSE

Free calcium is the gold standard for diagnosis of calcium disorders, although calcium assessment is routinely performed by albumin-adjusted calcium. Our objective was to develop a novel-specific correction equation for free calcium employing serum total calcium and other analytes.

METHODS

Retrospective single-center cohort study. A new equation for free calcium assessment was formulated from data of hospitalized patients (n = 3481, measurements = 7157) and tested in a validation cohort (n = 3218, measurements = 6911). All measurements were performed simultaneously from the same blood draw.

RESULTS

Total CO₂ and phosphate, in addition to albumin, were the principal factors associated to calcium misdiagnosis. A novel laboratory-specific prediction equation was developed: free calcium (mmol/L) = 0.541 + (total calcium [mmol/L] *0.441) - (serum albumin [g/L] *0.0067) - (serum phosphate [mmol/L] *0.0425) - (CO₂ [mmol/L] *0.003). This new equation substantially improved adjusted R² to 0.67 (95% CI 0.78-0.82, p < 0.001; Kendall's c-tau: 0.28, p < 0.001). Bland-Altman plots of estimated free calcium and free calcium showed a mean difference of - 0.0006 mmol/L (LOA + 0.126 to - 0.124). In validation cohort, the AUC-ROC curves for hypercalcemia and hypocalcemia diagnosis deploying the new equation were 0.88 (95% CI 0.86-0.89, p < 0.001) and 0.98 (95% CI 0.97-99, p < 0.001), respectively, which were superior to historical formulas for calcium. In univariate models, eGFR was associated with Ca-status misdiagnosis, yet this association disappeared when analysis was adjusted to phosphate and CO₂.

CONCLUSIONS

The novel equation proposed for prediction of free calcium could be useful when free calcium is not available. The conventional formulas misclassify many patients, in particular when phosphate or bicarbonate disturbances are present.

Thyroidectomy with and without laryngectomy: Differences in post-operative hypocalcemia and management

BACKGROUND

Total laryngectomy (TL) with thyroidectomy can pose significant risks to parathyroid function, and variance in rates of post-operative hypocalcemia (POH) based on extent of thyroidectomy have not been previously reported. Our objective is to identify the rates of hypocalcemia and hypoparathyroidism in TL+/-thyroidectomy and compare this to matched thyroidectomy alone cohorts.

METHODS

Multi-institutional retrospective chart review of patients treated surgically for laryngeal cancer with TL or benign/malignant thyroid disease with thyroidectomy at regional tertiary care centers in New Orleans and Baton Rouge, Louisiana from 2016 to 2019. Cases were evaluated for post-operative and post-discharge calcium and parathyroid hormone levels, post-operative and long-term calcium supplementation, and intraoperative parathyroid identification and management.

RESULTS

101 TL and 319 thyroidectomy patients' charts were reviewed. Regression analysis revealed increased odds of hypocalcemia and hypoparathyroidism in TL + TT versus TT alone (OR 10.7, OR 16.5, p < 0.001, respectively). TL + HT versus HT alone had increased odds of hypoparathyroidism (OR 1.6, p < 0.001). TL with any thyroidectomy compared to TL alone demonstrated both increased odds of hypocalcemia and hypoparathyroidism (OR 4.4 p = 0.009, and OR 4.5 p = 0.05). Odds of requiring long-term calcium supplementation were significantly increased with the addition of thyroidectomy across all groups. TL + TT was 8 times as likely (p = 0.002) and TL + HT was 5.3 times as likely (p = 0.001) to require long-term calcium supplementation compared to TL alone.

CONCLUSIONS

Thyroidectomy combined with TL demonstrates marked increased risk of parathyroid dysfunction and resultant POH. Despite improved visualization of soft tissue anatomy with TL, risk of parathyroid injury in these settings requires special attention to extent of parathyroid dissection and potential devascularization to reduce long-term sequelae of hyperparathyroidism. Therefore, post-operative calcium monitoring after TL is necessary and should resemble the long-standing stringent protocols that already exist for monitoring in thyroidectomy populations.

GIRK channel as a versatile regulator of neurotransmitter release via L-type Ca2+ channel-dependent mechanism in the neuromuscular junction

G protein-gated inwardly rectifying potassium (GIRK) channels are one of the main regulators of neuronal excitability. Activation of GIRK channels in the CNS usually leads to postsynaptic inhibition. However, the function of GIRK channels in the presynaptic processes, notably neurotransmitter release form motor nerve terminals, is yet to be comprehensively understood. Here, using electrophysiological and fluorescent approaches, the role of GIRK channels in neurotransmitter release from frog motor nerve terminals was studied. We found that the inhibition of GIRK channels with nanomolar tertiapin-Q synchronized exocytosis events with action potential but suppressed spontaneous and evoked neurotransmitter release, as well as Ca²⁺ transient and membrane permeability for K⁺. The action of GIRK channel inhibition on evoked neurotransmission was prevented by selective antagonist of voltage-gated Ca²⁺ channels of L-type. Furthermore, the effects of muscarinic acetylcholine receptor activation on neurotransmitter release, Ca²⁺ transient and K⁺ channel activity were markedly modulated by inhibition of GIRK channels. Thus, at the motor nerve terminals GIRK channels can regulate timing of neurotransmitter release and be a positive modulator of synaptic vesicle exocytosis acting partially via L-type Ca²⁺ channels. In addition, GIRK channels are key players in a feedback control of neurotransmitter release by muscarinic acetylcholine receptors.

Hypocalcemia-Induced QT Interval Prolongation

An 87-year-old man with a history of transcatheter aortic valve replacement, pulmonary hypertension, diastolic dysfunction with preserved systolic function, and myelofibrosis had a 12-lead ECG showed a prolonged QT interval of 508 ms with heart-rate correction placing it in the 99th percentile of the population. Reduction in the dose of furosemide and calcium supplementation increased serum calcium and shortened the QT interval. This case provides an opportunity to examine newer concepts for the understanding of the mechanisms by which hypocalcemia might induce QT prolongation. Hypocalcemia likely produces corrected QT interval prolongation primarily through a calcium-dependent inactivation (CDI) mechanism on the L-type calcium channel (LTCC). Lower extracellular calcium leads to a decreased ICaL, subsequently causing intracellular calcium to take longer to reach the critical threshold to induce CDI of the LTCC. The resulting prolonged repolarization of the ventricular myocyte can lead to early after-depolarizations and ensuing life-threatening ventricular arrhythmias. Genetic polymorphisms in Ca2+-binding protein calmodulin which can prolong QT, underscore the role for disturbances of intracellular myocardial calcium handling in arrhythmogenesis. Hypocalcemia is an under-recognized cause of QT prolongation and should be taken into careful consideration in patients presenting with incidental findings of a prolonged QT interval.

Zoledronic Acid Contraindications Prevalence among Hip-Fractured Patients Aged 75 Years or Over Hospitalized in an Orthogeriatric Unit

OBJECTIVE

Zoledronic acid (ZA) is an antiosteoporotic drug that has been proven to reduce mortality after a hip fracture (HF). ZA is however underused with older HF patients. One possible cause may be the high prevalence of severe renal failure and hypocalcemia which contraindicate ZA administration. The aim of this study was to assess the prevalence of these 2 contraindications in patients aged 75 years or older admitted into an orthogeriatric (OG) unit after a low-energy HF. The secondary objective was to assess the prevalence of situations in which ZA must be used with caution.

METHODS

Our retrospective descriptive monocentric study was performed in an OG unit on a cohort of elderly patients hospitalized for HF from August 2015 to August 2017. Prevalence of hypocalcemia lower than 2 mmol/L and Cockcroft creatinine clearance lower than 35 mL/min was recorded.

RESULTS

Among the 194 patients admitted for HF, 136 patients (mean age 86 ± 5.6 years; 101 women) were included. The mean length of hospital stay was 15 ± 9 days. 111 (81.5%) had no contraindications to ZA administration. More than 80% presented situations in which ZA had to be used with caution, including 25(OH)D deficiency (20%).

CONCLUSION

The majority of subjects aged 75 years or older admitted to hospital after an HF seem to have no contraindication for ZA administration during their immediate postoperative hospital stay. The hospitalization period after HF repair gives the opportunity to give most of them this treatment to improve their prognosis, taking into account situations in which ZA must be used with caution.