[Pain management using patient controlled epidural analgesia for transient osteoporosis of the hip in pregnancy].

We report the case of a 37-year-old woman who developed severe pain in bilateral legs and hip in the eighth month of pregnancy. She was diagnosed as transient osteoporosis of the hip in pregnancy by the MRI findings. NSAID is contraindicated for late pregnancy, and we selected epidural analgesia for the pain management of this case. Patient controlled epidural analgesia was effective and no complication occurred in both patient and baby. After delivery, diclofenac sodium was administered for three weeks. Complete clinical improvement was observed in the seventh month after delivery.

[Airway obstruction after tracheostomy in a neurologically impaired child].

A 14-year-old boy neurologically impaired was scheduled for tracheostomy under general anesthesia because of the prolonged tracheal intubation. He had twice received artificial respiration under tracheal intubation for aspiration pneumonia. During emergence from anesthesia, bucking occurred and suddenly the patient's lungs could not be ventilated. Neither anesthetic circuit nor tracheostomy tube were not functioning well, and airway obstruction was not relieved by manual and positive pressure ventilation within 40 mmHg. SpO2 gradually decreased to 48%, resulting in bradicardia. However, it became possible to inflate the lungs immediately because of the respiratory effort decreased. SpO2 rapidly increased to normal range and heart rate recovered. The patient was suspected of having tracheomalacia as a result of flexible bronchoscopy performed through tracheostomy tube, revealing slight collapse of the trachea. Tracheomalacia can be a cause of sudden difficult ventilation in neurologically impaired children.

Effect of parathyroid hormone administration in a patient with severe hypoparathyroidism caused by gain-of-function mutation of calcium-sensing receptor.

Hypoparathyroidism caused by gain-of-function mutations of the calcium-sensing receptor (CaR) in the transmembrane domain is usually severe and difficult to manage. A patient with severe hypoparathyroidism, caused by CaR activating mutation F821L, was treated for 3 days (Day 1 to Day 3) with synthetic human parathyroid hormone 1-34 (teriparatide, PTH). An Ellsworth-Howard test of the patient revealed normal responses of urine phosphate and cyclic AMP excretion, indicating that the patient's renal tubules normally responded to extrinsic PTH. On Day 1 to Day 3, 0.9 microg/kg/day of PTH was administered subcutaneously twice daily at 0800 and 2000. On Day 1, the serum calcium level that was 1.8 mmol/l before PTH administration increased to 2.1 mmol/l at 1200, and gradually decreased to 1.8 mmol/l at 2000. On Days 2 and 3, the maximum calcium levels were 2.5 and 2.4 mmol/l, respectively, at 1200. At 2000, they returned to or below basal levels at 0800. On Day 4 without PTH administration, the calcium levels were maintained at the basal levels at Day 0. The urine calcium/creatinine (Ca/Cr) ratio that was high (>0.4) before PTH injection decreased after PTH administration (0.4>). Changes in the ionized calcium levels were almost parallel with the total calcium levels. The serum inorganic phosphate (IP) level decreased to 2.4 mmol/l at 1000, but gradually increased before the second PTH injection to the level at 0800 on Day 1. The minimum IP level on Days 2 and 3 was 2.1 mmol/l and 2.0 mmol/l, respectively. In contrast to the remarkable changes in the serum calcium level by PTH treatment, the serum magnesium levels showed few changes. These results indicate that PTH therapy could be effective in correcting serum and urine calcium and the phosphate levels in hypoparathyroidism caused by activating mutation of CaR.