Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
.pdf
ENDOCRINOLOGY
Sunday, December 3rd, 2023
Dr. Jessica Mak
https://t.me/medicina_free
Outline (Lecture)
1. Hypercalcemia – **NEW Endo Society Hyper/Hypopara Guidelines 2022**
2. MEN Syndromes
3. Hyperthyroidism
4. Hypothyroidism
5. Thyroid Disease in Pregnancy
6. Osteoporosis & Metabolic Bone Disease – **NEW CMAJ Guidelines 2023**
7. Diabetes
8. Adrenal & Pituitary
9. Obesity Guidelines
10. Lipid Guidelines – **NEW CCS Guidelines 2021**
11. Care for Transgender Patients
12. Reproductive Endocrinology
13. Thyroid Nodules & Cancer
2
https://t.me/medicina_free
Endocrinology 101
Before we start… Interpreting Labs:
*Normal or inappropriately normal?
Always think critically about what the pattern
of hormones should be, not only whether a
value is in the normal range
3
https://t.me/medicina_free
1. Hypercalcemia
Resources:
2022 Hyperparathyroidism Guidelines from the Fifth International
Workshop
https://asbmr.onlinelibrary.wiley.com/doi/epdf/10.1002/jbmr.4677
Primary hyperparathyroidism: review and recommendations on
evaluation, diagnosis, and management. A Canadian and international
consensus: https://pubmed.ncbi.nlm.nih.gov/27613721/
4
https://t.me/medicina_free
Question 1
A 85yoF is referred for hypercalcemia. She is complaining of severe bone
pain. A CT scan done shows lytic lesions. sPEP, uPEP, FLC assay are normal,
malignant workup is normal. BMD do not have any T-scores <-2.5 at any
sites (including radius).
Meds: ramipril, atorvastatin, glargine, aspart
5
Lab Values
Reference Range
Calcium = 2.74
2.1
-2.6 mmol/L
Phosphate = 0.90
0.70
- 1.5 mmol/L
Cr = 123
53
- 97 µmol/L
25OHD = 74
75
– 200 nmol/L
PTH = 35
10
- 65 ng/L
Albumin = 40
35
- 50 g/L
https://t.me/medicina_free
Question 1 (cont’d)
A sestamibi scan shows a 1.3 cm parathyroid adenoma. Her
nephrologist and ENT do not think she is candidate for
parathyroidectomy due to her frailty. She has also declined
surgery. What treatment option is best to manage her
hypercalcemia?
1. Increase oral fluid intake with furosemide diuresis
2. Calcium restricted diet
3. IV bisphosphonate
4. Cinacalcet
5. Calcitriol
6
https://t.me/medicina_free
Calcium Physiology: Pearl 1 & 2
1. In a parathyroid-mediated
process, serum calcium and
phosphate go in the
opposite
direction
e.g.
Hyper
parathyroidism: ↑Ca ↓PO4
Hypo
parathyroidism: ↓Ca ↑PO4
2. In a vitamin D mediated process,
serum calcium and phosphate go
in the same direction
e.g.
Osteomalacia
: ↓Ca, ↓PO4
Vitamin D *Excess
:
↑Ca, ↑PO4
(*ex. 1,25-hydroxyvitamin D excess from
granulomatous disease)
7
https://t.me/medicina_free
Calcium Physiology: Pearl 3 & 4
3. When the calcium, phosphate
and PTH are all high
, think kidney
(reduced ability to excrete
phosphate)
e.g.
Terti ary Hyper parathyroidism
(in
long-standing renal failure):
↑Ca, ↑PO4
4. Magnesium deficiency reduces
PTH secretion and causes PTH
resistance. Therefore think of
hypomagnesemia in someone
with apparent
hypoparathyroidism (or
inappropriately normal PTH).
8
https://t.me/medicina_free
Lab Patterns in Calcium Problems
Disorder
Serum Calcium
Serum PO4
PTH
Urine Calcium
Primary
HyperPTH
High
Low
High
High
Ter ti ar y
HyperPTH
High
High
High
High
Pseudohypoparathyroidism
Low
High
High
Variable
FHH
High
Low
High
Low (<0.01)
Lithium
High
Low
High
Low
Thiazides
High
N/Low
Low/High
*
*
May unmask an underlying primary
hyperparathyroidism
Low
Vitamin D excess
High
High
Low
High
PTHrP
High
Low
Low
High
Osteolysis
High
High
Low
High
Vitamin D Deficiency
Low
Low
High
Norma
l / High
BONUS
Read on own
https://t.me/medicina_free
1o Hyperparathyroidism (PHPT): Surgical Managment
Know when to send someone for surgery…
Symptomatic PHPT = Surgery!
Asymptomatic PHPT= “Stay The Fudge Away U Stupid Calcium”
AT DIAGNOSIS:
Serum total calcium > 0.25 mmol/L above upper limit
T-score <= -2.5 at L-spine, total hip, femoral neck or distal 1/3 radius
Fractures (Vertebral only; by X-ray, CT, MRI or VFA)
Age < 50
Urine calcium >6.25 mmol/d (>250mg/d) in women or >7.5 mmol/d in men (>300mg/d)
Stones or nephrocalcinosis by x-ray, ultrasound, or CT
Creatinine clearance < 60 mL/min (stage 3 CKD)
JBMR 2022
10
Suggest Surgery in those being monitored in follow-up if:
• Serum calcium consistently >0.25 mmol/L above upper limit
• Low trauma fracture (+/- VFA if indicated)
• A kidney stone (abdo imaging if indicated)
• Significant reduction in BMD (every 1-2 yrs) to T-score <= -2.5 (any
site)
• Significant reduction in CrCl (defined as decline of >3ml/min
annually to <60 ml/min)
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана