Predicted annual costs for inpatients with diabetes and foot ulcers in a developing country-a simulation of the current situation in Brazil.

AIMS: The objective of this cost-of-illness analysis was to quantify the annual costs associated with hospital admission for people with diabetes and foot ulcers in Brazil. METHODS: A hypothetical cohort was simulated using a decision tree model. Prevalence and incidence rates and clinical outcomes were estimated from published studies and applied to the general Brazilian population over 30 years. Costs were quoted in Brazilian real (BRL) and converted to US dollars ($US) at the 2008 currency exchange rate ($US1 = BRL 1.64). In the sensitivity analysis, we reduced and increased rates to assess the robustness of the cost estimates. RESULTS: In this hypothetical cohort there are 6.48 million (95% confidence interval 4.47-7.12) Brazilians citizens with Type 2 diabetes. Each year, approximately 323,000 (89,500-484,500) of these people develop foot ulcers and almost 97,200 (17,900-169,600) require hospital admission as a result. Each year, almost 46,300 (8500-80,900) limb amputations and 12,400 (2300-21,700) deaths occur as a result of diabetic foot disease in Brazil. The annual cost associated with these hospital admissions is estimated to be almost $US264m ($US51m-461m). The estimated cost for patients with amputation is nearly $US128m ($US24.5m-222.3m). CONCLUSIONS: Our model shows that the social and economic impact of diabetic foot disease in Brazil is high. Government decision makers should reflect on the current situation and provide organized foot care throughout the whole country.

Resource utilisation and cost of ankylosing spondylitis in Brazil.

OBJECTIVES: The present study describes resource utilisation in patients with ankylosing spondylitis (AS) treated at a tertiary public health facility over a one-year period. It also investigates the direct and indirect costs for society associated with the treatment of AS. METHODS: Ninety AS patients were selected consecutively, and data was analysed retrospectively for one year. Resource utilisation was evaluated through systematic interviews with all patients. Demographic, socioeconomic, and clinical variables were recorded, and questionnaires evaluating quality of life, function, and disease activity were also applied (ASQoL, SF-36, HAQ-S, BASFI, and BASDAI). Estimates of indirect costs were performed using the human-capital approach based on the society perspective. RESULTS: Most of the patients were men (79%), with a mean age and disease duration of 40 and 16 years, respectively. The mean HAQ-S, BASFI and BASDAI scores were 1, 5, and 4, respectively. The mean ASQoL score for the sample was 8, and the mean Short-Form-36 scores were between 48 (body pain and general health) and 81 (emotional role). The average monthly household income for the group was US$ 520. The patients had an average of 6 outpatient visits, 6 physical therapy visits and 30 laboratory exams per patient, per year. The average total cost for society was US$ 4,597 per patient per year, of which 45% were direct costs and 55% were indirect costs. CONCLUSIONS: Ankylosing spondylitis is a disease that represents a considerable burden to Brazil. It is extremely important to carry out studies that assess the costs of chronic diseases, especially in developing nations, in order to determine the best manner of allocating the already scanty resources in such regions.

Clinical risk factors for osteoporotic fractures in Brazilian women and men: the Brazilian Osteoporosis Study (BRAZOS).

UNLABELLED: The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older. The prevalence of fragility fractures is about 15.1% in the women and 12.8% in the men. Moreover, advanced age, sedentarism, family history of hip fracture, current smoking, recurrent falls, diabetes mellitus and poor quality of life are the main clinical risk factors associated with fragility fractures. INTRODUCTION: The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older with the purpose of identifying the prevalence and the main clinical risk factors (CRF) associated with osteoporotic fracture in our population. METHODS: A total of 2,420 individuals (women, 70%) from 150 different cities in the five geographic regions in Brazil, and all different socio-economical classes were selected to participate in the present survey. Anthropometrical data as well as life habits, fracture history, food intake, physical activity, falls and quality of life were determined by individual quantitative interviews. The representative sampling was based on Brazilian National data provided by the 2000 and 2003 census. Low trauma fracture was defined as that resulting of a fall from standing height or less in individuals 50 years or older at specific skeletal sites: forearm, femur, ribs, vertebra and humerus. Sampling error was 2.2% with 95% confidence intervals. Logistic regression analysis models were designed having the fragility fracture as the dependent variable and all other parameters as the independent variable. Significance level was set as p < 0.05. RESULTS: The average of age, height and weight for men and women were 58.4 +/- 12.8 and 60.1 +/- 13.7 years, 1.67 +/- 0.08 and 1.56 +/- 0.07 m and 73.3 +/- 14.7 and 64.7 +/- 13.7 kg, respectively. About 15.1% of the women and 12.8% of the men reported fragility fractures. In the women, the main CRF associated with fractures were advanced age (OR = 1.6; 95% CI 1.06-2.4), family history of hip fracture (OR = 1.7; 95% CI 1.1-2.8), early menopause (OR = 1.7; 95% CI 1.02-2.9), sedentary lifestyle (OR = 1.6; 95% CI 1.02-2.7), poor quality of life (OR = 1.9; 95% CI 1.2-2.9), higher intake of phosphorus (OR = 1.9; 95% CI 1.2-2.9), diabetes mellitus (OR = 2.8; 95% CI 1.01-8.2), use of benzodiazepine drugs (OR = 2.0; 95% CI 1.1-3.6) and recurrent falls (OR = 2.4; 95% CI 1.2-5.0). In the men, the main CRF were poor quality of life (OR = 3.2; 95% CI 1.7-6.1), current smoking (OR = 3.5; 95% CI 1.28-9.77), diabetes mellitus (OR = 4.2; 95% CI 1.27-13.7) and sedentary lifestyle (OR = 6.3; 95% CI 1.1-36.1). CONCLUSION: Our findings suggest that CRF may contribute as an important tool to identify men and women with higher risk of osteoporotic fractures and that interventions aiming at specific risk factors (quit smoking, regular physical activity, prevention of falls) may help to manage patients to reduce their risk of fracture.

Resource utilization and the cost of rheumatoid arthritis in Brazil.

OBJECTIVE: To describe and analyze resource utilization in patients with rheumatoid arthritis (RA) treated at a tertiary public health facility over a one-year period. Costs for the patient and for society associated with the treatment of RA were also investigated. METHODS: One hundred consecutively selected RA patients were included. Resource utilization was evaluated retrospectively for one year. Systematic interviews were used in all patients and demographic, socioeconomic and clinical variables were recorded. RESULTS: One hundred patients were included. Most of the patients were women (92%) and had mean age and disease duration of 51 and 11 years, respectively. The majority of the patients were Steinbroker functional class I (48%). Mean HAQ score for the sample was 0.95 and mean Short-Form-36 scores were between 49.64 (bodily pain) and 70.00 (social functioning). The average monthly household income for the group was US$ 359. The patients had on average 4 outpatient visits and 21 laboratory exams per year. Drugs accounted for 59% of the total cost associated with RA. The average total cost for society was US$ 424.14 per patient per year, of which 95% were direct and 5% indirect costs. CONCLUSION: The management of RA patients is an important financial burden in Brazil. The effort to couple resource utilization with the best available evidence, associated with the limited funds available in the healthcare system (particularly in a developing country), emphasizes the importance of studies that critically evaluate resource utilization and cost in these chronic patients. The systematic use of such studies may prove helpful to optimize the health system.

Translation into Brazilian Portuguese, cultural adaptation and evaluation of the reliability of the Disabilities of the Arm, Shoulder and Hand Questionnaire.

The objective of the present study was to translate, adapt and validate a Brazilian Portuguese version of the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire. The study was carried out in two steps. The first was to translate the DASH into Portuguese and to perform cultural adaptation and the second involved the determination of the reliability and validity of the DASH for the Brazilian population. For this purpose, 65 rheumatoid arthritis patients of either sex (according to the classification criteria of the American College of Rheumatology), ranging in age from 18 to 60 years and presenting no other diseases involving the upper limbs, were interviewed. The patients were selected consecutively at the rheumatology outpatient clinic of UNIFESP. The following results were obtained: in the first step (translation and cultural adaptation), all patients answered the questions. In the second step, Spearman's correlation coefficients for interobserver evaluation ranged from 0.762 to 0.995, values considered to be highly reliable. In addition, intraclass correlation coefficients ranged from 0.97 to 0.99, also highly reliable values. Spearman's correlation coefficients and the intraclass correlation coefficients obtained during intra-observer evaluation ranged from 0.731 to 0.937 and from 0.90 to 0.96, respectively, being highly reliable values. The Ritchie Index showed a weak correlation with Brazilian DASH scores, while the visual analog scale of pain showed a good correlation with DASH score. We conclude that the Portuguese version of the DASH is a reliable instrument.

Knowledge in schizophrenia: The Portuguese version of KAST (Knowledge About Schizophrenia Test) and analysis of social-demographic and clinical factors' influence.

Schizophrenia is a complex disorder, and the knowledge about it can have a positive impact. The purpose of this study was to make the translation and cultural adaptation of the Knowledge About Schizophrenia Test (KAST) into Portuguese and determine the influence of clinical and socio-demographic factors on knowledge. The test was applied to 189 caregivers of patients enrolled in Schizophrenia Program of the Federal University of São Paulo, 30 caregivers of clinical patients of the General Outpatient Clinic of the same University, and 30 health professionals. The face and content validity of the test was established. The mean value (SD) obtained with the application of the final version to caregivers of schizophrenic patients was 12.96 (2.45) - maximum 17. Level of knowledge increased considering the following order: caregivers of clinical patients, caregivers of patients with schizophrenia and mental health professionals. The intraclass correlation coefficient (0.592) obtained in the test-retest was statistically significant. An influence of social class, race, gender and education of the caregiver on the test was observed, and the last two factors were more relevant. The KAST translated and adapted into Portuguese is a valid instrument and can be used as an evaluation tool on psychoeducational interventions.

Stressors in ICU: patients' evaluation.

OBJECTIVE: To study the physical and psychological stressors in the intensive care unit (ICU) and to correlate stressors with different demographic variables. DESIGN: Cross-sectional analytical survey. SETTING: Intensive care unit of a private hospital. PATIENTS AND PARTICIPANTS: 50 randomly selected ICU patients during the first week of their ICU stay. MEASUREMENTS AND RESULTS: The Intensive Care Unit Environmental Stressor Scale was administered to 50 patients. Pain and the impossibility of sleeping due to noise and having tubes in the nose and mouth were considered the most important physical stressors. Loss of self control and lack of understanding about the attitudes and procedures were the main psychological stressors. CONCLUSIONS: Interventions should be aimed at relieving the patient's pain and at controlling the level of noise to make sleep possible. From the psychological standpoint, the independence of the patient should be encouraged, thus stimulating the recovery of self-control. The team should also inform the patient about the procedures which will be carried out.

Stressors in ICU: perception of the patient, relatives and health care team.

OBJECTIVE: To compare the evaluation of the stressors present in the intensive care unit (ICU) from the point of view of the patient, relatives and the multiprofessional team and to identify differences and similarities with regard to the perception of stressors in order to optimize patient care. DESIGN: Cross-sectional analytical survey. SETTING: General ICU of a private hospital. PATIENTS AND PARTICIPANTS: From April 1st to June 30th, 1996, 50 ICU patients during the first week of their ICU stay, 50 of their respective relatives and 50 members of the professional team directly involved in the care of these patients. MEASUREMENTS AND RESULTS: The Intensive Care Unit Environmental Stressor Scale (ICUESS) was administered to all patients. The relatives and health care professionals were asked to complete the ICUESS on the basis of their perception of the patient's stressors. Being in pain, having tubes in the nose or mouth, being restrained by tubes and being unable to sleep were considered by the patients, relatives and health care professionals as the main stressors. The professional team evaluated the intensity of the stressors higher than either the family or the patient. No statistical significance was detected between the intensity of the stressors as evaluated by the patient and the intensity evaluated by relatives and by the professional team. CONCLUSIONS: Being in pain, being unable to sleep and having tubes in the nose and/or mouth were pointed out as the major stressors by the three groups. There was no statistically significant correlation between the total stress scores of the patients and their relatives (r = 0.193), between the patients and the team (r = -0.002), or between the total scores of the team and the relatives (r = -0.185). The results suggest that the views of the relatives and the professional team concerning the stressors have some similar points compared to the evaluation made by the patient himself, although the intensity of the evaluation for each group corresponds to its own perception.

Patient's preference regarding the option of performing unselective liver biopsy following methotrexate treatment in rheumatoid arthritis.

OBJECTIVE: This study was aimed at the evaluation of patient preferences concerning long-term methotrexate (MTX) therapy and whether or not to perform unselective liver biopsy to detect serious liver disease due to MTX therapy in rheumatoid arthritis (RA). METHODS: Seventeen literate patients with RA consecutively selected from a rheumatic disease unit and 17 rheumatologists (asked to consider themselves as RA patients) were assessed by a trained interviewer. The Bedside Decision Board instrument was used to assess the patient preference. Scenarios described the options in terms of follow-up for RA patients treated with MTX. The benefits and risks of liver biopsy, defined according to the published literature, were presented to RA patients and rheumatologists in an unbiased fashion. RESULTS: Twelve patients (71%) preferred not to be subjected to the liver biopsy within 1 month, even though they had already taken MTX for 3 years, and consequently ran the risk of development of cirrhosis in the long term. Conversely, 12 rheumatologists (71%) preferred to undergo an unselective liver biopsy. CONCLUSION: Given patients' preferences, liver biopsy following long term MTX treatment should not be performed unselectively. It can be postulated that rheumatologists did not perceive liver biopsy as an intimidating procedure or were influenced by the until recently recommended guidelines for following up patients treated with MTX.

EPM-ROM Scale: an evaluative instrument to be used in rheumatoid arthritis trials.

Different tools are available for the measurement of functional status; however, only a few of them are based on the evaluation of the joint range of motion (ROM). This study is aimed at the design and evaluation of the measurement properties of a ROM scale to be used as an evaluative instrument in rheumatoid arthritis (RA) trials. The EPM-ROM Scale evaluates 10 distinct movements of the small and large joints. The score of each joint varies from 0 (full movement) to 3 (severe limitation) and the cut-off degrees of motion are, in general, based on the lack of ability to perform some determined activities of daily living. The test-retest characteristic of the scale was assessed by administering the scale twice, 5 days apart, to 35 RA patients. The product moment correlation was 0.775 (P less than 0.001). The cross-sectional construct validity of the scale was assessed by the concomitant scoring of the EPM-ROM Scale and the functional ability dimension of the Health Assessment Questionnaire (a reliable, valid and responsive instrument) in these patients. The product moment correlation was 0.518 (P less than 0.001). The evaluation of its longitudinal construct validity and responsiveness are now in progress.

Evaluation of the European Spondylarthropathy Study Group (ESSG) preliminary classification criteria in Brazilian patients.

OBJECTIVE: To evaluate the sensitivity and specificity of the ESSG criteria when applied to Brazilian patients with SpA and control patients with other rheumatic diseases. METHODS: Seventy patients with spondylarthropathies and 62 patients with other rheumatic diseases were interviewed, examined and had their charts reviewed. The diagnoses of the diseases were based on published diagnostic guidelines or classification criteria. Data were also collected according to the ESSG criteria. RESULTS: The sensitivity and specificity of the ESSG classification criteria were 98.5% and 88.7%, respectively. The sensitivities of the criteria in the different subgroups of SpA ranged from a low of 97.7% in AS to a high of 100% in other SpA studied. CONCLUSION: Despite differences in the socio-cultural and geographic characteristics and in individual disease frequencies, the ESSG preliminary classification criteria performed well when applied to Brazilian patients.

Quality of life in patients with osteoporosis fractures: cultural adaptation, reliability and validity of the Osteoporosis Assessment Questionnaire.

OBJECTIVE: The purpose of this study was to translate into Brazilian-Portuguese the Osteoporosis Assessment Questionnaire (OPAQ), and to evaluate its reliability and validity. METHODS: The OPAQ was translated into Brazilian-Portuguese. This version was then back-translated into an English version which was compared to the original version, and a second Brazilian-Portuguese version was generated. This draft version of the Brazilian-Portuguese OPAQ was administered to 30 patients with lumbar osteoporosis and no fractures. The non-applicable questions were modified and, after being administered again, this Brazilian-Portuguese version of the OPAQ was accepted as definitive. Its reliability was tested in 30 osteoporotic out-patients, and was administered three times to the patients to check the intra/interobserver reliability. The patients were also clinically evaluated using HAQ, FIQ and a numerical rating scale for pain. For all patients the number of fractures and the bone mineral density at the spine were determined. RESULTS: The mean age of the patients was 69 years (54 to 89 years) and the mean number of fractures was 2.72. Twenty-one patients (70%) had had more than one vertebral fracture. All of the questionnaire components, except for mood (c16), presented statistically significant coefficients for intra/interobserver reliability. The highest score was observed for "the fear of falling" (6.70). Correlations between the OPAQ components and the number of fractures, bone density and Z-score were not statistically significant. CONCLUSIONS: This Brazilian-Portuguese version of the OPAQ is a reliable and valid instrument. Other aspects than bone mineral density and the number of fractures have an important influence on the quality of life in patients with osteoporosis and fractures.

Evaluation of the 1982 ARA lupus criteria data set in pediatric patients. Committees of Pediatric Rheumatology of the Brazilian Society of Pediatrics and the Brazilian Society of Rheumatology.

OBJECTIVE: Although commonly used, the 1982 revised criteria for the classification of Systemic Lupus Erythematosus (SLE) have not been completely evaluated in pediatric patients. This study was aimed at evaluating the sensitivity and specificity of the 1982 revised criteria when applied to pediatric patients. METHODS: One hundred and three children with SLE and 101 children with other rheumatic diseases were selected from 5 rheumatology centers in Brazil. Diagnosis of SLE by the 1982 criteria were compared with our clinical diagnosis. The diagnosis of other diseases was made according to internationally accepted classification criteria or, when these were not available, according to the physician's own experienced judgement. RESULTS: The median number of criteria fulfilled by the patients with SLE and the controls were 6 and 1, respectively. The most common criteria observed in children with SLE were: abnormal antinuclear antibody titers (94%), arthritis (83%), immunologic disorder (83%), hematologic disorder (70%), malar rash (67%), and photosensitivity (58%). When the immunologic disorder was broken down into its constituent elements, antibodies to dsDNA and Sm were observed in 73.0% (65/89) and 31.4% (15/48), respectively. The sensitivity and specificity observed were 96% and 100%, respectively. CONCLUSION: The 1982 classification criteria can be successfully applied to children with SLE. These criteria may serve as a basis for multi-center collaborative studies on children with SLE.

Availability of over-the-counter drugs for arthritis in Sao Paulo, Brazil.

Seventy pharmacies located in Sao Paulo were randomly selected and visited. Seven researchers posed as ordinary clients presenting with a standardized complaint of symptoms according to a scenario previously defined. The client asked for medicines to relieve his/her pain or discomfort. After the seller's suggestion the client asked for 2 drugs randomly selected from a drug list containing 30 trademarked drugs commonly prescribed to arthritis patients. These drugs should be available only on prescription. In only 12.8% of the pharmacies did the seller initially suggest the client see a physician. The sellers "prescribed' non-steroid anti-inflammatory drugs (NSAID), vitamins, analgesics (AN) and corticosteroids (CO) in respectively 42.8, 20.0, 14.3 and 5.7% of the visits. From the drug list, the client secured 67.7% of the NSAID, 65.0% of the CO and 20.0% of the sedatives without presenting a prescription. Pharmacy sellers usually comply with the clients demands. Future studies should aim at the evaluation of interventions to reduce the availability of the over-the-counter drugs for arthritis.

Symptomatic cardiac involvement in juvenile rheumatoid arthritis.

In a retrospective study of 172 patients with juvenile rheumatoid arthritis, symptomatic cardiac involvement occurred in 13 (7.6%) patients (11 systemic and 2 polyarticular). There was predominance of the male sex and in most patients the involvement occurred in the initial years of the disease. Pericarditis occurred in seven patients; perimyocarditis in four and myocarditis in two patients. In the follow-up, one of the patients with pericarditis died of an arrhythmia during pericardiocentesis for cardiac tamponade. Among the patients with myocarditis, three died of septicemia during active disease. One of these three patients had myocarditis associated with cardiac tamponade. Among the 172 patients with juvenile rheumatoid arthritis, five children died; four belonged to the symptomatic cardiac involvement group (P less than 0.001). Cardiac involvement, in particular myocarditis and cardiac tamponade, can be regarded as a factor of worse prognosis.

Psychological aspects of Brazilian women with fibromyalgia.

In order to determine the occurrence of psychological disturbances the authors studied 47 women who fulfilled the American College of Rheumatology Criteria for the classification of fibromyalgia and 25 random selected control patients without chronic muscle pain, all of whom live in Sorocaba, SP, Brazil. Personality disturbances were observable in 63.8% of the patients and 8.0% of the control group (p < 0.05); depression in 80.0% of the fibromyalgia group and 12.0% of the controls (p < 0.05) and anxiety in 63.8% of the patients and 16.0% of the controls (p < 0.05). The Hamilton test mean scores showed higher values for depression and anxiety among the fibromyalgia patients when compared to the control group. A significant association between fibromyalgia and depression, anxiety and personality disturbances was studied and recorded.

Translation, adaptation and validation of the Roland-Morris questionnaire--Brazil Roland-Morris.

The purpose of the present study was to translate the Roland-Morris (RM) questionnaire into Brazilian-Portuguese and adapt and validate it. First 3 English teachers independently translated the original questionnaire into Brazilian-Portuguese and a consensus version was generated. Later, 3 other translators, blind to the original questionnaire, performed a back translation. This version was then compared with the original English questionnaire. Discrepancies were discussed and solved by a panel of 3 rheumatologists and the final Brazilian version was established (Brazil-RM). This version was then pretested on 30 chronic low back pain patients consecutively selected from the spine disorders outpatient clinic. In addition to the traditional clinical outcome measures, the Brazil-RM, a 6-point pain scale (from no pain to unbearable pain), and its numerical pain rating scale (PS) (0 to 5) and a visual analog scale (VAS) (0 to 10) were administered twice by one interviewer (1 week apart) and once by one independent interviewer. Spearman's correlation coefficient (SCC) and intraclass correlation coefficient (ICC) were computed to assess test-retest and interobserver reliability. Cross-sectional construct validity was evaluated using the SCC. In the pretesting session, all questions were well understood by the patients. The mean time of questionnaire administration was 4 min and 53 s. The SCC and ICC were 0.88 (P<0.01) and 0.94, respectively, for the test-retest reliability and 0.86 (P<0.01) and 0.95, respectively, for interobserver reliability. The correlation coefficient was 0.80 (P<0.01) between the PS and Brazil-RM score and 0.79 (P<0.01) between the VAS and Brazil-RM score. We conclude that the Brazil-RM was successfully translated and adapted for application to Brazilian patients, with satisfactory reliability and cross-sectional construct validity.

A study of the gram-negative bacterial flora in patients with ankylosing spondylitis.

1. Twenty-eight patients with active definite primary ankylosing spondylitis and fifty-four healthy control subjects were studied. 2. The HLA-B27 antigen was found in 75% of patients and 3.7% of controls. 3. Fecal samples from these subjects were cultured for gram-negative enteric bacteria on two occasions within one month. Positive cultures for Klebsiella sp were found in 32.1% of patients and in 22.2% of healthy controls, but this difference was not statistically significant. All other microorganisms detected were qualitatively and quantitatively similar in both groups. 4. Significantly increased mean values of serum IgA levels were found in the patient group when compared with the control group (P less than 0.01). The mean serum IgG and IgM levels did not differ statistically between the two groups. There was no correlation between any laboratory or clinical parameter and presence of Klebsiella sp carriage in ankylosing spondylitis patients. 5. These data are consistent with the view that a long time elapses between exposure to a trigger factor and clinical manifestations of the disease.

Reduced bone mineral density in men after heart transplantation.

Heart transplantation is associated with rapid bone loss and an increased prevalence and incidence of fractures. The aim of the present study was to compare the bone mineral density (BMD) of 30 heart transplant (HT) recipients to that of 31 chronic heart failure (CHF) patients waiting for transplantation and to determine their biochemical markers of bone resorption and hormone levels. The BMD of lumbar spine and proximal femur was determined by dual-energy X-ray absorptiometry. Anteroposterior and lateral radiographs of the thoracic and lumbar spine were also obtained. The mean age of the two groups did not differ significantly. Mean time of transplantation was 25.4 +/- 21.1 months (6 to 88 months). Except for the albumin levels, which were significantly higher, and magnesium levels, which were significantly lower in HT patients when compared to CHF patients, all other biochemical parameters and hormone levels were within the normal range and similar in the two groups. Both groups had lower BMD of the spine and proximal femur compared to young healthy adults. However, the mean BMD of HT patients was significantly lower than in CHF patients at all sites studied. Bone mass did not correlate with time after transplantation or cumulative dose of cyclosporine A. There was a negative correlation between BMD and the cumulative dose of prednisone. These data suggest that bone loss occurs in HT patients mainly due to the use of corticosteroids and that in 30% of the patients it can be present before transplantation. It seems that cyclosporine A may also play a role in this loss.

Bone mineral density of the lumbar spine of Brazilian children and adolescents aged 6 to 14 years.

The authors performed a study of bone mass in eutrophic Brazilian children and adolescents using dual-energy X-ray absorptiometry (DXA) in order to obtain curves for bone mineral content (BMC) and bone mineral density (BMD) by chronological age and correlate these values with weight and height. Healthy Caucasian children and adolescents, 120 boys and 135 girls, 6 to 14 years of age, residents of São Paulo, Brazil, were selected from the Pediatric Department outpatient clinic of Hospital São Paulo (Universidade Federal de São Paulo). BMC, BMD and the area of the vertebral body of the L2-L4 segment were obtained by DXA. BMC and BMD for the lumbar spine (L2-L4) presented a progressive increase between 6 and 14 years of age in both sexes, with a distribution that fitted an exponential curve. We identified an increase of mineral content in female patients older than 11 years which was maintained until 13 years of age, when a new decrease in the velocity of bone mineralization occurred. Male patients presented a period of accelerated bone mass gain after 11 years of age that was maintained until 14 years of age. At 14 years of age the mean BMD values for boys and girls were 0.984 and 1.017 g/cm2, respectively. A stepwise multiple regression analysis of paired variables showed that the "vertebral area-age" pair was the most significant in the determination of BMD values and the introduction of a third variable (weight or height) did not significantly increase the correlation coefficient.