Medical Inspection – Health Blog

A hallmark of Paget’s disease is the presence of one or more skeletal deformities. The most readily apparent, but some­times subtle, is enlargement of the skull (Figure 1). This usually produces somewhat asymmetric enlargement of the cranium. In individuals who wear hats a history of a slow increase in hat size may be volunteered or mentioned in answer to a direct question. Hearing loss has been noted in 40-50% of patients with skull involvement and is more common with skull enlarge­ment. The degree of hearing loss is often sufficient to require the use of one or two hearing aids. Tinnitus, vertigo, or both has been reported in about 20% of patients. The lower extremity is another area which may call attention to the presence of Paget’s disease. Gradual bowing of either the

Introduction

Paget’s disease of bone is a skeletal disorder usually diag­nosed in patients over the age of 50 years whose clinical pre­sentation is highly variable. It may be suspected based on physical examination alone but more commonly is brought to attention by unexpected radiological or biochemical findings when an individual is under evaluation for another purpose.

femur, the tibia, or occasionally both may proceed so slowly that even the patient may not be aware of the problem. Bowing of a lower extremity bone is usually unilateral and when bilateral can produce a major impairment in ambulation. With increasing severity of the bowing degenerative changes in the articular car­tilage of hips, knees, or even ankles may be accelerated. On physical examination this is manifested most obviously in the hip as evidenced by reduced range of motion. Two other fea­tures of Paget’s disease of the lower extremity are a discern- able enlargement of an affected bone and increased skin tem­perature over the affected bone. This may be associated with enlargement of superficial veins in the region. Edema is occa­sionally noted, but is more likely related to varicose veins. The increased skin temperature reflects the increased vascularity of the underlying bone and concomitant increased blood flow to the surrounding soft tissue. This finding is easily reversed by treatment of Paget’s disease with effective drugs. Suppression of disease activity reduces vascularity of pagetic lesions. Less commonly enlargement and deformity may be noted in a clavicle or upper extremity long bone. Patients with Paget’s dis­ease may have kyphosis or scoliosis of the spine but the discern­ment of enlarged vertebrae by physical examination is difficult.

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In our diet, protein is the principal source of non-volatile, so- called fixed acids, which are eliminated via the kidneys, through the production of ammonium ions and titratable acidity. Their acidifying effect is linked to the metabolism of sulphate aminoacids (methionine and cysteine) which produce H+ and generate an increase in the renal excretion of calcium through the direct tubular mechanism and, when in excess, via a giving up of bone calcium. This is the metabolic basis that explains the well-documented hypercalciuria when the diet contains an excess of protein, particularly of animal origin. On the oth­er hand, it is known that, also in stone formers, the reduction in animal protein is able to significantly reduce the excretion of calcium. This knowledge is consistent with the epidemio- logical data showing that an intake of animal protein in excess of 76 g/day is able to increase by 33% the risk of forming kid­ney stones. The calciuretic effect of proteins is partly re­duced by the contemporary administration of alkaline salts such potassium bicarbonate or potassium citrate so, in dietary terms, in addition to a reduction in proteins, it could be impor­tant to increase the intake of alkaline potassium via an ade­quate consumption of fruit and vegetables. It is also necessary to consider that the proteins of vegetable origin (soya, chick­peas, French beans, broad beans, peas, lentils) have a lower sulphur aminoacids content and are therefore preferable for hy- percalciuric subjects. Canadian Drugstore canadian healthcare shop item

As already mentioned, the alkaline potassium found in fruit and vegetables is important for reducing the calciuretic effect of proteins, but not only for this reason. A depletion of potassium in itself is accompanied by an increase in calciuria and, on the other hand, its addition in the form of potassium citrate or potassium bicarbonate can reduce the calciuria significantly. The mechanism could be linked to the variations in intra­cellular pH in the acidic sense when there is potassium deple­tion, and in the alkaline sense when there is high potassium availability. Also in this case there is strong epidemiological ev­idence: in both men and women a high potassium intake (greater than 103 mEq/day) reduces the risk of stone formation by more than 50% in comparison with a low intake. Therefore, an important recommendation in idiopathic hypercalciuria is also that of consuming a reasonable quantity of fruit and vegetables on a regular basis, taking care to choose prod­ucts with a relatively low oxalate content to avoid increases in oxaluria. One cannot ignore the fact that some fruit juices have been shown to significantly increase the urinary citrate, which is a very good inhibitor of calcium oxalate crystallization. It is not possible to measure with accuracy the salt consump­tion of a person, but given that dietary sodium chloride is al­most completely absorbed in the intestine and eliminated in the urine, its consumption can be easily deduced by measuring its renal excretion. Kleeman et al. were the first to demonstrate that the increase of sodium chloride in the diet of normal sub­jects provoked an increase in the excretion of calcium. Various authors then confirmed the existence of a strict rela­tionship between the intake of sodium chloride and calciuria, in both normal and hypercalciuric subjects, and some experi­ences have been indicated where idiopathic hypercalciuria was corrected with the simple restriction of salt in the diet. Also on the epidemiological level, it could be detected that when the consumption of sodium exceeded certain levels, the risk of forming kidney stones increased. Many authors, when speaking of salt, make reference to sodium.

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This man has the typical clinical and laboratory characteristics that are often found in recurrent formers of calcium kidney stones and a significant idiopathic hypercalciuria was particu­larly evident.

The diet to which he was subjected we define as “antilithogen- ic” because it takes into consideration all of the nutritional fac­tors which are known to provoke or promote a high calcium ex­cretion level. canadian medshop 247 cheap canadian drugs

Calcium nephrolitiasis is a disease which effects a high per­centage of people in industrialized nations and idiopathic hy- percalciuria (calcium excretion in excess of 300 mg/day in men and 250 mg/day in women) is the most frequent urinary stone risk factor.

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