Radiographic Assessment of Bone Quality Using 4 Radiographic Indexes: Canal Diaphysis Ratio Is Superior.

BACKGROUND: Osteoporosis increases the risk of periprosthetic fracture and loosening in hip arthroplasty. Many methods have been proposed to assess bone quality in X-rays, including both qualitative such as the Dorr classification and quantitative such as the Calcar-Canal Ratio (CCR) and Cortical-Thickness index/Canal-Bone ratio (CTI/CBR). The Canal-Diaphysis ratio (CDR) has been described as a predictor for hip fragility fractures; however, its relationship with bone mineral density (BMD) has not been described. The purpose of this study was to evaluate the correlation of the Dorr classification, CCR, CTI/CBR, and CDR with BMD of the proximal femur in patients without hip fracture. METHODS: Forty-seven patients over 45 years of age who had less than 6 months between radiographs and dual-energy X-ray absorptiometry were evaluated. Measurements of CCR, CBR, CDR, and Dorr classification were performed in all radiographs by 2 independent observers. RESULTS: The CDR had a high correlation (r = 0.74, P=<0.01) with BMD, whereas the CTI/CBR had a moderate correlation (r = 0.49, P=<0.01), and the CCR had no correlation with BMD (r = 0.06, P = .96). When evaluating the receiver operating characteristic curve, CDR showed the best performance (area under curve [AUC] = 0.75) followed by CBR (AUC = 0.73) and CCR (AUC = 0.61). The optimal cutoff value for the CDR was 0.49, with 100% sensitivity and 58% specificity. The inter- and intra-observer variability was good for all methods. No differences were found between Dorr classification of patients who had or did not have osteoporosis. CONCLUSION: Of all the analyzed methods, the CDR was found to have the best correlation with BMD. This study proposes the use of CDR as a tool for assessing bone quality when deciding the implant fixation method in hip arthroplasty.

Epistemonikos: a comprehensive database of systematic reviews for health decision-making.

BACKGROUND: Systematic reviews allow health decisions to be informed by the best available research evidence. However, their number is proliferating quickly, and many skills are required to identify all the relevant reviews for a specific question. METHODS AND FINDINGS: We screen 10 bibliographic databases on a daily or weekly basis, to identify systematic reviews relevant for health decision-making. Using a machine-based approach developed for this project we select reviews, which are then validated by a network of more than 1000 collaborators. After screening over 1,400,000 records we have identified more than 300,000 systematic reviews, which are now stored in a single place and accessible through an easy-to-use search engine. This makes Epistemonikos the largest database of its kind. CONCLUSIONS: Using a systematic approach, recruiting a broad network of collaborators and implementing automated methods, we developed a one-stop shop for systematic reviews relevant for health decision making.

[Nutrients other than glucose might explain fetal overgrowth in gestational diabetic pregnancies]. / La hipótesis de Pedersen no es suficiente: otros nutrientes además de la glucosa explicarían la macrosomía fetal en pacientes diabéticas gestacionales con sobrepeso y buen control glicémico.

Since 1964, the hypothesis of Pedersen has been used to explain fetal macrosomia observed in gestational diabetes mellitus (GDM), by a mechanism involving maternal hyperglycemia--fetal hyperglycemia--fetal hyperinsulinemia. However, since the 1980-89 decade, it is known that pregnant women with pre-gestational overweight not suffering from GDM still have a higher frequency of fetal macrosomia. Furthermore, pregnant women with GDM, despite being subjected to optimal glycemic control, still show unacceptably high frequencies of fetal macrosomia, a phenomenon that is concentrated in pregnancies with overweight or obesity prior to pregnancy. If glucose is not the single nutrient responsible for fetal macrosomia in pregnant women with gestational diabetes that undergo strict glycemic control, other nutrients may cause excessive fetal growth in pre-pregnancy overweight mothers. In this review, we propose that triglycerides (TG) could be responsible for this accelerated fetal growth. If this hypothesis is validated in animal models and clinical studies, then normal and pathological ranges of TG should be defined, and monitoring of triglyceride levels during pregnancy should be advised as a possible new alternative, besides a good glycemic control, for the management of fetal macrosomia in GDM women with overweight prior to pregnancy.

[A new physiopathological classification of diabetic neuropathy]. / Bases fisiopatológicas para una clasificación de la neuropatía diabética.

Nowadays, Diabetic Neuropathy (DN) is considered the most common cause of peripheral neuropathy in clinical practice. It can affect sensitive, motor or autonomic nerve fibers, with symmetric, asymmetric, acute or chronic presentations. Due to this variability, with multiple physiopathologic mechanisms involved, a complex clinical classification has been used until recently. The aim of this review is to present a new classification of diabetic neuropathy, based on its physiopathology. It is divided in metabolic microvascular and hypoxic, autoimmune and inflammatory, compressive, secondary to complications of diabetes and related to treatment. It must be understood that DN is not just a functional disease, but a complication of diabetes with molecular and pathological substrates caused by hyperglycemia. Therefore, normalization of blood glucose is a fundamental step towards the successful prevention and treatment of DN.

Should we add beta-blockers to band ligation for secondary prophylaxis of variceal bleeding? / ¿Vale la pena agregar betabloqueadores a la ligadura endoscópica como profilaxis secundaria de hemorragia variceal en pacientes cirróticos?

Cirrhotic patients who have had an episode of bleeding from gastroesophageal varices are at high risk of rebleeding, despite treatment with endoscopic variceal ligation. Adding beta-blockers could reduce this risk, but it is associated with adverse effects. Searching in Epistemonikos database, which is maintained by screening multiple databases, we identified seven systematic reviews including 21 randomized controlled trials addressing the question of this article. We extracted data, combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded the addition of beta-blockers to endoscopic variceal ligation as secondary prophylaxis of variceal bleeding reduces the risk of rebleeding, but probably does not lead to any difference in terms of mortality. Even though it is associated to frequent adverse effects, these would be mild and generally do not lead to discontinuation of treatment.

Los pacientes cirróticos que han tenido un episodio de hemorragia por várices gastroesofágicas tienen un alto riesgo de resangrado, a pesar del tratamiento con ligadura variceal endoscópica. La adición de betabloqueadores podría disminuir este riesgo, pero se asocia a efectos adversos. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos, identificamos siete revisiones sistemáticas que en conjunto incluyen tres estudios aleatorizados que responden la pregunta. Extrajimos los datos, realizamos un metanálisis y confeccionamos tablas de resumen de los resultados utilizando el método GRADE. Concluimos que la adición de betabloquedores a la ligadura variceal endoscópica como profilaxis secundaria de hemorragia variceal disminuye el riesgo de resangrado, sin embargo, parece no disminuir la mortalidad, aunque la certeza de la evidencia para esto es baja. Si bien se asociaría a efectos adversos frecuentes estos serían leves y en general no llevan a suspender la terapia.

Are intraarticular steroids effective for knee osteoarthritis? / ¿Son efectivos los corticoides intraarticulares en artrosis de rodilla?

Knee osteoarthritis is a chronic disabling condition that is both progressive and irreversible. Intraarticular steroids are commonly used to reduce osteoarthritis symptoms and to minimize the need for surgery. Nevertheless, debate still exists regarding the efficacy and safety of steroids. To address this point, we searched Epistemonikos database which is maintained by screening 30 separate databases and identified 12 systematic reviews including 41 studies addressing steroids use in knee osteoarthritis. Of these, 40 were randomized trials. The evidence from these studies was combined using meta-analysis, and a summary of findings table was constructed following the GRADE approach. We concluded intraarticular steroid use slightly decreases short-term pain, makes little or no difference in the mid-term, and may have no effects in the long-term.

La hipótesis de Pedersen no es suficiente: Otros nutrientes además de la glucosaexplicarían la macrosomía fetal enpacientes diabéticas gestacionales consobrepeso y buen control glicémico / Nutrients other than glucose might explain fetal overgrowth in gestationaldiabetic pregnancies

Since 1964, the hypothesis of Pedersen has been used to explain fetal macrosomia observed in gestational diabetes mellitus (GDM), by a mechanism involving maternal hyperglycemia - fetal hyperglycemia - fetal hyperinsulinemia. However,since the 1980-89 decade, it is known that pregnant women with pre-gestationaloverweight not suffering from GDM still have a higher frequency of fetal macrosomia. Furthermore, pregnant women with GDM, despite being subjected to optimalglycemic control, still show unacceptably high frequencies of fetal macrosomia, aphenomenon that is concentrated in pregnancies with overweight or obesity priorto pregnancy. If glucose is not the single nutrient responsible for fetal macrosomiain pregnant women with gestational diabetes that undergo strict glycemic control,other nutrients may cause excessive fetal growth in pre-pregnancy overweightmothers. In this review, we propose that triglycerides (TG) could be responsible forthis accelerated fetal growth. If this hypothesis is validated in animal models andclinical studies, then normal and pathological ranges of TG should be defined, andmonitoring of triglyceride levels during pregnancy should be advised as a possiblenew alternative, besides a good glycemic control, for the management of fetal macrosomia in GDM women with overweight prior to pregnancy.

Bases fisiopatológicas para una clasificación de la neuropatía diabética / A new physiopathological classification of diabetic neuropathy

Nowadays, Diabetic Neuropathy (DN) is considered the most common cause of peripheral neuropathy in clinical practice. It can affect sensitive, motor or autonomic nerve fibers, with symmetric, asymmetric, acute or chronic presentations. Due to this variability, with multiple physiopathologic mechanisms involved, a complex clinical classification has been used until recently. The aim of this review is to present a new classification of diabetic neuropathy, based on its physiopathology. It is divided in metabolic microvascular and hypoxic, autoimmune and inflammatory, compressive, secondary to complications ofdiabetes and related to treatment. It must be understood that DN is notjust a functional disease, but a complication of diabetes with molecular and pathological substrates caused by hyperglycemia. Therefore, normalization of blood glucose is a fundamental step towards the successful prevention and treatment of DN.