[The hungry bone syndrome--an update]

The Hungry Bone Syndrome (HBS) represents an important cause of prolonged hypocalcemia after parathyreoidectomy (PTX) due to primary, secondary or tertiary hyperparathyreoidism. The sudden postoperative withdrawal of parathyroid hormone (PTH) induces a stop in osteoclastic bone resorption without affecting the osteoblastic activity. Consequently, an increased bone uptake of calcium, phosphate and magnesium is observed. Risk factors for the development of HBS include: Large parathyroid adenomas, age > 60 years, high preoperative levels of serum PTH, calcium and alkaline phosphatase. In these patients a careful monitoring of clinical symptoms of hypocalcemia as well as the laboratory parameters are warranted during the immediate postoperative period. Treatment with oral calcium, and especially in patients with renal failure, additionally active vitamin D should be started as soon as possible after PTX. In severe cases of HBS, the administration of intravenous calcium is necessary. The duration of therapy is governed by symptoms and severity of the HBS and may last for up to 12 or more months. While prevention of HBS in high risk patients includes preoperative Vitamin D, the role of bisphosphonates has yet to be established.

[Treatment of hypertension in type 2 diabetes mellitus--2002 update]

Arterial hypertension and diabetes are potent independent risk factors for cardiovascular, cerebral, renal and peripheral (atherosclerotic) vascular disease. The prevalence of hypertension in diabetic individuals is approximately twice that in the non-diabetic population. Diabetic individuals with hypertension have a greater risk of macrovascular and microvascular disease than normotensive diabetic individuals. Hypertension is a major contributor to morbidity and mortality in diabetes, and should be recognized and treated early. Type 2 diabetes and hypertension share certain risk factors such as overweight, visceral obesity, and possibly insulin resistance. Life-style modifications (weight reduction, exercise, limitation of daily alcohol intake, stop smoking) are the foundation of hypertension and diabetes management as the definitive treatment or adjunctive to pharmacological therapy. Additional pharmacological therapy should be initiated when life-style modifications are unsuccessful or hypertension is too severe at the time of diagnosis. All classes of antihypertensive drugs are effective in controlling blood pressure in diabetic patients. For single-agent therapy, ACE-inhibitors, angiotensin receptor blocker, beta-blockers, and diuretics can be recommended. Because of concerns about the lower effectiveness of calcium channel blockers in decreasing coronary events and heart failure and in reducing progression of renal disease in diabetes, it is recommended to use these agents as second-line drugs for patients who cannot tolerate the other preferred classes or who require additional agents to achieve the target blood pressure. The choice depends on the patients specific treatment indications since each of these drugs have potential advantages and disadvantages. In patients with microalbuminuria or clinical nephropathy, both ACE-inhibitors and angiotensin receptor blockers are considered first line therapy for the prevention of and progression of nephropathy. Since treatment is usually life-long, cost effectiveness should be included in treatment evaluation.

Effects of diabetes mellitus on periodontal and peri-implant conditions: update on associations and risks

OBJECTIVES: To review the evidence for the association between diabetes and periodontal and peri-implant conditions and the impact of periodontal therapy in subjects with diabetes. MATERIAL AND METHODS: A search of MEDLINE-PubMed was performed up to and including December 2007. The search was limited to clinical studies published in English. Publications on animal studies were excluded. The selection criteria included all levels of available evidence. RESULTS: Evidence on the association between diabetes and periodontitis supports the concept of increased severity but not extent of periodontitis in subjects with poorly controlled diabetes. Subjects with controlled diabetes do not show an increase in extent and severity of periodontitis. Periodontitis is associated with poor glycaemic control and diabetes-related complications. It is inconclusive that periodontal therapy with or without the use of antibiotics results in improvements of glycaemic control and of markers of systemic inflammation. Evidence is lacking to indicate that implant therapy in subjects with diabetes yields long-term outcomes comparable with those of non-diabetic subjects. CONCLUSIONS: Poorly controlled diabetes may be considered a risk factor for increased severity of periodontitis. The effects of periodontal therapy on glycaemic control and systemic inflammation is not proven beyond doubt and need to be confirmed in large-scale randomized-controlled clinical trials.

Cardiovascular disease and periodontitis: an update on the associations and risk

BACKGROUND: Associations between periodontitis and cardiovascular diseases have been recognized. MATERIAL AND METHODS: New literature since the last European Workshop on Periodontology has been reviewed. RESULTS: The lack of reliable epidemiological data on disease prevalence makes an assessment of the associations and risks between periodontitis and cardiovascular diseases difficult. Two recent meta-analysis reports have identified associations between periodontitis and cardiovascular diseases (odds ratios: 1.1-2.2). Different surrogate markers for both disease entities, including serum biomarkers, have been investigated. Brachial artery flow-mediated dilatation, and carotid intima media thickness have in some studies been linked to periodontitis. Studies are needed to confirm early results of improvements of such surrogate markers following periodontal therapy. While intensive periodontal therapy may enhance inflammatory responses and impair vascular functions, studies are needed to assess the outcome of periodontal therapies in subjects with confirmed cardiovascular conditions. Tooth eradication may also reduce the systemic inflammatory burden of individuals with severe periodontitis. The role of confounders remain unclear. CONCLUSIONS: Periodontitis may contribute to cardiovascular disease and stroke in susceptible subjects. Properly powered longitudinal case-control and intervention trials are needed to identify how periodontitis and periodontal interventions may have an impact on cardiovascular diseases.

Update on safety during pregnancy of biological agents and some immunosuppressive anti-rheumatic drugs

A consensus paper concerning the interaction of anti-rheumatic drugs and reproduction was published in 2006, representing data collected during the year 2004 and 2005. Because of an increasing use of biological agents in women of fertile age, the information was updated for the years 2006 and 2007. Experts disagree whether TNF-inhibitors should be stopped as soon as pregnancy is recognized or may be continued throughout pregnancy. Pregnancy experience with abatacept and rituximab is still too limited to prove their safety for the developing fetus. They must be withdrawn before a planned pregnancy. LEF has not been proven to be a human teratogen. Registries of transplant recipients have shown that cyclosporin (CsA) and tacrolimus do not increase the rate of congenital anomalies, whereas mycophenolate mofetil (MMF) clearly carries a risk for congenital anomalies. Prophylactic withdrawal of drugs before pregnancy is mandatory for abatacept, rituximab, LEF and MMF. Data remain insufficient for gonadal toxicity of immunosuppressive drugs in men and for excretion of these drugs in human breast milk.

Update on restless legs

Restless Legs Syndrome (RLS) has become a well known disorder in the medical community in Switzerland within the last ten years, particularly since the official introduction of dopaminergic drugs as first line treatment. However, even today, in some patients a correct diagnosis is delayed, preventing specific therapy and prolonging discomfort or even painful symptoms over years. It is important to recognise the syndrome of restless legs, and it is essential to search systematically for treatable causes and to treat separately frequent comorbidities such as depression or polyneuropathy. It is important to understand the impact of this progressive disease on the personal and professional life of the patient. In addition, therapy resistance and severe side effects, particularly augmentation and fibrosis, can be minimised by understanding important details of treatment and by an optimal follow up of such patients. Research on the genetic basis of RLS, on purported pathogenetic mechanisms in the dopaminergic and other neurotransmittor systems, on iron metabolism in the brain and spinal cord, and the socioeconomic burden of the disease, are urgently needed.

[Antibiotic therapy in the outpatient setting: update 2009]

Rational outpatient therapy restricts antibiotics to infections where they are beneficial and selects substances based on local resistance patterns. Respiratory tract infections typically caused by viruses should not be treated with antibiotics (e.g., rhinitis, bronchitis, sinusitis). Many respiratory infections likely caused by bacteria can be treated with aminopenicillin, sometimes combined with a beta-lactamase inhibitor. Quinolones should be used only as exception for respiratory tract infections, since resistance is rising. For this reason uncomplicated urinary tract infections (cystitis) should be treated with trimethoprim-sulfa-methoxazole (TMP-SMX) instead of quinolones, even though approximately 20% of Escherichia coli are resistant to TMP-SMX. Skin and soft tissue infections are best treated with beta-lactam antibiotics, as long as the community acquired methicillin-resistant strains of S. aureus frequently seen in certain countries remain uncommon here.