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PubMed1996

Double-phase Tc-99m MIBI scintigraphy in secondary hyperparathyroidism relapsing after parathyroidectomy and removal of a parathyroid autograft.

A 53-year-old woman with chronic renal failure had secondary hyperparathyroidism relapsing after undergoing a second parathyroidectomy and excision of an autologous parathyroid graft that had been implanted after her first parathyroidectomy. Double-phase scintigraphy with Tc-99m MIBI disclosed pathologic MIBI uptake in the right anterior thorax where the parathyroid transplant had been placed. Histopathologic examination of three nodules excised from this region yielded hyperplastic parathyroid tissue. This case report further illustrates the value of double-phase Tc-99m MIBI scintigraphy in atypical cases of hyperparathyroidism.

Diagnosis, Differential↗
PubMed2005

Parathyroidectomy in the third trimester of pregnancy.

UNLABELLED: The objective of this study was to estimate the incidence of complications when primary hyperparathyroidism (PHPT) is treated by parathyroidectomy in the third trimester of pregnancy. After searching the literature published through/including January 2005, we identified and analyzed 16 cases of PHPT treated surgically after 27 weeks of gestation. Parathyroid adenomas were detected in 81.2% of cases, hyperplasia in 6.3%, and carcinoma in 12.5%. Only one case failed surgical therapy. The postoperative incidence of clinically significant complications from the surgery was as low as 5.9% in fetuses and 0% in mothers. The incidence of clinically significant complications resulting from delayed diagnosis or postponed surgery ranged from 17.6% to 23.5% in fetuses and 18.8% to 25.0% in mothers. Postoperative hypocalcemia was detected in 62.5% of mothers and 17.6% of their newborns. All cases were easily treated with calcium replacement. Preeclampsia was diagnosed in 25% of cases. No clinically significant complications have been reported between 1993 and January 2005. This review suggests that parathyroidectomy performed in the third trimester of pregnancy is effective and has less risk than previously reported. Postponing surgery may be hazardous. Postoperative hypocalcemia is common but easily treated. Hyperparathyroidism should be considered a risk factor for preeclampsia. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to summarize the maternal and fetal complications of a delayed diagnosis and/or postponed surgery, recall that surgery of a parathyroid tumor can be safely performed in the third trimester, and describe pregnancy complications of hyperparathyroidism.

Adenoma↗
PubMed2003

Sestamibi scanning and minimally invasive radioguided parathyroidectomy without intraoperative parathyroid hormone measurement.

OBJECTIVE: To evaluate the results of a large series of patients undergoing minimally invasive radioguided parathyroidectomy (MIRP) in which routine use of the intraoperative parathyroid hormone assay was not used, and to investigate characteristics between patients who had positive preoperative parathyroid scans versus those with negative scans. SUMMARY BACKGROUND DATA: The technique of parathyroidectomy has traditionally involved bilateral exploration of the neck under general endotracheal anesthesia. Parathyroid imaging using technetium-99m sestamibi (MIBI) has evolved and can localize the adenomas in 80% to 90% of patients. The MIRP technique combines parathyroid scintigraphy with a hand-held gamma detector used intraoperatively to guide the surgeon to the adenoma in patients with positive MIBI scans. Central to this technique or other unilateral approaches is a positive MIBI scan. METHODS: One hundred seventy-three patients with primary hyperparathyroidism operated on by a single surgeon between January 1998 and July 2002 were included. One hundred twelve patients underwent the MIRP procedure and by definition had a positive preoperative parathyroid scan. The technique involved injecting 20 mCi MIBI 1 hour before the surgical procedure in patients who preoperatively had positive MIBI imaging. Patients had the choice of general or MAC anesthesia. Using an incision of less than 4 cm, the dissection to the adenoma was guided by the Navigator 11-mm probe. These 112 patients and 4 additional patients who for various reasons did not have the MIRP procedure yet had positive MIBI scans were compared to 57 patients who had clearly negative MIBI parathyroid imaging. RESULTS: Follow-up data were available for 108 of 112 patients who underwent MIRP. No patients had persistent hypercalcemia. The long-term success rate for the MIRP group was 98%. Fifty-two percent of the MIRP procedures were performed using MAC anesthesia. Overall, gland weight and serum PTH were related to the probability of a positive MIBI scan. Multiple logistic regression revealed that females were more likely to exhibit positive scans than were males for any fixed serum PTH level. For females, there was a significant relationship between increasing serum parathyroid hormone and a positive MIBI scan. Conversely, in males, the relationship between scan positivity and serum parathyroid hormone was weaker. CONCLUSIONS: The MIRP technique without routine intraoperative serum parathyroid hormone measurement resulted in an excellent cure rate for primary hyperparathyroidism. As the MIRP technique as well as other techniques for unilateral cervical exploration are predicated on a positive parathyroid scan, the possible effect of gender on the sensitivity of MIBI scintigraphy for the detection of parathyroid adenomas warrants further investigation.

Adenoma↗
PubMed1993

Ultrasonically guided chemical parathyroidectomy in patients with primary hyperparathyroidism: a follow-up study.

OBJECTIVE: We evaluated the long-term results in two different groups of patients with primary hyperparathyroidism treated with ultrasonically guided percutaneous ethanol (96%) injection into parathyroid tumours. DESIGN: A prospective long-term follow-up (more than 6 months). Ethanol (96%) was injected under ultrasonic guidance into biopsy verified solitary parathyroid tumours. Basic treatment included a maximum of three treatments with an interval of about 1 month (group 1) or 1 week (group 2). Dose of ethanol was half the volume of the parathyroid tumour. PATIENTS: Two different groups of patients with only one ultrasonically detected and biopsy verified parathyroid tumour were treated. Group 1 (n = 18) were treated regardless of the severity of the hyperparathyroid disease. Group 2 (n = 14) were selected for treatment either due to severe hypercalcaemic symptoms (n = 3), a high surgical risk (n = 5), or refusal of surgery (n = 6). MEASUREMENTS: The volume of the parathyroid tumours was measured as half the product of maximum length, width, and depth. Blood tests included measurements of ionized calcium, total calcium and PTH. RESULTS: In group 1, 12 of 18 patients (66%) could be followed more than 6 months. Follow-up ranged from 12 to 58 months (median 45 months). A significant decrease (P < 0.001) in serum concentrations of ionized calcium and total calcium was observed. Eight patients (44%) later underwent surgical parathyroidectomy. Injection therapy was regarded as successful in 10 of 18 patients (56%). In group 2, 11 of 14 patients (79%) were followed more than 6 months. Follow-up ranged from 18 to 50 months (median 39 months). A significant decrease (P < 0.001) in serum concentrations of ionized calcium, total calcium and intact PTH (1-84) was observed. Treatment was successful in 11 of 14 patients (79%). Two patients required parathyroid surgery. Re-examination with ultrasound showed a significant reduction in the volume of the treated parathyroid tumours. Fibrosis surrounding the parathyroid tumours was detected in eight of 10 patients who subsequently had operations. One patient from each group had a complication of a unilateral permanent vocal cord paralysis following injection therapy. CONCLUSION: Partial or complete long-term remission of primary hyperparathyroidism can be achieved using ultrasound-guided chemical parathyroidectomy. However, the intervals between treatments should be short and the treatment should be reserved only for patients not fit for surgery.

Adult↗
PubMed1993

Endothelium-derived relaxing factor, hypertension and chronic parathyroidectomy in spontaneously hypertensive and Wistar-Kyoto rats.

1. Parathyroidectomy (PTX) lessens the development of hypertension in young spontaneously hypertensive rats (SHR) and the involved mechanisms remain to be elucidated. We have studied here the aortic vascular reactivity to both norepinephrine (NE) and acetylcholine in 10 week old male PTX SHR and Wistar-Kyoto (WKY) rats. 2. Depolarized (KCl 100 mmol/L) and NE (1 mumol/L or cumulative 10(-9)-10(-5) mol/L) precontracted intact aortic rings from PTX rats show a significant and unexpected increase of maximal contractile responses in normotensive and hypertensive animals. These results are also obtained with low extracellular ionized calcium levels (0.625 and 0.9 mmol/L) similar to PTX ionized plasma calcium. N omega-Nitro-L-arginine methyl ester (L-NAME, 20 mumol/L) potentiates the NE response in SHR and WKY rats, more significantly in control than in PTX animals. 3. In the presence of indomethacin (10 mumol/L) in SHR the potentiating effect of PTX on NE contraction is still observed, ruling out a specific production of vasoconstrictors from the arachidonic cascade by the PTX rat aortic endothelium. 4. After PTX a moderate impairment of acetylcholine relaxant responses is observed in SHR and WKY rat aortas and basal aortic cyclic guanosine 3'-5' monophosphate (cGMP) content is also decreased; nevertheless sodium nitroprusside causes a similar relaxation. Furthermore in L-NAME-treated aortas and in the presence of L-arginine (100 mumol/L), acetylcholine (1 mumol/L) produces a significantly less pronounced relaxation in PTX rats. 5. In conclusion, the enhancement of NE contractile response in PTX rat aortas is not linked to the strain but probably related to a decrease in endothelial nitric oxide (NO) release or activity. Enhancement of force generation that we describe does not directly participate in the attenuated hypertension observed in SHR after parathyroidectomy.

Acetylcholine↗
PubMed1994

Characterization of endothelium-derived relaxing factor involvement in the potentiating effect of parathyroidectomy on norepinephrine-induced rat aortic contraction.

Previous results have shown that the contractile response to norepinephrine (NE) was enhanced in isolated aortae from SHR and normotensive Wistar parathyroidectomized rats. In this work we sought to characterize the contribution of endothelium-derived relaxing factor (EDRF) release to this effect which is not linked to hypertension. Parathyroidectomy (PTX) was performed by surgery on 5 week-old male Wistar rats. Five weeks later intact (E+) and rubbed (E-) aortic rings were mounted in an organ chamber for isometric tension recording. KCl-induced contractions were potentiated in PTX E+ aortae compared to sham operated (SO), (P < 0.05), but not in denuded E- aortae. Similarly NE (1 nM- 10 microM) induced a potentiated contractile response in PTX E+ (P < 0.01), but not in PTX E- rings; nevertheless the sensitivity did not change. After removal of endothelium, the expected enhanced contraction and sensitivity observed in SO rats was not present in PTX. The NO synthase inhibitor L-NAME (20 microM), enhanced sensitivity to NE in SO but not in PTX E+ aortic rings. In addition, hemoglobin (Hb, 10 microM) enhanced NE contraction in SO (P < 0.01) aortic rings, but to a lesser extent in PTX rat aortae. Moreover, in the presence of L-NAME or Hb, SO and PTX aortae displayed a similar contraction. Superoxide dismutase (SOD, 150 U/ml) diminished the NE contraction since NO was protected from degradation but the difference was still present between SO and PTX rat aortae, ruling out the possible implication of superoxide anions in the hyperreactivity of PTX aortae. On the other hand, A23187, which induces EDRF release, reduced the level of NE contraction as expected, but suppressed the PTX enhancing effect and in calcium-free solution the enhancement of contraction after PTX was not observed. These experiments extend to the rat the observations previously obtained in rabbit aorta: extracellular calcium is a major determining factor in NO production. Acetylcholine and A23187 (cumulative doses) produced an endothelium-dependent relaxation which was not significantly modified in NE-pre-contracted PTX aortae compared to SO aortae. L-arginine (100 microM), reversed the L-NAME inhibitory effect and induced an attenuated endothelium-dependent relaxation in PTX vessels (P < 0.01). In conclusion, in rat isolated aortae the enhancing effect of parathyroidectomy on norepinephrine and KCl contractions is due to a diminished endothelial nitric oxide production. This might arise via a decrease of the constitutive NO synthase activity in an extracellular calcium-dependent manner.

Acetylcholine↗
PubMedDate not supplied

Complete resorption of massive soft tissue calcification in a hemodialysis patient after parathyroidectomy.

Massive soft tissue calcification involving the abdomen of a dialysis patient is described. As the result of severe secondary hyperparathyroidism associated with intensive calcifications, the patient was disabled and confined to a wheelchair. Following parathyroidectomy, soft tissue calcifications resolved remarkably, symptoms were relieved and the patient was able to walk. Our patient presented an unusual site of soft tissue calcification in secondary hyperparathyroidism and showed an example of complete resorption of soft tissue calcification after parathyroidectomy.

Abdomen↗
PubMed1992

Exacerbation of latent heart failure by mild hypocalcemia after parathyroidectomy in a long-term hemodialysis patient.

A 60-year-old uremic patient treated with hemodialysis for 13 years developed acute hypotension during hemodialysis and overt heart failure subsequently in a period of relatively mild hypocalcemia after parathyroidectomy. Blood pressure during hemodialysis was maintained by continuous calcium infusion alone. Cardiomegaly was improved by normalization of serum calcium. The cardiac complication is considered to be exacerbation of the underlying myocardial dysfunction by the acute decline of serum calcium which might be a feature of the 'hungry bone' syndrome. Latent myocardial dysfunction might be exacerbated by only mild hypocalcemia after parathyroidectomy in long-term hemodialysis patients.

Heart Failure↗
PubMed1995

Increased bone mineral density after parathyroidectomy in primary hyperparathyroidism.

Skeletal involvement in primary hyperparathyroidism is characterized by preferential loss of cortical bone, whereas cancellous bone is relatively spared. Little data are available concerning changes in bone density, particularly at sites containing more cancellous bone, after successful parathyroidectomy. Most patients with primary hyperparathyroidism are asymptomatic, but approximately 50% meet one or more criteria for surgery. In a prospective study of 34 patients who met one or more such criteria, bone density rose at all skeletal sites (lumbar spine, femoral neck, and the radius) in the 4 yr after surgery. The lumbar spine, with most cancellous bone, showed a rapid (mean +/- SE, yr 1, 8.2 +/- 2.0%; P < 0.005) and sustained (yr 4, 12.8 +/- 2.8%; P < 0.001) rise. Post-menopausal patients were similar (by yr 4, 12.5 +/- 2.7%; P < 0.005). At the femoral neck, with intermediate cancellous and cortical composition, a similar increase was noted (12.7 +/- 3.8% by yr 4; P < 0.01). The distal radius, containing mostly cortical bone, rose modestly (4.0 +/- 1.5% by yr 3; P < 0.05), except in patients with lowest preoperative bone density, where the increase was marked (12.3 +/- 2.6% by yr 3; P < 0.05). In patients meeting surgical guidelines, parathyroidectomy is associated with improved bone mineral density.

Adult↗
PubMed2003

Marked improvement of left ventricular function after parathyroidectomy in a hemodialysis patient with secondary hyperparathyroidism and left ventricular dysfunction.

A 52-year-old woman, a hemodialysis patient, was admitted because of exertional dyspnea. Echocardiography showed left ventricular (LV) dilatation and reduced contraction. Coronary angiography showed no fixed stenosis. She had elevated levels of parathyroid hormone (PTH) as a result of secondary hyperparathyroidism with advanced renal failure. After parathyroidectomy, marked improvement of LV function following immediate decrease of blood levels of PTH was observed. It is suggested that PTH might have a significant role in the pathogenesis of LV dysfunction and that parathyroidectomy might be effective as a therapy for heart failure in some patients with secondary hyperparathyroidism and LV dysfunction.

Electrocardiography↗
PubMed2006

Persistent hypercalcemia after parathyroidectomy in an adolescent and effect of treatment with cinacalcet HCl.

BACKGROUND: Hyperparathyroidism is uncommon in adolescence and is more likely to persist after parathyroidectomy than in adults. Cinacalcet HCl is a new calcimimetic that has been used successfully for the treatment of primary and secondary hyperparathyroidism in adults, but its use in adolescents has not been reported. CASE: A 16 year-old male presented with hypercalcemia that had persisted for 1.5 years after parathyroidectomy for primary hyperparathyroidism. Parathyroid hormone (PTH) concentrations were nonsupressed despite a mean (SD) serum calcium concentration of 2.82 (0.06) mmol/L. Treatment with cinacalcet HCl was initiated and a pharmacodynamic profile was obtained for serum calcium, phosphorus, and PTH. Cinacalcet HCl normalized serum calcium. The changes in PTH were assay dependent. ISSUES: We use this case conference to review the evaluation of hypercalcemia in adolescents, examine the changes in relevant laboratory results during treatment with cinacalcet HCl, and discuss differences among assays for PTH. CONCLUSIONS: Interpretation of PTH results in patients treated with cinacalcet HCl requires consideration of the pharmacodynamic effects of the drug and the nature of the PTH assay.

Adolescent↗
PubMed1993

[Seven patients with hyperparathyroid crisis: emphasis on prompt parathyroidectomy].

Although hyperparathyroid crisis is rare, the management of this disease remains controversial. We analyzed the clinicopathological features and treatment outcome of this disease to evaluate the significance of prompt parathyroidectomy. Seven patients with an episode of hyperparathyroid crisis who consisted of 2.3% of all surgical patients of primary hyperparathyroidism were treated from 1981 to 1992 at the Department of Endocrine Surgery, Tokyo Women's Medical College. They all showed grave hypercalcemia greater than 15mg/dl, renal dysfunction and gastrointestinal toxicity. Their ages ranged between 33 and 75 years (mean age 49.7 years); two patients were men and five were women. Six patients had an adenoma, and only one had a carcinoma. The weights of the parathyroid tumors ranged between 3.5g and 11g, and ultrasonography disclosed an enlarged parathyroid gland in all patients. All of the seven patients underwent prolonged medical treatment (mean of durations 52 days), but four of them remained with hypercalcemia greater than 15mg/dl. On the other hand, the serum calcium levels of all patients returned to normal within five days after their operations without any surgical complication. Therefore, we recommend prompt parathyroidectomy for hyperparathyroid crisis, since medical treatment requires a prolonged clinical course and sometimes fails to control grave hypercalcemia.

Adenoma↗
PubMed1994

Insulin sensitivity and glycemic control before and after parathyroidectomy in a diabetic patient with familial multiple endocrine neoplasia type 1.

We treated a diabetic patient with familial multiple endocrine neoplasia type 1 (MEN 1) who had undergone total pancreatoduodenectomy. The patient received insulin and showed signs of symptomatic primary hyperparathyroidism (PHPT). The insulin requirement to control blood glucose before and after parathyroidectomy was compared by using an artificial pancreas. The insulin infusion rate during the day and at night was reduced to about one-third and half, respectively, after parathyroidectomy with autotransplantation of parathyroid tissues into the forearm. The daily insulin dose was reduced from 36 units to 14 units 2 weeks after surgery, and glycemic control showed further improvement 2 months after surgery with the same dose of insulin for up to 6 months. These observations suggest that insulin sensitivity increases after surgical correction of PHPT.

Adult↗
PubMed2004

Development of proximal calciphylaxis with penile involvement after parathyroidectomy in a patient on hemodialysis.

Elevated parathyroid hormone (PTH) levels and hyperphosphatemia are thought to be associated with the development of calciphylaxis. We report a patient on hemodialysis who developed proximal calciphylaxis with consistently low PTH levels after parathyroidectomy. A 31-year-old man was admitted to our hospital because of abdominal skin ulcerations. Calciphylaxis spread to the penis, and simultaneous progressive lung calcification was evident on chest X-ray, suggestive of pulmonary calciphylaxis on 99mTc-methylene disphosphonate scintigraphy. The patient died of respiratory failure despite intensive treatment including hyperbaric oxygen therapy. This is the first report of a patient on hemodialysis who developed calciphylaxis involving the penis after parathyroidectomy.

Adult↗
PubMed1996

Five to 10 years follow-up after total parathyroidectomy and autotransplantation of parathyroid tissue: evaluation of parathyroid function by use of ischaemic blockade manoeuvre.

The aim of the present study was to assess the long-term function of autotransplanted parathyroid tissue in patients with chronic renal disease. We examined the medical records of a consecutive series of 21 patients with chronic renal failure, who had undergone total parathyroidectomy with autotransplantation. During the time of follow-up, on average 79 months, one patient developed graft-dependent recurrent hyperparathyroidism and one patient suffered from persistent hypoparathyroidism. Nine of the patients were available for a clinical study. In these patients we measured the plasma concentration of intact PTH in blood from the arm contralateral to the graft-bearing arm at rest and during a short-lasting ischaemic blockade of the graft site from the circulating blood. At rest all nine patients had parathyroid hormone (PTH) values within the normal range. The ischaemic blockade produced a marked reduction in the plasma concentration of intact PTH in eight of the patients indicating well functioning autografts. Prior to the examination the patient with recurrent hyperparathyroidism had undergone resection of the autograft. In this patient, ischaemia of the former graft site did not cause any change in the concentration of PTH indicating normally functioning residual parathyroid tissue in the neck. Thus, the ischaemic blockade manoeuvre seems suitable for the assessment of autografted parathyroid tissue. Our results indicate that total parathyroidectomy with autotransplantation provides a rational alternative to the surgical treatment of secondary hyperparathyroidism.

Adult↗
PubMed2003

Cardiac and pulmonary calcification in a hemodialysis patient: partial regression 4 years after parathyroidectomy.

AIMS: The reversibility of extraskeletal calcifications in dialysis patients is an important and unresolved issue. Although periarticular calcifications have been shown to be reversible, little data are available on vascular or parenchymal calcifications. CASE HISTORY: A patient on maintenance hemodialysis with severe hyperparathyroidism, hypercalcemia and hyperphosphatemia was admitted to undergo parathyroidectomy. A preoperative total body bone scintigraphy was performed to better evaluate a lytic lesion in the pelvis, the histology of which proved to be a "brown tumor". The scan showed the typical findings of renal osteodystrophy, but also a diffuse extra-skeletal uptake of bone tracer in the lungs, kidneys, femoral arteries and myocardium. After surgery, good control of serum calcium, phosphate (Ca x P product < 50 mg2/dl2) and PTH levels was maintained during 4 years of follow-up. Bone scans were repeated after 2 and 4 years, showing marked improvement of periarticular uptake at the ends of long bones. Extraosseous calcium deposition was still markedly evident, but progressively decreased (at 4 years: heart -36%, lungs -18%). CONCLUSION: In this dialysis patient, extraskeletal calcification of visceral organs (particularly in the heart and the lungs) due to prolonged hypercalcemia and hyperphosphatemia was partially reversible by parathyroidectomy followed by good long-term control of serum phosphate and calcium.

Adult↗
PubMed2006

Reversible hypocalcemic heart failure with T wave alternans and increased QTc dispersion in a patient with chronic renal failure after parathyroidectomy.

Despite the crucial role of calcium in myocardial contractility, hypocalcemia has very rarely been reported as a reversible cause of heart failure. In this article, we describe a case of a 51-year-old woman with advanced stages of chronic renal failure after parathyroidectomy who exhibited congestive heart failure, severe hypocalcemia, hypomagnesemia and hypokalemia. Severe hypocalcemia resulted from discontinuation of taking calcium supplements after parathyroidectomy and from reduced 1.25(OH)2D3 synthesis by damaged kidneys. The patient presented with reduced left ventricular ejection fraction (EF) and ECG abnormalities (T wave alternans and increased QTc dispersion), both of which improved after correction of serum calcium levels. Her serum levels of total calcium corrected for serum albumin, but not serum levels of magnesium or potassium, positively and negatively correlated with EF and QTc dispersion, respectively. In the present case, both heart failure and the ECG abnormalities are directly associated with hypocalcemia.

Calcium↗
PubMed1992

[Clinical study of total parathyroidectomy and autotransplantation for secondary hyperparathyroidism].

From April 1983 to September 1991 total parathyroidectomy (PTX) and parathyroid autotransplantation were carried out in 27 patients for secondary hyperparathyroidism. Of these patients, 13 were males and 14 were females. Their average age was 43 years old and their mean duration of dialysis was 126.4 months. As preoperative clinical symptoms, bone pain was observed in 19 cases, joint pain in 18, decrease of height in 7, pruritus in 3, muscle pain in 2, red eyes in 2 and others in 2. As roentgenographic findings, subperiosteal bone resorption and skull-salt and pepper were demonstrated in 26 cases, rugger jersey spine in 15, soft tissue calcification in 11, and pathological fractures in 4. Four parathyroid glands were removed in 23 cases, three glands in 4. Serum calcium level decreased remarkably within 24 hours after parathyroidectomy in all cases. The average total weight of parathyroid glands was 4.48 g. The preoperative diagnostic accuracy of echogram was 94% and that of CT scan was 90%. The clinical improvement after PTX was excellent in 12 cases and good in 11. The roentgenographic improvement of skull and/or finger bone more than one year after PTX was excellent in 11 cases and good in 11. Judging from histopathological findings of the bone, the clinical and roentgenographic improvement was observed better in the osteitis fibrosa group than in mild group. A significant correlation was found between the level of preoperative c-PTH and the weight of resected parathyroid glands. The level of preoperative ALP correlated with intact-PTH and was higher in the osteitis fibrosa group than in the mild group.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗