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Okay, Uh, we'll get started then. So hi, guys. Minimize a human One of the co founders of the six PM Siris. And today we're going to be covering and the crime part to specifically focusing on the parathyroid gland. Okay, so if you haven't really done so, please join our social is your instagram Facebook and Twitter Page. It's how we keep you up today about the latest Siris are running a swell a what webinars we do on a day to day basis on Be soon got coming up the surgical syriza's well so you can look for today, I believe, will be starting on the 28th right after the Medical Siris. And so we've got some more stuff look forward to And if you haven't already done so please make sure to also drawing medal. It's where we supply our certificates. From its way, you can access our content such a slide and videos on we've course sponsored by the end of you. Without the MD, we wouldn't been able to get the six pm Siris off the ground. So if you're interested in joining once you complete medical school and you become a foundation doctor everybody's gonna need sort of medical legal advice, indemnity insurance or other forms to support which the end you can also provide or 60.32 awards. So here, interested in joining, please follow the QR code on the bottom right of the screen. And you can also get a freebie, such as a pocket prescriber book, the flash cards, revision cards and is one. Is that the foundation program handbook? Brill. So very quick in terms of Ames objectives, we're gonna obviously cover some parathyroid physiology going to deliberate vitamin D and calcium and how it relates the power fired physiology. We're gonna put calls, have some pathology questions there to end with a swell. And we'll also be, of course, touching on hyper case hypercalcemia and Hypocalcemia as well as other. So let's get started nice and easy. So you're 50. Medical student. You've been asked to see a patient following surgery for power. Fire it grand the surgical consultant Ask you what's the role of power firewood homeland and what does it do? Let me pull up the pool. Okay, so the majority of the answers correctly So yes, the correct answer is that the role of powerful our homelessness is that increases some calcium and decreases your sam force for state. So let's talk a little about the power fired brand and sort of where it's situated and what it does. So you got four parathyroid glands, which sit on top of your fire, a gland observed in your neck. And they said posterior to the fire or gland. And they have these calcium sort of sensitive receptors that are called CS on W, relevant in some pathology that we'll talk about later on within the webinar on. Of course, they respond to some calcium levels, but they also respond to respond to sound prostate levels, or B it a little bit less responsive to phosphate levels when you get parathyroid hormone released, important thing in terms of the end or function of what it does is the whole point is increases your some casting levels and decreases your phosphate levels. And it's what tightly controlled your calcium levels. But you're sort of counseling levels also levels, among other things, also with vitamin D levels and parathyroid home and also interlinked with vitamin D. So, question number two, your fifth year medical student, you're seeing a 75 year old lady with significant renal impairment with the consultant. They've been started on Adk. Are the consultant ask you What's the role of vitamin D? Let's pull up the pole. I'll come back on to come back to that question a little bit later on a mess. So let's shed and results. So order you going for majority? We've gone for increased Simon increased phosphate levels, which is the incorrect answer on the correct answer is again similar role to vitamin D. If you remember the role of its, um, India's will know what the role of parathyroid hormone it's. So something increases your, um, calcium levels and decreases your serum phosphate levels and increases samples. Excretion. Similarly to what? Power fire at home. So just remember parathyroid hormone increase some calcium decreases some phosphate vitamin D does the exact same thing increases. Calcium level decreases some for state levels. So question to be just to follow one is apart. So you're 50. A medical student. You're seeing a 75 year old lady with significant renal impairment with the consultant again, they've been Southern Cal, which form of vitamin D is physiologically active. Okay, so let's see the majority on said So the majority of the answer correctly Brennan correct answers calcitriol, which you haven't highlighted. But the correct answer is. See calcitriol on. We're gonna come back on to all of that because on the next slides, there will be a big diagram for you guys to have a look at. So question to see you're officially a medical student, you seeing again 75 year old lady with significant renal impairment. They're startin at Cal, which is in control of the final step of calcitriol synthesis. That's really cool brilliance a majority of your answer correctly. So the correct answer is the kidneys. So day on the final step again, my format. Things come out a bit funny, guys. Apologies for that. But the correct answer, his kidneys and see. So let's talk about vitamin D, and then we'll show you big diagram of how parathyroid hormone and vitamin D sort of interact with each other. So with Mindy is, you know, obviously from foods, among other things. But when you turn into an activated sort of form, it's it's a type of hormone, so in terms of its production, you can have it from all the intake where you have sort of two forms of it. One is ergocalciferal, which comes more from plants mushrooms, among other things. And it's more of a vitamin D two type of thing. And then you have a colon Calciferal, which is vitamin D free. And that is the more potent vitamin D. That tends to be sort of Maury active for us, if that makes sense. So if you're gonna be buying a supplement, make sure contains cholecalciferol instead of ago. Calciforce a Whitman D Free instead of two D two and again, Vitamin D's sort of has to go through these multiple steps of what we call sort of hydroxylation. Where is to sort of steps of hi doctor nations involved. Skin, liver and kidneys is the final step where gets sent into it's activated form. Calcitriol or dihydroxycholecalciferol has a lot of names on that I'm not gonna go for. But remember, activated Vitamin D has the same rules parathyroid hormone in that it increases your serum calcium levels and decreases your samples for levels by increasing the excretion of the phosphate levels on has a very short heart life of a few minutes when it's time to activated form doesn't stay in the system for very long. So let's talk about vitamin D and power fibroid hormone. So let's start with vitamin D. So as I mentioned, you get vitamin D from sort of sort of your foods. Vitamin D free cholecalciferol is what your particular looking for when sits in the skin, it gets exposed to UVB radiation from the sun, and that helps it sort of in its first step of being metabolized towards active form. Then it goes towards the level where it goes the first step of hydroxylation so hydroxy group oxygen hydrogen group gets added on, and that's when it becomes trying. 25 hydroxyvitamin d free or 25 hydroxycholecalciferol again, lots of names that could be interchanged and used. And then it goes on for a final step, which is the kidneys of horse and the kidneys. It will undergo a second hydroxylation, so then it will become 1 25 dihydroxy with him in the free or 1 25 dihydroxy cholecalciferol, or the simpler name is Calcitriol and the important enzyme that's involved in that second step of hydroxylation within the kidneys. The final step to produce calcium chews called one alpha hydroxy days. If you wanted to remember that, and then you've produced Calcitral, which is activated vitamin D free, and that has multiple sort of organ effects. So this free effects that you need to remember one is on the bone. Of course, the second is on the gut and the furnace on the kidneys, so let's start with the kidneys. So the whole point of one of those with calcium is is trying to increase sound calcium levels so bit, Um, and the free or activated vitamin D free calcitriol decreases your renal excretion of calcium. That's the first step. So that's how it increases just some calcium levels, then it also acts in the guts. Of course, it increases your absorption of calcium from the gut again, increasing the same calcium levels but country to what people think. So people think that you know vitamin D and other things help build up your bone. It doesn't really directly do that, although, you know the increased calcium levels help keep your bones strong because it caused increased calcium labs. But the whole point is it's controlling serum calcium levels, so it actually increases sort of a bit of bone turnover and breakdown again with the aim of increasing your serum, calcium levels and power filed hormone is it's very similar in its function and that again acts on the kidneys, gut and the bone in exact same way that vitamin D D Frieder's so both sort of works synergistically with each other. So again, parathyroid hormone with the kidneys decreases your renal excretion again. It causes increased got re absorption of calcium or increased carbs. Option, really, and it also causes bone breakdown. Exactly. Eso again by causing bone breakdown, it'll increase your fasting levels again. So question number free. You're a 50 year medical student on placement in the endocrinology clinic of 42. Your patient is being monitored for her fired cancer, the consultant expense that she has high levels of calcitonin because of the cancer. What type of thyroid cancer does she have? It's been cool, so fantastic, the majority answer correctly. So the correct answer is medullary. Thyroid cancer, four types of fired cancer that you need to know about pfm a and if you're gonna remember in terms of order of severity, which has the worst prognosis, if you remember in the same order. Papillion flicker of the sort of best prognosis in terms of fired cancer. Medullary on the plastic have the worst on a plastic being the worst fired cancer to have in terms of, uh, prognostically and yet, as mentioned, so it's medullary fired cancer. So where medullary fired cancers arise from, this is the C cells within the fire grants. And those are the same cells that produce calcitonin, which is why calcitonin can be used a sort of a part of the diagnosis in terms of trying to figure out sort of cancer. Somebody sort of fire a cancer. Somebody has. So in terms of the role of calcitonin, so calcitonin decreases your same calcium and phosphate levels by sort of helping it pack calcium and phosphate back into the bone. And the form of hydroxi appetite is what you know, as on just remembered. Fired C cells were police calcitonin, the same ones implicated in medullary fired cancers. So they decrease Austin cross activity. So if you remember, osteoblasts are types of cells that build up bone be for building in osteo class crash day. They cause bone breakdown essentially So if you decrease osteo across the activity, you decrease your bone breakdown on sort of results in, um on again. So calcitonin can also decrease. Renal was option of of calcium, so we would increase. We know excretion as well, which will decrease your sound calcium levels again on, um, all those sort of. So what some people have asked CVC is if someone has a low calcitonin level, will have any adverse effects know because more sort of an augmented hormone, so it doesn't have a very much of a significant role. A zoo think it was physiologically although it has some effect and the easiest in treatment of some things, such as hypocalcemia such as, you know, costume and derived from pink salmon. But it doesn't have as much of a significant factor in amount that's released from the body. So even if you have a low mind doesn't really have much adverse effect. And having high levels doesn't really cause many problems either, because remember, there's multiple other hormones involved in calcium metabolism have more of a significant effect, but where it's important again is one can from the beach, True part of the treatment of significant hypocalcemia but to have a diagnostic significance, particularly in medullary firing cancers. So question number four, you're a 50. A medical student on placement in the I c u. A 52 year old patient is being monitored for severe height hypocalcemia secondary to milk alkali syndrome. A consultant asked you, what state is the majority of some serum calcium within the blood in a healthy person, and that's one of the pool. So the majority of you went for albumin bone, which is the incorrect answer. I can see what you're thinking of. A lot of counseling is bound, Um, but actually the sort of the majority of the calcium's actually free, which is also known free calcium, is also known as I'm a Nice Calcium, which is the physiologically active calcium. Remember albumin to transport proteins. Anything bound albumin can't really exert its effect unless it's unbound from album. And so any calcium is mount albums inactive, it's actually about 40%. That's album in about in about 50%. That's ionized. In a normal, healthy person. There's a small amount that's four straight down, but it's not significant on some coming citrate bound. But again, it's not really that significant unless the patients undergoing hemodialysis, so his diagrammatically representation of what it should look like in healthy person. So as I've mentioned 50% is free calcium, which is also known as sort of ionized calcium on dot. So how the majority of your calcium is within the serum state, 40% of albumin bound and 10% is bound to other things like phosphate citrate and other other things, etcetera. I just remember free calcium. It's physiologically important. If it's free, it can enter cells. It can do all sorts of things and exert its effect. If it's album and bound, it's inactive. You can't really do anything. And when I said Healthy person, the reason why I specified that is because the proportion of things can change, depending on sort of things such as P hate. So example I could think of in more acidotic patients. Being acidotic will sort of, you know, denature enzymes a little bit more and sort of your proteins, so that means things will be less bound to albumin in general, which means in the radius arctic patient that have a higher sort of free calcium ionized calcium amount compared to sort of album in about, you know, if the alcohol tick will be the opposite. For example, of course, your serum albumin levels that old to amount, determine how much is free and how much is sort of albumin bound. And then, if you have a lower albumin amount, yes, your total calcium levels will be lower. But proportionally a higher amount will be free or ionized if that which makes sense and also, if you have the presence of other curating agents such a citrate, which could be because of hemodialysis or other things that can also determine how much free calcium you have. But this is what it should look like within a normal patient. And remember physiologically active calcium that exert its effect. And if it's low or high, can cause hypercalcemic symptoms or hypocalcemic symptoms. Is the ionized or freak housing? It's It's not really anything through the album albumin bound calcium, unless the proportions change. So Carlson Transport really mentioned majority. It's free, a significant months also albumin about, but it's a little bit less in the minority is bound to other things. T do. So let's take a 32nd break before we get on to them or difficult questions, and I can answer any questions that nobody has it this moment of time. So in terms of the power firewood home, it's it's really indirectly in terms of vitamin D levels because power fired hormone levels have been effect on calcium levels. I remember how much vitamin D activated vitamin D. Producing other things is the time, and by the amount of serum calcium that you have is more of a. It's a little bit more of an indirect effect if that makes sense, Um, on that question, somebody else asked, Will there be final stuff later? I'm not sure what you mean by final stuff gun. If you could elaborate a little bit on that, are you talking about what would be another medical Siris? At some point there will be, But there's going to be another surgical Syrian. Surgical sees that also help you with your with your finals as well. And does anybody else have any other questions at this point? Okay, bro, uh, I'll take that as a no Fine. Let's move on. So, question number five um, already given the answer, Thecal told me, Ask you in what state is calcium physiologically active? Let's just see who's who's listen to the quite who's listen to wipes that good, bro. We're going to move straight on, so you have the majority of the answer correctly. So remember physiologically active. Something has to be free to do with the undersell. So it's a free or I noticed, calcium that's physiologically important than exerts its effect. So a little bit about free and adjusted calcium, because this is a question that pops up quite often, and I get a little bit confused about Well, sometimes. So remember what I said. What's physiologically important is the free or ionized calcium. So, for instance, you could when you when we look at calcium, we measure it in terms of the serum blood in me to send off for normal blood to chest tests, which is a gold top with in the UK We look at the total calcium and we look at the A just calcium now, sometimes at a total calcium. Imagine this. Your total calcium could be low still, but you could still know have the symptoms of hypocalcemia, and if you ask me, why is because the proportions could be different. So if someone has a total low calcium, but they're physiologically active counseling for free calcium, it's still within normal physiological rangers. That means you shouldn't have be having side effects because that's the the calcium that exerts. It's physiological effects of that make sense. Um, no. People ask me what's adjusted. Calcium. So when they take your total calcium levels, what they do is they adjust it based on your serum albumin. Um um, because remember what I said. 40% of your calcium in a healthy patient is bound sort of two albumin. So this patient that could be in hypoalbuminemic states So when adjusted, calcium would say, is if their albumin levels were normal, what would their total calcium be? So the total calcium could be low because they have a low albumin. My less of it's bound to albumin is less storage of it by abdomen, But then when you adjust it, if someone had normal, um, and I was telling you what the total calcium level would be, And if that's normal, what that basically telling you in directly, Is that likely your free or a nice calcium is within normal amounts or in in a normal level. So when it's telling, is like your calcium levels are physiologically sort of important, are likely within a normal range despite how they're having low albumin levels, and I'm happy to explain it towards the end again. But that's what it means. Now you're asking there's a lot this path, you know, is that easier way of doing this instead of indirectly, you know, calculating adjusted calcium numbers. And there is so in. I see use O r. Hate to use wherever. When patients are are lines, they take cereal arterial blood gases to measure lots of things. One of the things that it looks at is your nice calcium levels or your free calcium levels. So the calcium that's measured on the blood gases, the ionized of free counseling. So that gives you a direct measure of what someone's visual article calcium is at that time. Now, the reason why it's more easier to do in I see use and other places because they can do serial calcium eyes, calcium levels, which is important because patients physiological state changes from day to day. Remember what I said. The proportionate arbem inbound and sort of free contains on simple factors, such as a change in your pee hate when the change in your albumin amount. So while it's useful on it, how's your direct measure? Those calcium levels can easily change, depending on the physiological state of the person at that time. So that's why in icy use and he chooses easier because you can take cerium sit cereal. Sarah Um, ionized calcium levels through multiple blood gases. So question six A. A 45 year old lady had a total fired acting before for lichenified cancer. On following surgery, you end enough to rust to review her in the night, as she's feeling on. Well, you know that as a BP is being taken, her wrist flexes and fingers extend, so this sort of position would have done it before. And you'll recognize what sign that is. She has had blood tests that have to ask you, How would you treat this surgical complication on Let's put up the pool? Yeah, so let's share the results of the majority of the answers. IV casting cried it slowly incurring on. So, to be honest, is to correct answers. One is IV calcium gluconate and casting chloride can be used. It depends on your trust guidance, but I tend to go for calcium gluconate because it can be given through a peripheral line. It's less they're taking to the veins on health and cried. Contains three times a much calcium about the calcium gluconate. But really, it depends on what your trust is used to. If you've got symptomatic hypocalcemia, which is what this lady is suffering as a result of post fired surgery causing hypo trauma sort of more of a traumatic hypoparathyroidism. If the symptomatic with it you want to give IV calcium? So that's why you wouldn't do a little because it's not rapid acting enough. And I have, like, these isn't really the wrong answer, and we'll talk about why. But there wasn't any indication or reason for it to be. No but smaller thinking. I know what some of you were thinking, and we'll we'll come in a little bit later on, but I'd be causing leukemia and IV calcium chloride are both the correct answer, but I prefer IV custom. Google it for the reasons mentioned, and so question six be, ah, 45 year old lady again the same one Appetite fired back to me. You know, their BP cuff is being taken. Her wrist flexes and figures extent she's had blood tests. What sign has been elicited? And that's really launched a pool? Fantastic. Most of you will not have it into multiple times. The correct answer is true, so sign. So when you flip the cough BP cuff for about 2 to 3 minutes because of hyper excited nerve hyper excited excitability because of low calcium amounts and because of the sort of temporary ischemia or like a blood flow that you cause it causes your your sort of rest of flexing your finger sticks then, which is known as true. So sign lost. X, as I mentioned, is tapping over the facial nerve over the prostate gland, which can cause this sort of party or twitching, which is again, another sign of hypocalcemia on been skis for upcoming brontuss for upper motor neuron lesions. So we've had this question before, but we're going to do it again. So which sign is more specific and sensitive towards hypocalcemia to look cool? Bring majority answered correctly, So if you're gonna pick one true so sign is more specific and sensitive for hypocalcemia because of our stacks that happened over the facial nerve over the prostate gland. You can also see in hypermagnesemia on metabolic alkalosis. Well, so true. So it is a bit more sensitive and specific, So approves talked about hypocalcemia, but let's cover it again. So with hypocalcemia in terms of causes, what you're on, one to remember is if you've got a low vitamin, the amount hypervigilant is, um, that's going to cause hypercalcemia, because remember what we said. It's within the supposed to increase your son Calcium levels. Hyper renal is, um, for the same reason that it affects the amount of activating vitamin D that you can produce. So if you go on a K I well, not particularly if you've got a CKD and chronic kidney disease more so that's gonna be affect the long term production of Calcitriol. Because, remember, the final step of vitamin D metabolism is in the kidneys through one hour, four hydroxylase of bad kidneys. You're less likely bruise vitamin activated vitamin D, and that can cause hypercalcemia hypoparathyroidism for the same reason that remember, it's supposed to increase your some calcium levels So if you're not releasing power fibroid hormone, that's again couldn't cause low same level serum calcium levels. And what's most common in terms of order is is the first injury, which could be trauma or surgery related, particularly thyroid surgery. Next surgery, where you work in close proximity to the area or two immune disease and as well as the infection. Hypoalbuminemic. Um, for again that we've mentioned that 40% of your abdomen is calcium bound on, as we have to sort of adjust the calcium to try and work out for ionized or free calcium levels are sort of normal for indirect marker. Some of you answered. Magnesium is the question to treatment for a low, for for sort of symptomatic, hyper costing, you know, encourage, you know, incorrect. But it wouldn't be necessary to fast. But when you want to do is when someone's got a low calcium or low potassium amount. And I've said this multiple times before. Measure that magnesium because magnesium effects, powerful blood hormone production and release, but it also in in potassium. It's sort of it's related sort of renal excretion, So if you got a low magnesium, it increases. Renew excreting potassium, so it was low calcium month. Make sure to check the magnesium levels are normal if they're low. Make sure to treat that because otherwise it makes it very difficult to treat hypocalcemia. So always make sure I have a magnesium blood and then treat as appropriate bisphosphonate. It's in that they, you know, like alendronate Andranik, Assad's alendronate, whatever you wanna pick their help, pack calcium and phosphate back into the bone in the form of hydroxy appetite. So that's why it's also part of the treatment for if almost part of the treatment for hypercalcemia, particularly malignant hypercalcemia caused by osteo. Uh, what's the word I'm looking for? Osteo lytic lesions, ones that break down bone pseudo hyperpower fire. It isn't so quite a mouthful. What it is is with pseudo hyperpara hypoparathyroidism. You've got a normal power firewood, hormone level or amount. However, the organs that parathyroid hormone acts on are resistant to its effects. So the gut, the kidneys and the bones are resistant to power farmer home, which means that which means that's similar to hyperpower fire. It isn't because your power fire home can act on those on those got it means you can't increase of serum calcium levels appropriately, hence causing a hypocalcemia. So pseudohypoparathyroidism is when the gut, the kidneys and the bone are resistant to the effects of power fire at home and hyperphosphatemia. So a state where you'll be hypophosphatemia because we don't want to talk about that is in someone with, uh, long time CKD because with CKD no, no, your sort of Remember how your vitamin D levels are affected in that vitamin D increases your some calcium levels but decreases your sound phosphate levels by increasing Reno excretion. When you've got CKD, you hold on to more phosphate, and I've sort of touched on it briefly. The problem with free phosphate in your blood is that it's accumulating agent, and it binds to the free. Oh, I nice calcium's um hum was hyper forCBT MC because of CKD. Not only do they have a low calcium amount because their vitamin D levels or Cal sexual levels are low because of the lack of production from the final step involved in in the kidneys. The increased phosphate that's running around is also mopping up your ionized calcium and binding to as accumulating agent, which makes you much more likely to get severe bouts of hypocalcemia, which is why sometimes in patients with severe CKD, they get these binding agent such a surveillance, which which are sort of phosphate mopping up or binding agents. So sometimes in patients with CKD or end stage renal disease on dialysis, you sometimes see him on a drug called Things Like 77. Lame are kind of a pronounce it. So that's why it's important to monitor hypophosphatemia, particularly in patients with CKD. The one thing that I didn't mention that's also important that should have been there is, of course, if you've got any stage liver disease, you've got severe liver disease. Remember, your liver's involved in the second step of vitamin D production so indirectly again that can also affect your calcium levels and cause someone to become get Finnbogason a swell so a bad level. Bad kidneys can make you hypocalcemic, but a bad kidneys more, more so I thought about the features of hypocalcemia previously, just remember spasmodic so you can get muscle spasms, parrot or harass seizure you that numbing around the area of the mouth anxiety. You can increase your risk of seizures, so someone comes in with new onset for seizures. Remember to take all the electrolytes. It can increase your muscle tone because this sort of tannic sort of paralysis cause you to sort of be confused and sort of delirious with your ent. A shin and pad can cause a form of dermatitis. In course, impetigo have had two forms, which has nothing to do with empty go and herpes. It's postular psoriasis. It always makes me laugh on some things just don't mean what they say. And, of course, C stands for lost X course cardiomyopathies in a long time and as well as that cataract as well. Remember spasmodic. If you're among the remember the features of hypocalcemia and approves, you talked about how to treat hypocalcemia. So if they're not, symptomatic is typically what they say on it depends on your trust guidance, but the numbers that I have in my head. It's always your total calcium, Uh, or just the calcium's above two. And your ionized calcium is above one. I tend to treat or all, and if it's symptomatic or you're a nice house and below one or your total calcium or justice below two, then I Treatment IV's. But look at your PSA trust. Guidance is why I say anything that's symptomatic hypocalcemia treat with IV because they're more like this experience, more severe things and also that risk of a redness or such as a prolonged QT, which can progress on to a point. More think VT or two sons The point because also the trouble so mixed to treat that I IV calcium gluconate or IV calcium chloride? Um, okay. And definitely replace my knees in my flow. Already mentioned. Make sure to measure the magnesium first before you pre emptively decide to treat it so. Question number seven What a lot of other electrolyte abnormality Can calcium be helpful in treating just a little bit of an extra bit? Brilliant Majority of you answered correctly. Correct answers hyperkalemic because of forms part hyperkalemic guidelines, and that stabilized the card it membrane you're less likely to progress on to more serious redness. Such a V, T and G f. I can see it, probably some of you thinking about hypophosphatemia, but not necessarily. I got some of your thinking about refilling syndrome where you get this life threatening shifts of electrolytes in interestingly because of the because of the introduction of food and glucose, which causes spike in the ancient levels, which would in free because usual potassium levels will become low and calcium and everything else is well. But not necessarily. Is it always used in that sort of state? But the correct answer is hyper kenya, Uh, and again of mentioned this previous in times of physiology. Sorry, this is repetitive guys, but when you get increased potassium amount, what it does is your resting. My memory potential becomes highest and you got your action potential. So if you imagine your action potentials were fresh hold because the cardiomyocyte to contract, what on and you got arresting memory and potential in the difference between the two is how hard it is to try and activate there, the cardiac myositis surgery looking to come by. If you've got increased potassium levels that increases your resting memory and potential for the difference between the action potential and the resting, the memory and potential becomes less so you're much more likely to get contractions and your cardio. My sites are much more likely to become hyper excitable, contract more often and make you more like it's a risk to be of at risk of a Every meal were given. Calcium does is it increases your action potential. Fresh hold against a difference between the two normalizes and make sure member cardiac membrane less excitable, so you're less likely to progress on to the F E T. So that's what it means by by Treat Ear by being a cardiac membrane stabilizer. So question number 86 year old lady presents with abdominal pain, excessive urination, pains and aches over her body. Her blood was shown in the table, the consults the consultant bloods on. So there's no blood. But she's hypocalcemic because I'll ask you what tests would you request? Next? It's we launched a pool, so she's hypocalcemic Uh, okay. And she's got normal kidney function as well. Sort of correct. The majority answered correctly. So this is more of an epidemiologic question in that what's most likely to be the correct answer. So it's gonna be paraphimosis home because that's the most common cause of hypocalcemia most common cause of hypocalcemia. First thing least in the UK is hyperpower fire. It is, um, and the second thing is malignancy. So let's talk a bit about hypocalcemia. So number one cause Always remember number one cause of high potassium is hyper parathyroidism. Always make sure to do a parathyroid hormone level, the second most common cause of malignancy. So make sure to four years that's for malignancy. And consider even a CT tap if you if if, if need be. If you if you are thinking malignancy is the most likely cause. Other things, of course, include sarcoidosis, which is this multi system inflammatory non noncaseating granuloma tissue disease. Multiple myeloma, which is just another form of negative which can cause these plasma Cytomel is that break the bone down and also cause an a k I because of all the proteins that are running around, such as Ben Drones, proteins, where you need to do things like protein electrophoresis and measure total immunoglobulin levels as well as that. So if someone comes in with a K, I, I pay calcemia and just generally unwell and Neemia eso remember crab so crabby hypocalcemia renal failure and need me, I'm a swell as that bone pain. Then think of multiple myeloma milk Alkali syndrome is this triad of metabolic alkalosis hypercalcemia and renal failure and it's easy way to excluded because it's caused by medications. Often things are sort of reflux. Preventing medications will do it such a milk of magnesium, which they used to use more often back in the day, but less so now. Fire toxicosis can also do it severe dehydration and that it just causes sort of increased concentration of the calcium level in the blood on vitamin D. Toxicity because remember it, um, in the increases your sound calcium levels. Clinical features remember renal stones because majority of the backbone of different types of stones is calcium causing urinary colic pissing Thrones because calcium is an osmotic agents painful bones, especially in diseases where the bones being broken town. Such a zen disease that can cause osteolytic lesions and breakdown of bone or multiple myeloma. Abdominal moans. Because calcium is the great stabilizer morning is it stabilize. The cardiac membrane also stabilizes the gut. So can cause constipation, less has grown and psychiatric overtones. It can basically make someone tired or delirious, and treatment is fluid from fluids. So salinization of blood. So you're saying, is the optimum flew to use you consider this phosphinates, especially if it's a malignant cause you to try and find with the underlying causes so you know, sarcoidosis, chest X ray. If it's multiple myeloma, you need to do protein. Electrophorous is you mean, maybe need to consider a seat up for other malignancies. Also check bends Jones proteins in the year and and as well as that, check immunoglobulin levels because often this sort of increased amount of one particular immunoglobulin in multiple myeloma such as IgG, Kappa or Lambda, is what they call it that that increases significantly in. And they look for that with the increased immunoglobulins amount. If it's the hydrated, obviously treat the hydration. If it's vitamin D toxicity, it's gonna be fluid on turn to stop taking so much of it. Um, in D. So primary hypoparathyroidism is probably what you guys want to know about because there's obviously powerful I teach. So as I've mentioned when you get increased power fired hormone amount, you get increased some calcium levels, and the most common cause of primary hypoparathyroidism is a singular adenoma. The second was common. Cause is sort of multigrain Angela, sort of, uh, other numbers affecting. Remember, you've got four power fibroid glands. Some people have extra pyre fired plans, in fact, and some people less than you got to think about familial causes some multiple endocrine neoplasia in which does type one type to a Type two B in which hyper parathyroidism is implicated in a few of them. So have a look at men in your own time if you haven't already, but I won't be covering in the Senate and the crime lectures carcinoma. Then it's less likely. But because carcinomas don't tend to produce a lot of things it clicking in the firing, the parathyroid glands about a carcinoma can do it. And then there's rare issues with the calcium sensitive, perceptive. So remember, parathyroid glands have these calcium since the perceptive that measure the amount of calcium within your serum. So if you've got, for instance, familial Hypo calcium, Rick Hypocalcemia, the normal saves If someone's got that disease, the normal amount of calcium that you and me have would be interpreted as a low calcium amount by people with these receptors issues, because interpret it has a low amount. Even though it's a normal amount, your body releases more parathyroid hormone in response, which causes your course. You're some calcium numbers to increase by a ridiculous amount and also for you to pee it out a bit. Maura's well. So that's why it can cause that. And then there's things such as a parathyroid hormone related every related peptide, which is released by different types of sort of secreted in tumors as part of a sort of paraneoplastic syndrome, particularly things such as apical lung tumors, pankos tumors, small cell lung carcinoma is they can release the sort of form of powerful ride home and related peptide, which is seven out of power filed home but a bit different because is the same thing in length hypocalcemia. But it's no is not affected by the same sort of negative feedback loops that fire fire at home one would be, and a little bit about primary, secondary and tertiary hyper prior, for it isn't because people get confused. So with primary, you can increase power five at home and then for all those reasons that we've mentioned before, and that increases your calcium levels with secondary, it's it's no pathological. It's a physiological response to low calcium amounts. So someone's hypocalcemic for whatever reason, your if your parathyroid hormone is functioning Normally, your parathyroid hormone level should increase by significant amount. So it's hypocalcemia that causes a creased parathyroid amount, so you'll see a low calcium and an increased power five at home. So it's a physiological natural response. An example of that. Patients with, um, sort of CKD, your low vitamin D amounts and in terms of what tertiary is tertiary is a response to secondary hyper para fire. It isn't quite a mouthful, so what it is is when you get chronic secondary sort of hyper parathyroidism so low calcium uncles and increased fire fire in a month. If that happens for a chronic period of time, what happens is eventually your calcium level will catch up and increased by quite a bit, and you actually get excessive. Parathyroid hormone's an excessive calcium amounts because of it. So it's a hypocalcemia with hypoparathyroidism as a result of secondary hyperparathyroidism. That's what tertiary is. Brennan. So that's the end of it, um, a post off the feedback ling first, and then I'll answer any questions that anybody has. If you just give me a second, Okay? Sorry, guys, in case you're wondering about my voice, just literally recovered it. Recovering from a bit of a cold at the minute. Let's have a little look, right? Yeah. So let's post up the feedback in first, and then I can answer all the questions that you guys have, so let's have a little look. Sorry. Could you please explain the role and clinical relevance? Tell Stone again. Stroke a mask. Calcitonin is released by the C cells of your firing guns, and in terms of what they do, they help act calcium or force way back into the bone. So when you have a high calcium level, you release more calcitonin, and that helps pack calcium and phosphate back into the bone. But it doesn't have sort of significant physiological effects that you think it does now, where it's sort of clinically relevant is in disease states. So remember what I said in the pipes of fired cancers. You have four types of firewood. Cancer, one is Propenerol to is follicular. Free is medullary and forth on a plastic capillary of follicular Have the best prognosis. Medullary anaplastic have the worst prognosis. Medullary fired cancers or cancers that have rise from the C cells off the firing plan, the same ones that release calcitonin. So when you're looking to diagnose medullary fired cancer in terms of likelihood and figuring out what it is off course, you're gonna be doing some sort of biopsy taking, checking the tissue. Another thing that you could do is measure the calcitonin numbers in there if they're significantly increase. That could suggest that in terms of likely had someone has a medullary firewood. Cancer is that. Does that make sense? I'm us in terms of other clinical relevance. It can also be used alarm mentioned as as a treatment for hypocalcemia. But it's very expensive on Do Again. It's more one of the one's further down the line. It's not one of the most common sort of treatments for hypocalcemia. Does that make sense? I guess Brennan. So let's answer. Next question. How do you differentiate between primary and touch your hypothyroidism on the plus Really difficult to do, to be honest on, So really, in terms of that, it's it's if you see someone with primary hypoparathyroidism. Well, someone with so again George, you're right. I can't pronounce the name of it. I think it's It's It's It's if. Sorry if I'm butchering your name. Um the way to differentiate them. It's really difficult. So it's going to be in terms of the history, because someone who has touched your hypothyroidism will have had been hypocalcemic for a long period of time. So you tried to work, and I had symptoms of reasons to be hypocalcemic for that period of time. And you're hoping that they've had bloods done previously as well, if that's what it makes sense. The other ways is that if someone has primary hypoparathyroidism, then you're still going to look to investigate for the other causes. So even if someone has a tertiary, you're still gonna it's because they have the same blood you're still gonna investigate for all the other part of the stuff that makes sense. So once you've excluded a we other part me stuff and in terms of history, you worked other than maybe have been hypocalcemic for a long period of time because X winds that then you'd probably say they had to rush. We should either has to be through blood evidence in that previously they previously had secondary hyperparathyroidism away. You have not found anything that would cause them to have a partner hyper parathyroidism does that make sense? If Brennan uh, let's see. Yes. Sorry. Mobile. You could tell me how it is less. I'm sorry about apologize for butchering your name. Sorry. Can you just go over albumin bound calcium again? Yep. We can do that. That's what Let's go back if I got it. Thank you. Um, let's go back today of man bound slide that so, um as for so remember what I said? No. All calcium is equal calcium. So 50% of the majority of a normal patient is ionized or free calcium. That's the physiologically important calcium. About 40% of it's bound to calcium, just acting as a sort of reservoir or transport medium. So what I was trying to get about before is is when someone's got a low, total calcium amount. It doesn't necessarily mean that it's going to be clinically important because, say, if someone's got a low albumin amount and the amount of calcium you're bound to, our albumin is his decreased. Your ionized or free calcium levels can be normal. So the way that we look to sort of assess that is fun adjusted calcium. It's what Adjust your calcium levels. Uh, to try. What is basically saying is if someone's hypoalbuminemic can have low albumin amount, what would the calcium be after had a normal albumin amount? So I would have a look online to see what adjusting calcium levels toe up, and I'll have a look of that online for yourself if you can. But all it means is that the adjusted calcium that they do is tell you is what would someone's total calcium be if the albumin levels were normal and indirectly, what it's telling you is is Remember what I said? About half of the calcium is is free or ionized if half the calcium of that, if you feel half that number of there just calcium, that sort of tells you what your free or a nice casting levels are. And if that's normal, that probably tells you you don't need to treat the hypocalcemia as long as they're not symptomatic. And they probably told you that they have normal ionized or free calcium amount. Sorry, it's quite a mouthful, and it's a difficult concept to explain on, but I would have a look at some research articles yourself if you can look at adjusted calcium levels online on what they actually mean. I hope that was a little bit. As for sorry, No, it's quite around about explanation. Um, so I just remember the adjusted calcium is an indirect way of looking at looking at your free or a nice calcium. If that makes sense, it's just adjusting for low albumin amount. That's the reason why did you adjust the calcium's? But what I prefer is is blood gases because it tells you the rectum mount. Anyway. That's why, like I say, use an HD use better that's going to be in intensive tests. Things like easier. Um, okay, I think that's the lost question than fantastic. I'm trying, so I'm going to be making a post. Unfortunately, gastroenterology teachers are consult for the next two days, but I will be posting about when they were going to do them again. And there's obviously going to be another medical Siris. I'm going to try on get those gastroenterology lectures, sort of where you guys as soon as possible. Apologies for that guys, but were spared the respect collectors coming up on a swell is that the dermatology doctors are going to be continuing on those are gonna be the last ones of the medical Siris. And following that on 28th, we've got the surgical Siris to help you with your finals done. So thank you for joining me. Guys. Please complete the feedback on, uh, we'll see you in about two days time. Take, uh oh. So why can't I submit the feedback? Not sure. Hey, I'm going to try again. If I posted the link. Uh huh. Posted the link again. Sorry, I'm not sure it should be working. Fine. And I can see that people have been able to fill out the feedback form, so it should be working fine. Or him. I was just trying to link out again. I'm going to leave it at that. All right. Thank you, guys.