Kurt A. Kennel

Vitamin D deficiency in adults: when to test and how to treat.

Recent evidence for the nonskeletal effects of vitamin D, coupled with recognition that vitamin D deficiency is common, has revived interest in this hormone. Vitamin D is produced by skin exposed to ultraviolet B radiation or obtained from dietary sources, including supplements. Persons commonly at risk for vitamin D deficiency include those with inadequate sun exposure, limited oral intake, or impaired intestinal absorption. Vitamin D adequacy is best determined by measurement of the 25-hydroxyvitamin D concentration in the blood. Average daily vitamin D intake in the population at large and current dietary reference intake values are often inadequate to maintain optimal vitamin D levels. Clinicians may recommend supplementation but be unsure how to choose the optimal dose and type of vitamin D and how to use testing to monitor therapy. This review outlines strategies to prevent, diagnose, and treat vitamin D deficiency in adults.

Adverse Effects of Bisphosphonates: Implications for Osteoporosis Management

Bisphosphonates are widely prescribed and highly effective at limiting the bone loss that occurs in many disorders characterized by increased osteoclast-mediated bone resorption, including senile osteoporosis in both men and women, glucocorticoid-associated osteoporosis, and malignancies metastatic to bone. Although they are generally well tolerated, potential adverse effects may limit bisphosphonate use in some patients. Optimal use of bisphosphonates for osteoporosis requires adequate calcium and vitamin D intake before and during therapy. The World Health Organization fracture risk assessment algorithm is currently available to determine absolute fracture risk in patients with low bone mass and is a useful tool for clinicians in identifying patients most likely to benefit from pharmacological intervention to limit fracture risk. This fracture risk estimate may facilitate shared decision making, especially when patients are wary of the rare but serious adverse effects that have recently been described for this class of drugs.

Bisphosphonates for the prevention and treatment of osteoporosis

Osteoporosis is a systemic skeletal disorder characterized by bone loss, which leads to impaired bone strength and an increased risk of fractures. Two million fractures are attributed to osteoporosis annually in the United States and they are associated with serious morbidity and mortality. Bisphosphonates reduce the risk of fracture by suppressing bone resorption and increasing bone strength, and they have been widely used for the prevention and treatment of osteoporosis. However, the use of these drugs for the management of osteoporosis remains a clinical challenge. There are several important considerations including appropriate patient selection, pretreatment evaluation, potential adverse effects, patient preferences, and adherence. This review will discuss the evidence informing the clinical strategy for using bisphosphonates in patients with osteoporosis and those at high risk of fracture, focusing on the benefits and risks of treatment. We will also consider issues related to the monitoring and duration of treatment.

Vitamin D in the cancer patient

Purpose of reviewTo briefly review recent work within the vitamin D and cancer field, whereas also providing context relating how these findings may impact clinical care and future research efforts. Recent findingsVitamin D has now been convincingly shown both in vitro and in preclinical animal models to alter the differentiation, proliferation, and apoptosis of cancer cells. Whether vitamin D prevents cancer in humans or limits cancer progression, however, remain open questions. Epidemiologic and observational data relating circulating 25(OH)D levels and cancer risk suggest an inverse relationship for most cancers including breast, colorectal, leukemia and lymphoma, and prostate, although for each malignancy there also exist studies that have failed to demonstrate such an inverse relationship. Likewise, a more recent report failed to confirm a previously reported association of increased pancreatic cancer risk in patients with higher 25(OH)D levels. A large prospective study in which patients aged at least 50 years receive 2000 IU vitamin D3 daily for 5 years, with cancer as a primary endpoint, has recently been launched. SummaryAlthough much effort has attempted to delineate a causal relationship between vitamin D and a wide array of human cancers, we await large-scale randomized controlled trial data for definitive answers.

SELECTION OF ENDOCRINOLOGY SUBSPECIALTY TRAINEES: WHICH APPLICANT CHARACTERISTICS ARE ASSOCIATED WITH PERFORMANCE DURING FELLOWSHIP TRAINING?

OBJECTIVE To determine which residency characteristics are associated with performance during endocrinology fellowship training as measured by competency-based faculty evaluation scores and faculty global ratings of trainee performance. METHODS We performed a retrospective review of interview applications from endocrinology fellows who graduated from a single academic institution between 2006 and 2013. Performance measures included competency-based faculty evaluation scores and faculty global ratings. The association between applicant characteristics and measures of performance during fellowship was examined by linear regression. RESULTS The presence of a laudatory comparative statement in the residency program directors letter of recommendation (LoR) or experience as a chief resident was significantly associated with competency-based faculty evaluation scores (β = 0.22, P = .001; and β = 0.24, P = .009, respectively) and faculty global ratings (β = 0.85, P = .006; and β = 0.96, P = .015, respectively). CONCLUSION The presence of a laudatory comparative statement in the residency program directors LoR or experience as a chief resident were significantly associated with overall performance during subspecialty fellowship training. Future studies are needed in other cohorts to determine the broader implications of these findings in the application and selection process.

THE USE OF VITAMINS AND MINERALS IN SKELETAL HEALTH: AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND THE AMERICAN COLLEGE OF ENDOCRINOLOGY (AACE/ACE) POSITION STATEMENT

ABBREVIATIONS 25(OH)D = 25-hydroxyvitamin D; BMD = bone mineral density; CV = cardiovascular; GI = gastrointestinal; IOM = Institute of Medicine; PTH = parathyroid hormone; RCT = randomized controlled trial; αTF = α-tocopherol; ucOC = undercarboxylated osteocalcin; VKA = vitamin K antagonist; WHI = Womens Health Initiative.

Methodology of a multispecialty outpatient Obesity Treatment Research Program

Despite the large number of U.S. adults who overweight or obese, few providers have ready access to comprehensive lifestyle interventions, the cornerstone of medical obesity management. Our goal was to establish a research infrastructure embedded in a comprehensive lifestyle intervention treatment for obesity. The Obesity Treatment Research Program (OTRP) is a multi-specialty project at Mayo Clinic in Rochester, Minnesota designed to provide a high intensity, year-long, comprehensive lifestyle obesity treatment. The program includes a nutritional intervention designed to reduce energy intake, a physical activity program and a cognitive behavioral approach to increase the likelihood of long-term adherence. The behavioral intervention template incorporated the Diabetes Prevention Program and the Look AHEAD trial materials. The OTRP is consistent with national recommendations for the management of overweight and obesity in adults, but with embedded features designed to identify patient characteristics that might help predict outcomes, assure long-term follow up and support various research initiatives. Our goal was to develop approaches to understand whether there are patient characteristics that predict treatment outcomes.

Persistent hyperparathyroidism due to ectopic parathyroid gland

A 51-year-old woman was evaluated for persistent hypercalcemia after parathyroid surgery. She was diagnosed with primary hyperparathyroidism at an outside institution one year prior with unrevealing localizing images. She underwent bilateral neck exploration with left superior, left inferior and right inferior parathyroidectomy as well as right superior parathyroidectomy with auto-transplantation into the left neck. The serum parathyroid hormone (PTH) levels were persistently elevated intra-operatively and she continued to have biochemical primary hyperparathyroidism post-operatively. Her laboratory evaluation at Mayo Clinic was consistent with persistent primary hyper-parathyroidism (supplemental table). Parathyroid sestamibi imaging with single-photon emission computed tomography (SPECT) showed ectopic sestamibi uptake in the lower right mid chest without discordance in the neck on planar images. SPECT images confirmed an approximately 1 cm soft tissue nodule in the right para-cardiac fat superiorly and just anterior and to the right of the lower superior vena cava and above the right atrial junction, consistent with a solitary parathyroid gland in the anterior mediastinum. (Fig. 1) She underwent a resection of intrathymic ectopic parathyroid gland and parathyroid auto-transplantation to the

Authors’ reply to Minisola and colleagues, Kausar, and Sharvill

We appreciate Minisola and colleagues’ comments and confirm that bisphosphonates may be considered in patients with monoclonal gammopathy of undetermined significance, which affects bone health.1 2 An oral solution of alendronate sodium is available in the US in a 70 mg/75 mL formulation. We were unaware of the alendronic acid solution 70 mg/100 mL available in the UK. We could find no comparisons of the tolerability of these products with other oral bisphosphonate formulations but note the high prevalence of baseline gastrointestinal problems in those who might be prescribed bisphosphonates.3 We wrote “Before starting bisphosphonates it is necessary to assess for and correct hypocalcemia and vitamin D deficiency” with Bertoldo and colleagues’ data in mind but appreciate the additional attention Minisola and colleagues bring to this matter.4 These respondents allude to “treatment failure” and …

The Patient With Medically Complicated Obesity

Obesity is a worldwide epidemic as evidenced by the number of overweight and obese individuals and the magnitude of their obesity (1). At the end of the last millennium, nearly one-third of all adults in the United States were classified as obese (2). The prevalence of severe obesity (body mass index [BMI] >40 kg/m2), which is associated with the highest health risk, doubled between 1990 and 2000 (3). Given the prevalence of overweight among children and teens aged 6–19 yr tripled between 1980 and 2000 (4) and that overweight children often become overweight adults (5) the problem is likely to persist for some time (6). Obesity in adults is associated with excess morbidity most notably excess risk of coronary heart disease, hypertension, hyperlipidemia, diabetes, gallbladder disease, certain cancers, and osteoarthritis (7,8). Beyond morbidity, strong evidence links obesity to increased mortality. For example, young men and women with severe obesity may lose as much as 13 and 8 yr of life, respectively, as compared to peers of a healthy weight (9).