This document summarizes calcium homeostasis and rickets. It discusses how parathyroid hormone (PTH), calcitonin, vitamin D, and other factors regulate calcium levels in the blood and bone. It also describes the causes, signs, symptoms, and treatments of rickets, which is a softening and weakening of bones in children due to vitamin D deficiency or other nutritional deficiencies that limit bone mineralization. The treatment for different types of rickets depends on the underlying cause but may involve calcium, vitamin D, phosphorus supplementation, or drugs like calcitriol. Laboratory tests can help diagnose rickets based on levels of calcium, phosphorus, PTH, vitamin D metabolites and other markers.
This slide describes briefly the controlling mechanism to balance the calcium & phosphorous levels within human serum, involving several hormones and other factors; this post carries valuable information regarding this topic and references for further readings.
This slide describes briefly the controlling mechanism to balance the calcium & phosphorous levels within human serum, involving several hormones and other factors; this post carries valuable information regarding this topic and references for further readings.
Calcium metabolism disorders
1. CALCIUM METABOLISM DISORDERS
2. OVERVIEW: Calcium definition and requirement . Calcium metabolism regulators : VD , PTH and calcitonin. Functions of calcium. Calcium metabolic bone diseases. Calcium metabolism disorders. CASE !!
3. WHAT IS CALCIUM? Calcium is a mineral that is essential to bone health, cardiovascular health, muscle maintenance, circulatory health, and blood clotting. Calcium also acts as an enzyme activator. While calcium is found in milk and dairy products, it is also available from other food sources, such as green leafy vegetables, seafood (eating salmon with the bones provides an even greater dose), almonds, blackstrap molasses, broccoli, enriched soy and rice milk products, figs, soybeans and tofu.
Biochemistry of Calcium metabolism covering the source, factors effecting absorption, normal level of calcium, regulation of the calcium, hypercalcemia, hypocalcemia, disorders related to calcium and bone markers.
Useful for students of MBBS, BDS, BSc, MSc, MLT, Physiotherapy (BPT), Nursing etc.
This seminar includes sources,daily requirement,metabolism i.e absorption and excretion of calcium and phosphate and various factors associated due to increase or decrease in the levels of calcium and phosphate within the body
Calcium metabolism disorders
1. CALCIUM METABOLISM DISORDERS
2. OVERVIEW: Calcium definition and requirement . Calcium metabolism regulators : VD , PTH and calcitonin. Functions of calcium. Calcium metabolic bone diseases. Calcium metabolism disorders. CASE !!
3. WHAT IS CALCIUM? Calcium is a mineral that is essential to bone health, cardiovascular health, muscle maintenance, circulatory health, and blood clotting. Calcium also acts as an enzyme activator. While calcium is found in milk and dairy products, it is also available from other food sources, such as green leafy vegetables, seafood (eating salmon with the bones provides an even greater dose), almonds, blackstrap molasses, broccoli, enriched soy and rice milk products, figs, soybeans and tofu.
Biochemistry of Calcium metabolism covering the source, factors effecting absorption, normal level of calcium, regulation of the calcium, hypercalcemia, hypocalcemia, disorders related to calcium and bone markers.
Useful for students of MBBS, BDS, BSc, MSc, MLT, Physiotherapy (BPT), Nursing etc.
This seminar includes sources,daily requirement,metabolism i.e absorption and excretion of calcium and phosphate and various factors associated due to increase or decrease in the levels of calcium and phosphate within the body
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
6. Rickets
O It is a disease of growing bone, unmineralized matrix at the growth plates
and occurs in children only before fusion of the
epiphyses.
O An increase in the circumference of the growth plate and the metaphysis,
increasing bone width at the location of the growth plates.
7. Causes
O VITAMIN D DISORDERS
Nutritional vitamin D deficiency
Congenital vitamin D deficiency
Secondary vitamin D deficiency
Malabsorption
Increased degradation
Decreased liver 25-hydroxylase
Vitamin D–dependent rickets type 1 A and B
Vitamin D–dependent rickets type 2 A and B
Chronic kidney disease
8. O CALCIUM DEFICIENCY
Low intake
Diet
Premature infants (rickets of prematurity)
Malabsorption
Primary disease
Dietary inhibitors of calcium absorption
O PHOSPHORUS DEFICIENCY
Inadequate intake
Premature infants (rickets of prematurity)
Aluminum-containing antacids
10. Clinical features
O GENERAL – Failure to thrive, Listlessness, Protruding
abdomen, Muscle weakness (especially proximal) &
Fractures
O BACK – Scoliosis, Kyphosis & Lordosis
O HYPOCALCEMIC SYMPTOMS – Tetany, Seizures &
Stridor due to laryngeal spasm
12. CHEST – Rachitic rosary, Harrison groove &
Respiratory infections and atelectasis
13. EXTREMITIES – Enlargement of wrists and ankles, Valgus or varus deformities, Windswept
deformity, Anterior bowing of the tibia and femur, Coxa vara & Leg pain
14.
15. Vitamin D Deficiency
Nutritional
O 1st two months of life no deficiency
O Sun – melanin
O These children have increased risk of
pneumonia and muscle weakness leading to
delayed motor development
17. Treatment
O 300,000 – 600,000 IU orally or intramuscularly 2-4 doses over 1 day OR
O 2000 – 5000 IU/day over 4 – 6 weeks
O Followed by daily 400 IU/day for < 1 year and 600 IU / day > 1 year
O Symptomatic hypocalcemia 20mg/kg of calcium chloride
O Calcitriol – 0.05 mcg/kg/day in case of symptomatic hypocalcemia
O Prevention – breast fed (400IU/day) & child (600IU/day)
18. Congenital Vitamin D Deficiency
O Maternal vitamin D deficiency
O Risk factors – poor dietary, inadequate exposure
to sun and closely placed pregnancies
O Predisposes to hypocalcemic tetany
O Treated with Vit D supplement, calcium and
phosphorus
19. Secondary Vit D Deficiency
O Liver (>90% dysfunction) and GI disorders (pancreatic
dysfunction)
O Drugs like - phenobarbital, phenytoin, isoniazid and rifampin by
activating cytochrome P450
O High dose of 25 D helps in better absorption 25-50mcg/day or
5-7 mcg/kg/day
O In case of increased degradation of Vit D long term
administration = 1000-4000IU/day
20. Vitamin D-dependent rickets type 1
O AR – 1α-hydroxylase defect
O These patients respond to long-term treatment
with 1,25-D (calcitriol). Initial doses are 0.25-2
µg/day, and lower doses are used once the rickets
has healed.
21. O Targeting a low-normal calcium concentration
and a high-normal PTH level avoids excessive
dosing of calcitriol, which can cause
hypercalciuria and nephrocalcinosis.
O Periodic assessment of urinary calcium
excretion, with a target of <4 mg/kg/day.
22. Vitamin D-dependent rickets type 2
O AR mutation in Vit D receptor
O 1,25-D increased
O Less likely to have rickets due to partially functional D
receptors
O 50-70% have alopecia
O Managed initially with high does of 1,25-D 2mcg/day ---- 50-
60mcg/day and calcium 1000 to 3000mg/day
23.
24. Chronic Kidney Disease
Therapy requires Calcitriol
Dietary phosphorus restriction and the use of
oral phosphate binders is as important as the
use of activated vitamin D
25. Calcium Deficiency
O Excellent sources of calcium – breast milk and formula
feed
O Intravenous nutrition without adequate calcium or
malabsorption in celiac disease, intestinal
abetalipoproteinemia, and after small bowel resection.
There may be concurrent malabsorption of vitamin D.
27. Treatment
O Elemental calcium 700mg/day – 1 to 3 years of
age
O 1000mg/day – 4 to 8 years of age
O 1300mg/day – 9 to 18 years
28. Phosphorus Deficiency
O Malabsorption (celiac disease, cystic fibrosis,
cholestatic liver disease), but if rickets develops,
the primary problem is usually malabsorption of
vitamin D and/or calcium.
O Isolated malabsorption of phosphorus long-
term use of aluminum-containing antacids.
31. Fibroblast Growth Factor-23
O Fibroblast growth factor-23 (FGF-23) is a
humoral mediator that decreases renal tubular
reabsorption of phosphate and therefore
decreases serum phosphorus.
O It is synthesized by osteocytes, also decreases the
activity of renal 1α-hydroxylase, resulting in a
decrease in the production of 1,25-D.
32. X-Linked Hypophosphatemic Rickets
O AD – Defective gene is on the X chromosome
O PHEX – PHosphate-regulating gene with homology to
Endopeptidases on the X chromosome
O Indirect role in inactivating FGF-23, defect in this gene
causes over production of FGF-23
O Rickets with involving lower extremities and poor growth
are the dominant features
33. Treatment
O Phosphorus supplementation is 1-3 g of elemental
phosphorus divided into 4-5 doses
O Calcitriol is administered 30-70 ng/kg/day divided into 2
doses
O Laboratory monitoring of serum calcium, phosphorus,
alkaline phosphatase, PTH, and urinary calcium, as well as
periodic renal ultrasounds for nephrocalcinosis
35. Autosomal Recessive Hypophosphatemic
Rickets
O Type 1 is an extremely rare disorder caused by mutations in the
gene encoding dentin matrix protein 1 (DMP1).
O Type 2 – mutations in the ENPP1 gene. Mutations in ENPP1
also cause generalized arterial calcification of infancy
O Treatment is similar to the approach used in XLH, although
monitoring for arterial calcification is prudent in patients with
ENPP1 mutations
36. Hereditary Hypophosphatemic Rickets
with Hypercalciuria
O AR – Sodium-phosphate cotransporter in the
proximal tubule (SLC34A3).
O Hypophosphatemia 1,25-D(stimulation)
intestinal absorption of calcium, suppressing PTH.
O Hypercalciuria ensues as a result of the high
absorption of calcium and the low level of PTH,
which normally decreases renal excretion of calcium.
37. O Hypophosphatemia, renal phosphate wasting, elevated serum
alkaline phosphatase levels, and elevated 1,25-D levels. PTH levels
are low
O Oral phosphorus replacement (1-2.5 g/day of elemental
phosphorus in 5 divided oral doses)
O Treatment of the hypophosphatemia decreases serum levels of
1,25-D and corrects the
hypercalciuria
38. Tumor-induced osteomalacia
O Overproduction of FGF-23 is more common in
adults than in children, where it can produce
classic rachitic findings.
O Most tumors are mesenchymal in origin and are
usually benign, small, and located in bone.
O Treatment is removal of the tumor
40. Fanconi Syndrome
O It is secondary to generalized dysfunction of the
renal proximal tubule.
O Hypophosphatemia caused by phosphate losses
and proximal renal tubular acidosis caused by
bicarbonate losses. Failure to thrive is a
consequence of both rickets and renal tubular
acidosis.
42. Rickets Of Prematurity
O 80% Calcium and Phosphorus transfer 3rd trimester
O Infants with a birth weight <1,000 g
O Rickets of prematurity occurs 1-4 month after birth.
O Infants can have nontraumatic fractures, especially of the legs,
arms, and ribs. Most fractures are not suspected clinically
43. O Rachitic respiratory distress >5 week after birth
O Early supplementation of Calcium, phosphorus, and vitamin D Prevention
O Parenteral nutrition is often necessary initially in very premature infants
O Increased mineral feedings should continue until the infant weighs 3-3.5 kg. These
infants should also receive approximately 400 IU/day of vitamin D via formula and
vitamin supplements.
44. Disorder Calcium Inorganic
Phosphor
us(pi)
PTH 25-(OH)D 1,25-
(OH)2D
Alk phos Urine Ca Urine
phosphoru
s
Vitamin D
deficiency
N,
DECREASE
D
DECREASE
D
INCREASE
D
DECREASE
D
DECREASE
D, N,
INCREASE
D
INCREASE
D
DECREASE
D
INCREASE
D
Chronic
kidney
disease
N,
DECREASE
D
INCREASE
D
INCREASE
D
N DECREASE
D
INCREASE
D
N,
DECREASE
D
DECREASE
D
Dietary pi
deficiency
N DECREASE
D
N,
DECREASE
D
N INCREASE
D
INCREASE
D
INCREASE
D
DECREASE
D
Tumor-
induced
rickets
N DECREASE
D
N N RELATIVEL
Y
DECREASE
D
INCREASE
D
DECREASE
D
INCREASE
D
Fanconi
syndrome
N DECREASE
D
N N RELATIVEL
Y
DECREASE
D
/
INCREASE
D
INCREASE
D
DECREASE
D/INCREA
SED
INCREASE
D
Dietary Ca
deficiency
N,
DECREASE
D
DECREASE
D
INCREASE
D
N INCREASE
D
INCREASE
D
DECREASE
D
INCREASE
D
46. O A Randomized controlled trial on safety and efficacy of
single intramuscular versus staggered oral dose
of 600000IU Vitamin D in treatment of nutritional rickets.
J Trop Pediatr. 2014 Jun;60(3):203-10. doi:
10.1093/tropej/fmt105. Epub 2014 Jan 8.
O Comparing the Effects of Two Feeding Methods on
Metabolic Bone Disease in Newborns with Very Low Birth
Weights. Glob J Health Sci. 2015 May 29;8(1):249-54. doi:
10.5539/gjhs.v8n1p249.