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DO YOU KNOW?-3

DO YOU KNOW?-3
CREATININE CHEMISTRY

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Monday, 2 May 2016

CALCIUM HOMEOSTASIS-PART-II

CALCIUM METABOLIC DEFECTS-TREATMENTS

HYPOCALCEMIA

 Symptoms 1.Muscular excitability
                    2.Parasthesiasis
                    3.Laryngospasm
                    4.Seizures
                    5.Tetany
                    Chvostek's and Troussean's sign
The facial muscle spasm that occurs when the facial nerve is streatched towards the anterior to the ear.This condition is known as Chvostek's syndrom
Carpal or carpopedal spasms in the hands during or after tied a tight cuff for a blood pressure measurement due to the occlution of the blood in that area.This condition is known as Troussean's syndrom
Common causes of Hypocalcemia
1.Chronic renal failure or End Stage Renal Failure
2.Parathyroid deficiency
3.Vitamin D deficiency
4.Malabsorption due to some diseases
5.Malnutritions.
Treatment options for Hypocalcemia
1.Calcium salts
a)Calcium chloride
b)Calcium gluceptate
c) Calcium gluconate
d)Calcium carbonate
Side effects
1.Peripheral vasodilation
2.Transienttigling
3.Rapid infusions may cause arrhyhmias
2.Vitamin D preparations 
a)Calcitrol a metabolite of vitamin D can cause quick raising of calcium levels
b)Ergocalciferol (Vit.D-2)
c)Cholecalciferol(Vit.D-3)
Mechanism Vitamin d is helping and facilitating calcium absorption at the intestine and decreasing its excretion by the kidneys.
Clinical Indications
1.Osteoporosis
2.End Stage Kidrey Failure
3.Rickets due to inadequate intake vit D
4.Rickets due to tissue resistance to vit- D
5.Osteomalacia
6.Hypoparathyroidism
Side effects
1.Vascular calcifications
2.Kidney calcium stones
3.Soft tissue calcium deposits.
 

CALCIUM HOMEOSTASIS-PART-I

CALCIUM METABOLISM

Calcium is an important mineral that our body needs for various functions.Unlike iodine which is almost available in our body mostly in the form of thyroid hormone,  plasma protein bound  and as a free iodine  ion or elemental iodine.Iodine may not stay in our body as a free ion unless for elimination.But in the case of calcium our body needed it in all the forms mostly ionic form for the contractions of various smooth muscles like heart,liver,kidney,pancreas,lungs and stomach etc.etc..About 80% of calcium is stored in bone as phosphates.

Calcium is distributed in our body almost in compartments including bones,plasma,intra-cellular (ICF) and extra-cellular(ECF) fluids.
Our bone contains most of the calcium content of our body  approximately 80% as phosphate salts.Approximately our body's total content of calcium is 1 kg.Bone serves as healthy and safety storage for calcium and phosphorus.10% of calcium is exchanged between bone and ECF in almost every day. 
Thus ECF serves as the next storage compartment,followed by blood plasma {2.3 mmol per liter(9.5 mg/dl) out of which the ionized calcium is 1.4mmol per liter(5.5 mg/dl) and ICF (>0.0002 mmol per liter)}
Calcium helps blood clotting factors by activating them at times of need.
The nerve cells are very sensitive to calcium concentration of in plasma as a small decrease in calcium level below the normal range (Hypocalcemia)may cause the opening of the voltage gated sodium channel and sodium is leaked into the cells of nerve axons and causes nerve hyper excitability which results in muscular spasms a disease known as tetany and paraesthesia (a pricking skin sensation around the mouth and extermities)
Conversely if the plasma calcium level rises above the normal range (Hypercalcemia) the sodium exchange is restriced from out side to inside of the nerve and muscular cells and the nerves are hyper polarised,and lost their normal sense of excitability,and become weak and tired leads to smooth muscle weakness which causes,lethergy,anorexia,constipation and emotions.
Calcium gives the structure,shape and strength for bones by forming as phosphate salts (calcium hydroxyapatite)
Pharmacokinetics
A normal daily diet contains 30 mmol calcium out of which 6 mmol is absorbed by our intestine daily.
Calcium absorption is almost regulated by vitamin D-3 a cholesterol derivative prepared by our skin. 
95% of the calcium from the glomerular filterate is reabsorbed by the kidneys leaving a small fraction to be excreted.If this level is disturbed by some pathological defects such as defects in calcium metabolism or bone desorption then there are possibilities of kidney stone formations occurs.
 
  In general calcium is metabolized  by our body in three ways as follows
1.By a hormone secreted by parathyroid gland (PTH)
2.By calcitonin an hormone secreted by paraglobular cells of thyroid glands
3.By viamin D-3.
1.Parathyroid glands are two pairs in number and each pair is positioned at either lobe of the thyroid glands.As these glands are situated at the back of the thyroid glands these glands are not visible during an exhamination of neck.The usual weight of parathyroid glands are  30 gms in men and 35 gms in women.
The major function of this gland is to maintain calcium and phosphate levels in a very narrow ranges in order to regulate the neuro muscular functions properly.Thus the PTH takes active part in the homeostasis of calcium. 
To keep up the plasma calcium ion within almost in a stable range thyroid and parathyroid glands working in an opposite direction to each other.Thus when the plasma concentrations of calcium ion rises above the narrowly fixed set level (Hypercalcemia) the thyroid secretion of calcitonin act on it and bring it down to normal range.
Conversely if the plasma calcium level go down below the normal set level(Hypocalcemia) then Para Thyroid Hormone (PTH) secreted by parathyroid gland act on it to raise its level to normal range.
Pathology
Hypocalcemia
Hypercalcemia 
 

THYROID DISEASES-IV-HYPER THYROIDSM

THYROTOXICOSIS-TREATMENTS

This is the over whelming secretions of thyroid hormone above the body's need.Unlike in hypothyroidsm in this condition the main cause of defect is on the gland only and not originated from the pituitary or hypothalamus.

Graves's Disease

This is having a synonym as Diffuse Toxic Goiter .This is most probably attacking young children but rarely target adult.
In this condition the gland is stimulated on TSH receptors not by TSH from the pituitary but by the autoimmune antibodies in the blood.Hence when pituitary is normal,and hypothalamus is normal but the gland is overstimulated by the body's own defence system. 
These antibodies are having prolonged gland stimulating effects and since they are only mimiking the action of pituitary and testing for TSH in the blood may not give positive results.
The required results will be yielded only by the titration of these antibodies in the blood.
Symptoms 
1.Diffusely enlarged nontender goiter
2.Nervousness,weakness,and insomnia. 
3.Heat intolerance and heavy sweating.
4.Weight loss inspite of elevated appetite
5.Tremour,muscle weakness
6.Palpitation and tachky arrythmias
7.Incomplete and slow eye lid closing (Exophthalmos)
8.Loose motion
9.Periorbital edema.

Plummer's Disease

This a highly toxic form of nodular goiter.This is more common in adults over 50 years and mostly females.The actual cause is unknown but preferably arise from untreated long standing non toxic goiter. 
In this disease one or more adenomatous nodules of the thyroid gland autonomously secreting excess hormone without being stimulated by pituitary hormone.Enlargedv nodules are formed within the goiter.
Basically deficiency in dietary iodine may cause not only hypothyroidsm but some times cause hyperthyroidsm too as follows by counter activity.
a)Availability of less dietary iodine leads to less T-4 production.
b)Less T-4 production may induce more mutations and introductions of TSH cells.
c)TSH cells on pseudostimulation by body's auto immune antibodies will induce more nodular autonomous T-4 producing cells which secretes automatically without getting any pituitary stimulation excess T-4 hormone result in Hyperthyroidsm.
Symptoms
Many of the symptoms are similar to Graves disease except the goiter shows enlarged nodules inside and usually in this disease slow eye lid movement is absent.
Heart abnormalities are more impressive and predominant in this disease.

Jodebasedow Phenomenon

It is a kind of Hyperthyroidsm in which there is a over production of thyroid hormone due to sudden large intake of iodine.either by food,by drugs (e.g.Antiarrhythmic drugs like amiodarone) or by contrast media like radio iodine.

Factitious Hyperthyroidsm

This hyperthyroidsm occurs mostly by misguided weightloss treatments which involves excessive intake of thyroid replacement agents.
Many of the symptoms of hyperthyroidsm like exophtalmia,glandular swelling.and auto immune activity are all absent in the diagnosis of this disease.

TREATMENTS

1.Beta-adrenergic blockers-Propranolol
Propranolol can reduce some of the peripheral symptoms of hyperthyroidsm such as
Palpitations
Tremour
Tachycardia(Increased heart beats)
Sweatting
Nervousness
In addition to the above symptomatic releives propranolol also inhibit the conversion of T-4 to T-3 in the circulation.
2.Propylthiouracil and Methimazole
Chemically these are sulphur containing thiamides.
They suppress the production of T-3 and T-4 by inhibiting the coupling of thyroglobulin molecule.
Can be taken orally
Side effects 1.Agranulocytosis (Rare but very serious)
2.Rash(Most common)
3.Edema
3.Iodine salts
The mechanism is not clear.Usually thyroid gland cannot take iodide as it is unless it should be converted into nonpolar inorganic iodine molecule.Hence ingesting large quantity of polar iodide ion may well result in decreased conversion into polar form and decreased iodine uptake and eventually leads to decreased productions of the T-4,decreased vascularity and decreased gland size.
Iodides are nowadays not used as a sole thrapy but in conjunction with thioamide and propranolol in thyroid cresis.Iodides also can be used prior to surgery.
Preparations 1.A mixture of iodine and potassium iodide (Lugol's solution)
2.Potassium iodide.
Side effects
1.Anaphylactic reactions such as Angioedema and swelling of the larynx
2.Iodism charectorised by burning taste,and mouth
3.soreness of teeth and mouth
4.swelling of eyelids
5.Cold like  senses
6.Breathing problem
7.Enlargement of the salivary glands
4.Ionic inhibitors
These are perchlorates and thiocyanates.
They competitively inhibit the iodide transport mechanism.
Nowadays their use is limited in favour of other advanced therapies
5.Radio Iodine
The mechanism is thyroid gland can readily absorb iodine in radioform which can ablate the gland and decrease the hormone production.
It can be used very coveniently to adults ove 21 years.
This is very useful in treating Profuse Grave's Disease which is not responding properly to drugs and surgery.
One common advantage with iodine is that there is no any upto date proof  Iodine can cause cancer
Side effects 
Delayed hypothyroidsm has been observed.
Contraindications
Radio iodine is highly contraindicated in pregnancy and milk feeding. 

THYROID STROM 

It is a dangerous emergency situation caused by extreme effects of hyperthyroidsm.
This condition is elevated by sickness,trauma,stress and surgery of the patient who is already thyrotoxic.
Treatments include the treatments of hyperthyroidsm especially and preferably with the beta blockers like propranolol,and glucocorticoids to inhibit the plasma conversions of T-3 to T-4.
Other options are a)Propyl thiouracil and methimazole, 
b)I.V sodium iodide injections

 


 

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