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Original article
The impact of vitamin D deficiency on clinical, biochemical and metabolic parameters in primary hyperparathyroidism
El impacto de la deficiencia de vitamina D en los parámetros clínicos, bioquímicos y metabólicos en el hiperparatiroidismo primario
Gözde Şengül Ayçiçek, Berna İmge Aydoğan
Corresponding author
imgehalici@gmail.com

Corresponding author.
, Mustafa Şahin, Rıfat Emral, Murat Faik Erdoğan, Sevim Güllü, Nilgün Başkal, Demet Çorapçıoğlu
Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Vitamin D deficiency has been reported to be more common in patients with PHPT when compared to healthy subjects and suggested to be associated with worse disease outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#8211;3</span></a> In addition&#44; a limited number of studies reported higher alkaline phosphatase &#40;ALP&#41;&#44; calcium&#44; and parathyroid hormone &#40;PTH&#41; levels and larger parathyroid adenoma &#40;PA&#41; size in PHPT patients with vitamin D deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#8211;7</span></a> However&#44; these findings were not confirmed in all clinical studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#44;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In addition to the classic bone and kidney complications of PHPT&#44; several metabolic consequences of disease have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">8&#44;9</span></a> Hypertension&#44; glucose intolerance&#44; diabetes mellitus&#44; dyslipidemia and obesity were reported to be related to PHPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">8&#44;10</span></a> Direct effects of parathyroid hormone &#40;PTH&#41; on adipocyte differentiation&#44; insulin resistance and lipogenesis induced by increased intracellular calcium in adipocytes were suggested mechanisms of obesity and glucose intolerance in PHPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">11&#44;12</span></a> Vitamin D deficiency has also been suggested to be related to cardiometabolic disorders including hypertension&#44; type 2 diabetes&#44; dyslipidaemia&#44; obesity&#44; metabolic syndrome and cardiovascular diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13&#44;14</span></a> Several mechanisms were postulated to explain the interactions between vitamin D deficiency and metabolic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">15&#8211;17</span></a> However&#44; the causal relationship between vitamin D deficiency&#44; obesity and related disorders has not been clearly identified&#46; Low grade inflammation&#44; lipogenesis induced by increased PTH synthesis and direct effects of vitamin D deficiency on adipogenesis were suggested as pathogenic factors for obesity and metabolic disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">11&#44;18</span></a> On the other hand&#44; volumetric dilution or sequestration of vitamin D in adipose tissue has been accepted as the most reasonable explanation for the link between obesity and vitamin D deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">15&#44;17</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the present study&#44; we aimed to investigate the impact of vitamin D deficiency on the clinical features and biochemical and metabolic parameters of PHPT&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0020" class="elsevierStylePara elsevierViewall">In this study&#44; 128 patients with newly diagnosed PHPT at the Ankara University Faculty of Medicine Endocrinology Clinic were included&#46; The PHPT diagnosis depended on both hypercalcaemia and high&#47;inappropriately non-suppressed levels of PTH&#46; Thiazide&#47;lithium-induced hyperparathyroidism and familial hypocalciuric hypercalcaemia were excluded by measuring 24-h urinary calcium excretion and reviewing the medical history&#46; Ninety-one patients underwent parathyroidectomy and adenoma was proven by histopathology&#46; Patients who used agents which may affect calcium&#44; vitamin D and bone metabolism &#40;calcium&#44; vitamin D&#44; bisphosphonates&#44; denosumab&#44; corticosteroid&#44; antidepressant&#44; antiepileptic&#44; selective oestrogen receptor modulator&#44; teriparatide&#41; and&#47;or had a condition that may affect vitamin D&#47;calcium metabolism &#40;cancer&#44; sarcoidosis&#44; stage 4&#8211;5 chronic renal failure&#44; active liver disease&#44; malabsorption syndromes&#44; immobilization&#44; bariatric surgery&#44; Cushing&#39;s syndrome&#41; were excluded&#46; Pregnant women were not included&#46; The body mass index &#40;BMI&#41; was defined as the weight in kilograms divided by the square height in meters&#46; Metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> All patients were screened with urinary tract ultrasonography if they did not have medical history of nephrolithiasis&#47;nephrocalcinosis or surgery for nephrolithiasis&#46; Informed consent was obtained from all patients&#46; The study was approved by the Ankara University ethics committee&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ultrasonography</span><p id="par0025" class="elsevierStylePara elsevierViewall">Neck ultrasonography was performed using high-resolution&#44; B-mode&#44; grey-scale US &#40;Hitachi EUB 7000 HV machine with a 6&#8211;13<span class="elsevierStyleHsp" style=""></span>MHz linear transducer&#41;&#46; The PA was measured in three dimensions&#44; and the greatest dimension was categorized as &#60;15<span class="elsevierStyleHsp" style=""></span>mm and &#8805;15<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Eighty-six PAs that were not proven by histopathology and thirty-three PAs that were not treated surgically were identified by US&#46; If a lesion with atypical sonographic findings suggestive of adenoma or multiple lesions suggestive of adenoma were observed&#44; a sestamibi parathyroid scan or parathyroid hormone wash-out procedure was performed to prove PA&#46; Parathyroid adenomas were not detected on US in nine patients &#40;7&#46;0&#37;&#41;&#46; Adenoma size was defined as the greatest diameter as measured by ultrasonography&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">DEXA</span><p id="par0035" class="elsevierStylePara elsevierViewall">Dual energy X-ray absorptiometry was performed on the lumbar spine&#44; femoral neck&#44; and total hip with the Hologic Discovery QDR&#8482; series DXA systems&#44; USA&#46; Osteoporosis was defined according to WHO criteria as femoral or lumbar density 2&#46;5 standard deviations below that of a young adult&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Biochemistry</span><p id="par0040" class="elsevierStylePara elsevierViewall">25-Hydroxyvitamin D &#40;25OHD&#41; was measured with high performance liquid chromatography using a Shimadzu device and an Immuchro-HPLC kit&#46; Parathyroid hormone &#40;PTH&#41; was measured using the chemiluminescence method with a Beckman Coulter AU5800 &#40;Brea&#44; California&#44; USA&#41;&#46; Serum creatinine&#44; albumin and phosphorus were measured with a Beckman Coulter DXI 800&#46; Fasting blood glucose and insulin were measured after at least 8<span class="elsevierStyleHsp" style=""></span>h overnight fasting with Roche P800 and Cobas e411 &#40;Roche Diagnostics&#44; Switzerland&#41;&#46; Corrected calcium &#40;cCa&#41; was calculated using the equation&#58; cCa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#91;&#40;4<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>albumin&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#93;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Ca&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Statistical analysis was performed with SPSS version 11&#46;5 &#40;BM Corp&#44; NY&#44; USA&#41;&#46; Categorical data were presented as counts and percentages&#46; Continuous variables with a normal distribution were presented as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#46; Variables with a non-normal distribution were presented as median &#40;minimum&#8211;maximum&#41;&#46; Categorical data were compared using the Chi-square or Fisher&#39;s exact tests&#46; Group data with a normal distribution were compared using Student&#39;s <span class="elsevierStyleItalic">t</span> test or analysis of variance&#46; Nonparametric data were compared using the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> or Kruskal&#8211;Wallis tests&#46; The associations between continuous variables were determined by Pearson or Spearman correlation analysis according to distribution&#46; A <span class="elsevierStyleItalic">p</span>-value &#60;0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study group included 128 patients &#91;106 female &#40;82&#46;8&#37;&#41; and 22 &#40;17&#46;2&#37;&#41; male&#93;&#46; Among them&#44; 66 patients &#40;51&#46;6&#37;&#41; had vitamin D deficiency &#40;&#60;50<span class="elsevierStyleHsp" style=""></span>nmol&#47;L&#41; and 60 &#40;48&#46;4&#37;&#41; had normal vitamin D levels &#40;&#8805;50<span class="elsevierStyleHsp" style=""></span>nmol&#47;L&#41;&#46; Twenty-one patients &#40;17&#37;&#41; had severe vitamin D deficiency&#46; Prevalence of hypertension &#40;HTN&#41;&#44; type 2 diabetes mellitus &#40;T2DM&#41; and metabolic syndrome &#40;MetS&#41; were 20&#46;3&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>36&#41;&#44; 14&#46;1&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#41; and 32&#46;8&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>42&#41;&#44; respectively&#46; Nephrolithiasis and osteoporosis were found in 26&#46;6&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41; and 30&#46;5&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&#41; of subjects&#44; respectively&#46; None of the patients had a history of fracture&#46; Vitamin D levels according to comorbidities and complications in PHPT patients are given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Mean BMI was similar in both vitamin D groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;1&#41;&#46; Obesity&#44; metabolic syndrome and hypertension were more common in the vitamin D deficient group when compared to the normal vitamin D group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#44; respectively&#41;&#46; Type 2 diabetes was more common in the vitamin D deficient group when compared to the normal group&#44; but this finding was not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;058&#41;&#46; Prevalence of osteoporosis and nephrolithiasis were similar in both groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;29&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;30&#44; respectively&#41;&#46; Serum PTH&#44; Ca&#44; 24-h urinary calcium level were not different in the two groups&#46; The comparison of normal and deficient vitamin D groups is summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Adenoma size was not associated with the vitamin D level &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;32&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The vitamin D level was not correlated with PTH&#44; Ca&#44; P&#44; ALP and 24-h urinary Ca &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;84&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;70&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;43&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;73 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;45&#44; respectively&#41;&#46; BMI was negatively correlated with the vitamin D level &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;27&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#46; Lumbar spine&#44; total hip&#44; femoral neck and distal radius <span class="elsevierStyleItalic">T</span> scores were not associated with vitamin D levels&#44; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;20&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;54 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;97 respectively&#41;&#46; The mean age of patients with OP was 59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;7 years&#46; After adjusting for age and BMI&#44; the vitamin D level was not related to osteoporosis or the <span class="elsevierStyleItalic">T</span> score of any sites&#46; There was a negative association between BMI and osteoporosis &#40;OR&#58; 0&#46;84&#59; 95&#37; CI&#58; 0&#46;749&#8211;0&#46;956&#41;&#46; BMI was correlated with the total hip&#44; lumbar spine&#44; and femoral neck <span class="elsevierStyleItalic">T</span> scores &#40;<span class="elsevierStyleItalic">r</span>&#58; 0&#46;41&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#59; <span class="elsevierStyleItalic">r</span>&#58; 0&#46;32&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#44; <span class="elsevierStyleItalic">r</span>&#58; 0&#46;35&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#44; respectively&#41; but not with distal radius &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;74&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The median PTH level was not different between obese and non-obese groups &#91;136&#46;0<span class="elsevierStyleHsp" style=""></span>ng&#47;L &#40;73&#46;9&#8211;602&#46;0&#41; vs&#46; 136&#46;8<span class="elsevierStyleHsp" style=""></span>ng&#47;L &#40;65&#46;1&#8211;1229&#41;&#93;&#46; The prevalence of nephrolithiasis was similar in obese and non-obese patients &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;59&#41;&#46; The prevalence of osteoporosis was 30&#46;1&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>28&#41; in non-obese and 20&#46;0&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#41; in obese patients &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;026&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">In this study&#44; we could not demonstrate an association between the severity of clinical and biochemical features of PHPT and vitamin D deficiency&#46; The prevalence of vitamin D deficiency was 51&#46;6&#37; and severe deficiency was 17&#37;&#46; Osteoporosis and nephrolithiasis frequencies were similar in the normal and vitamin D deficient groups&#46; Serum corrected calcium&#44; phosphorus&#44; PTH&#44; ALP levels&#44; glomerular filtration rate and urinary calcium excretion were not associated with the vitamin D level&#46; Obesity&#44; MetS and HTN were more frequent in vitamin D deficient group when compared to normal vitamin D group&#46; Type 2 DM was also more frequent in vitamin D deficient patients&#44; although the difference was not statistically significant&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Previously&#44; a relationship between vitamin D deficiency&#44; low BMD&#44; and severe bone disease was suggested in PHPT patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;2&#44;21</span></a> However&#44; this finding was not confirmed in all studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#44;7&#44;22&#44;23</span></a> A study by Walker et al&#46; revealed that the relationship between vitamin D deficiency and BMD in PHPT patients was limited to the distal radius&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">4</span></a> In the study by Carnevale et al&#46;&#44; the effect of vitamin D levels on BMD was found to be negligible&#44; while PTH level&#44; age and BMI were significantly correlated with BMD in women with PHPT&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">22</span></a> Vitamin D status was associated with bone specific ALP and PTH&#44; but not with BMD in a study by Viccica et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> In a recent study&#44; Walker et al&#46; evaluated the effect of low vitamin D on volumetric BMD&#44; bone microarchitecture and strength measured with quantitative computed tomography&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">24</span></a> The authors observed that vitamin D deficiency was not related to any skeletal integrity parameters and hypothesized that the potential anabolic effects of high PTH might compensate for the negative effects of vitamin D deficiency on bone&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">24</span></a> Furthermore&#44; another study by the same group demonstrated an association between low vitamin D levels&#44; higher volumetric BMD and vertebral integrity&#44; supporting the possibility of positive impact of high PTH levels at the spine&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The association between the vitamin D level and nephrolithiasis has also been controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">7&#44;23&#44;26</span></a> In a recent study&#44; Reid et al&#46; investigated the predictors of nephrolithiasis&#44; osteoporosis and mortality in 611 patients with PHPT&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a> Vitamin D deficiency was not related with the risk of nephrolithiasis or osteoporosis&#46; Consistent with the findings of Walker et al&#46; and Reid et al&#46;&#44; vitamin D deficiency was not correlated with osteoporosis or nephrolithiasis in our study group&#44; although our cohort had a relatively high prevalence of vitamin D deficiency and severe deficiency&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">None of the patients in our study group had a history of fracture&#46; Recent studies show that the symptomatic course of PHPT has shifted to an asymptomatic disease&#44; which presents as hypercalcemia and subclinical organ involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">27&#44;28</span></a> This shift was caused by early detection of PHPT via routine calcium examinations during patient assessment&#46; A study from Turkey reported that the vast majority of PHPT cases who underwent surgery were asymptomatic at the time&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">29</span></a> Factors such as older age&#44; longer disease duration and prior fractures increase the risk of fracture in PHPT patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">30&#44;31</span></a> Only newly diagnosed cases at our outpatient clinic were included in our study&#46; Shorter disease duration due to immediate referral of patients to the Endocrinology Outpatient Clinic may be one of the causes of the lack of bone fragility in our group&#46; Also&#44; the mean age of patients with OP was relatively young&#46; As a limitation&#44; underestimation of silent fractures on X-ray in asymptomatic PHPT&#44; especially mild vertebral fractures with 20&#8211;25&#37; vertebral height reduction&#44; cannot be ruled out in our study&#44; as many factors such as BMI and patient-specific factors decrease the reliability of screening&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> The false negative rate of X-ray in identifying vertebral fractures was reported as up to 30&#37; in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a> Our study was not designed to assess the fracture risk&#44; so we did not perform further imaging studies&#46; Finally&#44; a history of peripheral fractures was taken from the patients&#46; So the reliability for non-vertebral&#44; non-hip fractures may be low in our study group&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Vitamin D deficiency was also suggested to be related to the biochemical severity of PHPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#44;7</span></a> Higher levels of PTH&#44; ALP&#44; Ca and lower levels of P have been reported to be correlated with low vitamin D concentrations&#44; but results from clinical studies are inconsistent&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#8211;7</span></a> Our results did not confirm any relationship between the vitamin D level and biochemical severity of disease&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">An inverse relationship between adenoma size and vitamin D status was suggested in previous reports&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;34</span></a> In the study by Rao et al&#46;&#44; PA weight was found to be inversely associated with 25-hydroxyvitamin D levels&#44; but not 1&#44;25-dihydroxyvitamin D levels&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> This finding was explained by the expression of 1&#945;-hydroxylase enzyme in parathyroid cells&#44; which could cause parathyroid cell proliferation and induce PTH secretion during 25-hydroxyvitamin D deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> We did not include the PA weight as a parameter&#44; because 29&#37; of our study group did not undergo surgery and the PA weight was not available in most pathology reports&#46; Additionally&#44; radio-guided occult lesion localization was performed occasionally and this procedure might affect the adenoma weight and size in the surgical specimen&#46; We evaluated the greatest dimension on ultrasonography and could not demonstrate an association between vitamin D status and adenoma size&#46; However&#44; our method has limitations in defining the size of adenoma appropriately&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Metabolic consequences including glucose intolerance&#44; hypertension&#44; dyslipidaemia and cardiovascular disease have been reported to be more common in PHPT&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">9&#44;35</span></a> However&#44; the causal relationship between PHPT&#44; obesity and related metabolic consequences is not yet understood&#46; The proposed mechanisms included possible PTH-induced adipocyte differentiation&#44; the effect of elevated intracellular calcium on enhanced insulin resistance and lipolysis inhibition&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">12&#44;36</span></a> Conversely&#44; obesity was suggested as a risk factor for developing PHPT via vitamin D deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> In our study&#44; hypertension&#44; MetS and obesity were more common in the vitamin D deficient group when compared to the normal group&#44; whereas PTH levels were similar in both groups&#46; Limited sun exposure in obese patients&#44; volumetric vitamin dilution in overweight patients and vitamin D sequestration by adipose tissue were all suggested as possible contributing factors between vitamin D deficiency and obesity&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">15&#44;17</span></a> Additionally&#44; vitamin D deficiency was suggested to promote adipocyte differentiation directly via the inhibitory effects of active vitamin D on adipogenesis&#44; or indirectly by increasing PTH level&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">16</span></a> Renin-angiotensin-aldosterone system activation by vitamin D deficiency due to decreased vitamin D receptor &#40;VDR&#41; production was also suggested as a possible explanation for the association between vitamin D deficiency and hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">37</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">A possible link between vitamin D deficiency&#44; CVD risk and CVD-related mortality was previously suggested&#44; but the causality remained unexplained&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">38&#44;39</span></a> It was hypothesized that vitamin D deficiency may not have a direct&#44; rather an indirect role in CVD fatality via its immunological effects&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">38</span></a> RAA system activation and atherogenesis caused by alterations in proinflammatory and anti-inflammatory molecules were proposed as possible mechanisms by which vitamin D deficiency may be related to CVD&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> Finally&#44; MetS and its components are confounders of CVD and vitamin D deficiency was suggested to be associated with CVD indirectly by its effects on these confounders&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">39</span></a> In this study&#44; we did not evaluate the CVD risk&#44; but our results showed that vitamin D deficiency in PHPT patients was correlated with MetS&#44; hypertension and obesity&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The major limitation of our study was the single measurement of the vitamin D level&#46; The estimated duration of PHPT and vitamin D deficiency was not available&#46; The number of female patients was significantly higher than the number of male patients in both groups&#44; but the female-to-male ratio was similar in both groups&#46; Also&#44; the effect of sun exposure and dietary calcium intake could not be evaluated&#46; Patients who were not taking vitamin D supplements were included in this cross-sectional study&#44; so the effect of supplementation on parameters could not be evaluated&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion&#44; vitamin D deficiency was not associated with biochemical or clinical severity of PHPT&#44; although the prevalence of vitamin D deficiency was greater than 50&#37; in our study population&#46; The frequency of obesity&#44; hypertension and metabolic syndrome were higher in the vitamin D deficient group when compared to the normal group&#46; Further research is needed to explain the underlying mechanisms of relationship between metabolic parameters and vitamin D deficiency in PHPT patients&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Authors&#8217; contributions</span><p id="par0120" class="elsevierStylePara elsevierViewall">All authors contributed to the conception&#44; design and data collection of this study&#46; Analyses were performed by G&#350;A&#44; B&#304;A and M&#350;&#46; G&#350;A&#44; B&#304;A and M&#350; were responsible for the literature review and writing the draft&#46; All authors supervised the study&#44; reviewed and approved the final version&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical approval</span><p id="par0130" class="elsevierStylePara elsevierViewall">The study was approved by the Ankara University Faculty of Medicine Ethics Committee&#46; Informed consent was obtained from all participants&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">This research received no specific grant from any funding agency&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to disclose&#46;</p></span></span>"
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          "titulo" => "Abstract"
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          "titulo" => "Resumen"
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              "titulo" => "Antecedentes"
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          "titulo" => "Introduction"
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          "titulo" => "Materials and methods"
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              "titulo" => "DEXA"
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              "identificador" => "sec0030"
              "titulo" => "Biochemistry"
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              "titulo" => "Statistical analysis"
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    "fechaRecibido" => "2022-03-24"
    "fechaAceptado" => "2022-06-29"
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          "clase" => "keyword"
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          "palabras" => array:8 [
            0 => "Primary hyperparathyroidism"
            1 => "Vitamin D deficiency"
            2 => "Nephrolithiasis"
            3 => "Osteoporosis"
            4 => "Adenoma size"
            5 => "Metabolic syndrome"
            6 => "Obesity"
            7 => "Hypertension"
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          "palabras" => array:8 [
            0 => "Hiperparatiroidismo primario"
            1 => "Deficiencia de vitamina D"
            2 => "Nefrolitiasis"
            3 => "Osteoporosis"
            4 => "Tama&#241;o del adenoma"
            5 => "S&#237;ndrome metab&#243;lico"
            6 => "Obesidad"
            7 => "Hipertensi&#243;n"
          ]
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">It has been suggested that vitamin D deficiency is associated with worse clinical outcomes in primary hyperparathyroidism &#40;PHPT&#41;&#46; We aimed to evaluate the relationship between vitamin D deficiency and clinical&#44; biochemical and metabolic parameters in PHPT patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A total of 128 patients with biochemically confirmed PHPT were included&#46; Patients were categorized as vitamin D deficient if 25-OH vitamin D was &#60;50<span class="elsevierStyleHsp" style=""></span>nmol&#47;L&#44; or normal if vitamin D was &#8805;50<span class="elsevierStyleHsp" style=""></span>nmol&#47;L&#46; Biochemical parameters&#44; bone mineral densitometry &#40;BMD&#41;&#44; and urinary tract and neck ultrasonography were assessed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In the study group&#44; 66 &#40;51&#46;6&#37;&#41; patients had vitamin D deficiency and 60 &#40;48&#46;4&#37;&#41; had normal vitamin D levels&#46; Nephrolithiasis and osteoporosis were found in 26&#46;6&#37; and 30&#46;5&#37; of subjects&#44; respectively&#46; The prevalence of metabolic syndrome &#40;MetS&#41;&#44; obesity &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#8805;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; and hypertension &#40;HTN&#41; were higher in the vitamin D deficient group when compared to the normal group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#44; respectively&#41;&#46; There was no difference regarding the presence of nephrolithiasis and osteoporosis between the groups&#46; The mean adenoma size was similar in both groups&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Vitamin D deficiency was not associated with osteoporosis&#44; nephrolithiasis&#44; adenoma size or biochemical parameters in PHPT&#46; However&#44; vitamin D deficiency may be a risk factor for developing HTN and MetS in PHPT&#46;</p></span>"
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            "titulo" => "Background"
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            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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        ]
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se ha sugerido que la deficiencia de vitamina D se asocia a peores resultados cl&#237;nicos en el hiperparatiroidismo primario &#40;HPTP&#41;&#46; Nuestro objetivo es evaluar la relaci&#243;n entre la deficiencia de vitamina D y los par&#225;metros cl&#237;nicos&#44; bioqu&#237;micos y metab&#243;licos en pacientes con HPTP&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 128 pacientes con HPTP confirmado bioqu&#237;micamente&#46; Los pacientes fueron categorizados de acuerdo con sus niveles de vitamina D&#44; siendo deficientes si los niveles de 25-OH vitamina D eran &#60;50<span class="elsevierStyleHsp" style=""></span>nmol&#47;l&#44; o normales si los niveles de vitamina D eran &#8805;50<span class="elsevierStyleHsp" style=""></span>nmol&#47;l&#46; Se evaluaron los par&#225;metros bioqu&#237;micos&#44; la densitometr&#237;a mineral &#243;sea &#40;DMO&#41; y la ecograf&#237;a del tracto urinario y del cuello&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En el grupo de estudio&#44; 66 &#40;51&#44;6&#37;&#41; pacientes ten&#237;an niveles deficientes de vitamina D y 60 &#40;48&#44;4&#37;&#41; mostraban niveles normales de vitamina D&#46; Se detectaron nefrolitiasis y osteoporosis en 26&#44;6 y 30&#44;5&#37; de los sujetos&#44; respectivamente&#46; La prevalencia del s&#237;ndrome metab&#243;lico &#40;SM&#41;&#44; la obesidad &#40;IMC<span class="elsevierStyleHsp" style=""></span>&#8805;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; y la hipertensi&#243;n &#40;HTA&#41; fueron mayores en el grupo con niveles deficientes de vitamina D en comparaci&#243;n con el grupo con niveles normales &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#44; respectivamente&#41;&#46; No hubo diferencias en cuanto a la presencia de nefrolitiasis y osteoporosis entre los grupos&#46; El tama&#241;o medio del adenoma fue similar en ambos grupos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La deficiencia de vitamina D no se asoci&#243; a la osteoporosis&#44; la nefrolitiasis&#44; al tama&#241;o del adenoma ni a los par&#225;metros bioqu&#237;micos en el HPTP&#46; Sin embargo&#44; la deficiencia de vitamina D puede ser un factor de riesgo para el desarrollo de HTA y SM en el HPTP&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Antecedentes"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
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      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          0 => array:3 [
            "identificador" => "at1"
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            0 => array:1 [
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                0 => """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">25-hydroxyvitamin D level &#40;nmol&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">54&#46;0 &#40;10&#46;0&#8211;206&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">40&#46;0 &#40;13&#46;5&#8211;136&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">47&#46;8 &#40;10&#46;0&#8211;206&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Metabolic syndrome</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">40&#46;8 &#40;10&#46;0&#8211;150&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Absent&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">52&#46;8 &#40;10&#46;0&#8211;206&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Dyslipidaemia</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#46;3 &#40;10&#46;0&#8211;200&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;8 &#40;10&#46;0&#8211;206&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Obesity</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;5 &#40;13&#46;0&#8211;127&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&#46;0 &#40;10&#46;0&#8211;206&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Osteoporosis</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Femoral neck T score</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Total hip T score</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">24 &#40;36&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;19&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;19&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;8&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27 &#40;40&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">FBG&#44; mmol&#47;L</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">HDL&#44; mmol&#47;L</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">LDL&#44; mmol&#47;L</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">TG&#44; mmol&#47;L</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;87&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">TSH&#44; mIU&#47;L</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">138 &#40;65&#8211;700&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">135 &#40;72&#8211;1229&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;80&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">cCa&#44; mmol&#47;L</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">24-h urinary calcium&#44; mg&#47;day</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">311 &#40;100&#8211;922&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">282 &#40;98&#8211;1300&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Osteoporosis&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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