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Calcium supplementation (1 2 g/d) is given, along with a vitamin D preparation Patients with chronic hypoparathyroidism must be treated with some type of vitamin D (Table 26 9) Vitamin D2 (ergocalciferol) is derived from plants and is commercially available The usual dose ranges from 25,000 to 150,000 units/d Vitamin D3 (cholecalciferol), the form of vitamin D that is naturally produced in unprotected human skin with UV sunlight exposure, is not generally commercially available in the United States in large doses but may be compounded Vitamin D3 is at least three times more bioavailable than vitamin D2, so that appropriate dosing adjustments must be made when changing from one type of vitamin D to another Both forms of vitamin D are slow-acting preparation, and if toxicity develops, hypercalcemia treatable with hydration and prednisone may persist for weeks after it is discontinued Ergocalciferol and cholecalciferol usually produce a more stable serum calcium level than do the shorter-acting preparations Despite its high cost, calcitriol is being used with increasing frequency for the treatment of chronic hypoparathyroidism; the maintenance dosage of calcitriol ranges from 025 mcg/d to 20 mcg/d Monitoring of serum calcium at regular intervals (at least every 3 months) is mandatory PTH acts upon the kidney to increase tubular reabsorption of calcium Therefore, patients with hypoparathyroidism are prone to hypercalciuria and calcium nephrolithiasis during treatment Target serum calcium levels should be 8 86 mg/dL, keeping it mildly low to avoid hypercalciuria It is prudent to monitor urine calcium with spot urine determinations and keep the level below 30 mg/dL if possible Hypercalciuria may respond to oral hydrochlorothiazide, usually given with a potassium supplement Caution: Phenothiazine drugs should be administered with caution, since they may precipitate extrapyramidal symptoms in hypocalcemic patients Furosemide should be avoided, since it may worsen hypocalcemia

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Renal stones, polyuria, hypertension, constipation, fatigue, mental changes Bone pain; rarely, cystic lesions and pathologic fractures Serum and urine calcium elevated; urine phosphate high with low to normal serum phosphate; alkaline phosphatase normal to elevated Elevated PTH

int x = 8; int y = 12; if ((x == 5) && (y == 12))

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Primary hyperparathyroidism is characterized by chronic poorly regulated excessive secretion of PTH by one or more parathyroid glands that results in hypercalcemia It is an increasingly recognized disorder, present in up to 01% of adult patients examined It can be seen at any age but is more frequent in persons over the age of 50 years and is three times more common in women than in men The disease is caused by hypersecretion of PTH, usually by a single parathyroid adenoma (80%), and less commonly by hyperplasia by two or more parathyroid glands (20%), or carcinoma ( 1%) However, when hyperparathyroidism presents before age 30 years, there is a higher incidence of multiglandular disease (36%) and carcinoma (5%) The size of the parathyroid adenoma correlates with the serum PTH level Parathyroid adenomas or hyperplasia can be familial (about 5%) and may be part of MEN types 1, 2A, and 2B In MEN 1, multiglandular hyperparathyroidism is usually the initial manifestation and ultimately occurs in 90% of affected individuals Hyperparathyroidism in MEN 2A is less frequent that in MEN 1 and is usually milder Familial hyperparathyroidism can occur without MEN It can also occur in the hyperparathyroidism-jaw tumor syndrome, a rare autosomal dominant familial condition in which parathyroid cystic adenomas or carcinomas are associated with ossifying fibromas of the mandible and maxilla as well as renal lesions (cysts, hamartomas, Wilms tumors) (see Table 26 17) Hyperparathyroidism results in the excessive excretion of calcium and phosphate by the kidneys PTH stimulates renal tubular reabsorption of calcium; however, hyperparathyroidism causes hypercalcemia and an increase in calcium in the glomerular filtrate that overwhelms tubular reabsorption capacity, resulting in hypercalciuria At least 5% of renal stones are associated with this disease Diffuse parenchymal calcification (nephrocalcinosis) is seen less commonly Chronic bone resorption induced by excessive PTH in the circulation may produce diffuse demineralization, pathologic fractures, or cystic bone lesions throughout the skeleton ( osteitis fibrosa cystica ) In chronic renal failure, hyperphosphatemia and decreased renal production of 1,25-dihydroxycholecalciferol (1,25[OH]2D3) initially produce a decrease in ionized calcium The parathyroid glands are stimulated (secondary hyperparathyroidism) and may enlarge, becoming autonomous (tertiary hyperparathyroidism) The bone disease seen in this setting is known as renal osteodystrophy This syndrome seems somewhat less likely to develop in patients with diabetes Hypercalcemia often occurs after renal transplant but usually subsides spontaneously.

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The outlook is good if the diagnosis is made promptly and treatment instituted Any dental changes, cataracts, and brain calcifications are permanent Periodic blood chemical evaluation is required, since changes in calcium levels may call for modification of the treatment schedule Hypercalcemia that develops in patients with seemingly stable, treated hypoparathyroidism may be a presenting sign of Addison s disease

Again, there is no need to evaluate the second term. Because the first term is false, the and must fail. (Remember, for an and statement to evaluate true, both tested expressions must evaluate true.) In cases such as these, the C# compiler will short-circuit the evaluation; the second test will never be performed. This allows you to create if statements in which you

Tartaglia F et al Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy Am J Surg 2005 Sep;190(3):424 9 [PMID: 16105530] Tfelt-Hansen J et al The calcium-sensing receptor in normal physiology and pathophysiology: a review Crit Rev Clin Lab Sci 2005;42(1):35 70 [PMID: 15697170]

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