Curriculum standards
Knowledge guides
LG20: Parathyroid, calcium, and bone disorders
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.
Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.
Presentations
- Abdominal pain
- Acquired low bone mass
- Altered cognition
- Asymptomatic with incidental findings
- Bone pain
- Cardiac arrythmias
- Constipation
- Fractures
- Long bone deformities
- Nausea and vomiting
- Paraesthesia
- Renal stones
- Tetany and/or cramping
Conditions
- Bone disorders:
-
osteoporosis:
- primary, including osteogenesis imperfecta
-
secondary to other primary conditions or treatments:
- endocrine disorders
- infective or inflammatory conditions
- malignancy
- neuromuscular conditions
-
osteoporosis:
- Disorders of phosphate metabolism:
- FGF23 independent
- FGF23 mediated, such as XLH
- Hypercalcaemia:
- calcium-sensing receptor mutations
- hyperparathyroidism jaw-tumour syndrome
-
parathyroid hormone-dependent hypercalcaemia – hyperparathyroidism:
-
hyperparathyroidism due to underlying genetic disorder:
- familial hypercalcaemic hypocalciuria
- familial isolated idiopathic
- MEN1
- MEN2
- primary
- tertiary
-
hyperparathyroidism due to underlying genetic disorder:
- parathyroid hormone-independent hypercalcaemia:
- granulomatous disease
- idiopathic infantile hypercalcaemia
- immobility
- malignancy-related osteolysis
- milk-alkali syndrome
- sarcoidosis
- subcutaneous fat necrosis
- vitamin D excess
- Williams syndrome
- Hypocalcaemia:
- calcium-sensing receptor mutations
- hypoparathyroidism:
- acquired
- associated with genetic condition or syndrome:
- 22q11 deletion
- autoimmune polyglandular syndrome (APS) type 1
- congenital
- post-operative:
- parathyroidectomy
- thyroidectomy
- primary disorders of vitamin D metabolism and vitamin D receptor
- pseudohypoparathyroidism
- vitamin D deficiency
- Medication-related:
- fibrous dysplasia:
- McCune Albright syndrome
- rickets:
- calcipenic
- phosphopenic
- fibrous dysplasia:
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
- Hypophosphataemia:
- acquired
- inherited
- Osteopetrosis
- Parathyroid adenoma / carcinoma
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Inherited disorders / Disorders with a genetic basis
- Incidence and prevalence of conditions in the Australian population
- Recognise and screen for the possibility of known genetic variants causing pathology
- Referral for genetic counselling, wherever needed
- Screening for associated pathology in known inherited disorders
- Screening of family members, when indicated
Therapeutics
- Best practice and individualised approach of anabolic and anti-resorptive bone medications, including knowledge of benefits, indications, risks, and side effects
- Importance of taking preventative action to avoid or mitigate risk of adverse events from available pharmaceutical agents
- Management principles of:
- acute and/or severe hypercalcaemia
- hyperparathyroidism with medical therapies, when appropriate
- phosphataemic
- phosphophenic rickets, such as:
- calcitriol
- monoclonal antibody therapy
- phosphate replacement
- vitamin D deficiency
Clinical assessment
- Identify and refer patients for surgery where appropriate:
- provide perioperative care in patients undergoing parathyroid or thyroid surgery
- triage patients with indications for surgical intervention according to condition severity
- Monitoring disease activity
- Monitoring response to therapy
Imaging
- Bone mineral density, including:
- considerations for patient’s age, pubertal stage, and size
- use of Z-scores, not T-scores, in children
- usefulness and limitations
- Localisation of parathyroid adenoma / cancer
- Plain x-rays:
- pQCT
- rickets
- skeletal survey
- Renal ultrasound:
- 4D CT
- neck ultrasound for parathyroid disease
- sestamibi scanning for parathyroid adenoma localisation
Laboratory tests
- 1,25 OH vitamin D level
- 24-hour collections for urinary calcium:
- spot calcium – creatinine ratio
- 25 hydroxyvitamin D level
- Bone-specific ALP
- Bone turnover markers
- Calcium – corrected and ionised
- Electrolytes
- FGF-23
- Genetic testing
- Liver function tests
- Magnesium
- Parathyroid hormone (PTH)
- Phosphate
- Renal function
- Screening for secondary causes of osteoporosis, including:
- ACTH and cortisol
- acute leukaemia
- coeliac disease and other malabsorptive conditions
- hypogonadism
- TFTs
- Urine phosphate – creatinine ratio and tubular reabsorption of phosphate (TRP)
Evidence-based practice
- Evidence for best practice and application of this, using clinical judgement and individual circumstances, in partnership with patients
Management considerations
- Antenatal counselling
- Conservative management according to individualised care
- Counsel patients with up-to-date best practice guidelines for dietary, exercise, and lifestyle recommendations
- Environmentally sustainable practices in clinical care
- Genetic counselling
- Incorporate a multidisciplinary approach to treatment, and refer appropriately
- Understand the causes and treatment strategies (including preventative strategies) for children with a chronic condition impacting bone health