#vitamin d test dubai

[dardocuae]

Get a Vitamin Test from the comfort of your own home starting at AED 149. Book your test or health package online to get quality reports.

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The Ultimate Guide to Healthy Living in Dubai: Tips from a Top Nutritionist.

Dubai, with its fast-paced lifestyle, diverse culinary scene, and hot climate, presents unique health challenges and opportunities. Whether you're a long-time resident or a newcomer, maintaining a balanced diet and healthy lifestyle can be challenging. However, with the right guidance, you can achieve optimal health and well-being. As a leading nutritionist in Dubai, I've compiled this ultimate guide to help you navigate the city's nutritional landscape.

1. Understanding Dubai’s Dietary Culture

Nutritional in Dubai is a melting pot of cultures, which is reflected in its diverse food scene. From Emirati cuisine to international delicacies, the options are endless. However, with the abundance of fast food and rich, indulgent dishes, it's easy to stray from a healthy diet. Balancing traditional and modern eating habits is key to maintaining health. Incorporating local ingredients such as dates, camel milk, and fresh seafood can offer nutritious alternatives to more calorie-dense options.

2. Staying Hydrated in the Desert Heat

Dubai's climate is notoriously hot, making hydration crucial. Dehydration can lead to fatigue, headaches, and even more serious health issues. Drinking at least 8-10 glasses of water a day is essential, especially during the summer months. Additionally, incorporating hydrating foods like cucumbers, watermelon, and leafy greens into your diet can help maintain optimal hydration levels.

3. Managing Weight in a City Full of Temptations

With the plethora of dining options, from lavish buffets to street food festivals, managing weight can be challenging in Dubai. Portion control, mindful eating, and regular physical activity are essential strategies. I recommend planning meals ahead, choosing restaurants that offer healthy options, and incorporating regular exercise into your routine. Whether it's a morning jog along the beach or a yoga class, staying active is key to maintaining a healthy weight.

4. Nutritional Support for Dubai’s Busy Professionals

Dubai's fast-paced lifestyle often leaves little time for proper meal planning. For busy professionals, it’s crucial to prioritize nutrition despite hectic schedules. Meal prepping, opting for nutrient-dense snacks, and staying away from sugary, processed foods can help maintain energy levels throughout the day. A well-balanced diet not only supports physical health but also enhances mental clarity and productivity.

5. Special Considerations for Expats

Dubai is home to a large expatriate community, many of whom may find adjusting to the local diet and climate challenging. For expats, it’s important to adapt to local eating patterns while staying true to your dietary needs. Whether you're a vegetarian, vegan, or following a specific diet for health reasons, Dubai offers a range of options. Consulting with a nutritionist can help tailor your diet to suit your lifestyle while ensuring you get all the essential nutrients.

6. The Importance of Regular Health Check-Ups

Preventive care is crucial for long-term health. Regular check-ups with a healthcare provider can help identify potential health issues before they become serious. As a nutritionist, I recommend routine blood tests to monitor key markers such as cholesterol levels, blood sugar, and vitamin D, which is particularly important given Dubai's high prevalence of vitamin D deficiency due to limited sun exposure.

7. Personalized Nutrition Plans for Optimal Health

Every individual is unique, and so are their nutritional needs. A personalized nutrition plan, tailored to your specific health goals, lifestyle, and dietary preferences, is the most effective way to achieve and maintain optimal health. Whether you’re looking to manage weight, improve gut health, or boost your energy levels, a customized approach ensures that you’re getting the right nutrients in the right amounts.

Conclusion

Living in Dubai offers many opportunities for a vibrant and healthy lifestyle, but it also comes with its own set of challenges. By staying informed and making conscious choices about your diet and lifestyle, you can enjoy all that this dynamic city has to offer while maintaining your health and well-being. As a nutritionist in Dubai, I'm here to help you navigate your journey to better health, offering personalized guidance and support every step of the way.

Discover a healthier you with the expertise of Dubai's top nutritionist. Specializing in personalized nutrition plans, we cater to your unique health needs, whether you're looking to manage weight, improve gut health, or enhance overall well-being. Our evidence-based approach combines the latest in nutritional science with a deep understanding of Dubai's diverse cultural landscape, ensuring that your diet is not only effective but also enjoyable.

We offer a range of services, including individualized meal plans, nutritional counseling, and ongoing support to help you achieve and maintain your health goals. Whether you're navigating Dubai's fast-paced lifestyle or adapting to a new diet as an expat, our tailored solutions are designed to fit seamlessly into your life.

[cancercarespecialties]

Understanding Parathyroid Disease: Causes, Symptoms, and Treatments

Parathyroid disease encompasses various disorders affecting the parathyroid glands, which are small glands located behind the thyroid gland in the neck. These glands play a crucial role in regulating calcium levels in the blood through the production of parathyroid hormone (PTH). When these glands malfunction, it can lead to significant health issues.

One common condition associated with parathyroid disease is primary hyperparathyroidism, where one or more of the parathyroid glands become overactive and produce excessive amounts of PTH. This results in elevated calcium levels in the blood, which can cause symptoms such as frequent urination, kidney stones, bone pain, fatigue, and digestive issues. The condition is often caused by a benign tumor called an adenoma, but it can also be due to glandular hyperplasia or, rarely, parathyroid cancer.

Another condition is secondary hyperparathyroidism, typically resulting from another underlying health problem such as chronic kidney disease. In this case, the parathyroid glands produce more PTH in response to low calcium levels caused by the kidneys' inability to convert vitamin D into its active form.

On the other hand, hypoparathyroidism occurs when the parathyroid glands produce insufficient PTH, leading to low calcium levels and high phosphorus levels in the blood. This can cause symptoms like muscle cramps, tingling in the fingers, and, in severe cases, seizures. Causes of hypoparathyroidism include autoimmune disorders, genetic conditions, or damage to the parathyroid glands during thyroid surgery.

Cancer screening Dubai diagnosis of parathyroid disease generally involves blood tests to measure calcium, phosphate, and PTH levels, along with imaging studies to examine the glands. Treatment varies depending on the specific condition and may include medications, hormone replacement therapy, or surgical intervention to remove affected glands or tumors.

Effective management of Parathyroid disease is crucial for maintaining bone health and overall well-being. Regular monitoring and appropriate treatment can help alleviate symptoms and prevent complications associated with these disorders.

[diettoxsupplements]

How Can You Improve Your Health with the Finest Multivitamin Supplements?

Maintaining optimal health requires a balanced diet, regular exercise, and sometimes, a little extra help from supplements. Multivitamins can fill nutritional gaps and ensure you get all the essential vitamins and minerals your body needs. In this blog, we will explore how you can improve your health with the finest multivitamin supplements in Dubai and Multivitamin Supplements in Abu Dhabi.

The Importance of Multivitamins

Fills Nutritional Gaps

Even with a well-balanced diet, it can be challenging to get all the nutrients your body needs. Multivitamins help fill these gaps by providing essential vitamins and minerals, ensuring your body functions at its best.

Boosts Immune System

Multivitamins play a crucial role in supporting a strong immune system. Vitamins like C, D, and E, along with minerals like zinc, are known to enhance immune function and help your body fight off infections and illnesses.

Supports Energy Levels

B vitamins, commonly found in multivitamins, are essential for converting food into energy. Taking a daily multivitamin can help maintain your energy levels throughout the day, reducing fatigue and boosting overall vitality.

Enhances Mental Health

Certain vitamins and minerals, such as B vitamins, magnesium, and vitamin D, have been linked to improved mood and cognitive function. Multivitamins can support brain health and reduce symptoms of anxiety and depression.

Choosing the Best Multivitamin Supplements in Dubai and Abu Dhabi

High-Quality Ingredients

When selecting multivitamin supplements, it’s important to choose products with high-quality ingredients. Look for multivitamins that are free from artificial additives, fillers, and allergens. In both Dubai and Abu Dhabi, you can find premium multivitamins that meet these criteria.

Tailored to Your Needs

Multivitamins are available in various formulations to suit different needs, such as women’s health, men’s health, prenatal, and seniors. Ensure you choose a multivitamin that aligns with your specific health requirements and age group.

Trusted Brands

Opt for multivitamins from reputable brands that have undergone rigorous testing and quality control. Trusted brands ensure their products are safe, effective, and meet the highest standards. Both multivitamin supplements in Dubai and multivitamin supplements in Abu Dhabi offer a range of trusted options.

Expert Advice

Consulting with a healthcare professional or a nutritionist can help you select the right multivitamin for your needs. They can provide personalized recommendations based on your dietary habits, lifestyle, and health goals.

Benefits of Multivitamin Supplements in Dubai and Abu Dhabi

Accessibility

In both Dubai and Abu Dhabi, multivitamin supplements are readily available in pharmacies, health stores, and online platforms. This accessibility makes it easy to find the right supplements for your health needs.

Variety of Options

The health and wellness market in Dubai and Abu Dhabi offers a diverse range of multivitamins, catering to various dietary preferences and health conditions. Whether you’re looking for organic, vegan, or allergen-free options, you’ll find plenty of choices.

Commitment to Quality

Health products in Dubai and Abu Dhabi adhere to strict quality standards, ensuring that the multivitamins you purchase are safe and effective. This commitment to quality provides peace of mind when choosing supplements.

Conclusion

Improving your health with the finest Multivitamin Supplements in Dubai and multivitamin supplements in Abu Dhabi is a practical and effective way to ensure your body gets the essential nutrients it needs. By filling nutritional gaps, boosting your immune system, supporting energy levels, and enhancing mental health, multivitamins play a vital role in overall well-being. At Diettox, we are committed to helping you find the best multivitamins to support your health journey. Explore our range of high-quality multivitamin supplements and take a proactive step towards better health today!

Visit our website for more information:-https://diettox.com/

[indiamedicaltourism]

Prostate Cancer Treatment in India for Foreigners

Prostate cancer is seen in men’s and it mostly occurs as the age increases, most of the time it is seen in men's who are around or above 50 years of age. Some of the reason for it is family history, hormones level, pesticides or obesity and weight. Research shows that black men’s are more prone to prostate cancer compared to White Men. In black people prostate cancer is more outraged and in onward motion. However this type of cancer increases slowly compared to other type of cancer. In some people regular monitoring is required so that treatment can be affective. Also obese people are at high risk of prostate cancer compared to a person with the healthy weight. Symptoms that shouldn't be avoided are frequent urination especially at night, problem in urination or burning, holding back urine, blood in the urine. Prostate cancer can be cured completely when detected at the early age and treated on time. This is the second type of cancer seen very common in men in the world. India ranks in Top 10 countries that are leading in cancer treatment. Survival rate of prostate cancer is much better than any other type of cancer. A person should maintain healthy weight, improved and balanced diet should increase vitamin D intake to avoid prostate cancer.

Prostate Cancer Treatment Cost in India: Prices include hospital stay, in case of any additional tests to be done before and after the surgery.

Chemotherapy                                   Rs 44300 to Rs 58100

Prostate Cancer Surgical                   Rs 221000 to Rs 292000

Top Hospitals for Prostate Cancer Treatment in India: Hospitals in India has the team of expert for the treatment of prostate cancer. Since India has the maximum success rate in the treatment of prostate cancer it is possible only because of the techniques used by the oncologist here along with the trained staff appointed to take care of patients before and after the treatment. Hospitals here consist of all the multi special facilities that are required for effective treatment.

Top Doctors for Prostate Cancer Treatment: The doctor who deals with urinary track and male reproduction system is known as Urologist. Urologist is specialized doctor who plays an important role in the treatment of prostate cancer. Our best and skilled urologist performs the surgery and prescribes the necessary medication for the better results they keep a track of the patience treatment and pre and post follow-ups so that the patient can rely on doctors for their treatment.

Al AfiyaMedi Tour is a leading medical tourism company in India. We offer medical tourism services such as finding the right doctor, the right hospital, and cost estimation for medical treatment in India for foreign patients. Some of the main countries are Bangladesh, South Africa, Egypt, Uganda, Zambia, Sudan, Dubai, Namibia, Iraq, Kenya, Saudi Arabia, Ethiopia, Nigeria, and so on. We provide free medical assistance for TURP surgery cost, lung cancer treatment, blood cancer treatment cost, the best hospital for heart valve replacement, arthroscopic surgery, bone marrow transplant cost, best liver transplant hospital, cosmetic andplastic surgery, heart surgery, spine tumor surgery,cancer treatment cost, lung transplant, top knee replacement surgeons, knee replacement surgery cost, top shoulder replacement surgeons,.  If you are searching for free medical and healthcare consulting to find the best hospitals and top doctors and surgeons in India for any treatment then contact us- Alafiyameditour.com.

Source: https://alafiyameditour1.blogspot.com/2024/05/prostate-cancer-treatment-in-india-for.html

[dr-humeira-badsha]

What is a Rheumatologist and what are the Things to Do for Healthy Bones and Joints?

About

A Rheumatologist is a doctor who specializes in arthritis and bone and joint diseases. Rheumatologist uae prescribe medication to control inflammation and pain and monitor the patient closely. The rheumatologist may give joint injections, order blood tests, or refer you to a surgeon or physical therapist – as appropriate.

Top 10 Things To Do For Healthy Bones and Joints

Dr. Humeira Badsha recommends the following pointers for maintaining healthy bones and joints:

Maintain a healthy body weight and body mass index. Research has shown that every kilogram increase in body weight above normal increases the stress on knees by 5 kilograms.

Consume sufficient calcium. An adult needs 1000 mg of calcium daily, and a post-menopausal woman needs 1500 mg. One glass (200 ml) of milk contains about 300 mg of calcium.

Get enough Vitamin D. The daily requirement is 1000 IU, which can be obtained by exposure to the sun for about 15 minutes per day for very light-skinned people. More pigmented skins may struggle to absorb vitamin D, necessitating a supplement or fortified foods. Surprisingly, many people in sunny Dubai, UAE, are deficient in vitamin D.

Exercise daily or at least 3-4 times per week. A combination of aerobic activities and strength training is beneficial.

Quit smoking. Research has shown that smoking can increase your risk of rheumatoid arthritis by up to 20-fold.

Pay attention to your body. Do not ignore aches, pains, joint swelling, or stiffness. Consult a Rheumatologist promptly if you experience these symptoms.

Eat fish. The Omega oils in certain types of fish and walnuts help prevent arthritis.

Watch your diet. Beneficial anti-inflammatory properties can be found in ginger, turmeric, and avocado. Try to limit the consumption of excess red meats and alcohol.

Relax. Stress can trigger autoimmune diseases and certain forms of arthritis such as rheumatoid arthritis.

Stretch regularly. Stretching before exercise and throughout the day can prevent muscle strain and repetitive stress injuries.

[health-connect-polyclinic]

Navigating Fertility Challenges: Expert Guidance for Your Journey to Parenthood

If you’re on the journey to parenthood and facing challenges in conceiving, consulting a Gynaecologist in Dubai or your Obstetrician is a crucial step. Fertility issues can be daunting, but there are proactive measures you can take to enhance your chances of conceiving and maintaining a healthy pregnancy. At Health Connect Poly Clinic, our Consultant Obstetrician and Gynecologist, Dr. Majida AlMaarof, is here to guide you through this journey. Let’s explore how you can resolve fertility problems and increase your chances of having a successful pregnancy.

1.Embrace a Healthy Diet:

A well-balanced diet is essential when trying to conceive. Incorporate dark green leafy vegetables and fruits into your meals. These foods provide your body with essential nutrients and minerals, including folic acid, which is crucial for preventing birth defects. Additionally, consuming healthy fats in moderation can reduce inflammation in your body and improve fertility. Choose complex carbohydrates and limit highly processed carbs to prevent blood sugar spikes, insulin resistance, and potential ovulation issues.

2. Consider Supplements:

Start taking folic acid supplements (400 mcg per day) before conception. Ensure your vitamin D levels are adequate; sunlight is an excellent natural source of this vitamin.

3. Lifestyle Adjustments:

Quit smoking, limit alcohol consumption, and reduce caffeine intake. These substances can negatively impact fertility and pregnancy.

4. Maintain a Healthy Weight:

Achieving and maintaining a healthy body weight is vital for enhancing ovulation and reducing the risk of pregnancy complications like gestational diabetes.

5. Exercise Moderately:

Engage in exercises you enjoy, such as walking, aerobics, or swimming in moderation. Avoid strenuous or exhausting workouts that could potentially affect fertility.

6. Stress Management:

High stress levels can hinder fertility. Manage stress through activities like meditation, yoga, and staying hydrated.

7. Track Ovulation:

Monitor your ovulation cycle to identify the most fertile days. You can use home kits, measure your basal body temperature, or observe changes in cervical mucus. A pelvic ultrasound at our clinic can also provide valuable insights into your ovulation.

8. Investigate Irregular Periods:

If you experience irregular periods, it’s essential to determine the underlying cause. Hormonal tests, ovarian reserve assessments (AMH), and evaluations for conditions like polycystic ovary syndrome (PCOS) or high prolactin levels can help diagnose and treat these issues, improving your chances of getting pregnant.

At Health Connect Poly Clinic, we are committed to supporting your journey towards parenthood. Dr. Majida AlMaarof and our dedicated team are here to provide personalized care and guidance. If you’re ready to take the next step or have any questions, don’t hesitate to contact us at 04 554 7335 or 052 218 9240.

Following these tips and seeking professional guidance will help you on your path to a successful pregnancy. Your dream of starting a family is within reach, and we are here to help you achieve it.

[farzanatrading]

The role of micronutrients in enhancing digestion

Vitamin D

A high dose of vitamin D controls energy digestion and increments insulin responsiveness however is related with elevated degrees of kidney harm. Moreover, this daylight nutrient further develops stomach vegetation, forestalls metabolic disorder, and reestablishes the great microscopic organisms in the stomach.

According to the review, vitamin D keeps a solid stomach and is a strong treatment for gastrointestinal illnesses. Notwithstanding, a high dose of vitamin D controls energy digestion and increments insulin responsiveness yet is related with elevated degrees of kidney harm.

Magnesium

Magnesium is fundamental for nucleic corrosive and protein amalgamation. Furthermore, it is basic in go-between metabolic wellbeing and explicit capabilities in various organs like neuromuscular and cardiovascular frameworks.

Nucleic acids are fundamental during the time spent DNA replication, recombination in the turnover of DNA record of RNA and DNA, and purine pyrimidine union. Likewise, in excess of 300 compounds are subject to magnesium.

 In ordinary grown-ups, test magnesium lack brings about changed cardiovascular capability joined by side effects like upset heart cadence and electrocardiographic anomalies. Moreover, it suggests carb digestion, insulin opposition, and diminished insulin emission.

Concentrates on show magnesium assumes a part in north of 300 metabolic responses in the body. These responses will adversely affect fundamental body processes, including protein combination, cell energy creation, and capacity.

Manganese

Manganese is one more fundamental micronutrient associated with integrating or initiating numerous compounds. It likewise acts in intracellular exercises as a cofactor of numerous chemicals. Research recommends that it likewise supports the legitimate guideline of the digestion of glucose and lipids in people.

Manganese invigorates the actuation of different chemicals liable for metabolic responses. It incorporates protein and amino corrosive processing and usage and the digestion of cholesterol and carbs.

Being one of the unavoidable components, it helps produce compounds liable for the digestion of protein and fats. Moreover, it upholds the resistant framework's glucose balance, which is associated with the development of cell energy creation and bone development. In any case, both lack and overconsumption can antagonistically influence digestion, so keeping this mineral in the perfect sum in the diet is fundamental.

Zinc

Concentrates on show that zinc assumes a crucial part in the legitimate working of lipid and glucose digestion guideline and helps in the system of insulin. What's more, as indicated by a few examinations, those zinc supplementations can further develop pulse, glucose, and low-thickness lipoprotein cholesterol serum level.

Zinc-intervened energy digestion guideline could likewise be useful for DNA support crypto security and malignant growth discernibility. Hence this significant micronutrient can broadly lessen energy digestion and basically reestablish the disabled fiery digestion of Cell physiology.

Globally sourced ingredients offer a limitless range of flavors and textures. Delivered to your door are genuine herbs online and spices that have been acquired from all across Dubai.

[edenderma-blog]

How To Keep Your Skin Healthy

Beautiful, young-looking skin is a goal we all want to achieve; but it can be easier said than done. There are many factors that go into the health of your skin, and you will have to pay attention to each if you want your skin looking its best.

These ten tips will get you on the right path toward proper skincare:

No Smoking

Everyone knows that smoking is bad for your lungs, but you may be surprised to hear that it is also damaging to your skin. Research has shown that smoking contributes to wrinkles and can make your skin look older. Not only does smoking deplete the skin of oxygen and nutrients, but it also reduces the skin's elasticity.

Stress Management

Has your skin ever broken out when you were stressing out about a test or a job interview? That’s because stress can have a number of adverse health effects, including its impact on your skin. Stress increases the body’s production of hormones that make skin oily. It also decreases the body’s ability to fight off bacteria that causes acne.

There are many things you can do to keep your stress in check. You may want to consider yoga, exercise, or massage.

Wear Sunscreen

In small doses, spending time in the sun can be valuable to your skin because it exposes you to Vitamin D. Unfortunately, too much exposure to the sun can cause wrinkles, age spots, and can increase the risk of cancer. It is highly recommended that you use sunscreen (SPF 15 or stronger) whenever you go outside. Sunscreen should be reapplied every two hours. Hats, long sleeve shirts, and pants can also help prevent your skin from being exposed to the sun.

Eat Healthily

A healthy diet will improve your overall health and the health of your skin. A diet full of fruits, vegetables, whole grains, and proteins will have your skin looking its best. Nuts and fish are especially good for cleaning out the bad oils from your body. Cutting down on soda and candy is highly recommended.

Staying hydrated is also pivotal to your skin’s health. Water helps clear toxins that cause blemishes. It also helps transport oxygen and nutrients to your skin cells. Ultimately, water prevents dehydration, which can lead to older looking skin. Don’t forget to drink plenty of water.

Clean Skin Regularly and Moisturize

Obviously, cleaning your skin on a regular basis is extremely important. When you wash your skin you remove dirt and bacteria that can lead to breakouts. Remember to wash your skin gently so that you do not aggravate or damage it. You should also avoid using soaps that are too strong so that you do not irritate your skin.

Moisturizing your skin is highly recommended because it protects your skin from drying up. It also helps your skin maintain natural moisture levels. It is best to apply moisturizer while your skin is still damp so that it traps the surface moisture into your skin. As I mentioned above, keeping your skin hydrated extremely important for your skin’s health.

Get a Facial

Facial treatments are one of our most popular spa services. Facials manage to deeply clean one’s skin and pores and rejuvenate skin that has begun to age or appear dry. They also can hydrate the skin and provide relaxing and soothing overall experiences.

Threads’ facials are customized for your individual needs, whether you want to detoxify, oxygenate, hydrate, purify your skin or reduce puffiness.

Get Some Sleep

It’s called Beauty Sleep for a reason. Getting enough quality sleep every night is essential for healthy skin. While you are sleeping, your skin and entire body rests and repairs itself. If you are not getting enough sleep, you are putting extra stress on your body which can lead to breakouts and other skin issues. Between 6-8 hours of sleep, night is recommended.

Also, remember to keep your sheets and pillowcase clean in order to avoid a buildup of grease and oil that can irritate your skin. If you want to keep your skin healthy and beautiful in Dubai, don’t hesitate and visit Eden Derma Clinic, check our website here

[rabbitbois-blog]

Isn't There An Easier Way?

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[dardocuae]

Your test results will indicate if your vitamin D level is inadequate, adequate, or excessive. Vitamin D has numerous critical roles in the body, including bone formation and immune function. ​

Checking your vitamin D level might help you determine if you're getting enough of this vital nutrient.​

Book now! Contact us on our Toll-Free Number – 800-DARDOCTOR (800327362867).

[thecareoncall]

Vitamin D Deficiency in Adults: When to take Vitamin D Test in Dubai?

Vitamin D is produced by the skin when exposed to ultraviolet B radiation or obtained through dietary sources such as supplements. Individuals who have insufficient sun exposure, limited oral intake, or impaired intestinal absorption are commonly at risk for vitamin D deficiency. The best way to determine vitamin D sufficiency is to measure the 25-hydroxyvitamin D concentration in the blood. Average daily vitamin D intake in the general population and current dietary reference intake values are frequently insufficient to maintain optimal vitamin D levels. Take your Vitamin D test in Dubai

[cancercarespecialties]

Understanding Parathyroid Disease: Symptoms, Diagnosis, and Treatment

Parathyroid disease encompasses a range of disorders affecting the parathyroid glands, which are small glands located near the thyroid gland in the neck. These glands play a crucial role in regulating calcium levels in the blood through the secretion of parathyroid hormone (PTH). Disruptions in this balance can lead to various health issues.

The most common parathyroid disorder is primary hyperparathyroidism, where one or more of the parathyroid glands become overactive, producing excess PTH. This condition often leads to elevated calcium levels in the blood, known as hypercalcemia. Symptoms can include fatigue, kidney stones, bone pain, and abdominal discomfort. In severe cases, it can cause osteoporosis or renal failure.

Secondary hyperparathyroidism occurs as a response to another condition that causes low calcium levels, such as chronic kidney disease or vitamin D deficiency. The parathyroid glands increase PTH production to compensate for the low calcium, which can eventually lead to bone loss and other complications if not addressed.

Another parathyroid disorder is tertiary hyperparathyroidism, which often develops after long-standing secondary hyperparathyroidism. Best Cancer Surgeon Dubai case, the parathyroid glands remain overactive even after the initial cause of the calcium imbalance has been treated.

On the other hand, parathyroid cancer is a rare but serious condition where a malignant tumor develops in one of the parathyroid glands, leading to uncontrolled hormone secretion and severe hypercalcemia.

Diagnosis of parathyroid diseases typically involves blood tests to measure calcium and PTH levels, imaging studies to locate abnormal glands, and sometimes biopsy procedures. Treatment options vary based on the specific disorder and may include medication, dietary changes, or surgical intervention to remove affected glands.

Overall, understanding and managing Parathyroid disease is essential for maintaining bone health and overall well-being. Regular monitoring and timely treatment can help prevent complications and improve quality of life for those affected.

[diettoxsupplements]

Maximizing Your Health with Multivitamin Supplements in Abu Dhabi

In today’s fast-paced world, maintaining optimal health can be a challenge. Between busy work schedules, family commitments, and social activities, it can be difficult to ensure that you’re getting all the necessary nutrients from your diet alone. This is where multivitamin supplements come in. By incorporating multivitamin supplements into your daily routine, you can bridge nutritional gaps and support your overall health. Let’s explore how Multivitamin Supplements in Abu Dhabi can help you maximize your health, and how you can also find similar benefits with multivitamin supplements in Dubai.

Why Take Multivitamin Supplements?

Multivitamin supplements are designed to provide a convenient way to get a balanced intake of essential vitamins and minerals. Here are some key reasons to consider taking them:

Nutrient Insurance: Even with a balanced diet, it can be challenging to consume all the necessary nutrients daily. Multivitamins can help fill these gaps.

Boost Energy Levels: Vitamins and minerals play a crucial role in energy production. A deficiency can lead to fatigue and decreased energy levels.

Support Immune Function: Essential vitamins such as vitamin C, vitamin D, and zinc can boost your immune system, helping you stay healthy.

Improve Bone Health: Calcium, vitamin D, and magnesium are vital for maintaining strong and healthy bones.

Enhance Cognitive Function: B vitamins are essential for brain health and cognitive function.

Finding the Right Multivitamin Supplements in Abu Dhabi

When it comes to choosing multivitamin supplements in Abu Dhabi, it’s important to consider your specific health needs and lifestyle. Here are some tips to help you make the best choice:

Read Labels Carefully: Look for a multivitamin that includes a broad range of essential nutrients without unnecessary fillers or additives.

Check Dosages: Ensure that the supplement provides adequate amounts of each vitamin and mineral according to your daily recommended intake.

Consider Your Age and Gender: There are multivitamins formulated specifically for men, women, children, and seniors, catering to their unique nutritional needs.

Opt for Quality Brands: Choose reputable brands known for their high-quality ingredients and rigorous testing standards.

Popular Places to Buy Multivitamin Supplements in Abu Dhabi

You can find a wide range of multivitamin supplements in various health stores, pharmacies, and online retailers in Abu Dhabi. Some popular places include:

Life Pharmacy: Known for its extensive selection of health and wellness products.

Holland & Barrett: Offers a variety of natural health products, including multivitamins.

i Herb: An online retailer with a vast selection of supplements and health products available for delivery.

Multivitamin Supplements in Dubai

If you frequently travel between Abu Dhabi and Dubai, you’ll be pleased to know that you can find excellent multivitamin supplements in Dubai as well. Here are some top spots to consider:

Dubai Mall Pharmacies: Various pharmacies within the mall offer a wide selection of multivitamins.

Organic Foods and Café: Provides a range of organic and natural health products.

Kcal Life: Offers personalized nutrition plans and high-quality supplements.

Tips for Maximizing the Benefits of Multivitamin Supplements

Consistency is Key: Take your multivitamin supplement daily to ensure consistent nutrient intake.

Pair with a Balanced Diet: While multivitamins are beneficial, they should complement a healthy diet rich in fruits, vegetables, lean proteins, and whole grains.

Stay Hydrated: Adequate water intake helps your body absorb and utilize vitamins and minerals more effectively.

Consult a Healthcare Professional: Before starting any new supplement, it’s always a good idea to consult with a healthcare provider to tailor the supplement to your specific needs.

Conclusion

Maximizing your health with multivitamin supplements in Abu Dhabi is a practical and effective way to ensure you’re meeting your nutritional needs. By choosing the right supplements and incorporating them into your daily routine, you can support your overall health, boost your energy levels, and enhance your well-being. Whether you’re in Abu Dhabi or exploring options for Multivitamin Supplements in Dubai, you’ll find plenty of high-quality products to help you stay on track with your health goals.

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Biomed Grid | Arab Society for Pediatric Endocrinology and Diabetes (ASPED) Masterclass in Pediatric Bone Disease 2nd November 2018, Dubai, United Arab Emirates

The Arab society of Pediatric Endocrinology and diabetes held a masterclass for pediatric bone diseases in Dubai, United Arab Emirates (UAE) in collaboration of Kyowa Kirin. This 1-day event was run within the framework of the ASPED School and was attended by 76 delegates and 14 faculty. Plenary lectures and. patient case reports were presented. The talks covered all aspects related to rickets and highlighted that nutritional vitamin D deficiencies are relatively common. This is the case despite the availability of proper nutrition and the adequate level of sun light. It was emphasized that is it vital to establish a diagnosis considering potential underlying genetic abnormalities or comorbidities which may mask initial laboratory assessments and potentially lead to an unsuitable treatment choice. Considering a less common genetic form of rickets is important in the region owing to the high frequency of consanguinity. It has been pointed out that even when a correct diagnosis and initial management is selected, it is essential to follow up patients regularly and adjust their treatment to match their needs during different growth phases.

Overall, the 14 regional and international speakers discussed nutritional and hereditary rickets, disorders of phosphate homeostasis, management of hypophosphataemic rickets and skeletal disorders beyond rickets. Lively discussions around all presented topics dominated the day, with an interest in new treatments, including burosumab as a novel fully human anti-FGF23 monoclonal antibody therapy. Burosumab has demonstrated effective inhibition of the FGF23-mediated pathway and has received approval by the US Food and Drug Administration (FDA) for the treatment of adults and children with X-linked hypophosphataemia (XLH). Preliminary experience in the region of its use has been presented.

The Arab Society for Pediatric Endocrinology and Diabetes (ASPED) www.asped.orgmmary

ASPED was launched in Abu Dhabi, UAE in September 2012, upon the initiative of a group of pediatric endocrinologists from the Middle East and North Africa. The society is a non-profit scientific organization and is registered under the Dubai Association Center (DAC) under license number DAC-0001. Its aim is to ensure a high standard of care and development in the field of pediatric endocrinology and diabetes in the Arab region extending from the Gulf through the Northern African countries.

Kyowa Kirin

Founded in 1949 in Japan, Kyowa Hakko Kirin Co., Ltd (KHK) has a track record in Japan and is now expanding globally. Its daughter company, Kyowa Kirin International (KKI) showed a rapid growth in pharmaceutical industry in various therapeutic areas including oncology, nephrology and central nervous system disorder. Many of KKI’s therapies are based on antibody technology with enhanced antibody efficacy and safety.

Acknowledgement

ASPED is grateful to all the speakers and moderators (regional and international) who contributed to the course and made it a meeting appreciated for its high educational level. We also thank Kyowa Kirin, Gulf for its collaboration and support of pediatric bone disease education in our region.

Kyowa Kirin-ASPED Pediatric Bone Disease

Masterclass

The Kyowa Kirin-ASPED masterclass in pediatric bone disease was a 1-day meeting as part of a 3-day ASPED School at the Holiday Inn, Festival City, Dubai, 31 October-3 November 2018. The masterclass aimed to educate, empower and update physicians practicing in Arab countries and involved in the care of young people with bone disorders. The masterclass was planned to be a platform to share expertise and the latest developments in clinical approaches to treatment of diseases linked to metabolic and genetic bone diseases. Including prominent international and regional speakers, the masterclass attracted 76 attendees from the Middle East and African countries.

Presentation Summaries

Nutritional and Hereditary Rickets

Aetiology and Treatment of Rickets: an overview

Abdelhadi Habeb, Kingdom of Saudi Arabia (KSA): Maternity and Children Hospital & Prince Mohammed bin Abdulaziz Hospital, KSA. Rickets occurs relatively commonly in the Middle East, Africa, and Asia. It is a gender-independent condition that starts typically between the ages of 3 and 18 months resulting in weak or soft bones in children. Although first described in 1650, the treatment of rickets remained a medical challenge well into the 20th century Early treatments were based on cod liver oil trials, and experimentation with sunlight exposure. Four subtypes of rickets are commonly distinguished and include vitamin D-related, hypocalcemia-related, hypophosphatemia-related and secondary rickets with alternative causes, such as cancer.

Hypophosphatasemia is fundamental in the development of rickets, and it was recognized early on that vitamin D deficiency, hereditary or nutritional, is the leading cause of reduced intestinal calcium absorption, resulting in increased renal phosphate excretion via activation of the parathyroid hormone pathway. Hypophosphatasemia results in accumulation or impaired apoptosis of the hypertrophic chondrocytes in the growth plate of long bone joints without enough calcification; this leads to symptoms such as bowed legs, stunted growth, bone pain and swollen joint areas. Complications may include bone fractures, muscle spasms, an abnormally curved spine or intellectual disability. Diagnosis is generally based on X-rays together with blood test findings of low calcium, low phosphorus, and high alkaline phosphatase (ALP) levels. Radiological assessment has been reported as not very successful in the diagnosis.

Treatment depends on the underlying cause or subtype of rickets. Enough vitamin D levels can be achieved through dietary supplementation and/or exposure to sunlight. Various vitamin D supplements are available, with vitamin D3 being a preferred treatment option as it is more readily absorbed than vitamin D2. However, vitamin D treatment for other forms of rickets may require calcium or phosphate supplementation to ensure appropriate metabolism of vitamin D.

Nutritional Rickets Revisited: Zulf Mughal, UK: Royal Manchester Children’s Hospital Manchester, UK. Nutritional rickets is a preventable disease and a result of insufficient vitamin D intake or absorption. A diagnosis of nutritional rickets is unlikely if there is a strong family history of rickets, associated features such as alopecia or hepatomegaly are displayed, severe skeletal deformities at a very young age or poor response to vitamin D therapy. In young children, manifestations of vitamin D deficiency include wide gait, swollen long bone joints, rachitic rosary, dental problems and osteomalacia in adolescents. In rare instances, cases of dilated cardiomyopathy have been reported.

While in early vitamin D deficiency, calcium levels are still normal and phosphate levels are decreased, patients with severe vitamin D deficiency display reductions in both calcium and phosphate. In rare cases of parathyroid hormone resistance, where calcium levels are reduced, and phosphate levels increased, calcium supplementation was seen to rescue the biochemical pattern of this phenotype. Calcium supplementation has shown to reverse symptoms of rickets in terms of radiological, histological and biochemical features. For infants 0-6 and 6-12 months of age, adequate calcium intake is 200 and 260 mg/day, respectively.

For children over 12 months of age, dietary calcium intake of <300 mg/day increases the risk of rickets independent of serum vitamin D levels. For children over 12 months of age, dietary calcium intake was classified as enough (>500 mg/day), insufficient (300- 500 mg/day) and deficient (<300 mg/day). Therefore, guidelines recommend treatment doses for 12 weeks based on age and level of deficiency with a follow-up maintenance dose as regular reassessment of the patient’s mineral status. In prevention studies, a dose of 400 IU daily has been shown as adequate to prevent rickets.

Rickets Case Reports

Case 1: Asmahan T Abdalla, Sudan: Gaafar Ibn Auf Pediatric Tertiary Hospital, Sudan Medical Specializations Board, Sudan. A case of rickets was reported in a female Sudanese child of consanguineous parents, despite high exposure to sunlight. The patient presented with recurring rickets on treatment discontinuation from the ages of 18 months to 20 years with clinical, laboratory and radiological features. First symptoms at 18 months old included floppy infant syndrome, open anterior fontanel, broad wrists, bowing of the legs and rosaries without organomegaly, skin, nail or hair abnormalities.

Following 6 months of conventional therapy of vitamin D3 and calcium, her walking abilities and laboratory parameters started to improve. Over the years she started having dental abnormalities and bone pain coupled with severe genu varum deformity. Repeat therapy alleviated the symptoms. The patient’s sisters presented at the ages of 2 and 12 years with similar symptoms, most prominently a very low vitamin D level at <7.5 ng/mL. Therefore, treatment with various doses of calcium and calcitriol was initiated and genetic testing was performed after investigations ruled out liver or renal disease and malabsorption.

Molecular analysis identified a previously unknown mutation (homozygosity at position 85 [C>T]), which resulted in a truncated and non-functional CYP2R1 gene. As a result of this analysis, 25-hydroxylase deficiency and, ultimately, vitamin D-dependent rickets type 1B was diagnosed. In general, even if genetic testing is not available, genetic rickets should be suspected in an environment with high levels of sunlight in a child who presents with history of rickets that is dependent on therapy or resistant to it, with history of consanguinity and a similar history in the family.

Case 2: Abdulla Al-Harbi, KSA: Madinah Maternity and Children Hospital, Madinah, KSA. A case of rickets was reported in the second child of consanguineous parents at 3 months of age following a fullterm pregnancy. The couple’s first child died at 3 months showing signs of hypocalcemia and skeletal deformities. The patient was bottle fed and received vitamin D3 supplement. However, supplementation was ineffective and lower limb deformities, wrist widening, and frontal bossing were observed at 14 months of age. Laboratory analyses demonstrated highly elevated ALP and parathyroid hormone (PTH) levels. Following a 1-week vitamin D3 washout, biochemical analysis was repeated showing even more increased ALP and PTH levels and calcium and phosphate levels below the normal range, while both 25-hydroxyvitamin D (25[OH] D) and 1,25-dihydroxycholecalciferol (1,25 [OH]2D) were normal.

To ascertain the type of rickets, renal phosphate regulation was assessed. Results showed low phosphate levels, low tubular reabsorption of phosphate (TRP) at 80% and normal vitamin D levels, and the patient was diagnosed with XLH-linked rickets. Treatment with phosphate 40 mg/kg/day and 1-alpha vitamin D was initiated. At 3 months follow-up, all values had normalized; however, phosphate levels were higher than normal. After a further 3 months, the child was referred to an endocrinologist as no improvements were seen in phosphate biochemistry or lower limb deformities.

Endocrinological assessment highlighted short stature and low weight, generalized hypotonia, sitting with support, wide wrists and fontanels, rachitic rosaries, and angulation of tibias and ankles without organomegaly or components of the cardiovascular system (CVS)/chest abnormalities. Repeated laboratory analysis showed low calcium levels, high phosphate and PTH levels with normal ALP. The patient was re-diagnosed with vitamin D deficient rickets type 1 (1-alpha hydroxylase deficiency) as a result of a frame-shift mutation in the CYP27B1 gene. Phosphate treatment was discontinued while the patient continued 1-alpha calcidiol only, which normalized all laboratory values and over time induced improvements of bone deformities. The patient has been stable for the past 2.5 years, highlighting that continued monitoring and re-evaluation of the underlying disease is required to adequately manage patients with mineral and bone abnormalities. When diagnosing a patient, it is vital to bear in mind that empirical use of 1-alpha calcitriol can mask 1-alpha hydroxylase deficiency and that in XLH-related rickets, very high ALP and PTH are unusual, although it can be difficult to normalize phosphate levels.

Case 3: Ahmed Yousef, UAE: Sheikh Khalifa Medical City, Abu Dhabi, UAE. A 16-month old boy presented to the clinic after unsuccessful treatment in various hospitals with systemic pain, especially under movement or when touched, leading to irritability, crying and failure to thrive. His symptoms started to become apparent at 10 months old and included arrested gross motor development, deformity in all extremities, respiratory distress and recurrent chest infections.

Initial biochemical analysis showed low levels of phosphate, calcium, and 25(OH)D, whereas ALP and PTH were at high levels. The patient was treated with 15 μg/day calcitriol and oral calcium carbonate up to 6400 mg/day.

A slight clinical improvement could be observed with stabilization of calcium levels; however, PTH and ALP remained high. Repeat analysis for 1,25 (OH)2D in another laboratory revealed a much higher level than previously reported. Genetic testing confirmed a pathological novel mutation in the VDR gene, which led to a diagnosis of vitamin D-dependent rickets type 2 (VDDR2) or hereditary vitamin D-resistant rickets.

Subsequently, the patient was treated with long-term continuous infusion of calcium to which he responded well. Radiological features improved, pain subsided, and the child achieved growth expected for his age. After a few years, the patient returned to the clinic with pain in his limbs, worsening gait and leg deformities. Home treatment with calcium carbonate 324 mg/ kg/day and cholecalciferol 10,000 IU daily was not effective, and laboratory values indicated a worsening of the condition with calcium, phosphorus and magnesium well below the normal range and ALP and PTH above normal levels. Vitamin D levels had improved to within the normal range and urine creatinine analysis did not show any abnormalities.

A repeat continuous infusion with calcium gluconate 570 mg/kg/24 hour, cholecalciferol 600,000 IU injection, hydrochlorothiazide 35 mg once daily (OD), magnesium oxide 200 mg twice daily (BID) and phosphate 250 mg BID was administered, which brought calcium, phosphate and PTH levels close to or within the normal range. This case highlights that, despite a correct diagnosis and correct initial management, it is essential to follow up with patients regularly and adjust their treatment to match the body’s needs during different growth phases.

Disorders of phosphate homeostasis

Physiology of phosphate homeostasis: Dieter Haffner, Germany: Medizinische Hochschule Hannover, Germany. Phosphates are pivotal for the regulation of metabolic processes and cellular functions. Phosphate is a constituent of DNA, membrane lipids, high-energy phosphates, and second messengers such as inositol trisphosphate, cyclic adenosine monophosphate and cyclic guanosine monophosphate and is used in protein phosphorylation. It is essential for the regulation of enzyme and receptor activities, energy metabolism, cell signaling, nucleic acid synthesis and membrane function, as well as skeletal health and integrity and growth. Physiology has evolved to conserve this rare mineral through efficient use of phosphate transport systems. Phosphate homeostasis is tightly regulated via feedback loops by hormones including the PTH and fibroblast growth factor 23 (FGF-23) and phosphorus is mainly contained within the intestine, kidney and bone.

The regulation of phosphorus is complex and involves both acute and chronic processes. Recent evidence showed that FGF23 regulates serum phosphate concentration and calcitriol metabolism. FGF23 is secreted in response to hyperphosphatemia and vitamin D decreasing renal phosphate reabsorption by lowering NPT2a and NPT2c expression and diminishing calcitriol (Vitamin D) synthesis by inhibiting 1α hydroxylase and stimulating its catabolizing enzyme 24, 25 hydroxylases. To achieve this, FGF23 binds to and activates a composite receptor formed by the conjunction of FGF receptor 1 (FGFR1), FGFR3 and or FGFR4 with klotho. Overexpression of FGF23 results in marked increase in urinary phosphate excretion and severe hypophosphatemia leading to many bone disorders.

Klotho is a transmembrane protein expressed on the surface of tissues like kidneys, parathyroid glands, brain and skeletal muscle, and acts as a co-factor that is mandatory for FGF23 activity. In the kidney, Klotho is mainly expressed in the distal tubule, whereas FGF23 exerts its action on the proximal tubule. The mechanism by which FGF23 modifies proximal tubule functions is unknown. Furthermore, a soluble form of Klotho provides a non-enzymatic molecular scaffold for FGF23 hormone signaling.

High dietary or serum phosphorus is reduced by stimulation of PTH or increased secretion of FGF23 and a feedback loop between both systems, which in turn reduce phosphorus reabsorption in the kidney. An additional mechanism acts via decreased vitamin D synthesis in the kidney as a result of high FGF23 secretion and a resulting reduction in intestinal phosphorus absorption. However, in XLH, an excess of FGF23 impairs renal phosphate and vitamin D metabolism. In patients with advanced or chronic kidney disease (CKD), elevated PTH levels are required to eliminate excess phosphate (a known cardiovascular toxin) and counterbalance vitamin D deficiency. At later stages of CKD, PTH levels progressively increase with declining glomerular filtration rate due to hyperphosphatemia, hypocalcemia and vitamin D deficiency, in order to increase phosphaturia, calcitriol synthesis and serum calcium.

Hypophosphatemic rickets: clinical features, genetics and differential diagnosis: Zulf Mughal, UK: Royal Manchester Children’s Hospital, UK. The clinical features of hypophosphataemic rickets often include impaired skeletal mineralization, impaired linear growth, impaired muscle function, propensity to dental abscess development, premature fusion of cranial sutures, fractures and pseudo-fractures, hearing impairment and calcification of spinal and paraspinal ligaments in adults, which results in stiffness.

A biochemical work-up including serum calcium, phosphate and ALP, as well as serum sodium, potassium, creatinine, 25OHD and 1,25(OH)2D should be performed. Plasma analysis should include PTH and intact FGF23. Urine testing should always be performed and analyzed for TRP, renal tubular maximum reabsorption rate of phosphate to glomerular filtration rate (TmP/ GFR), calcium/creatinine ratio, urine amino acids, urine potassium and bicarbonate, as well as urine protein/creatinine ratio and low-molecular-weight protein. A schematic developed to diagnose patients with low serum phosphate demonstrates the sequence of assessments necessary to identify the cause of hypophosphatemia (Figure 1).

Figure 1:Decision chart for identification of the underlying cause of hypophosphatemia rickets. P, phosphate.

This schematic allows to identify whether rickets due to low serum P-value is caused by dietary deficiency or malabsorption of phosphate, isolated urinary phosphate loss or Fanconi syndrome. Rickets due to urinary phosphate loss may be FGF23-mediated or due to FGF23-independent renal tubular disorders. Family history and genetic studies will help in distinguishing between XLH, autosomal dominant hypophosphataemic rickets (ADHR), AHRH-1 & AHRH-2 without prior history of generalized arterial calcification of infancy. It is also important to consider tumorinduced osteomalacia, especially in patients with isolated urinary phosphate loss and profound myopathy. However, urinary testing for hypercalciuria, and proteinuria by dipstick is vital as it may make downstream diagnostic testing obsolete.

Unusual Cause of Hypophosphataemic Rickets: Najlla Al- Jassas, KSA: King Fahd Specialist Hospital and Research Centre, Dammam (please check), KSA. The case of a 10-year-old Saudi boy with polyostotic fibrous dysplasia (FD) and hypophosphataemic rickets was reported. FD consists of rare and benign osseous lesions of unknown aetiology and represents 2.5% of all bone and 7% of benign bone tumors in young, predominantly male patients. Although hypophosphatasemia and hypophosphataemic rickets in patients with FD is infrequent, a renal tubulopathy including some degree of phosphate wasting is one of the most commonly associated extra-skeletal manifestations. It is now understood that FD-associated phosphate wasting arises from overproduction of FGF23 by abnormal osteogenic precursors. Treatment with bisphosphonate has been promising.

The patient presented at the age of 6 years with right thigh pain and limping for the past year. X-ray of the right femur revealed a lytic lesion and active rickets. In addition to a history of fractures, on physical examination, the boy appeared well, but showed symptoms of wide wrists and ankles, antalgic gait and heterogeneous increased density of the frontal skull region with extensive craniofacial involvement. The patient did not display signs of skin hyperpigmentation or endocrine hyperfunction. Bone biopsy confirmed the diagnosis of FD with a bone mineral density (BMD) Z-score of –3.6 SD below the mean.

Biochemical investigation revealed low phosphate, phosphaturia, normokalaemia, normal PTH and elevated FGF23 and ALP levels. Therefore, the diagnosis was extended to polyostotic FD with hypophosphataemic rickets due to vitamin D insufficiency. Genetic testing did not reveal mutations in the GNAS1 gene, the product of which is responsible for G-protein function and involved in hormonal signaling. The patient was treated for rickets with 1-alpha calcidol, oral calcium and oral phosphate and zoledronic acid infusion every 6 months for FD. Bisphosphonate was used due to its ability to reduce pain and fracture rate. Bisphosphonate has also been implicated in FD lesion size reduction and filling in of bony defects in adults and children; however, the effect is not consistent across patients. On follow-up, while progression of FD has been positively impacted with zoledronic acid in terms of lack of new lesions and improvement of BMD, the main challenge identified with this patient was persistent elevation of FGF23 and phosphaturia, which may be the result of non-adherence to rickets treatment. This case highlights the challenges of treating XLH in the presence of active FD lesions and the benefit of zoledronic acid in the management of pain and disease progression.

XLH with Mild Renal Phenotype: Bashir Elnaem, KSA: Madinah Maternity and Children Hospital, Madinah, KSA. Identifying the type of hypophosphataemic rickets requires detailed analysis. A boy of just under 6 years presented to gain a second opinion for his bowed legs. He showed symptoms of severe skeletal deformity including short stature, frontal posing and palpable sagittal suture, craniosynostosis, small dental abscess, bilateral genu, coxa Varus and mild renal phenotype without rickets rosary or organomegaly.

He has been treated with different vitamin D preparations for rickets by three individual hospitals for the past 2 years but has not received medication for the past 2 months. His medical history was unremarkable without neonatal or systemic problems and he showed no signs of developmental abnormalities. Initial investigations identified low phosphate levels (0.9 mmol/L), low TRP (80%) and low TmP/GFR (0.81 mmol), as well as radiological signs of rickets. All other laboratory values were within normal range. Both parents tested within the normal range for calcium, phosphate and ALP.

The child was treated initially with phosphate 40 mg/kg/day and 1 μg/day of one-alpha, which was subsequently increased to 125 mg/kg/day and was seen by an orthopedic surgeon for epiphysiodesis, a neurosurgeon and dentist. Over time (2 years) his phosphate levels normalized but remained close to the lower limit, while his PTH levels increased above normal. Calcium, ALP and TRP% remained stable and his bone deformities improved markedly without any signs of nephrocalcinosis. This patient case demonstrates the need for adequate assessment of potentially underlying comorbidities which may mask initial laboratory measurements and potentially result in inadequate treatment.

Challenges in Hypophosphataemic Rickets Management

Traditional and new management of XLH: Dieter Haffner, Germany: Medizinische Hochschule Hannover, Germany. XLH requires life-long management from a range of specialists owing to the multitude of symptoms and organ systems affected by this inherited disorder. Early diagnosis and management is vital to address symptoms early before they impact development and result in functional limitations and poor quality of life. Combination therapy with multiple doses of oral phosphorus and active vitamin D analogues to counter calcitriol deficiency, prevent secondary hyperparathyroidism and increase phosphorus reabsorption from the gut are the conventional treatment regimens. The overall treatment goals include healing rickets for clinical and radiological signs, control pain, encourage growth within the normal range and prevention of rickets in infants with a positive family history.

Despite the wide-spread use of these therapies, patient response is variable and the disease itself is not cured. Furthermore, there is an increased risk to develop side effects such as nephrocalcinosis and hyperparathyroidism, as well as stimulation of FGF23 secretion, which in turn promotes increased phosphate leakage. Strict monitoring every 3 months for biochemical values and every 12 months for ultrasound and radiological features is recommended. Before burosumab was available, conventional treatment was tailored to address specific clinical features and individualize patient management. However, especially in children and adolescents, inconsistent adherence to therapy might negate positive treatment outcomes. In addition to medicine-based therapy, collaboration with experienced orthopedic surgeons and physiotherapists are recommended to correct complex misalignments, reinforce muscles, improve joint stability and provide a good physical framework in which children can grow to their adult stature.

A novel fully human anti-FGF23 monoclonal antibody therapy, burosumab, has demonstrated effective inhibition of the FGF23- mediated pathway and phosphate excretion. It has been trialled as 2-weekly and 4-weekly injectable formulation in children and adults with XLH in Phase 2 and 3 studies, where it demonstrated significant improvements in the rickets severity score, radiographic features, walking test, growth velocity, standing height and markers of bone turnover to support fracture healing. Furthermore, normalisation of ALP, vitamin D and serum phosphate levels have been reported. In terms of patient-reported outcomes, burosumab significantly improved stiffness and physical functions, and provided alleviation from pain compared with placebo. These results led to burosumab approval by both the EMA and the FDA.

Genotype and Phenotype of XLH in Riyadh: A Case Series: Fahd Al-Juraibah, KSA: King Abdullah Specialized Children’s Hospital, Riyadh, KSA.Normal bone growth and mineralization require adequate calcium and phosphate. Hypophosphatemic rickets are a result of renal phosphate wasting due to primary renal tubular defects in phosphate reabsorption or the generation of excessive amounts of phophatonins (FGF23, MEPE, FRP4 and FGF7), which inhibit renal tubular reabsorption of phosphate. Causes of phosphopenia include non-hyperphosphaturic causes such as low body weight, vitamin D deficiency, total parenteral nutrition, short bowel syndrome, chronic diarrhea, and aluminum/ calcium-containing antacids, as well as hyperphosphaturic pathways including non-FGF23-mediated, FGF23-mediated and those governed by high PTH.

A case series of six patients with XLH in Riyadh was discussed highlighting the different symptoms patients can present with and the importance of assessing their laboratory values considering these symptoms. All patients, evenly mixed by gender, presented very early on in life between the ages of 5 months and 1 year often with tell-tale deformities. In all but one of the patients, the family history of rickets was known, supporting diagnosis by genetic testing. Heterozygous mutations in the PHEX gene, the product is thought to be involved in bone and dentin mineralization and renal phosphate reabsorption, were the most prominent causes of XLH, albeit different mutations within the same gene were causing the disease (c.2070+5G>A and c.1682G>A). A homozygous mutation in the DMP1 gene exon 2, a protein critical for correct mineralization of bone and dentin, as well as a novel frameshift mutation of the PHEX gene (c.1077del) have been identified as contributing to a hypophosphataemic rickets phenotype.

New Management of XLH: KSA Experience: Mohamed Al- Dubayee, KSA: King Abdullah Specialized Children’s Hospital, Riyadh, KSA. In addition to conventional treatment of XLH, a novel fully human anti-FGF23 monoclonal antibody therapy, burosumab, has demonstrated effective inhibition of the FGF23-mediated pathway, thus stimulating renal phosphate reabsorption and increasing serum phosphorus and active vitamin D levels.

Monoclonal antibodies are an effective therapy characterized by high target specificity. The FDA and EMA have recently approved burosumab for the treatment of XLH in adult and pediatric patients 1 year of age and older for the treatment of XLH with radiographic evidence of bone disease in children 1 year of age and older and adolescents with growing skeletons, respectively.

In children, burosumab demonstrated improvements in serum phosphorus levels, renal tubular phosphate reabsorption, serum 1,25(OH)2D and ALP into the normal range with both 2-weekly and 4-weekly administrations and a rapid onset of action within the first 2–4 weeks. When compared with conventional therapy of oral phosphate and active vitamin D, burosumab showed superiority leading to the adoption of this treatment by the Saudi Food and Drug Authority.

The recommended starting dose is 0.8 mg/kg, rounded to the nearest 10 mg administered every 2 weeks in children and 1 mg/ kg rounded to the nearest 10 mg up to a maximum dose of 90 mg every 4 weeks in adults. The first dose of burosumab should be given in an inpatient setting to allow observation of any side effects. Oral phosphate and vitamin D analogues must be stopped 1 week prior to burosumab initiation to allow fasting serum phosphate to drop below the reference range for age prior to initiation of treatment. Furthermore, burosumab should not be initiated if serum phosphorus is within or above the normal range for age or in patients with renal impairment or end-stage renal disease.

Prior to initiation of subcutaneous burosumab injection, fasting baseline tests should be performed to assess standard biochemistry of the patient. Testing should include serum complete blood count, urea and electrolytes, bone profile, liver profile, ALP, PTH, 25(OH)D, 1,25(OH)2D, urine phosphate, calcium and creatinine to calculate TmP/GFR, as well left-hand X-ray for a rickets survey. After starting burosumab, fasting serum phosphate should be monitored every 2 weeks for the first month of treatment, every 4 weeks for the following 2 months and thereafter every 3 months or as appropriate. Serum phosphorus should be maintained between 1–1.6 mmol/L. The burosumab dose may be increased stepwise up to approximately 2 mg/kg if serum phosphorus is below the reference for age; however, dosing should not be adjusted more frequently than every 4 weeks and adequate monitoring should be provided.

Burosumab is the first treatment to target regulatory pathways instead of achieving clinically normal levels of minerals by dietary supplementation.

Skeletal Disorders Beyond Rickets

An approach to a child with multiple fracture: Rasha Hamza, Egypt: Ain Shams University, Cairo, Egypt. Recurrent fractures in children are not coincidental and the underlying disease may present at differing severity across a wide spectrum, creating a challenge for diagnosis. Patients may present with several numbers of fractures, stature abnormalities, hearing problems, dental or eye abnormalities, deformities, osteopenia, bone formation abnormalities and random calcifications.

Bone strength is affected when there is an imbalance of bone formation and bone resorption, a finely tuned system that is regulated via the receptor activator of nuclear factorkappa B-receptor activator of nuclear factor-kappa B ligandosteoprotegerin (RANK-RANKL-OPG) pathway. RANKL/RANK signaling regulates osteoclast formation, activation and survival in normal bone modelling and remodeling and in a variety of pathologic conditions characterized by increased bone turnover. OPG protects bone from excessive resorption by binding to RANKL and preventing it from binding to RANK. Thus, the relative concentration of RANKL and OPG in bone is a major determinant of bone mass and strength. Bone strength is further determined by bone mineral density and material as well as structural properties such as geometry, microarchitecture, mineralization, collagen and non-collagen proteins. Bone mass, however, can be governed by hormonal factors such as growth hormone and nutritional factors including vitamin D and calcium among others. There are currently no guidelines for the management of fractures in healthy children, and general measures to improve bone health include weightbearing physical activities, diet adequate in calcium and correction of vitamin D deficiency.

In a child with a history of fractures (vertebral or long bones), bone health as well as dietary calcium intake need to be assessed. Furthermore, clinical/social and laboratory assessments of serum calcium, serum phosphorus, serum ALP, serum 25OHD and serum PTH together with radiological imaging and genetic testing should be performed prior to a bone biopsy for ultimate confirmation for disease. Various antibody-based therapies have been developed to regulate imbalanced bone development pathways.

Challenges in the Management of Hypocalcemia: Amir Babiker, KSA: King Abdullah Specialized Children’s Hospital, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, KSA. Calcium is a physiologically important element governing many functions throughout the body. Calcium plays a part in neuromuscular excitability, blood coagulation, hormonal secretion and enzymatic regulation, as well as providing structural integrity to the skeleton. Calcium homeostasis is regulated by the hormones PTH and 1,25(OH)2D (the active form of vitamin D). Hypocalcemia stimulates PTH secretion, which acts via three mechanisms to increase calcium levels: firstly, PTH stimulates the release of Ca from the bone, in part by stimulating bone resorption, secondly PTH decreases urinary loss of Ca by stimulating Ca reabsorption and lastly, PTH indirectly stimulates Ca absorption in the small intestine by stimulating synthesis of 1,25(OH)2D in the kidney.

Causes of hypocalcemia tend to fall within three categories: hypo parathyroid, non-Para hypothyroid or PTH resistance with each category containing multiple diseases itself. Clinical features include neuromuscular irritability, neurological signs and symptoms, abnormal mental status, ectodermal changes, smooth-muscle involvement, ophthalmological manifestations and cardiac features. Extensive laboratory investigations should be performed to identify the exact cause of calcium deficiency and treatment should be based on the underlying cause. If the patient has a vitamin D imbalance, vitamin D and calcium supplementation should be prescribed, whereas acid citrate dextrose and calcium or PTH replacement therapy should be employed if PTH imbalance is diagnosed.

An Approach to the Child with Hypercalcemia: Sarah Ehtisham, UAE: Mediclinic City Hospital, Dubai Healthcare City, Dubai, UAE. Hypercalcemia is a disorder which is specified by excessive calcium levels in the blood serum. Clinical symptoms include insidious onset, a general feeling of discomfort, behavioral change, constipation, anorexia, weight loss, dehydration, polyuria and polydipsia, bone pain, hypertension and short QTc.

Hypercalcemia can have many underlying causes that are stratified based on PTH level. Low PTH can have genetic causes or secondary causes such as malignancy, vitamin D excess, adrenal insufficiency or thyrotoxicosis. Normal PTH levels in hypercalcemia can be associated with familial hypocalciuric hypercalcemia’s and elevated PTH can be attributed to hyperparathyroidism or parathyroid carcinoma. Key investigations that should be performed to identify the underlying cause of hypercalcemia include bone profiling (calcium, phosphate, ALP and AIb), renal function assessment (electrolytes and creatinine), PTH, 25(OH) D, urine calcium/creatinine ratio or 24 hour urine calcium, store serum (may require 1,25(OH)2D, PTH-related peptide or genetic analysis) and potentially renal ultrasound, parental bloods, skeletal survey and parathyroid imaging.

The treatment of hypercalcemia includes the lowering of calcium at first, but also correcting the underlying disease. Calcium-intake reduction, promotion of mobility, as well as an increase in urinary calcium excretion through hydration and diuretic use support the reduction of overall systemic calcium. In addition, a reduction in PTH secretion, intestinal calcium absorption and bone resorption and treatment with cinacalcet, glucocorticoids, bisphosphonates, calcitonin, dialysis or parathyroidectomy contribute to a calciumlowering effect.

Genetic Backgrounds of Bone Diseases in the UAE: Asma Deeb, UAE: Mafraq Hospital, Abu Dhabi, UAE. Bone diseases are often associated with dysregulation of complex metabolic or hormonal systems and constitute an interesting spectrum in pediatrics. Genetic testing may be required to confirm diagnosis of bone disease if initial treatment is ineffective or no clear diagnosis can be drawn from physical, biochemical and radiological assessments, especially in a region with a high rate of consanguinity. As genetic testing is not widely available in the Middle East, regional and international collaborations are crucial to support this line of investigation. A series of cases in whom genetic diagnosis was made was presented highlighting the complexity and multiple pathways involved in bone disease.

In a family with consanguineous parents, seven of their 11 children presented with symptoms of hematuria, loin pain or recurrent urinary tract infection. Although symptoms were relatively consistent between the siblings, calcium, magnesium, hypercalciuria and nephrocalcinosis status were relatively varied. Genetic analysis identified a novel mutation in the CLDN16 gene as responsible for this phenotype. In another case, heterozygous mutation in the CaSR gene (Ser113Cys) led to the diagnosis of autosomal dominant hypocalcemia and familial hypocalcemia hypocalciuria. Two partial gene deletions have also been associated with syndromes of abnormal calcaemia, namely William syndrome and DiGeorge syndrome.

A novel FOXI1 homozygous missense mutation, p.L146F, located within evolutionary highly conserved residues of the FOXI1 protein, was the underlying cause of patients presenting with earlyonset sensorineural deafness and distal renal tubular acidosis based on dysfunction of electrolyte regulation. Fanconi syndrome has been identified in a patient with mutations in the SLC34A1 gene on chromosome 5q35 resulting in poor growth, subtle dysmorphic features and low phosphate. In another case, a 5-year-old child presented with increasing deformity, hypophosphatemia, high 1,25(OH)2D and normal FGF23 levels. Genetic analysis did not identify abnormalities in the PHEX or SLC34A3 genes, excluding XLH and hereditary hypophosphataemic rickets with hypercalciuria from the diagnosis, respectively. Potential mutations in the FGF23 gene could be responsible for this phenotype.

Mutations leading to abnormal bone growth and abnormal growth plates include COL1A gene mutation type 3, LIFR (5p13.1) gene mutation leading to Stuve-Weidemann syndrome/Schwartz- Jampel type 2 syndrome, MMP2 gene mutation (TPOp.R665Q, c.1994G>A) leading to multicentric osteolysis and nodulus arthropathy, homozygous ADAMTSL2 gene mutation (c.938T˃C, p.M313T, exon 10), homozygous mutation of the EVC gene (c.1405delC) leading to Ellis-van Creveld syndrome, GALNS gene mutation, FGFR3 gene mutation, deletions in the CHRNA1 gene associated with congenital myasthenia, heterozygous mutations in the NPR2 gene causing short stature, COL2A1 gene mutation leading to sporadic Spondyloepiphysia congenita, homozygous RAB33B gene mutation causing Smith McCort dysplasia and a novel homozygous mutation in the PAPSS2 gene (c.826_828delGAG(p. E276del)) leading to brachyolmia type 4 with mild epiphysial and metaphyseal changes.

Meeting discussions

Lively discussions around all presented topics dominated the day. Table 1 captures the most discussed topics by theme Figure 2.

Figure 2: ASPED steering committee with regional and international speakers.

Table 1: Discussion themes throughout the meeting.

EMA, European Medicines Agency; FDA, Food and Drug Administration; FGF23, fibroblast growth factor 23; GCC, Gulf Cooperation Council; GFR, glomerular filtration rate; IGF-1, insulinlike growth factor-1; KSA, Kingdom of Saudi Arabia; MRI, magnetic resonance imaging; PTH, parathyroid hormone; RAAS, reninangiotensin- aldosterone system; RSS, rickets severity scoring; XLH, X-linked hypophosphataemia

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