Calcium,magnesium,phosphate and chloride imbalances Jyothi Swaroop
Calcium,magnesium,phosphate and chloride imbalances
Their treatment,my main reference is Eric strong's lectures in youtube,and some of the websites.Hope everyone finding Serum electrolytes find atleast some use of it .
Thank you
Calcium,magnesium,phosphate and chloride imbalances jyothiswaroopb1
i could make best of me ,by collecting information from mainly Eric's strongs medical lectures in youtube and from many websites .
Hope you guys may find any important information.
Thank you
Calcium,magnesium,phosphate and chloride imbalances Jyothi Swaroop
Calcium,magnesium,phosphate and chloride imbalances
Their treatment,my main reference is Eric strong's lectures in youtube,and some of the websites.Hope everyone finding Serum electrolytes find atleast some use of it .
Thank you
Calcium,magnesium,phosphate and chloride imbalances jyothiswaroopb1
i could make best of me ,by collecting information from mainly Eric's strongs medical lectures in youtube and from many websites .
Hope you guys may find any important information.
Thank you
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
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Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
Ethnobotany and Ethnopharmacology:
Ethnobotany in herbal drug evaluation,
Impact of Ethnobotany in traditional medicine,
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The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
2. • Commonly encountered in Practice
• Diagnosis often is made incidentally
• The most common causes are primary
hyperparathyroidism and malignancy
• Diagnostic work-up includes measurement
of serum calcium, intact parathyroid
hormone (I-PTH), h/o any medications
• Hypercalcemic crisis is a life-threatening
emergency
2
3. • Most often asymptomatic – Incidental Dx
• Mild Hypercalcemia is asymptomatic
• Most important cause is hyper parathyroid
• DD is needed to decide the treatment
• Optimal step by step evaluation is a must.
3
4. • 98% of the body calcium is in the skeleton
• Only 2% is circulation and only half of this
is free calcium (ionized Ca++)
• This only is physiologically active
• The reminder 1% is bound to proteins
• Direct measurement of free Calcium ??
4
8. Hormone Effect Bone Gut Kidney
PTH Ca Po4
Increases
Osteoclasts
Indirect
via Vit. D
Ca reab
Po4 exr.
Vitamin D3 Ca Po4
No direct
action
Ca Po4
absorption
No direct
effect
Calcitonin Ca Po4
Inhibits
Osteoclasts
No direct
effect
Ca & Po4
excretion
8
9. Corrected total calcium (mg%) =
[(Measured total calcium mg%) +
{(4.4 - measured albumin g%) x 0.8}]
Example:
[12.0 + {(4.4 – 2.4) x 0.8}] =
[ 12.0 + (2 x 0.8)] = 12.0 + 1.6 = 13.6
mg%
9
11. Second hydroxylation in the Kidney at first position
1,25 dihydroxy Cholecalciferol Active Vitamin D (Calcitriol)
Successive hydroxylations of Cholecalciferol
25 hydroxylation in the Liver 25 hydroxy Cholecalciferol
Vitamin D is a steroid hormone
From dietary sources Action of Sunlight on skin
11
12. PTH
• 4 PT glands
• 84 AA
hormone
• Low Ca
stimulates it
Calcitriol (D)
• Active bone
formation
• Main effect is
on the Gut
• PTH Vit. D
Calcitonin
• Para follicular
C of Thyroid
• 34 AA hormone
• On Kidney
12
13. 13
Critical - > 14 mg %
Moderate - 12 to 14 mg %
Mild – 10.4 to 11.9 mg %
Normal – 8.5 to 10.3 mg %
16. • More than 90 percent of hypercalcemia cases are
Primary hyperparathyroidism and malignancy
• These conditions must be differentiated early
to provide optimal treatment & accurate prognosis
• Humoral hypercalcemia of malignancy implies a
very limited life expectancy — only a matter of
weeks
• Primary hyperparathyroidism has a benign course.
16
17. • Primary hyperparathyroidism
• Sporadic, familial, associated with
Multiple Endocrine Neoplasia (MEN I or II)
• Tertiary hyperparathyroidism
• Associated with chronic renal failure
• PTH due to Vitamin D deficiency
17
18. • Vitamin D intoxication
• Iatrogenic Vitamin D injections
• Usually 25-hydroxyvitamin D2 in
over-the-counter supplements
• Granulomatous disease –
Sarcoidosis, Berylliosis, Tuberculosis
• Hodgkin’s lymphoma
18
19. • Humoral hypercalcemia of malignancy
(mediated by PTHrP) – common cause
• Solid tumors, especially lung, head and
neck squamous cancers
• Renal Cell Carcinoma (RCC)
• Local osteolysis (mediated by cytokines)
• Multiple Myeloma
• Breast cancer
19
20. • Thiazide diuretics (usually mild) - common
• Lithium for depressive illnesses
• Milk-alkali syndrome (calcium + antacids)
• Vitamin A intoxication (including
analogs used to treat acne)
20
33. 33
• Increased screening for serum Ca++ and
• Wider availability of I-PTH assay
• 80% of cases single parathyroid adenoma
• Usually benign adenoma or hyperplasia
• Rarely parathyroid cancer
• High PTH in the setting of hypercalcemia
• Slowly progressive – Sestamibi N-scan
• 25% require surgery – RLN paralysis
34. 34
64 yrs male - “hyper parathyroid storm”
with a serum calcium level of 16.4 mg%
35. • Serum calcium level > 12 mg % at any time
• Episodes of hyper parathyroid crisis
• Marked hypercalciuria (urinary Ca++ > 400 mg /day)
• Nephrolithiasis; Impaired renal function
• Osteitis fibrosa cystica – Thinning of cortical bone
• Reduced bone density by DEXA scan (Z score < 2)
• Classic neuromuscular symptoms, Proximal muscle
weakness and atrophy, Hyper reflexia and ataxia
• Age younger than 50 years
35
36. 36
• 25 OH - Vitamin D2 is the supplemental Vit D
• Level of 25 OH – Vitamin D3 is to be measured
• Macrophages in the granulomas, lymphomas
cause extra renal conversion of 25 OH form to
the1,25 hydroxy derivative –the active Calcitriol
• PTH levels are suppressed; Calcitriol levels
• Stop the offending use of Vitamin D
• Glucocorticoids – for over one month or more
• Manage hypercalcemia vigorously
37. 37
• Most commonly mediated by systemic PTHrP
• Humoral Hypercalcemia of malignancy
• PTHrP mimics the bone & renal effects of PTH
• Normal Calcitriol and suppressed PTH levels
• Excessive bone lysis due to primary or bone
secondaries can cause hypercalcemia
• MM and metastatic Br Ca present in this way.
• In Osteolytic hypercalcemia, SAP is markedly
• Hodgkin’s lymphoma – production of Calcitriol
38. • Thiazide diuretics increase renal calcium
resorption and cause mild hypercalcemia
• Resolves after discontinuing the drug
• Thiazide unmasks hyperparathyroidism
• Milk–alkali syndrome – Ca + Antacids
• Lithium – the set point for PTH
• Excess Vitamin A - bone resorption and
causes hypercalcemia.
38
39. • FHH – Familial Hypocalciuric Hypercalcemia
• AD – 100% penetrance – Ca-R gene mutation
• Moderate hypercalcemia with normal/ PTH
• 24 hour urinary calcium is very low
• No benefit from parathyroidectomy
• High bone turnover in Paget’s disease or
prolonged immobilization
• Recovery phase of Rhabdomyolysis
39
40. • Ca <12 but > 10.3 mg% – no appreciable
clinical benefit – they need evaluation
• Any patient with Serum Ca > 12 mg%
should be aggressively treated
• Ca > 14 mg% is Hypercalcemic crisis
• Always correct the Ca value for Sr
Albumin
40
42. • Vigorous I.V. Nacl Diuresis – N Saline
• Adequate hydration – urine out put must be
maintained 200 ml/hour = 5 L /day
• The safest and most effective treatment of
Hypercalcemic crisis is saline rehydration
• Once the urine out put is maintained – give I.V.
Furosemide – a loop diuretic in low doses of 10
to 20 mg
• ERT - might be beneficial in PMW – new RCT
42
43. • In severe hypercalcemia refractory to
saline diuresis
• Calcitonin (Zycalcit, Miacalcin) 6 -8 U/kg
IM/SC (400 i.u) given every six hours.
• This treatment has a rapid onset but short
duration of effect
• Patients develop tolerance to the calcium-
lowering effect of Calcitonin.
43
44. • Zoledronic acid (Zometa) - 4 mg IV diluted in
100 ml of N Saline - over at least 15’ once a
M
• Pamindronate (Pamidria) - 60 mg IV infusion
over 4 h initial – repeated after a month
• Etidronate (Didronel) - 7.5 mg/kg IV over 4 h
daily for 3-7 d; dilute in at least 250 ml of
sterile N Saline
• They inhibit bone resorption, inhibit the
Osteoclastic activity. 44
45. • Dialysis for refractory Hypercalcemic crisis
• Parathyroidectomy for adenomas
• Rx. of the underlying cause – Eliminate drugs
• Plicamycin (Mithracin) 25 mcg/kg/d IV for 4 d
• Gallium nitrate (Ganite) 100 mg/m2/d IV for 5
days in 1 L of NS or 5% Dextrose
• Cinacalcet (Sensipar) - 30 mg PO od –
(increases sensitivity of calcium sensing
receptor) 45
46. • Hypercalcemia is often asymptomatic
• Screen all suspected by doing Sr Calcium
• If elevated, do I-PTH and follow algorithm
• 90% Hyperparathyroidism and malignancy
• Vitamin D toxicity is an important cause
• Thiazide diuretics common cause, Vitamin A
• Adequate hydration - N Saline + Furosemide
• Calcitonin + Zoledronic acid main stay of Rx.
46