Sarcopenia em pacientes de 40 a 64 anos hospitalizados por insuficiência cardíaca / Sarcopenia in patients aged 40­64 years hospitalized for heart failure

Introdução: a insuficiência cardíaca (IC) e a sarcopenia são condições prevalentes e inter-relacionadas, figurando como importantes causas de limitações funcionais. Objetivo: avaliar critérios de sarcopenia, e suas relações com parâmetros cardiometabólicos, em pacientes de 40 a 64 anos hospitalizados por IC. Metodologia: estudo de corte transversal com caráter analítico envolvendo indivíduos com IC confirmada. A massa muscular apendicular (MMA) foi avaliada através da absorciometria por raios-X de dupla energia (DXA), considerando-se baixa MMA mulheres com MMA/altura² <5,5 kg/m² ou MMA/índice de massa corporal (IMC) <0,512 e homens com MMA/altura² <7,0 kg/m² ou MMA/IMC <0,789. Baixa força de preensão manual (FPM) foi considerada quando <16 kg em mulheres e <27 kg em homens. Resultados: avaliou-se 109 pacientes (50,5% mulheres), com mediana de idade de 58 anos. Constatou-se baixa MMA em 41,3% e baixa FPM em 64,2%, não havendo correlação significativa entre FPM e MMA em nenhum dos gêneros. Baixa MMA se associou ao gênero masculino (68,9% versus 35,9%; p=0,001), a maiores idades (60,0 [53,0-63,0] versus 57,0 [51,3-60,0] anos; p=0,039) e maiores níveis séricos de paratormônio (48,0 [30,5-94,4] versus 29,9 [23,0-54,1] pg/mL; p=0,009). Baixa FPM se associou a maior sintomatologia cardíaca (75,7% com baixa FPM tinham classificação funcional da New York Heart Association III-IV, versus 51,3% daqueles com FPM normal; p=0,009). Conclusões: há uma relevante prevalência de sarcopenia em pacientes de 40 a 64 anos hospitalizados por IC, observando-se maior frequência de baixa MMA nos homens, associação entre baixa FPM e sintomatologia cardíaca, e maiores níveis de paratormônio naqueles com perda muscular.

Introduction: heart failure (HF) and sarcopenia are prevalent and interrelated conditions, being important causes of functional limitations. Objective: to evaluate sarcopenia criteria, and their relationship with cardiometabolic parameters, in patients aged 40­64 years hospitalized for HF. Methodology: Cross-sectional study including patients with established HF. Appendicular skeletal muscle mass (ASMM) was assessed using dual-energy X-ray absorptiometry (DXA), considering low ASMM women with ASMM/height² <5.5 kg/m² or ASMM/body mass index (BMI) <0.512 and men with ASMM/height² <7.0 kg/m² or ASMM/BMI <0.789. Low handgrip strength (HGS) was considered when <16 kg in women and <27 kg in men. Results: we evaluated 109 patients (50.5% women), with a median age of 58 years. Low ASMM was found in 41.3% and low HGS in 64.2%, with no significant correlation between HGS and ASMM in either gender. Low ASMM was associated with male gender (68.9% versus 35.9%; p=0.001), older age (60.0 [53.0-63.0] versus 57.0 [51.3-60, 0] years; p=0.039) and higher serum parathyroid hormone (48.0 [30.5-94.4] versus 29.9 [23.0-54.1] pg/mL; p=0.009). Low HGS was associated with greater cardiac symptoms (75.7% with low HGS had a New York Heart Association III-IV functional classification, versus 51.3% of those with normal HGS; p=0.009). Conclusions: there is a relevant prevalence of sarcopenia in patients aged 40­64 years hospitalized for HF, observing a higher frequency of low ASMM in men, an association between low HGS and cardiac symptoms, and higher levels of parathyroid hormone in those with muscle wasting.

Skeletal consequences of heart failure.

Heart failure (HF) is a prevalent clinical syndrome that causes significant physical limitations. Osteoporosis is also an important cause of loss of functionality, and it mainly affects women. There are several reports linking HF and osteoporosis, and both share risk factors. Most of the data available so far point to bone fragility as a consequence of HF, and several mechanisms have been identified to explain this relationship. Among the proposed pathophysiological mechanisms are the hyperactivation of the renin-angiotensin-aldosterone system and the increase in parathyroid hormone, functional limitation, production of inflammatory mediators and the use of drugs for HF. The role of osteoprotegerin has gained attention owing to its cardiovascular and skeletal effects, its observed deficiency during the postmenopausal period along with its compensatory increases in HF and severe osteoporosis. The objective of this review was to perform a literature search for the main evidence on skeletal impairment in HF, with emphasis on women. As for epidemiological studies, we selected data from 3 meta-analyses and 20 individual observational studies, which together showed the interrelationship between the two clinical conditions in terms of both decreased bone density and increased fracture risk. In conclusion, HF and osteoporosis are interrelated conditions mediated by complex pathophysiological mechanisms which may be more relevant for postmenopausal women, considered to be a vulnerable population for both cardiovascular diseases and bone fragility.

Medical management of primary hyperparathyroidism

ABSTRACT Primary hyperparathyroidism (PHPT) is an endocrine disorder resulting from the hyperfunction of one or more parathyroid glands, with hypersecretion of parathyroid hormone (PTH). It can be managed by parathyroidectomy (PTX) or non-surgically. Medical therapy with pharmacological agents is an alternative for those patients with asymptomatic PHPT who meet guidelines for surgery but are unable or unwilling to undergo PTX. In this review, we focus upon these non-surgical aspects of PHPT management. We emphasize the most studied and widely used pharmacological alternatives: bisphosphonates, denosumab, cinacalcet and hormone therapy, in addition to combined therapy. We also address the relevant aspects of perioperative management.

Long-term consequences of osteoporosis therapy with denosumab

ABSTRACT Denosumab (DMAb) is a human monoclonal antibody used as an antiresorptive drug in the treatment of osteoporosis. Approval at a dosage of 60 mg every 6 months was based on the results of the randomized, placebo-controlled trial (FREEDOM). The design of this 3-year study included an extension for up to 10 years. Those who were randomized to DMAb continued on drug, while those who were randomized to placebo transitioned to DMAb. The 10-year experience with DMAb provides data on efficacy of drug in terms of reduced fractures and continued increases in bone mineral density (BMD). The 10-year experience with denosumab also provides information about rare complications associated with the use of DMAb, such as osteonecrosis of the jaw (ONJ), and atypical femoral fractures (AFF). This experience provided new insights into the reversibility of effects upon discontinuation without follow-on therapy with another agent. This review focuses upon prolonged treatment with DMAb, with regard to beneficial effects on fracture reduction and safety. Additionally, its use in patients with impaired renal function, compare its results with those of bisphosphonates (BPs), the occurrence/frequency of complications, in addition to the use of different tools, from imaging techniques to histological findings, to evaluate its effects on bone tissue.

Prevalência de doença hepática gordurosa não alcoólica apontada por ultrassonografia em pacientes com diabetes tipo 2 hospitalizados / Prevalence of non-alcoholic fatty liver disease indicated by ultrasound in hospitalized patients with type 2 diabetes

Introdução: a doença hepática gordurosa não alcoólica (DHGNA) é caracterizada pela infiltração gordurosa do fígado em indivíduos sem histórico de ingestão significativa de álcool ou de outras doenças hepáticas. A DHGNA é subdividida em fígado gorduroso não alcoólico e esteato-hepatite não alcoólica (NASH). A resistência à insulina e o diabetes mellitus tipo 2 (DM2) apresentam importante associação com DHGNA. Objetivos: avaliar a prevalência de DHGNA, predita por ultrassonografia, em pacientes com DM2 hospitalizados, verificando sua associação com tempo de DM2, comorbidades, terapêutica previamente utilizada, parâmetros antropométricos e controle glicêmico e pressórico. Metodologia: estudo observacional, transversal e analítico, realizado nas enfermarias de Clínica Médica e de Endocrinologia do Hospital Universitário Alcides Carneiro envolvendo pacientes adultos com DM2. Foram excluídos pacientes com outras hepatopatias diagnosticadas, com histórico de etilismo significativo ou que não aceitaram participar da pesquisa. Resultados: a amostra válida foi de 20 pacientes, com média de idade de 62,9 anos (± 10,9). A prevalência de DHGNA foi de 40%. Houve associação estatisticamente significativa entre DHGNA e maiores níveis de índice de massa corpórea (IMC) (p = 0,025) e de circunferência abdominal (CA) (p = 0,041). Entre as comorbidades, houve relação entre DHGNA e hipotireoidismo (p = 0,049). Conclusão: Apesar das limitações relacionadas ao tamanho da amostra, observa-se que a DHGNA está associada à obesidade central, o que é apontado pelos maiores níveis de IMC e de CA, de forma que uma abordagem multidisciplinar pode impedir o desenvolvimento ou a progressão de DHGNA.

Introduction: Non-alcoholic fatty liver disease (NAFLD) is characterized by fatty infiltration of the liver in individuals without a history of significant alcohol intake or other liver diseases. NAFLD is subdivided into non-alcoholic fatty liver and non-alcoholic steatohepatitis (NASH). Insulin resistance and type 2 diabetes mellitus (DM2) have an important association with NAFLD. Objectives: to evaluate the prevalence of NAFLD, predicted by ultrasound, in hospitalized patients with DM2, checking its association with DM2 duration, comorbidities, previously used therapy, anthropometric parameters and glycemic and blood pressure control. Methodology: observational, cross-sectional and analytical study, carried out in the Medical Clinic and Endocrinology wards of the Hospital Universitário Alcides Carneiro, involving adult patients with DM2. Patients with other diagnosed liver diseases, with a history of significant alcoholism or who did not want to participate in the research were excluded. Results: the valid sample consisted of 20 patients, with a mean age of 62.9 years (± 10.9). The prevalence of NAFLD was 40%. There was a statistically significant association between NAFLD and higher levels of body mass index (BMI) (p = 0.025) and waist circumference (WC) (p = 0.041). Among comorbidities, there was a relationship between NAFLD and hypothyroidism (p = 0.049). Conclusion: despite the limitations related to the sample size, it is observed that NAFLD is associated with central obesity, which is pointed out by the higher levels of BMI and WC, so that a multidisciplinary approach can prevent the development or progression of NAFLD.

Associação entre sarcopenia e história de fraturas em pacientes idosos com diabetes tipo 2 / Association between sarcopenia and history of fractures in elderly patients with type 2 diabetes

RESUMO: Objetivo: Avaliar a prevalência de sarcopenia em pacientes idosos portadores de diabetes mellitus (DM), verificando sua associação com histórico de fraturas e quedas. Modelo do estudo: Observacional, transversal e analítico. Metodologia: Estudo realizado em hospital universitário de Campina Grande, Paraíba. Envolveu pacientes idosos (≥60 anos) com DM. Foram excluídos aqueles com diagnóstico de osteoporose. O critério preditor de sarcopenia foi a circunferência da panturrilha (CP): <33 cm para mulheres e <34 cm para homens. Resultados: A amostra válida foi de 44 pacientes, todos com diabetes mellitus tipo 2 (DM2). A prevalência de sarcopenia foi de 20,4%. Houve relação estatisticamente significativa entre sarcopenia e história de fraturas em traumas de baixa energia (p = 0,022). Não houve diferença entre os grupos com e sem sarcopenia em relação à história de quedas no último ano (p = 0,589). Houve associação entre uso de psicotrópicos e ocorrência de quedas (p = 0,001). A maioria dos achados convergiram para aqueles já presentes na literatura. Conclusão: Apesar da CP não ser, de forma isolada, um método estabelecido para o diagnóstico de sarcopenia, a perda muscular apontada por tal medida mostrou-se associada a histórico de fraturas em idosos com DM2, de forma que essa acessível mensuração pode alertar para iniciar intervenções que possam melhorar a qualidade de vida dos idosos. (AU)

ABSTRACT: Objective: Evaluating the prevalence of sarcopenia in elderly patients with diabetes mellitus (DM), verifying their association with a history of fractures and falls. Study model: Observational, cross-sectional, and analytical. Method: The study was conducted at a university hospital in Campina Grande, Paraíba. It included elderly patients (≥60 years) with DM. Those with a diagnosis of osteoporosis were excluded. The predictor criterion for sarcopenia was calf circumference (CC): <33 cm for women and <34 cm for men. Results: The valid sample was 44 patients, all with type 2 diabetes mellitus (DM2). The prevalence of sarcopenia was 20.4%. There was a statistically signifi-cant relationship between sarcopenia and history of fractures in low energy traumas (p=0.022). There was no dif-ference between the groups with and without sarcopenia in relation to the history of falls in the last year (p=0.589). There was an association between the use of psychotropic drugs and the occurrence of falls (p=0.001). Most of the findings converged with those already present in the literature. Conclusion: Although CC is not an established method for the diagnosis of sarcopenia, muscle loss indicated by this measure has been associated with a history of fractures in the elderly with DM2, so that this accessible measurement can alert to initiate interventions that can improve the quality of life of the elderly. (AU)

Incidência de near miss neonatal em uma maternidade de médio porte do Nordeste Brasileiro / Incidence of neonatal near miss in a midsize maternity in the Northeast Brazil

RESUMO: Objetivo: Verificar a incidência de near miss neonatal (NMN), indicador de "quase morte" por complicações pré ou pós-natais, em uma maternidade de médio porte no Nordeste brasileiro. Modelo do estudo: Coorte retrospectiva, com abordagem indutiva e procedimentos descritivos. Metodologia: Analisou-se prontuários de nascidos no mês de janeiro de 2016, identificando-se os casos de NMN conforme os seguintes critérios: idade gestacional < 32 semanas, recém-nascido (RN) que necessitou de manobra de reanimação ou deprimido, peso ao nascimento < 1500 g, necessidade de cuidados em unidade de terapia intensiva neonatal (UTIN), necessidade de ventilação mecânica, escore de Apgar no 1º e 5º minutos < 7. Para verificar a associação entre as variáveis maternas e o diagnóstico de NMN, foi utilizado o teste t de Student. Resultados: Foram avaliados 120 RN. Dentre eles, 26 nascidos de parto normal e 94 de parto cesáreo. A média de idade materna foi de 26,61 (±7,9). A maioria das genitoras apresentava doenças cardiovasculares (71,7%) e 70,8% pré-natal com número de consultas inferior a sete. Identificou-se uma incidência de 30% de NMN, sendo a maioria do sexo masculino (55%). A taxa de internação na UTIN foi de 17,5%. O menor número de filhos vivos e médias superiores de partos cesáreos apresentaram associação significativa (p < 0,05) com o NMN. Conclusão: O indicador de NMN apresentou uma elevada incidência, mesmo em hospital de referência para gestação de alto risco, sendo um método de grande relevância para avaliação e prevenção de morbidades graves do RN. (AU)

ABSTRACTObjective: Verifying the incidence of neonatal near miss (NNM), an indicator of "near-death" due to pre or postnatal complications, in a medium-sized maternity hospital in the Northeast of Brazil. Study model: retrospective cohort, with an inductive approach and descriptive procedures. Method: Birth charts were analyzed during January 2016, and NNM cases were identified according to the following criteria: gestational age < 32 weeks, newborn (NB) requiring resuscitation or depressed maneuver, birth weight < 1500 g, need for care in a neonatal intensive care unit (NICU), need for mechanical ventilation, Apgar score at 1 and 5 minutes ≤ 7. To verify the association between maternal variables and NMN diagnosis the Student's t-test was used. Results: 120 NB were evaluated. Among them, 26 born of normal birth and 94 of cesarean delivery. The mean maternal age was 26.61 (± 7.9). The majority of the mothers had cardiovascular diseases (71.7%) and 70.8% had a prenatal visit with several consultations below seven. An incidence of 30% of NNM was observed, most of them male (55 %). The hospitalization rate in the NICU was 17.5%. The lower number of live children and higher mean cesarean births had a significant association (p <0.05) with the NNM. Conclusion: The NNM indicator presented a high incidence, even in a reference hospital for a high-risk pregnancy, being a highly relevant method for the evaluation and prevention of severe morbidity in the NB. (AU)