Prepartum anionic diet induces hyperchloremic acidosis in high-producing dairy cows without preventing subclinical hypocalcemia / Dieta aniônica pré-parto provoca acidose hiperclorêmica em vacas leiteiras de alta produção mas não evita a hipocalcemia subclínica

In this study we evaluated the effects of the prepartum anionic diet on the electrolyte balance and calcemia of high producing dairy cows in the first days of lactation, and investigated the impact on the frequency of subclinical hypocalcemia (SCH). Sixty healthy Holstein cows, producing 30 kg of milk/day, handled in intensive system (compost barn), were distributed in groups (n=15) according to lactation order: first, second, third, and fourth to sixth. In the last three weeks before calving they received a diet with negative DCAD (-6mEq/100g DM) and high chloride content. After calving, they received a diet with positive DCAD (18mEq/100g DM). Urine pH was measured before calving. Serum Na+, Cl-, K+, and total Ca concentrations, and the strong ion difference (SID3) were determined in samples taken soon after calving (0h), 24, 48, 72 and 96h after. The frequencies of SCH were determined considering the critical value of 2.125mmol/L (8.5mg/dL). Two-way repeated measures ANOVA and chi-square test were used for comparisons. The cows eliminated acidic urine before calving. Na+, K+, Cl-, and SID3 values did not differ between groups. Na+ and K+ did not vary between days; Cl- was elevated at calving and decreased until 72h; and SID3 was reduced at calving and increased up to 48h. The Ca levels were reduced until 24h and increased up to 72h. Cows of third and fourth to sixth lactations presented lower values up to 24h. SCH was observed in almost half of the cows (43.3% to 55%) until 48h. The maintenance of hypocalcemia for three or more consecutive days occurred in 53.3% of third and fourth to sixth lactations cows. Ingestion of a high chloride prepartum anionic diet led to hyperchloremic acidosis and this imbalance was reversed on the second postpartum day. The induced effects on electrolyte and acid-base balances were not able to prevent the occurrence of SCH in the first days of lactation.(AU)

Os objetivos do estudo foram avaliar os efeitos que a dieta aniônica pré-parto provoca sobre o equilíbrio eletrolítico e sobre a calcemia de vacas leiteiras de alta produção nos primeiros dias de lactação, e verificar o impacto sobre a frequência da hipocalcemia subclínica (HSC). Sessenta fêmeas hígidas HPB, com produção de 30 kg de leite/dia, manejadas em sistema intensivo (compost barn), foram distribuídas por grupos (n=15) de acordo com a ordem de lactação: primeira, segunda, terceira e quarta a sexta. Nas três semanas pré-parto receberam dieta com DCAD negativa (-6mEq/100g MS) e teor de cloreto elevado. Após o parto receberam dieta com DCAD positiva (18mEq/100g MS). O pH da urina foi mensurado antes do parto. As concentrações séricas de Na+, Cl-, K+ e Ca total e a diferença de íons fortes (SID3) foram determinadas em amostras colhidas ao parto (0h), 24, 48, 72 e 96h após. As frequências de HSC foram determinadas considerando-se o valor crítico de 2,125mmol/L (8,5mg/dL). ANOVA de medidas repetidas e teste de qui-quadrado foram empregados para as comparações. As vacas eliminavam urina ácida antes do parto. Os valores de Na+, K+, Cl- e SID3 não diferiram entre os grupos. Na+ e K+ não variaram entre os dias; Cl- era elevado ao parto e diminuiu até 72h; e SID3 era reduzida ao parto e aumentou até 48h. A calcemia era reduzida até 24h e se elevou até 72h. Vacas de terceira e de quarta a sexta lactações apresentaram valores mais baixos até 24h. A HSC foi observada em quase metade das vacas (43,3% a 55%) até 48h. A manutenção de hipocalcemia por três ou mais dias seguidos ocorreu em 53,3% das vacas de terceira e de quarta a sexta lactações. A ingestão de dieta aniônica pré-parto com alto teor de cloreto provocou acidose hiperclorêmica e este desequilíbrio se reverteu no segundo dia pós-parto. Os efeitos induzidos sobre os equilíbrios eletrolítico e ácido base não foram capazes de prevenir a ocorrência de HSC nos primeiros dias da lactação.(AU)

Osteoactivos en insuficiencia renal crónica avanzada: a propósito de un caso / Osteoactive in advanced chronic renal failure: a case report

El propósito de la terapia en el desorden del metabolismo óseo mineral asociado a la enfermedad renal crónica (IRC) consiste en restaurar el balance mineral, y, en la osteoporosis, mantener o aumentar la masa ósea. Ambas terapias tratan de evitar la fractura ósea. La mayoría de los osteoactivos están contraindicados en la insuficiencia renal crónica avanzada (estadios 4 y 5), y las terapias son empíricas. Algunos autores opinan que sin anomalías bioquímicas del desorden del metabolismo óseo mineral asociado a la enfermedad renal crónica avanzada se podría intentar el tratamiento estándar para la osteoporosis. Antes de intentar la terapia osteoactiva se debe corregir el desorden mineral óseo que pudiera presentarse asociado a la IRC, y en la indicación del tipo de osteoactivo se sugiere seleccionar al paciente según su estado óseo. Se aconseja que la administración de los antirresortivos se realice a dosis menores con respecto a los que tienen mejor función renal junto con aportes adecuados de calcio y vitamina D, antes y durante el tratamiento para prevenir el riesgo de severas hipocalcemias y un efecto óseo excesivo. Se presenta el caso clínico de una mujer de 65 años, con diagnóstico de osteoporosis de etiología multifactorial, fractura de pelvis, múltiples fracturas vertebrales e insuficiencia renal crónica avanzada, entre otras comorbilidades, y probable enfermedad ósea adinámica. Recibió inicialmente terapia con teriparatide y luego con denosumab, complicándose con hipocalcemia asintomática. (AU)

The purpose of therapy for the bone mineral metabolism disorder associated with chronic kidney disease is to restore the mineral balance; and to maintain or increase bone mass in osteoporosis. The goal of both types of therapy is to avoid bone fractures. Most antiosteoporotic drugs are contraindicated in advanced chronic renal failure (CRF) stages 4 and 5, and the therapies are empirical. Some authors believe that without biochemical abnormalities of the mineral bone metabolism disorder associated with advanced chronic kidney disease, standard treatment for osteoporosis could be attempted. Before attempting antiosteoporotic therapy, the bone mineral disorder that may be associated with CRF must be corrected, and in the indication of the type drug it is suggested that the patient be selected according to their bone status. It is advised that the administration of anti-resorptives be performed at lower doses in individuals with poor renal function compared to those with better renal function together with adequate calcium and vitamin D, before and during treatment to prevent the risk of severe hypocalcemia, and an excessive bone effect. We present the clinical case of a 65-year-old woman with a diagnosis of osteoporosis of multifactorial etiology, pelvic fracture, multiple vertebral fractures and advanced chronic renal failure, among other comorbidities and probable adynamic bone disease. The patient received initial therapy with teriparatide and followed by denosumab administration and exhibited asymptomatic hypocalcemia. (AU)

Factores perioperatorios relacionados con la hipocalcemia postiroidectomía total / Perioperative factors related to hypocalcemia after total thyroidectomy / Fatores peri-operatórios envolvidos com hipocalcemia pós tireoidectomia total

INTRODUCCIÓN: Pretendemos analizar qué factores son los que determinan la aparición de hipocalcemia en el postoperatorio de la tiroidectomía total, mediante análisis estadístico, utilizando el paquete SPSS versión 25. MATERIAL Y MÉTODO: Se han estudiado 105 pacientes intervenidos de tiroidectomía total en nuestro centro durante los años 2015 a 2017. RESULTADOS: Se trataba de 85 mujeres (81%) y 20 hombres (19%), con edades comprendidas entre 30 y 91 años, con media de 57 años. El diagnóstico anatomopatológico más frecuente fue patología benigna (82,9%), con 87 casos...

INTRODUCTION: We intend to analyze which factors are responsible for the appearance of hypocalcemia in the postoperative period of total thyroidectomy, using statistical analysis with the SPSS version 25 package. MATERIAL AND METHOD: We studied 105 patients who underwent total thyroidectomy in our center during the years 2015 to 2017. RESULTS: There were 85 women (81%) and 20 men (19%), aged between 30 and 91 years, with an average of 57 years. The most frequent anatomopathological diagnosis was benign pathology (82.9%), with 87 cases…

INTRODUÇÃO: Pretendemos analisar quais são os fatores que determinam a ocorrência de hipocalcemia na tireoidectomia total no pós-operatório, utilizando análise estatística usando SPSS versão 25. MATERIAL E MÉTODO: Foram estudados 105 pacientes que foram submetidos a tireoidectomia total em nosso centro ao longo dos anos 2015 a 2017. RESULTADOS: Foram 85 mulheres (81%) e 20 homens (19%), com idade entre 30 e 91 anos, com média de 57 anos. O diagnóstico anatomopatológico mais frequente foi a patologia benigna (82,9%), com 87 casos...

Use of prophylactic oral calcium after total thyroidectomy: a prospective study

ABSTRACT Objective The aim of this study was to evaluate the use of prophylactic oral calcium after total thyroidectomy in the prevention of symptomatic hypocalcemia, and to develop a rational strategy of oral calcium supplementation following this type of surgery. Subjects and methods Prospective study including 47 patients undergoing total thyroidectomy from January 2007 to February 2012. The patients were allocated to one of the following groups: I (no postoperative calcium) or II (oral calcium 3 g per day). Oral calcium was started at the first postoperative day and administered until the sixth postoperative day. The patients were followed up for a minimum of 6 months and evaluated with a minimum of five measurements of ionized calcium: preoperative, 16 hours after surgery, seventh postoperative day, and at postoperative days 90 (PO90) and 180 (PO180). The cohort included three men and 44 women, of whom 24 (51.9%) had benign thyroid disease, and 23 had suspected or confirmed malignant disease. Results When compared with Group II, Group I had significantly higher rates of postoperative biochemical hypocalcemia at PO1 and PO180, and of symptomatic hypocalcemia at PO1, PO7, and PO90. Other data were not significantly different between the groups. Conclusion We conclude that postoperative calcium supplementation effectively prevents symptomatic and biochemical hypocalcemia after total thyroidectomy, and can be safely used after this procedure. The presented strategy of oral calcium supplementation may be implemented in a viable manner.

Postoperative calcium levels as a diagnostic measure for hypoparathyroidism after total thyroidectomy

ObjectiveThe aim of the present study was to identify a fast, efficient and low-cost method to diagnose hypoparathyroidism after total thyroidectomy.Materials and methodsOne hundred and forty medical records, which contained patients’ clinical and laboratory data, were retrospectively analyzed. Patient parathyroid hormone values, which were obtained immediately following operation, were compared with their ionized calcium levels the morning after surgery. This comparison was used to examine the correlation between the two variables in predicting hypoparathyroidism because measuring calcium levels is low-cost and more available in the hospitals compared to measuring parathormone (PTH) levels.ResultsThere was a positive and statistically significant correlation between PTH and ionized calcium values (Pearson correlation coefficient, r = 0.456; p < 0.0001). The values of first postoperative day ionized calcium levels (stratified by the 1.10 mmol/l cut-off value) were tested as a diagnostic measure for hypoparathyroidism, and a PTH < 15 pg/mL obtained immediately following operation served as a reference. This analysis showed that ionized calcium levels measured on the first postoperative day had a sensitivity of 45.6% (95% CI 30.9-61.0%), a specificity of 88.9% (95% CI 80.5-94.5%) and an accuracy of 76.7% (95% CI 68.7-83.5%) as a diagnostic measure for hypoparathyroidism.ConclusionIn conclusion, we demonstrated that patients who had high ionized calcium levels on the first postoperative day also had high PTH levels immediately following operation and, therefore, they had lower rates of hypoparathyroidism.

Cost-effectiveness analysis regarding postoperative administration of vitamin-D and calcium after thyroidectomy to prevent hypocalcaemia / Análisis de costo-efectividad de la administración postoperatoria de Vitamina D y calcio después de tiroidectomía para la prevención de la hipo calcemia

Objective Hypocalcaemia is a frequently arising complication following total thyroidectomy. Routine postoperative prophylactic administration of vitamin D or metabolites and calcium reduce the incidence of symptomatic hypocalcaemia; this article reports evaluating its cost-effectiveness in Colombia. Methods Meta-analysis was used for comparing the administration of vitamin D or metabolites to oral calcium or no treatment at all in patients following total thyroidectomy and a cost-effectiveness analysis was designed based on a decision-tree model with local costs. Results The OR value for the comparison between calcitriol and calcium compared to no treatment and to exclusive calcium treatment groups was 0.32 (0.13-0.79 95 %CI) and 0.31 (0.14-0.70 95 %CI), respectively. The most cost-effective strategy was vitamin D or metabolites and calcium administration, having a US $0.05 incremental cost-effectiveness ratio. Conclusion Prophylactic treatment of hypocalcaemia with vitamin D or metabolites + calcium or calcium alone is a cost-effective strategy.

Objetivos La hipo calcemia es la complicación más frecuente después de tiroidectomía. La administración profiláctica de vitamina D o metabolitos y calcio reduce la incidencia de hipocalcémia sintomática. Se evalúa su costo-efectividad en Colombia. Materiales y métodos Utilizamos la información de un meta-análisis que comparó la administración de vitamina D o metabolitos contra calcio no tratamiento en pacientes llevados a tiroidectomía total y diseñamos un análisis de costo-efectividad basados en un modelos de decisiones con costos locales. Resultados El valor del OR para la comparación entre calcitriol y calcio comparado con no tratamiento o calcio exclusivo fue de 0.32 (95 % IC, 0.13- 0.79) y 0.31 (95 % IC, 0.14-0.70), respectivamente. La estrategia más costo-efectiva fue la administración de vitamina D o metabolitos y calcio, con una relación de costo-efectividad incremental de US $0.05. Conclusiones El tratamiento profiláctico de la hipo calcemia con vitamina D o metabolitos y calcio o calcio exclusivo después de tiroidectomía total es una estrategia costo-efectiva.

Bisfosfonatos podem minimizar a fome óssea após paratireoidectomia em pacientes com hiperparatireoidismo primário e osteíte fibrosa cística / Bisphosphonates can reduce bone hunger after parathyroidectomy in patients with primary hyperparathyroidism and osteitis fibrosa cystica

OBJETIVO: Avaliar o efeito dos bisfosfonatos na hipocalcemia pós-paratireoidectomia em pacientes com osteíte fibrosa cística. MÉTODOS: Foram revisados os prontuários de seis pacientes que fizeram uso pré-operatório de bisfosfonatos. RESULTADOS: A idade média foi de 35,6 ± 10,5 anos; cálcio sérico 13,51 ± 0,87 mg/dL; PTHi 1.389 ± 609 pg/mL. O valor médio de deoxipiridinolina urinária (UDPD) de três pacientes foi de 131 ± 183 nmol/mmol Cr; e do C-telopeptídeo (CTX) de 2.253 ± 1.587 pg/mL. Densitometria óssea (escore T) obteve média de 0,673 ± 0,150 g/cm² (-4,42 ± 1,23) em coluna lombar (CL); 0,456 ± 0,149 g/cm² (-5,58 ± 1,79) em colo de fêmur (CF) e 0,316 ± 0,055 g/cm² (-5,85 ± 0,53) em rádio 33 (RD). Um paciente recebeu alendronato oral 30 mg/dia por 4 semanas; o cálcio diminuiu de 14 para 11,6 mg/dL e UDPD de 342 para 160 nmol/mmol Cr. Outro usou alendronato oral 20 mg/dia por 6 semanas; o cálcio baixou de 14 para 11,0 mg/dL e UDPD de 28,8 para 14 nmol/mmol Cr. Um paciente recebeu pamidronato 90 mg endovenoso antes da cirurgia. Um paciente usou alendronato oral 140 mg/semana por 6 semanas; o cálcio diminuiu de 13,7 para 12,3 mg/dL e o CTX de 2.160 para 1.340 pg/mL. Outro usou alendronato VO 140 mg/semana por 6 semanas; o cálcio baixou de 14,3 para 14,1 mg/dL; o CTX não reduziu. Um paciente fez ibandronato 150 mg 10 dias antes da cirurgia; o CTX caiu em 62 por cento. Nenhum paciente desenvolveu hipocalcemia grave na primeira semana do pós-operatório. Um ano após a cirurgia, houve aumento de 40 ± 29 por cento em CL, 86 ± 39 por cento em CF e 22 ± 11 por cento em RD. CONCLUSÃO: O uso pré-operatório de bisfosfonatos parece atenuar a fome óssea sem impedir o marcante aumento de massa óssea no seguimento da paratireoidectomia.

OBJECTIVE: To assess the effect of bisphosphonates on post-parathyroidectomy hypocalcemia in patients with osteitis fibrosa cystica. METHODS: Review of the medical records of six patients using bisphosphonates preoperatively. RESULTS: Mean age was 35.6 ± 10.5 years; serum calcium = 13.51 + 0.87 mg/dL; iPTH = 1,389 + 609 pg/mL. The mean value of urine deoxypyridinoline (UDPD) of three patients was 131 ± 183 nmol/mmol Cr, and of C-telopeptide (CTX), 2,253 ± 1,587 pg/mL. The mean values of bone densitometry (T score) were as follows: 0.673 ± 0.150 g/cm² (-4.42 ± 1.23) in lumbar spine (L2-L4); 0.456 ± 0.149 g/cm² (-5.58 ± 1.79) in the femoral neck; and 0.316 ± 0.055 g/cm² (-5.85 ± 0.53) in radius 33. Patient 1 received oral alendronate, 30 mg/day for four weeks; his calcium decreased from 14 to 11.6 mg/dL, and his UDPD from 342 to 160 nmol/mmol Cr. Patient 2 received oral alendronate, 20 mg/day for six weeks; his calcium decreased from 14 to 11.0 mg/dL and his UDPD from 28.8 to 14 nmol/mmol Cr. Patient 3 received intravenous pamidronate, 90 mg prior to surgery. Patient 4 received oral alendronate, 140 mg/week for six weeks; her calcium decreased from 13.7 to 12.3 mg/dL and her CTX from 2,160 to 1,340 pg/mL. Patient 5 received oral alendronate, 140 mg/ week for six weeks; her calcium levels dropped from 14.3 to 14.1 mg/dL; her CTX did not change. Patient 6 received ibandronate, 150 mg, ten days prior to surgery; his CTX reduced by 62 percent. No patient developed severe hypocalcemia in the first postoperative week. One year after surgery, the mean gain in bone mineral density was 40 percent ± 29 percent in L2-L4, 86 ± 39 percent in the femoral neck, and 22 percent ± 11 percent in radius 33. CONCLUSION: The preoperative use of bisphosphonates seems to attenuate bone hunger without preventing a significant increase in bone mass in the follow-up of parathyroidectomy.

[ rare case report of the Thyroidea Ima and the thymic arteries common trunk, arising from the brachiocephalic artery]

The Thyroidea Ima artery [The artery of Neubauer], was recognized and described by Neubauer in 1786. This artery which was described in the all anatomical textbooks may arise from the arch of aorta, brachiocephalic trunk or other arteries in the upper mediastina. It is considered as a compensatory artery when the other thyroidal vessels showed deficiencies. This artery showed greatly variation in size and gave some anastomotic branches to the thymic artery. The thymic artery arised from the anterior mediastinal branch of the internal thoracic artery but, may also arise from the brachiocephalic trunk, arch of aorta, common carotid or the main trunk of the internal thoracic artery. Its origin from the thyroidea ima is rare. This rare case was seen in a 65 years old male cadaver, the common trunk of the thyroida ima and the thymic arteries originated from the brachiocephalic artery. After a short course it divided into two branches: an ascending [thyroida ima] and descending [thymic] branches. The thyroidea ima artery turned to left and upward to the lower border of the isthmus of thyroid gland. At this point it sent a branch to the lower part of the left lobe of the thyroid which penetrated it deeply and ended in the left inferior parathyroid gland. The main branch continued its course upward to the upper border of the thyroidal isthmus and divided into right and left branches. Each of these branches, after sending a great anastomotic branch to the superior thyroidal artery of their own side, terminated as several small branches in the upper part of the right and left lobes of the thyroid gland. The thymic artery continued its course downward for about three centimeters and ended as two branches in the right and left lobes of thymus. The thyroid gland of this cadaver was larger than the normal ones and the thymus was also clearly noticeable with right and left bobs. According to the embryonic origin and the developmental processes of the inferior parathyroid glands and the Thymus from the neighboring pharyngeal pouches, their blood supply from a common trunk will be acceptable especially when these two glands show some degree of enlargement as shown in this case. In the cases of thyroidectomies, when a surgeon is going to resect an enlarged thyroid gland, the presence of thyroidea ima artery and its branches to the lower part of lobes of thyroid gland would be a useful guidance to identify the inferior parathyroid glands an save them for the prevention of the next hypocalcemia

Manejo postoperatorio en pacientes intervenidos de tiroidectomía total / Postoperation management in patients in surgery of total thyroidectomy

Con el objeto de evaluar las principales complicaciones tras la tiroidectomía total se realizó un estudio prospectivo histórico sobre 256 pacientes operados en nuestro servicio entre los años 1985 y 1997. La mayoría de ellos fueron intervenidos por enfermedades tiroideas benignas. Encontramos hipocalcemia permanente en el 1,5 por ciento de los casos y parálisis recurrenciales unilaterales definitivas en el 0,9 por ciento. Nuestro índice de mortalidad fue del 0,4 por ciento. Otras complicaciones evaluadas incluyeron: serohematoma, hemorragia postoperatoria, infección de la herida y embolismo pulmonar

Hipocalcemia, hipomagnesemia e hipofosfatemia en pacientes pediátricos críticamente enfermos

Las alteraciones en las concentraciones séricas de iones como el calcio, el magnesio y el fósforo han sido estudiadas extensamente en los últimos años en pacientes críticamente enfermos y han sido asociadas con aumento de la mortalidad. En los reportes de Broner, de valores de electrolitos en pacientes pediátricos, al ingreso en una unidad de cuidado intensivo (1), la alteración electrolítica más frecuente fue alteración en la concentración de magnesio sérico (43.4 por ciento) de los pacientes, estando 25.6 por ciento de éstos por debajo y 17.8 por ciento por encima de los valores considerados como normales (0.74 - 0.95 mmol/dl) y encontrándose además una rata significativamente diferente de mortalidad (38 por ciento) en los pacientes hipermagnesémicos. Se encontró además 16.5 por ciento de alteración en los valores de calcio ionizado y una correlación estadísticamente significativa entre la presencia de hipocalcemia ionizada y mayor mortalidad. Los valores de calcio total no se correlacionaron con los valores de calcio iónico. Otro estudio realizado por Cárdenas-Rivero y cols (2), reporta una incidencia de hipocalcemia ionizada de 18 por ciento entre pacientes pediátricos que ingresan a una UCIP, correlacionando además la presencia de hipocalcemia ionizada con una mayor severidad de la enfermedad y una mayor mortalidad. El reporte de Reinhart y Desbiens (3) muestra una incidencia de 20 por ciento de hipomagnesemia y de 9 por ciento de hipermagnesemia en adultos que ingresan a una UCI médica. Se ha reportado una importante incidencia de hipofosfatemia en pacientes adultos que ingresan a unidades de cuidado intensivo por trauma como en el estudio de Daily (4), que sugiere la administración rutinaria de infusión de fosfato a estos pacientes para evitar la presencia de hipofosfatemia. Se conoce además la importancia de la fosfatemia como causante de muchas de las manifestaciones que presentan pacientes desnutridos a los que se les administra una dieta hipercalórica. Todos los anteriores datos nos llevan a revisar la fisiopatología de estas alteraciones, para poder detectar y tratar oportunamente sus manifestaciones.