Chiefs’ Inquiry Corner-9/13/22

September 13, 2022

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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Primary hyperparathyroidism typically presents with lab abnormalities including elevated PTH and hypercalcemia.  Hypercalciuria and hypophosphatemia may also be present. Women are often more affected than men and typically present in the seventh decade of life. While some patients present with symptoms of hypercalcemia, many are asymptomatic. As per the Fourth International Workshop for the Management of Asymptomatic Primary Hyperparathyroidism, parathyroidectomy is indicated in asymptomatic patients if any of the following are observed: 1) age less than 50, 2) serum calcium greater than 1 mg/dL above the upper limit of normal, 3) changes in kidney function (GFR < 60ml/min or severe hypercalciuria > 400 mg/d), 4) Bone densitometry T-score less than -2.5, 5) vertebral fractures on imaging, or 6) evidence of occult nephrolithiasis on imaging. It is generally thought that one in three patients with asymptomatic primary hyperparathyroidism will develop an indication for surgery in the following 10-15 years. Thus close follow-up with annual serum calcium and creatinine, in addition to bone mineral density scanning is essential.

References:  Primary Hyperparathyroidism
Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions, repeated twisting movements, and abnormal postures of the trunk, neck, or face. The etiology may be primary (where dystonia is the only clinical sign, i.e., genetic abnormality) or secondary (acquired cause such as a lesion in the brain). Evaluation for dystonia should include a thorough history and examination to ensure secondary causes are ruled out. Specific pharmacotherapy is sparse and is largely focused on symptom relief. If dystonia is focal, it can be managed via botulinum toxin. If generalized, potential treatment options include levodopa, anticholinergics (trihexyphenidyl), and baclofen. Benzodiazepines have also been utilized for potential symptom relief. If dystonia is severe and refractory to medical treatment, intrathecal and surgical therapies such as deep brain stimulation exist. For secondary causes, treatment revolves on treating underlying conditions and withdrawing potential inciting agents.

References: Treatments for Dystonia
 Beta blockers are among the most commonly prescribed medications. Overdose and toxicity are relatively common and may present with bradycardia, hypotension, hypoglycemia, altered mental status, and seizures. Symptoms typically occur within 2-6 hours of ingestion but may be delayed, especially in the case of sotalol which may present 24-72 hours after ingestion. Beyond supportive care, glucagon may be administered for overdose. The mechanism involves the activation of adenylate cyclase, which increases cAMP. This leads to elevations in intracellular calcium which can aid with contractility and improve hemodynamics. It will also increase gluconeogenesis, counteracting the hypoglycemia caused by beta blockers. Data in clinical practice primarily comes from case series and reports. No clinical trials assessing the efficacy of this currently exist.

References: Beta-Blocker Toxicity