Hypocalcemia Diagnosis in the Surgical Environment.

Serum calcium, phosphorus and albumin levels in relation to the angiographic severity of coronary artery disease

Calcium phosphorus metabolism in dialysis patients with and without mitral anular calcium: Analysis of 30 patients

Proton pump inhibitors (PPIs) are a widely used class of drugs because of a generally acceptable safety profile. Among recently raised safety issues of the long-term use of PPIs is the increased risk of developing hypomagnesemia. As there have been very few prospective studies measuring serum magnesium levels before and after PPI therapy, we aimed to prospectively assess the potential association between PPI therapy for 12 months and the risk of hypomagnesemia as well as the incidence of new-onset hypomagnesemia during the study. In addition, the association of PPI therapy with the risk of hypocalcemia was assessed. The study included 250 patients with normal serum magnesium and total calcium levels, who underwent a long-term PPI treatment. Serum magnesium, total calcium, and parathormone (PTH) levels were measured at baseline and after 12 months. Of the 250 study participants, 209 completed 12 months of treatment and were included in the statistical analysis. The Wilcoxon signed rank test showed no statistically significant differences in serum magnesium levels between measurements at two different time points. However, there were statistically significant differences in serum total calcium and PTH levels in PPI users. Stable serum magnesium levels were demonstrated after 12 months and no association between PPI use and risk of hypomagnesemia was shown in the general population. Significant reductions of serum total calcium levels were demonstrated among PPI users; nevertheless, further research is required before recommending any serum calcium and PTH level monitoring in patients initiated on long-term PPI therapy.

Background: Primary hyperparathyroidism is a relatively common disorder caused by the inappropriate autonomous secretion of parathyroid hormone which subsequently leads to hypercalcemia. There is increased prevalence of vitamin D deficiency in patients with primary hyperparathyroidism. As these patients are already hypercalcemic, there is reluctance within the medical community to provide vitamin D supplementation due to fear of exacerbating hypercalcemia. Clinical Case: A 17 year old African American male was referred to the pediatric endocrinology clinic for hypercalcemia (total serum calcium level 11.2 mg/dL, 8.6-10.6). His past medical history was significant for a diagnosis of membranoproliferative glomerulonephritis type 2 which was in remission. His most recent blood tests showed normal renal function. A review of his hospital chart showed that his calcium levels had been on the upper end of the reference range or above it for at least a year prior to his presentation to the clinic. He had no signs or symptoms concerning for hypercalcemia. He was not taking any calcium supplements or other medications which are known to be associated with elevated calcium levels. There was no known family history of hypercalcemia. He denied any history of renal stones, adrenal disease, weight loss, or osteoporosis but did report a wrist and knee fracture both of which occurred during competitive wrestling matches. His vital signs and physical exam were unremarkable. On laboratory analysis his serum calcium was 11.0 mg/dL, intact PTH 112 pg/mL (ref range 12-88), 25 hydroxyvitamin D was 10 ng/mL (ref range 20-80), Alk Phos 145 U/L (ref range 100-300), Albumin 4.8 g/dL (3.4-5.0), TSH 1.97 mcIU/mL (0.35-4.0), Free T4 0.8 ng/dL (0.6-1.7), Cr 0.94 mg/dL (0.5-1.3), 24 hour urine calcium excretion was 228 mg and calculated calcium to creatinine ratio was 0.07. Ultrasound of the neck and nuclear parathyroid scan and did not definitively show a parathyroid adenoma but could also not rule out the presence of an adenoma. Given patient’s low 25 OH vitamin D level he was given a 4 week course of supplemental vitamin D (1,000 units daily) with resultant 25 OH vitamin D level of 21 ng/mL. His serum calcium and intact PTH level remained elevated at 10.9 mg/dL and 108 pg/mL respectively. The patient was sent to otolaryngology for evaluation should the need arise in the future for surgical intervention and genetic testing to definitively rule out familial hypocalciuric hypercalcemia was sent. As he is asymptomatic with mild hypercalcemia currently, we will continue to monitor yearly per guideline recommendations. Conclusion: Supplementation with modest doses of vitamin D did not significantly raise our patient’s calcium level and led to an improvement in the 25 hydroxyvitamin D level. Vitamin D repletion should be considered in cases of asymptomatic primary hyperparathyroidism associated with mild hypercalcemia.

Plasma Parathyroid Hormone Level and Prevalent Cardiovascular Disease in CKD Stages 3 and 4: An Analysis From the Kidney Early Evaluation Program (KEEP)

Background: The pathophysiology of preeclampsia remains poorly understood despite having many studies. The association of decreased calcium level Preeclampsia (PE) has been proposed for decades. This study aimed to compare serum total calcium levels between women with preeclampsia and normotensive pregnant women at a tertiary care teaching hospital in Bangladesh. Materials and methods: One hundred pregnant women with a gestational age of more than 28 weeks and singleton pregnancy [50 preeclamptic (Cases) women and 50 normotensive pregnant women (Control)] were included in the selected case-control study from the Obstetrics & Gynecology Department of Chittagong Medical College Hospital. On admission, venous blood samples were collected before the commencement of treatment. Serum total calcium levels were estimated and compared between the two groups. Results: Out of 50 cases, 23 (46%) had preeclampsia without severe features and 27 (54%) had preeclampsia with severe features. The mean (± standard deviation) serum level of calcium in the control group, PE patients without severe features and PE patients with severe features were 9.14±0.48 mg/dl, 8.31±0.59and 8.29±0.61mg/dl, respectively. The meanserum total calcium level was significantly lower in preeclamptic patients with severe features and preeclamptic patients without severe features than the normotensive women (p<0.001 for both). Hypocalcemia was found to have an incidence rate of 12% in controls and 58% among cases. The adjusted odds of having preeclampsia was almost eleven times higher among those participants with low total serum calcium level (Odds ratio 10.81, 95% confidence interval 2.98-39.16). Conclusion: In conclusion, reducing serum calcium levels during pregnancy might contribute to the aetiology of preeclampsia, and supplementing these elements to the diet may be useful in preventing preeclampsia. JCMCTA 2024 ; 35 (1) : 114-119

We measured parathyroid hormone levels in pregnant and nonpregnant women and at 1, 2 and 5 days of life in healthy term neonates and in hypocalcemic preterm infants using a new immunoradiometric assay which measures only biologically active intact parathyroid hormone and by a mid-molecule parathyroid hormone radioimmunoassay. During pregnancy intact and mid-molecule parathyroid hormone levels did not show any modification and were not different from parathyroid hormone levels of nonpregnant age-matched controls. Serum calcium and phosphorus levels did not vary during each trimester of pregnancy. In cord serum intact and mid-molecule parathyroid hormone values were low in both term and preterm infants. In term neonates intact and mid-molecule parathyroid hormone levels peaked on day 1; in preterm infants intact parathyroid hormone levels peaked on day 1 while mid-molecule parathyroid hormone values peaked on day 2. Intact parathyroid hormone levels showed a more marked increase in preterm (19-fold) than in term neonates (7.5-fold) on day 1. Our data do not confirm the previously reported "physiologic" hyperparathyroidism in pregnancy. Moreover we found a normal parathyroid gland responsiveness to decreasing serum calcium levels in the first days of life in term and preterm infants. Our results suggest that measurement of intact parathyroid hormone 1-84 by immunoradiometric assay in the first days of life is a more sensitive index of parathyroid gland secretory function than the measurement of middle or carboxyl-terminal parathyroid hormone fragments allowing the detection of the dynamic changes of parathyroid hormone which occur in hypocalcemic preterm infants.

BACKGROUND:Pregnancy is described as a normal physiologic state associated with various biochemical changes. Magnesium and calcium are essential macronutrients required for foetal growth. Complications associated with their deficiency during normal pregnancy include; low neonatal birth weight, pre-eclampsia, eclampsia and preterm labour. Changes in serum levels of magnesium and calcium in normal pregnancy have not been extensively studied among Ghanaian women.AIM:To determine the variation in serum magnesium and calcium levels with gestational age in normal pregnancy in Ghanaian women.METHODS:A hospital-based comparative cross-sectional study was conducted among 32 normal non-pregnant women (Group A) and 100 normal pregnant women (Group B) attending the clinic at the Korle-Bu Teaching hospital. The group B pregnant women were further divided into Group B1 (n = 33), Group B2 (n = 37) and Group B3 (n = 30) based on their pregnancy gestation as first, second and third trimester respectively. Blood samples were obtained from the antecubital vein of subjects and total serum calcium, magnesium, protein and albumin were estimated. Data obtained were analysed using SPSS for windows version 20. Analysis of variance (ANOVA) was employed to determine the statistical differences between the groups. A p-value of ≤ 0.05 was considered significant.RESULTS:Mean serum total calcium and magnesium in first, second and third trimester normal pregnant women were 2.14 ± 0.16, 2.13 ± 0.44, 2.13 ± 0.35 mmol/L and 0.77 ± 0.11, 0.77 ± 0.16 and 0.76 ± 0.14 mmol/L respectively. Mean serum total calcium and magnesium levels in non-pregnant women were 2.20 ± 0.16 and 0.80 ± 0.10 mmol/L respectively. There was a statistically non-significant difference in serum total calcium and magnesium between non-pregnant and normal pregnant women, with p-values of 0.779 and 0.566 respectively. Mean total serum protein and albumin in first, second and third-trimester normal pregnant women were 68.42 ± 10.37, 70.46 ± 6.84, 66.70 ± 7.83 g/L and 39.92 ± 3.22, 40.75 ± 8.06, 38.26 ± 3.02 g/L respectively. Mean total serum protein and albumin in non-pregnant women were 73.13 ± 7.02 and 42.94 ± 3.03 g/L respectively. Mean total serum protein and albumin levels were lower in pregnant women as compared to non-pregnant women with the difference being significant in the third trimester (p-values of 0.012 and 0.002).CONCLUSION:Total serum calcium and magnesium levels in normal pregnancy were non-significantly lower compared to non-pregnant women in Ghana. There was a reduction in total serum protein, and albumin levels during pregnancy with a significant reduction noticed during the third trimester compared to the non-pregnant state.

Background:Our study aims to explore the effect of total parathyroidectomy (PTX) with forearm autotransplantation (FAT) on the quality of life and recurrence of secondary hyperparathyroidism (SHPT) in chronic kidney disease patients.Methods:A total of 104 chronic kidney disease patients with SHPT were enrolled and divided into the PTX (n = 62) and PTX + FAT (n = 42) groups. The operation efficacy was evaluated by analyzing preoperative and postoperative values, including levels of intact parathyroid hormone (iPTH), serum phosphorus, serum calcium, alkaline phosphatase (ALP), calcium-phosphorus product, signs and symptoms, and MOS 36-item short-form health survey (SF-36) scores. Moreover, complications and recurrences were followed up for 12 months after the operation. Binary logistic regression was to present the risk factors for the recurrence of chronic kidney disease patients with SHPT.Results:Compared with the preoperative values, the PTX and PTX + FAT groups showed decrease postoperative levels of iPTH, serum phosphorus, serum calcium, calcium-phosphorus product, bone pain, and skin pruritus at all time periods. The PTX and PTX + FAT groups demonstrated decreased ALP, fracture or deformity, and coronary artery calcification at 1 month, decreased short stature at 3 months after the operation but increased SF-36 score after operation. Compared with the PTX group, the level of iPTH decreased and the levels of serum calcium, calcium-phosphorus product increased at 3, 6, and 12 months after the operation in the PTX + FAT group. The levels of ALP, fracture or deformity, short stature, and SF-36 decreased separately at 1 week and 6 and 12 months after the operation, along with the decrease of coronary artery calcification and the recurrence rate, respectively, at 6 and 12 months after the operation in the PTX + FAT group when compared with those in the PTX group. Logistic regression analysis evidenced that the preoperative iPTH level, SF-36 score, and operation type were the risk factors for the recurrence of chronic kidney disease with SHPT.Conclusion:Total PTX combined with FAT is more effective in improving the quality of life and reducing the recurrence of chronic kidney disease with SHPT than PTX alone.

Background: Lactation encompasses the process of milk production and secretion by mammary glands. It significantly influences the levels of serum iron, calcium, and phosphorus, thereby elevating the risks of osteoporosis, malnutrition, and other maternal complications. Objective: the aim of this study was to evaluate serum iron, calcium and phosphorus status in lactating women in Bangladesh. Materials and method: This case control study was carried out in the department of Biochemistry, Mymensingh Medical Collcge, Mymensingh, with the collaboration of the department of Gynaecology and Obstetrics, Mymensingh Medical College Hospital, Mymensingh, during the period of July 2016 to June 2017. A total of 60 apparently healthy lactating women were selected as case and 60 apparently healthy non-lactating women were selected as control. Serum iron, calcium and phosphorus levels were measured for both groups. Statistical analyses of the results were obtained by using Statistical Packages for Social Sciences (SPSS-22) software. Results: The mean ± SD serum calcium levels were estimated to be 7.74±0.67 mg/dL in lactating women and 8.75±0.78 mg/dL in non-lactating women respectively, and the difference was statistically significant (p<0.05). But the serum iron and serum phosphorus were not significantly changed between two groups. Conclusion: There is no significant difference in serum iron and phosphorus levels between lactating and non-lactating women but significantly decreased serum calcium level is observed in lactating women. Delta Med Col J. Jan 2022;10(1): 25-30

The compositional and functional properties of commercial retail and/or wholesale samples (n = 8) of low‐moisture mozzarella, cheddar and analogue (pizza) cheeses were compared. Inter‐and intravariety differences were evident with intravariety differences in composition being relatively large for the analogue cheese. Cheddar had the lowest mean pH and level of expressible serum and the highest mean levels of proteolysis, expressible fat, and serum calcium and nitrogen (p < 0.05). Compared to mozzarella, the analogue cheeses had significantly lower (p < 0.05) mean levels of total protein and serum calcium, higher levels of total calcium and higher cheese pH. The mean stretchability of the melted mozzarella cheese was significantly higher than that of the melted cheddar or analogue cheeses. The melted cheddar had the highest mean flowability and lowest mean apparent viscosity (p < 0.05). The mean flowability and apparent viscosity of the analogue cheese were numerically lower and higher, respectively, than those of mozzarella.

INTRODUCTIONPrimary hyperparathyroidism is not an uncommon disorder in our region. Eighty to 90% of cases of primary hyperparathyroidism are due to solitary parathyroid adenoma, with only 1% due to parathyroid carcinoma. Giant parathyroid adenoma is defined by a tumor weight or >3.5 g. Parathyroid carcinoma should also be considered in patients with giant adenoma. METHODOLOGYCase 1 is a 78-year-old Chinese lady, with underlying hypertension and breast cancer in remission. She presented with dizziness and mild hypercalcemic symptoms. Serum calcium level was 3.61 mmol/L, with intact parathyroid hormone (iPTH) level of 88.2 pmol/L. Neck ultrasonography showed a large right inferior pole parathyroid adenoma, measuring 5.5 cm x 3.0 cm x 6.6 cm. Intraoperatively, a large parathyroid gland weighing 38 g was resected and reported as parathyroid carcinoma with soft tissue and vascular invasion. She developed mild hypocalcemia postoperatively. Case 2 is a 19-year-old Malay lady who presented with bilateral pathologic fractures of the hip and severe hypercalcemic symptoms. Elevated serum calcium (4.18 mmol/L) and iPTH (186 pmol/L) levels were noted. Neck ultrasonography revealed a left parathyroid adenoma measuring 2.2. cm x 1.5 cm x 3.5 cm. Intraoperatively, a 7 gparathyroid gland was resected, which was subsequently reported as parathyroid adenoma. Postoperatively, she developed hungry bone syndrome with prolonged hospital stay (16 days). Repeated iPTH and serum calcium done 6 weeks postoperatively were normal for both patients. RESULTSGiant parathyroid adenoma is a rare entity with distinct manifestations, but may also be asymptomatic. Patients have higher preoperative serum calcium and iPTH levels, with significant occurrence of symptomatic postoperative hypocalcemia, as presented by Case 2. On the other hand, parathyroid carcinoma should also be suspected in a patient with an unusually large tumor, higher serum calcium (>3.5 mmol/L) and iPTH (10 times the normal upper limit) levels, as in Cases 1 and 2. Histopathologic examinations will confirm parathyroid carcinoma. CONCLUSIONIt is important to suspect both cases parathyroid carcinoma or giant adenoma as this will determine the surgical and further management.

A 66-year-old Caucasian man with schizoaffective disorder was admitted to the psychiatric unit for a relapse of psychotic mania. The patient’s syndromal affective and psychotic symptoms had been in remission for the previous 11 years, duringwhich time the patient had been treatedwith lithium, 1200 mg/day, and olanzapine, 15 mg/day. He took no additional medications or supplements andwas otherwise healthy. Four months before admission, routine primary care screening revealed an elevated serum calcium level, at 11.0 mg/dL (reference range, 8.6–10.2 mg/dL). Records showed elevated calcium levels dating back 9 years. Three months before admission, the patient’s serum lithium levelwas 1.0mmol/L (reference range, 0.6–1.2 mmol/L) and his intact parathyroid hormone (iPTH) level was 92.2 pg/mL (reference range, 12–88 pg/mL). His primary care provider conferredwith an endocrinologist, who noted that lithium therapy is a well-documented cause of hypercalcemia and suggested discontinuing lithium. Lithiumwas discontinued and divalproex initiated at 1000 mg/day, 17 days before admission.At admission, the emergency department evaluation noted pressured speech, disorganized thought process, religious preoccupations, paranoia, five sleepless nights, elevated energy, labile mood, and uncharacteristically impulsive behaviors. Laboratory studies showed a serum calcium level of 10.7 mg/dL. Results of physical examination, comprehensive metabolic screening, CBC, and toxicology screeningwere otherwisenormal, aswas thepatient’s thyroidstimulating hormone level. An increase in the dosage of divalproex to 2000 mg/day, along with trials of olanzapine (20 mg/day), haloperidol (15 mg/day), and risperidone (4.5 mg/day), were ineffective in controlling the patient’s mania. The endocrinologydepartmentwas consulted once again to determine the risks and advisability of reinstituting lithium. The consultant recommended a further hypercalcemia workup. On hospital day 10, the patient’s calcium level normalized to 9.8 mg/dL, while his iPTH level was an inappropriately high-normal 76.7 pg/mL. His urinary calcium level was elevated at 362.5mg/24 hours (reference range, 100–300 mg). His 25-hydroxy vitamin D level was noted tobe lowat 21.0ng/mL(reference range, 30–100ng/mL). A technetium-99m sestamibi scan revealed increased uptake in one parathyroid gland, suggestive of adenoma. Bone mineral density testing by DXA (dual-energy X-ray absorptiometry) scan showed mild osteopenia in the left hip only (T-score51.4 SD). ECG results were unremarkable. Based on hypercalciuria and enhanced localized parathyroid uptake, the consultant diagnosed primary hyperparathyroidism. Because it was considered asymptomatic, surgical intervention was not deemed necessary. The consultant concluded that it was a reasonable risk to reinitiate lithium with follow-up monitoring in the endocrinology clinic. Lithium was restarted on hospital day 10 and titrated to the previously effective dosage. The patient’s manic psychosis remitted, and he was discharged on a regimen of lithium, 1200 mg/day, and risperidone, 3 mg/day. The patient remained in psychiatric remission at the 5week and 15-week follow-up appointments. Twelve weeks after discharge, his serum calcium and iPTH levels were again elevated at 10.7 mg/dL and 86.3 pg/mL, respectively, and his serum lithium level was 0.98 mmol/L.

Background: Neonatal hyperbilirubinemia is common morbidity in the first week of life. Approximately 5-10% of them requires intervention like phototherapy and even exchange transfusion. Phototherapy has various adverse effects and hypocalcemia is one of them. Thus assessment of serum calcium levels after phototherapy should be done in neonates with jaundice. Background: Neonatal hyperbilirubinemia is common morbidity in the 1st week of life. Approximately 5-10% of them requires intervention like phototherapy and even exchange transfusion. Phototherapy has various adverse effects and hypocalcemia is one of them. Thus, assessment of serum calcium levels after phototherapy should be done in neonates with jaundice. Objectives were to study prevalence of hypocalcemia in neonates with unconjugated hyperbilirubinemia receiving phototherapy and to observe association of hypocalcemia with duration of phototherapy.Methods: This was a prospective observational study conducted over a period of 18 months among 75 neonates (both term and preterm) in the neonatal intensive care unit of Manipal teaching hospital, Pokhara. Total serum calcium level was measured at 0 hours (control), 12 hours, and after 48 hours and data were analyzed using statistical package for social sciences version 21.Results: Hypocalcemia was found only in term neonates (n=8; 14%). Of those who had hypocalcemia, the majority experienced hypocalcemia after 48 hours of starting phototherapy. The mean difference of total serum calcium level before and after phototherapy in preterm and term neonates was found to be statistically significant. Hypocalcemia was not found to be associated with the duration of phototherapy.Conclusions: The present study concludes that though there is a reduction in the serum calcium with increased duration of phototherapy, however, it does not fall to the level where treatment is required. Hence it is not recommended to monitor serum calcium levels in neonates receiving phototherapy.

Background: Worldwide, rickets had a significant impact on children and adolescents', growth, and development as well as their general health. The fibroblast growth factor 23 (FGF23) gene, which encodes a secreted protein that is related to the fibroblast growth factors, is present in certain forms of rickets. This study aimed to assess the FGF 23 level among different types of rickets.Methods: In this observational study we included 64 children who were divided into four groups: hypophosphatemic rickets: 16 cases, vitamin D resistance: 16 cases, vitamin D deficiency: 16 cases, and normal: 16 cases. We measured parameters including age, weight, height, ionized serum calcium, total serum calcium, alkaline phosphatase, serum phosphorus, vitamin D, parathormone, serum creatinine, and serum FGF23 levels.Results: Ionized and total serum calcium, serum phosphorus, alkaline phosphatase, vitamin D, parathormone, serum creatinine, and serum FGF23 levels showed highly significant differences (P-values < 0.0001). Compared to vitamin D deficiency, hypophosphatemic rickets displayed notably lower levels of serum phosphorus and parathormone. However, the hypophosphatemic rickets group demonstrated significantly higher levels of certain biomarkers in comparison to the vitamin D deficiency group. The prognostic performance of serum FGF23 levels indicated a high area under the curve, with a specificity of 50.0%, and a sensitivity of 93.8% using a cutoff value of 131.5 to identify hypophosphatemic rickets. Conclusions: Our findings highlight the potential of serum FGF23 levels as a diagnostic indicator for hypophosphatemic rickets