Combination carboplatin and nab-paclitaxel as a first-line treatment for advanced thymic carcinoma.

Thymic carcinoma is a very rare neoplasm for which no optimal chemotherapeutic regimen has been established to date. Hence, we performed this study to investigate the efficacy and safety of carboplatin plus nanoparticle albumin-bound (nab)-paclitaxel as a first-line regimen for patients with advanced thymic carcinoma. We conducted this multi-institutional retrospective cohort study of patients with advanced thymic carcinoma who had received carboplatin plus nab-paclitaxel as a first-line chemotherapy between August 2013 and December 2021. Twelve patients were included in this study and were subjected to efficacy and safety analysis. Their median age was 62 years (range, 47-74 years), and all had an Eastern Cooperative Oncology Group performance status score of 0 or 1. After a median follow-up time of 19.7 months, the overall response rate was 50%; the median progression-free and overall survival times were 8.8 months and 23.3 months, respectively. Chemotherapy-related peripheral neuropathy was observed in 2 patients (16%; each with grade 1). Other toxicities were manageable, and there were no treatment-related deaths. Carboplatin plus nab-paclitaxel as a first-line chemotherapy regimen showed good efficacy and safety in patients with advanced thymic carcinoma.

[Current Status and Development of Drug Information Infrastructure System for the Public in Japan and Overseas].

With the progress of medical treatment, information on drugs, etc. is overflowing on the media and the Internet, and some of them are leading to uncertain information for the purpose of profit, and some of them are wrong information or inaccurate information, and the effect on the patient is regarded as a problem. In Japan, information on public pharmaceuticals for patients and consumers is provided on the Internet, but its utilization is not sufficient. In the Pharmaceuticals and Medical Devices Act, it is stated that "Citizens shall endeavor to use pharmaceuticals, etc., properly and deepen their knowledge and understanding of their efficacy and safety". On the other hand, there is a variety of information available on the Internet, and simply searching does not necessarily lead to reliable information. It is necessary to provide information with a mechanism to ensure that the information is reliable so that it can lead to appropriate medical care. Overseas, medical information infrastructure systems, including highly reliable public pharmaceuticals based on evidence, have been developed. Examples include National Health Service (NHS) in the United Kingdom, MedlinePlus in the United States, and National Prescribing Service (NPS) MedicineWise in Australia. In the era of digital health, it is necessary to discuss issues and prospects for the construction and dissemination of information provision infrastructure that meets the needs of patients and consumers from the perspective of industry, government, academia, and patients.

A Prospective, Randomized, Open-Label Trial of Early versus Late Favipiravir Therapy in Hospitalized Patients with COVID-19.

Favipiravir is an oral broad-spectrum inhibitor of viral RNA-dependent RNA polymerase that is approved for treatment of influenza in Japan. We conducted a prospective, randomized, open-label, multicenter trial of favipiravir for the treatment of COVID-19 at 25 hospitals across Japan. Eligible patients were adolescents and adults admitted with COVID-19 who were asymptomatic or mildly ill and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Patients were randomly assigned at a 1:1 ratio to early or late favipiravir therapy (in the latter case, the same regimen starting on day 6 instead of day 1). The primary endpoint was viral clearance by day 6. The secondary endpoint was change in viral load by day 6. Exploratory endpoints included time to defervescence and resolution of symptoms. Eighty-nine patients were enrolled, of whom 69 were virologically evaluable. Viral clearance occurred within 6 days in 66.7% and 56.1% of the early and late treatment groups (adjusted hazard ratio [aHR], 1.42; 95% confidence interval [95% CI], 0.76 to 2.62). Of 30 patients who had a fever (≥37.5°C) on day 1, times to defervescence were 2.1 days and 3.2 days in the early and late treatment groups (aHR, 1.88; 95% CI, 0.81 to 4.35). During therapy, 84.1% developed transient hyperuricemia. Favipiravir did not significantly improve viral clearance as measured by reverse transcription-PCR (RT-PCR) by day 6 but was associated with numerical reduction in time to defervescence. Neither disease progression nor death occurred in any of the patients in either treatment group during the 28-day participation. (This study has been registered with the Japan Registry of Clinical Trials under number jRCTs041190120.).

[Activities of Choosing Wisely and Role of Pharmacists].

Choosing Wisely (CW) is a pharmaceutical campaign activity that is spreading rapidly internationally. Briefly, it is an activity "aiming for appropriate medical care by reviewing the medical practice that is practiced despite lack of evidence from the viewpoint of evidence based medicine (EBM)". Here, healthcare workers and patients, through dialogue, are aiming to be able to carry out medical practices (examinations, treatment) that are scientifically validated, truly necessary, and have few side effects. In 2012, the American Institute of Internal Medicine listed five topics (Top Five Lists) and presented the medical practices and reasons that should be reconsidered. Based on this, many academic societies and medical professional organizations around the world presented five unique lists from their respective standpoints. And, in 2016, CW Japan was established in our country. The ultimate goal of this activity is to encourage dialogue and share decision-making with the patients so that healthcare workers can "select wisely" appropriate medicine for their patients based on professionalism. In Japan, recent attention has also been paid to problems concerning proper use of polypharmacy and antibiotics, especially for elderly people. To support a sustainable medical system in the future, it is desirable to promote efforts to realize "high-value care" for patients, paying particular attention to limit unnecessary medical care. Under such circumstances, I will introduce some issues and activities that overseas pharmacists are working on in the context of CW, and discuss roles and tasks to be taken by pharmacists in Japan.

Multicenter Phase II Study of Nedaplatin and Irinotecan for Patients with Squamous Cell Carcinoma of the Lung: Thoracic Oncology Research Group 0910.

Squamous cell carcinoma (SCC) of the lung is moderately responsive to anticancer drugs, but no specific chemotherapy regimens have yet been established. We conducted a multicenter phase II study of nedaplatin (NP) and irinotecan (CPT) for SCC of the lung. Fifty patients underwent 4 to 6 cycles of chemotherapy comprising of NP at 100 mg/m(2) on day 1 and CPT at 60 mg/m(2) on days 1 and 8 every 4 weeks. Twenty-seven patients received 4 to 6 cycles of chemotherapy (median=4 cycles). Major toxicities included neutropenia (46.0%), grade 3 or 4 anorexia (22.0%), febrile neutropenia (16.0%), diarrhea (12.0%), hyponatremia (12.0%), grade 4 anemia (10.0%), thrombocytopenia (10.0%) and infection (10.0%). There were no treatment-related deaths. One patient achieved a complete response and 16 a partial response, with an overall response rate of 34.0%. The median survival time was 11.8 months (95% CI=8.3-15.8 months) and the 2-year survival rate was 22.0%. In conclusion, the NP and CPT regimen is not recommend for further evaluation for patients with advanced SCC of the lung.

Phase I and pharmacokinetic study of erlotinib administered in combination with amrubicin in patients with previously treated, advanced non-small cell lung cancer.

OBJECTIVES: We conducted a phase I trial of erlotinib, an epidermal growth factor receptor tyrosine kinase inhibitor, combined with amrubicin, a topoisomerase II inhibitor. The aim was to determine the maximum tolerated dose, the dose-limiting toxicities (DLTs), and the pharmacokinetics of this combination in patients with non-small cell lung cancer who had received previous chemotherapy. METHODS: A total of 9 patients with stage IV disease were treated at 3-week intervals with erlotinib once daily on days 1 through 21 plus a 5-minute intravenous injection of amrubicin on days 1 through 3. RESULTS: The dose levels evaluated were erlotinib (mg/body)/amrubicin (mg/m): 100/30 (n=3), 100/35 (n=3), and 150/30 (n=3). The maximum tolerated dose of erlotinib and amrubicin was 100 mg/body and 35 mg/m because 2 of the 3 patients experienced DLTs during the first cycle of treatment at the third dose level of 150 mg/body and 30 mg/m. Cessation of erlotinib administration for 8 days because of grade 3 leukopenia and grade 3 skin infection (erysipelas) were the DLTs. No drug-drug interactions between erlotinib and amrubicin were observed in this study. The overall response rate was 33%, including 3 partial responses, in the 9 patients. The median progression-free survival for all patients was quite long, 11.3 months, and the median overall survival has not yet been reached. CONCLUSIONS: Combined erlotinib plus amrubicin therapy seems to be highly effective, with acceptable toxicity, against non-small cell lung cancer. The recommended dose for phase II studies was erlotinib 100 mg once daily on days 1 through 21, and amrubicin 35 mg/m on days 1 through 3 administered every 21 days.

Relationship between health literacy, health information access, health behavior, and health status in Japanese people.

OBJECTIVE: To examine the relationship between health literacy (HL), health information access, health behavior, and health status in Japanese people. METHODS: A questionnaire survey was conducted at six healthcare facilities in Japan. Eligible respondents aged 20-64 years (n=1218) were included. Path analysis with structural equation modeling was performed to test the hypothesis model linking HL to health information access, health behavior, and health status. RESULTS: The acceptable fitting model indicated that the pathways linking HL to health status consisted of two indirect paths; one intermediated by health information access and another intermediated by health behavior. Those with higher HL as measured by the 14-item Health Literacy Scale (HLS-14) were significantly more likely to get sufficient health information from multiple sources, less likely to have risky habits of smoking, regular drinking, and lack of exercise, and in turn, more likely to report good self-rated health. CONCLUSION: HL was significantly associated with health information access and health behavior in Japanese people. HL may play a key role in health promotion, even in highly educated countries like Japan. PRACTICE IMPLICATIONS: In order to enhance the effects of health promotion interventions, health professionals should aim at raising HL levels of their target population groups.

Rapid deconjugation of SN-38 glucuronide and adsorption of released free SN-38 by intestinal microorganisms in rat.

One of the dose-limiting toxicities of irinotecan hydrochloride (CPT-11) is delayed-onset diarrhea. CPT-11 is converted to its active metabolite, SN-38, which is conjugated to SN-38 glucuronide (SN-38G). SN-38G excreted in the intestinal lumen is extensively deconjugated by bacterial ß-glucuronidase, resulting in the regeneration of SN-38, which causes diarrhea. However, the deconjugation of SN-38G by the intestinal microflora remains to be clarified. This study aimed to investigate the microbial transformation of SN-38G by an anaerobic mixed culture of rat cecal microorganisms. Concentrations of SN-38G and SN-38 were then determined using high-performance liquid chromatography. Complete deconjugation of SN-38G to SN-38 in the mixed cultures was observed within 1 h of incubation, with 62.7% of the added SN-38G being found in the supernatant. Approximately 80.4% of the SN-38 in the supernatant was bound to protein, and the remaining 19.6% was detected as active free SN-38. In total, only 12.3% (19.6 × 62.7%) of the SN-38G added to the test tube was found in the supernatant in the ultrafiltrable free form, indicating that approximately 90% of the SN-38G added to the growth medium either remained adsorbed onto the pelleted fraction or occurred in a protein-bound form in the supernatant. The remaining 10% of the SN-38G added to the growth medium existed in the unbound form, the form capable of causing damage to the intestinal membrane. In conclusion, these results indicated that the greater part of the SN-38 produced from SN-38G by the action of bacterial ß-glucuronidase is rapidly adsorbed onto intestinal bacterial cell walls or dietary fibers in pelleted fraction, and only 10% remains in the ultrafiltrable unbound form in the intestinal luminal fluid.

Phase I trial of irinotecan and amrubicin with granulocyte colony-stimulating factor support in extensive-stage small-cell lung cancer.

PURPOSE: We conducted a phase I trial of irinotecan (CPT-11), a topoisomerase I inhibitor, combined with amrubicin, a topoisomerase II inhibitor, with recombinant human granulocyte colony-stimulating factor (rhG-CSF) support to overcome the neutropenia associated with this particular combination. The aim was to determine the maximum tolerated dose (MTD) of amrubicin combined with a fixed dose of CPT-11 and the dose-limiting toxicities (DLTs) of this combination in extensive-stage small-cell lung cancer (ED-SCLC) patients. METHODS: Fifteen patients with ED-SCLC were treated at 3-week intervals with amrubicin on days 1-3 plus 60 mg/m(2) CPT-11 on days 1 and 8. In addition, prophylactic rhG-CSF (50 µg/m(2)) was given from day 4 to day 21, except on the day of CPT-11 administration. Amrubicin was started at 30 mg/m(2) and then escalated in 5 mg/m(2) increments until MTD was reached. RESULTS: The MTD of amrubicin was 35 mg/m(2), since 2 of 4 patients experienced DLTs during the first cycle of treatment at the 40 mg/m(2) dose level. Neutropenia, neutropenic fever, ileus, and diarrhea were the DLTs. There were 13 partial responses among the 13 assessable patients, yielding an overall response rate of 100 %. Median progression-free survival and overall survival were 7.4 months and 13.4 months, respectively. CONCLUSION: The combination of amrubicin and CPT-11 showed high activity against ED-SCLC with acceptable toxicity. Use of rhG-CSF allowed the dose of amrubicin to be raised 40 % above that in the original regimen (60 mg/m(2) CPT-11 and 25 mg/m(2) amrubicin).

[A long-term case of Sjögren's syndrome with pulmonary multiple cystic lesions].

A 68-year-old woman was admitted to our institution's respiratory section because of dyspnea on effort in January, 2007. She had previously received a diagnosis of Sjögren's syndrome because of dryness in her eyes in 1991. Chest radiography and chest CT in 2001 revealed diffuse multiple cystic lesions in both lungs which had progressed gradually for 6 years. Biopsy specimens obtained by video-assisted thoracoscopy showed lymphoid hyperplasia with follicular bronchiolitis and lymphocytic alveolitis. Narrowing of the small airways and obstructive lung disease with multiple bullae were observed and we suspected them to be related to peribronchiolar lymphocytic infiltration. These were lung involvements associated with Sjögren's syndrome. The patient's cystic lesions gradually worsened despite the administration of corticosteroid and cyclophosphamide. Cystic lesions in Sjögren's syndrome may be a treatment-resistant finding.

[Use of sugammadex in a patient with narrow angle glaucoma].

An 86-year-old woman was scheduled to receive fourth reconstructive surgery for femoral bone fracture under general anesthesia. She had been suspected with narrow angle glaucoma due to headache and bloodshot eyes during gastroscopy. During transfer to our hospital, she fell down and suffered from the right femoral neck fracture. The patient underwent femoral head replacement under spinal anesthesia. Later, she received surgeries twice uneventfully under spinal anesthesia; removal and re-implantation of the femoral bone head due to infection of the implanted head. Six months later, she fell down again and femoral bone was fractured during rehabilitation. Anesthesia was induced with propofol followed by rocuronium 0.9 mg x kg(-1) i.v. Anesthesia was maintained with propofol and remifentanil, and rocuronium was administered to maintain PTC of 10 or less. The surgery was completed in 150 minutes. At the end of surgery, a laryngeal mask was inserted and the tracheal tube was removed. TOF ratio recovered to 80% 8 minutes after sugammadex 2 mg kg(-1) i.v., and increased to 100% 3 minutes after additional 1 mg x kg(-1). Intraocular pressure stayed below 20 mmHg during the intervention. We could achieve full reversal of neuromuscular blockade and suppress increase in intraocular pressure with use of sugammadex.

The cytostatic effects of lovastatin on ACC-MESO-1 cells.

BACKGROUND: Malignant pleural mesothelioma is known to be widely resistant to therapy, and new treatment strategies are needed. Statins are small molecules that suppress the production of multiple hydrophobic substrates in the mevalonate pathway. Although still controversial, statins may decrease the risk of certain cancers such as colon cancer, lung cancer, and prostate cancer. Since the evaluations of the direct effect of statins on malignant mesothelioma are still few, the present study was done to evaluate the effects of lovastatin on ACC-MESO-1 cells in vivo and to investigate the potential mechanisms involved in vitro. MATERIALS AND METHODS: The in vivo effect of lovastatin was evaluated using an NOD/SCID/γnull (NOG) mouse model of human malignant mesothelioma using ACC-MESO-1 cells. Lovastatin was also applied to ACC-MESO-1 cells in vitro and the effects were observed. RESULTS: Lovastatin administration reduced primary tumor and metastasis in the NOG mouse model of human malignant mesothelioma. In vitro studies showed that lovastatin administration induced cytostatic effects as per reduced cell viability and cell migration in ACC-MESO-1 cells. These effects were suggested to be dependent on autophagic changes rather than apoptosis. Furthermore, induction of autophagic changes by lovastatin in ACC-MESO-1 cells was independent of mTOR, and was considered to be dependent at least in part on Rac/phospholipase C/ inositol 1,4,5-triphosphate axis. CONCLUSIONS: These results suggest that it may be possible to utilize statins, or other pharmacological agents that are known to induce mTOR-independent autophagy, as an adjunct to standard treatments in malignant mesothelioma.

Genetic Polymorphism of Cancer Susceptibility Genes and HPV Infection in Cervical Carcinogenesis.

It is widely accepted that specific human papillomavirus (HPV) types are the central etiologic agent of cervical carcinogenesis. However, a number of infected women do not develop invasive lesions, suggesting that other environmental and host factors may play decisive roles in the persistence of HPV infection and further malignant conversion of cervical epithelium. Although many previous reports have focused on HPV and environmental factors, the role of host susceptibility to cervical carcinogenesis is largely unknown. Here, we review the findings of genetic association studies in cervical carcinogenesis with special reference to polymorphisms of glutathione-S-transferase (GST) isoforms, p53 codon 72, murine double-minute 2 homolog (MDM2) gene promoter 309, and FAS gene promoter -670 together with HPV types including our recent research results.

Notificação espontânea de erros de medicação em hospital universitário pediátrico / Spontaneous reporting of medication errors in pediatric university hospital

OBJETIVO: Analisar os erros de medicação notificados em um hospital universitário pediátrico no Município de São Paulo. MÉTODOS: Estudo descritivo retrospectivo no qual foram analisadas 120 ocorrências de erros de medicação registradas em 115 notificações espontâneas, entre janeiro de 2007 e dezembro de 2008. RESULTADOS: O índice de erros foi o de 1,15 por 1.000 pacientes-dia; 27,5 por cento das notificações envolveram pacientes na faixa etária escolar. A Unidade de Terapia Intensiva Pediátrica (UTIP) foi o setor com o maior número de notificações. Predominou o tipo de erro relacionado à velocidade de infusão errada (25 por cento). A dimensão fator humano na categoria desempenho deficiente (54 por cento) foi a causa mais frequente para ocorrência do erro. CONCLUSÃO: O índice de erros de medicação foi de 1,15 por 1.000 pacientes-dia, com predomínio na faixa etária escolar (27,5 por cento) e na UTI Pediátrica (35 por cento). Diante desses resultados, medidas de melhoria devem ser incorporadas na instituição selecionada, sejam elas relacionadas à revisão do processo de trabalho ou à capacitação da equipe.

OBJECTIVE: To analyze medication errors notified at a pediatric teaching hospital in São Paulo city. METHOD: Retrospective and descriptive study in which 120 error events and 115 spontaneous notifications were analyzed, between January 2007 and December 2008. RESULTS: The error rate was 1.15 per 1000 patients-day; 27.5 percent of notifications referred to the school age range and the Pediatric ICU was the sector with most notifications. The error type related to wrong infusion speed predominated (25 percent). The human factor dimension in the performance deficit category (54 percent) was the most frequent cause of error events. CONCLUSION: The safety culture is a continuous process in institutions and the notification of adverse events is part of the strategies. Improvement measures should be incorporated based on their analysis, whether related to the review of the work process or to team training.

OBJETIVO: Analizar los errores de medicación notificados en un hospital universitario pediátrico en el Municipio de Sao Paulo. MÉTODOS: Estudio descriptivo retrospectivo en el cual fueron analizadas 120 ocurrencias de errores de medicación registradas en 115 notificaciones espontáneas, entre enero del 2007 y diciembre del 2008. RESULTADOS: El índice de errores fue de 1,15 por 1.000 pacientes-dia; el 27,5 por ciento de las notificaciones involucraron pacientes en el grupo etáreo escolar. La Unidad de Cuidados Intensivos Pediátrico (UCIP) fue el sector con el mayor número de notificaciones. Predominó el tipo de error relacionado a la velocidad de infusión errada (25 por ciento). La dimensión factor humano en la categoría desempeño deficiente (54 por ciento) fue la causa más frecuente para la ocurrencia del error. CONCLUSIÓN: El índice de errores de medicación fue de 1,15 por 1.000 pacientes-dia, con predominio en el grupo etáreo escolar (27,5 por ciento) y en la UCI Pediátrica (35 por ciento). Frente a estos resultados, deben ser incorporadas medidas de mejora en la institución seleccionada, estén ellas relacionadas a la revisión del proceso de trabajo o a la capacitación del equipo.

[A case of recurrent invasive thymic cancer showing a stable disease to carboplatin plus paclitaxel].

A 56-year-old man was admitted to our hospital because of increasing chest discomfort and abnormal chest shadow. Computed tomography (CT) of the chest revealed an anterior mediastinal mass, pleural dissemination and lung metastasis. Percutaneus needle biopsy guided by CT showed that the mass was advanced thymic cancer (stage IV b according to the classification proposed by Masaoka). After failure of combination chemotherapy of cisplatin, vincristine, doxorubicin and etoposide (CODE), he received 4 cycles of carboplatin plus paclitaxel and then achieved confirmed stable disease. In terms of toxicity profile, grade 4 anemia, grade 2 leucopenia and neutropenia were observed, and particularly non-severe toxicity was not observed in terms of non-hematologic toxicity. Carboplatin plus paclitaxel can be an active agent against pretreated thymic cancer.

[Spinal anesthesia in a patient with SMON disease].

We report a patient with subacute myelo-optico-neuropathy (SMON) in whom spinal anesthesia was employed to treat fracture of the femur neck. An 87-year-old woman was diagnosed as having SMON at the age of 45. The patient was admitted to our hospital with fracture of the femur neck. Aspiration pneumonia was also suspected with shadow in the right lung on the chest X-P The percutaneous oxygen saturation (Spo2) with room air was 77%. Spinal anesthesia with 5 mg of 0.5% hyperbaric bupivacaine and 20 mcg of fentanyl was performed at L3-4. The level of anesthesia was T4. During surgery, no severe pain in the lower limbs was observed. Three hours after the end of surgery, the level of anesthesia was T9. On the day after surgery, the extent of dysesthesia and reflex were similar to those before surgery. General anesthesia has been chosen in SMON patients, because there was a report of severe pain of the lower limbs after spinal anesthesia with dibucaine. In our patient, general anesthesia was considered inappropriate due to hypoxemia. We used a mixture of bupivacaine and fentanyl for spinal anesthesia, because the neurotoxicity of bupivacaine is weaker than that of dibucaine.

MDM2 SNP 309 human papillomavirus infection in cervical carcinogenesis.

OBJECTIVE: To investigate the biological significance of single nucleotide polymorphism (SNP) at murine double-minute 2 homolog (MDM2) promoter 309 in cervical carcinogenesis. METHODS: SNP at MDM2 promoter 309 (T/G) together with human papillomavirus (HPV) types was examined in a total of 195 cervical smear samples and 8 human cervical squamous carcinoma cell lines using two independent PCR assays and PCR-RFLP techniques. RESULTS: Forty-one patients with high-grade squamous intraepithelial lesion (HSIL) had higher frequency of high-risk HPV than 102 with low-grade SIL (LSIL) and 52 controls. There was an increased OR (8.88; CI=2.34-33.63; P=0.003) for TG+GG genotype in HSIL cases compared to controls among 68 patients with high-risk HPV. Twenty-one cases with HPV types 16 and/or 18 had significantly higher frequency of the TG+GG genotype and G allele than 47 with other types of high-risk HPV. Seven of 8 cervical carcinoma cell lines also showed TG or GG genotype. CONCLUSION: MDM2-SNP309 (T/G) and high-risk HPV infection may be closely associated with cervical carcinogenesis in a Japanese population.

Vitamin D deficiency in two young adults with biochemical findings resembling pseudohypoparathyroidism type I and type II.

We report two patients with vitamin D deficiency due to unbalanced diet. The patients initially presented with severe hypocalcemia, normophosphatemia and markedly elevated serum PTH levels. Although nutritional vitamin D deficiency was suspected from their history of gastrointestinal problems and dietary restriction, we conducted Ellsworth- Howard test to exclude the possibility of pseudohypoparathyroidism (PHP). Both patients showed no incremental response of urinary phosphate excretion. However, the urinary cAMP response to exogenous PTH was different between the two. Case 1 showed a blunted response (5-fold and 1.54 micro mol/h increase) and case 2 showed a normal response (39-fold and 3.04 micro mol/h increase). According to the criteria of Ellsworth-Howard test, the data of case 1 was compatible with PHP type I, and of case 2 with PHP type II. The final diagnosis of vitamin D deficiency was established in both patients based on very low serum 25-hydroxyvitamin D levels (less than 5 ng/mL) and the effect of treatment. After calcium supplementation with or without vitamin D, their biochemical abnormalities disappeared. They maintained normocalcemia without medication after correction of their unbalanced diet. The present study indicated that patients with vitamin D deficiency occasionally showed biochemical findings suggestive of PHP and that such patients could exhibit not only PHP type II pattern of response to exogenous PTH but also of type I pattern. Thus our clinical observation suggests the complexity of PTH resistance in vitamin D deficiency and underscores the importance of diet to prevent the disorder.