Blog

• While all patients with symptomatic primary hyperparathyroidism (PHPT) should consider surgery (95% of patients are usually symptomatic when appropriate history is taken):
  • It is also indicated in some asymptomatic patients (5% of the cases of PHPT):
    • Indications:
      • Age less than 50
      • Kidney disease:
        • GFR less than 60
      • Osteoporosis
      • Serum calcium greater than 1 mg/dl above normal
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393490/

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #PrimaryHyperparathyroidism #CancerSurgeon #EndocrineSurgery #Teacher #Surgeon #HeadandNeckSurgeon #SurgicalOncologist #ParathyroidAdenoma #Hypercalcemia #ElevatedCalciumLevels #Miami #MountSinaiMedicalCenter #MSMC #Mexico #Hialeah

• In primary hyperparathyroidism due to adenomas:
  • The normal feedback on parathyroid hormone production by extracellular calcium seems to be lost:
    • Resulting in a change in the set point
• In primary hyperparathyroidism from parathyroid hyperplasia:
  • An increase in the cell numbers is probably the cause of the change in the set point
• The chronic excessive resorption of calcium from bone caused by excessive parathyroid hormone can result in:
  • Osteopenia
  • In severe cases, this may result in osteitis fibrosa cystica:
    • Which is characterized by subperiosteal resorption of the distal phalanges, tapering of the distal clavicles, salt-and-pepper appearance of the skull, and brown tumors of the long bones
      • This is not commonly seen now
• In addition, the chronically increased excretion of calcium in the urine:
  • Can predispose to the formation of renal stones
• The other symptoms of hyperparathyroidism:
  • Are due to the hypercalcemia itself:
    • And are not specific to hyperparathyroidism
  • These can include:
    • Muscle weakness
    • Fatigue
    • Volume depletion
    • Nausea and vomiting
    • In severe cases, coma and death
  • Neuropsychiatric manifestations are particularly common and may include:
    • Depression
    • Confusion
    • Subtle deficits that are often characterized poorly and may not be noted by the patient (or may be attributed to aging)
  • Increased calcium can increase gastric acid secretion, and persons with hyperparathyroidism:
    • May have a higher prevalence of peptic ulcer disease
  • Rare cases of pancreatitis have also been attributed to hypercalcemia
• A prospective cohort study by Ejlsmark-Svensson et al:
  • Reported that in patients with primary hyperparathyroidism, quality-of-life questionnaire scores were significantly lower:
    • In association with moderate-severe hypercalcemia:
      • Than in relation to mild hypercalcemia:
        • However, quality of life did not seem to be related to the presence of organ-related manifestations of primary hyperparathyroidism, such as osteoporosis, renal calcifications, and renal function impairment
        • This suggests that hypercalcemia is the primary driver of an impaired quality of life

#Arrangoiz #PrimaryHyperparathyroidism #Hyperparathyroidism #Hypercalcemia #ParathyroidSurgeon #ParathyroidExpert #HeadandNeckSurgeon #EndocrineSurgery #MSMC #MountSinaiMedicalCenter #Mexico #Miami

• Postoperative radioactive iodine (RAI) use in ATA intermediate-risk differentiated thyroid cancer (DTC):
  • With stratification into low‑intermediate and high‑intermediate subsets
• Evidence Base Overview:
  • No randomized trials specifically focus on RAI impact in ATA intermediate-risk patients
  • Evidence is primarily retrospective:
    • Using multivariate, propensity-adjusted analyses, registry data (SEER), cohort series, and a few prospective studies
• ATA Intermediate‑Risk Definition:
  • The 2015 ATA guidelines (1) classified patients as intermediate-risk if they exhibit:
    • Microscopic extrathyroidal extension (ETE)
    • Vascular invasion
    • Clinical N1 or > 5 pathologic N1 with nodes < 3 cm
    • Aggressive histotypes (e.g., Hobnail, tall cell, insular)
    • RAI-avid foci outside thyroid bed
    • Multifocal microcarcinoma with ETE and BRAF mutation 
• Within this, it’s helpful to subdivide into (most likely will appear in the new 2025 ATA guidelines):
  • Low-intermediate:
    • A single low-volume risk feature:
      • Microscopic ETE
      • Small-volume N1a
  • High-intermediate:
    • Multiple or higher-risk features, such as:
      • ≥ 5 nodes
      • Vascular invasion
• Observational and Registry Data:
  • SEER Registry Studies (2,3):
    • Showed improved overall survival following RAI in:
      • N1 disease
      • pT3 (or > 4 cm)
      • Aggressive histology 
    • However:
      • Absolute benefit is small in patients < 45 years (~ 1%) vs larger in older patients (~ 4%) (3)
  • Single‑Center Cohorts:
    • Mayo Clinic (4) (20‑year follow-up):
      • Found no impact on outcomes for node-positive with MACIS < 6 
    • One Hong Kong study (5):
      • Showed better lymph node recurrence-free survival post-RAI in:
        • N1b or nodes > 1 cm
• Retrospective Low–Intermediate Series (6) (Italy, 2024):
  • RAI reduced recurrence by 42%:
    • 9.6% vs 15.9% using inverse‑probability regression in patients with ≥ 2 intermediate risk factors 
• Polish Prospective RAI Dose Trial (Arch Med Sci, 2022): (7)
  • Intermediate-risk group receiving 60 vs 100 mCi:
    • Had similar excellent response (~ 85%), low structural recurrence (~ 6.5%), and excellent long-term outcomes 
• Prospective / Clinical Trials:
  • No RCTs isolating intermediate-risk exist:
    • However, the rhTSH + RAI Prep trial included many intermediate-risk patients (n ≈ 307) and found non-inferiority of rhTSH vs withdrawal for RAI effectiveness (8)
• Guideline Position Statements:
  • The 2015 ATA guidelines recommend selective use of RAI in intermediate-risk DTC based on individual risk features, with a weak recommendation and low-quality evidence (1)
  • The 2022 European Thyroid Association / EANM consensus also supports personalized RAI use in this group, prioritizing shared decision-making and individual risk-benefit assessment (9)
• Clinical Take‑Home Points:
  • Selective RAI yields a survival / recurrence benefit:
    • Strongest in older patients or those with > 1 intermediate risk feature
  • Low-intermediate risk (e.g., single small node, microscopic ETE):
    • RAI benefit is less definitive:
      • Consider active surveillance vs low-dose RAI
    • High‑intermediate risk (multi-node, vascular invasion, aggressive histology):
      • More likely to benefit:
        • RAI recommended:
      • Dose considerations:
        • 60 mCi sufficient for intermediate risk (Polish RCT)
      • rhTSH prep is validated
      • Shared decision-making essential, given evidence limitations and QoL trade-offs
• Recommendation Framework:
  • Low‑intermediate (one minor feature, younger age):
    • Discuss omission vs low-dose RAI (e.g., 60 mCi + rhTSH) with surveillance plan
  • High‑intermediate (multi-factor, older age):
    • Offer RAI routinely; evidence supports 60 to 100 mCi
  • Shared consent vital, addressing patient goals, comorbidities, and center’s surveillance capabilities
• References:
  • 1. Haugen BR, et al. 2015 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26(1):1–133.
    
  • 2. Nixon IJ, et al. The impact of RAI on survival in intermediate-risk patients: SEER analysis. Ann Surg Oncol. 2012;19(6):2025–33.
  • 3, Haymart MR, et al. Radioactive iodine in thyroid cancer: SEER-based outcomes. JAMA. 2011;306(7):721–8.
    
  • 4. Mazzaferri EL, et al. Management of differentiated thyroid cancer: Mayo Clinic experience. J Clin Endocrinol Metab. 2001;86(4):1447–63.
  • 5. Lam AK, et al. RAI impact on lymph node recurrence: Hong Kong cohort study. Cancer. 2005;103(5):920–9.
  • 6. Prete A, et al. Benefit of RAI in intermediate-risk DTC patients with multiple features. Endocrine. 2024;84(1):123–131.
  • 7. Piciu D, et al. Prospective evaluation of 60 vs 100 mCi in intermediate-risk thyroid cancer. Arch Med Sci. 2022;18(4):1002–1012.
  • 8. Mallick U, et al. Preparation for RAI: rhTSH vs withdrawal in low- and intermediate-risk patients. Lancet. 2012;379(9825):823–830.
  • 9. Luster M, et al. EANM/ETA consensus on RAI therapy in thyroid cancer. Eur J Nucl Med Mol Imaging. 2022;49(1):13–25.

• Name: IoN – Is Ablative Radioiodine Necessary?
• Type:
  • Multicenter, open-label, non-inferiority RCT across 33 UK cancer centers 
• Enrollment Period:
  • June 2012 to March 2020
• Participants:
  • 504 patients post–total thyroidectomy:
    • R0 resection
• Pathology Stage:
  • pT1 to pT3 (TNM 7 edition):
    • Including pT3a (TNM 8 edition)
  • Nodes:
    • N0, Nx, or N1a
  • Exclusions:
    • pT1a unifocal
    • pN1b
    • M1
    • Aggressive variants 
• Intervention and Follow-Up:
  • Randomization (1:1):
    • RAI Arm:
      • 1.1 GBq (30 mCi) RAI post-surgery
    • No RAI Arm:
      • Surveillance only
  • Preparation:
    • rhTSH used where standard:
      • All received TSH suppression
  • Monitoring:
    • Neck US annually
    • Thyroglobulin (Tg) every 6 months
  • Primary Endpoint:
    • 5-year recurrence-free survival (RFS):
      • Absence of locoregional or distant structural disease or thyroid cancer related death 
  • Statistical Non-Inferiority Margin:
    • 5% absolute difference 
• Stratified Outcomes and Safety:
  • Subgroup analysis:
    • Recurrence was slightly higher for:
      • pT3 / pT3a tumors (9%) vs pT1 to pT2 (3%)
      • N1a nodes had 13% recurrence versus 2% in N0 / Nx 
    • Adverse events:
      • Similar between arms
      • Most common were:
        • Fatigue (~ 25%),
        • Lethargy (~ 14%)
        • Dry mouth (~ 10%)
        • No treatment-related deaths 
• Clinical Implications for Head and Neck Surgeons:
  • RAI omission is safe in patients meeting strict criteria (pT1 to pT2, N0 / Nx, complete thyroidectomy):
    • With no compromise in 5-year RFS
  • Non-inferiority achieved:
    • Difference lies well within prespecified 5% margin
  • Patient-centered benefits:
    • Avoids radiation isolation
    • Reduces side effects
    • Enhances QoL:
      • Especially important for younger patients
  • RAI may still be considered for pT3 / pT3a or N1a cases:
    • Due to higher recurrence observed:
      • Individual multidisciplinary tumor board (MDT) discussion is warranted
  • Supports 2025 Lancet recommendations:
    • Omission of adjuvant RAI is reasonable in selected low-risk DTC patients 
• Final Take-Home Points:
  • IoN validates RAI omission in strictly defined low-risk DTC post-total thyroidectomy:
    • 98% RFS at 5 years without RAI
  • Reinforces a move toward risk-adapted, de-escalated care in line with ATA risk guidelines and emerging global consensus
  • Tailor decision-making in MDT:
    • Offer RAI to > T2 or with nodal involvement:
      • Otherwise, provide informed reassurance and structured surveillance

Health‐related quality of life commonly improves following parathyroidectomy for primary hyperparathyroidism.

https://www.ncbi.nlm.nih.gov/pubmed/30267589

#CheckYourCalcium #JAM2020 American #Arrangoiz #ParathyroidSurgeon #EndocrineSurgery #ParathyroidExpert #HeadandNeckSurgeon #MountSinaiMedicalCenter MSMC #Miami #Mexico

• LIBRETTO‑531:
  • Design & Patient Population:
    • Phase III, global, multicenter, open-label, randomized (2:1) trial (NCT04211337):
      • Comparing selpercatinib (160 mg BID) to physician’s choice of cabozantinib or vandetanib:
        • In MKI-naïve, progressive advanced /metastatic RET-mutant MTC patients 
      • Stratified by RET M918T mutation status and intended control arm MKI
      • Crossover permitted from MKI arm to selpercatinib upon progression
  • Efficacy Results (Interim, ~ 12-months follow-up):
    • Primary endpoint (PFS, RECIST v1.1):
      • Selpercatinib:
        • Median not reached
      • MKI arm:
        • 16.8 months (95% CI, 12.2–25.1); HR 0.28; P<0.001 
      • 12‑month PFS:
        • 86.8% vs 65.7%
    • Secondary endpoint (Treatment Failure-Free Survival – TFFS):
      • Not reached vs 13.9 months in MKI arm; HR 0.25
    • Overall Response Rate (ORR):
      • 69.4% in selpercatinib group vs 38.8% in MKI group 
    • Safety-driven dose modifications:
      • 38.9% with selpercatinib vs 77.3% with MKIs
    • Discontinuations 4.7% vs 26.8% 
• Safety & Patient-Reported Outcomes:
• Common ≥ 25% AEs:
  • Hypertension, edema, dry mouth, fatigue, diarrhea
• Grade 3/4 laboratory abnormalities:
  • Lymphopenia, elevated ALT / AST, electrolyte disturbances
• Patient-reported tolerability (FACT-GP5):
  • Demonstrated robust reliability (ICC 0.80–0.85); high side-effect burden correlated with decreased functioning
• Mechanism of Action:
  • Selpercatinib is a highly selective RET inhibitor, effective against both:
    • RET point mutations (e.g., M918T in MTC)
    • RET fusions (common in papillary thyroid carcinoma and NSCLC)
  • High selectivity translates to less off-target toxicity compared to multikinase inhibitors (vandetanib/cabozantinib), which inhibit VEGFR, MET, etc.
• Guideline Endorsements:
  • NCCN (2024) now includes selpercatinib as a Category 1 first-line option:
    • For RET-mutant, progressive/unresectable MTC, alongside cabozantinib and vandetanib
  • ATA Guidelines:
    • Similarly endorse selective RET inhibitors as preferred agents for RET-driven MTC
  • ESMO / European Consensus:
    • Align with use in RET-mutant MTC post-MKI therapy
• Regulatory Perspective:
  • FDA granted traditional approval on September 27, 2024 for adults and pediatrics ≥ 2 years with advanced / metastatic RET-mutant MTC requirement systemic therapy
  • Earlier accelerated approval received in 2020 for patients ≥ 12 years; expanded to ≥ 2 years with pediatric dosing in May 2024
• Clinical Implications for Head and Neck Oncology Teams:
  • First-line therapy improvement:
    • LIBRETTO‑531 is the first randomized trial demonstrating selpercatinib superiority over MKIs in efficacy and tolerability
    • Reduced surgical urgency:
      • Durable responses may defer or potentially downstage extra-thyroidal or metastatic disease, assisting in surgical planning
    • Multidisciplinary coordination:
      • Shared decision-making essential for selecting candidates, managing MTC lesion status, and monitoring biochemical markers (calcitonin, CEA)
    • Monitoring & sequencing:
      • Be vigilant for long-term tolerability needs, dose adjustments, and resistance (e.g., RET solvent-front mutations); TKIs sequencing should involve endocrine-oncology collaboration
• Recommended References for Further Reading:
  • Primary LIBRETTO‑531 publication: NEJM (PubMed PMID: 37870969) 
  • Preceding phase I/II evidence: Wirth et al., N Engl J Med 2020 (LIBRETTO‑001)
  • NCCN Thyroid Carcinoma Guidelines, v2.2024  .
    FDA approval details for selpercatinib
  • Patient-reported outcomes analysis: Regnault et al., J Patient Rep Outcomes 2024
• Summary for Surgical Experts:
  • Selpercatinib sets a new standard first-line systemic therapy in RET-mutant MTC, delivering superior tumor and nodal responses while maintaining patient quality-of-life
  • Surgeons should integrate molecular profiling early, allowing neoadjuvant-like benefit of targeted therapy before considering resection or resection of metastatic deposits
  • Long-term surgical planning may be increasingly influenced by TKI response and durability

• Clinical Implications for Surgeons and Oncologists:
  • Preoperative:
    • Patients with borderline resectable MTC may benefit from downstaging with selpercatinib
    • Early molecular testing for RET mutations is essential
  • Postoperative:
    • Patients with biochemical persistence (calcitonin / CEA) or structural recurrence can receive selpercatinib earlier
    • More favorable AE profile allows longer-term outpatient management
• References:
  • Wirth LJ, et al. Selpercatinib vs Standard Therapy in RET-Mutant MTC. N Engl J Med. 2023;389(15):1344-1356. PMID: 37870969
    NCCN Guidelines: Thyroid Carcinoma v2.2024. https://www.nccn.org
  • ATA Guidelines Update (Thyroid, 2022): Use of targeted therapy in RET-mutant disease
    FDA Approval Summary: https://www.fda.gov/drugs
  • Drilon A, et al. Targeting RET-driven cancers with selpercatinib. Cancer Discov. 2020. PMID: 3221355

• The Delphi criteria for advanced disease in thyroid cancer:
  • Refer to a consensus-based set of clinical, pathological, and radiological features:
    • Developed by expert panels (often using the Delphi method):
      • To define what constitutes advanced thyroid cancer
  • These criteria help guide decision-making:
    • In terms of treatment strategies, referral to tertiary centers, and inclusion in clinical trials
• While there is no universal single set of “Delphi criteria” adopted globally for thyroid cancer:
  • Multiple Delphi panels have been convened in recent years to create consensus on what features define advanced or aggressive disease
• Below is a synthesis of key features commonly included in such panels and used in high-level consensus guidelines:
  • ATA, NCCN, and expert Delphi studies
• Delphi-Based Criteria for Advanced Thyroid Cancer:
  • Clinical Features:
    • Age > 55 years:
      • For differentiated thyroid cancer (DTC)
    • Rapid tumor growth
    • Hoarseness or vocal cord paralysis
    • Dysphagia or airway compression
    • Distant metastases:
      • Lung, bone, brain
    • Recurrent or persistent disease after initial therapy
  • Pathological Features:
    • High-risk histologies:
      • Poorly differentiated thyroid carcinoma
      • Anaplastic thyroid carcinoma
      • Hürthle cell carcinoma with widely invasive features
      • Tall cell, hobnail, or columnar variants of PTC
      • Extensive vascular invasion
      • Extrathyroidal extension:
        • Especially gross
      • Incomplete resection margins:
        • R2 or R1
  • Radiological Features:
    • Evidence of invasion into adjacent structures::
      • Trachea, esophagus, larynx, recurrent laryngeal nerve, carotid artery
    • Radiographic evidence of unresectability
    • Distant metastases confirmed via CT, MRI, or PET / CT
  • Molecular/Functional Criteria:
    • RAI-refractory disease:
      • Based on functional imaging and response
    • Presence of high-risk mutations:
      • TERT promoter
      • TP53
      • BRAF + TERT
    • High FDG-avidity on PET scan:
      • Often correlates with aggressiveness
  • Biochemical Markers:
    • Rapidly rising thyroglobulin levels post-thyroidectomy and RAI
    • Elevated Tg levels with negative RAI uptake:
      • Suggesting RAI-refractory disease
• Notable Delphi Studies / Consensus Papers:
  • Tuttle RM et al., Memorial Sloan Kettering Cancer Center: Clinical criteria for RAI-refractory DTC
  • American Thyroid Association (ATA) 2015 Guidelines: Use a similar risk stratification model that incorporates many of these features
  • NCCN Guidelines (latest version): Lists features of unresectable, progressive, or symptomatic disease requiring systemic therapy
  • Molecular Oncology Tumor Boards have also developed decision-making algorithms based on Delphi consensus

• After initial parathyroidectomy, reported rates of moderate postoperative hypocalcemia range from 5% to 47%:
  • However, permanent hypoparathyroidism and severe hypocalcemia due to hungry bone syndrome are rare

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #PrimaryHyperparathyroidism #CancerSurgeon #EndocrineSurgery #Teacher #Surgeon #HeadandNeckSurgeon #SurgicalOncologist #ParathyroidAdenoma #Hypercalcemia #ElevatedCalciumLevels #Miami #MountSinaiMedicalCenter #MSMC #Mexico #Hialeah

• Trial Overview – ESTIMABL2 (NCT01837745):
  • Is a French, multicenter, phase III randomized trial investigating the necessity of post-thyroidectomy radioactive iodine (RAI) in patients with low-risk DTC:
    • Defined as intrathyroidal papillary carcinomas ≤ 1 cm (pT1a-m) or 1 to 2 cm (pT1b), with no suspicious lymph nodes on preoperative neck ultrasound (N0 / Nx)
  • All underwent total thyroidectomy (with or without prophylactic central neck dissection) and were randomized at 2 to 5 months post-op to:
    • RAI group:
      • 1.1 GBq (30 mCi) after rhTSH preparation
    • No‑RAI group:
      • Surveillance only 
  • Follow-up Protocol:
    • 3-year endpoint:
      • Thyroglobulin (Tg) and anti-Tg antibodies annually, neck ultrasound in alternating years
  • Event definition:
    • Need for further radioactive iodine or surgery:
      • Due to abnormal uptake, ultrasound changes, Tg rise, or antibody surge
    • Non-inferiority margin:
      • 5% difference in event-free survival 
  • Primary (3-Year) Results:
    • Evaluable patients:
      • 729 (FU: 367; RAI: 362)
      • Events:
        • 18 (4.9%) in surveillance vs 15 (4.1%) in RAI
      • Event-free survival:
        • 95.1% (no RAI) vs 95.9% (RAI)
        • Difference 0.8% (95% CI –3.3% to 1.8%) → non-inferiority confirmed 
  • Secondary interventions (surgery / RAI):
    • 6 (1.6%) vs 9 (2.5%)
• 5-Year Long-Term Outcomes:
  • Evaluable at 5 years:
    • 698 patients
  • Event-free survival:
    • No RAI: 93.2%
    • RAI: 94.8%
      • Difference: 1.6% (90% CI –4.5 to 1.4%)
        • Remains within non-inferiority bounds 
• Quality of response:
  • Surveillance group had higher rates of “excellent response” (83.3% vs 75.6%) and fewer indeterminate results 
• Clinical Implications for Surgeons:
  • Omission of adjuvant RAI in strictly defined ATA low-risk patients (pT1, cN0, complete surgery, normal Tg and US) is safe and effective, even at 5 years
  • Non-inferiority margin of 5% comfortably met at both 3 and 5 years, a robust outcome
  • Superior biochemical and imaging outcomes in the surveillance arm suggest less overdiagnosis and overtreatment
  • Reduces patient burden:
    • Avoids radiation, isolation, and enhances convenience
  • Supports tailored management:
    • RAI can be reserved for cases with unfavorable histology, remnant tissue on US, or rising Tg / antibodies
• Recommendations for Practice:
  • Strict selection is essential:
    • Only patients with pT1 N0 / Nx, complete surgery, and negative post-op US are eligible for RAI omission
  • Omit RAI in these low-risk patients, with follow-up consisting of Tg, TgAb, and periodic neck ultrasound
  • Reserve RAI for patients with adverse features:
    • Aggressive histology
    • Tg rise
    • Suspicious imaging
  • Discuss care pathway in MDT rounds, highlighting QoL gains and similar oncologic outcomes
  • Educate patients:
    • Provide clear rationale and plan for surveillance to avoid anxiety over omitted therapy
• Final Takeaways:
  • The ESTIMABL2 trial delivers strong evidence that surveillance alone post-thyroidectomy is a safe, effective, and patient-centric strategy in carefully selected ATA low-risk DTC patient:
    • Offering similar long-term outcomes to standard RAI treatment, with additional QoL and diagnostic benefits

👉Elevated serum calcium levels have been associated with thiazide diuretic use and need to be differentiated from primary hyperparthyroidism – Dr. Rodrigo Arrangoiz

👉The overall annual age- and sex-adjusted (to 2000 U.S. whites) incidence of hypercalcemia due to thiazide diuretic use was 7.7 (95% CI, 5.9 to 9.5) per 100,000 individuals.

👉The average 24-hour plasma calcium concentrations are increased with thiazide diuretic use, but the mean 24-hour PTH levels remain unchanged in subjects with normal baseline PTH levels and no evidence of hypercalciuria.

👉Thiazides diuretics have several metabolic effects that may contribute to increased calcium levels:

• A decrease in urine calcium excretion is the most likely cause.
• In some cases of diuretic use metabolic alkalosis can occur that could cause an increase in total serum calcium levels through a pH-dependent increase in protein-bound calcium.
• Although plasma 1,25 (OH) vitamin D levels are unchanged, increased intestinal calcium absorption in response to thiazide diurectic use has been noted and could also contribute to an increase in serum calcium.
• One last possible explanation for the elevated serum calcium levels associated with thiazide diuretic use is hemoconcentration associated with diuresis.

👉CheckYourCalcium (realízate un calcio total en sangre).

#CheckYourCalcium #Arrangoiz #ParathyroidExpert #ParathyroidSurgeon #Hiperparatiroidism #Hipercalcemia #CheckYourCalcium #HeadandNeckSurgeon #MountSinaiMedicalCenter #MSMC #Miami #Mexico #Hyperparathyroidism

👉 Para obtener más información sobre el hiperparatiroidismo:

https://s3.amazonaws.com/academia.edu.documents/48239291/Current_Thinking_in_Hyperparathyroidism.pdf?response-content-disposition=attachment%3B%20filename%3DCurrent_Thinking_in_Hyperparathyroidism.pdf&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWOWYYGZ2Y53UL3A%2F20190724%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20190724T015127Z&X-Amz-Expires=3600&X-Amz-SignedHeaders=host&X-Amz-Signature=9633131723dc3e5fa1671838123524ae980c0bfb31e4a92be406b43a103bc355