Paricalcitol for Secondary Hyperparathyroidism in Renal Transplantation

Secondary hyperparathyroidism contributes to post-transplant CKD mineral and bone disorder. Paricalcitol, a selective vitamin D receptor activator, decreased serum parathyroid hormone levels and proteinuria in patients with secondary hyperparathyroidism. This single-center, prospective, randomized, crossover, open-label study compared the effect of 6-month treatment with paricalcitol (1 μg/d for 3 months and then uptitrated to 2 µg/d if tolerated) or nonparicalcitol therapy on serum parathyroid hormone levels (primary outcome), mineral metabolism, and proteinuria in 43 consenting recipients of renal transplants with secondary hyperparathyroidism. Participants were randomized 1:1 according to a computer-generated sequence. Compared with baseline, median (interquartile range) serum parathyroid hormone levels significantly declined on paricalcitol from 115.6 (94.8–152.0) to 63.3 (52.0–79.7) pg/ml (P<0.001) but not on nonparicalcitol therapy. At 6 months, levels significantly differed between treatments (P<0.001 by analysis of covariance). Serum bone-specific alkaline phosphatase and osteocalcin decreased on paricalcitol therapy only and significantly differed between treatments at 6 months (P<0.001 for all comparisons). At 6 months, urinary deoxypyridinoline-to-creatinine ratio and 24-hour proteinuria level decreased only on paricalcitol (P<0.05). L3 and L4 vertebral mineral bone density, assessed by dual-energy x-ray absorption, significantly improved with paricalcitol at 6 months (P<0.05 for both densities). Paricalcitol was well tolerated. Overall, 6-month paricalcitol supplementation reduced parathyroid hormone levels and proteinuria, attenuated bone remodeling and mineral loss, and reduced eGFR in renal transplant recipients with secondary hyperparathyroidism. Long-term studies are needed to monitor directly measured GFR, ensure that the bone remodeling and mineral effects are sustained, and determine if the reduction in proteinuria improves renal and cardiovascular outcomes.     

Surgical assessment: measuring unobserved health

Background

The federal and provincial governments in Canada have invested an enormous amount of resources to measure, report and reduce surgical wait times. Yet these measures under-report the wait period that patients’ actually experience, because they do not capture the length of time a patient spends waiting to see the surgeon for a surgical assessment. This unmeasured time is referred to as the “wait one” (W1). Little is known about W1 and the effects that this has on patients’ health. Similarly, it is not understood whether patients waiting for surgical assessment actually want or need surgery. Existing administrative and clinical dataset do not capture information on health and decision-making while the patient is waiting for care form a specialist. The objective of this proposed study is to understand the impact that W1 for elective surgeries has on the health of patients and to determine whether this time can be reduced.

Methods/Design

A prospective survey design will be used to measure the health of patients waiting for surgical assessment. Working with the support of the surgical specialities in Vancouver Coastal Health, we will survey patients immediately after being referred for surgical assessment, and every four months thereafter, until they are seen by the surgeon.Validated survey instruments will be used, including: generic and condition-specific health status questionnaires, pain and depression assessments. Other factors that will be measured include: patients’ knowledge about their condition, and their desired autonomy in the decision making process. We have piloted data collection in one surgical specialty in order to demonstrate feasibility.

Discussion

The results from this study will be used to quantify changes in patients’ health while they wait for surgical assessment. Based on this, policy- and decision-makers could design care interventions during W1, aimed at mitigating any negative health consequences associated with waiting. The results from this study will also be used to better understand whether there are factors that predict patients’ desire to proceed to surgery. These could be used to guide future research into experimenting with interventions to minimize inappropriate referrals and where they are best targeted.     

Inhibition of secondary caries in vitro by addition of chlorhexidine to adhesive components

Objective

To investigate secondary caries inhibition after dentine pre-treatment with 2% CHX, experimental addition of CHX in primer and adhesive of a 3-step adhesive system, and industrial addition od CHX in a 2-step adhesive system.

咽成形术失败后再次手术后语音功能的评价

目的：客观评价咽成形术失败后语音障碍患者可以弥补治疗的方法。方法：对6例一期咽成形术后失败患者,再次实施咽后壁组织瓣转移术,术后进行详细观察和随访,并在术后4周开始吹气训练、行为疗法、语音治疗;对每例患者术前、语音治疗前后行汉语语音清晰度、吹气和冷镜检查,同时用CSL比较其音声特征的变化。结果：6例患者术后供区和受区伤口均一期愈合,聘咽闭合功能(VPC)明显改善,经语音治疗后,患者的语音清晰度达到或接近正常。结论：咽成形术失败后再次手术能补救一期咽成形术后失败的部分病例,除应该严格掌握咽成形术失败后再次手术的适应证外,术者熟练的操作技能也非常重要,同时术后语音治疗必不可少。     

双侧唇裂术后复裂的因素分析

目的:探讨双侧唇裂术后复裂的原因,以利于提高双侧唇裂的整复效果.方法:选择采用格洛弗式法经治的412例双侧唇裂术后复裂的患儿38例,对其复裂前的临床表现、复裂的时间特点及全身和局部情况进行分析.结果:完全性、混合性等严重复裂,复裂前的全身及局部症状较轻,复裂的高峰期在手术后第5、6天.结论:完全性复裂主要原因是松弛减张不彻底;而部分复裂与患儿的全身及局部情况、操作技巧及术前、术中、术后护理密切相关.     

腮腺淋巴结炎继发化脓性腮腺炎的CT及声像图特点

目的 探讨腮腺淋巴结炎继发化脓性腮腺炎的CT及声像图特点，以明确诊断，指导临床治疗。方法 对10例腮腺淋巴结炎继发化脓性腮腺炎患者进行临床资料分析，并进行CT和B超检查，分析其影像学特点。结果 腮腺淋巴结炎继发化脓性腮腺炎CT检查虽可见腺体内斑点状密度减低，密度不均，但腮腺轮廓完整：B超检查表现为腺体内点状低回声，或多个厚壁无回声区，随病变减轻，无回声区缩小并减少。结论 腮腺淋巴结炎继发化脓性腮腺炎可以通过CT及B超检查，并结合临床表现，与腮腺恶性肿瘤相鉴别，避免不必要的手术。     

Changes in voice quality,swallowing, and pulmonary function after parathyroidectomy for secondary hyperparathyroidism

ObjectiveTo find changes in voice quality, airway invasion during swallowing, pharyngeal residue after swallowing, acoustic and aerodynamic measurements and pulmonary function tests after total parathyroidectomy plus auto-transplantation for secondary hyperparathyroidism.MethodsWe recruited 38 patients who underwent successful surgery for secondary hyperparathyroidism in this study. Voice quality was evaluated using voice handicap index (VHI-10), eating assessment tool (EAT-10), voice impairment, and the grade, roughness, breathiness, asthenia, strain (GRBAS) scale. Acoustic and aerodynamic measurements included fundamental frequency (F0), maximal phonation time, high pitch, jitter, s/z, shimmer and noise-to-harmonic ratio. Vocal cord mobility, vocal cord closure, premature spillage, the penetration–aspiration scale and the Yale pharyngeal residue severity rating scale (PRSRS) after swallowing were examined using fiber-optic endoscopy. Pulmonary function tests included forced vital capacity, forced expiratory volume in 1 s, bronchodilator test, total lung capacity, diffusion capacity of the lung for carbon monoxide, alveolar volume, and distance and O2 desaturation of the 6 min walking test (6MWT).ResultsFour months after successful parathyroidectomy, VHI-10 improved significantly (p < 0.01); incomplete vocal cord closure decreased significantly (p < 0.01); the Yale PRSRS for vallecula and pyriform sinus improved significantly (p = 0.02 and p = 0.02); F0 and high pitch increased significantly (p < 0.01 and p = 0.01); O2 desaturation (<4%) of 6MWT improved significantly (p = 0.04).ConclusionsParathyroidectomy for secondary hyperparathyroidism can improve the voice quality, vocal cord closure, the Yale PRSRS for vallecular and pyriform sinus and O2 desaturation of 6MWT, and increase F0 and high pitch.     

Bone and primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a disease caused by excessive and inappropriate secretion of parathyroid hormone resulting in hypercalcemia. It is usually diagnosed incidentally in case of hypercalcemia, osteoporosis or, more rarely, renal involvement such as lithiasis. The clinical presentation reflects hypercalcemia and involves several organs, mainly the cardiovascular system, bone, and kidneys. However, most patients with PHPT are asymptomatic. The diagnosis is biological, obvious when serum calcium and parathyroid hormone levels are high, but difficult when one of these two values is normal. The diagnosis of normocalcemic PHPT is possible only after ruling out all causes of secondary hyperparathyroidism. Parathyroid imaging does not contribute to the positive diagnosis but guides surgery and rules out an associated thyroid abnormality. Parathyroid surgery is the gold standard treatment. Parathyroid surgery is indicated in the presence or risk of complications, and it is the only treatment that prevents fractures. Pharmaceutical treatments have only limited effects on complications and are limited to cases where surgery is contraindicated. After parathyroid surgery, the use of bisphosphonates must be avoided as they seem to interfere with the parathyroidectomy's fracture-preventing effects. In the absence of surgical indication, medical monitoring of patients includes assessment of laboratory values, bone density, and renal function.     

原发性甲状旁腺功能亢进症围手术期处理中国专家共识（2020版）

正甲状旁腺是人体重要的内分泌腺体之一,其分泌的甲状旁腺激素(parathyroid hormone,PTH)可直接或间接作用于骨、肾和小肠等组织器官,调节和维持血钙水平。甲状旁腺功能亢进症(hyperparathyroidism,HPT),简称甲状旁腺功能亢进,是由于甲状旁腺激素主动或被动分泌过多而导致的钙磷及骨代谢紊乱,从而引起的一组特殊临床综合