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Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). Methods: Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high-risk features, a new dual-action therapy option, and transitions from therapeutic options. Conclusion: This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of post-menopausal osteoporosis. Abbreviations: 25(OH)D = 25-hydroxyvitamin D; AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AFF = atypical femoral fracture; ASBMR = American Society for Bone and Mineral Research; BEL = best evidence level; BMD = bone mineral density; BTM = bone turnover marker; CI = confidence interval; CPG = clinical practice guideline; CTX = C-terminal telopeptide type-I collagen; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = U.S. Food and Drug Administration; FRAX® = Fracture Risk Assessment Tool; GI = gastrointestinal; HORIZON = Health Outcomes and Reduced Incidence with Zoledronic acid ONce yearly Pivotal Fracture Trial (zoledronic acid and zoledronate are equivalent terms); ISCD = International Society for Clinical Densitometry; IU = international units; IV = intravenous; LSC = least significant change; NOF = National Osteoporosis Foundation; ONJ = osteonecrosis of the jaw; PINP = serum amino-terminal propeptide of type-I collagen; PTH = parathyroid hormone; R = recommendation; ROI = region of interest; RR = relative risk; SD = standard deviation; TBS = trabecular bone score; VFA = vertebral fracture assessment; WHO = World Health Organization.
Assuntos
Osteoporose Pós-Menopausa , Absorciometria de Fóton , Idoso , Densidade Óssea , Endocrinologistas , Feminino , Humanos , Pessoa de Meia-Idade , Osteoporose Pós-Menopausa/diagnóstico , Osteoporose Pós-Menopausa/terapia , Estados UnidosRESUMO
Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). Methods: Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high-risk features, a new dual-action therapy option, and transitions from therapeutic options. Conclusion: This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of post-menopausal osteoporosis.
Assuntos
Osteoporose Pós-Menopausa , Idoso , Endocrinologistas , Medicina Baseada em Evidências , Feminino , Humanos , Pessoa de Meia-Idade , Osteoporose Pós-Menopausa/diagnóstico , Osteoporose Pós-Menopausa/terapia , Estados UnidosRESUMO
The American Association of Clinical Endocrinologists (AACE) has created a transculturalized diabetes chronic disease care model that is adapted for patients across a spectrum of ethnicities and cultures. AACE has conducted several transcultural activities on global issues in clinical endocrinology and completed a 3-city series of conferences in December 2017 that focused on diabetes care for ethnic minorities in the U.S. Proceedings from the "Diabetes Care Across America" series of transcultural summits are presented here. Information from community leaders, practicing health care professionals, and other stakeholders in diabetes care is analyzed according to biological and environmental factors. Four specific U.S. ethnicities are detailed: African Americans, Latino/Hispanics, Asian Americans, and Native Americans. A core set of recommendations to culturally adapt diabetes care is presented that emphasizes culturally appropriate terminology, transculturalization of white papers, culturally adapting clinic infrastructure, flexible office hours, behavioral medicine-especially motivational interviewing and building trust-culturally competent nutritional messaging and health literacy, community partnerships for care delivery, technology innovation, clinical trial recruitment and retention of ethnic minorities, and more funding for scientific studies on epigenetic mechanisms of cultural impact on disease expression. It is hoped that through education, research, and clinical practice enhancements, diabetes care can be optimized in terms of precision and clinical outcomes for the individual and U.S. population as a whole.
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Diabetes Mellitus Tipo 2 , Endocrinologia , Asiático , Endocrinologistas , Hispânico ou Latino , Humanos , Sociedades Médicas , Estados UnidosRESUMO
Recent media have highlighted the controversy surrounding treatment of elite athletes for hypothyroidism. The World Anti-Doping Agency denied a request by the United States Anti-Doping Agency to ban the use of thyroid medication. At present, there is no scientific evidence that thyroid medication has the potential to enhance performance. Clinical practice guidelines are not definitive in regard to what classifies a patient as having hypothyroidism. Thyroid-stimulating hormone and free T4 are recommended to screen for thyroid disease; however, the thyrotropin-releasing hormone stimulation test is still advocated by some for detecting the earliest stages of hypothyroidism. Hypothyroidism has been demonstrated to reduce cardiopulmonary function and result in musculoskeletal symptoms, such as fatigue and muscle stiffness. Symptoms of hypothyroidism, including depression, fatigue, and impaired sleep, are similar to those reported in overtraining. These patients may have hypothalamic-pituitary dysfunction that may complicate interpretation of basal thyroid-stimulating hormone and free T4. To date, no association has been identified between training state and hypothyroidism. Research to more clearly define hypothyroidism using provocative testing, evaluate the potential for thyroid medication to enhance performance, and examine whether training may induce hypothyroidism in athletes is desirable.
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Hipotireoidismo/diagnóstico , Testes de Função Tireóidea , Glândula Tireoide/fisiopatologia , Atletas , Exercício Físico , Humanos , Hipotireoidismo/tratamento farmacológico , Guias de Prática Clínica como Assunto , Tireotropina/sangue , Tiroxina/uso terapêuticoRESUMO
OBJECTIVE: High-quality dual-energy X-ray absorptiometry (DXA) scans are necessary for accurate diagnosis of osteoporosis and monitoring of therapy; however, DXA scan reports may contain errors that cause confusion about diagnosis and treatment. This American Association of Clinical Endocrinologists/American College of Endocrinology consensus statement was generated to draw attention to many common technical problems affecting DXA report conclusions and provide guidance on how to address them to ensure that patients receive appropriate osteoporosis care. METHODS: The DXA Writing Committee developed a consensus based on discussion and evaluation of available literature related to osteoporosis and osteodensitometry. RESULTS: Technical errors may include errors in scan acquisition and/or analysis, leading to incorrect diagnosis and reporting of change over time. Although the International Society for Clinical Densitometry advocates training for technologists and medical interpreters to help eliminate these problems, many lack skill in this technology. Suspicion that reports are wrong arises when clinical history is not compatible with scan interpretation (e.g., dramatic increase/decrease in a short period of time; declines in previously stable bone density after years of treatment), when different scanners are used, or when inconsistent anatomic sites are used for monitoring the response to therapy. Understanding the concept of least significant change will minimize erroneous conclusions about changes in bone density. CONCLUSION: Clinicians must develop the skills to differentiate technical problems, which confound reports, from real biological changes. We recommend that clinicians review actual scan images and data, instead of relying solely on the impression of the report, to pinpoint errors and accurately interpret DXA scan images. ABBREVIATIONS: AACE = American Association of Clinical Endocrinologists; BMC = bone mineral content; BMD = bone mineral density; DXA = dual-energy X-ray absorptiometry; ISCD = International Society for Clinical Densitometry; LSC = least significant change; TBS = trabecular bone score; WHO = World Health Organization.
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Absorciometria de Fóton/normas , Consenso , Confiabilidade dos Dados , Endocrinologia/normas , Osteoporose/diagnóstico , Densidade Óssea , Endocrinologistas/organização & administração , Endocrinologistas/normas , Endocrinologia/organização & administração , Humanos , Processamento de Imagem Assistida por Computador/normas , Monitorização Fisiológica/métodos , Monitorização Fisiológica/normas , Relatório de Pesquisa/normas , Sociedades Médicas/organização & administração , Sociedades Médicas/normas , Estados Unidos , Filme para Raios X/normasRESUMO
ABBREVIATIONS: AACE = American Association of Clinical Endocrinologists AFF = atypical femur fracture ASBMR = American Society for Bone and Mineral Research BEL = best evidence level BMD = bone mineral density BTM = bone turnover marker CBC = complete blood count CI = confidence interval DXA = dual-energy X-ray absorptiometry EL = evidence level FDA = U.S. Food and Drug Administration FLEX = Fracture Intervention Trial (FIT) Long-term Extension FRAX® = Fracture Risk Assessment Tool GFR = glomerular filtration rate GI = gastrointestinal HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly IOF = International Osteoporosis Foundation ISCD = International Society for Clinical Densitometry IU = international units IV = intravenous LSC = least significant change NBHA = National Bone Health Alliance NOF = National Osteoporosis Foundation 25(OH)D = 25-hydroxy vitamin D ONJ = osteonecrosis of the jaw PINP = serum carboxy-terminal propeptide of type I collagen PTH = parathyroid hormone R = recommendation RANK = receptor activator of nuclear factor kappa-B RANKL = receptor activator of nuclear factor kappa-B ligand RCT = randomized controlled trial RR = relative risk S-CTX = serum C-terminal telopeptide SQ = subcutaneous VFA = vertebral fracture assessment WHO = World Health Organization.
Assuntos
Endocrinologia/normas , Osteoporose Pós-Menopausa/diagnóstico , Osteoporose Pós-Menopausa/terapia , Absorciometria de Fóton , Densidade Óssea , Endocrinologistas/normas , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/prevenção & controle , Humanos , Osteoporose Pós-Menopausa/epidemiologia , Sociedades Médicas/organização & administração , Sociedades Médicas/normas , Estados Unidos/epidemiologiaRESUMO
ABBREVIATIONS: AACE = American Association of Clinical Endocrinologists AFF = atypical femur fracture ASBMR = American Society for Bone and Mineral Research BEL = best evidence level BMD = bone mineral density BTM = bone turnover marker CBC = complete blood count CI = confidence interval DXA = dual-energy X-ray absorptiometry EL = evidence level FDA = U.S. Food and Drug Administration FLEX = Fracture Intervention Trial (FIT) Long-term Extension FRAX(®) = Fracture Risk Assessment Tool GFR = glomerular filtration rate GI = gastrointestinal HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly IOF = International Osteoporosis Foundation ISCD = International Society for Clinical Densitometry IU = international units IV = intravenous LSC = least significant change NBHA = National Bone Health Alliance NOF = National Osteoporosis Foundation 25(OH)D = 25-hydroxy vitamin D ONJ = osteonecrosis of the jaw PINP = serum carboxy-terminal propeptide of type I collagen PTH = parathyroid hormone R = recommendation RANK = receptor activator of nuclear factor kappa-B RANKL = receptor activator of nuclear factor kappa-B ligand RCT = randomized controlled trial RR = relative risk S-CTX = serum C-terminal telopeptide SQ = subcutaneous VFA = vertebral fracture assessment WHO = World Health Organization.
Assuntos
Osteoporose Pós-Menopausa/diagnóstico , Osteoporose Pós-Menopausa/terapia , Biomarcadores/sangue , Densidade Óssea , Colágeno Tipo I/sangue , Endocrinologia/organização & administração , Endocrinologia/normas , Prática Clínica Baseada em Evidências , Humanos , Fraturas por Osteoporose/diagnóstico , Fraturas por Osteoporose/terapia , Hormônio Paratireóideo/sangue , Sociedades Médicas/organização & administração , Sociedades Médicas/normas , Estados Unidos , Vitamina D/análogos & derivados , Vitamina D/sangueRESUMO
In 2010, the American Association of Clinical Endocrinologists (AACE) published an update to the original 2004 guidelines. This update hybridized strict evidence-based medicine methods with subjective factors and improved the efficiency of clinical practice guidelines (CPG) production, clinical applicability, and usefulness. Current and persistent shortcomings involving suboptimal implementation and protracted development timelines are addressed in the current 2014 update. The major advances include 1) formulation of an organizational educational strategy, represented by the AACE Council on Education, to address relevant teaching and decision-making tools for clinical endocrinologists, and to generate specific clinical questions to drive CPG, clinical algorithm (CA), and clinical checklist (CC) development; 2) creation and prioritization of printed and online CAs and CCs with a supporting evidence base; 3) focus on clinically relevant and question-oriented topics; 4) utilization of "cascades," where there can be more than 1 recommendation for 1 clinical question; and 5) incorporation of performance metrics to validate, optimize, and effectively update CPG, CAs, and CCs. Efforts continue to translate these clinical tools to electronic formats that can be integrated into a paperless healthcare delivery system, as well as applying them to diverse clinical settings by incorporating transcultural factors.
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Algoritmos , Lista de Checagem , Endocrinologia , Humanos , Fatores de TempoRESUMO
Background/Objective: Hypophosphatasia (HPP) is a rare disease associated with low serum alkaline phosphatase (ALP) activity. Here, we present a case of a patient with normal serum ALP levels diagnosed with HPP. Case Report: A 36-year-old woman presented with progressive fatigue, weakness, and joint pain. She had been evaluated in the past for genetic disorders due to these symptoms and was found to have a history of several total ALP levels within normal limits but elevated vitamin B6 levels. She also reported having loose teeth and "gray gums" during her childhood. Bone-specific ALP was tested for suspicion of HPP and returned at 4.4 µ/L (reference range, 5.3-19.5 µg/L), which prompted genetic testing. Genetic testing confirmed a positive pathogenetic variant of the ALPL gene, the c.542C>T (p.Ser181Leu) variant. She started asfotase alfa treatment to improve her symptoms. Discussion: HPP was diagnosed based on clinical suspicion supported by laboratory findings, which can cause it to be underdiagnosed or misdiagnosed. Current literature reports that a low total ALP level is the main biochemical marker of HPP and the only level needed to diagnose the disease. However, bone-specific ALP, a common marker used for bone turnover, has not been required to be tested. Conclusion: This case highlights a patient with normal total ALP, but low bone-specific ALP diagnosed with HPP confirmed by genetic testing. This case warrants future investigation into the diagnostic approach to HPP and the diagnostic utility between ALP and bone-specific ALP.
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Dual-energy x-ray absorptiometry (DXA) measurements of body composition increasingly are used in the evaluation of clinical disorders, but there has been little guidance on how to effectively report these measures. Uniformity in reporting of body composition measures will aid in the diagnosis of clinical disorders such as obesity, sarcopenia, and lipodystrophy. At the 2013 International Society for Clinical Densitometry Position Development Conference on body composition, the reporting section recommended that all DXA body composition reports should contain parameters of body mass index, bone mineral density, BMC, total mass, total lean mass, total fat mass, and percent fat mass. The inclusion of additional measures of adiposity and lean mass are optional, including visceral adipose tissue, appendicular lean mass index, android/gynoid percent fat ratio, trunk to leg fat mass ratio, lean mass index, and fat mass index. Within the United States, we recommend the use of the National Health and Nutrition Examination Survey 1999-2004 body composition dataset as an age-, gender-, and race-specific reference and to calibrate BMC in 4-compartment models. Z-scores and percentiles of body composition measures may be useful for clinical interpretation if methods are used to adjust for non-normality. In particular, DXA body composition measures may be useful for risk-stratification of obese and sarcopenic patients, but there needs to be validation of thresholds to define obesity and sarcopenia. To summarize, these guidelines provide evidence-based standards for the reporting and clinical application of DXA-based measures of body composition.
Assuntos
Absorciometria de Fóton/normas , Composição Corporal , Congressos como Assunto , Osteoporose/diagnóstico por imagem , Guias de Prática Clínica como Assunto , Sociedades Médicas , Densidade Óssea , HumanosRESUMO
Background/Objective: Osteogenesis imperfecta (OI) is a genetic disorder that affects type 1 collagen synthesis causing increased bone fragility, low bone mass, and skeletal deformity. Bisphosphonates are recommended for treatment of OI patients; however, the efficacy of sclerostin inhibitors such as romosozumab has not been determined in OI patients with osteoporosis. Case Report: A 52-year-old G2P2 clinically diagnosed with OI, with a history of multiple fractures beginning in childhood presented with low bone mass. On physical examination, blue sclera was observed. She was previously treated with alendronate therapy from April 2014 to June 2015 without significant improvement in bone mineral density (BMD). After the onset of menopause, she began romosozumab 210 mg subcutaneous therapy once a month for 12 months. Repeat dual-energy X-ray absorptiometry showed an increase of 10.3% in BMD of the spine and a 5.4% increase in BMD of the right hip. The trabecular bone score increased by 5.2%. Discussion: Current literature is limited regarding the use of sclerostin inhibitors in OI patients. Our patient's improvement in BMD of the spine and right hip after romosozumab therapy was significant at a 95% confidence level, compared to treatment initiation. Her trabecular bone score also improved significantly. Six months into our patient's treatment course, a case in Japan of a male with severe osteoporotic OI and recurrent fractures showed improvement in BMD after romosozumab therapy. Conclusion: This case highlights our patient's significant response to romosozumab and warrants further investigation of romosozumab as a potential treatment option for OI patients with osteoporosis.
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BACKGROUND: Persistent postoperative elevation of parathyroid hormone (POePTH) following successful parathyroidectomy for primary hyperparathyroidism (PHPT) is presumed to result from bone remineralization. Predicting which patients may need treatment is difficult. This study investigated whether preoperative serum osteocalcin (OC), a bone turnover marker involved in mineralization, can predict POePTH. METHODS: A total of 198 patients (155 women and 43 men) with parathyroidectomy from November 2007 to October 2009 in MD Anderson Cancer Center, Houston, TX, USA, were included in our analysis. Separate multivariate regression models determined associations between preoperative OC and POePTH at 6 and 12 months postoperatively. Regression models were adjusted for demographics (age, gender, race, height, weight, BMI), preoperative BMD and bisphosphonate use, adenoma weight, serum levels of PTH, calcium, vitamin D, creatinine, and phosphate. Patients with baseline GFR <60 ml/min/1.73 m(2) and postoperative serum calcium >10.14 mg/dl at 6 and 12 months were excluded. RESULTS: Patients' mean age (±SD) was 60 (±14) years. POePTH (>80 pg/ml) occurred in 13 and 12% patients at 6 and 12 months, respectively. Preoperative serum creatinine and bisphosphonate use were positively associated with POePTH (p < 0.05) both at 6 and 12 months. Preoperative OC was predictive of POePTH (p < 0.05) at 6 months (ß 0.35; 95% confidence interval (CI), 0.11-0.58) and at 12 months (ß 0.79; 95% CI, 0.27-1.31). CONCLUSIONS: Preoperative OC may help to predict risk of POePTH in patients with PHPT. Research with longer follow-up in patients with no known baseline chronic kidney disease stratified by high versus normal preoperative serum creatinine is recommended.
Assuntos
Técnicas de Apoio para a Decisão , Hiperparatireoidismo Primário/cirurgia , Osteocalcina/sangue , Hormônio Paratireóideo/sangue , Paratireoidectomia , Idoso , Biomarcadores/sangue , Feminino , Seguimentos , Humanos , Hiperparatireoidismo Primário/sangue , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Período Pós-Operatório , Período Pré-Operatório , Recidiva , Análise de Regressão , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Background/Objective: Spondylodysplastic Ehlers-Danlos syndrome (spEDS) is a rare subtype of the heritable connective tissue disorder characterized in the 2017 Ehlers-Danlos syndrome (EDS) nosology. Three biallelic mutations, B4GALT7, B3GALT6, and SLC39A13, confirm the diagnosis of spEDS. Hypophosphatasia (HPP) is a heritable disorder caused by a genetic sequence variation in the ALPL gene affecting bone mineralization. Common symptoms in the adult form of HPP are joint pain, muscle hypotonia, and metatarsal fractures. Here we present a case of spEDS and HPP in a patient. Case Report: A 38-year-old woman was evaluated for chronic diffuse joint pain and a low alkaline phosphatase level of 27 U/L (reference, 31-125 U/L). In addition, she presented with a history of hypermobility, limb bowing, and hyperextensible skin, prompting genetic testing for EDS and HPP. The results returned significant for a synonymous sequence variant at c.441G>A in the B4GALT7 gene indicative of spEDS. HPP was clinically diagnosed by a repeat low alkaline phosphatase level of 23 U/L and high vitamin B6 level of 24.4 ng/mL (reference, 2.1-21.7 ng/mL), despite the absence of the ALPL gene sequence variation on genetic testing. Discussion: Remarkable personal and family history of this patient suggest that co-occurrence of EDS and HPP is not merely coincidental. Given the overlapping features of muscle hypotonia and joint pain between the 2 heritable disorders, a possible relationship between the 2 may have been previously overlooked. Conclusion: Further investigation in the relationship and management of the 2 heritable diseases is warranted as enzyme replacement therapy, asfotase alfa, approved for infantile and juvenile onset of HPP may improve the symptoms shared with EDS.
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Stress fractures are common among elite ballet dancers whereby musculoskeletal health may be affected by energy balance and overtraining. PURPOSE: This study aimed to characterize bone health in relation to stress fracture history, body composition, eating disorder risk, and blood biomarkers in professional male and female ballet dancers. METHODS: A single cohort of 112 dancers (male: 55, 25 ± 6 yr; female: 57, 24 ± 6 yr) was recruited. All participants underwent bone and body composition measures using dual-energy x-ray absorptiometry. In a subset of our cohort (male: 30, 24 ± 6 yr; female, 29, 23 ± 5 yr), a blood panel, disordered eating screen, menstrual history, and stress fracture history were also collected. Age-matched Z scores and young-adult T scores were calculated for bone mineral density (BMD) and body composition. Independent-samples t-tests and Fisher's exact tests were used to compare BMD, Z-scores, T scores, and those with and without history of stress fractures. A 1 × 3 ANOVA was used to compare BMD for those scoring 0-1, 2-6, and 7+ using the EAT26 questionnaire for eating disorder risk. Regression was used to predict BMD from demographic and body composition measures. RESULTS: Female dancers demonstrated reduced spinal (42nd percentile, 10%T < -1) and pelvic (16th percentile, 76%T < -1) BMD. Several anthropometric measures were predictive of BMD (P < 0.05, r = 0.65-0.81, standard error of estimate = 0.08-0.10 g·cm, percent error = 6.3-8.5). Those scoring >1 on EAT26 had lower BMD than did those with a score of 0-1 (P < 0.05). CONCLUSIONS: Professional female ballet dancers exhibit reduced BMD, fat mass, and lean mass compared with the general population whereby low BMD and stress fractures tend to be more prevalent in those with a higher risk of disordered eating. Anthropometric and demographic measures are predictive of BMD in this population.
Assuntos
Densidade Óssea/fisiologia , Dança/lesões , Dança/fisiologia , Fraturas de Estresse/fisiopatologia , Absorciometria de Fóton , Adulto , Biomarcadores/sangue , Composição Corporal , Distribuição da Gordura Corporal , Transtornos Traumáticos Cumulativos/fisiopatologia , Transtornos da Alimentação e da Ingestão de Alimentos/fisiopatologia , Feminino , Humanos , Masculino , Oligomenorreia/fisiopatologia , Ossos Pélvicos/lesões , Ossos Pélvicos/fisiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Traumatismos da Coluna Vertebral/fisiopatologia , Coluna Vertebral/fisiologia , Adulto JovemRESUMO
Cardiovascular autonomic neuropathy (CAN) is a severely debilitating yet underdiagnosed condition in patients with diabetes. The prevalence can range from 2.5% (based on the primary prevention cohort in the Diabetes Control and Complications Trial) to as high as 90% of patients with type 1 diabetes. Clinical manifestations range from orthostasis to myocardial infarction. The diagnosis is made using multiple autonomic function tests to assess both sympathetic and parasympathetic function. The pathophysiology of CAN is complex, likely multifactorial, and not completely understood. Treatment is limited to symptomatic control of orthostatic hypotension, which is a late complication, and current strategies to reverse CAN are limited. This review explores the epidemiology, pathophysiology, clinical manifestations, diagnosis, and complications of CAN as well as current treatment options.
Assuntos
Doenças do Sistema Nervoso Autônomo , Sistema Nervoso Autônomo/fisiopatologia , Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Neuropatias Diabéticas , Coração/inervação , Doenças do Sistema Nervoso Autônomo/diagnóstico , Doenças do Sistema Nervoso Autônomo/epidemiologia , Doenças do Sistema Nervoso Autônomo/fisiopatologia , Doenças do Sistema Nervoso Autônomo/terapia , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/epidemiologia , Diabetes Mellitus Tipo 1/fisiopatologia , Diabetes Mellitus Tipo 1/terapia , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/fisiopatologia , Diabetes Mellitus Tipo 2/terapia , Neuropatias Diabéticas/diagnóstico , Neuropatias Diabéticas/epidemiologia , Neuropatias Diabéticas/fisiopatologia , Neuropatias Diabéticas/terapia , Humanos , Valor Preditivo dos Testes , Fatores de Risco , Resultado do TratamentoRESUMO
Testosterone (T) has a number of important effects on the cardiovascular system. In men, T levels begin to decrease after age 40, and this decrease has been associated with an increase in all-cause mortality and cardiovascular (CV) risk. Low T levels in men may increase their risk of developing coronary artery disease (CAD), metabolic syndrome, and type 2 diabetes. Reduced T levels in men with congestive heart failure (CHF) portends a poor prognosis and is associated with increased mortality. Studies have reported a reduced CV risk with higher endogenous T concentration, improvement of known CV risk factors with T therapy, and reduced mortality in T-deficient men who underwent T replacement therapy versus untreated men. Testosterone replacement therapy (TRT) has been shown to improve myocardial ischemia in men with CAD, improve exercise capacity in patients with CHF, and improve serum glucose levels, HbA1c, and insulin resistance in men with diabetes and prediabetes. There are no large long-term, placebo-controlled, randomized clinical trials to provide definitive conclusions about TRT and CV risk. However, there currently is no credible evidence that T therapy increases CV risk and substantial evidence that it does not. In fact, existing data suggests that T therapy may offer CV benefits to men.
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Doenças Cardiovasculares/sangue , Sistema Cardiovascular/metabolismo , Testosterona/sangue , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/fisiopatologia , Sistema Cardiovascular/efeitos dos fármacos , Sistema Cardiovascular/fisiopatologia , Feminino , Terapia de Reposição Hormonal , Humanos , Masculino , Recuperação de Função Fisiológica , Fatores de Risco , Testosterona/deficiência , Testosterona/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: We investigated whether the outcome of bone disease of primary hyperparathyroidism differs in multiple endocrine neoplasia type 1-associated disease and sporadic hyperparathyroidism at 1-year postoperatively. METHODS: Multiple endocrine neoplasia type 1/hyperparathyroidism and sporadic hyperparathyroidism patients who underwent parathyroidectomy from 1990 to 2013 and dual-energy x-ray absorptiometry at baseline and 1-year postoperatively were included. Preoperative and postoperative dual-energy x-ray absorptiometry measurements (bone mineral density and Z-score at the lumbar spine, total hip, and femoral neck) were analyzed. RESULTS: We evaluated 14 multiple endocrine neoplasia type 1/hyperparathyroidism and 104 sporadic hyperparathyroidism patients. The preoperative Z-scores at the lumbar spine, total hip, and femoral neck were lower in the multiple endocrine neoplasia type 1/hyperparathyroidism group (P = .05, P = .04, and P = .0081, respectively). Comparison of preoperative and postoperative dual-energy x-ray absorptiometry measurements demonstrated that the multiple endocrine neoplasia type 1/hyperparathyroidism group had a significantly higher Z-score at the lumbar spine (P = .02) at 1 year after operation, whereas the sporadic hyperparathyroidism group had a significantly higher Z-score at the lumbar spine, total hip, and femoral neck (P < .0001, P = .0004, and P = .0001) and higher bone mineral density at the lumbar spine (P = .0001). CONCLUSION: Long-term monitoring of these patients using dual-energy x-ray absorptiometry is required to assess outcomes and facilitate decisions on the timing of operative intervention.
Assuntos
Remodelação Óssea/fisiologia , Hiperparatireoidismo Primário/cirurgia , Neoplasia Endócrina Múltipla Tipo 1/cirurgia , Paratireoidectomia/métodos , Absorciometria de Fóton/métodos , Centros Médicos Acadêmicos , Adulto , Idoso , Densidade Óssea , Estudos de Coortes , Feminino , Seguimentos , Humanos , Hiperparatireoidismo Primário/diagnóstico , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Neoplasia Endócrina Múltipla Tipo 1/diagnóstico , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
The proliferation of devices to measure bone mineral density (BMD), with large numbers of technologists operating these instruments and numerous physicians interpreting/reporting the results, raises concern regarding the quality of the studies. High quality BMD measurement and reporting is essential, since referring healthcare providers rely on these reports to make patient care decisions that include additional medical evaluation (laboratory or imaging tests), drug therapy (starting, stopping, or changing), and possibly referral to an osteoporosis specialist. Incorrect BMD acquisition or reporting may generate unnecessary medical expenses and result in therapeutic decisions that could be harmful to patients. Contrary to the common misperception that BMD measurement and interpretation is a simple procedure requiring no special expertise, densitometer maintenance/operation, data acquisition, and interpretation/reporting of the results are skills that must be acquired and maintained. We recommend that technologists and clinicians involved with performing or interpreting BMD tests be educated and trained in bone densitometry and that they update their skills regularly. We also suggest that they provide demonstration of proficiency in bone densitometry in order to assure patients, referring healthcare providers, and payers of medical services that these skills have been acquired and maintained.