java aztec barcode library G Hyperthyroidism in Objective-C

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G Hyperthyroidism
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Increased bone turnover is a feature of thyrotoxicosis Mild hypercalcemia may also be present
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H Other Causes
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Other causes of hypercalcemia are shown in Table 21 9 Modest hypercalcemia is also occasionally seen in patients taking thiazide diuretics or lithium; such patients may have an inappropriately nonsuppressed PTH level with hypercalcemia Prolonged immobilization at bed rest may also cause hypercalcemia, especially in adolescents and patients with extensive Paget s disease of bone Hypercalcemia is noted in up to one-third of acutely ill patients being treated in intensive care units, particularly patients with acute renal failure Serum PTH levels are usually slightly elevated, consistent with mild hyperparathyroidism Bisphosphonates can increase serum calcium in 20% and serum PTH becomes high in 10%, mimicking hyperparathyroidism
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A Surgical Parathyroidectomy
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Parathyroidectomy is recommended for patients with symptomatic hyperparathyroidism, kidney stones, bone disease, and pregnancy Some patients with seemingly asymptomatic hyperparathyroidism may be surgical candidates for other reasons such as (1) serum calcium 1 mg/dL above the upper limit of normal with urine calcium excretion > 50 mg/24 h (off thiazide diuretics), (2) urine calcium excretion over 400 mg/24 h, (3) cortical bone density (wrist, hip) 2 SD below normal, (4) relative youth (under age 50 60 years), (5) difficulty ensuring medical follow-up, or (6) pregnancy During pregnancy, parathyroidectomy is performed in the second trimester Patients who undergo surgery for asymptomatic hyperparathyroidism have been reported to have modest benefits in social and emotional function, with improvements in anxiety and phobias being reported in comparison to similar patients who are monitored without surgery Preoperative parathyroid imaging has been used in an attempt to allow unilateral minimally invasive neck surgery The usefulness of preoperative parathyroid imaging was eval-
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thyroid hormone during surgical manipulation of the thyroid Short-term treatment with propranolol may be required for several days
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B Medical Measures
1 Fluids Hypercalcemia is treated with a large fluid intake unless contraindicated Severe hypercalcemia requires hospitalization and intensive hydration with intravenous saline (See 21) 2 Bisphosphonates Intravenous bisphosphonates are potent inhibitors of bone resorption and can temporarily treat the hypercalcemia of hyperparathyroidism, malignancy, or immobilization They may relieve bone pain as with patients with metastatic breast or prostate cancer Pamidronate in doses of 30 90 mg (in 09% saline) is administered intravenously over 2 4 hours Zoledronic acid 2 4 mg is administered intravenously over 15 to 20 minutes; it is quite effective but also very expensive These drugs cause a gradual decline in serum calcium over several days that may last for weeks to months Such intravenous bisphosphonates are used generally for patients with severe hyperparathyroidism in preparation for surgery Oral bisphosphonates, such as alendronate, are not effective for treating the hypercalcemia or hypercalciuria of hyperparathyroidism However, oral alendronate has been shown to improve bone mineral density in the lumbar spine and hip (not distal radius) and may be used for asymptomatic patients with hyperparathyroidism who have a low bone mineral density 3 Calcimimetics Cinacalcet hydrochloride is a calcimimetic agent that binds to sites of the parathyroid glands extracellular CaSRs to increase their affinity for extracellular calcium, thereby decreasing PTH secretion Cinacalcet may be administered orally in doses of 30 250 mg daily Patients with primary hyperparathyroidism have also been treated successfully with cinacalcet in oral doses of 30 50 mg twice daily, with 73% of patients achieving normocalcemia Administering cinacalcet for secondary parathyroidism of renal failure causes a drop of serum PTH levels to < 250 pg/mL in 41% of patients receiving dialysis Cinacalcet is given to patients with severe hypercalcemia due to parathyroid carcinoma at initial doses of 30 mg orally twice daily and increased progressively to 60 mg twice daily, then 90 mg twice daily to a maximum of 90 mg every 6 8 hours Cinacalcet is usually well tolerated but may cause nausea and vomiting, which are usually transient It is very expensive 4 Vitamin D and vitamin D analogs a Primary hyperparathyroidism For patients with vitamin D deficiency, careful vitamin D replacement may be beneficial to patients with hyperparathyroidism Aggravation of hypercalcemia does not ordinarily occur Serum PTH levels may fall with vitamin D replacement in doses of 400 to 1200 units daily Occasionally, larger doses are required to achieve normal 25-OH vitamin D levels b Secondary and tertiary hyperparathyroidism associated with renal failure Calcitriol, given orally or intravenously after dialysis, suppresses parathyroid hyperplasia of renal failure Certain vitamin D analogs suppress
PTH secretion but cause less hypercalcemia than calcitriol Doxercalciferol (Hectorol) is administered three times weekly orally with hemodialysis to patients with azotemic secondary hyperparathyroidism in the following doses according to serum immunoradiometric PTH (iPTH) levels: give 10 mcg three times weekly for iPTH > 400 pg/mL and increase the dose by 25 mcg every 8 weeks if iPTH remains > 300 pg/mL, to a maximum dose of 20 mcg three times weekly If iPTH drops to < 100 pg/mL, doxercalciferol is held for 1 week and the dose is reduced by at least 25 mcg Paricalcitol (Zemplar) is administered intravenously during dialysis three times weekly in starting doses of 004 01 mcg/kg body weight; the dosage is increased for iPTH levels > 300 pg/mL to a maximum dose of 024 mcg/kg three times weekly; paricalcitol is held if iPTH levels drop to < 100 pg/mL 5 Other measures Patients with mild, asymptomatic hyperparathyroidism may be monitored closely medically Such patients are advised to keep active, avoid immobilization, and drink adequate fluids They need to avoid thiazide diuretics, large doses of vitamins A, and calcium-containing antacids or supplements Serum calcium and albumin are checked about twice yearly, renal function and urine calcium once yealy, and three-site bone density (distal radius, hip, and spine) every 2 years Estrogen replacement, given to postmenopausal women, reduces hypercalcemia slightly Similarly, raloxifene (a selective estrogen receptor modulator) also reduces the hypercalcemia of hyperparathyroidism, reducing serum calcium levels an average of 04 mg/dL Digitalis preparations are avoided, since patients with hypercalcemia are sensitive to its toxic effects Propranolol may be useful for preventing the adverse cardiac effects of hypercalcemia Corticosteroid therapy is ineffective for treating hypercalcemia in hyperparathyroidism Renal osteodystrophy is caused by secondary hyperthyroidism during renal failure It can be prevented or delayed by avoiding hyperphosphatemia by dietary avoidance of phosphate and with phosphate binding medication
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