TOTAL THYROIDECTOMY FOR MALIGNANCY - IS CENTRAL NECK DISSECTION A RISK FACTOR FOR RECURRENT NERVE INJURY AND POSTOPERATIVE HYPOCALCEMIA? A TERTIARY CENTER EXPERIENCE IN ROMANIA.

INTRODUCTION: Surgery for thyroid cancer carries a higher risk of morbidity given the region's complicated anatomy, the setting of malignancy and extent of the surgery. AIM: To investigate the rate of complications related to the recurrent nerve and parathyroid glands lesions in patients with thyroid carcinoma that undergo thyroid surgery and lymph node dissection. PATIENTS AND METHODS: The data of 71 patients who underwent total thyroidectomy and 19 patients who underwent total thyroidectomy and central neck dissection with various associated neck dissection techniques were investigated using appropriate statistical tests. RESULTS: As expected, the rate of recurrent nerve injury observed in the neck dissection group was higher than in the total thyroidectomy group (15.7% vs. 2.8%, p=0.05). As for postoperative hypocalcemia, the rate observed in the neck dissection group, both for postoperative day 1 (p<0.0001) and day 30 (p=0.0003) was higher than in the total thyroidectomy group (68.4% vs. 19.7% postoperative day 1, 31.5% vs. 4.2% postoperative day 30). CONCLUSIONS: The risk of morbidity concerning the recurrent nerve injury and postoperative hypoparathyroidism increases with the extent of surgery. Extensive surgery may achieve proper oncologic outcomes but increases the risk of postoperative morbidity and decreases quality of life. In deciding for extensive surgery, both patient and medical team need to understand these risks.

PATIENTS TREATED WITH INSULIN AND SULPHONYLUREA ARE AT INCREASED MORTALITY RISK AS COMPARED WITH THOSE TREATED WITH INSULIN PLUS METFORMIN.

AIMS: To investigate the effect of sulphonylurea (SU) treatment on all-cause and cardiovascular mortality as compared with metformin (MET), when used in combination with insulin (INS) in type 2 diabetes. METHODS: All type 2 diabetes patients aged ≥40 years were included at their first prescription of INS+MET or INS+SU, during 2001-2008. They were considered at risk until death or December 31st, 2011. Mortality rates were calculated per 1000 person-years. Crude and adjusted rate ratios (RR) were calculated using time dependent analysis with INS+MET as reference. RESULTS: There were 7122 patients (60.8% women) included in the analysis, with a mean age at baseline of 62.0±9.9 years. During the 11 years of study, patients on INS+MET contributed 13620 person-years and 330 deaths (mortality rate 24, CI95% 22-27), while those on INS+SU contributed 8720 person-years and 393 deaths (mortality rate 45, CI95% 41-50). Adjusted all-cause mortality RR were: SU 1.6 (CI95% 1.21-2.11, p<0.001), glimepiride 1.18 (CI95% 0.73-1.91, p=0.51), gliclazide 1.78 (CI95% 1.07-2.95, p=0.024), glibenclamide 1.66 (CI95% 0.71-3.88, p=0.23), glipizide 1.24 (CI95% 0.68-2.27, p=0.49), and gliquidonum 2.32 (CI95% 1.54-3.50, p=0.001). CONCLUSIONS: When combined with insulin as dual therapy, patients treated with SU were at increased mortality risk as compared with insulin + MET.

Early Improvement in Glycemic Metabolism after Laparoscopic Sleeve Gastrectomy in Obese Patients - A Prospective Study.

BACKGROUND: according to W.H.O. in 2014 more than 600 million adults were obese, (more than doubled since 1980), and face a major risk for the onset of metabolic syndrome, including T2DM. Due to the poor control of glycemic imbalance for the conservative treatment of T2DM, the metabolic surgery was able to gain an important role in modern management of T2DM, with significant reported improvements or remissions for these patients. OBJECTIVE: to study the effects of laparoscopic sleeve gastrectomy (LSG) on glycemic metabolism in obese patients, with or without T2DM. METHODS: 60 consecutive patients were included in a prospective study and were submitted to laparoscopic sleeve gastrectomy in Ponderas Hospital between February - March 2013. BMI, waist circumference and glycemic parameters were studied at the moment of entering the study, 10 days after surgery and at 6 months follow up. RESULTS: the glycemic control was significantly improved starting with postoperative day 10. Statistically significant improvements were noticed after six months postoperatively in BMI values (p 0,0001), waist circumference (p 0,0001), glycemic levels (p 0,0001), insulin (p 0,0001), C-peptide (p 0,0001) and HOMA. CONCLUSIONS: a rapid induced improvement of glucose metabolism in both diabetic and non-diabetic patients occurs before a significant weight loss (POD 10). At 6 months, when associated with an important weight loss, both diabetic and non-diabetic patients present a furthermore improvement in glycemic metabolism, that enables us to consider that sleeve gastrectomy is an efficient method for a sustained improvement in the metabolic status of patients with obesity. These beneficial changes that can explain the remission of T2DM can also explain the prevention of T2DM after metabolic surgery.

Iatrogenic Cushing's syndrome related to the interaction between oral budesonide with fluvoxamine: a case report.

WHAT IS KNOWN AND OBJECTIVE: Budesonide, an oral glucocorticoid indicated for the treatment of Crohn's disease, rarely interferes with the hypothalamic-pituitary-adrenal axis because more than 80% of it is metabolized by cytochrome P450 enzymes. CASE SUMMARY: A 33-year-old female patient diagnosed with Crohn's disease, treated with oral budesonide, was admitted for Cushingoid symptoms and signs. The onset coincided with the use of fluvoxamine, a serotonin reuptake inhibitor and also a potent inhibitor of cytochrome P450 enzymes that presumably led to budesonide accumulation. WHAT IS NEW AND CONCLUSION: Practitioners should take into consideration the possibility of iatrogenic Cushing's syndrome caused by the association of oral budesonide with a P450 cytochrome inhibitor.

The Impact of Thyroid Autoimmunity on the Clinical and Diabetes Parameters of Patients with Latent Autoimmune Diabetes in Adults.

AIM: We evaluated the clinical and diabetes parameters of latent autoimmune diabetes in adults (LADA) patients according to the presence of thyroid autoimmunity (TA). MATERIALS AND METHODS: Patients with LADA (diabetes onset after 30 years of age, no need for insulin treatment for at least 6 months after diabetes onset, positive for glutamic acid decarboxylase antibodies (GADA)) were evaluated for the presence of thyroid peroxidase antibodies (TPOAb) and were subjected to clinical and laboratory evaluations of the glycated hemoglobin and basal C peptide levels. The patients were stratified into either group A (with TA) or group B (without TA). RESULTS: We evaluated 104 (57 female and 47 male) patients with LADA. The mean age at diabetes onset was 44±10 years. The prevalence of TA among the LADA patients was 28.8% (30 patients; 23 female and 7 male). In groups A and B, the mean age at diabetes onset was 41.47±10.15 and 45.07±10 years (p=0.03), the basal C peptide level was 0.69±0.16 and 1.9±1.3 ng/ml (p<0.0001), the glycated hemoglobin level was 9.8±2.2 and 9.1±2.2 (p=0.04), and the time to insulin treatment was 3.2±2.1 years and 4.98±2.2 years (p=0.038), respectively. The use of a basal bolus insulin regimen was more frequent in group A than in group B (56.7% and 35.1%, respectively; p=0.03). CONCLUSION: TA identifies a particular phenotype of LADA displaying a higher GADA titer, lower basal C peptide levels and poorer glycemic control.

The impact of obesity on the male reproductive axis.

Obesity, defined as a body mass index (BMI) >30 kg/m2, has seen an important increase in prevalence in the last decades, not only in Europe and the United States, but also in developing countries. It is an established risk factor for numerous pathologic conditions like diabetes mellitus, cardiovascular diseases and cancer, but has also been linked to male hypogonadism. Several studies showed a negative impact of excessive BMI on testosterone levels, sexual function and sperm parameters. Possible mechanisms beyond this phenomenon are reduced hypothalamic and pituitary secretory function, excess estrogen production and reduced circulating sex-hormone binding globulin (SHBG). Peptides produced by the adipocyte may also trigger modifications of the reproductive function. Independently of the method used, non-surgical approach or bariatric techniques, weight reduction and a return to a normal BMI have been associated with improvement in the sexual function and levels of sexual hormones in obese males, showing that obesity related hypogonadism is preventable. Sexual and reproductive health might represent additional motivational factors for men in order to maintain a healthy life-style.

Laparoscopic sleeve gastrectomy improves reproductive hormone levels in morbidly obese males -- a series of 28 cases.

BACKGROUND: Obese males frequently present with low androgen levels that may improve after weight loss achieved by bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been used often in the last decade as treatment for morbid obesity. The aim of this study was to evaluate modifications in the male reproductive hormone profile after LSG. PATIENTS AND METHODS: The prospective study included 28 males with body mass index (BMI) 35 kg m2 who underwent LSG.Total Testosterone (TT), Sex Hormone Binding Globulin(SHBG) and Luteinizing hormone (LH), together with biochemical and anthropometric data, were evaluated at baseline and after LSG. RESULTS: Baseline patients had a mean BMI of 50.10 (+-11.19)kg m2, SHBG 23.37 (+-17.47) nmol L, LH 3.83 (+-1.76)mUI ml and TT 8.31 (+-3.24) nmol L. After LSG, patients showed a mean BMI of 35.87 (+-7.02) kg m2 (p 0.001),SHBG 37.81 (+-18.95) nmol L (p 0.05), LH 4.76 (+-2.49)mUI ml (p 0.05), whereas mean TT was 12.7 (Â+-3.8) nmol L(p 0.001). The percentage of excess body weight loss (%EBL)was 43.07 (+-9.56) and metabolic syndrome prevalence decreased significantly from 75% to 25% (p 0.001). CONCLUSIONS: Beyond BMI loss, LSG significantly improved reproductive hormone levels in morbidly obese males.

Association of serum adiponectin and insulin-like growth factor I levels with parameters of cardiac remodeling in severely obese patients.

BACKGROUND: Obesity is associated with various changes in cardiac geometry and this process involves both hemodynamic and non-hemodynamic factors, among which adipocitokines and growth factors may play an important role. The aim of this study was to identify the extent and pattern of cardiac remodeling in a group of severely obese patients and analyze the relationship between adiponectin, IGFI and cardiac parameters reflecting obesity-associated structural changes. SUBJECTS AND METHODS: Our study included 344 patients (104 men) with severe obesity [mean body mass index (BMI)= 45.7 ± 8.5 kg/m(2)], extensively evaluated clinically and biologically (complete metabolic tests, serum adiponectin, and IGF-I measurements). Left ventricular (LV) mass index (LVMI), left atrium (LA) size, and LV geometry were determined by means of cardiac ultrasound. RESULTS: The most prevalent pattern of LV geometry was eccentric hypertrophy (28.7% of patients). In a gender-, age-, BMI-, diabetes- and hypertension-adjusted general linear model, patients with concentric or eccentric hypertrophy had significantly lower values of adiponectin than those with normal geometry (6.75 ± 0.41, 6.96 ± 0.53, vs 9.04 ± 0.42 mg/l, p<0.05). In multivariate analysis, independent determinants for LVMI were BMI (ß=0.364, p<0.001), systolic blood pressure (BP) (ß=0.187, p=0.004), age (ß=0.246, p<0.001), adiponectin (ß=-0.151, p=0.012), and IGF-I z-score (ß=0.134, p=0.025) while factors independently related to LA size were systolic BP (ß=0.218, p<0.001), BMI (ß=0.194, p<0.001), age (ß=0.273, p<0.001), gender (ß=-0.195, p<0.001), and adiponectin (ß=-0.180, p=0.005). CONCLUSIONS: In patients with severe obesity, IGF-I z score and adiponectin correlate with parameters of cardiac remodeling independently of anthropometric, hemodynamic or metabolic factors.

Adiponectin, body mass index and hepatic steatosis are independently associated with IGF-I status in obese non-diabetic women.

OBJECTIVE: Low IGF-I levels have been associated with obesity, insulin resistance, hepatic steatosis, and were shown to predict cardiovascular mortality. Adiponectin, on the other hand, was proved to have an important protective role against metabolic and cardiovascular diseases. This study investigates the relation between hepatic steatosis, adiponectin and IGF-I levels in a group of non-diabetic obese Romanian women. DESIGN: This cross-sectional study included 201 obese non-diabetic women, with mean age of 41.1±11.9 years and mean body mass index (BMI) of 44.1±8.3 kg/m(2), consecutively admitted to the Endocrinology Department of a University Hospital to be evaluated as candidates for bariatric surgery. Main measured parameters included total adiponectin (detected by ELISA method), insulin, C reactive protein (CRP), and IGF-I (all by chemiluminescence methods). Insulin sensitivity was assessed using the Quantitative Insulin Sensitivity Check Index (QUICKI). Patients were considered IGF-deficient if IGF-I z score was ≤2 standard deviations from mean for age. Hepatic ultrasound was used to determine the presence of significant steatosis (SS+). RESULTS: Significant steatosis was observed in 60.7% of our patients and this feature was associated with reduced total adiponectin levels (p<0.001) and lower IGF-I z scores (p<0.001). IGF-I z score negatively correlated with BMI (r=-0.283, p<0.001), alanine aminotransferase (ALT) (r=-0.130, p=0.032), gamma glutamyltransferase (GGT) (r=-0.158, p=0.018) and logarithmic transformed (log) CRP (r=-0.232, p=0.001) and positively correlated with QUICKI (r=0.148, p=0.023) and log adiponectin (r=0.216, p=0.003). The relationship between IGF-I z score and log adiponectin remained significant after adjusting for age, BMI, ALT, QUICKI and log CRP (r=0.183, p=0.012). IGF-I deficiency was present in 33.3% of these obese women. In multivariate logistic analysis, BMI (p<0.001), ALT (p=0.003), log adiponectin (p<0.001) and SS (p=0.043) proved to be independently associated with IGF-I deficiency. CONCLUSIONS: Adiponectin is significantly correlated with IGF-I z scores and, along with BMI, ALT and significant steatosis, is independently associated with IGF-I deficiency in obese non-diabetic women.

The dynamics of life expectancy over the last six decades in elderly people with diabetes.

AIM: To investigate the historical changes in survival with diabetes in elderly people with diabetes. RESEARCH DESIGN AND METHODS: We analyzed 6504 deaths (44.5% males) registered in a large urban population, aged ≥65 years, and deceased between 1943 and 2009. We split the analysis into three time periods according to year of death: 1943-1965, 1966-1988 and 1989-2009. The parallel changes in the corresponding general population were available. RESULTS: The mean age at diabetes onset was 70.8 ± 4.7 years, with mean disease duration at death 7.5 ± 5 years, and mean age at death 78.3 ± 5.9 years. The mean survival loss due to diabetes (expected minus observed survival) was 4.5 ± 5.1 years (4.9 ± 5.1 years for females versus 4.1 ± 5.2 years for males, p<0.001). The mean disease duration at death was 6.4 ± 5.7 years in the period 1943-1965, followed by a significant (p=0.019) rise to 7 ± 5 years in 1966-1988, and 8.3 ± 4.9 years (p<0.001) in 1989-2009. There was a significant increase in coronary heart disease and stroke, and a significant decrease in infections and end-stage renal disease as causes of death. CONCLUSIONS: We found a significant increase in age at onset and survival with diabetes leading to a significant increase in age at death. Females had a higher survival loss due to diabetes compared with males.

Six months results of laparoscopic sleeve gastrectomy in treatment of obesity and its metabolic complications.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric surgical procedure, with proven results in achieving weight loss, however data regarding its effectiveness on metabolic syndrome (MetS) components are scarce. The aims of the present study were to assess the outcomes of LSG on weight loss and obesity associated metabolic complications at six months following intervention. PATIENTS AND METHODS: This was a retrospective study on 124 consecutive obese patients (29.8% men), who had undergone LSG between 01/01/2008 and 12/31/2010, in a highly specialized clinic. The dynamic of anthropometric and biochemical data between baseline and six months following LSG were evaluated. We also determined the change in MetS prevalence and used logistic regression to estimate predictors of MetS remission RESULTS: 6 months after LSG, the body mass index (BMI) decreased from 46.84 +/- 8.62 to 33.81 +/- 7.04 kg/m2 (p < 0.001). Mean excess BMI loss (EBL) was 65.24 +/- 25.16%. The best results on weight loss were observed in young patients, not affected by MetS, with lower initial BMI. Lipids profile suffered a significant improvement (HDL cholesterol increased, while LDL, total cholesterol, triglycerides decreased, p < 0.05 for each). HOMA-IR values decreased by 75.2%, from 5.24 +/- 4.49 to 1.30 +/- 1.22 (p < 0.001). MetS prevalence was reduced from 74.3% to 18.4% (p < 0.001). In multivariate analysis, % EBL remained the only significant predictor of MetS remission, the risk for lack of a MetS remission being practically 3 times higher in patients with EBL < 50%, compared to those with EBL > 50% (OR: 2.97, CI: 1.1-10.23, p < 0.05). CONCLUSIONS: As early as 6 months after LSG we recorded a significant weight loss and improvement in insulin resistance and lipids metabolism, as well as an impressive reduction in metabolic syndrome prevalence.

Noninvasive clinical model for the diagnosis of nonalcoholic steatohepatitis in overweight and morbidly obese patients undergoing bariatric surgery.

BACKGROUND: Liver biopsy, an invasive method, is the gold standard for differentiate nonalcoholic steatohepatitis (NASH) from other stages of fatty liver disease. A noninvasive test to diagnose NASH and disease severity before surgery and also for monitoring disease status after bariatric surgery (BS) will be an important medical challenge. AIM: To create a noninvasive biomarkers model for the diagnosis of NASH in overweight, obese and morbidly obese patients (MOP). PATIENTS AND METHODS: Sixty patients (mean BMI= 47.81kg/m2) were admitted after exclusion of other causes of liver disease. Liver biopsies were obtained at the time of the bariatric surgery or by percutaneous liver biopsy and graded using Kleiner score. Continuous variables were compared using Wilcoxon rank sum test and for prediction of NASH we used logistic regression. RESULTS: Logistic regression analysis showed that BMI, ALT, AST, alkaline phosphatase (ALP), HOMA-R, hs-CRP, M30, M65, leptine and adiponectine levels remained independent predictors for NASH (p less than 0.02). Using AUC analysis, we established the following cutoff levels being indicative of NASH: BMI e 47 kg/m2, ALT e 32 IU/mL, AST e 25 IU/mL, ALP e 85 IU/mL, HOMA-IR e 4, M65 e 389 U/L. Adiponectine less than 13.5 mg/L. A NASH-score, calculated as the sum of these 7 parameters, at a cutoff level of 4 points, can accurately predict NASH (sensitivity of 90%, specificity of 93.94% and AUC of 0.9576). CONCLUSIONS: We propose a noninvasive model for NASH diagnosis in MOP that should be validated prospectively. Using this noninvasive score, NASH would be predicted without the risks of liver biopsy.

[Insulinoma of the pancreas: analysis of a clinical series of 30 cases]. / Insulinomul pancreatic--analiza unei serii clinice de 30 de cazuri.

UNLABELLED: Insulinoma is the most frequent neuroendocrine pancreatic tumor and is the main cause for hypoglicemia due to endogenous hyperinsulinism. We performed an analysis of a clinical series in order to study the clinical and biological spectrum of presentation, the preoperatory imagistic diagnosis and results of the surgical approach. Between 1986-2009, 30 patients with symptoms suggesting an insulinoma were hospitalized in our department. Preoperatory localization of insulinomas was possible in 16 patients. The most sensitive imagistic methods were ecoendoscopy and magnetic resonance. Intraoperatory ultrasound was performed in 16 patients and its sensitivity in detection of insulinomas was 93%; the combination between intraoperative ultrasound and manual exploration of pancreas by the surgeon reached a 100% sensitivity. Before the intraoperatory ultrasound was used the tumor excision was predominantly done by extensive pancreatic resection, while after this was available in our centre more conservative (enucleo-resection) procedures were chosen. In 1 patient the resection was done by laparoscopy, and in 1 patient by robotic surgery. The dimensions of the tumor were less than 2 cm in most of the patients; 2 had nesidioblastosis and 2 had multiple insulinomas; all 28 patients proved to have benign insulinomas at histological specimens. Following surgery, the symptoms disappear in all patients. The most common complication following extensive pancreatic resections was acute pancreatitis, while after enucleation pancreatic fistula occurred more frequently. CONCLUSIONS: Due to small dimensions, the preoperative diagnosis of insulinomas is usually difficult, ecoendoscopy being the most sensitive method. Intraoperative ultrasound is essential for insulinoma localization and for chosing the optimal type of excision. Enucleation is the resection method to be chosen whenever this it is technical possible. In benign insulinomas the prognosis is excellent, surgical resection being curative in all cases.

[Postoperative hypoparathyroidism, an assumed risk in total thyroidectomy for Graves disease]. / Hipoparatiroidismul postoperator, un risc asumat în cazul tiroidectomiei totale pentru boala Graves.

Hypocalcemia is a common clinical occurrence and has many potential causes, one of which can be congenital or acquired hypoparathyroidism. Acquired hypoparathyroidism is most commonly the result of damage to the glands, usually to their blood supply, during thyroidectomy, parathyroidectomy, or radical neck dissection. We present the case of a 40-year-old female known with Waldenström macroglobulinemia, cronic hepatitis C, who has been diagnosed with Graves disease and associated ophtalmopathy in 2004 and treated with antithyroid drugs for 1.5 years; a decision of total thyroidectomy was made considering the complexity of comorbidities and the fact that the patient already had a relapse under methymazol treatment. The postsurgical evolution was impeared by a sever hypocalcemia, necessitating repeted parenteral calcium administration associated with p.o. calcium and vitamin D, with rapid recovery, seric calcium beeing kept in normal limits and without symptoms.

Malignant insulinoma with hepatic and pulmonary metastases associated with primary hyperparathyroidism. Case report and review of the literature.

Malignant insulinomas are rare tumors (10% of insulinomas) that often present as mnulticentric macro nodules with multiple liver metastases before diagnosis. We report the case of a 55 year old female with a medical history of severe hypoglycemic attacks for two months. Blood tests showed a decreased value of glycemia (30 mg/dl) associated with increased insulin level (l6 microU/ml) and an increased glycemia/insulinemia ratio of 1.87 supporting the diagnosis of insulinoma. Abdominal CT showed a 1.5 cm mass localized in the head of the pancreas with disseminated hepatic tumors, confirmed as neuroendocrine metastases by biopsy (which proved the presence of a malignant insulinoma). Primary hyperparathyroidism was diagnosed based on mild elevation of calcium (10.4 mg/dl) associated with a high level of PTH (71.2 pg/ml). The coexistence of the two endocrinopathies suggested the presence of type 1 multiple endocrine neoplasia (MEN 1). Because of multiple hepatic masses and liver function impairment, surgery and hepatic artery embolization were not performed. Somatostatin analog therapy was started with symptomatic control in the beginning, but rapid loss of beneficial effect. Finally, systemic chemotherapy with doxorubicin was administered, but the disease was progressive and after three months we decided to stop it. The patient died at home after one month, probably in hypoglycemic coma.

[Is there a role for a random measurement of 24-hour urine calcium excretion and serum total alkaline phosphatase in the determination of fracture risk in osteoporotic postmenopausal women?]. / Rolul fosfatazei alcaline totale si al Calciuriei in determinarea riscului de fractura, la femei cu osteoporoza de postmenopauza.

UNLABELLED: Our objective was to explore whether a casual determination of 24-hour urinary calcium excretion and serum total alkaline phosphatase (TAP), in osteoporotic postmenopausal women are independent predictors for osteoporotic fracture. Subjects were 121 women with postmenopausal osteoporosis (mean age 62.8 +/- 9.9) segregated in two study groups based on prevalence of osteoporotic fractures (51 women with prevalent fractures and 70 without fractures), similar in terms of age and BMI. We measured bone mineral density (BMD) by DXA at lumbar spine and femoral neck. Vertebral fracture assessment was done by plain X ray evaluation. Routine blood tests and extensive endocrine evaluation were performed in all patients to exclude secondary causes of osteoporosis. Serum TAP, calcium, phosphate and urinary calcium excretion was measured to evaluate bone metabolism. We did not find any significant differences between groups regarding lumbar T score (-3.1/-2.9 SD), femoral neck T score (-2.2/-1.8 SD), lumbar Z score (-1.5/-1.9 SD) or femoral neck Z score (-1.5/-1.8 SD). Serum TAP was higher in fracture group (211.5 UI) comparing to non-fracture osteoporotic women (208.3 UI) without statistical significance. We were not able to find any significant difference between groups in terms of urinary calcium excretion (9.13/5.4 mEq/24h) or serum total calcium (4.8/4.9 mmol/l). CONCLUSION: in spite of a mean TAP near the upper limit of normal range which could be related to low bone mass, there is no significant relationship to fracture risk in osteoporotic postmenopausal women. Based on our data, a casual measurement of urinary calcium excretion seems irrelevant for BMD independent fracture risk assessment in this clinical setup.