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Infection, Nutrition and Thyroid Disease

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Title: Infection, Nutrition and Thyroid Disease


1
Infection, Nutrition and Thyroid Disease
2
Choose the correct statement about
community-acquired methicillin-resistant
Staphylococcus aureus (CA-MRSA). (A) Likely arose
from hospital strains that spread into the
community (B) Likely arose from de novo
acquisition of resistance by a methicillin-suscept
ible strain (C) Is genetically almost identical
to HA-MRSA (D) Is less susceptible to
non?-lactam antibiotics than HA-MRSA
3
Answer
  • (B) Likely arose from de novo acquisition of
    resistance by a methicillin-susceptible strain

4
Data show the majority of pregnant women who
present with CA-MRSA are nulliparous. (A) True
(B) False
5
Answer
  • (B) False

6
Which of the following is the first-line
treatment for uncomplicated skin and soft tissue
infection with MRSA? (A) Incision and drainage
(B) Daptomycin (C) Linezolid (D) Tigecycline
7
Answer
  • (A) Incision and drainage

8
Which of the following is considered first-line
therapy for complicated skin and soft tissue MRSA
infection? (A) Co-trimoxazole (TMP/SMX) (B)
Clindamycin (C) Doxycycline (D) Vancomycin
9
Answer
  • (D) Vancomycin

10
MRSA active surveillance cultures (ASC) that are
required in California
  • They are required within 24 hr of admission for
    patients scheduled for inpatient surgery,
    discharged from acute care hospital during past
    30 days, admitted to ICU, receiving inpatient
    dialysis, or transferred from skilled nursing
    facility Rationale for ASCprevents
    patient-to-patient transmission (by using contact
    precautions, isolation, and/or decolonization)
  • prevents subsequent infection of previously
    colonized patients
  • enables appropriate modification of perioperative
    prophylaxis
  • conflicting data supporting ASC led professional
    societies to conclude evidence insufficient to
    warrant routine or mandated use of ASC for
    detection of MRSA

11
Contact isolation
  • supporting data inconclusive
  • Potential adverse events associated with contact
    precautions (patients likely examined less
    frequently and for shorter periods, compared to
    nonisolated patients)
  • patients more likely to experience preventable
    adverse events (eg, pressure ulcers, falls,
    electrolyte imbalances)
  • increased rates of depression and anxiety
  • trial currently ongoing to address question of
    whether intensive infection control strategies
    reduce transmission of pathogens

12
Origin of community-acquired MRSA (CA-MRSA)
  • 4 deaths due to MRSA reported in previously
    healthy children in 1999
  • outbreaks of CA-MRSA then reported in multiple
    diverse populations
  • 2006 paper cited CA-MRSA as predominant cause of
    skin and soft tissue infection among patients
    presenting to 11 emergency departments
  • likely arose de novo from acquisition of
    resistance by methicillin-susceptible strain
  • CA-MRSA genetically distinct from
    hospital-acquired MRSA (HA-MRSA)
  • Has novel staphylococcal chromosomal cassette
    element lacks multiple antibiotic resistance
    genes
  • contains other genetic elements that may
    contribute to virulence

13
Spectrum of disease
  • skin and soft tissue infections most common,
    followed by wound infections, urinary tract
    infections, and bacteremia
  • CA-MRSA more susceptible to nonBeta-lactam
    antibiotics (compared to HA-MRSA)
  • Cochrane Database of Systematic Reviews
    (2008)reported reduction of nosocomial S aureus
    infections in surgical and dialysis patients
  • however, most patients had methicillin- sensitive
    S aureus (MSSA), and those with MRSA had HA
    strain
  • studies of nonsurgical patients and MRSA
  • carriers showed no benefit
  • 2003 reviewtopical mupirocin and systemic
    antimicrobial therapy not effective in
    eradicating nasal or extranasal MRSA
  • adverse events and development of resistance
    observed with oral systemic decolonization

14
MRSA carriage in pregnancy
  • approximately one-third of women carriers (1
    colonized with MRSA both rates consistent with
    general population) 5 of infants carriers (lt1
    MRSA)
  • no evidence of maternal-infant transmission
    vaginal- rectal colonizationprevalence 0.4 to
    3.5
  • Conflicting data on association with Group B
    streptococcus carriage
  • data looking at colonization and risk for
    vertical transmission showed no cases of
    early-onset invasive neonatal MRSA infections
  • no evidence of substantial cost benefit with MRSA
    screening and decolonization, regardless of
    success of treatment
  • perioperative prophylaxismeta-analysis of
    cardiac surgery patients treated with vancomycin
    or Beta-lactam showed no increased benefit from
    use of either drug
  • vancomycin did appear to reduce rate of surgical
    site infection in subgroup of patients with MRSA
  • threshold prevalence of MRSA infections for
    changing prophylaxis regimens not yet defined
  • protocol at UCSFperform ASC on selected patient
    group
  • focus on education of patient and health care
    personnel to reinforce standard precautions and
    hand hygiene

15
MRSA in pregnancy
  • clinical presentationdata show majority of
    infected patients multiparous
  • clinical infection mostly during second trimester
  • mastitis and surgical site infection most common
    postpartum infections skin and
  • soft tissue infections predominant clinical
    presentation
  • data show no significant difference in obstetric
    outcomes between women with CA-MRSA and those
    without CA-MRSA
  • postpartum mastitisdata show no difference in
    age, pregnancy history, clinical presentation, or
    prenatal or intrapartum risk factors
  • patients more likely multiparous (may reflect
    increased prevalence of MRSA among children)
  • no significant differences in clinical outcomes
    with antibiotic use
  • MSSA predominant organism in women without
    abscess
  • MRSA dominant organism in women with abscess
  • MRSA and MSSA significant pathogens in
    nonpuerperal mastitis
  • management of uncomplicated skin and soft tissue
    infectionsincision and drainage (I and D)
    primary treatment
  • benefit of antibiotic beyond that of I and D
    unknown
  • consider empiric treatment with systemic
    symptoms, severe local symptoms, or
    immunosuppression antibiotics may have more
    important role in patients treated with minimally
    invasive drainage techniques
  • Empiric therapyif abscess present and antibiotic
    therapy indicated, consider coverage for CA-MRSA
    (pending culture)
  • for mastitis without abscess, consider coverage
    for CA-MRSA based on local epidemiology or
    failure to respond to Beta-lactam therapy

16
Antimicrobial therapy
  • co-trimoxazole (TMP/SMX)low rate of resistance
  • covers MRSA and MSSA
  • unreliable for group A streptococcal infection
    pregnancy category C or D in third trimester
  • clindamycincovers MRSA, MSSA, and group A
    streptococci
  • excellent tissue and abscess penetration
  • potential for resistance
  • risk for Clostridium difficile
  • pregnancy category B
  • doxycyclinelow resistance covers MRSA and MSSA,
    but unreliable for group A
  • Streptococci
  • pregnancy category D
  • linezolidindicated for complicated skin and soft
    tissue infections
  • Adverse events associated with long-term use (eg,
    potential bone marrow suppression, neurotoxicity)
  • pregnancy category C
  • inducible clindamycin resistancenot detected by
    standard broth microdilution testing
  • consider with erythromycin-resistant but
    clindamycin-susceptible isolate
  • If disk diffusion-test positive but patient
    improving, continue clindamycin
  • change therapy with failure or moderately severe
    infection
  • management of complicated skin or soft tissue
    infectionsempiric therapy for MRSA recommended
    (vancomycin first-line drug)

17
MRSA and breastfeeding
  • one case report of transmission of MRSA via
    breast milk (mother asymptomatic)
  • no clear data on whether woman with postpartum
    mastitis should continue breastfeeding
  • breast emptying mainstay of therapy
  • some experts recommend continuing breastfeeding
    if mother on antibiotics, unless draining wound
    or cellulitis in area
  • another recommends breastfeeding on contralateral
    side and expressing on infected side

18
Vulvar abscesses
  • data show MRSA dominant pathogen in 64 of women
    treated for vulvar abscess
  • no distinguishing clinical signs or symptoms
  • no difference in clinical outcomes perform I and
    D
  • treat with TMP/SMX (covers MRSA and majority of
    other pathogens)

19
Study Lesser-known bug a bigger hospital threat
  • March 20, 2010By MIKE STOBBE, AP Medical Writer
  • 2010-03-20 061200 PDT Atlanta, , United States
    (03-20) 0612 PDT ATLANTA (AP) --
  • As one superbug seems to be fading as a threat in
    hospitals, another is on the rise, a new study
    suggests.
  • A dangerous, drug-resistant staph infection
    called MRSA is often seen as the biggest germ
    threat to patients in hospitals and other health
    care facilities.
  • But infections from Clostridium difficile known
    as C-diff are surpassing MRSA infections, the
    study of 28 hospitals in the Southeast found.

20
C-Diff
  • "I think MRSA is almost a household name.
  • Everybody thinks of MRSA as a serious threat,"
    said Dr. Becky Miller, an infectious diseases
    specialist at Duke University Medical Center. She
    presented the research Saturday in Atlanta, at a
    medical conference on infection in health care
    facilities.
  • "But C. difficile deserves more attention," she
    added.
  • MRSA, or methicillin-resistant Staphylococcus
    aureus, are bacteria that can't be treated with
    common antibiotics. They are often harmless as
    they ride on the skin, but become deadly once
    they get in the bloodstream. They enter through
    wounds, intravenous lines and other paths.
  • C-diff, also resistant to some antibiotics, is
    found in the colon and can cause diarrhea and a
    more serious intestinal condition known as
    colitis.
  • It is spread by spores in feces. The spores are
    difficult to kill with most conventional
    household cleaners or alcohol-based hand
    sanitizers, so some of the disinfection measures
    against MRSA don't work on C-diff.
  • Deaths from C-diff traditionally have been rare,
    but a more dangerous form has emerged in the last
    ten years.
  • Still, MRSA is generally considered a more lethal
    threat, causing an estimated 18,000 U.S. deaths
    annually.

21
C-Diff
  • The new study looked at infection rates from
    community hospitals in Virginia, North Carolina,
    South Carolina and Georgia in 2008 and 2009.
  • It found the rate of hospital-acquired C-diff
    infections was 25 percent higher than MRSA
    infections.
  • Here are the numbers The hospitals counted 847
    infections of hospital-acquired C-diff, and 680
    cases of MRSA.
  • Miller also reported that C-diff was increasing
    at the hospitals since 2007, while MRSA has been
    declining since 2005.
  • Last year, a government report noted a decline in
    MRSA infections in a study of 600 hospital
    intensive-care units.
  • MRSA bloodstream infections connected with
    intravenous tubes fell almost 50 percent from
    1997 to 2007, according to data reported to the
    Centers for Disease Control and Prevention.
  • C-diff has seemed to be increasing in recent
    years, but the trend is not uniform some
    hospitals report falling rates.
  • The prevalence of different infections can vary
    in different parts of the country, said Dr. L.
    Clifford McDonald, a CDC expert who was not part
    of the Duke study.

22
What is a Hospital Acquired Infection
  • An infection that is not present or incubating at
    the time healthcare services are delivered
  • IT presents symptomatically 48 hours or more
    after admission or provision of care

23
HAI Frequency
  • Each year in the US, five to ten percent of all
    patients admitted to the hospital develop HAIs
  • This translates to almost two million cases of
    HAI each year, in hospitals alone.
  • HAIs may also be acquired in the Ambulatory care
    setting and Home care setting

24
Overview thyroid nodules
  • common found in 50 of patients on
    ultrasonography (US)
  • About 10 of patients on palpation
  • thyroid dysfunctionoccurs in up to 1 in 8
    patients, especially in elderly population
  • thyroid conditions found predominantly in women

25
Thyrotropin (TSH) as monitoring tool
  • only 0.04 of TSH in free bioactive form
  • remainder bound (ie, inactive hormone) to
    thyroxine-binding globulin (TBG) and albumin
  • therefore, never use total T4 to assess thyroid
    function

26
Factors affecting T4 levels, Use TSH in pregnancy
  • estrogenincreases TBG
  • pregnancytotal T4 can increase (to 14-16 g/dL),
    becauseo of increased binding proteins, and stay
    within normal range
  • other estrogen sourcesreplacement therapy,
    contraception, and infertility treatments with
    follicle-stimulating hormone (FSH) injections
  • long-term narcotic useelevates T4 leuprolide
    (eg, Lupron)lowers TBG and T4
  • changes in pregnancyTGB levels rise quickly at
    start, plateau at 20 wk, then stabilize
  • 50 increase in T4 during first 20 wk (eg, from 9
    to 13 µg/dL)
  • estimate thyroid functions with TSH (levels
    decrease when thyroid hormone increases, and vice
    versa)
  • 2-fold change in T4 levels results in 100-fold
    change in TSH
  • TSH more sensitive, accurate, and can diagnose
    euthyroidism, hypothyroidism, and hyperthyroidism

27
Hypothyroid Prevalence
  • In men it is 2 to 3 over decades,
  • until gt70 yr of age (increases to 10 of men)
  • womenstepwise increase starting at 30 yr of age
  • by gt70 yr of age, 1 in 7 or 8 womem has
    unsuspected hypothyroidism

28
Screening
  • TSHmost sensitive and specific test for
    hypothyroidism
  • inexpensive

29
Causes
  • Hashimoto disease most common
  • other causes radioactive iodine therapy or
    thyroid surgery
  • Hashimoto disease ask about family history of
    thyroid and other autoimmune diseases (eg, lupus
    erythematosus, colitis)
  • environmental factors include pregnancy (presence
    of fetus can activate maternal immune system and
    initiate autoimmune disease)
  • thyroperoxidase (TPO) antibody rises before onset
    of disease predicting disease
  • measure TPO antibody levels rather than
    antithyroglobulin antibodies
  • after destruction, TSH will rise
  • Patient with mildly elevated TSH and positive
    antibody has 5 per year chance of developing
    hypothyroidism

30
TSH and TPO antibody in diagnosis
  • slightly elevated TSH does not always lead to
    disease
  • study of elderly patients with mildly elevated
    TSHin patients positive for TPO, 80 developed
    hypothyroidism after 4 yr (vs very few in
    negative TPO group)
  • if hypothyroidism suspectedmeasure TSH if TSH
    lowpatient possibly hyperthyroid
  • 0.3 to 3.5 g/dL considered restricted normal
    range
  • if gt9 g/dLpatient hypothyroid requires
    treatment
  • if 3.5 to 9 g/dLrepeat TSH 2 mo later (about 50
    of patients normalize) and measure TPO antibody
  • treat if positive

31
Treatment
  • levothyroxine standard treatment
  • structure identical to that of natural thyroid
    hormone
  • long half-life (7- 10 days)
  • once-daily dosing (can take 2 next day if 1 dose
    missed)
  • T350 to 100 times more active than T4
  • dosedetermined by age and weight
  • drastic weight loss may require reduction in dose
  • younger patients need more thyroid hormone
    because of faster metabolism

32
Contraindications drugs
  • estrogen therapy and antiseizure drugs increase
    binding protein
  • may need more hormone to fill binding sites
  • pregnancy50 to 80 of pregnant women taking
    thyroid hormone require 25 to 50 increase in
    dose
  • interference with thyroid hormone absorption
  • Levothyroxine locked by supplementation with iron
    or calcium, and sucralfate
  • history of malabsorption (eg, celiac disease),
    and ingestion of high-fat foods
  • Best time to take is on empty stomach one half
    hour prior to breakfast.

33
Importance of thyroid hormone brand
  • study of patients using 4 brands of hormone
  • normal thyroid function at start of study
  • change in brand (not dose) increased risk for
    abnormal thyroid function by 40 to 50 (50 of
    affected patients hyperthyroid, 50 hypothyroid)
  • Take home messagesspecify no substitution of
    brand
  • Instruct patient to verify that same manufacturer
    used for each refill
  • if manufacturer changes, patient must return for
    recheck of thyroid hormone levels after 1 mo

34
Maintenance of thyroid function
  • study data show only 60 of patients taking
    thyroid hormone fall within normal range
  • 20 have excess hormone 20 undertreated
  • New England Journal of Medicine (NEJM) study
    found after initiation of oral contraceptives in
    25 women on thyroid hormone, 10 had elevated TSH
    levels
  • Hashimoto diseaseadd 25 to 50 g of thyroid
    hormone (25 dose increase)
  • no thyroid functionafter, eg, radioactive iodine
    or thyroid surgery, 50 dose increase required

35
Changes in thyroid function during pregnancy
  • if untreated, increases risk of worsening of
    hypothyroidism and for preeclampsia, anemia,
    postpartum hemorrhage, and cardiac ventricular
    dysfunction
  • effects on offspringincreased risk for
    spontaneous abortion, low birth weight, abnormal
    brain development, and lower intelligence
    quotient (IQ)
  • Controversial NEJM studyIQ lt85 in 4 of children
    born to control women vs 13 born to women with
    hypothyroidism
  • thyroid testing by primary care physicians
    recommended
  • may see pregnant women earlier than obstetricians
    (in first trimester)
  • Hypothyroidism may occur in first 20 wk (when
    TBGs rising)
  • check TSH as soon as pregnancy confirmed
  • check every 4 wk until week 20
  • increase dose by 50 to 75 g/day
  • after delivery, return to previous dose

36
Subclinical hypothyroidism
  • signs and symptomsweight gain, fatigue, or TPO
    antibody positivity
  • treatmentL-thyroxine (brand name or consistent
    generic manufacturer)
  • taken on empty stomach
  • avoid calcium and iron at the same time

37
Graves disease
  • most common cause of thyrotoxicosis
  • Autoimmune disease caused by thyroid-stimulating
    immunoglobulin (TSI)
  • occurs predominantly in women 30 to 49 yr of age
  • pregnancycondition exacerbated during first
    trimester
  • improves in second and third trimesters (ie, can
    stop antithyroid medicine)
  • worsens 1 to 6 mo postpartum
  • fluctuations most likely due to changes in immune
    status

38
Treatment
  • methimazole or propylthiouracil (PTU)interfere
    with thyroid hormone synthesis
  • complicationspruritus occurs in 20 of patients
    (treat with antihistamines)
  • 3 in 1000 have agranulocytosis
  • if extreme sore throat or fever gt101F develop,
    stop medication and obtain complete blood count
    hepatitis and arthralgia (rare)
  • dosage during pregnancy and breastfeedingPTU
    preferred (less transfer through placenta and
    breast milk) to decrease likelihood of fetal
    goiter
  • Give lowest possible dose of antithyroid drug
  • T3 and T4 in pregnancy
  • maintain higher limits of normal, or slightly
    high (studies show no negative outcomes of mild
    thyrotoxicosis)
  • check thyroid functions monthly in pregnant women
    taking antithyroid drugs
  • TSIextremely high levels at end of pregnancy
    predict neonatal hyperthyroidism
  • fetal US recommended, as large fetal goiter can
    cause asphyxiation during delivery
  • if noncompliant or requiring high doses of
    antithyroid medication recommend surgery during
    second trimester

39
Alternative cause of low TSH during pregnancy
  • Beta-human chorionic gonadotropin (Beta hCG)
    structurally similar to TSH
  • Beta-hCG rises to maximal level at 12 wk, then
    falls to high but stable level Beta-hCG binds to
    TSH receptors and causes slight increase in
    thyroid hormone
  • therefore, TSH drops during first trimester, then
    rises as Beta-hCG drops
  • take-home message
  • low TSH during pregnancy not always indicative of
    hyperthyroidism
  • measure thyroid function at end of first
    trimester if TSH suppressed and T4 or free T4
    normal or slightly elevated, do not treat
  • check levels next month

40
Which of the following statements about zinc is
CORRECT? A Oral zinc improves healing of venous
and arterial ulcers of the legs. B Nasal zinc
gel reduces the duration of symptoms of the
common cold. C Most zinc is absorbed in the
ileum and renally excreted. D Routine zinc
supplementation is necessary in healthy
adults. E Citrus fruits are an excellent source
of zinc.
41
Answer
  • B
  • Nasal zinc gel reduces the duration of symptoms
    of the common cold.

42
Zinc
  •  Zinc is an essential trace element and a
    component of many metalloenzymes. It is involved
    in alcohol, carbohydrate and nucleic acids
    metabolism. Zinc plays a role in DNA, RNA and
    protein synthesis and stabilization. It has a
    structural function in ribosomes and cell
    membranes and impacts polynucleotide
    transcription and genetic expression. Steroid
    hormone receptors depend on zinc for hormone
    binding. Zinc influences spermatogenesis,
    embryonic development and fetal growth.
    Additionally, zinc influences taste
    and smell, promotes wound healing and supports
    the immune system.
  •  Vegetables, lean red meat, eggs, nuts and
    shellfish are all good sources for zinc. The
    recommended daily allowance (RDA) for zinc in
    males is 11 mg daily females require 9 mg daily
    with slightly more needed during pregnancy and
    lactation. Children 4-8 years old require 5 mg
    daily, while children 9-13 years need 8 mg per
    day. Supplementation is not necessary in persons
    who eat a regular diet.
  •  Zinc is absorbed in the jejunum. Both dietary
    fiber and phytate found in whole grain can
    inhibit absorption. Copper, iron and oxalate may
    impair uptake. Drugs that decrease zinc
    absorption includepenicillamine, ethambutol and
    sodium valproate.
  • Zinc is stored intracellularly, mostly in bone
    and muscle, with less stored in the liver and
    kidneys. The majority is excreted in stool,
    although 10 percent is lost in urine. Sweat and
    desquamated epithelial cells also contain zinc.
  •  Zinc deficiency is seen with diets that are low
    in calories and proteins. Because pancreatic
    enzymes are required for absorption of dietary
    zinc, pancreatic disease can also cause zinc
    deficiency. Mild zinc deficiency is sometimes
    seen with diabetes mellitus, cirrhosis,
    inflammatory bowl disease (Crohns)
    andmalabsorption syndromes. Excess renal
    excretion of zinc due to renal disease also
    causes a deficiency.Acrodermatitis enteropathica i
    s a rare autosomal recessive condition in which
    zinc is not absorbed normally and results in a
    zinc deficit. Patients receiving
    total parenteral nutrition (TPN) develop zinc
    deficiency unless supplements are provided.
  •  Clinical Findings with Zinc Deficiency
  •  Abdominal pAlopeciAnorexia
  • Anxiety Depression
  • Dermatitis Diarrhea
  • Glossitis,, Growth delay
  • Impaired wound healing Night blindness
  • Poor concentration
  • Stomatitis
  •  Measurement of zinc level is possible using
    either plasma or white blood cells. Plasma levels
    less than60mcg/dL are considered low. Because
    zinc is a cofactor for alkaline phosphatase (ALP),
    low ALP levels are confirmatory for zinc
    deficiency. Zinc 60 mg given twice daily is
    recommended for supplementation.
  •  While zinc toxicity is uncommon, it is
    associated with overzealous use of supplements,
    contamination of food or absorption of fumes
    while welding using zinc. Symptoms include
    vomiting, diarrhea, fever and renal failure.
    Decreased serum copper, iron and HDL levels are
    also seen. Welding fumes specifically cause
    respiratory distress, excess salivation,
    headaches and sweating.
  •  Zinc is purported to be effective for numerous
    medical problems. One randomized, controlled
    trial (RCT) involved medicating children and
    adolescents with zinc lozenges to treat the
    common cold. The lozenges were ineffective and
    made most subjects feel worse. Another RCT on the
    effectiveness of zinc nasal gel in treating the
    common cold found that zinc reduced the duration
    of cold symptoms by 1.7 days over placebo.
  •  One Cochrane review found that oral zinc sulfate
    did not improve healing of arterial and venous
    ulcers of the legs. Zinc also was not effective
    for preventing type 2 diabetes mellitus in
    overweight women in another Cochrane review.
  •  While routine zinc supplementation is not
    currently recommended, children with stunted
    growth and low plasma zinc concentrations may
    benefit from extra zinc. In a recent systematic
    review, zinc supplementation produced significant
    changes in height and weight in prepubertal childr
    en who were small for their age (SOR B Ref. 2).
  •  Selected references     

43
A 32-year-old female presents to your office
after Roux-en-y gastric bypass surgery 3 months
prior for morbid obesity and hypertension. She
has lost weight rapidly after the surgery, but
she complains of persistent nausea and vomiting
with hand tingling for the previous 2 weeks. When
she called the surgeon?s office, she was
prescribed metoclopramide (generic, Reglan) and
advised to see her family physician. On
examination her gait is unsteady, she appears
slightly confused and forgetful and nystagmus is
noted her examination is otherwise unremarkable.
Select the most appropriate next step in her
management. A Reassurance to continue oral
vitamin supplementation and oral
hydration B Referral for endoscopy to treat
likely gastric outlet stenosis C Routine
neurology referral for gastric bypass
neuropathy D Urine toxicology screen for illicit
drug use E Emergent admission for parental
thiamine treatment
44
Answer
  • E
  • Emergent admission for parental thiamine
    treatment

45
Wernicke Encephalopathy Following Bariatric Surger
y
  • Obesity surgery provides benefits in treating the
    complications of obesity including diabetes,
    sleep apnea and hypertension. As obesity rates
    increase (two thirds of Americans are overweight
    or obese),bariatric surgery rates have increased,
    with more than 170,000 operations performed in
    2005. Given the number of cases, family
    physicians are caring for these patients along
    with bariatric surgeons, especially after the
    initial 30-day postoperative period when almost 1
    percent of patients die from pulmonary
    emboli, anastomotic leaks or respiratory failure.
  •  
  • In the long term, however, functionally diverting
    food past the stomach and duodenum (except for a
    20 ml stomach pouch) predisposes patients to a
    host of nutritional deficiencies to include iron,
    thiamine (Vitamin B1), pyridoxine (Vitamin B6),
    folic acid (Vitamin B9) and cobalamin (Vitamin
    B12). Despite use of lifelong vitamin
    supplements, poor absorption may cause
    complications such as peripheral neuropathy from
    B12 deficiency and Wernicke encephalopathy from
    B1 deficiency (as seen in this case).
    Characterized by a classic symptom triad of
    confusion, ataxia and nystagmus, Wernickeencephalo
    pathy was recently described in a systematic
    review of more than 30 obesity surgery cases.
    Most Wernicke cases were seen 1-3
    months postsurgery, occurred in women and were
    associated with abnormal vomiting (vomiting
    despite appropriately sized meals) and peripheral
    neuropathy. Of note, the classic symptom triad
    may be incomplete in one third of bariatric surgic
    al patients.
  •  Clinicians need to maintain a high index of
    suspicion in bariatric surgery patients who
    present with neurological symptoms serum
    thiamine levels and erythrocyte transketolase leve
    ls may be normal and characteristic radiographic
    findings on magnetic resonance imaging (MRI)
     hyperintense signal around the thalamus and
    3rd/ 4th ventricles) may be absent. MRI has a
    sensitivity of 53 percent and a specificity of 93
    percent for the diagnosis of Wernicke encephalopat
    hy.
  •  Patients suspected to have Wernicke encephalopath
    y need prompt thiamine replacement (at least 100
    mg daily) to reverse symptoms and prevent
    long-term sequelae, such as Korsakoffsyndrome
    (amnesia, apathy, ataxia and confabulation).
    Treatment response can be dramatic, with
    improvement seen in the first 24 hours (SOR A
    Ref. 2).
  •  Urine toxicology drug screening could be helpful
    if the patient had no response to thiamine, but
    it would not be the initial indicated action,
    given the classic combination of Wernicke-like
    symptoms in a gastric bypass patient. Gastric
    bypass neuropathy can occur due to
    thiamine-deficiency-related defects in the myelin
    sheath, but thiamine replacement would be the
    best response, not delaying treatment for
    a neurologic consult. While nausea after obesity
    surgery is common, persistent vomiting is
    abnormal. Proceeding directly to
    therapeutic endoscopic dilatation would be
    premature without first performing a diagnostic
    upper gastrointestinal series.
  •  Selected references
  • 1. Sechi G, Serra A. Wernicke's encephalopathy
    new clinical settings and recent advances in
    diagnosis and management. Lancet Neurol 2007
    6(5)442-455.
  • 2. Singh S, Kumar A. Wernicke encephalopathy
    after obesity surgery a systematic review.
    Neurology 2007 68(11)807-811.
  • 3. Virji A, Murr MM. Caring for patients
    after bariatric surgery. Am Fam Physician 2006
    73(8) 1403-8.http//www.aafp.org/afp/20060415/140
    3.html  Accessed March 2008

46
Water-soluble vitamins are absorbed, transported
and quickly excreted. Because they are not
stored, water-soluble vitamins must be regularly
replaced. Which group of symptoms is correctly
paired with its causative vitamin deficiency?
A Vitamin B3 (niacin) deficiency ? cheilitis,
stomatitis, glossitis B Vitamin B2 (riboflavin)
deficiency ? scurvy C Vitamin B1 (thiamine)
deficiency ? Beriberi D Vitamin B6 (pyridoxine)
deficiency ? dermatitis, dementia,
diarrhea E Vitamin C (ascorbic acid) deficiency
? elevated homocysteine levels
47
Answer
  • C
  • Vitamin B1 (thiamine) deficiency ? Beriber

48
Water Soluble Vitamins
  •  Vitamin B1 (thiamine) is important for normal
    cardiac, muscle and nervous tissue function.
    Thiamine deficiency is associated with
    beriberi, Wernicke-Korsakoff syndrome and Leighs
    syndrome. Beriberi is a symmetric peripheral
    neuropathy. Dry beriberi is a combination
    sensory/motor neuropathy. Wet beriberi involves
    a combination of neuropathy and cardiac
    impairments (cardiomyopathy and congestive heart
    failure). Wernicke-Korsakoff syndrome is
    characterized by the triad of nystagmus,ophthalmop
    legia and ataxia. Leighs syndrome is a form
    of subacute necrotizing encephalomyopathy.
  •  Vitamin B3 (niacin) is metabolized to active
    forms that are involved in the synthesis and
    metabolism of carbohydrates, fatty acids and
    proteins. Niacin deficiency is rare but is
    occasionally seen withcarcinoid syndrome, Hartnup 
    disease and prolonged use of isoniazid. Symptoms
    of niacin deficiency include diarrhea, dementia,
    delusions and dermatitis. The dermatitis is a
    symmetric, hyperpigmented, sunburn-like rash in
    sun-exposed areas.
  •  Vitamin B2 (riboflavin) promotes development of
    skin and red blood cells through energy
    conversion of glucose. Riboflavin deficiency
    causes dry, cracked skin cheilitis stomatitis
    and glossitis. Anormocytic-normochromic anemia is
    often seen. While riboflavin deficiency is rare,
    certain groups are at risk. Persons with anorexia
    nervosa, lactose intolerance, malabsorption syndro
    mes, inborn errors of metabolism or long-term
    barbiturate use are at increased risk.
  •  Vitamin B6 (pyridoxine) is necessary for the
    formation of amino acids, red blood cells and
    antibodies. Low levels of pyridoxine are
    associated with elevated homocysteine levels and
    increased risk for heart disease. Pyridoxine
    deficiency also causes stomatitis, glossitis, chei
    losis, confusion and depression.
  •  Vitamin C (ascorbic acid) has several important
    functions. It helps build and maintain collagen
    and connective tissue. Vitamin C enhances iron
    and folic acid absorption, aids in wound healing
    and is an antioxidant. Scurvy, ecchymoses,
    bleeding gums, petechiae and impaired wound
    healing are all associated with vitamin C
    deficiency. Other symptoms include weakness,
    malaise, joint swelling,arthralgias and
    neuropathy. Routine vitamin C supplementation
    provides a consistent, statistically significant
    benefit, albeit small, on the duration and
    severity in the common cold (SOR B Ref. 2).
  •  Selected references
  • 1. Cervantes-Laurean N, McElvaney G, Moss J.
    Niacin. In Shils M, ed, Modern Nutrition in
    Health and Medicine.Philadelphia Lippincott,
    2000401.
  • 2. Douglas R, Hemila H, Chalker E, et al. Vitamin
    C for preventing and treating the common
    cold. Cochrane DatabasSyst Rev 1998
    (1)CD000980. http//www.cochrane.org/reviews/en/a
    b000980.html  Accessed March 2008
  • 3. Elsas LS, Longo N, Rosenberg LE. Inherited
    defects of membrane transport. In Fauci AS, Braun
    wald E, IsselbacherK, et al., eds, Harrisons
    Principles of Internal Medicine. 14th ed. New
    York McGraw-Hill, 19982203.
  • 4. Jacob R. Vitamin C. In Shils M, Olson
    J, Shike M, et al., eds, Modern Nutrition in
    Health and Disease. PhiladelphiaLippincott,
    2000467.
  • 5. Siegfried DR, Simmons K. Vitamins
    minerals. Arthritis Today. 2007 9-1069-71.
  • 6. Tanphalchitr V. In Shils M, ed, Modern
    Nutrition in Health and Medicine.
    9th ed. Philadelphia Lippincott, 2000381.
  • 7. Wilson JA. Vitamin deficiency and
    excess. In Fauci AS, Braunwald E, Isselbacher K, 
     et al., eds, Harrisons Principles of Internal
    Medicine. 14th ed. New York McGraw-Hill,
    1998481

49
A 75-year-old patient who resides in a nursing
home has just become your patient. She states
that her bones are brittle. She has a family
history of osteoporosis and hates taking
medications, although she has been on 1,500
milligrams of calcium citrate daily for years.
She wants to know whether vitamin D
supplementation, as recommended by her grandson
who is a nurse, would help her bones. Of the
following options, what dose and form of vitamin
D would be most likely to help prevent fractures
in this patient? A 200 IU vitamin D3 B 400 IU
vitamin D2 C 800 IU 25-hydroxyvitamin D D 800
IU vitamin D3 E 2,000 IU vitamin D of any form
50
Answer
  • 800 IU vitamin D3

51
A 6-month-old infant girl is being evaluated for
recurrent vomiting, diarrhea and a relatively
rapid fall from the 50th percentile for weight to
the 10th percentile over a period of
approximately 6 weeks. She was the product of a
normal term pregnancy and delivery. Both parents
are healthy and have two other healthy children
ages 6 and 4 years. The baby was breast-fed
exclusively until very recently (after her
symptoms were noted). On examination she is
hypotonic, somnolent and does not play or smile.
She is pale and has fasciculations and sucking
movements of the tongue. Laboratory evaluation
reveals hemoglobin, 6.8 g/dL (normal, 11.2-16.5
g/dL) hematocrit, 24 percent (normal, 35-49
percent) MCV, 102 fL (normal, 80-96 fL) MCH, 32
pg/cell (normal, 26-34 pg/cell) MCHC, 32.8 g/dL
(normal, 32-36 g/dL) platelet count, 412 x 109/L
(normal, 150-400 x 109/L) and WBC, 5,500
/mm3 (normal, 4,500-11,000/mm3). The peripheral
blood film showed megaloblastic features
including oval macrocytosis, anisopoikilocytosis
and hypersegmented polymorphs. Additional
evaluation for her anemia reveals normal serum
iron and thyroid function tests. She has a normal
folate level however, her B12 is low at 75 pg/mL
(normal, 180-900 pg/mL). In a search for the
cause for the vitamin B12 deficiency, additional
questioning of the parents reveals that the
mother has been a strict vegetarian (no animal
products or byproducts) for almost 4 years. Which
of the following statements regarding Vitamin
B12 deficiency in infants is CORRECT?
A Maternal vitamin B12 serum levels normally
increase during pregnancy without vitamin
supplementation. B Guidelines recommend serum
testing of vitamin B12levels in infants of
pregnant women who are strict vegetarians. C Preg
nant vegetarians who consume milk in their diet
are not at risk for low vitamin
B12 levels. D Most infants born of mothers with
low vitamin B12 levels immediately show signs of
a neurological problem. E Intramuscular vitamin
B12 injections with iron and folate supplements
are the treatment of choice.
52
Answer
  • E
  • Intramuscular vitamin B12 injections with iron
    and folate supplements are the treatment of
    choice.

53
B12 Deficiency In Infants  
  • Although the maternal vitamin B12 level is known
    to fall throughout pregnancy, this is not
    considered to be significant. However,
    correlation exists between maternal and neonatal
    vitamin levels and corresponding
    neonatal homocysteine levels. With severe
    maternal vitamin B12 deficiency, spontaneous
    abortions may occur, and, if this persists,
    infertility may ensue. With a mild deficiency, a
    normal pregnancy and delivery at term may occur,
    but such infants have low vitamin B12 levels at
    birth and may also be at risk of developmental
    defects. The situation of vitamin deficiency is
    perpetuated if the vitamin B12-deficient mother
    breast-feeds her infant. Vitamin B12 levels are
    very low in the milk of these mothers.
  •  One of the causes of low maternal vitamin B12 is
    dietary deficiency. Vegans (vegetarians without
    intake of any animal products) have no vitamin
    B12 in their diet unless there is contamination
    by soil or bacteria. Vegetarians who also consume
    milk, milk products and eggs may also have low
    vitamin B12 levels. Vegetarians may mask the
    hematological effects of vitamin B12 deficiency
    due to their high folate (folic acid) intake and,
    therefore, have normal hemoglobin levels.
    Oral folatesupplement in the diet and the taking
    of folate preparations in pregnancy to prevent
    neural tube defects may also have a masking
    effect.
  •  The clinical picture of vitamin B12 deficiency
    may appear in the infant several months after
    birth and after a period of normal development.
    The first signs of deficiency are irritability,
    anorexia, apathy, vomiting, weak cry and
    regression of motor development. The infant then
    fails to thrive and may develop neurological
    features such as head lag, hyporeflexia, hypotonia
     and choreoathetoidmovements. Heart failure may
    eventually develop. This may be associated
    with macrocytic anemia (which may be
    severe), hypersegmented polymorphonuclear leukocyt
    es and tissue evidence of vitamin B12 deficiency
    such as raised methylmalonic acid levels. Little
    information is available about long-term
    neurological sequelae. Intellectual impairment,
    gait disturbance and epilepsy may result.
  •  can cause severe disease and since treatment is
    readily available and effective, screening of
    newborns of mothers who are vegetarian may be
    indicated. Guidelines for screening have not been
    established, although screening for increased
    urinary methylmalonic acid (a sign of
    B12 deficiency) at 3 weeks of age has been
    suggested but requires additional study.
    Treatment includes intramuscular vitamin
    B12administration as well as iron
    and folate supplementation.
  •  Selected references
  • 1. Campbell CD, Ganesh J, Ficicioglu C. Two
    newborns with nutritional vitamin B12 deficiency
    challenges in newborn screening for vitamin
    B12 deficiency. Haematologica 2005
    90(12 Suppl)ECR45.
  • 2. Casella EB, Valente M, de Navarro JM, et
    al. Vitamin B12 deficiency in infancy as a cause
    of developmental regression. Brain Dev 2005
    27(8)592-594.
  • 3. Simsek OP, Gonc N, Gumruk F, et al. A child
    with vitamin B12 deficiency presenting
    with pancytopenia andhyperpigmentation. J Pediatr 
    Hematol Oncol 2004 26(12)834-836.
  •  

54
Ginger is a common spice and culinary herb. Which
of the following statements regarding ginger is
CORRECT? A Ginger is approved by the U.S. Food
and Drug Administration for the treatment of
nausea associated with chemotherapy. B At least
one randomized controlled study suggests that
ginger is effective in the treatment of nausea
associated with early pregnancy. C A common side
effect of ginger is constipation. D Ginger tends
to elevate cholesterol levels. E Ginger tends to
promote blood clotting.
55
Answer
  • B
  • At least one randomized controlled study suggests
    that ginger is effective in the treatment of
    nausea associated with early pregnancy.

56
Ginger
  •  Ginger has been used for its medicinal effects
    since ancient times. Today, it is one of the most
    popular herbal supplements and is purported to be
    helpful for several medical conditions. The U.S.
    Food and Drug Administration categorizes ginger
    as a food additive. Ginger has been studied for
    the treatment for nausea and vomiting, especially
    during early pregnancy, and arthritis.
  •  
  • Ginger 250 mg PO QID has been proven effective in
    treating nausea and vomiting of early pregnancy.
    Human studies show no adverse effects on the
    fetus. Ginger has been found to suppress gastric
    contractions and increase gastrointestinal
    motility (SOR B Ref. 4). Six studies involving
    approximately 700 patients support the
    effectiveness of ginger on nausea and vomiting of
    early pregnancy. Ginger was superior to placebo
    in 4 of the studies and comparable to vitamin
    B6(pyridoxine) in 2 studies. One possible
    mechanism to explain gingers antiemetic property
    is that it appears to inhibit serotonin receptors
    of both the gastrointestinal and central nervous
    systems. Ginger has also been recommended for the
    treatment of motion sickness and
    chemotherapy-induced nausea and vomiting.
    However, evidence has not proved its
    effectiveness for these conditions.
  •  
  • Another common medicinal use of ginger is to
    decrease inflammation. Ginger has been shown to
    inhibit the activation of tumor necrosis factor
    alpha and cyclooxygenase-2 expression. It is used
    widely today for the treatment of osteoarthritis
    and ulcerative colitis. Studies of its efficacy,
    however, have concluded shown mixed results.
  •  
  • Ginger has also been reported to have a wide
    range of effects on the cardiovascular system. A
    few preliminary studies have suggested a
    protective effect on coronary artery disease by
    lowering cholesterol and preventing blood from
    clotting. In contrast, ginger may
    be inotropic and has been reported to cause
    arrhythmias. It should be used cautiously in
    patients taking warfarin (generic,Coumadin),
    since it may prolong bleeding time. Overall,
    ginger has few side effects. The most common ones
    are heartburn, diarrhea and irritation of the
    mucous membrane of the mouth.
  •  
  • Selected references
  • 1. Altman RD, Marcussen KC. Effects of a ginger
    extract on knee pain in patients with
    osteoarthritis. Arthritis Rheum 2001
    442531-2538.
  • 2. Chaiyakunapruk N, Kitikannakorn N, Nathisuwan S
    , et al. The efficacy of ginger for the
    prevention of postoperative nausea and vomiting
    a meta-analysis. Am J Obstet Gynecol 2006
    19495-99.
  • 3. Frondoza CG, Sohrabi A, Polotsky A, et al. An
    in vitro screening assay for inhibitors
    of proinflammatory mediators in herbal extracts
    using human synoviocyte cultures. In Vitro Cell
    Dev Biol Anim 2004 4095-101.
  • 4. Jewell D, Young G. Interventions for nausea
    and vomiting in early pregnancy. Cochrane
    Database Syst Rev2003(4)CD000145. http//www.coc
    hrane.org/reviews/en/ab000145.html  Accessed
    March 2008
  • 5. University of Texas at Austin. Recommendations
    for the evaluation and management of nausea and
    vomiting of early pregnancy (lt20 weeks
    gestation). http//www.guideline.gov/guidelines/FT
    NGC-2454.html  Accessed March 2008
  • 6. White B. Ginger an overview. Am Fam Physician
    2007 75(11)1689-1691.http//www.aafp.org/afp/200
    70601/1689.html  Accessed March 2008
  •  

57
Which of the following statements regarding
high-density lipoprotein (HDL) cholesterol is
CORRECT? A Low HDL cholesterol level is defined
as less than 30 mg/dL. B The use of
beta-blockers has been associated with an
increase in HDL serum levels. C Elimination of
dietary trans fat can increase HDL serum
levels. D The Mediterranean diet for improvement
of HDL serum levels consists of a relatively high
intake of red meat and alcohol with low
carbohydrate intake. E Thirty to 60 minutes of
exercise on most days of the week will decrease
LDL serum levels but should not be expected to
change HDL levels.
58
Answer
  • C
  • Elimination of dietary trans fat can increase HDL
    serum levels.

59
HDL Diets
  • A low-serum high-density lipoprotein (HDL)
    cholesterol level has been recognized as an
    independent risk factor for development of
    cardiovascular disease. HDL levels vary among
    different racial/ethnic groups, with African
    Americans having higher HDL levels in general
    than Caucasians. Up to half of the variability
    in HDL levels is related to genetic inheritance.
  •  
  • Every 1mg/dL increase in HDL level is associated
    with a 2-3 percent decrease in coronary artery
    disease risk. A low HDL is defined as lt40
    mg/dL and is often associated with elevated
    triglyceride levels, obesity, cigarette smoking,
    type II diabetes mellitus and ingestion of
    certain medications (e.g., beta-blockers,
    steroids and progestins). Lifestyle modification
    is the first line of treatment for low
    serum HDL levels. Thirty to 60 minutes of
    exercise on most days of the week can
    increase HDL. Elimination of dietary trans fatty
    acids can help decrease LDL levels and,
    simultaneously, increase HDL.Trans fat
    is monosaturated or polyunsaturated fat that has
    been commercially hydrogenated, making it
    chemically similar to saturated fats. The
    hydrogenation process increases the melting
    point, makingtrans fat easier to bake with, and
    the reduction in oxidation potential increases
    shelf life. Replacingtrans fats with
    healthy, monosaturated fats (canola oil,
    safflower oil, olive oil), polyunsaturated fats
    (corn oil, soybean oil) and monosaturated-rich
    nuts (hazelnuts, almonds, pecans, cashews,
    walnuts, macadamia nuts) can increase HDL levels.
    Although both monosaturated and polyunsaturated
    fats are preferred over trans fat, monosaturated f
    ats are recommended over polyunsaturated fats
    (which have been associated with increased
    platelet aggregation and incorporation
    of LDL into the arterial intima, leading to
    plaque formation). The addition of fiber
    (particularly soluble) or a fish oil supplement
    can add further gains in HDL levels. Moderate
    alcohol intake (up to 1 drink daily for women and
    2 drinks daily for men) has also been shown to
    increase HDL levels.
  •  
  • A Mediterranean diet, one that is rich in fruits
    and vegetables and includes healthy fat, is the
    best diet to increase HDL levels. The
    Mediterranean diet was first studied more than 50
    years ago when it was noticed that adults on
    the island of Crete lived longer and had fewer
    cardiovascular events than adults in the United
    States. While this is not a specific diet,
    general guidelines include high intake of
    vegetables, fruit, nuts, legumes and grains high
    intake of olive oil (but low intake of saturated
    fats) moderate intake of fish low to moderate
    intake of dairy products (primarily cheese or
    yogurt) limitation of eggs low consumption of
    poultry and very low consumption of red meat.
    Moderate alcohol consumption, primarily wine with
    meals, is also part of the diet. The food pyramid
    in Figure 2 gives a graphic representation of one
    interpretation of the diet.
  •  

60
DIRECTIONS The following series of questions
deals with primary and secondary
hyperparathyroidism. For the following four
questions, select the answer most closely
associated with the statement.  Surgery is the
primary form of treatment.  A if primary
hyperparathyroidism is associated with the
statement  B if secondary hyperparathyroidism is
associated with the statement  C if BOTH primary
hyperparathyroidism and secondary
hyperparathyroidism are associated with the
statement  D if NEITHER primary
hyperparathyroidism NOR secondary
hyperparathyroidism is associated with the
statement
61
Answer
  •  A
  • if primary hyperparathyroidism is associated with
    the statement

62
Treatment with 1,25-hydroxycholecalciferol
(1,25-dihydroxy vitamin D3, calcitriol) is
indicated. A if primary hyperparathyroidism is
associated with the statement  B if secondary
hyperparathyroidism is associated with the
statement  C if BOTH primary hyperparathyroidism
and secondary hyperparathyroidism are associated
with the statement  D if NEITHER primary
hyperparathyroidism NOR secondary
hyperparathyroidism is associated with the
statement
63
Answer
  •  B
  • if secondary hyperparathyroidism is associated
    with the statement

64
Most commonly caused by chronic kidney disease
  A if primary hyperparathyroidism is associated
with the statement  B if secondary
hyperparathyroidism is associated with the
statement  C if BOTH primary hyperparathyroidism
and secondary hyperparathyroidism are associated
with the statement  D if NEITHER primary
hyperparathyroidism NOR secondary
hyperparathyroidism is associated with the
statement
65
Answer
  •  B
  • if secondary hyperparathyroidism is associated
    with the statemen

66
May result in hypercalcemia  A if primary
hyperparathyroidism is associated with the
statement  B if secondary hyperparathyroidism is
associated with the statement  C if BOTH primary
hyperparathyroidism and secondary
hyperparathyroidism are associated with the
statement  D if NEITHER primary
hyperparathyroidism NOR secondary
hyperparathyroidism is associated with the
statement
67
Answer
  •  C
  • if BOTH primary hyperparathyroidism and secondary
    hyperparathyroidism are associated with the
    statement

68
Hyperparathyroidism
  •  Four parathyroid glands are located behind the
    thyroid gland. Through the secretion of
    parathyroid hormone (PTH), these small glands
    regulate calcium absorption from the gut, calcium
    secretion by the kidneys and calcium storage in
    bones. Calcium plays multiple roles within the
    human body including bone metabolism, nerve
    function and muscle activity. When serum calcium
    levels fall, PTH secretion increases. If serum
    levels of calcium are chronically low, the
    parathyroid glands may hypertrophy as they
    attempt to produce adequate amounts of PTH to
    maintain a normal calcium level.
  •  Vitamin D also has an important role in calcium
    metabolism. PTH and vitamin D closely influence
    each other. Inadequate vitamin D leads to reduced
    calcium absorption, reduced serum calcium and a
    reactionary increase in PTH production. Vitamin D
    is not a true vitamin in the sense that it is not
    a required part of a human diet. Human skin when
    exposed to ultraviolet radiation creates vitamin
    D. In temperate climates and for those who spend
    most of their time indoors, dietary vitamin D or
    vitamin D supplements are usually necessary.
    Vitamin D has a confusing taxonomy. Vitamin D
    from dietary sources and the form of vitamin D
    used in nutritional supplements
    is cholecalciferol (vitamin D3). This form
    of vitamin D is metabolized in the liver to
    25-hydroxycholecalciferol (25-hydroxy vitamin
    D3). This in turn is metabolized by the kidney to
    produce 1,25-hydroxycholecalciferol (1,25-dihydrox
    y vitamin D3). This form is also
    called calcitriol and it is the most active form
    of vitamin D.
  •  Primary hyperparathyroidism is caused by an
    adenoma of usually one but sometimes more that
    one parathyroid gland, producing excessive
    amounts of PTH. This results in hypercalcemia.
    The hypercalcemia may initially be asymptomatic,
    but as the serum calcium level increases,
    symptoms such as proximal muscle weakness,
    abdominal pain and generalized fatigue may occur.
    The serum level at which symptoms are noted
    partially depends on the rate of increase. With a
    relatively acute rise, symptoms may be noticed at
    a serum level of 12 mg/dL (normal, 8.4-10.6
    mg/dL). However, with a slow, chronic elevation,
    symptoms may not be noticed at a serum levels as
    high as 12-14 mg/dL. Prolonged hypercalcemia may
    result in nephrocalcinosis and or osteitis fibrosa
     cystica.
  •  Primary hyperparathyroidism resulting in
    significant symptoms or complications is best
    treated by surgical excision of the hypertrophied
    gland. Criteria for surgery include age younger
    than 50 years, serum calcium gt12
    mg/dL, hypercalciuria (gt400 mg/day), nephrolithias
    is, impaired renal function, osteitis fibrosa cyst
    ica, reduced bone mass and neuromuscular symptoms
    including weakness, atrophy, hyperreflexia or
    gait disturbance. Minimally invasive procedures
    are now commonly used to remove parathyroid
    adenomas. In older patients who are asymptomatic,
    who have well-preserved renal function and who
    have no evidence of bone disease, it may be
    reasonable to follow the patient regularly and
    decide whether symptoms subsequently require
    surgery.
  •  Secondary hyperparathyroidism is most often
    caused by renal disease that negatively impacts
    the conversion of 25-hydroxycholecalciferol to
    the more active 1,25-hydroxycholecalciferol. Insuf
    ficient 1,25-hydroxycholecalciferol leads
    initially to hypocalcemia. This results in
    increased PTH secretion. The increased PTH secreti
    on often results in hypercalcemia.
    Supplementation with 1,25-hydroxycholecalciferol (
    calcitriol) is the most effective means of
    treatment. In most cases calcitriol (generic, Roca
    ltrol) treatment results in decreased PTH levels
    and a normalization of serum calcium. Patients
    with a mild degree of renal impairment may have
    secondary hyperparathyroidism without their
    physicians being aware of it. Physicians who care
    for patients with renal impairment should measure
    1,25-hydroxycholecalciferol intermittently. In
    rare circumstanceshypertrophic parathyroid tissue
    may not respond to treatment with calcitriol,
    resulting in tertiary hyperparathyroidism. This
    may then require surgical treatment to remove one
    or more hypertrophicglands.
  •  Selected references
  • 1. Bailie GR, Massry SG. Clinical practice
    guidelines for bone metabolism and disease in
    chronic kidney disease an overview. Pharmacothera
    py 2005 25(12)1687-1707.
  • 2. Carroll MF, Schade DS. A practical approach
    to hypercalcemia. Am Fam Physician 2003
    671959-1966. http//www.aafp.org/afp/20030501/195
    9.html  Accessed March 2008
  • 3. Diaz-Corte C, Cannata-Andia J. Management of
    secondary hyperparathyroidism the gap between
    diagnosis and treatment. Am J Med Sci 2000
    320(2)107-111
  • 4. Potts JT. Parathyroid hormone past and
    present. J Endocrinol 2005 187(3)311-325.
  • 5. Taniegra ED. Hyperparathyroidism.
    Am Fam Physician 2004 69333-339,
    340. http//www.aafp.org/afp/20040115/333.html  Ac
    cessed March 2008 
  •  

69
Many different types of infant formulas are
available. Parents often have questions
concerning infant formulas for their family
physicians. Which of the following is TRUE
concerning infant formulas? A Whey is the main
protein source in standard cow?s milk-based
formulas (e.g., Similar, Enfamil). B Infants
on formulas supplemented with docosahexaenoic
acid (DHA) and arachidonic acid (ARA) have been
shown to have greater growth parameters than
infants on formulas without DHA and ARA. C Soy
protein formulas (e.g., ProSobee, Isomil) are
hypoallergenic formulas. D Soy protein formulas
are recommended for infants weighing less than
1,800 grams. E Elemental formulas (e.g.,
Neocate, EleCare) are recommended for infants
who cannot tolerate protein hydrolysate formulas.
70
Answer
  • E
  • Elemental formulas (e.g., Neocate, EleCare) are
    recommended for infants who cannot tolerate
    protein hydrolysate formulas

71
Infant Formulas
  •  Most infant formulas are designed to approximate
    the nutritional value of human milk. Standard
    infant formulas are cows milk-based and are
    available with (Enfamil LIPIL, Good Start
    Supreme, SimilacAdvance) and without
    (Similac with Iron, Good Start
    Essentials) docosahexaenoic acid (DHA)
    andarachidonic acid (ARA) supplementation. DHA and
     ARA supplementation have been shown to improve
    visual acuity and cognitive development in some
    studies. There is no significant difference in
    growth parameters, however, with this
    supplementation. Formulas usually contain
    approximately 40-50 percent of calories from
    carbohydrates, 40-50 percent from fat and 5-10
    percent of calories from protein. Casein is the
    main protein source in standard infant formulas.
    Infants who cannot tolerate casein are given
    whey-predominant or whey-only formulas (e.g.,
    Good Start). All infant formulas are also
    fortified with iron as recommended by
    the American Academy of Pediatrics (AAP). While
    some formulas are labeled low iron, these are not
    recommended by AAP (SOR C Ref. 3).
  •  Some formulas (ProSobee LIPIL, Good Start
    Supreme Soy, Similac Isomil Advance) are
    designed for infants who are allergic to standard
    formulas. Soy protein formulas are not true
    hypoallergenic formulas. Formulas are defined as
    hypoallergenic if randomized controlled trials
    show that they do not cause reactions in 90
    percent of infants or children with confirmed
    cows milk allergy. Although soy protein formulas
    are often used for infants with cows milk
    protein-induced enterocolitis, up to 60 percent
    of these infants will be equally sensitive to soy
    protein. The AAP does not recommend soy formulas
    for infants weighing less than 1,800 grams due to
    the potential for aluminum toxicity and
    inadequate weight gain in premature infants.
  •  Protein hydrolysate formulas (Nutramigen LIPIL, 
    Pregestimil, Similac Alimentum) are
    hypoa
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