Chemical elements of a cell and its contents in the body. Chemical elements in the cells of living organisms

99% of calcium and more than 80% of phosphorus are found in the body as crystalline hydroxyapatite in the bones. Bones consist of matrices composed of collagen fibrils and ground substance (containing mucoproteins and chondroitin sulfate, in which apatite crystals are located in the direction of the fibrils. Some of the calcium and phosphorus ions are weakly bound and are relatively easily exchanged with the corresponding ions of the extracellular fluid.

Despite the fact that extracellular fluid contains only a small portion of total calcium, it physiological significance great: calcium plays a role in membrane permeability, conduction nerve impulse, in muscle excitability, in blood clotting processes. Phosphates found in organic connection with proteins are structural elements cells, take part in transport mechanisms, in the activity of enzymes, in energy exchange processes, in the transmission genetic information. Inorganic phosphates have important for ossification processes, as well as in the renal release of H+ ions, that is, in the regulation acid-base balance body fluids.

Homeostasis of calcium and phosphorus. Plasma calcium concentrations are among the most carefully maintained body constants: deviations from the average value - 10 mg% - do not exceed 1 mg%. More than half of the calcium in the blood is in the form of ions, about 1/3 is bound to protein, and a small amount is found in complex salts. The content of inorganic phosphorus in the body of a growing child is slightly higher than in the body of an adult; In a child, the phosphorus concentration fluctuates around 5 mg%.

In the metabolism of calcium and phosphates decisive role parathyroid hormone, vitamin D, calcitonin synthesized in the thyroid gland and bones play. Ca and HPO4 ions enter the bones and can be mobilized from there as needed at any age.

The level of calcium in plasma is significantly influenced by the amount of intestinal absorption corresponding to endogenous demand, and not by the amount of renal excretion, which healthy person almost constant. It has been established that vitamin D3 (cholecal-ciferol) supplied with food undergoes successive transformations in the body. The first step is the hydroxylation of vitamin D at carbon 25, resulting in the formation of 25-hydroxycholecalciferol, which is rehydroxylated at carbon 1 in the kidneys. It has been established that 1,25-dihydroxyvitamin D, formed as a result of these transformations, has the properties of a hormone, since this compound directly affects the genetic apparatus of intestinal and kidney cells, stimulating the synthesis of a specific protein that provides active transport calcium.

In a rapidly growing body, in accordance with the colossal needs of bone growth, it is absorbed and retained significantly. most of of calcium entering the body than in the body of an adult. For vitamin D deficiency and high content phosphorus in food, calcium absorption decreases. Parathyroid hormone has a relatively slow effect, calcitonin is mobilized very quickly: due to its influence, the concentration of Ca decreases, thus compensating for the effect of parathyroid hormone, which increases the level of Ca.

The level of phosphorus in the blood is influenced more significantly by the amount of renal excretion than by the amount of enteral absorption. The latter largely depends on the magnitude of Ca absorption. With a significant intake of calcium or with reduced absorption due to a lack of vitamin D, poorly soluble calcium phosphates are formed in the intestine, which reduces the absorption of phosphorus.

If glomerular filtration is normal, then renal excretion of phosphorus depends on the amount of tubular reabsorption.

Tubular reabsorption, in other words, the amount of phosphorus excretion is determined by the maximum tubular reabsorption capacity (TtR) and the amount of parathyroid hormone secretion. With an increased intake of phosphorus, TTP is achieved quickly, and most of the ingested phosphorus is released. This process regulates upper limit phosphorus content. However, with a sharp decrease in glomerular filtration, the concentration of phosphorus in the blood increases. Parathyroid hormone increases the renal excretion of phosphorus, and its absence weakens it. Although under the influence of the hormone about thyroid gland phosphorus can also be mobilized from bones along with calcium, the renal effect of this hormone is more pronounced - increasing the excretion of phosphorus. Therefore, with hyperparathyroidism, along with hypercalcemia, hypophosphatemia is also detected, and with hypoparathyroidism, along with hyperphosphatemia, hypocalcemia develops. In pathological conditions, changes in the concentrations of calcium and phosphorus usually have the opposite character.

Most important role Vitamin D in these processes is to enhance the intestinal resorption of calcium and phosphorus, thereby providing the substances necessary for bone growth. Parathyroid hormone and vitamin D have opposite effects on bone calcium levels.

An estimate of the amount of renal calcium excretion can be made on the basis of a convenient clinical practice Sulkovich's semi-quantitative test: the reagent is prepared by dissolving 2.5 g of oxalic acid and ammonium oxalate and 5 ml of acetic acid. One part of the reagent is mixed with 2 parts of urine. With hypercalciuria, severe turbidity or sediment immediately occurs. With normal calcium excretion, slight turbidity occurs after 1-2 minutes. With hypocalciuria, the Sulkovich test is negative.
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Physiology
Mineral metabolism disorders are changes in the levels of calcium, phosphorus or magnesium. Calcium is of primary importance in cell function. In the process of regulating the homeostasis of these basic mineral macroelements, mainly three organs - kidneys, bones and intestines - and two hormones - calcitriol and parathyroid hormone - take part.

The role of calcium in the body
About 1 kg of calcium is contained in the skeleton. Only 1% general content Calcium circulates in the body between intracellular and extracellular fluid. Ionized calcium makes up about 50% of the total calcium circulating in the blood, about 40% of which is bound to proteins (albumin, globulin).

When assessing the level of calcium in the blood, it is necessary to measure the ionized fraction or simultaneously total calcium and blood albumin, on the basis of which the level of ionized calcium can be calculated using the formula (Ca, mmol/l + 0.02x (40 - albumin, g/l).

Normal level total serum calcium 2.1-2.6 mmol/l (8.5-10.5 mg/dl).

The role of calcium in the body is diverse. We list the main processes in which calcium takes part:
provides bone density, being the most important mineral component in the form of hydroxyapatite and carbonate apatite;
participates in neuromuscular transmission;
regulates signaling systems cells through the work of calcium channels,
regulates the activity of calmodulin, which affects the functioning of enzyme systems, ion pumps and cytoskeletal components;
participates in the regulation of the coagulation system.

Homeostasis of calcium and phosphorus
Below are the main mechanisms involved in the regulation of calcium levels.
The active metabolite of vitamin D - the hormone calcitriol (1,25 (OH) 2calciferol) is formed during the hydroxylation of cholecalciferol under the influence of sun rays and with the participation of two main hydroxylation enzymes - 25-hydroxylase in the liver and 1-a-hydroxylase in the kidneys. Calcitriol is the main hormone that stimulates the absorption of calcium and phosphorus in the intestine. In addition, it enhances the reabsorption of calcium and excretion of phosphorus in the kidneys, as well as the resorption of calcium and phosphorus from the bones, like parathyroid hormone. The level of calcitriol is regulated directly by blood calcium, as well as by the level of parathyroid hormone, which affects the activity of 1-a-hydroxylase.
The calcium-sensing receptor is located on the surface of the cells of the parathyroid glands and in the kidneys. Its activity normally depends on the level of ionized calcium in the blood. An increase in the level of calcium in the blood leads to a decrease in its activity and, as a consequence, a decrease in the level of parathyroid hormone secretion in the parathyroid gland and an increase in calcium excretion in the urine. On the contrary, when the level of calcium in the blood decreases, the receptor is activated, the level of parathyroid hormone secretion increases and the excretion of calcium in the urine decreases. Defects in the calcium-sensing receptor lead to disruption of calcium homeostasis (hypercalciuric hypocalcemia, familial hypocalciuric hypercalcemia).
Parathyroid hormone is synthesized by the cells of the parathyroid glands. It exerts its effect through a G-protein-coupled receptor on the surface of cells of target organs - bones, kidneys, intestines. In the kidneys, parathyroid hormone stimulates the hydroxylation of 25(OH)D to form the hormone calcitriol, which plays a major role in the regulation of calcium homeostasis. In addition, parathyroid hormone increases calcium reabsorption in the distal nephron and increases calcium absorption in the intestine. The effect of parathyroid hormone on bone metabolism is twofold: it enhances both bone resorption and bone formation. Depending on the level of parathyroid hormone and the duration of exposure to its high concentration, the state of bone tissue changes differently in different parts (cortical and trabecular). In calcium homeostasis, the dominant effect of parathyroid hormone is to enhance bone resorption.
Parathyroid hormone-like peptide is structurally identical to parathyroid hormone only in the first eight amino acids. However, it can bind to the parathyroid hormone receptor and have the same effects. Parathyroid hormone has clinical significance only for malignant tumors that can synthesize it. In routine practice, the level of parathyroid hormone-like peptide is not determined.
Calcitonin is synthesized in the C-cells of the thyroid gland, stimulates the excretion of calcium in the urine, and suppresses the function of osteoclasts. The essential role of calcitonin in calcium homeostasis in fish and rats is known. In humans, calcitonin does not have a significant effect on blood calcium levels. This is confirmed by the absence of disturbances in calcium homeostasis after thyroidectomy, when C-cells are removed. The level of calcitonin is of clinical significance only for the diagnosis of malignant tumors - C-cell thyroid cancer and neuroendocrine tumors, which can also synthesize calcitonin (insulinoma, gastrinoma, VIPoma, etc.).
Glucocorticoids normally do not significantly affect the level of calcium in the blood. At pharmacological doses, glucocorticoids significantly reduce intestinal calcium absorption and renal reabsorption, thereby lowering blood calcium levels. High doses of glucocorticoids also affect bone metabolism, increasing bone resorption and decreasing bone formation. These effects are important in patients receiving glucocorticoid therapy.

Abstract of the dissertationin medicine on the topic Features of phosphorus-calcium metabolism in children and adolescents with postural disorders in the Republic of Sakha (Yakutia)

KRIVOSHAPKINADora Mikhailovna

FEATURES OF PHOSPHORUS-CALCIUM METABOLISM IN CHILDREN AND ADOLESCENTS WITH POSTURAL DISORDERS IN THE REPUBLIC (SAKHA) YAKUTIA

dissertations for competition scientific degree candidate medical sciences

St. Petersburg2004

The work was carried out at the Department of Pediatrics with courses in perinatology and pediatric endocrinology of the Faculty of Training and the PP GOUVPO "St. Petersburg State Pediatric Medical Academy of the Ministry of Health of the Russian Federation" and the Consultative Diagnostic Center National Center Medicine - Republican Hospital No. 1 of the Ministry of Health of the Republic of Sakha (Yakutia)

Scientific supervisors:

Honored Scientist of the Russian Federation Nikolay Pavlovich Shabalov

Doctor of Medical Sciences, Professor Khandy Maria Vasilievna

Official opponents:

Doctor of Medical Sciences, Professor

Alferov Vyacheslav Petrovich Chasnyk Vyacheslav Grigorievich

The leading organization is the State Educational Institution “St. Petersburg State medical University named after academician I.P. Pavlova Ministry of Health of the Russian Federation"

The defense of the dissertation will take place on December 14, 2004 at 10 o’clock at the meeting dissertation council D 208.087.03 at the State Educational Institution of Higher Professional Education "St. Petersburg State Pediatric Medical Academy of the Ministry of Health of the Russian Federation" (194100, St. Petersburg, Litovskaya st., 2).

The dissertation can be found in the fundamental library of the St. Petersburg State Pediatric medical academy Ministry of Health of the Russian Federation (194100, St. Petersburg, Kantemirovskaya st., 16).

Scientific secretary of the dissertation council: Doctor of Medical Sciences, Professor

Chukhlovina M.L.

GENERAL DESCRIPTION OF WORK

Relevance of the problem

Among the factors that have a decisive influence on the growth and formation of the skeleton, an important role belongs to a balanced diet, especially a sufficient supply of calcium and nutrition child's body vitamin D [Spirichev V.B., 2003; Shabalov N.P., 2003; Shcheplyagina L.A., Moiseeva T.Yu., 2003; Saggese G., Baroncelli G.L. et al, 2001 and others].

The critical periods for the formation of a genetically programmed peak of bone mass are the first three years of a child’s life and the prepubertal period [Kotova SM. et al., 2002; Sabatier JP.et al., 1996, etc.].

By modern ideas, calcium and vitamin D deficiency can lead to the development wide range diseases, including the musculoskeletal system [Nasonov E.L., 1998; Shcheplyagina L.A. et al., 2002; Dambacher M.A., Shakht E., 1996; Lips R., 1996, etc.].

In the structure of diseases in children in the Republic of Sakha (Yakutia), one of the leading places is occupied by diseases of the musculoskeletal system, among which posture disorders are the most common [Nikolaeva A.A., 2003]. According to the Yakut Republican Medical Information and Analytical Center of the Ministry of Health of the Republic of Sakha (Yakutia), the number of children and adolescents with scoliosis was 12.9 (2001); 17.1

(2002); 16.9 (2003) and with postural disorders - 45.1 (2001); 63.0 (2002); 52.4

(2003) per 1000 surveyed. This explains the interest of clinicians in the problem of calcium and bone metabolism.

Purpose of the work: Study of indicators of phosphorus-calcium metabolism in children and adolescents with postural disorders in the Republic of Sakha (Yakutia).

Research objectives:

Scientific novelty: For the first time in the Republic of Sakha (Yakutia), a study of indicators of phosphorus-calcium metabolism in practically healthy children and in children and adolescents with postural disorders was conducted.

The relationship between 25(OH)D3 content and serum PTH levels was confirmed; serum 25(OH)D3 and calcium levels; the level of 25(OH)O3 and the activity of total alkaline phosphatase in the blood serum and the dependence of the level of 25(OH)O3 in the blood serum in winter on its content in the summer.

Practical significance of the study: The results of a study of phosphorus-calcium metabolism in healthy children and adolescents and children with posture disorders in the city of Yakutsk were obtained. The identified deviations made it possible to justify the need for therapeutic and diagnostic measures in children and adolescents with postural disorders and preventive measures in healthy children and adolescents in the conditions of Yakutia.

Implementation of work results: The results and recommendations obtained as a result of the study are used in practical activities children's clinical and advisory department of the consultative and diagnostic center NCM - RB No. 1 in Yakutsk and in children's treatment and preventive institutions of the republic.

The dissertation materials are included in the student training program, and are also used in the process of postgraduate training of doctors at the Yakut Medical Institute state university.

Publications and testing of the work: The main provisions of the dissertation work were presented: at the IX Congress of Pediatricians of Russia " Actual problems pediatrics" (Moscow, 2004), international Russian-Japanese symposium (Yakutsk, 2003; Niagata, Japan, 2004), regional scientific and practical conference "Ecology and human health in the North" (Yakutsk, 2004), scientific and practical conferences Medical Institute Yakut State University, National Center of Medicine (Yakutsk, 2004), meeting regional office Union of Pediatricians of Russia of the Republic of Sakha (Yakutia) (Yakutsk, 2004), meeting of the Department of Pediatrics with courses of perinatology and endocrinology of the Faculty of Education and Training of the St. Petersburg State Pediatric Medical Academy (2003, 2004)

1. Fluctuations in serum 25(OH)D3 in practically healthy children and patients with postural disorders in the Republic of Sakha (Yakutia) are seasonal. Vitamin D deficiency is detected much more often in winter than in summer and is more pronounced in children and adolescents with postural disorders than in healthy children.

3. The use of the combined drug Calcium Dz Nycomed causes a therapeutic effect, manifested by the disappearance of complaints, improvement of well-being, normalization of phosphorus-calcium metabolism and calcium-regulating hormones.

Scope and structure of the dissertation: The dissertation is presented on 127 pages of typewritten text and includes the following sections: introduction, literature review, chapters outlining the material and methods, research results, discussion of the results, conclusions, practical recommendations, applications. The bibliographic index includes 101 domestic and 112 foreign scientific works. The dissertation contains 27 tables, 16 figures, illustrated with 1 clinical example.

Materials and research methods

The studies were carried out on the basis of the children's clinical and advisory department of the consultative and diagnostic center NIM - RB No. 1 in Yakutsk from 2002 to 2004. The examination group included 131 children with postural disorders and idiopathic scoliosis of the first degree (111 and 20, respectively), aged from 9 to 15 years. The ratio of girls and boys was 1:1, Yakuts and Russians 1.8:1. Comparison group - 83 practically healthy child, comparable in age, gender and nationality with the survey group.

In the majority of patients in the examination group, physical and sexual development corresponded to age. Growth retardation was noted in 5 patients (3.8%), advanced growth - in 6 (4.6%), underweight - in 15 (11.5%), excess body weight - in 4 patients (3%) and delayed sexual development - in 22 patients (16.8%). The patients in the examination group did not have chronic diseases that could negatively affect the formation of the skeleton.

When examining children, we used a developed formalized research map. All patients underwent hygienic assessment nutrition using tables chemical composition food products. The diet was assessed for 5 days and the average calcium content was calculated.

Physical development (body length and weight) was assessed in children of Russian nationality based on standard tables(Dr. Michel Sempe" et al., 1997), in children of Yakut nationality - according to the "Standards individual assessment physical development schoolchildren of the Republic of Sakha (Yakutia)" (Savvina N.V., Handy M.V., 2001).

The stage of sexual development was determined according to the classification of Tanner J.M. (cited in reference book Liss V.L. et al. "Diagnostics and treatment of endocrine diseases in children and adolescents" edited by Professor N.P. Shabalova, 2003).

Indicators of phosphorus-calcium metabolism: levels of total calcium, inorganic phosphate, magnesium, total protein, albumin, total alkaline phosphatase activity in blood serum and daily excretion of calcium and inorganic phosphate were determined according to generally accepted methods. The basal level of the intact PTH molecule in the blood serum was determined by enzyme immunoassay using commercial kits DSL - 10 - 800 ACTIVE I-PTH, from Diagnostic Systems Laboratories, USA. The content of 25(OH)D3 in blood serum was studied using enzyme immunoassay using commercial kits from BCM Diagnostics and IDS OCTEIA 25-Hydroxy Vitamin D kits from Immunodiagnostic systems, USA.

The studies were carried out in February - March and in August.

All patients underwent an electrocardiographic study to identify possible signs hypocalcemia.

Patients in the examination group underwent radiographic examinations of the thoracolumbar spine, hip joint, shin bones on the recommendation of an orthopedist and hands with the capture of the wrist joints - for children with delayed growth and sexual development.

Statistical processing of digital results was carried out using the method of variation statistics with calculation of average values, statistical deviations and errors on personal computer by using standard programs in the Windows 98 operating environment using the package Microsoft programs Office (Word, Excel, Access) and statistical processing programs Biostat V.4.03 Stanton A. Glantz. The significance of differences was determined according to Student's test. The results were assessed with a significance level of p< 0,05. Взаимосвязь сравниваемых показателей изучали с помощью линейного корреляционного анализа.

Research results and discussion

Results of a study of phosphorus-calcium metabolism indicators

in the comparison group, indicators of phosphorus-calcium metabolism are presented in Table 1.

Table 1

Indicators of phosphorus-calcium metabolism in the comparison group.

Indicators Winter Summer R

M±t n M±t n

Blood calcium (mmol/l) 2.33 ± 0.01 80 2.32 ±0.01 67 p > 0.05

Blood phosphate (mmol/l) 1.48 ±0.02 80 1.58 ±0.03 67 r<0,01

Total alkaline phosphatase i/b 498.17 ±33.85 66 633.39 ± 34.56 56 r<0,01

Protein (g/l) 69.93 ±0.51 58 75.19 ±0.72 52 r<0,001

Albumin (g/l) 43.92 ± 0.37 58 44.24 ± 0.48 52 p> 0.05

Blood magnesium (mmol/l) 0.84 ± 0.009 65

Daily calcium excretion in urine (mmol/day) 2.33 ± 0.28 73 2.34 ± 0.22 53 p> 0.05

Daily excretion of phosphate in urine (mmol/day) 20.87 ±1.29 73 27.36 ± 2.03 53 r< 0,01

PTH (pg/ml) 45.81 ±2.56 80 35.36 ±2.41 67 r< 0,01

(ng/ml) 14.04 ±0.88 80 28.55 ± 2.75 67 r<0,001

The average level of total serum calcium in healthy children with normoproteinemia corresponded to normal values and did not significantly change depending on the season of the year (Table 1).

Hypocalcemia (calcium below 2.2 mmol/l) was observed in winter in 3 (3.7%) and in summer in 3 (4.4%) apparently healthy children.

The average daily urinary calcium excretion in winter and summer corresponded to normal values for a given dietary calcium intake (less than 800 mg/day) and did not change depending on the season of the year.

The average level of inorganic phosphate in blood serum in children in winter corresponded to normal values and was significantly higher in summer (p< 0,01) (табл. 1).

The average daily urinary excretion of phosphate in children corresponded to normal values and was significantly higher in summer (p< 0,01).

The average serum magnesium level in the comparison group did not differ from normal values.

The activity of total alkaline phosphatase in blood serum during the winter period of the study corresponded to the upper limit of the range of normal values and significantly increased in summer (p< 0,01) (табл. 1).

In apparently healthy children, distinct seasonal fluctuations in serum 25(OH)D3 levels were revealed. The average concentration of 25(OH)D3 during the winter period of the study corresponded to the lower limit of normal values and was significantly lower than in the summer period (p< 0,001) (табл. 1). В зимний период исследования у 60 % детей отмечалась недостаточность витамина D, из них в 42,5% - выраженная. Летом недостаточность витамина D наблюдалась только у 10,4 % детей и выраженная - в 4,4 %.

The average PTH level of blood serum in winter corresponded to normal values and was significantly higher when compared with the indicator in summer (p< 0,01) (табл. 1). Частота вторичного гиперпаратиреоза у здоровых детей была значительно выше в зимний период исследования, чем в летний. Повышенный уровень ПТГ сыворотки крови отмечался зимой в 32,5 % и летом - 7,4 % случаев.

During the correlation analysis in the comparison group, an inverse correlation was found between the level of 25(OH)D3 and PTH in the blood serum during the winter period of the study (r = - 0.23; p = 0.03) and between the low level of 25(OH)D3 in the blood serum and serum PTH in summer (r = - 0.91; p = 0.003).

A direct correlation was found between the level of 25(OH)D3 and serum calcium during the summer study period (r = 0.31; p = 0.03).

An inverse relationship was found between the level of 25(OH)D3 and the activity of total alkaline phosphatase in the blood serum in winter (r = - 0.32; p = 0.008).

In addition, a direct relationship was found between the level of 25(OH)D3 in blood serum in winter and its content in summer (r = 0.29; p = 0.04).

Due to the decisive influence of vitamin D deficiency in winter, the relationship between indicators of phosphorus-calcium metabolism was assessed using data obtained during the summer study period.

In healthy children, the influence of the nature of nutrition on some indicators of phosphorus-calcium metabolism was found. Thus, the daily urinary excretion of calcium in children with all types of nutrition was within the normal range for a given dietary intake of calcium (less than 800 mg/day) and significantly lower with the carbohydrate type of diet compared to protein and mixed (p<0,05). Суточная экскреция фосфата у детей при всех типах питания соответствовала нормальным значения и была достоверно ниже при углеводном типе питания по сравнению с смешанным (р < 0,05). Средний уровень ПТГ сыворотки крови у детей соответствовал нормальным значениям и был достоверно ниже при смешанном типе питания по сравнению с белковым (р < 0,05). Содержание 25(ОН^з сыворотки крови у детей при всех типах питания было нормальным, но можно отметить тенденцию к более высокому его среднему уровню при белковом типе питания.

No peculiarities were identified in the indicators of phosphorus-calcium metabolism in children of Yakut and Russian nationalities. Statistically significant, but physiologically insignificant differences were found in the calcium content of blood serum in both the winter and summer periods of the study (p<0,001 и р<0,01 соответственно). Также выявлены статистически достоверные, но физиологически незначимые отличия в содержании неорганического фосфата сыворотки крови в зимний период исследования (р<0,01).

There were no statistically significant differences in the indicators of phosphorus-calcium metabolism in children of the comparison group depending on gender, except for a lower level of inorganic phosphate in the blood serum in girls during the winter period of the study (p< 0,01).

Significant differences in some indicators of phosphorus-calcium metabolism were revealed during the summer study period depending on the stage of puberty. The average level of inorganic phosphate in the blood serum in children with stage IV of sexual development was lower than the average values and significantly lower compared to this indicator in children of stage I b and stage II (p<0,001). Наблюдалась достоверно более низкая активность общей щелочной фосфатазы сыворотки крови у детей с III и IV стадиями полового развития по сравнению с I б и II стадиями (р < 0,01). Средний уровень ПТГ сыворотки крови у детей с разными стадиями пубертата соответствовал средним значениям и был достоверно выше у детей с IV стадией при сравнении с III стадией (р < 0,05).

Thus, in healthy children in the Republic of Sakha (Yakutia), seasonal fluctuations in the levels of 25(OH)D3 and PTH, as well as the activity of total alkaline phosphatase and the concentration of inorganic phosphate in the blood serum were revealed.

Results of the study of phosphorus-calcium metabolism indicators in the examination group

A comparison of phosphorus-calcium metabolism parameters in patients in the study group depending on the season of the year is presented in Table 2.

table 2

Indicators of phosphorus-calcium metabolism in the examination group depending on the season of the year.

Indicators winter summer

M±t p M±t p

Blood calcium (mmol/l) 2.24 ±0.01 125 2.33 ±0.01* 92

Blood phosphate (mmol/l) 1.55 ±0.02 125 1.67 ±0.02 * 92

Total alkaline phosphatase i/b 566.22 ± 27.89 107 686.4 ±31.5** 88

Protein (g/l) 70.56 ± 0.46 93 74.38 ±0.52 * 89

Albumin (g/l) 43.68 ± 0.35 93 43.12 ±0.42 89

Blood magnesium (mmol/l) 0.86 ±0.01 110

Daily urinary calcium excretion (mmol/day) 1.8 ±0.13 118 2.49 ±0.18 ** 80

Daily excretion of phosphate in urine (mmol/day) 21.0 ±1.09 118 28.24 ±1.36 * 80

PTH (pg/ml) 72.2 ±3.81 125 47.49 ±2.47 * 92

25(OI)B3 (ng/ml) 10.01 ±0.38 125 21.43 ±1.39 * 92

*-R< 0,001; **-р<0,01

Indicators of phosphorus-calcium metabolism during the winter period of the study are presented in Table 3.

Table 3

Indicators of phosphorus-calcium metabolism in patients of the examination group during the winter study period.

M±t p M±t p

Blood calcium (mmol/l) 2.24 ±0.01 125 2.33 ± 0.01 80 r<0,001

Blood phosphate (mmol/l) 1.55 ±0.02 125 1.48 ±0.02 80 r< 0,05

Alkaline phosphatase I/b 566.22±27.89 107 498.17±33.85 66 p > 0.05

Protein (g/l) 70.56 ±0.46 93 69.93 ±0.51 58 p > 0.05

Albumin (g/l) 43.68 ± 0.35 93 43.92 ±0.37 58 p > 0.05

Blood magnesium (mmol/l) 0.86 ±0.01 110 0.84 ± 0.009 65 p > 0.05

Daily urinary calcium excretion (mmol/day) 1.8 ±0.13 118 2.33 ± 0.28 73 r< 0,05

Daily excretion of phosphate in urine (mmol/day) 21.0 ±1.09 118 20.87 ±1.29 73 p > 0.05

PTH (pg/ml) 72.2 ±3.81 125 45.81 ±2.56 80 r<0,001

25(OH)B3 (ng/ml) 10.01 ±0.38 125 14.04 ± 0.88 80 r<0,001

Indicators of phosphorus-calcium metabolism in patients of the examination group during the summer period of the study are presented in Table 4.

Table 4

Indicators of phosphorus-calcium metabolism in patients of the examination group during the summer study period.

Indicators Survey group Comparison group P

M±t p M±t p

Blood calcium (mmol/l) 2.33 ±0.01 92 2.32 ±0.01 67 p > 0.05

Blood phosphate (mmol/l) 1.67 ±0.02 92 1.58 ±0.03 67 r< 0,05

Total alkaline phosphatase i/b 686.41 ±31.75 88 633.39+34.56 56 p > 0.05

Protein (g/l) 74.38 ±0.52 89 75.19 ±0.72 52 p > 0.05

Albumin (g/l) 43.12 ±0.42 89 44.24 ± 0.48 52 p > 0.05

Daily urinary calcium excretion (mmol/day) 2.49 ±0.18 80 2.34 ± 0.22 53 p > 0.05

Daily excretion of phosphate in urine (mmol/day) 28.24 ±1.36 80 27.36 ±2.03 53 p > 0.05

PTH (pg/ml) 47.49 ±2.47 92 35.36 ±2.41 67 r<0,001

25(OH)B3 (ng/ml) 21.43 ± 1.39 92 28.55 ± 2.75 67 r<0,001

The average level of total blood calcium in patients in the examination group with normoproteinemia during the winter period of the study corresponded to the lower limit of normal and was significantly lower than in the comparison group (p<0,001). В летние месяцы содержание кальция сыворотки крови было в пределах нормальных значений, достоверно выше, чем зимой (р < 0,001) и не отличалось от показателя группы сравнения (табл. 2 - 4).

In addition, hypocalcemia, clinically and electrocardiographically insignificant, was observed significantly more often during the winter period of the study than in the comparison group: in the winter in 20%, and in the comparison group in 3.7% of cases.

The average level of inorganic phosphate in the blood serum in children with postural disorders corresponded to normal values and was significantly higher in the summer months than in winter (p< 0,001) (табл. 2). У пациентов группы обследования выявлен достоверно более высокий уровень неорганического фосфата сыворотки крови, чем в группе сравнения, как в зимний, так и в летний периоды (р < 0,05) (табл. 3 и 4).

The average daily excretion of calcium and inorganic phosphate in urine during the winter period of the study was within the normal range for a given dietary intake of calcium (less than 800 mg/day) and was significantly higher in the summer period (p< 0,01 и р < 0,001 соответственно) (табл. 2). Кроме того, отмечается более низкая суточная экскреция кальция с мочой в зимний период исследования по отношению к группе сравнения (р < 0,05) (табл. 3).

The activity of total alkaline phosphatase in the blood serum corresponded to the upper limit of normal values during the winter period of the study and was significantly higher in the summer (p< 0,01) (табл. 2). Эти результаты аналогичны таковым у детей группы сравнения.

In the examination group, as well as in the comparison group, seasonal fluctuations in the level of 25(OH)D3 in blood serum were revealed. The average concentration of 25(OH)D3 in blood serum during the summer period of the study significantly increased compared to the winter period (p< 0,001) (табл. 2 и рис. 1). Средний уровень 25(ОН)Оз сыворотки крови зимой был ниже нормы и достоверно ниже, чем в группе сравнения (р<0,001) (табл. 3 и рис. 1). Уровень 25(OH)Dз сыворотки крови в летний период исследования соответствовал нормальным значениям, но достоверно был ниже, чем в группе сравнения (р<0,001)(табл.4 и рис. 1).

The average serum PTH level in children with postural disorders during the winter study period was higher than normal values and significantly higher than in summer (p< 0,001) (табл. 2 и рис. 2). Средний уровень ПТГ сыворотки крови в зимний и в летний период исследования был достоверно выше этого показателя в группе сравнения (р < 0,001) (табл. 3,4 и рис 2).

Rice. 1. Seasonal fluctuations in serum 25(OH)B3 levels in patients in the study group.

The frequency of vitamin D deficiency in patients in the study group is presented in Table 5.

Table 5

Frequency of vitamin D deficiency in patients in the study group

Study group

Comparison group

Winter Summer Winter Summer

p % p % p % p %

Normal 24 19.2 61 66.4 32 40 60 89.6

(greater than or equal to 14.0 ng/ml)

Insufficiency 101 80.8 31 33.6 48 60 7 10.4

(below 14.0 ng/ml)

Severe deficiency 65 52 7 7.6 34 42.5 3 4.4

(below 10.0 ng/ml)

Vitamin deficiency B 9 7.2 2 2.1

(below 5 ng/ml)

Vitamin D deficiency was observed more often than in healthy children: in winter in 80.8% of cases (52% - severe deficiency and 7.2% - vitamin B deficiency), and in summer - in 33.6% of patients (7.6 % - severe deficiency and 2.1% - vitamin deficiency B) (Table 5).

The frequency of secondary hyperparathyroidism in patients in the study group is presented in Table 6.

Table 6

Frequency of secondary hyperparathyroidism in patients in the study group

PTG Survey group Comparison group

Winter Summer Winter Summer

p % p % p % p %

Normal 47 37.6 60 65.3 54 67.5 62 92.6

(9-52 pg/ml)

Increased 78 62.4 32 34.7 26 32.5 5 7.4

(above 52.0 pg/ml)

Total analyzes 125 100 92 100 80 100 67 100

Secondary hyperparathyroidism in the study group occurred significantly more often during the winter period of the study and more often than in healthy children (Table 6).

During the correlation analysis, an inverse correlation was found between the levels of 25(OH)B3 and 1111 blood serum not only in the winter, but also in the summer period of the study (r = - 0.28; p = 0.001 and r = - 0.27; p = 0.008 respectively) and between the low level of 25(OH)B3 and the activity of total alkaline phosphatase in the blood serum (r = - 0.32; p = 0.002). In addition, a direct relationship was found between the level of 25(OH)B3 and reduced calcium levels

blood serum during the winter period of the study (r = 0.53; p = 0.005), the level of 25(OH)B3 in blood serum in winter from its content in the summer (r = 0.43; p = 0.01). The discovered relationships between indicators of phosphorus-calcium metabolism are similar to those in healthy children.

In families of children with postural disorders, a large proportion of carbohydrate nutrition was noted, even among patients of Yakut nationality.

In patients with postural disorders, the influence of the nature of nutrition on some indicators of phosphorus-calcium metabolism was found. The average level of serum calcium for all types of nutrition corresponded to normal values and was significantly lower with a mixed type of nutrition compared to protein (p< 0,05). Средний уровень неорганического фосфата сыворотки крови соответствовал нормальным значениям и был достоверно ниже при углеводном типе питания при сравнении с белковым (р<0,01). Активность общей щелочной фосфатазы сыворотки крови была выше нормы и достоверно выше при белковом типе питания при сравнении с смешанным (р < 0,05).

When analyzing the indicators of phosphorus-calcium metabolism depending on nationality, physiologically insignificant but statistically significant differences were noted in the average levels of calcium, inorganic phosphate and the activity of total alkaline phosphatase in blood serum during the winter period of the study (p<0,001; р<0,001; р<0,01 соответственно).

There were no significant differences in the indicators of phosphorus-calcium metabolism depending on gender, except for a significantly higher level of inorganic phosphate and the activity of total alkaline phosphatase in the blood serum in boys in the summer, as well as in the comparison group (p< 0,01 и р < 0,05, соответственно).

In the examination group, significant differences were revealed in some indicators of phosphorus-calcium metabolism depending on the stage of puberty. Thus, stage IV of puberty was accompanied by a significant decrease in the level of inorganic phosphate when compared with stages Ia, I6, II, III (p<0,01; p <0,001; р <0,001; р <0,05 соответственно). Кроме того, наблюдалась более низкая (но в пределах нормальных значений) суточная экскреция фосфата с мочой у детей 16 стадией полового развития при сравнении с IV стадией (р<0,05). Также как и в группе сравнения, на начальных и завершающих стадиях пубертата найдены достоверные различия активности щелочной фосфатазы сыворотки крови: так, у детей на IV стадии полового развития этот показатель достоверно ниже при сравнении с Ia и I6 стадиями (р <0,05). Кроме того, у детей с IV стадией полового развития отмечается достоверно более низкая активность щелочной фосфатазы сыворотки крови при сравнении с показателем у детей II и III стадий (р <0,05). На III стадии пубертата средний уровень 25(OH)D3 сыворотки крови оказался достоверно ниже при сравнении с детьми!а стадии (р<0,05), а средний уровень ПТГ сыворотки крови достоверно выше, чем до начала пубертата (р<0,05). Снижение 25(OH)D3 в течение III стадии пубертата (аналогичная тенденция наблюдалась и у здоровых детей), связана, по-видимому, с периодом наиболее активного роста и созревания.

Thus, in patients with postural disorders, pronounced seasonal fluctuations in the level of 25^^^, a higher incidence of vitamin D deficiency, hypocalcemia and secondary hyperparathyroidism were revealed, compared with healthy children. Identified vitamin D deficiency and associated secondary hyperparathyroidism (especially during the period of active growth and maturation) may be factors predisposing to the formation of postural disorders.

Evaluation of the effectiveness of treatment with Calcium D3 Nycomed in the examination group

For this purpose, patients in the examination group were divided into two subgroups. Subgroup I - 50 patients - received the combined drug Calcium D3 Nycomed (Nycomed, Norway) in age-specific doses during February - March. Subgroup II - 75 patients - did not receive treatment with Calcium D3 Nycomed. Dynamic observation of patients was carried out for 8 months.

During the follow-up examination of patients in subgroup I, an improvement in general well-being and the disappearance of complaints of pain in the limbs and back were observed. Objectively, the condition of the skin, hair and nails improved in all patients. The growth rate was 6.4 ± 0.2 cm/year, body weight gain was 4.77 ± 0.15 kg/year.

During the control examination of children of subgroup II, it was revealed that 12% continued to have complaints of pain in the extremities and back, and 8% continued to have dry skin, brittle nails and hair. The growth rate was 5.6 ± 0.2 cm/year, body weight gain was 3.84 ± 0.17 kg/year.

The average concentration of 25(OH)D3 serum in patients of subgroup I was significantly higher than in children who did not take the drug (p<0,01) и не отличалась от показателя группы сравнения. У пациентов II подгруппы средний уровень 25(ОН^з сыворотки крови был достоверно ниже, чем этот показатель группы сравнения (р<0,01) (рис. 3).

The average serum PTH level in patients of subgroup I was significantly lower than in patients of subgroup II (p<0,05) и не отличался от этого показателя группы сравнения. У пациентов II подгруппы средний уровень ПТГ сыворотки крови был достоверно выше, чем у здоровых детей (р<0,001) (рис. 3).

The frequency of vitamin D deficiency in patients in the study group, depending on the use of the drug Calcium P3 Nycomed, is presented in Table 7.

Table 7

Frequency of vitamin D deficiency in patients of the examination group depending on the use of the drug Calcium RZ Nycomed

Study group

I subgroup

Value of 25(OH)P3 p % p % p %

Normal (greater than or equal to 14 ng/ml) 37 76 23 54.8 60 89.6

Insufficiency (below 14 ng/ml) 12 24 19 45.2 7 10.4

Severe deficiency (below Jung/ml) 7 16.7 3 4.4

Vitamin deficiency P (below 5 ng/ml) 1 2 1 2.3

II subgroup

Comparison group

In subgroup I, the frequency of vitamin P3 deficiency is significantly lower than in patients of subgroup II (24% and 45.2%, respectively), but remained higher than in healthy children (10.4%) (Table 7).

The frequency of secondary hyperparathyroidism in patients in the study group, depending on the use of the drug Calcium P3 Nycomed, is presented in Table 8.

Table 8

Frequency of secondary hyperparathyroidism in patients of the examination group depending on the use of the drug Calcium R3 Nycomed _

Survey group Group

I subgroup II comparison subgroup

PTH value p % p % p %

Total analyzes 49,100 42,100 67,100

Normal values (9 - 52.0 pg/ml) 37 76 22 52 62 92.6

Elevated values (more than 52.0 pg/ml) 12 24 20 48 5 7.4

The frequency of secondary hyperparathyroidism in patients of subgroup I was less common than in patients of subgroup II (24% and 48%, respectively), but remained higher than in healthy children (7.4%) (Table 8).

The activity of total alkaline phosphatase in the blood serum in patients of subgroup I did not differ from the corresponding indicator in children of the group

comparisons. In patients of subgroup II, the activity of total alkaline phosphatase in the blood serum was significantly higher than in healthy children (p<0,05).

Thus, our data confirm that the use of the drug Calcium D3 Nycomed in patients with postural disorders can achieve a significant improvement in phosphorus-calcium metabolism.

In a group of healthy children and adolescents of the Republic of Sakha (Yakutia), pronounced seasonal fluctuations in the incidence of vitamin D deficiency and secondary hyperparathyroidism were revealed. Vitamin D deficiency is observed in 60% in winter, 10.4% in summer, and secondary hyperparathyroidism in 32.5% in winter, 7.4% in summer.

In the group of children and adolescents with postural disorders, the incidence of vitamin D deficiency and secondary hyperparathyroidism was higher than in healthy children. Hypocalcemia in winter was observed in every fifth child.

There were no statistically significant differences in the content of 25(OH)D3 and PTH in blood serum depending on gender and nationality in children in the Republic of Sakha (Yakutia).

In children and adolescents with postural disorders in the final stages of puberty, the average level of 25(OH)D3 was significantly lower, and serum PTH was higher than in children before the onset of puberty. The drug Calcium D3 Nycomed can be used in children and adolescents in the Republic of Sakha (Yakutia) for the purpose of preventing and correcting vitamin D deficiency.

1. Krivoshapkina D.M. Features of calcium - phosphorus metabolism in minor orthopedic pathology in children of Yakutsk / Krivoshapkina D.M., Handy M.V. // Yakut Medical Journal. - No. 4. - 2003. - P. 10 - 13.

2. Krivoshapkina D.M. Indicators of calcium-phosphorus metabolism in children of Yakutsk / Krivoshapkina D.M., Handy M.V. // Modern aspects of prevention, health improvement and rehabilitation of children in the Far North: Materials of the Republican Scientific and Practical Conference. -Yakutsk, 2003.-S. 46-51.

3. Krivoshapkina D.M. Peculiarities of phosphoris - calcic metabolism in children of Yakutsk / D. Krivoshapkina, M. Khandy, E. Popova, R. Andreeva, N. Titova, R. Matveeva // X Russia - Japan International medical symposium. - Yakutsk, 2003.-P. 401-402.

4. Krivoshapkina D.M. Features of calcium metabolism in children of Yakutsk with minor orthopedic pathology / Krivoshapkina D.M., Handy M.V., Shabalov N.P., Skorodok Yu.L. // Current problems of pediatrics: Materials of the IX Congress of Pediatricians of Russia. Issues of modern pediatrics. - 2004. - T.Z. - Adj. No. 1. - P. 224.

5. Krivoshapkina D.M. Seasonal vitamin D deficiency in children with postural disorders / Krivoshapkina D.M., Handy M.V. // Current issues in pediatrics and pediatric surgery: Materials of scientific and practical research. Conf., dedicated to the 5th anniversary of the Human Rights Center of the Republic of Belarus No. 1 - NCM. - Yakutsk. - 2004. - P. 52-54.

6. Krivoshapkina D.M. Features of phosphorus-calcium metabolism in children of Yakutsk / Krivoshapkina D.M., Lise V.L., Handy M.V., Shabalov N.P. // Problems of human health formation in the perinatal period and childhood: Collection of scientific papers edited by Dr. med. Sciences Professor N.P. Shabalova. - St. Petersburg: Olga Publishing House, 2004.- P. 110112.

7. Krivoshapkina D.M. On the question of the role of calcium in children in the formation of a healthy skeleton / Krivoshapkina D.M., Handy M.V., Nikolaeva A.A., Ilistyanova N.V. // Ecology and health in the North: Materials of regional scientific and practical research. conf. Yakutsk, 2004 - Far Eastern Medical Journal. - 2004. - App. No. 1. - P. 107 -108.

8. Krivoshapkina D.M. Insufficiency of vitamin D and secondary hyperparathyroidism in winter in children and adolescents in Jakutia / M.V. Khandy, D.M. Krivoshapkina, N.V. Ilistyanova // XI International Symposium of the Japan-Russia Medical Exchange. -Niigata, 2004. - P. 143.

9. Krivoshapkina D.M. Vitamin D deficiency in older children (problem and ways of prevention) / Krivoshapkina D.M., Okhlopkova L.G., Petrova I.R. // Information mail. Approved 05/21/2004 Yakutsk: Yakut Scientific Center of the Russian Academy of Medical Sciences and the Government of the Republic of Sakha (Yakutia), 2004.

List of abbreviations:

25-hydroxycholecalciferol (calcidiol)

1,25^)^3 1,25-dihydroxycholecalciferol (calcitriol)

Intact parathyroid hormone

PTH Parathyroid hormone

Ca Calcium

P Inorganic phosphate

BMD Bone mineral density

IGF-1 Insulin-like growth factor-I

IGF - II Insulin-like growth factor - II

IGFBP Insulin-like growth factor binding protein

NCM - RB No. 1 National Center of Medicine - Republican

hospital no. 1

Signed for publication on October 21, 2004. Format 60x 84/16 Paper type. No. 2. Typeface "Time" Offset printing. Pech. l. 1.5. Academician l. 1.87. Circulation 100 copies. Order YSU Publishing House, 677891, Yakutsk, st. Belinsky, 58

Printed in the printing house of the YSU publishing house

RNB Russian Fund

INTRODUCTION.

CHAPTER 1. Calcium, vitamin D - the main factors influencing growth and skeletal formation (literature review).

1.1. Physiology of calcium - phosphorus metabolism.

1.2. The influence of calcium and other factors on the growth and formation of the skeleton.

1.3. The role of vitamin D in providing the body with calcium.

1.4. Calcium metabolism in children with postural disorders and idiopathic scoliosis.

1.5. Climate is a geographical characteristic of the city of Yakutsk.

CHAPTER 2. Research methods.

CHAPTER 3. Clinical characteristics of the examined groups.

CHAPTER 4. Research results.

4.1. Results of examination of children from the comparison group.

4.1.1. Analysis of the nutritional pattern of children in the comparison group.

4.1.2. Indicators of phosphorus-calcium metabolism in children of the comparison group.5O

4.1.3. Results of linear correlation analysis in the comparison group.

4.1.4. Results of analysis of phosphorus-calcium metabolism indicators in children of the comparison group depending on nationality, gender and stage of sexual development.

4.2. Results of examination of patients in the examination group.

4.2.1. Analysis of the nutritional pattern of patients in the study group.

4.2.2. Results of a study of phosphorus-calcium metabolism in the examination group.

4.2.3. Results of linear correlation analysis in the examination group.

4.2.4. Results of a study of phosphorus-calcium metabolism indicators in the examination group depending on nationality, gender and stage of sexual development.

4.2.5. Results of radiographic examination of patients in the examination group.

4.3. Evaluation of the effectiveness of treatment, patients in the examination group, with the drug Calcium D3 Nycomed.

Introduction of the dissertationon the topic "Pediatrics", Krivoshapkina, Dora Mikhailovna, abstract

Relevance of the problem. Among the factors that have a decisive influence on the growth and formation of the skeleton, an important role belongs to a balanced diet, primarily a sufficient supply of calcium and the supply of vitamin D to the child’s body [Spirichev V.B., 2003; Shabalov N.P., 2003; Shcheplyagina L.A., Moiseeva T.Yu., 2003; Saggese G., Baroncelli G.L. et al, 2001 and others].

The critical periods for the formation of a genetically programmed peak of bone mass are the first three years of a child’s life and the prepubertal period [Kotova S.M. et al., 2002; Shcheplyagina JT.A. et al., 2003; Sabatier JP.et al., 1996, etc.].

According to modern concepts, calcium and vitamin D deficiency can lead to the development of a wide range of diseases, including the musculoskeletal system [Nasonov E.L., 1998; Shcheplyagina L.A. et al., 2002; Dambacher M.A., Shakht E., 1996; Lips R., 1996, etc.].

Non-surgical pathology of the musculoskeletal system, in particular, flat feet, postural abnormalities, scoliosis and others, in recent years has been classified as a population-significant pathology in children of indigenous residents of the regions of the Far North of Russia [Bobko Ya.N., 2003; Chasnyk V.G., 2003].

The Republic of Sakha (Yakutia) belongs to the regions of the Russian Federation that have unfavorable health indicators for the child population. This is due both to extreme natural and climatic conditions, and to the peculiarities of nutrition and lifestyle of the population [Petrova P.G., 1996; Handy M.V., 1995, 1997]. The sharply continental climate of Yakutia, the long winter season, and insufficient insolation negatively affect the health and development of children and adolescents. In this regard, it can be assumed that in the conditions of Yakutia, the supply of vitamin D is reduced in children and adolescents.

2002); 16.9 (2003) and with postural disorders - 45.1 (2001); 63.0 (2002); 52.4

2003) per 1000 examined. This explains the interest of clinicians in the problem of calcium and bone metabolism.

In the Republic of Sakha (Yakutia), no studies have been conducted to study phosphorus-calcium metabolism, including in children with orthopedic pathologies.

Goal of the work. Study of indicators of phosphorus-calcium metabolism in children and adolescents with postural disorders in the Republic of Sakha (Yakutia) Research objectives:

1. To study indicators of phosphorus-calcium metabolism, the content of calcium-regulating hormones in blood serum in healthy children and adolescents in the conditions of the Republic of Sakha (Yakutia).

2. To study the state of calcium homeostasis and serum levels of PTH and 25(OH)D3 in patients with postural disorders.

3. Formulate a hypothesis of the possible influence of calcium and vitamin D deficiency on the formation of postural disorders in children and adolescents in the conditions of the Republic of Sakha (Yakutia).

4. Develop proposals for the prevention of vitamin D deficiency in children and adolescents living in the Republic of Sakha (Yakutia).

Scientific novelty

For the first time in the Republic of Sakha (Yakutia), a study of phosphorus-calcium metabolism indicators was conducted in practically healthy children, as well as in children and adolescents with postural disorders.

Seasonal vitamin D deficiency was identified in children and adolescents living in the Republic of Sakha (Yakutia); secondary hyperparathyroidism associated with vitamin D deficiency; higher incidence of hypocalcemia, vitamin D deficiency, and secondary hyperparathyroidism among patients with postural disorders.

The relationship between the content of 25(OH)Oz and the level of PTH in the blood serum was confirmed; serum 25(OH)D3 and calcium levels; the level of 25(OH)Oz and the activity of total alkaline phosphatase in the blood serum and the dependence of the level of 25(OH)D3 in the blood serum in winter on its content in the summer.

It has been established that calcium deficiency and vitamin D deficiency affect the formation of postural disorders in children and adolescents in the Republic of Sakha (Yakutia).

Practical significance of the study. The results of a study of phosphorus-calcium metabolism in healthy children and adolescents and children with posture disorders in the city of Yakutsk were obtained. The identified deviations made it possible to justify the need for therapeutic and diagnostic measures in children and adolescents with postural disorders and preventive measures in healthy children and adolescents in the conditions of Yakutia.

The main provisions of the dissertation submitted for defense:

2. Secondary hyperparathyroidism as a compensatory reaction of the parathyroid glands to hypocalcemia, caused, in particular, by vitamin D deficiency, is more common in winter than in summer and is more pronounced in children and adolescents with postural disorders than in healthy children.

3. The use of the combined drug Calcium D3 Nycomed causes a therapeutic effect, manifested by the disappearance of complaints, improvement of well-being, normalization of phosphorus-calcium metabolism and calcium-regulating hormones. Implementation of work results

The results and recommendations obtained as a result of the study are used in the practical activities of the children's clinical and advisory department of the Consultative and Diagnostic Center of the Republic of Belarus No. 1-NTsM in Yakutsk and in children's medical institutions of the republic. The dissertation materials are included in the student training program and are also used in the postgraduate training of doctors at the Medical Institute of Yakut State University. Publications and testing of work. The main provisions of the dissertation work were presented: at the IX Congress of Pediatricians of Russia “Current Problems of Pediatrics” (Moscow, 2004), the International Russian-Japanese Symposium (Yakutsk, 2003; Niagata, Japan, 2004), the regional scientific and practical conference " Ecology and human health in the North" (Yakutsk, 2004), scientific and practical conferences of the Medical Institute of Yakut State University, National Center of Medicine (Yakutsk, 2004), meeting of the regional branch of the Union of Pediatricians of Russia of the Republic of Sakha (Yakutia) (Yakutsk, 2004) , meeting of the Department of Pediatrics FPK and PP with courses of perinatology and endocrinology of the St. Petersburg State Pediatric Medical Academy (2003, 2004) Based on the materials of the research, 9 printed works were published, including 2 in the central press and 1 information letter. Scope and structure of the dissertation

Conclusion of the dissertation researchon the topic "Features of phosphorus-calcium metabolism in children and adolescents with postural disorders in the conditions of the Republic of Sakha (Yakutia)"

1. In a group of healthy children and adolescents of the Republic of Sakha (Yakutia), pronounced seasonal fluctuations in the incidence of vitamin D deficiency and secondary hyperparathyroidism were revealed. Vitamin D deficiency is observed in 60% in winter, 10.4% in summer, and secondary hyperparathyroidism in 32.5% in winter, 7.4% in summer.

2. In the group of children and adolescents with postural disorders, the incidence of vitamin D deficiency and secondary hyperparathyroidism was higher than in healthy children. Hypocalcemia in winter was observed in every fifth child.

3. Statistically significant differences in the content of 25(OH)D3 and PTH in blood serum depending on gender and nationality in children in the Republic of Sakha (Yakutia) were not revealed.

4. In children and adolescents with postural disorders in the final stages of puberty, the average level of 25(OH)D3 was significantly lower, and serum PTH was higher than in children before the onset of puberty.

5. The drug Calcium D 3 Nycomed can be used in children and adolescents in the Republic of Sakha (Yakutia) for the prevention and correction of vitamin D deficiency.

1. During the winter season, children and adolescents in the Republic of Sakha (Yakutia) are recommended to be prescribed complex calcium and vitamin D supplements for preventive purposes.

2. Include in the examination plan for children and adolescents with postural disorders the determination of serum 25(OH)D3 and PTH levels.

3. In case of detection of vitamin D deficiency and/or elevated PTH levels, treatment with vitamin D and calcium preparations is indicated for children and adolescents with postural disorders.

List of used literaturein medicine, dissertation 2004, Krivoshapkina, Dora Mikhailovna

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7. Bobko Y.N. Non-surgical pathology of the musculoskeletal system in children of the Far North of Russia // Children's healthcare in the Republic of Sakha (Yakutia): optimization of work and development strategy: Mater, scientific-practical. Conf. - Yakutsk, 2003. - P. 8 9.

8. Bogatyreva A.O. Clinical significance of assessing bone mineral density in children. Author's abstract. dis. Ph.D. M., 2003. 23 p.

9. Blazheevich N.V., Spirichev V.B., Pereverzeva L.V. and others. Features of calcium-phosphorus metabolism and vitamin D supply in the Far North // Questions of nutrition. 1983. - No. 1. - P. 17-21.

10. Yu. Brickman A. Disorders of calcium and phosphorus metabolism in adults // Endocrinology: Transl. from English / Ed. N. Lavina - M.: Praktika, 1999. -P. 413-454.

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Minerals (minerals)- natural substances, approximately homogeneous in chemical composition and physical properties, included in the composition of rocks, ores, meteorites (from the Latin minera - ore).

Minerals, along with proteins, fats, carbohydrates and vitamins, are vital components of human food, necessary for building the structures of living tissues and carrying out the biochemical and physiological processes that underlie the life of the body. Minerals participate in the body’s most important metabolic processes: water-salt and acid-base. Many enzymatic processes in the body are impossible without the participation of certain minerals.

The human body receives these elements from the environment, food and water.

The quantitative content of a particular chemical element in the body is determined by its content in the external environment, as well as by the properties of the element itself, taking into account the solubility of its compounds.

For the first time, the scientific foundations of the doctrine of microelements in our country were substantiated by V. I. Vernadsky (1960). Fundamental research was carried out by A.P. Vinogradov (1957) - the founder of the doctrine of biogeochemical provinces and their role in the occurrence of endemic diseases of humans and animals and V.V. Kovalsky (1974) - the founder of geochemical ecology and biogeography of chemical elements.

Currently, out of 92 naturally occurring elements, 81 chemical elements are found in the human body.

Minerals make up a significant portion of the human body by mass (on average, the body contains about 3 kg of ash). In bones, minerals are presented in the form of crystals, in soft tissues - in the form of a true or colloidal solution in combination mainly with proteins. For clarity, we can give the following example: the body of an adult contains about 1 kg of calcium, 0.5 kg of phosphorus, 150 g of potassium, sodium and chlorine, 25 g of magnesium, 4 g of iron.

Classification of chemical elements
- Classification of chemical elements according to their biological significance. All chemical elements can be divided into groups:
  - The 12 structural elements are carbon, oxygen, hydrogen, nitrogen, calcium, magnesium, sodium, potassium, sulfur, phosphorus, fluorine and chlorine.
  - 15 essential (vital) elements - iron, iodine, copper, zinc, cobalt, chromium, molybdenum, nickel, vanadium, selenium, manganese, arsenic, fluorine, silicon, lithium.
  - 2 conditionally necessary elements - boron and bromine.
  - 4 elements are serious "candidates for necessity" - cadmium, lead, aluminum and rubidium.
  - The remaining 48 elements are less significant for the body.
- Classification of chemical elements based on a quantitative assessment of their content in the human body Traditionally, all mineral substances are divided into two groups according to their content in the human body.
  - Macroelements.
  - Microelements.
    The concentration of trace elements in the body is low. The body contains quantities measured in milligrams or micrograms. Trace elements are those minerals for which the estimated dietary requirement is typically less than 1 μg/g and often less than 50 ng/g of diet for laboratory animals and humans.
    
    Despite the low need, these elements are part of enzyme systems as coenzymes (activators and catalysts of biochemical processes). The group of microelements includes: zinc, iodine, fluorine, silicon, chromium, copper, manganese, cobalt, molybdenum, nickel, boron, bromine, arsenic, lead, tin, lithium, cadmium, vanadium and other substances.

The influence of minerals on the human body.
Minerals do not have energy value like proteins, fats and carbohydrates. However, without them, human life is impossible. Just as with a lack of basic nutrients or vitamins, with a deficiency of minerals in the human body, specific disorders arise that lead to characteristic diseases.

Microelements and vitamins are in some ways even more important than nutrients, because without them the latter will not be properly absorbed by the body.

Mineral substances are especially important for children during the period of intensive growth of bones, muscles, and internal organs. Naturally, pregnant women and nursing mothers need increased intake of minerals. With age, the need for minerals decreases.
- Deficiency and excess intake of minerals
  The influence of micro- and macroelements on the life activity of animals and humans is being actively studied for medical purposes. Any pathology, any deviation in the health of a biological organism is accompanied by either a deficiency of vital (essential) elements, or an excess of both essential and toxic microelements. This imbalance of macro- and microelements received the unifying name “microelementosis”.
  
  Since the 1970s, there have been many speculative claims that micronutrient deficiencies are a significant contributor to a number of chronic diseases. In many cases, this statement has been experimentally confirmed, but some scientists today believe that insufficient intake of a particular micronutrient is significant only when the body is exposed to stress, which increases the need for this micronutrient.
  
  Chemical substances, despite their importance and necessity for the human body, can also have a negative effect on plants, animals and humans if the concentration of their available forms exceeds certain limits. Cadmium, tin, lead and rubidium are considered conditionally necessary, because they appear to be of little importance to plants and animals and are hazardous to human health even at relatively low concentrations. The biological role of some trace elements is currently not sufficiently studied.
  
  It is necessary to remember certain precautions when consuming mineral complexes (both medications and biologically active food additives).
  
  An overdose of one mineral can lead to functional impairment and increased excretion of another mineral. The development of unwanted side effects is also possible. For example, excess zinc leads to a decrease in the level of cholesterol-containing high-density lipids ("good" cholesterol).
  
  Excess calcium can lead to phosphorus deficiency, and vice versa.
  
  Excess molybdenum reduces copper content.
  
  Some trace elements (selenium, chromium, copper) are toxic in excess doses. This especially applies to salts of many metals.
  
  When consuming minerals, you should strictly adhere to medical recommendations.
- Effect of heavy metals on the human body
  In recent years, the effects of heavy metals on the human body have been isolated. Heavy metals are a group of chemical elements with a relative atomic mass greater than 40.
  
  The appearance of the term “heavy metals” in the literature was associated with the manifestation of the toxicity of certain metals and their danger to living organisms.
  
  However, the “heavy” group also includes some microelements, the vital necessity and wide range of biological effects of which have been irrefutably proven.
  
  “Heavy” metals are lead, cadmium, zinc, copper, nickel, chromium.
  
  In recent years, the important biological role of most “heavy” metals has been increasingly confirmed. Numerous studies have established that the influence of metals is very diverse and depends on their content in the environment and the degree of need for them by microorganisms, plants, animals and humans.
  
  The influence of “heavy” metals on living organisms is very diverse. This is due, firstly, to the chemical characteristics of metals, secondly, to the attitude of organisms towards them and, thirdly, to environmental conditions.
  
  Already now, in many regions of the world, the environment is becoming more and more “aggressive” from a chemical point of view. In recent decades, the main objects of biogeochemical research have become the territories of industrial cities and adjacent lands, especially if agricultural plants are grown on them and then used for food.

Modern scientific data on the biological role of the studied chemical elements, their metabolism in the human body, daily consumption rates, and the content of chemicals in food products are presented in separate articles describing each chemical element. The articles also present data on deficiency conditions that develop with insufficient consumption of these chemicals, as well as the body's reaction to excess consumption of nutrients.

Macronutrients
- Salt

Microelements