The 499th case: Roux-en-Y gastric bypass, limb weakness, and ostealgia / 中华内科杂志

A 36-year-old woman was admitted to the Peking Union Medical College Hospital with a history of fractures for 2 years, limb weakness for 1 year, and ostealgia for 2 months. The patient's examination identified iron deficiency anemia, significantly decreased serum calcium and 25-hydroxyvitamin D3 levels, and increased alkaline phosphatase and parathyroid hormone levels. Imaging showed several typical signs of osteomalacia. Considering the history of Roux-en-Y gastric bypass surgery, the diagnosis was considered to be osteomalacia caused by a postoperative nutritional absorption disorder. The patient was supplemented with calcitriol, calcium, and vitamin D and gradually returned to normal physical activity. The bone metabolism indicators and bone density were significantly improved.

Comparison of effectiveness and safety of high-dose native vitamin D versus active vitamin D in the treatment of hypoparathyroidism / 中华内分泌代谢杂志

Objective To investigate the effectiveness and safety of high-dose native vitamin D versus active vitamin D by retrospective analysis of clinical data in patients with non-surgical hypoparathyroidism ( ns-HP) in our hospital. Methods ns-HP patients with stable therapeutic schedule in recent three years were included. According to the vitamin D agents used, patients were divided into three groups: active vitamin D group, native vitamin D group, and mixed vitamin D group. The effectiveness was evaluated by analysis of markers including post-treatment serum calcium, incidence of hypocalcemia, hypocalcemic symptoms and signs. The safety was evaluated in various groups by analyzing incidences of hypercalcemia and hypercalciuria, glomerular filtration rate, percentage of thiazide diuretic use, nephrocalcinosis or renal stone. Results Patients in active vitamin D group were more likely to experience episodes of hypocalcemia compared with those in native group (32.94% ± 21.46% vs 24.86% ± 10.1%, P＜0.05). No significant differences in other indexes for assessing effectiveness and safety were found among three groups ( P＞0.05). Conclusions Under the circumstance of regular follow-up, both high-dose native vitamin D and active vitamin D could treat ns-HP effectively and safely. Native vitamin D may be better in maintaining eucalcemia and reducing incidence of hypocalcemia compared with active vitamin D.

Comparison of effectiveness and safety of high-dose native vitamin D versus active vitamin D in the treatment of hypoparathyroidism / 中华内分泌代谢杂志

Objective@#To investigate the effectiveness and safety of high-dose native vitamin D versus active vitamin D by retrospective analysis of clinical data in patients with non-surgical hypoparathyroidism (ns-HP) in our hospital.@*Methods@#ns-HP patients with stable therapeutic schedule in recent three years were included. According to the vitamin D agents used, patients were divided into three groups: active vitamin D group, native vitamin D group, and mixed vitamin D group. The effectiveness was evaluated by analysis of markers including post-treatment serum calcium, incidence of hypocalcemia, hypocalcemic symptoms and signs. The safety was evaluated in various groups by analyzing incidences of hypercalcemia and hypercalciuria, glomerular filtration rate, percentage of thiazide diuretic use, nephrocalcinosis or renal stone.@*Results@#Patients in active vitamin D group were more likely to experience episodes of hypocalcemia compared with those in native group (32.94%±21.46% vs 24.86%±10.1%, P<0.05). No significant differences in other indexes for assessing effectiveness and safety were found among three groups (P>0.05).@*Conclusions@#Under the circumstance of regular follow-up, both high-dose native vitamin D and active vitamin D could treat ns-HP effectively and safely. Native vitamin D may be better in maintaining eucalcemia and reducing incidence of hypocalcemia compared with active vitamin D.

Tumor-induced osteomalacia

Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is a rare paraneoplastic syndrome characterized by hypophosphatemia resulting from decreased tubular phosphate reabsorption, with a low or inappropriately normal level of active vitamin D. The culprit tumors of TIO could produce fibroblast growth factor 23 which plays a role in regulating renal Pi handling and 25-hydroxyvitamin D 1α-hydroxylase activity. Chronic hypophosphatemia could eventually lead to inadequate bone mineralization, presenting as osteomalacia. The diagnosis should be considered when patients manifest as hypophosphatemia and osteomalacia, or rickets and needs to be differentiated from other disorders of phosphate metabolism, such as the inhereditary diseases like X-linked hypophosphataemic rickets, autosomal dominant hypophosphataemic rickets, autosomal recessive hypophosphataemic rickets and acquired diseases like vitamin D deficiency. Localization of responsible tumors could be rather difficult since the vast majority are very small and could be everywhere in the body. A combination of thorough physical examination, laboratory tests and imaging techniques should be applied and sometimes a venous sampling may come into handy. The technology of somatostatin-receptor functional scintigraphy markedly facilitates the localization of TIO tumor. Patients undergoing complete removal of the causative neoplasm generally have favorable prognoses while a few have been reported to suffer from recurrence and metastasis. For those undetectable or unresectable cases, phosphate supplements and active vitamin D should be administrated and curative intended radiotherapy or ablation is optional.

Effects of Enhanced Exercise and Combined Vitamin D and Calcium Supplementation on Muscle Strength and Fracture Risk in Postmenopausal Chinese Women / 中国医学科学院学报

Objective To observe the effects of enhanced exercise and combined vitamin D and calcium supplementation on muscular strength and fracture occurrence in postmenopausal women with a high risk of osteoporosis.Methods Totally 614 postmenopausal women at high risk factors of osteoporosis were enrolled in Dongcheng district of Beijing and randomized into four groups:group A(control group,n=173),group B(regular Tai Chi exercise,n=171),group C(calcium 600 mg/d+VitD800 U/d,n=139),and group D[calcium 600 mg/d+25 hydroxyl vitamin D(25OHD) 0.25 μg/d,n=131].Muscular strength was measured at baseline and one and two years after intervention.Bone turnover markers were measured at baseline and during the two-year follow-up.Falls and fractures were recorded.Results The incidence of 25OHD<50 nmol/L was approximately 92.6%.During the follow-up,the left grip strength decreased significantly two years after intervention(t=-3.252,P=0.001)in group A.Right grip strength decreased significantly in group B(t=2.460,P=0.015)while left grip strength improved significantly in group C(t=-2.051,P=0.043)one year after intervention.In group D,muscular strength in both 12-month and 24-month did not change compared with baseline(both P>0.05).Furthermore,serum procollagen type I N-terminal propeptide elevated significantly in group A(t=-2.962,P=0.004),group B(t=-2.888,P=0.005),and group C(t=-2.441,P=0.016),whereas β-C-terminal telopeptide of type I collagen decreased significantly in group B(t=2.285,P=0.024)and group D(t=2.596,P=0.011)two years after intervention.Conclusion Enhanced exercise and combined calcium vitamin D supplementation may help sustain muscle strength in postmenopausal women,while calcium and vitamin D supplementation may improve muscular strength within a short period of time.

Clinical characteristics of adult-onset primary hypoparathyroidism：a retrospective analysis of 200 ;cases / 中华内科杂志

Objective To study the clinical characteristics of primary hypoparathyroidism in adults.Methods The clinical data of 200 cases with adult-onset primary hypoparathyroidism in Peking Union Medical College Hospital during December 1987 to December 2015 were collected and analyzed retrospectively.Among them, 128 cases were followed up for a median period of 3 years.Results The major manifestations at their first visits were tetany and numbness in the distal extremities (81.5%,163/200 and 62.0%, 124/200).Thirty-two percent of the cases (62 cases) had history of seizures, and 60.9%( 98/161 ) and 74.4% ( 96/129 ) of them were with intracerebral calcifications and cataracts , respectively.Most of subjects(155/200)had more than one year delay in diagnosis.Hypercalciuria occurred in 67.2%( 86/128 ) of the cases during the follow-up.No significant differences in the clinical characteristics and biochemical markers between the hypercalciuria subjects and the non -hypercalciuria subjects.Renal nephrocalcinosis or stones were found in 6.5%( 5/77 ) of the cases , and kidney function decreased in 6.6%(6/91) of the patients.Kidney function was negatively associated with age and duration of disease.Conclusions The predominant manifestations of primary hypoparathyroidism in adults included tetany and numbness in the distal extremities and seizures .It is often misdiagnosed.Calcium supplement combined with vitamin D or its metabolites effectively relieve clinical symptoms and signs.The serum and urinary calcium levels should be monitored frequently to reduce renal complications .

Clinical features of Gorham-Stout syndrome and literature review / 中华内科杂志

Objective To describe the clinical presentations,radiographic findings and histological pathology of bones,diagnosis,treatment options and prognosis for patients with Gorham-Stout syndrome (GSS).Methods Clinical data of 5 GSS patients seen from January 1980 to January 2008 were reviewed.Results(1)There were 2 males and 3 females,aged 15 years to 37 years(mean age was 30.2 years).(2)All of thern had osteolysis,but the site and extent of involved bones were not the same.Three cases had large amount of bloody pieural effusion and two of them had also chylous effusion.All of the 5 cases had no evidence of malignancies.Four cases accepted bone biopsy.Among them,2 cases having local puncture and open biopsy showed typical bone pathologic manifestations.(3)Various forms of treatment including bisphosphonates,calcium supplementation,active vitD3 treatment,local radiation therapy and surgical ligation of thoracic duct were tried.(4)Follow up and clinical outcomes:the two cases,who had only bone osteolysis remained stable.Of the other three cases who had bone osteolysis associated with pleural effusion,one patient needed interrupted effusion drainage with stable bone impairment and the other two cases were out of contact.Conclusions GSS is a rare disorder charactcrized by progressive osteoIysis.The clinical presentations of this disease are variable and depend on the sites of involvement.There were no standard therapy available.Prognosis depends on the site of involvement,extent of the disease and presence of complications.Those who have plueral effusion had poor prognosis.