Anhand von 2019 Schilddrüsenoperationen, die in den Jahren 1985-1996 im Universitätsklinikum Charite, Standort Rudolf-Virchow-Klinikum in Berlin durchgeführt wurden, wird die Bedeutung der Operationstechnik und der Operationsindikation für die chirurgische Komplikationsrate untersucht. Insgesamt wurden 3471 Schilddrüsenlappen operiert. Anhand einer Nachuntersuchung und der direkten postoperativen Dokumentation ließen sich die postoperativen Komplikationen dokumentieren. Die Rate an transienten Rekurrensparesen betrug 4,5%, bei 0,7 der Operierten fanden sich permanente Paresen. Bezogen auf die "nerves at risk" fanden sich in 2,8% transiente und in 0,5% permanente Paresen. Die Darstellung des Nervus laryngeus rekurrens erwies sich in dieser Untersuchung als signifikant komplikationsärmer im Bezug auf permanente Paresen. Hier waren bei der Darstellung des Nervens 0,5% permanente Läsionen aufgetreten, im Gegensatz zu 0,9% permanenter Läsionen ohne Darstellung des Nerven. Der direkte Vergleich von Komplikationen der Hemithyreoidektomien und der kontralateralen subtotalen Resektion ergab keinen signifikanten Unterschied betreffs der Paresen. Die Hemithyreoidektomie mit kontralateraler subtotaler Resektion war im Vergleich zu der Thyreoidektomie oder der subtotalen Resektion beidseits die komplikationsärmste Operationsmöglichkeit. Eine postoperative Erniedrigung des Serumkalziumspiegels wurde bei 18,9% der Patienten festgestellt, aber nur 0,9% waren persistent. Die schilddrüsennahe Ligatur der Arteria thyroidea inferior ergab eine niedrigere Rate an postoperativen Hypokalzämien, die jedoch statistisch nicht signifikant war. Da aber weder eine erhöhte Rate an Rekurrensparesen, noch eine vermehrte Rezidivneigung zu befürchten ist, scheint die schilddrüsennahe Ligatur vorteilhafter zu sein. Unter 149 Rezidivoperationen fanden sich 126 "echte" Rezidive, die Rate an permanenten Rekurrensparesen betrug hier 1,6%, bezogen auf "nerves at risk". Die Rate an Hypokalzämien lag bei 23,8%, wovon 0,8% permanenter Natur waren. Patienten über 70 Jahre haben sowohl perioperativ, als auch postoperativ kein erhöhtes Risiko eine Komplikation zu erleiden, so daß Operationen an der Schilddrüse durchaus auch im hohen Alter gerechtfertigt werden können. / Abstract During the years from 1986 until 1996 2019 thyroid gland surgeries have been performed at the university clinic charite', campus virchow-clinic. That means 3471 thyroid gland lobes have been treated. This paper is investigating the complications directly caused by the surgical procedures. Data gained directly during surgery and 6 month after surgery allow a very detailed view on the complications. There have been 4.5% transient recurrent nerve palsies and 0.7% permanent. Data based on the "nerves at risk" show 2.8% transient and 0.5% permanent palsies. A direct comparison of hemithyroidectomy and near-total thyroidectomy on the contralateral side show no significant difference in permanent nerve palsies. The hemithyroidectomy with contralateral near-total thyroidectomy was the surgical procedure with the lowest rate of complications compared to the thyroidectomy or the near-total thyroidectomy of both lobes. Postoperative Hypocalcemia was seen in 18,9% of all patients, but only 0.9% suffered from permanent hypocalcemia. The ligature of the lower thyroid artery close to the thyroid gland showed lower rates of hypocalcemia , but the results haven't been statistically significant. There has not been a higher rate of nerve palsies or a higher rate of relapses, so the ligature close to the gland is recommended. 149 operations were necessary due to recurrent growth of the thyroid gland. There have been126 real relapses, the rate of permanent nerve palsy was 1,6% for the "nerves at risk". Hypocalcemia was found in 23,8% of all cases, 0.8% were permanent. Patients older than 70 years do not have a higher risks to suffer from complications than younger patients, so thyroid surgery should also be performed for the elderly.

O presente estudo teve como objetivo relacionar os níveis de indicadores sanguíneos energéticos e de cálcio na ocorrência de afecções uterinas, mastite clínica e mastite subclínica em vacas de raça Holandesa. A presença de mastite foi monitorada através do California Mastitis Test (CMT) e da contagem de células somáticas, para a identificação de mastite subclínica, e do Teste da Caneca de Fundo Preta (TCFP), para identificação de mastite clínica. A presença das afecções uterinas foi identificada mediante exame clínico. Foram feitas coletas de sangue para a determinação dos níveis de cálcio (Ca), glicose e β-hidroxi-butirato (BHB). O CMT foi realizado nas duas primeiras semanas após o parto, o TCFP foi realizado conforme a rotina de ordenha, estabelecida pela propriedade, e as coletas de sangue foram realizadas na semana anterior ao parto e duas coletas até os 21 dias posteriores ao parto. A ocorrência de hipocalcemia subclínica foi determinada quando o Ca no soro atingiu valores ≤ 8,00 mg/dL, hipoglicemia com valores de glicose ≤ 50 mg/dL e hipercetonemia com valores de BHB ≥ 1,2 mmol/L. Nas vacas com mastite clínica foi realizado tratamento conforme estabelecido pelo protocolo de ordenha e tratamentos da fazenda. Os dados de mastite subclínica obtidos através do teste de CMT, por quarto mamário, foram validados através de cultura microbiológica realizada em laboratório de referência e em laboratório na fazenda para identificar crescimento bacteriano, bem como através da contagem de células somáticas (CCS) e da contagem bacteriana total (CBT). Não foi encontrada relação significativa entre a hipocalcemia subclínica, a hipoglicemia e a hipercetonemia com afecções uterinas e da glandula mamária nas vacas após o parto. / This study aimed to relate the levels of energy and calcium in the occurence of both uterine diseases, clinic and subclinic mastitis in Holstein cows. The presence of mastitis was monitored through California Mastitis Test (CMT) and the counting of somatic cells (CSC), for the identification of subclinic mastitis, and strip cup test, for the identification of clinic mastitis. The presence of uterine disorders was identified by clinical examination. Blood collections were made for determining calcium, glicose and β-hydroxy-butyrate (BHB). CMT was realized in the first two weeks after calving, BBMT was realized according to the routine of milking settled by the farm and the blood collections were made in the week before the calving and also two collections were made after it. The occurrence of subclinic hypocalcemia was determined when serum Ca reached ≤ 8,00 mg/dL, hypoglycemia with glucose values ≤ 50 mg/dL and hyperketonemia values with BHB BHB ≥ 1,2 mmol/L. Data of clinic mastitis were obtained through the identification of altered milk in BBMT and subsequently realized treatment as settled by the milking protocol and treatments of the farm. Data of subclinic mastitis were obtained through CMT test, for mammary quarter, and validated by microbiological culture in reference laboratory, culture in the farm for identifying the bacterial growth, counting of somatic cells (CSC) and total bacterial counting (TBC). It was not identified in the study any relationship between subclinical hypocalcemia and uterine and mammary gland diseases in cows after calving.

O presente estudo teve como objetivo relacionar os níveis de indicadores sanguíneos energéticos e de cálcio na ocorrência de afecções uterinas, mastite clínica e mastite subclínica em vacas de raça Holandesa. A presença de mastite foi monitorada através do California Mastitis Test (CMT) e da contagem de células somáticas, para a identificação de mastite subclínica, e do Teste da Caneca de Fundo Preta (TCFP), para identificação de mastite clínica. A presença das afecções uterinas foi identificada mediante exame clínico. Foram feitas coletas de sangue para a determinação dos níveis de cálcio (Ca), glicose e β-hidroxi-butirato (BHB). O CMT foi realizado nas duas primeiras semanas após o parto, o TCFP foi realizado conforme a rotina de ordenha, estabelecida pela propriedade, e as coletas de sangue foram realizadas na semana anterior ao parto e duas coletas até os 21 dias posteriores ao parto. A ocorrência de hipocalcemia subclínica foi determinada quando o Ca no soro atingiu valores ≤ 8,00 mg/dL, hipoglicemia com valores de glicose ≤ 50 mg/dL e hipercetonemia com valores de BHB ≥ 1,2 mmol/L. Nas vacas com mastite clínica foi realizado tratamento conforme estabelecido pelo protocolo de ordenha e tratamentos da fazenda. Os dados de mastite subclínica obtidos através do teste de CMT, por quarto mamário, foram validados através de cultura microbiológica realizada em laboratório de referência e em laboratório na fazenda para identificar crescimento bacteriano, bem como através da contagem de células somáticas (CCS) e da contagem bacteriana total (CBT). Não foi encontrada relação significativa entre a hipocalcemia subclínica, a hipoglicemia e a hipercetonemia com afecções uterinas e da glandula mamária nas vacas após o parto. / This study aimed to relate the levels of energy and calcium in the occurence of both uterine diseases, clinic and subclinic mastitis in Holstein cows. The presence of mastitis was monitored through California Mastitis Test (CMT) and the counting of somatic cells (CSC), for the identification of subclinic mastitis, and strip cup test, for the identification of clinic mastitis. The presence of uterine disorders was identified by clinical examination. Blood collections were made for determining calcium, glicose and β-hydroxy-butyrate (BHB). CMT was realized in the first two weeks after calving, BBMT was realized according to the routine of milking settled by the farm and the blood collections were made in the week before the calving and also two collections were made after it. The occurrence of subclinic hypocalcemia was determined when serum Ca reached ≤ 8,00 mg/dL, hypoglycemia with glucose values ≤ 50 mg/dL and hyperketonemia values with BHB BHB ≥ 1,2 mmol/L. Data of clinic mastitis were obtained through the identification of altered milk in BBMT and subsequently realized treatment as settled by the milking protocol and treatments of the farm. Data of subclinic mastitis were obtained through CMT test, for mammary quarter, and validated by microbiological culture in reference laboratory, culture in the farm for identifying the bacterial growth, counting of somatic cells (CSC) and total bacterial counting (TBC). It was not identified in the study any relationship between subclinical hypocalcemia and uterine and mammary gland diseases in cows after calving.

O presente estudo teve como objetivo relacionar os níveis de indicadores sanguíneos energéticos e de cálcio na ocorrência de afecções uterinas, mastite clínica e mastite subclínica em vacas de raça Holandesa. A presença de mastite foi monitorada através do California Mastitis Test (CMT) e da contagem de células somáticas, para a identificação de mastite subclínica, e do Teste da Caneca de Fundo Preta (TCFP), para identificação de mastite clínica. A presença das afecções uterinas foi identificada mediante exame clínico. Foram feitas coletas de sangue para a determinação dos níveis de cálcio (Ca), glicose e β-hidroxi-butirato (BHB). O CMT foi realizado nas duas primeiras semanas após o parto, o TCFP foi realizado conforme a rotina de ordenha, estabelecida pela propriedade, e as coletas de sangue foram realizadas na semana anterior ao parto e duas coletas até os 21 dias posteriores ao parto. A ocorrência de hipocalcemia subclínica foi determinada quando o Ca no soro atingiu valores ≤ 8,00 mg/dL, hipoglicemia com valores de glicose ≤ 50 mg/dL e hipercetonemia com valores de BHB ≥ 1,2 mmol/L. Nas vacas com mastite clínica foi realizado tratamento conforme estabelecido pelo protocolo de ordenha e tratamentos da fazenda. Os dados de mastite subclínica obtidos através do teste de CMT, por quarto mamário, foram validados através de cultura microbiológica realizada em laboratório de referência e em laboratório na fazenda para identificar crescimento bacteriano, bem como através da contagem de células somáticas (CCS) e da contagem bacteriana total (CBT). Não foi encontrada relação significativa entre a hipocalcemia subclínica, a hipoglicemia e a hipercetonemia com afecções uterinas e da glandula mamária nas vacas após o parto. / This study aimed to relate the levels of energy and calcium in the occurence of both uterine diseases, clinic and subclinic mastitis in Holstein cows. The presence of mastitis was monitored through California Mastitis Test (CMT) and the counting of somatic cells (CSC), for the identification of subclinic mastitis, and strip cup test, for the identification of clinic mastitis. The presence of uterine disorders was identified by clinical examination. Blood collections were made for determining calcium, glicose and β-hydroxy-butyrate (BHB). CMT was realized in the first two weeks after calving, BBMT was realized according to the routine of milking settled by the farm and the blood collections were made in the week before the calving and also two collections were made after it. The occurrence of subclinic hypocalcemia was determined when serum Ca reached ≤ 8,00 mg/dL, hypoglycemia with glucose values ≤ 50 mg/dL and hyperketonemia values with BHB BHB ≥ 1,2 mmol/L. Data of clinic mastitis were obtained through the identification of altered milk in BBMT and subsequently realized treatment as settled by the milking protocol and treatments of the farm. Data of subclinic mastitis were obtained through CMT test, for mammary quarter, and validated by microbiological culture in reference laboratory, culture in the farm for identifying the bacterial growth, counting of somatic cells (CSC) and total bacterial counting (TBC). It was not identified in the study any relationship between subclinical hypocalcemia and uterine and mammary gland diseases in cows after calving.

O receptor sensor do cálcio (CASR) desempenha um importante papel na manutenção da concentração plasmática do cálcio. Desde a sua descrição, mais de 200 mutações foram descritas podendo levar à perda ou ao ganho de função, resultando em situações de hiper ou hipocalcemia, respectivamente. Mutações inativadoras estão associadas à hipercalcemia hipocalciúrica familiar (HHF) e ao hiperparatireoidismo neonatal grave (HPTNG), enquanto que mutações ativadoras estão associadas à hipocalcemia autossômica dominante (HAD) e à Síndrome de Bartter tipo V. O objetivo deste estudo foi realizar o diagnóstico molecular, por meio da análise do gene CASR, em pacientes com HPTNG, HHF, hipocalcemia com PTH inapropriadamente normal ou baixo e hipoparatireoidismo idiopático com hipercalciúria na vigência de tratamento. Para cada criança (n = 2) com diagnóstico clínico e laboratorial de HPTNG, uma mutação \"nonsense\" em homozigose foi identificada na região codificadora do CASR (p.E519X e p.R544X). O estudo molecular dos pais das crianças mostrou tratar-se de casos herdados caracterizando-os como indivíduos com HHF e possibilitou o aconselhamento genético para estas famílias. Mutações pontuais em heterozigose na região codificadora do CASR (p.R25X, p.R69H, p.T627I) foram detectadas em três dos quatro pacientes selecionados com diagnóstico inicial de hiperparatireoidismo primário e bioquímica compatível com hipercalcemia hipocalciúrica. Estes achados constituem a base molecular da HHF e permitiram o rastreamento de outros casos de HHF nas respectivas famílias com impacto na abordagem terapêutica dos mesmos. Na paciente em que não foi detectada nenhuma mutação na região codificadora do CASR, o estudo prosseguiu com a pesquisa de alterações no número de cópias gênicas e de mutações nas regiões promotoras P1 e P2 como possíveis causas do fenótipo em questão. O resultado destas abordagens foi normal. Dos quatro pacientes selecionados com quadro de hipoparatireoidismo idiopático e hipercalciúria na vigência de tratamento, em apenas uma, a causa molecular foi definida por mutação \"missense\" em heterozigose na região codificadora do CASR (p.E767K) repercutindo positivamente no seu tratamento. Nos demais casos (n = 3), a pesquisa de alterações no número de cópias gênicas e de mutações nas regiões promotoras P1 e P2 também resultou normal. / The calcium sensing receptor (CASR) plays an important role in maintaining the plasma concentration of calcium. From its first description, more than 200 mutations have been described leading to loss or gain of function, resulting in conditions of either hyper or hypocalcemia, respectively. Inactivating mutations are associated with familial hypocalciuric hypercalcemia (FHH) and neonatal severe hyperparathyroidism (NSHPT), whereas activating mutations are associated with autosomal dominant hypocalcemia (ADH) and type V Bartter\'s syndrome. The aim of this study was to perform the molecular diagnosis, by analyzing the CASR gene, in patients with NSHPT, FHH, hypocalcemia with inappropriately normal or low PTH and idiopathic hypoparathyroidism with hypercalciuria during treatment. In every child (n = 2) with clinical and laboratory diagnosis of NSHPT, a nonsense mutation in homozygosity was identified in the coding region of the CASR (p.E519X and p.R544X). The molecular analysis of the child\'s parents showed that they were inherited cases qualifying them as individuals with FHH and it enabled a genetic counseling for these families. Point mutations in heterozygosity in the coding region of the CASR (p.R25X, p.R69H, p.T627I) have been detected in three out of the four selected patients with an initial diagnosis of primary hyperparathyroidism and biochemistry compatible with hypocalciuric hipercalcemia. These findings are the molecular basis of FHH and allowed the screening of other FHH cases in these families impacting on their therapeutic approach. In patients where no mutation in the coding region of the CASR was detected, the study went on researching for changes in the number of gene copies and mutations in P1 and P2 promoter regions as possible causes to the phenotype in question. The result of these approaches has been normal. The molecular cause has been defined as missense mutation in heterozygosis in the coding region of the CASR (p.E767K) in only one out of the four selected patients with idiopathic hypoparathyroidism and hypercalciuria during treatment, with a positive impact on her treatment. In the other cases (n = 3), the search for changes in the number of gene copies and mutations in the P1 and P2 promoter regions was normal.

Submitted by Ubirajara Cruz (ubirajara.cruz@gmail.com) on 2018-05-22T16:51:16Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) tese_josiane_feijo.pdf: 1901281 bytes, checksum: 4995490ffaaf74c8692c66cfb785d3df (MD5) / Approved for entry into archive by Aline Batista (alinehb.ufpel@gmail.com) on 2018-05-22T16:58:41Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) tese_josiane_feijo.pdf: 1901281 bytes, checksum: 4995490ffaaf74c8692c66cfb785d3df (MD5) / Made available in DSpace on 2018-05-22T16:58:41Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) tese_josiane_feijo.pdf: 1901281 bytes, checksum: 4995490ffaaf74c8692c66cfb785d3df (MD5) Previous issue date: 2016-07-05 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / O cálcio é um mineral essencial para uma variedade de processos fisiológicos do organismo da vaca leiteira, sua deficiência pode causar vários distúrbios metabólicos, que levam a redução do desempenho produtivo e reprodutivo, com consequentes perdas econômicas. Atualmente há no mercado veterinário algumas estratégias para a prevenção da hipocalcemia, como: dieta aniônica, dieta deficiente de cálcio, administração de vitamina D3 no pré-parto e tratamento com cálcio oral no pós-parto recente, mas todas essas requerem ajustes a serem melhorados. Com isso, o objetivo desta Tese, é desenvolver uma estratégia farmacêutica eficiente no pré-parto, para prevenir a hipocalcemia subclínica (HSC) no pós-parto, para tal foi realizado dois experimentos in vivo, aprovados pelo Comitê de Ética de Experimentação animal da Universidade Federal de Pelotas. O primeiro foi relacionar a queda do cálcio no periparto com a síntese de proteínas de fase aguda, observamos que vacas com concentrações de cálcio  8,5 mg/dL alteram a síntese de proteínas de fase aguda já no pré-parto, causando diminuição no escore de condição corporal, no peso e na produção de leite. O segundo experimento foi analisar o efeito da suplementação de diferentes dietas cátion-anionica no pré-parto e relacionar com a hemogasometria e concentrações de cálcio sanguíneo. Observamos que a suplementação com dieta aniônica, proporciona um aumento na concentração de cálcio ionizado disponível no plasma e redução nas globulinas, demonstrando que o pH levemente ácido provavelmente altera a síntese de glubulinas. / Calcium is an essential mineral for a variety of physiological processes in the body of the dairy cow, its deficiency can cause various metabolic disorders, leading to reduced production and reproductive performance, with consequent economic losses. There are currently in the veterinary market some strategies for the prevention of hypocalcemia, such as anionic diet, deficient in dietary calcium, vitamin D3 administration in pre-partum and treatment with oral calcium in the recent post-partum, but all of these require adjustments to be improved. Thus, the aim of this thesis is to develop an effective strategy in the pre-partum to prevent subclinical hypocalcemia (HSC) postpartum, for this was done two in vivo experiments, approved by the Animal Experimentation Ethics Committee of the University Federal of the Pelotas. The first was to correlate the drop of calcium in the peripartum with the synthesis of acute phase proteins, we observed that cows in concentrations of calcium  8.5 mg / dL alter the synthesis of acute phase proteins, causing decrease in body condition score, in weight and milk production. The second experiment was to evaluate the effect of supplementation of different cation-anion diets in prepartum and relate to the blood gas analysis and blood calcium levels. We observed that supplementation with dietary anion, provides an increase in concentration of available calcium in ionized plasma and reduction in globulins, demonstrating that pH may change glubulinas synthesis.

Die hypocalcämische Gebärparese, insbesondere die subklinische Hypocalcämie, die oft nicht erkannt wird und Ursache vieler sekundär auftretender Folgeerkrankungen ist, stellt in der intensiven Milchviehhaltung ein bedeutendes Problem dar. Inzwischen gibt es eine Reihe verschiedener Vorbeugungsstrategien, wobei der Einsatz von Zeolith A als Ca-Binder in der Ration gegen Ende der Trächtigkeit eine relativ neue Präventionsmöglichkeit darstellt. Da zu diesem Futterzusatzstoff noch wenige Untersuchungen, insbesondere auf Nebeneffekte vorliegen, war das Ziel dieser Studien, den Einfluss von Zeolith A in verschiedenen Dosierungen auf die Futteraufnahme, den Energiestoffwechsel, die Futterverdaulichkeit und den Ca-, Mg- und P-Stoffwechsel sowie in hohen Dosierungen auch auf den Spurenelement-stoffwechsel zu untersuchen. Des Weiteren sollte untersucht werden, wie sich Zeolith A im Verdauungstrakt hinsichtlich der Freisetzung von Al verhält. In einer ersten Studie an 46 Kühen (≥ 3. Laktation), die in zwei Gruppen unterteilt wurden, wurde Zeolith A in einer Dosierung von 90 g/kg Trockensubstanz (T) in den letzten 2 Wochen der Trächtigkeit bis zum Kalbetag in eine totale Mischration (TMR), welche zur freien Aufnahme vorgelegt wurde, eingemischt. Die Zeolith A-Zulage ante partum zeigte peripartal eine stabilisierende Wirkung auf die Ca-Konzentration im Serum (> 2 mmol/l). Der Rückgang der Häufigkeit der Hypocalcämie (< 2 mmol/l) am Tag der Kalbung lag bei 76 %. Die mittlere Mg-Konzentration im Serum war bei den Kontrolltieren am Tag der Kalbung und 1 Tag post partum signifikant höher im Vergleich zu den Tieren der Versuchsgruppe, lag aber in beiden Gruppen im physiologischen Bereich (0,75-1,30 mmol/l). Auf die Spurenelement-konzentrationen (Cu, Zn, Mn und Fe) im Plasma wurde kein Zeolith A-Effekt festgestellt. Allerdings zeigten die Zeolith A-supplementierten Kühe ante partum einen signifikanten Rückgang in der Futteraufnahme, welche in einer negativen Energiebilanz mit einem signifi-kanten Anstieg der freien Fettsäuren und des Beta-Hydroxybutyrats im Serum resultierte. Dieser Effekt hatte allerdings keine Auswirkung auf die Futteraufnahme post partum und auf die Milchleistung in den ersten 105 Tagen der Folgelaktation. Des weiteren war die mittlere Konzentration des anorganischen Phosphats (Pi) bereits 7 Tage nach Beginn der Zeolith A-Zulage signifikant niedriger im Vergleich zu den Tieren der Kontrollgruppe und lag bis zum Tag der Kalbung deutlich unter der unteren physiologischen Grenze von 1,25 mmol/l. Die zweite Studie war ein Dosis-Wirkungsversuch an 80 Milchkühen (1.-7. Laktation) mit verschiedenen Zeolith A-Dosierungen (0, 12, 23 bzw. 43 g Zeolith A/kg T TMR). Dazu wurden die Tiere ca. 4 Wochen ante partum in 4 Gruppen und für die Untersuchung des Mineralstoffwechsel noch in zwei Untergruppen (1. + 2. Laktation bzw. ≥ 3. Laktation) unterteilt. Die Tiere erhielten eine TMR ad libitum vorgelegt. In den letzten zwei Wochen erhielten die Tiere Zeolith A in die Ration eingemischt. Eine Einmischung von 43 g Zeolith A/kg T TMR zeigte auf den Ca-, Mg- und Pi-Stoffwechsel sowie auf die Futteraufnahme und den Energiestoffwechsel vergleichbare Effekte wie in der ersten Studie bei einer Zulage von 90 g/kg T TMR. Eine Zeolith A-Zulage von 23 g/kg T TMR bei einem Zeolith A/Ca-Verhältnis von 5,6:1 hatte ebenfalls noch einen stabilisierenden Effekt auf den peripartalen Ca-Stoffwechsel (> 2 mmol/l) bei Kühen ≥ 3. Laktation, jedoch ohne markanten Rückgang in der Futteraufnahme. In dieser Tiergruppe war ein Rückgang der Häufigkeit der Hypocalcämie um 71 % zu verzeichnen. Diese Tiere zeigten auch nur eine moderate Hypophosphatämie. Eine Zeolith A-Zulage von 12 g/kg T TMR zeigte dagegen keine Effekte. In einem Stoffwechselversuch an 8 doppelt fistulierten Milchkühen (Pansen und proximales Duodenum) wurde schließlich der Einfluss von Zeolith A auf verdauungsphysiologische Para-meter und den Mineralstoffwechsel, insbesondere des Phosphors im Verdauungstrakt, sowie auf die Freisetzung von Al aus dem Zeolithverband untersucht. Die Tiere erhielten Mais- und Grassilage und Kraftfutter. Es wurde 0, 10 bzw. 20 g Zeolith A/kg T über einen Zeitraum von 3 Wochen mit dem Kraftfutter verabreicht. Eine Zeolith A-Zulage führte zu einer signifikant reduzierten scheinbaren ruminalen Verdaulichkeit der T sowie der ruminal fermentierten organischen Substanz. Allerdings waren in der fäkalen Ausscheidung der Nährstoffe keine signifikanten Unterschiede zwischen den Fütterungsgruppen festzustellen. Es zeigte sich kein Effekt auf die Ca- und Mg-Verdauung. Dagegen korrelierte die Konzentration des löslichen P im Pansen signifikant negativ mit der mittleren Zeolith A-Aufnahme. Des Weiteren hatten die Kühe mit einer Zeolith A-Zulage von 20 g/kg T eine signifikant höhere fäkale Ausscheidung des Gesamtphosphors im Vergleich zu den Tieren der Kontrollgruppe. Die herabgesetzte Bio-verfügbarkeit von P resultierte in einer signifikant erniedrigten Pi-Konzentration im Serum. Gleichzeitig war eine signifikant erhöhte Konzentration des gelösten Al im Pansen und ein signifikant höherer Fluss des gelösten Al im Duodenum festgestellt worden was auf eine Instabilität des Zeolithverbands beruht. Da eine Zeolith A-Dosierung von 12 g/kg T keinen Effekt auf den Ca-Stoffwechsel und eine Dosierung 43 g/kg T unerwünschte Effekte zeigte kann anhand dieser Untersuchungen geschlussfolgert werden, dass eine Einmischung in einem Bereich von 20 bis 30 g Zeolith A/kg T TMR, was bei einer mittleren täglichen T-Aufnahme von 10 kg ca. 200 bis 300 g Zeolith A/Tier/Tag entspricht, bei einem Zeolith A/Ca-Verhältnis von 6 bis 10:1 in der Ration in den letzten 2 Wochen der Trächtigkeit zur Vorbeugung der peripartalen Hypocalcämie zu empfehlen ist, ohne dass negative Effekte auf die Tiergesundheit zu erwarten sind. / Parturient paresis is known to be a frequent problem in high-yielding dairy cows. Subclinical hypocalcemia around calving is especially of particular importance, because it often remains undetected and may cause secondary diseases. In practice different preventive methods have been established, whereas feeding of zeolite A (synthetic sodium-aluminium-silikate) as a calcium binder in the last two weeks of pregnancy is a new strategy to prevent parturient hypocalcemia. However, there exists only little information about side effects of zeolite addition. The aim of this study was to investigate the influence of zeolite A, in several doses, on feed intake, energy metabolism, nutrient digestibility, as well as on calcium (Ca), magnesium (Mg) and phosphorus (P) metabolism, and in high doses on trace element metabolism. Further, it was to investigate the mechanism of zeolite A in the gastrointestinal tract, focused on releasing aluminium (Al). In a first study with 46 cows (≥ 3rd lactation) zeolite A was tested in a dose of 90 g/kg dry matter (DM) in the last two weeks of pregnancy. Therefore the cows were divided in two groups (control and zeolite supplemented group). All cows were fed a total mixed ration (TMR) ad libitum. The supplementation of zeolite A had a stabilising effect on Ca concentration in serum (> 2 mmol/l) around calving. The reduction of the hypocalcemia incidence (< 2 mmol/l) was 76 % on the day of calving. The Mg-concentration in serum was significantly higher for the cows without zeolite A supplementation compared to the cows of the experimental group on the day of calving and on the day after calving. However, the mean serum Mg concentration stayed in the physiological range (0.75-1.30 mmol/l) for both groups. No significant effect of the zeolite A supplementation was observed on the mean plasma concentration of trace elements (copper, zinc, manganese, iron). However, the zeolite A supplementation led to a significantly reduced feed intake ante partum, which resulted in a negative energy balance. Furthermore, non esterified fatty acid and beta-hydroxybutyrate in serum were increased significantly. However, no significant differences were observed in feed intake post partum as well as in milk yield in the first 105 days in the subsequent lactation between the two groups. Furthermore, zeolite A supplementation decreased significantly the concentration of inorganic phosphate (Pi) in serum. Seven days after beginning zeolite A supplementation, on the day of calving, the mean Pi-concentration was considerably below the physiological limit of 1.25 mmol/l. In the second study, zeolite A was tested in several lower doses. Therefore 80 dairy cows (1st – 7th lactation) were divided into four groups in the last 4 weeks of pregnancy. Additionally, the cows of each group were divided in two subgroups (1st + 2nd lactation and ≥ 3rd lactation) to determine the influence of zeolite A on mineral metabolism. All animals were fed a TMR ad libitum. In the last two weeks the cows received a daily dose of 0, 12, 23 and 43 g zeolite A/kg DM. Zeolite A supplementation of 43 g/kg DM showed comparable effects on Ca, Mg, and Pi metabolism, as well as on feed intake and energy metabolism as in the first study. For older cows (> 3rd lactation), supplementation of 23 g zeolite A/kg DM, and a zeolite A-Ca ratio of 5.6:1 resulted also in a stabilising effect on Ca metabolism (> 2 mmol/l) around calving without significant reduction of feed intake. The incidence of hypocalcemia was reduced by 71 %. The cows showed only a moderate hypophosphatemia. A zeolite A supplementation of 12 g did not have any preventive effects. In a metabolic-study with eight double fistulated dairy cows (rumen and proximal duodenum), the influence of zeolite A supplementation on several physiological parameters of digestion and on mineral metabolism, especially P in the rumino-intestinal-tract, was determined. Further releasing of Al from the zeolite structure was investigated. The cows were fed a maize/grass-silage (60:40 % based on DM) and concentrate. Several doses of zeolite A (0, 10 and 20 g/kg DM) were added to the concentrate over a period of three weeks. Zeolite A supplementation resulted in a significantly reduced ruminal digestibility of dry matter (DM) and fermentation of organic matter. No effect was observed on faecal digestion of DM and OM. Digestion of Ca and Mg in the rumino-intestinal tract was not influenced by zeolite A supplementation. However, the concentration of soluble P in rumen fluid correlated negatively with the mean zeolite A intake. The faecal excretion of total P increased significantly for cows with a zeolite A dose of 20 g/kg DM compared to the control group. The reduced bioavailability of P resulted in a significantly decreased concentration of Pi in serum. The zeolite A supplemented cows further showed a significantly higher concentration of soluble Al in rumen fluid as well as a significantly higher flow of soluble Al at the duodenum, which is a consequence of an instability of the zeolite structure. According to these results it can be concluded that a daily amount of 20 to 30 g zeolite A/kg DM, which complies a daily amount of 200 to 300 g zeolite A/cow at a daily DM intake of 10 kg, with a zeolite-Ca ratio of 6–10 to 1, for two weeks ante partum seems to be an adequate dose for reducing subclinical hypocalcemia in older cows without negative side effects on animal health. At an expected daily mean DM intake of 10 kg it is a daily amount of 200 to 300 g zeolite A/cow. A zeolite dose of 12 g/kg DM did not have any effect on Ca metabolism, and a dose of 43g/kg DM showed negative side effects.

INTRODUÇÃO: A primeira doença humana atribuída à resistência hormonal foi o pseudo-hipoparatireoidismo (PHP), uma doença rara caracterizada por hipocalcemia, hiperfosfatemia e níveis elevados de hormônio paratireoidiano (PTH) na presença de função renal normal, quadro condizente com resistência ao PTH. A classificação original do PHP leva em consideração a osteodistrofia hereditária de Albright (AHO): presente no PHP1a e ausente no PHP1b. Na medida em que as bases moleculares do PHP têm sido compreendidas, uma classificação baseada no genótipo tem surgido. Segundo ela, pacientes com PHP1a apresentam mutações na região codificadora da Gsalfa do GNAS e o padrão de herança é autossômico dominante relacionado à transmissão materna. Por outro lado, o PHP1b é caracterizado por alterações nas regiões diferencialmente metiladas (DMRs) do GNAS por mecanismos não completamente esclarecidos, limitando a previsão do seu padrão de herança. Pacientes que apresentam a AHO na ausência de resistência hormonal têm o diagnóstico de pseudopseudo-hipoparatireoidismo (PPHP) e seu padrão de herança é autossômico dominante relacionado à transmissão paterna de mutações na região codificadora da Gsalfa do GNAS. OBJETIVOS: Classificar 25 pacientes com PHP com base em defeitos no GNAS e caracterizar seu fenótipo. Pesquisar mutações no GNAS nos quatro pacientes com PPHP e também caracterizar seu fenótipo. MÉTODOS: A avaliação fenotípica incluiu análise das resistências hormonais, pesquisa de repercussões crônicas da hipocalcemia/hiperfosfatemia (calcificações em sistema nervoso central: SNC e catarata) e identificação da AHO. A análise do GNAS foi feita por sequenciamento automático e MLPA (região codificadora da Gsalfa) e por MS-MLPA (região regulatória: DMRs). RESULTADOS: Resistência ao PTH foi identificada nos 25 pacientes com PHP e resistência ao TSH em 17/25. Calcificações em SNC e catarata estiveram presentes em 18 e 10 pacientes com PHP, respectivamente. A AHO foi caracterizada por: face arredondada (n=18), braquidactilia (n=11), baixa estatura (n=8), ossificações subcutâneas (n=6), obesidade (n=9) e retardo mental (n=3). Identificamos oito mutações (cinco novas) na região codificadora da Gsalfa em 10 pacientes com PHP1a e quatro pacientes com PPHP. Quinze pacientes apresentaram alteração no padrão de metilação das DMRs (genótipo: PHP1b). O fenótipo dos pacientes foi semelhante nos dois grupos. DISCUSSÃO E CONCLUSÃO: Nenhuma das classificações do PHP foi capaz de predizer gravidade ou o curso clínico da doença. Porém, o diagnóstico do PHP1a baseado no genótipo possibilitou a identificação precoce de uma paciente, a exclusão de PHP1a na filha de outra paciente e o aconselhamento genético em duas famílias. O diagnóstico de PHP1b em uma paciente só foi possível graças ao genótipo, visto que seu perfil laboratorial osteometabólico era inconclusivo. Com base no fenótipo, 8/15 pacientes com PHP1b seriam classificados como PHP1a considerando a presença de dois ou mais estigmas da AHO, podendo levar a falhas no aconselhamento genético. Portanto, concluímos que a classificação do PHP baseada na análise do GNAS é mais informativa do que a baseada no fenótipo, permitindo o diagnóstico precoce e o aconselhamento genético de casos familiais de PHP1a. A identificação do PHP1b deve ser promissora na medida em que seus mecanismos de transmissão forem mais bem entendidos / BACKGROUND: The first human disease attributed to hormone resistance was pseudohypoparathyroidism (PHP), a rare disease characterized by hypocalcemia, hyperphosphatemia and elevated parathyroid hormone (PTH) levels in the presence of normal renal function, consistent picture of PTH resistance. The original classification of PHP takes into account the Albright hereditary osteodystrophy (AHO): present in PHP1a and absent in PHP1b. As the molecular bases of PHP have been understood, a classification based on genotype has emerged. According to it, PHP1a patients present mutations in the Gsalpha coding region of the GNAS and the pattern of inheritance is autosomal dominant related to maternal transmission. On the other hand, PHP1b is characterized by alterations in differentially methylated regions (DMRs) of the GNAS by mechanisms not completely clear, limiting the prediction of the pattern of inheritance. Patients who present AHO in the absence of hormone resistance have the diagnosis of pseudopseudohypoparathyroidism (PPHP) and their pattern of inheritance is autosomal dominant related to paternal transmission of mutations in the Gsalfa coding region of the GNAS. OBJECTIVE: To classify 25 patients with PHP based on GNAS molecular defects and to characterize their phenotype. To search for GNAS mutations in four patients with PPHP and also to characterize their phenotype. METHODS: The phenotypic evaluation included analysis of hormone resistances, research of chronic repercussions of hypocalcemia/hyperphosphatemia (calcifications in central nervous system: CNS and cataract) and identification of AHO. The analysis of the GNAS was done by automated sequencing and MLPA (Gsalphaa coding region) and by MS-MLPA (regulatory region: DMRs). RESULTS: PTH resistance was identified in 25 patients with PHP and TSH resistance in 17/25. Calcifications in CNS and cataract were present in 18 and 10 patients with PHP, respectively. AHO was characterized by: rounded face (n=18), brachydactyly (n=11), short stature (n=8), subcutaneous ossifications (n=6), obesity (n=9) and mental retardation (n=3). We identified eight mutations (five novels) in the Gsalpha coding region in 10 patients with PHP1a. Fifteen patients presented alterations in the methylation pattern of DMRs (genotype: PHP1b). The phenotype of patients was similar in both groups. DISCUSSION AND CONCLUSION: None of the PHP classifications was able to predict the severity or clinical course of the disease. However, the diagnosis of PHP1a based on genotype allowed the early identification of one patient, the exclusion of PHP1a in the daughter of another patient and genetic counseling in two families. The PHP1b diagnosis in one patient was only possible due to the genotype, as her bone metabolism profile was inconclusive. Based on phenotype, 8/15 PHP1b patients would have been classified as PHP1a considering the presence of two or more AHO stigmas, being able to lead to failures in genetic counseling. Therefore, we conclude that the PHP classification based on GNAS analysis is more informative than that based on phenotype, allowing the early diagnosis and the genetic counseling for familial cases of PHP1a. The identification of PHP1b may be promising as its transmission mechanisms are better clarified

INTRODUÇÃO: A primeira doença humana atribuída à resistência hormonal foi o pseudo-hipoparatireoidismo (PHP), uma doença rara caracterizada por hipocalcemia, hiperfosfatemia e níveis elevados de hormônio paratireoidiano (PTH) na presença de função renal normal, quadro condizente com resistência ao PTH. A classificação original do PHP leva em consideração a osteodistrofia hereditária de Albright (AHO): presente no PHP1a e ausente no PHP1b. Na medida em que as bases moleculares do PHP têm sido compreendidas, uma classificação baseada no genótipo tem surgido. Segundo ela, pacientes com PHP1a apresentam mutações na região codificadora da Gsalfa do GNAS e o padrão de herança é autossômico dominante relacionado à transmissão materna. Por outro lado, o PHP1b é caracterizado por alterações nas regiões diferencialmente metiladas (DMRs) do GNAS por mecanismos não completamente esclarecidos, limitando a previsão do seu padrão de herança. Pacientes que apresentam a AHO na ausência de resistência hormonal têm o diagnóstico de pseudopseudo-hipoparatireoidismo (PPHP) e seu padrão de herança é autossômico dominante relacionado à transmissão paterna de mutações na região codificadora da Gsalfa do GNAS. OBJETIVOS: Classificar 25 pacientes com PHP com base em defeitos no GNAS e caracterizar seu fenótipo. Pesquisar mutações no GNAS nos quatro pacientes com PPHP e também caracterizar seu fenótipo. MÉTODOS: A avaliação fenotípica incluiu análise das resistências hormonais, pesquisa de repercussões crônicas da hipocalcemia/hiperfosfatemia (calcificações em sistema nervoso central: SNC e catarata) e identificação da AHO. A análise do GNAS foi feita por sequenciamento automático e MLPA (região codificadora da Gsalfa) e por MS-MLPA (região regulatória: DMRs). RESULTADOS: Resistência ao PTH foi identificada nos 25 pacientes com PHP e resistência ao TSH em 17/25. Calcificações em SNC e catarata estiveram presentes em 18 e 10 pacientes com PHP, respectivamente. A AHO foi caracterizada por: face arredondada (n=18), braquidactilia (n=11), baixa estatura (n=8), ossificações subcutâneas (n=6), obesidade (n=9) e retardo mental (n=3). Identificamos oito mutações (cinco novas) na região codificadora da Gsalfa em 10 pacientes com PHP1a e quatro pacientes com PPHP. Quinze pacientes apresentaram alteração no padrão de metilação das DMRs (genótipo: PHP1b). O fenótipo dos pacientes foi semelhante nos dois grupos. DISCUSSÃO E CONCLUSÃO: Nenhuma das classificações do PHP foi capaz de predizer gravidade ou o curso clínico da doença. Porém, o diagnóstico do PHP1a baseado no genótipo possibilitou a identificação precoce de uma paciente, a exclusão de PHP1a na filha de outra paciente e o aconselhamento genético em duas famílias. O diagnóstico de PHP1b em uma paciente só foi possível graças ao genótipo, visto que seu perfil laboratorial osteometabólico era inconclusivo. Com base no fenótipo, 8/15 pacientes com PHP1b seriam classificados como PHP1a considerando a presença de dois ou mais estigmas da AHO, podendo levar a falhas no aconselhamento genético. Portanto, concluímos que a classificação do PHP baseada na análise do GNAS é mais informativa do que a baseada no fenótipo, permitindo o diagnóstico precoce e o aconselhamento genético de casos familiais de PHP1a. A identificação do PHP1b deve ser promissora na medida em que seus mecanismos de transmissão forem mais bem entendidos / BACKGROUND: The first human disease attributed to hormone resistance was pseudohypoparathyroidism (PHP), a rare disease characterized by hypocalcemia, hyperphosphatemia and elevated parathyroid hormone (PTH) levels in the presence of normal renal function, consistent picture of PTH resistance. The original classification of PHP takes into account the Albright hereditary osteodystrophy (AHO): present in PHP1a and absent in PHP1b. As the molecular bases of PHP have been understood, a classification based on genotype has emerged. According to it, PHP1a patients present mutations in the Gsalpha coding region of the GNAS and the pattern of inheritance is autosomal dominant related to maternal transmission. On the other hand, PHP1b is characterized by alterations in differentially methylated regions (DMRs) of the GNAS by mechanisms not completely clear, limiting the prediction of the pattern of inheritance. Patients who present AHO in the absence of hormone resistance have the diagnosis of pseudopseudohypoparathyroidism (PPHP) and their pattern of inheritance is autosomal dominant related to paternal transmission of mutations in the Gsalfa coding region of the GNAS. OBJECTIVE: To classify 25 patients with PHP based on GNAS molecular defects and to characterize their phenotype. To search for GNAS mutations in four patients with PPHP and also to characterize their phenotype. METHODS: The phenotypic evaluation included analysis of hormone resistances, research of chronic repercussions of hypocalcemia/hyperphosphatemia (calcifications in central nervous system: CNS and cataract) and identification of AHO. The analysis of the GNAS was done by automated sequencing and MLPA (Gsalphaa coding region) and by MS-MLPA (regulatory region: DMRs). RESULTS: PTH resistance was identified in 25 patients with PHP and TSH resistance in 17/25. Calcifications in CNS and cataract were present in 18 and 10 patients with PHP, respectively. AHO was characterized by: rounded face (n=18), brachydactyly (n=11), short stature (n=8), subcutaneous ossifications (n=6), obesity (n=9) and mental retardation (n=3). We identified eight mutations (five novels) in the Gsalpha coding region in 10 patients with PHP1a. Fifteen patients presented alterations in the methylation pattern of DMRs (genotype: PHP1b). The phenotype of patients was similar in both groups. DISCUSSION AND CONCLUSION: None of the PHP classifications was able to predict the severity or clinical course of the disease. However, the diagnosis of PHP1a based on genotype allowed the early identification of one patient, the exclusion of PHP1a in the daughter of another patient and genetic counseling in two families. The PHP1b diagnosis in one patient was only possible due to the genotype, as her bone metabolism profile was inconclusive. Based on phenotype, 8/15 PHP1b patients would have been classified as PHP1a considering the presence of two or more AHO stigmas, being able to lead to failures in genetic counseling. Therefore, we conclude that the PHP classification based on GNAS analysis is more informative than that based on phenotype, allowing the early diagnosis and the genetic counseling for familial cases of PHP1a. The identification of PHP1b may be promising as its transmission mechanisms are better clarified