Clinical usefulness of the (chloride-90)/phosphate ratio for distinguishing primary hyperparathyroidism from hypercalcemia due to other causes

In order to obtain a good separation line between patients with primary hyperparathyroidism (1 degree HPT) and those with non-parathyroidal hypercalcemia (NPHC), serum chloride (Cl) and phosphate (P) concentrations were analyzed. Ninety-nine per cent of the patients with 1 degree HPT had a Cl/P ratio greater than or equal to 33, but 29% of patients with NPHC were also included in this range. When the (Cl-90)/P ratio was used to separate into two groups, 98% of the patients with 1 degree HPT had a ratio greater than or equal to 5.0, and 94% of the patients with NPHC had a ratio less than 5.0. From these results, while high sensitivity was achieved both with the Cl/P and (Cl-90)/P ratios, the (Cl-90)/P ratio provided higher specificity. Therefore we conclude that the (Cl-90)/P ratio was excellent in distinguishing 1 degree HPT from other types of hypercalcemia.     

Gastrointestinal Replacement Solution

The mean sodium concentration of 61 gastrointestinal aspirations in peritonitis was 103 mEq/l. (S.D. 16·66), of 16 aspirations in vagotomy 88 mEq/l. (S.D. 19·49), of 12 aspirations in perforated duodenal ulcer 81 mEq/l. (S.D. 19·49), and of 15 aspirations in intestinal obstruction 89 mEq/l. (S.D. 19·49). The mean potassium concentrations were 9, 9·9, 13, and 8·8 mEq/l. respectively, and the mean chloride concentrations 122, 131, 125, and 112 mEq/l. respectively. It is suggested that a gastrointestinal replacement solution should contain 100 mEq of sodium, 12 mEq of potassium, and 122 mEq of chloride per litre; 50 g. of dextrose or 100 g. of fructose may be added to provide energy.     

Long term follow up of untreated primary hyperparathyroidism.

Fourteen patients with primary hyperparathyroidism and whose initial serum calcium concentrations were 2.75 mmol/l (11.0 mg/100 ml) or more were followed up for five to 23 years without operative treatment. One had osteitis fibrosa when seen and died with a fibrosarcoma 22 years later. The remaining 13 patients, who were followed up for a mean of 10 years, came to little obvious harm from not being operated on. Their serum calcium concentrations did not rise and there was no evidence of progressive renal impairment. In four patients who presented originally with renal calculi there were three further episodes of renal colic in 54 patient years of follow up. Conservative management of primary hyperparathyroidism is not an unreasonable option, and patients who do not have symptoms need not necessarily be pressed to accept surgery.     

The chemistry of insect hemolymph; organic components of the hemolymph of the silkworm,Bombyx mori,and two other species

1. Hemolymph was collected for analysis from the silkworm, Bombyx mori, in a series of developmental stages ranging from the second molt to the late pupa. The mean pH of larval hemolymph after collection was found to be 6.45, that of pupal hemolymph, 6.57; in vivo values may be slightly lower. Total dry solids ranged from 5.4 to 10.6 per cent. Total protein ranged from 1.2 to 5.3 per cent, increasing rapidly during the fifth instar. 2. Free amino acids were separated chromatographically and estimated. Of 19 amino acids identified, amounting collectively to 823 to 1497 mg. per 100 ml., glutamine, histidine, and lysine generally occurred in greatest amount. Tryptophan was not detected, and cystine (or cysteine) was found in only one sample. The total free amino acids account for 35 to 55 per cent of the non-protein nitrogen of the plasma. 3. Free sugars, estimated semiquantitatively on chromatograms, comprise glucose, fructose, and sucrose in total amount ranging from about 5 to 40 mg. per 100 ml. Total acid-soluble, ultrafiltrable carbohydrate, estimated as glucose by the anthrone reaction, ranged from 166 to 635 mg. per 100 ml., indicating the presence of low molecular weight sugar derivatives. 4. Inorganic phosphate amounted to 5 to 15 mg. per 100 ml., and acid-soluble organic phosphate to 100 to 200 mg. per 100 ml. The latter fraction includes several substances, of which one was tentatively identified as glucose-6-phosphate and the remainder are as yet unidentified. 5. Single samples of hemolymph were also taken from larvae of the wax moth, Galleria mellonella, and the spruce sawfly, Diprion hercyniae. These contained even higher concentrations of solutes than the silkworm samples, but with a generally similar distribution. The proportions of the free amino acids were different in each species.     

INTRAVENOUS NUTRITION—A Clinical Evaluation of a 50 Per Cent Dextrose in Water Solution,Containing 1 mg. of Hydrocortisone per 100 ml

A 50 per cent dextrose in water solution, containing 1 mg. of hydrocortisone per 100 ml., was used successfully in 70 patients for intravenous nutritional maintenance and repletion. There were no adverse systemic effects during or following 216 infusions. The only undesirable local reaction was the rare occurrence of pain in the arm when the concentrated solutions were given too rapidly. Glycosuria was minimal if the infusion rate did not exceed 0.85 gm. of glucose per kilogram of body weight per hour, particularly if 50 units of insulin were added to each 550 ml. bottle of 50 per cent dextrose. In patients without significantly elevated serum potassium content, 30 mEq. of potassium chloride, acetate or phosphate was added to each bottle to prevent hypokalemia.Preliminary observations suggest that this new solution may be given safely intravenously, without need for cutdowns or plastic catheters, if the needle is carefully inserted and well immobilized in the arm vein and the duration of the infusion is not too prolonged. Further studies on the effect of such high caloric supplementation plus protein hydrolysates in parenteral nutritional repletion and maintenance are indicated.     

Role of residual insulin secretion in protecting against ketoacidosis in insulin-dependent diabetes.

The role of preserved beta-cell function in preventing ketoacidosis in type I insulin-dependent diabetes was assessed in eight patients with and seven patients without residual beta-cell function as determined from C-peptide concentrations. After 12 hours of insulin fatty-acid, and glycerol concentrations were all significantly higher in patients without beta-cell function than in those with residual secretion. Mean blood glucose concentrations reached 17.2 +/- SE of mean 1.3 mmol/l (310 +/- 23 mg/100 ml) in the first group compared with 8.8 +/- 1.4 mmol/l (159 +/- 25 mg/100 ml) in the second (P less than 0.01), while 3-hydroxybutyrate concentrations rose to 5.5 +/- mmol/l (57 +/- 5 mg/100 ml) and 1.4 +/- 0.3 mmol/l (15 +/- 3 mg/100 ml) in the two groups respectively (P less than 0.01). Individual mean C-peptide concentrations showed a significant inverse correlation with the final blood glucose values (r = -0.91; P less than 0.02). These findings strongly suggest that even minimal residual insulin secretion is important for metabolic wellbeing in diabetes and may prevent the development of severe ketoacidosis when insulin delivery is inadequate.     

Venous Stasis and Forearm Exercise During Venipuncture as Sources of Error in Plasma Electrolyte Determinations

A study was made of errors in plasma sodium, potassiu, chloride and calcium determinations caused by venous stasis and forearm exercise during venipuncture. Blood samples were taken from both arms of healthy young adults, one arm being used as a control. Analyses were performed in a routine hospital laboratory and the technicians were unaware of the identity of the samples. Laboratory precision was assessed at the same time.Venous stasis alone for two minutes caused no significant change, but the use of continuous slow forearm exercise for one minute caused mean elevations of 0.73 mEq./1. in potassium, and 0.4 mg. per 100 ml. in calcium, the maximum elevations being 1.1 mEq/1. and 1.3 mg. per 100 ml., respectively. A clinically unimportant but significant increase in sodium values of 1.40 mEq./1. was also observed. Chloride values were not affected. In addition there was a substantial error in calcium determinations in the laboratory, which emphasizes the need for repeated calcium determinations to avoid diagnostic error.The conclusion is reached that forearm exercise must be avoided during venipuncture.     

Sexual maturity in rabbits defined by the physical and chemical characteristics of the semen

Semen was collected weekly from New Zealand white rabbits from the 1st positive mounting test to 43 weeks of age by means of an artificial vagina. The mean values of the results obtained in the 1st and 20th collection weeks were respectively: volume (ml) 0.61 +/- 0.30 and 0.70 +/- 0.19; pH 7.22 +/- 0.50 and 7.19 +/- 0.15; concentration (sperm/mm3 X 10(3)) 750 +/- 207 and 381 +/- 90; fructose (mg/100 ml) 117 +/- 58 and 203 +/- 121; citric acid (mg/100 ml) 256 +/- 90 and 200 +/- 97; sodium ions (mEq/l) 133 +/- 31 and 163 +/- 46; potassium ions (mEq/l) 40 +/- 21 and 29 +/- 14. On the basis of these results, New Zealand white rabbits reach sexual maturity by 6 months of age.     

Effect of aluminium hydroxide on serum ionised calcium,immunoreactive parathyroid hormone,and aluminium in chronic renal failure.

According to the Bricker-Slatopolsky theory, secretion of parathyroid hormone (PTH) is switched on in chronic renal failure by hypocalcaemia due to phosphate retention. In an attempt to reverse this process 20 patients in preterminal renal failure (plasma creatinine 569 +/- 195 mumol/l) were given aluminium hydroxide, 3.8 g daily. They were studied for four weeks and all measurements were made at the start and weekly, except measurements of serum aluminium concentration, which were made at the start and at the end of the fourth week. Mean serum phosphate fell from 1.89 to 1.47 mmol/l (5.9 to 4.6 mg/100), mean serum calcium rose from 2.07 to 2.24 mmol/l (8.3 to 9.0 mg/100 ml), and serum ionised calcium rose from 1.07 to 1.20 mmol/l (4.3 to 4.8 mg/100 ml), but serum immunoreactive PTH did not fall. Thirteen patients had initial serum immunoreactive PTH concentrations at or near to normal and 11 were taking beta-blockers but even in those with neither explanation, PTH concentrations did not fall. Serum aluminium concentrations rose from 0.4 to 1.02 mumol/l (10.9 to 27.4 microgram/l). Aluminium hydroxide corrects serum phosphate, total calcium, and ionised calcium at the price of a rise in serum aluminium concentration; in this study it did not affect serum immunoreactive PTH. The Bricker-Slatopolsky theory still needs verification in studies of patients with chronic renal failure.     

Home blood glucose concentrations in maturity-onset diabetes.

Blood glucose concentrations during normal daily activities were measured in 106 patients with maturity-onset diabetes from capillary blood samples collected on to filter paper. Samples were taken before and two hours after main meals, before going to bed, and, in 51 cases, during the night. Fasting and mid-morning values were closely correlated with the mean values over 24 hours irrespective of the type of anti-diabetic treatment being given. Postprandial blood glucose concentrations remained below 11.5 mmol/l (207 mg/100 ml) when the fasting blood glucose value was 7.0 mmol/l (126 mg/100 ml) or less, and repeated fasting blood glucose values exceeding 7.0 mmol/l were associated with raised blood glycosylated haemoglobin concentrations. Diabetic control in maturity-onset diabetes may be satisfactorily monitored by regular measurement of fasting or mid-morning blood glucose values.     

Hypercalcemia in glucocorticoid withdrawal

We found severe hypercalcemia in the course of hydrocortisone withdrawal in a patient who had undergone unilateral adrenalectomy to resect a cortisol-hypersecreting adenoma. Serum calcium gradually but progressively increased after unilateral adrenalectomy. Severe hypercalcemia developed on the 77th postoperative day (the 15th day after discontinuing hydrocortisone replacement). The serum concentration of calcium, PTH, 25(OH)D, and 1,25(OH)2D were 8.0 mEq/l, less than 100 pg/ml, 10.1 ng/ml and 29.6 pg/ml, respectively. This hypercalcemia was accompanied by marked urinary hydroxyproline excretion and less calcium excretion in the urine than the prevailing level of serum calcium. Serum concentrations of 25(OH)D, 1,25(OH)2D and PTH were not elevated during the severe hypercalcemia. We concluded that the hypercalcemia in this patient was due in part to enhanced bone resorption and increased renal tubular reabsorption of calcium as a result of glucocorticoid withdrawal, but not to the elevation of serum PTH or serum 25(OH)D and serum 1,25(OH)2D.     

Suppressibility of Parathyroid Hormone in Primary Hyperparathyroidism

ObjectiveTo describe an unusual case of pathologically confirmed primary hyperparathyroidism in a patient presenting with severe hypercalcemia and an undetectable parathyroid hormone (PTH) level.MethodsWe present a detailed case report and outline the serial laboratory findings. In addition, the possible causes of low serum PTH levels in the setting of primary hyperparathyroidism are discussed.ResultsA 16-year-old female patient presented with severe epigastric pain, found to be attributable to acute pancreatitis. At hospital admission, her serum calcium concentration was high (14.0 mg/dL); the patient also had a normal serum phosphorus level of 3.6 mg/dL and an undetectable PTH level (< 0.2 pmol/L). An evaluation for non-PTH-mediated causes of hypercalcemia revealed a partially suppressed thyroid-stimulating hormone concentration and a below normal 1,25-dihydroxyvitamin D level, consistent with her suppressed PTH. One week after the patient was dismissed from the hospital, repeated laboratory studies showed a serum calcium value of 11.1 mg/dL, a serum phosphorus level of 2.8 mg/dL, and an elevated PTH concentration of 11.0 pmol/L, consistent with primary hyperparathyroidism. A repeated 1,25-dihy-droxyvitamin D measurement was elevated. A parathyroid scan showed a parathyroid adenoma in the left lower neck area, and she subsequently underwent successful surgical resection of a pathologically confirmed parathyroid adenoma.ConclusionThis case demonstrates that the serum PTH level can be suppressed in patients with primary hyperparathyroidism. Moreover, it emphasizes the need for careful evaluation of the clinical context in which the PTH measurement is determined. Consideration should be given to repeating measurement of PTH and serum calcium levels when the initial laboratory evaluation of hypercalcemia is unclear because dynamic changes in calcium metabolism may occur in the presence of secondary contributing factors. (Endocr Pract. 2007;13:785-789)     

Biophysical and biochemical characteristics of bactrian camel semen collected by artificial vagina

Seminal characteristics were investigated in Bactrian camel in this study. Semen samples from ten mature Bactrian camel bulls were collected using a modified bovine artificial vagina. The biophysical parameters including volume, color, sperm concentration and fast forward progressive motility, percentage of live sperm and the biochemical parameters including osmolarity, pH, glucose, calcium, phosphorus, chloride, triglycerides, phospholipids, total protein, albumin and non-protein nitrogen concentrations in seminal plasma were measured. The mean time for semen collection was 5.3 +/- 0.29 min. The volume of semen varies from 1.2 to 26 (8.2 +/- 0.7 mls). The majority of semen samples (83.6%) were milky in color and consistency. The average osmolarity of semen was 316.1 +/- 1.48 mOsm/kg H(2)O. The pH of semen was slightly alkaline (7.4 +/- 0.03). The mean concentration of spermatozoa was 414.8 +/- 25.04 x 10(6)cells/ml. The fast forward progressive motility of spermatozoa was 62.4 +/- 1.57%. The percentage of live spermatozoa was 85.6 +/- 1.15. Seminal plasma concentration of glucose was 35.8 +/- 0.9 mg/dl. Non-protein nitrogen, total protein and albumin were 32.5 +/- 2.5, 2200 +/- 100 and 1100 +/- 100mg/dl, respectively. The average concentrations of phospholipids and triglycerides in seminal plasma were 36.4 +/- 2.1 and 101.6 +/- 5.5mg/dl, respectively. The concentrations of calcium, phosphorus and chloride were 8.2 +/- 0.1, 2.9 +/- 1.7 mg/dl and 97.9 +/- 2.9 mEq./l, respectively.     

Ionized calcium in exchange transfusion with THAM-buffered ACD blood

In 20 exchange transfusions with THAM-buffered ACD blood 5 ml. of 2% calcium gluconate (8 mg. elemental calcium) was injected after each 100 ml. of blood exchanged. Plasma ionized calcium decreased significantly during the procedure, although after each injection of calcium gluconate, levels returned briefly to normal. Ten minutes after the end of exchange ionized calcium had returned to pre-exchange levels and remained there until at least 30 mins. postexchange.Total calcium also increased significantly. Short periods of extreme hypercalcemia (between 7 and 8 mEq./l.) were noted after each injection of calcium gluconate.The amount of calcium gluconate was insufficient to counteract the calcium-chelating effect of citrate. If no heparinized blood is available we suggest adding heparin and calcium chloride to THAM-buffered ACD blood to avoid the repeated sudden fluctuations between low and high calcium ion activity.     

A microbiological test system for determining dioxidine levels in biological fluids

A microbiological procedure for determining dioxidine concentrations in biological fluids with using E. coli AB 2472 rec A 16, a reparation deficient strain as a test organism is described. Cell suspension of the strain 24-hour culture is added to 1.2 per cent agar with Hottinger digest (140 mg per cent of amine nitrogen), 3 g/l of disubstituted sodium phosphate and 0.4 per cent of glucose cooled to 50 degrees C. 10 ml of the medium are added to every Petri dish with metallic cylinders put on the agar. After the medium solidification the cylinders are removed and 0.1 ml of the solution being tested is added to every well. The dishes are incubated for 24 hours under anaerobic conditions. The test system sensitivity is 0.2 microgram/ml of dioxidine. The relationship between the growth inhibition zone and the drug concentration is linear within dioxidine concentrations of 0.2 to 3.2 micrograms/ml.     

Low Urine Calcium Excretion in African American Patients with Primary Hyperparathyroidism

ObjectiveTo evaluate the prevalence of low urine calcium excretion in African American patients with primary hyperparathyroidism (PHPT), a common disorder associated with bone and renal complications, and to assess the distinction between PHPT and familial hypocalciuric hypercalcemia (FHH), a rare benign genetic disease.MethodsWe conducted a retrospective study on a cohort of 1,297 patients in whom a 24-hour urine study was performed for measurement of urine calcium and creatinine. PHPT was diagnosed if the serum calcium concentration was ≥ 10.5 mg/dL and intact parathyroid hormone (PTH) was ≥ 40 pg/mL. Patients receiving medications that affect urine calcium or with glomerular filtration rate ≤ 30 mL/min were excluded.ResultsNinety-six patients satisfied the diagnostic criteria for PHPT. The African American (n = 70) and non-African American (n = 26) patients did not differ in their mean age, body mass index, glomerular filtration rate, serum PTH, 25-hydroxyvitamin D levels, and 24-hour urine creatinine values. Median values of urine calcium/creatinine (mg/g) were 122 for African American versus 214 for non-African American patients (P = .006). Thirty-one of 70 African American patients (44%) had a urine calcium/creatinine ratio ≤ 100 mg/g, whereas only 2 of 26 non-African American patients (8%) had this value (P = .001).ConclusionThe prevalence of low urine calcium excretion among African American patients with PHPT is unexpectedly high. A threshold of 100 mg/g urine calcium/ creatinine identified 44% of such patients with PHPT as having FHH in this cohort. Therefore, other clinical criteria and laboratory variables should be used to distinguish PHPT from FHH in African American patients with PTH-dependent hypercalcemia. (Endocr Pract. 2011;17: 867-872)     

Serum tolbutamide and chlorpropamide concentrations in patients with diabetes mellitus

A selective and sensitive gas chromatographic technique was used to measure the steady-state serum concentrations of tolbutamide and chlorpropamide in 97 patients with maturity-onset diabetes mellitus who had been taking these drugs (37 tolbutamide, 60 chlorpropamide) for at least a year. No other antidiabetic agents had been given. The serum tolbutamide concentrations varied widely between the patients (from close to zero to 370 μmol/l (100 μg/ml)), yet the variation in dosage was only sixfold (0·5-3·9 g daily). The serum chlorpropamide concentrations varied even more widely (from close to zero to 882 μmol/l (244 μg/ml)), though the dosage variation was fourfold (125-500 mg daily). There was no systematic relation between dosage and serum concentrations of the drugs.Only 2 (5·4%) of the tolbutamide-treated patients and 10 (16·7%) of the chlorpropamide-treated patients had normal fasting blood glucose concentrations (below 5·5 mmol/l (99 mg/100 ml)), and fewer than half had values below 8·0 mmol/l (144 mg/100 ml). In most cases, therefore, the treatment was insufficient.There was no significant difference in mean fasting blood glucose concentrations between the two treatment groups. The mean steady-state concentration of chlorpropamide, however, was significantly higher than that of tolbutamide. Thus, contrary to common belief, the intrinsic activity of chlorpropamide is apparently not greater than that of tolbutamide. The alleged greater potency of chlorpropamide seems to be related wholly to kinetic differences, such as the less extensive metabolic degradation and slower elimination of the drug.We conclude that treatment with sulphonylureas in conventional dosage is far from optimal and that monitoring the concentrations of these drugs in the blood may help to improve their efficacy.     

Failure of cyproheptadine to affect calcium homoeostasis and PTH levels in primary hyperparathyroidism

In this study we evaluated the influence of cyproheptadine treatment on serum PTH values, as well as serum Ca, Mg and P levels in patients with primary hyperparathyroidism. For this purpose, cyproheptadine was given in a dose of 4 mg orally every 4 hours during 10 consecutive days to six patients with primary hyperparathyroidism. Control fasting blood samples for PTH, Ca, Mg and P were obtained every other day for a week. Afterwards cyproheptadine treatment was applied as mentioned above. Then blood samples were taken on the 4th, 6th, and 10th day of treatment to determine serum PTH, Ca, Mg and P. Before treatment the mean PTH (+/- SE) values were 22.95 +/- 1.4 mlU/ml and during cyproheptadine treatment were 23.06 +/- 0.9, 22.95 +/- 0.8, 22.32 +/- 0.8 mlU/ml, respectively. There were no significant changes in serum PTH levels before and during treatment (P greater than 0.05). Also serum Ca, Mg and P levels remained unchanged. Our data suggest that cyproheptadine treatment does not affect calcium homoeostasis and serum PTH levels in primary hyperparathyroidism.     

Plasma creatinine and urea: creatinine ratio in patients with raised plasma urea.

We examined the plasma urea and creatinine concentrations and the ratio between them according to diagnosis in 100 unselected and 31 selected adult hospital patients with a plasma urea concentration greater than or equal to 10 mmol/l (60mg/100ml). We also examined plasma urea and creatinine concentrations in 350 unselected consecutive patients, but found no useful relation between the two values. Congestive heart failure was the most common identifiable cause of a raised plasma urea concentration in the 100 unselected patients (36%). Among these 100 patinets the plasma creatinine concentration was a more useful discriminant between prerenal uraemia and intrinsic renal failure than was the urea:creatinine ratio or the plasma urea concentration. A plasma creatinine concentration greater than 250 mumol/1 (2-8 mg/100ml) indicated intrinsic renal failure with a 90% probability.     

Severe hypophosphataemia during recovery from acute respiratory acidosis.

Three elderly patients with established chronic obstructive airways disease were admitted with a short history of increasing dyspnoea and tiredness and (in two cases) a deterioration in mental state. Acute respiratory acidosis was diagnosed and mechanical ventilation instituted. Two hours after beginning mechanical ventilation the mean arterial pH had risen to 7.40, but all patients showed a dramatic fall in the serum phosphate concentration (lowest value 0.3 mmol/l (0.9 mg/100 ml] accompanied by a low urinary excretion of phosphate. No patient could tolerate withdrawal of mechanical ventilation until the serum and urinary concentrations of phosphate had returned to normal. Recovery from acute respiratory acidosis should be added to the list of conditions associated with severe hypophosphataemia.