Significance of QTc interval in chronic hypoparathyroidism and its correlates.

CONTEXT: Hypocalcemia predisposes patients with chronic hypoparathyroidism (cHypoPT) to an increased risk of QTc prolongation and life-threatening arrhythmias. Information on clinical and biochemical correlates of QTc in cHypoPT is limited. DESIGN AND SETTING: Observational cohort study at tertiary-care-center. SUBJECTS AND METHODS: Eighty-eight non-surgical cHypoPT (mean age 44.1 ± 15.4 years, 45 males) were assessed for QTc interval and its possible correlates including arrhythmic symptoms (palpitation/giddiness/syncope), serum total-calcium, phosphate, 25(OH)D and iPTH. RESULTS: The mean QTc in HypoPT cohort was 428 ± 34 ms with 13.6% having prolonged QTc. There was a significant inverse correlation between QTc interval and serum total-calcium measured on the same day (r = -0.43, p < 0.001). The mean serum total-calcium was significantly lower in patients with prolonged QTc (7.05 ± 1.94 vs. 8.49 ± 1.01 mg/dL, p = 0.02). 21.6% of cHypoPT patients had arrhythmic symptoms. They had significantly higher mean QTc (p = 0.02) and also tended to have lower mean serum total-calcium during follow-up (p = 0.06). In multivariable regression, female gender, higher current-age, higher BMI, and low serum total-calcium showed significant association with prolonged QTc. For every mg/dL decrease in serum total-calcium, QTc increased by 13 ms. Receiver-operating-characteristic analysis revealed serum total-calcium at cut-off of 8.3 mg/dL discriminated prolonged QTc with area-under-curve being 0.72 [95% CI: 0.51,0.93]. CONCLUSION: One-fifth of cHypoPT had arrhythmic symptoms and a significant proportion had prolonged QTc. This highlights the need for close monitoring of cHypoPT patients for arrhythmic symptoms and QTc prolongation. The serum total-calcium should be maintained to at least 8.3 mg/dL to minimize the risk of potentially life-threatening arrhythmia in cHypoPT.

A minimal kinetic model for the interpretation of complex catalysis in single enzyme molecules.

Multi-exponential waiting-time distribution and randomness parameter greater than unity ascribe dynamic disorder in single-enzyme catalysis corroborated to the interplay of transforming conformers [English et al., Nat. Chem. Biol., 2006, 2, 87]. The associated multi-state model of enzymatic turnovers with statically heterogeneous catalytic rates misdescribes the non-linear uprising of the randomness parameter from unity in relation to the attributes of the fall-offs of the waiting-time distribution at different substrate concentrations. To resolve this crucial issue, we first employ a comprehensive stochastic reaction scenario and further rationalize and work out the minimal indispensable dynamic-disorder model that ensures the foregoing relationship upon comparison with the data. We elucidate that specific disregard for the transition rate coefficients in the multi-state model on account of the especially slow conformational transitions is the underlying reason for not achieving interrelation between the observables.

Innate differences in the molecular signature of normal inferior & superior human parathyroid glands: potential implications for parathyroid adenoma.

Primary hyperparathyroidism is a common endocrine disorder. Interestingly, the majority (75%) of parathyroid tumors are localized to the inferior parathyroid glands. To date, the reason for this natural bias has not been investigated. We assessed the global gene expression profile of superior and inferior glands obtained from forensic autopsies. The genes with significant differential expression between superior and inferior parathyroids were further assessed by RT-PCR in 19 pairs. As an iterative approach, additional genes with an established role in parathyroid disorders, i.e., CASR, MAFB, PAX9, TBCE, TBX1, VDR, MEN1, CCND1, and CDC73 were also evaluated by RT-PCR in all 19 pairs of superior and inferior parathyroid glands. Seven homeobox genes, namely HOXA4, HOXA5, HOXBAS3, HOXB4, HOXB6, HOXB9, IRX1, and one encoding for ALDH1A2 showed a lower expression in the inferior parathyroid glands than in the superior. Conversely, SLC6A1 showed a higher expression in the inferior glands. Of the nine genes with significant differential mRNA expression among superior and inferior glands HOXB9, HOXB4 and IRX1 could be detected by western blotting/mass spectrometry. The study is the first to show the differential expression of nine genes HOXA4, HOXA5, HOXBAS3, HOXB4, HOXB6, HOXB9, IRX1, ALDH1A2, and SLC6A1 in inferior versus the superior parathyroid glands. This could have potential implications for the preferential localization of parathyroid tumors to the inferior parathyroid glands as observed in patients with primary hyperparathyroidism.

Coronary artery disease and its vascular associates in patients with chronic nonsurgical hypoparathyroidism.

OBJECTIVE: Patients with chronic hypoparathyroidism (cHypoPT) are prone to intracranial-calcification, cataract and nephrocalcinosis. In this study, we systematically investigated the possibility of increased coronary artery calcification (CAC) and coronary artery disease (CAD) in them. DESIGN: Cross-sectional. PATIENTS AND MEASUREMENTS: Ninety-four nonsurgical cHypoPT (M:F = 50:44; age = 45 ± 15 years) with 18.6 ± 9.3 years of illness were assessed. Those with dyspnoea, angina, syncope, abnormal electrocardiogram, echocardiography or significant CAC underwent coronary angiography or myocardial-perfusion-stress imaging. Their lipid parameters and high-sensitivity C-reactive protein (hsCRP) were compared with age-matched healthy controls (Group A, n = 101). The prevalence of CAC in cHypoPT was compared with that of subjects referred from cardiology-clinics (Group B, n = 148, age = 52 ± 11 years). RESULTS: One of 94 cHypoPT had known CAD. On screening, 17 cHypoPT required evaluation for CAD. Two of 17 had severe coronary stenosis, and 12 showed subclinical CAD. CAC and aortic-valve calcification occurred in 21.5% and 11.8%. Clinical and subclinical CAD, CAC and aortic-valve calcification in cHypoPT ≥50 years of age was 8.1%, 27.0%, 52.8% and 27.8%, respectively. Frequency of age-adjusted CAC was comparable between cHypoPT and control Group B (30.2% vs. 30.7%, p = .93). Elevated hsCRP was higher in cHypoPT than in controls A (52% vs. 32%, p < .01). Factors associated with CAD in cHypoPT were CAC and hypertension. However, CAD and CAC showed no association with long-term calcemic or phosphatemic control and intracranial-calcification in cHypoPT. CONCLUSIONS: Clinical and subclinical CAD was observed in 3.2% and 12.8% of cHypoPT patients. The increased prevalence of CAD, CAC and aortic-valve calcification in cHypoPT above 50 years of age suggested their careful cardiac evaluation during follow-up.

Bone Mineral Density, Bone Microarchitecture and Vertebral Fractures in Male Patients with Alcohol Use Disorders.

AIM: To investigate abnormalities in bone mineral density, trabecular bone score and vertebral fractures in male patients with alcohol use disorder to understand the impact on bone health. METHODS: The study subjects included 134 male patients. Controls were 134 age matched healthy males. Assessments were made of the bone mineral density (BMD), trabecular bone score (TBS) and vertebral morphometry (VFA) for vertebral fractures. Biochemical measurements included serum total T4, thyroid stimulating hormone (TSH), parathyroid hormone (PTH) and 25- Hydroxyvitamin D 25(OH) D. RESULTS: The mean BMD at total forearm, proximal forearm (or distal 1/3) and mid forearm was significantly higher in the alcohol use disorders (AUD) group than the controls (P < 0.01). Around 15% of patients with AUD had VFs compared with 9.0% of the healthy controls (P = 0.19). For each kg/m2 gain in body mass index (BMI), lumbar spine and total hip BMD increased by 0.009 and 0.014 g/cm2, respectively. Lumbar and hip BMD decreased by 0.002 and 0.003 g/cm2 per year increase in duration of alcohol used. For every 5 years increase in age of the patients the odds of having VFs increased by 39% (odds ratio 1.393 [95% confidence interval = 1.031-1.881, P = 0.03]). CONCLUSION: The findings of the current study suggest that persons with AUD in third and fourth decades of life, with BMI in normal range and with alcohol use disorder duration of around one decade might have no major alteration in BMD and TBS. Impact of alcohol use in this population was manifest by marginal increase in the prevalence of mild grade of vertebral fractures, mostly in the thoracic region.

A Revisit to Turnover Kinetics of Individual Escherichia coli ß-Galactosidase Molecules.

Single-molecule experiments on ß-galactosidase from Escherichia coli that catalyzes the hydrolysis of resorufin-ß-d-galactopyranoside revealed important observations like fluctuating catalytic rate, memory effects arising from temporal correlations between the enzymatic turnovers and nonexponential waiting time distributions. The root cause of the observed results is intrinsic fluctuations among the different conformers of the active species, during the course of the reaction, thereby imparting dynamic disorder in the system under investigation. Originally, a multistate stochastic kinetic theory was employed that, despite satisfying the measured waiting time distributions and the mean waiting times at different substrate concentrations, yields a constant estimate of the randomness parameter. Inevitably, this manifests a strong disagreement with the substrate-concentration-dependent time variations of the said distribution, which at the same time misinterprets the measured magnitudes of the randomness parameter at lower concentrations. Here, we suggest a dual approach to the single-enzyme reaction, independently, making important improvements over the parent study and the recently suggested two-state stochastic analyses followed by quantitative rationalization of the experimental data. In the first case, an off-pathway mechanism satisfied the Michaelis-Menten equation under the circumstance of prevailing disorder while tested against the single-molecule data. However, recovery of randomness data in the lower-concentration regime, albeit primarily marks a significant refinement, a qualitative agreement at the growing concentrations seems to be reasoned by an account of switching among the limited numbers of discrete conformers. Consequently, in the second case, we circumvented the conventional way of approaching the enzyme catalysis and mapped the dynamics of structural transitions of the biocatalyst with the temporal fluctuations of the spatial distance between the different locations along a coarse-grained polymer chain. Exploiting a general mechanism for dynamic disorder, a reaction-diffusion formalism yielded an analytical expression for the waiting time distribution of the enzymatic turnovers, from which the mean waiting time and the randomness parameter were readily determined. Application of our results to the findings of the experiment on single ß-galactosidase shows a quantitative agreement in each case. This soundly validates the usefulness of accounting for a more rigorous microscopic description pertinent to the conformational multiplicity in rationalizing the real-time data over the routine state-based sketch of the reaction system.

Osteogenic Mechanisms of Basal Ganglia Calcification and its ex vivo Model in the Hypoparathyroid Milieu.

CONTEXT: Basal-ganglia calcification (BGC) is common (70%) in patients with chronic hypoparathyroidism. Interestingly, cortical gray matter is spared from calcification. The mechanism of BGC, role of hyperphosphatemia, and modulation of osteogenic molecules by parathyroid hormone (PTH) in its pathogenesis is not clear. OBJECTIVE: We assessed the expression of a large repertoire of molecules with proosteogenic or antiosteogenic effects, including neuroprogenitor cells in caudate, dentate, and cortical gray matter from normal autopsy tissues. The effect of high phosphate and PTH was assessed in an ex vivo model of BGC using striatum tissue culture of the Sprague-Dawley rat. METHODS: The messenger RNA and protein expression of 39 molecules involved in multiple osteogenic pathways were assessed in 25 autopsy tissues using reverse-transcriptase polymerase chain reaction, Western blot, and immunofluorescence. The striatal culture was maintained in a hypoparathyroid milieu for 24 days with and without (a) high phosphate (10-mm ß-glycerophosphate) and (b) PTH(1-34) (50 ng/mL Dulbecco's modified Eagle's medium-F12 media) for their effect on striatal calcification and osteogenic molecules. RESULTS: Procalcification molecules (osteonectin, ß-catenin, klotho, FZD4, NT5E, LRP5, WNT3A, collagen-1α, and SOX2-positive neuroprogenitor stem cells) had significantly higher expression in the caudate than gray matter. Caudate nuclei also had higher expression of antiosteogenic molecules (osteopontin, carbonic anhydrase-II [CA-II], MGP, sclerostin, ISG15, ENPP1, and USP18). In an ex vivo model, striatum culture showed an increased propensity for calcified nodules with mineral deposition similar to that of bone tissue on Fourier-transformed infrared spectroscopy, alizarin, and von Kossa stain. Mineralization in striatal culture was enhanced by high phosphate and decreased by exogenous PTH through increased expression of CA-II. CONCLUSION: This study provides a conceptual advance on the molecular mechanisms of BGC and the possibility of PTH therapy to prevent this complication in a hypoparathyroid milieu.

Alfacalcidol vs Calcitriol in the Management of Patient With Hypoparathyroidism: A Randomized Controlled Trial.

CONTEXT: Alfacalcidol and calcitriol are commonly used for managing hypoparathyroidism. Their relative merits have not been systematically assessed. OBJECTIVE: We compared the effect of alfacalcidol and calcitriol on phosphatemic control, hypercalciuria, and associated factors in idiopathic-hypoparathyroidism (IH). DESIGN AND SETTING: Open-label randomized controlled trial, tertiary care center. SUBJECTS AND METHODS: IH patients with optimal calcemic control on alfacalcidol were continued on the same (n = 20) or switched to calcitriol (n = 25) at half of the ongoing alfacalcidol dose. The dose was adjusted during follow-up to maintain serum total calcium between 8.0 and 9.5 mg/dL. Serum calcium, phosphorus, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, 24-h urine calcium-to-creatinine ratio, and fractional excretion of phosphorus (FEPh) were measured at baseline and 6 months. Plasma intact-FGF23 was measured at final follow-up. RESULT: Patients receiving alfacalcidol and calcitriol had comparable serum calcium at 6 months (8.7 ±â€…0.4 vs 8.9 ±â€…0.4 mg/dL, P = 0.13). Their median [interquartile range (IQR)] dose at 6 months was 2.0 (1.0-2.5) and 0.75 (0.5-1.0) µg/d, respectively. Serum 1,25(OH)2D levels were physiological in both (35.3 ±â€…11.6 and 32.3 ±â€…16.9 pg/mL). Serum phosphate and calcium excretion were comparable in 2 arms. A majority had hyperphosphatemia (75% vs 76%), hypercalciuria (75% vs 72%), and elevated FGF23 (116 ±â€…68 and 113 ±â€…57 pg/mL). Age showed significant independent association with plasma FGF23 (ß = 1.9, P = 0.001). Average FEPh was low despite high FGF23. CONCLUSION: At optimal calcium control, both alfacalcidol and calcitriol lead to comparable but high serum phosphate levels, hypercalciuria, physiological circulating 1,25(OH)2D, and elevated FGF23. Further studies are required to systematically investigate other treatment options.

Kinetics of Allosteric Inhibition of Single Enzyme by Product Molecules.

Single-molecule experiment probed the catalytic conversions of Amplex Red to resorufin by horseradish peroxidase in which the product molecules were found to act as the allosteric inhibitor for the individual enzyme. While broad distributions of the initial reaction velocities and the number of product molecules required to cease the reaction unraveled the underlying dynamic disorder in the reaction pathway, bulk experimental measurements established the particularity of noncompetitive inhibition of the enzyme species. In this work, to rationalize the observed phenomena, we present a stochastic kinetic model of the enzymatic reaction taking into account the inhibitions of the enzyme and enzyme-substrate complex in the circumstance of their structural fluctuations. Starting from a chemical master equation that can further be reduced into a set of ordinary differential equations for the case of single-enzyme kinetics, we derived an analytical expression for the turnover time distribution, the first moment of which yielded the mean turnover time. The inverse of the latter showed excellent agreement with the bulk data of the initial enzymatic velocities measured in the presence of varying inhibitor concentrations. This supports the observed nature of inhibition which we further confirmed by constructing double-reciprocal plots for the inhibited kinetics. In addition, we successfully recovered ensemble data from another experiment that redesigned the aforesaid single-molecule catalysis to investigate the effects of molecular crowders on reaction velocity; the latter was greatly alleviated with increasing the molecular weight of the crowders. On the other hand, the calculated randomness parameter, determined from the higher moment of the turnover time distribution, clearly inferred dynamic disorder in the catalytic turnovers. Our work under a unified framework provides a robust theoretical description for the experimental kinetic study and eradicates the necessity of assuming an alternative mode of inhibition in analyzing the data, not consistent with the experiments, considered earlier.

An Exactly Solvable Stochastic Kinetic Theory of Single-Molecule Force Experiments.

The unfolding of a protein in single-molecule pulling experiments subjected to a constant force (force-clamp) and constant velocity (force-ramp) is analyzed by introducing an exactly solvable two-state kinetic model framed based on the general stochastic approach of discrete state and continuous time formulation. The effect of perturbation is interpreted in the presence of dynamic disorder, resulting from intrinsic conformational fluctuations, by deriving an exact analytical expression for the unfolding time distribution, which in turn allowed us to calculate the expressions for the quantities of experimental interest explicitly. In particular, the novelty of our method lies in the fact that it reduced the need for a lengthy calculation, contrary to the previous dynamic disorder studies, and provides a fairly concise but sufficient mathematical analysis, which becomes much easier to implement quantitatively. We tested our results against the measured data from a number of force unfolding experiments on various proteins, ubiquitin, titin, and filamin, and the force unzipping of DNA and observed excellent agreement in each case. This asserts the reliability of the present technique, which suggests a plausible extension of the stochastic kinetic theory in single-molecule force experiments beyond its present-day widespread implications.

Stochastic Kinetic Approach to the Escape of DNA Hairpins from an α-Hemolysin Channel.

Escape experiments probed the dynamics of DNA hairpins inside a membrane-embedded α-hemolysin channel, which revealed the orientation and voltage-dependent nature of the DNA-pore interactions. The mean escape times measured at different assisting voltages were strongly influenced by these interactions. Clearly, an escape process from the nanopore was stochastic in nature that occurred in milliseconds. In this paper, we present a new methodology for describing the experimental observations based on the stochastic kinetic approach of discrete-state and continuous-time formulations. Our model considers that a hairpin attains different states inside and out of the pore, and we derived the expression for the escape time distribution from which survival probability of the hairpin that still exists inside the nanopore is determined. On the other hand, the first moment of the above distribution readily yields the mean escape time. Importantly, we show that the recovery of the experimental results was possible taking into account the slow structural fluctuations of the combined DNA-pore system. Additional investigation tested the profound influence of conformational dynamics by considering a pure kinetic scheme, which satisfied the measured data only partially. Therefore, the single stochastic framework suggested here provides a powerful tool that leads to a significant improvement in the theoretical analysis of the experimental results over a range of applied voltages by removing the inadequacy of the original attempt constructed following a number of formulations in the absence of intrinsic fluctuations.

Effects of digoxin on full-type hyperactivation in bovine ejaculated spermatozoa with relatively lower survivability for incubation with stimulators of cAMP signaling cascades.

Previous researches of our laboratory reported that addition of cAMP analog cBiMPS and protein phosphatase inhibitor calyculin A (stimulators of cAMP signaling cascades) improved the capacity of incubation medium to induce full-type hyperactivation in bovine ejaculated spermatozoa. However, this modified medium was valid only for samples with relatively good survivability for incubation with stimulators of cAMP signaling cascades. Thus, it is necessary to make further modified medium for evaluation of potentials to exhibit full-type hyperactivation in bovine sperm samples with relatively lower survivability. Na+/K+-ATPase is an integral membrane protein and involved with the regulation of rodent sperm motility. To make further modification of the medium, we examined effects of Na+/K+-ATPase inhibition with digoxin on motility, full-type hyperactivation and protein tyrosine phosphorylation in bovine ejaculated spermatozoa with relatively lower survivability for incubation with stimulators of cAMP signaling cascades and also performed the immunodetection of bovine sperm Na+/K+-ATPase. The addition of Na+/K+-ATPase inhibitor digoxin to the incubation medium containing cBiMPS and calyculin A had the tendency to lessen the decreases in the percentages of motile spermatozoa in all of 12 samples after the incubation for 1-3 h and significantly increased the percentages of full-type hyperactivation in one group of 4 samples (Sample-A1) and another group of 4 samples (Sample-A2) after 1 and 2 h respectively, though it had no significant effects on full-type hyperactivation in the other group of 4 samples (Sample-B). In addition, incubation time-related changes in the sperm protein tyrosine phosphorylation (a good marker for sperm capacitation) were correlated with those in the percentages of full-type hyperactivation in Sample-A1 containing digoxin. Immunodetection showed that Na+/K+-ATPase is present in the middle and principal pieces of the flagella, indicating that Na+/K+-ATPase has possible relations with sperm motility. These results obtained with bull ejaculated spermatozoa with relatively lower survivability indicate that incubation method using digoxin is useful to evaluate potentials of sperm samples to exhibit full-type hyperactivation, that digoxin has effects on suppressing reduction of sperm motility, and that prolonged incubation with digoxin induces reduction of capacitation state which may suppress the maintenance of full-type hyperactivation.

Mechanical Unfolding of Single Polyubiquitin Molecules Reveals Evidence of Dynamic Disorder.

Mechanical unfolding of single polyubiquitin molecules subjected to a constant stretching force showed nonexponentiality in the measured probability density of unfolding (waiting time distribution) and the survival probability of the folded state during the course of the measurements. These observations explored the relevance of disorder present in the system under study with implications for a static disorder approach to rationalize the experimental results. Here, an approach for dynamic disorder is presented based on Zwanzig's fluctuating bottleneck (FB) model, in which the rate of the reaction is controlled by the passage through the cross-sectional area of the bottleneck. The radius of the latter undergoes stochastic fluctuations that in turn is described in terms of the end-to-end distance fluctuations of the Rouse-like dynamics using a non-Markovian generalized Langevin equation with a memory kernel and Gaussian colored noise. Our results are comprised of analytical expressions for the survival probability and waiting time distribution, which show excellent agreement with the experimental data throughout the range of the applied forces. In addition, by fitting the survival probabilities at different stretching forces, we quantify two system parameters, namely, the average free energy ΔG av and the average distance to the transition state Δx av, both perfectly recovered the experimental estimates. These agreements validate the present model of polymer dynamics, which captures the very essence of dynamic disorder in single-molecule pulling experiments.

Nephrocalcinosis, Renal Dysfunction, and Calculi in Patients With Primary Hypoparathyroidism on Long-Term Conventional Therapy.

CONTEXT: There are concerns about the long-term safety of conventional therapy on renal health in patients with hypoparathyroidism. Careful audit of these would help comparisons with upcoming parathyroid hormone therapy. OBJECTIVE: We investigated nephrocalcinosis, renal dysfunction, and calculi, their predictors and progression over long-term follow-up in patients with primary hypoparathyroidism (PH). DESIGN AND SETTING: An observational study at a tertiary care center was conducted. PARTICIPANTS AND METHODS: A total of 165 PH patients receiving conventional therapy were evaluated by radiographs, ultrasonography, and computed tomography. Their glomerular filtration rate (GFR) was measured by Tc-99m-diethylenetriamine penta-acetic acid clearance. Clinical characteristics, serum total calcium, phosphorus, creatinine, hypercalciuria, and fractional excretion of phosphorus (FEPh) at presentation and during follow-up were analyzed as possible predictors of renal complications. Controls were 165 apparently healthy individuals. RESULTS: Nephrocalcinosis was present in 6.7% of PH patients but not in controls. Patients younger than 15 years at presentation and with higher serum calcium-phosphorus product were at higher risk. Nephrocalcinosis showed no significant association with cataract and intracranial calcification. Prevalence of renal calculi was comparable between hypoparathyroid patients and controls (5% vs 3.6%, P = .58). Fourteen percent of patients had a GFR less than 60 mL/min/1.73 m2. Increased FEPh during follow-up was the significant predictor of low GFR. Nephrocalcinosis developed in 9% of patients over 10 years of conventional therapy. CONCLUSION: A total of 6.7% of PH patients had nephrocalcinosis, and 14% showed renal dysfunction. Prevalence of renal calculi was similar in patients and controls. Nine percent of patients developed nephrocalcinosis over 10 years of conventional therapy.

Pulmonary alveolar proteinosis (PAP) in idiopathic hypoparathyroidism.

Idiopathic hypoparathyroidism (IH) and autoimmune pulmonary alveolar proteinosis (PAP) are rare disorders. A patient with IH and optimal calcaemic control on calcium and alfacalcidol was detected to have PAP after 8 years of follow-up. Patient had no respiratory complaints. Routine abdominal imaging for renal calcification showed patchy ground glass opacities in the lower lung fields leading to incidental diagnosis of PAP. Pulmonary function tests showed impaired diffusion capacity of the lung. Anti-granulocyte macrophage-colony stimulating factor autoantibodies were positive. Patient regularly attended the pulmonary clinic and showed progressive improvement in diffusion capacity of the lung during 2 years of follow-up. The calcaemic control in IH remained stable despite its presence with PAP. The autoimmune PAP in the presented case suggests a possible autoimmune basis of IH.

Absence of vitamin D deficiency among common outdoor workers in Delhi.

BACKGROUND: There is reservation about accepting the notion of widespread vitamin D deficiency (VDD) in sunny countries because information base is largely urban indoors, and the cut-off serum 25(OH)D > 75.0 nmol/L to define sufficiency is perceived as high. OBJECTIVE: We assessed the vitamin D status of subjects engaged in six types of outdoor jobs with freedom to seek shade, when needed. DESIGN: Descriptive observational study. SUBJECTS AND METHODS: A total of 573 outdoors, (hawkers, n = 144; auto-rickshaw drivers, n = 113; manual rickshaw pullers, n = 49; fuel-station attendants, n = 84; gardeners, n = 96; traffic police personnel, n = 87) were assessed for serum 25(OH)D, iPTH and total calcium during summer and winter. Bank employees were indoor controls (n = 72). Serum 25(OH)D was defined as sufficient if ≥50.0 nmol/L and deficient when <30.0 nmol/L, as per 'Institute of Medicine'. RESULTS: Mean serum 25(OH)D of 573 outdoors was 44.8 ± 19.6 nmol/L and showed a physiological inverse relation with iPTH (P < 0.001). 77.5% of the outdoors did not have VDD. Hawkers, gardeners, fuel-station attendants and rickshaw pullers had sufficient or near sufficient serum 25(OH)D. The mean serum 25(OH)D (30.6 ± 23.2 nmol/L) of indoors though lower by 12.7 nmol/L than outdoors was above the cut-off of VDD. Proportions with supranormal iPTH were comparable between outdoors and indoors (14.0% vs 20.8%). Despite winter dip, the mean serum 25(OH)D (31.2 ± 14.3 nmol/l) of outdoors was not deficient. CONCLUSIONS: Vitamin D deficiency is not universal. Most urban outdoor workers do not have VDD.

Central Immune Tolerance of T and B Cells in Patients With Idiopathic Hypoparathyroidism, T1D, and Autoimmune Thyroiditis.

CONTEXT: Pathogenesis of idiopathic hypoparathyroidism (IH) is under investigation. Abnormalities in central immune tolerance have yet not been investigated in this condition. T-cell receptor excision circles (TRECs) and kappa-deleting recombination excision circles (KRECs), formed during receptor gene rearrangements, are tools to assess central T- and B-cell output. OBJECTIVE: We assessed the number of circulating TRECs and KRECs in patients with IH, autoimmune type 1 diabetes (T1D), and autoimmune thyroiditis (ATs) and healthy controls (HCs). DESIGN: Comparative case-control at tertiary care center. SUBJECTS AND METHODS: Absolute and relative TRECs and KRECs were measured in DNA extracted from whole blood of patients with IH (n = 181, 22 of whom were reassessed after a decade of follow-up) and T1D (n = 133), AT (n = 53), and HC (n = 135) using a quantitative real-time PCR/TaqMan® probe technique. RESULTS: Absolute and relative means of TRECs and KRECs in IH were comparable to HCs, and no differences were found between IH with and without calcium-sensing receptor antibodies or class I HLA-A*26:01 association. TRECs and KRECs did not change after a decade of follow-up. T1D had significantly higher absolute TRECs than IH, AT, and HCs, whereas AT patients showed lower TRECs and the highest KRECs; these levels showed no noteworthy correlation with thyroid dysfunctions. CONCLUSION: Patients with IH showed TRECs and KRECs comparable to HCs, indicating an intact mechanism of T- and B-cell central immune tolerance. Interestingly, absolute TRECs were significantly higher in T1D than HCs, suggesting impaired central immune tolerance in T1D.

Auditing the Efficacy and Safety of Alfacalcidol and Calcium Therapy in Idiopathic Hypoparathyroidism.

CONTEXT: Patients with hypoparathyroidism are treated with vitamin D and calcium. PTH is an emerging option because of its physiological action. It is important to assess the efficacy and shortcomings of conventional therapy. OBJECTIVE: We assessed the efficacy and safety of alfacalcidol in a large cohort of patients with idiopathic hypoparathyroidism (IH) and identified a subset who could be treated without oral calcium. DESIGN AND SETTING: Observational study at tertiary care center. SUBJECTS AND METHODS: We assessed 92 patients with IH who were receiving alfacalcidol and oral calcium to maintain an optimal serum total calcium level of 8.0 to 8.5 mg/dL during routine follow-up. Patients with suboptimal control were provided free medicines and followed up frequently. Oral calcium and alfacalcidol doses were titrated sequentially to determine the minimum doses for optimal calcium control. Serum phosphate level, 1,25-dihydroxyvitamin D, fractional excretion of phosphorus (FEPh), and hypercalciuria (urine calcium-to-creatinine ratio, >0.2) were assessed at each step of titration. RESULTS: Only 38% of patients had optimal calcium control during routine follow-up. With good compliance, all achieved optimal serum calcium and 1,25-dihydroxyvitamin D levels and 43% of patients could stop taking oral calcium. Hyperphosphatemia, hypercalciuria, and low FEPh persisted at all stages of therapy. Serum phosphorus levels normalized when the serum calcium level increased to 9.9 mg/dL, but this level of serum total calcium was associated with hypercalciuria in 90% of patients. CONCLUSION: Alfacalcidol is effective in achieving calcemic control in IH. Calcemic control without oral calcium was achieved in 43% of patients receiving alfacalcidol. However, optimal calcium control was associated with hyperphosphatemia and hypercalciuria in most patients.

Vitamin D and calcium supplementation, skeletal muscle strength and serum testosterone in young healthy adult males: Randomized control trial.

BACKGROUND: Cholecalciferol and/or calcium supplementation might increase skeletal muscle strength and serum testosterone in young adult males. OBJECTIVE: We performed a randomized control trial assessing the effect of cholecalciferol/calcium on skeletal muscle strength and serum testosterone in vitamin D deficient young males. DESIGN: Two-by-two factorial RCT. SUBJECT AND INTERVENTION: Two-hundred and twenty-eight young males were block-randomized to (i) double-placebo, (ii) calcium/placebo, (iii) cholecalciferol/placebo and (iv) cholecalciferol/calcium. Doses for cholecalciferol were 60 000 IU/wk for 8 weeks followed by 60 000 IU/fortnightly, and doses for elemental calcium were 500 mg/twice daily for 6 months. A total of 180 subjects completed the study protocol. Their  ean age, body mass index and baseline 25(OH)D were 20.2 ± 2.2 years, 23.0 ± 3.6 kg/m2 and 21.5 ± 9.5 nmol/L, respectively. MEASUREMENTS: Handgrip (primary outcome), pinch-grip strength, distance walked in 6 minutes, dyspnoea-score, quality of life by Short Form 36, serum 25(OH)D, 1,25(OH)2 D, iPTH, total testosterone and free androgen index (FAI). RESULTS: After intervention, mean serum 25(OH)D was >75.0 nmol/L in cholecalciferol groups. However, the handgrip strength (29.7 ± 4.4, 29.3 ± 4.6, 30.6 ± 5.0 and 28.8 ± 4.3 kg, P = .28) was comparable in the 4 groups. Subgroups analysis among subjects with baseline serum 25OH)D < 25.0 and <12.0 nmol/L showed similar results. The mean serum testosterone decreased significantly at 6 months; however, delta change was similar in 4 groups. Change in handgrip strength and other outcomes was similar in 4 groups with and without adjustment for delta testosterone and FAI. CONCLUSIONS: Six months of cholecalciferol/calcium supplementation had no significant effect on skeletal muscle strength and serum testosterone in young adult males.