Objective: To evaluate a case of pembrolizumab-induced hypoparathyroidism leading to hypocalcemia. Methods: The diagnostic tests performed included calcium and parathyroid hormone level detection and calcium-sensing receptor gene analysis. Results: A 71-year-old Caucasian man was diagnosed with stage IIIB adenocarcinoma of the lung and received radiation therapy but had no other exposure to radiation. Pembrolizumab 200 mg intravenous every 3 weeks was started 5 years after the initial diagnosis. The patient's corrected calcium level was 9.2 mg/dL (normal, 8.5-10.5 mg/dL) at the start of pembrolizumab therapy. The calcium level after the 13th dose of pembrolizumab was 8.1 mg/dL (normal, 8.5-10.2 mg/dL), leading to endocrinology referral. The patient's parathyroid hormone and corrected calcium levels after the 22nd dose were 4.3 mg/dL (normal, 14-72 pg/mL) and 6.5 mg/dL (normal, 8.5-10.2 mg/dL), respectively. He denied symptoms of latent tetany on presentation while on pembrolizumab for 15 months but complained of fatigue and weakness. The patient had no history of autoimmune diseases or neck injuries. Calcium-sensing receptor gene analysis was negative for genetic mutations. Immunotherapy-mediated hypoparathyroidism was diagnosed. He was treated with daily oral calcium carbonate (2000 mg), calcitriol 0.5 mg, 1 dose of calcium gluconate 2 g intravenous, and 3 doses of calcium chloride 1 g intravenous. His fatigue, weakness, and calcium levels improved with therapy. Conclusion: Pembrolizumab treatment may have resulted in immune-mediated hypoparathyroidism, leading to hypocalcemia. It is important to report such cases to understand its presentation and timing in relation to pembrolizumab, which further facilitates its timely treatment.

Article BackgroundSeveral studies have found that low levels of serum 25-hydroxyvitamin D (25(OH)D) are linked to many diseases and disorders such as premenstrual syndrome, nonspecific mood disorder, major depressive disorder, cancer, autoimmune disorders, bone diseases, cardiovascular diseases, preeclampsia, seasonal affective disorder, and post-partum depression (PPD). 1-4 It is suggested that vitamin D is a potential neurosteroid and that it is found in high concentrations in the amygdala, thalamus, hypothalamus, dorsal raphae nucleus, and in the motor neurons, which supports possible effects on the sensory pathway, as well as on endocrine, autonomic, and motor systems. Thus, deficiency in vitamin D could be related to many of the symptoms of depression such as fatigue, mood disturbance, and motor function. 5,6 Vitamin D is a cholesterol-derivative steroid hormone that can be synthesized in the human body after the cutaneous exposure to ultraviolet B radiation. It may also be obtained from dietary sources such as fish and egg yolk.Pregnant women often do not get sufficient vitamin D due to the liberal application of sunscreen, related to fear of skin cancer as well as decreased fish in the diet, due to fear of mercury content. 7,8 Vitamin D deficiency in the general population is more prevalent than many realize, especially during pregnancy. Studies have found that pregnant women are more likely to have low serum 25(OH)D than nonpregnant women and that the level of 25(OH)D seems to vary among trimesters with the first and third trimesters being lower than second trimester in 25(OH)D concentration. 9,10 Abstract Objective: To evaluate evidence regarding 25-hydroxyvitamin D (25(OD)D) levels during pregnancy and its association with postpartum depression (PPD). Data Sources: Primary literature was accessed through MEDLINE, Google Scholar, and International Pharmaceutical Abstracts searches through January 2015. Data from published trials were retrieved for analysis using the following search terms: vitamin D, 25-hydroxyvitamin D, 25(OH)D, postpartum, pregnancy, and depression. Data Extraction: Inclusion criteria were human subjects, English language, vitamin D as the sole micronutrient under study, and measurement of vitamin D level during pregnancy. Studies measuring vitamin D levels after delivery were excluded. Also any antenatal or prepartum depression was excluded. Data Synthesis: Although a variety factors may contribute to the likelihood and severity of PPD, there are 3 published prospective cohort studies specifically evaluating the relationship between vitamin D and PPD. The results are conflicting: 2 of these studies found a significant correlation between patients with low vitamin D level and PPD, but the third found that high vitamin D levels are associated with a greater incidence of PPD. Conclusion: Available evidence suggests a possible correlation between vitamin D levels at midpregnancy and PPD. Women with risk factors for PPD should be educated on this potential association and ways to maintain ...

PurposeTraditional classification algorithms always have an incorrect prediction. As the misclassification rate increases, the usefulness of the learning model decreases. This paper presents the development of a wisdom framework that reduces the error rate to less than 3% without human intervention.Design/methodology/approachThe proposed WisdomModel consists of four stages: build a classifier, isolate the misclassified instances, construct an automated knowledge base for the misclassified instances and rectify incorrect prediction. This approach will identify misclassified instances by comparing them against the knowledge base. If an instance is close to a rule in the knowledge base by a certain threshold, then this instance is considered misclassified.FindingsThe authors have evaluated the WisdomModel using different measures such as accuracy, recall, precision, f-measure, receiver operating characteristics (ROC) curve, area under the curve (AUC) and error rate with various data sets to prove its ability to generalize without human involvement. The results of the proposed model minimize the number of misclassified instances by at least 70% and increase the accuracy of the model minimally by 7%.Originality/valueThis research focuses on defining wisdom in practical applications. Despite of the development in information system, there is still no framework or algorithm that can be used to extract wisdom from data. This research will build a general wisdom framework that can be used in any domain to reach wisdom.

We hypothesized that the combination therapy of SGLT-2(Sodium-glucose co-transporter-2)inhibitor and Glucagon-like peptide-1 receptor agonist(GLP-1RA) provide renal protection in adults with T2D with estimated GFR (eGFR) below 30ml/minute/1.73 m2. We hereby describe four consecutively treated high renal risk patients with T2D with eGFR between 21 to 30ml/minute/1.73m2.

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