Factores de riesgo y prevalencia de osteopenia y osteoporosis en mujeres posmenopáusicas diagnosticadas por densitometría ósea / Risk factors and prevalence of osteopenia and osteoporosis in postmenopausal women diagnosed by bone densitometry

Resumen Objetivo: Determinar la prevalencia de la osteoporosis en mujeres costarricenses posmenopáusicas, atendidas en el Hospital San Juan de Dios de la Caja Costarricense del Seguro Social, y relacionar con características clínicas y de estilo de vida. Métodos. Estudio transversal. Se analizó un total de 923 estudios de densitometría ósea de mujeres con edad entre los 45 y 80 años, en etapa posmenopáusica; se registró un valor de T-score obtenido por densitometría ósea para columna lumbar y cadera; se documentó las variables como la edad, el índice de masa corporal, tabaquismo y otros reconocidos factores de riesgo; se estimó la prevalencia y se analizó la relación con los factores. Resultados. A partir de 923 estudios y los factores de riesgo comúnmente asociados con la enfermedad, fueron estadísticamente significativos los siguientes: la edad (p<0,001), la edad en la menarquia (p = 0,001), la cantidad de años transcurridos desde la menopausia (p<0,001) y el antecedente familiar de fractura de cadera (p = 0,01). Otros factores no resultaron significativos. Conclusiones. Para la población estudiada, se demostró una prevalencia de 47% para osteopenia y de 39% para osteoporosis en mujeres posmenopáusicas. No se logró establecer una relación en las variables de estilo de vida, tales como tabaquismo, alcoholismo, actividad física y consumo de lácteos. Se deben realizar otras investigaciones con un mayor control sobre estas variables para conocer su riesgo relacionado con la enfermedad.

Abstract Aim: To determine the prevalence of osteoporosis in postmenopausal Costa Rican women treated at the San Juan de Dios Hospital of the Costa Rican Social Security Fund, and relate it to clinical and lifestyle characteristics. Methods. Transversal study. A total of 923 bone densitometry studies of postmenopausal women aged between 45 and 80 years were analyzed; A T-score value obtained by bone densitometry was recorded for the lumbar spine and hip; variables such as age, bodymass index, smoking, and other recognized risk factors were documented; the prevalence was estimated and the relationship with the factors was analyzed. Results. From 923 studies and risk factors commonly associated with the disease, the following were statistically significant: age (p<0.001), age at menarche (p = 0.001), number of years since menopause (p<0.001) and family history of hip fracture (p = 0.01). Other factors were not significant. Conclusions. For the population studied, a prevalence of 47% for osteopenia and 39% for osteoporosis in postmenopausal women was demonstrated. It was not possible to establish a relationship in lifestyle variables, such as smoking, alcoholism, physical activity and dairy consumption. Other investigations with greater control over these variables should be carried out to know their risk related to the disease.

The bone densitometry is normal in Turner syndrome prepubertal patients after height age correction / A densitometria óssea é normal em pacientes pré-púberes com síndrome de turner quando corrigida pela idade estatura

Abstract Objectives: to evaluate the bone mass in prepubertal patients with Turner Syndrome (TS) according to height age (HA) and verify the influence of karyotype and adiposity. Methods: retrospective and analytical study of prepubertal TS patients. The variables analyzed were: karyotype, age at bone densitometry (BD), height, body mass index (BMI) and BD result. The result of the BD was corrected using HA. BMI and BD were calculated on Z score for chronological age (CA) and for HA. Results: thirty-seven prepubertal patients were selected and after exclusion criteria, 13 cases between 10 and 13 years old were included in the study. The BD for HA was significantly higher than for CA (0.39 ± 1.18 x −1.62 ± 1.32), without karyotype (p=0.369) and BMI (p=0.697) influence. Conclusion: prepubertal TS patients present normal BD when corrected for HA, without influence of karyotype and BMI.

Resumo Objetivos: avaliar a massa óssea de pacientes pré-púberes com Síndrome de Turner (ST) de acordo com a idade estatura (IE) e verificar a influência do cariótipo e da adiposidade. Métodos: estudo retrospectivo e analítico de pacientes pré-púberes com ST. As variáveis analisadas foram: cariótipo, idade na realização da densitometria óssea (DO); estatura, índice de massa corporal (IMC) e resultado da DO. Realizou-se a correção do resultado da DO utilizando a IE. O IMC e a DO foram calculados em Z score para idade cronológica (IC) e para IE. Resultados: foram selecionadas 37 pacientes pré-púberes e após critério de exclusão foram incluídas no estudo 13 casos entre 10 e 13 anos de idade. A DO para IE foi significativamente maior que para IC (0,39 ± 1,18 × −1,62 ± 1,32), sem influência do cariótipo (p=0,369) e do IMC (p=0,697). Conclusão: pacientes pré-púberes com ST apresentam DO normal quando corrigida para IE, sem influência do cariótipo e do IMC.

Frequency of osteopenia and osteoporosis in men and women living with HIV/Aids: an observational study / Frequência de osteopenia e osteoporose em homens e mulheres vivendo com HIV/Aids: um estudo observacional

ABSTRACT: Aims: To identify the frequency in changes of bone metabolism, including below the average value for age, osteopenia, and osteoporosis, in people living with HIV/AIDS (PLWHA) and to compare the frequency of factors associated with bone mineral density (BMD) and body composition between sex. Methods: This observational study assessed 106 PLWHA (65 male) recruited from the University Hospital of Ribeirão Preto Medical School from 2013 to 2014. BMD was measured using Dual Energy X-ray Absorptiometry (DXA). Standard deviation values for Z- and T-score proposed by the International Society for Clinical Densitometry were adopted to classify participants below the average value for age, osteopenia, and osteoporosis. Qui-square and Fischer's exact tests were employed to compare males and females based on their factors associated with BMD reduction. Results: Fifty-two (49%) PLWHA presented at least one diagnosis for below the average value for age, osteopenia, and osteoporosis, being 37 (57%) and 15 (37%) male and female, respec-tively. Frequency of alcohol consumption was higher in males (n=20; 30.8%) than females (n=05; 12.2%) (p=0.028).Conclusions: A high rate of PLWHA showed changes in bone metabolism, with a higher frequency in males. The fre-quency of alcohol consumption was higher in males, and it may partially explain the possible causes of the increased rates of bone metabolism changes observed in this group. This information may help develop strategies for reducing the frequency of diagnosis for below the average value for age, osteopenia, osteoporosis improving quality of life in PLWHA. (AU)

RESUMO: Objetivos: Identificar a frequência de alterações no metabolismo ósseo, incluindo valores abaixo do estimado para idade, osteopenia e osteoporose, em pessoas vivendo com HIV/Aids (PVHA) e comparar a frequência de fatores associados à redução da densidade mineral óssea (DMO) e composição corporal entre sexos. Métodos: Estudo observacional que ava-liou 106 PVHA (65 do sexo masculino) recrutadas do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo entre os anos 2013 e 2014. A DMO foi medida utilizando a Absorciometria Radiológica de Dupla Energia (DXA). Valores de desvio padrão Z- e T- scores propostos pela Sociedade Internacional para Densitometria Clí-nica foram adotados para classificar os participantes em abaixo do valor estimado para idade, osteopenia e osteoporose. Os testes do qui-quadrado e exato de Fischer foram empregados na comparação entre os sexos baseado em seus respec-tivos fatores associados à redução da densidade mineral óssea. Resultados: Cinquenta e dois (49%) PVHA apresentaram ao menos um diagnóstico para abaixo do valor estimado para idade, osteopenia e osteoporose, sendo 37 (57%) do sexo masculino e 15 (37%) feminino. A frequência de consumo de álcool foi maior no sexo masculino (n=20; 30,8%) compara-do ao feminino (n=5; 12,2%) (p=0,028). Conclusões: Uma alta taxa de PVHA apresentaram alterações no metabolismo ósseo, com maior frequência no sexo masculino. A frequência no consumo de álcool foi maior no sexo masculino, podendo explicar parcialmente as possíveis causas para taxa aumentada de alterações no metabolismo ósseo observada nesse grupo. Essa informação pode contribuir no desenvolvimento de estratégias para redução da frequência do diagnóstico para valores abaixo do estimado para idade, osteopenia e osteoporose, melhorando a qualidade de vida em PVHA

El FRAX como herramienta para evaluar el riesgo de fracturas en población general y grupos especiales de riesgo / FRAX as a tool to assess the risk of fractures in the general population and special risk groups

El FRAX es una herramienta que mide el riesgo de fractura y cuenta con un algoritmo computarizado desarrollado por la Organización Mundial de la Salud, basado en modelos globales de cohortes de población, combinados con factores de riesgo clínico. La herramienta fue diseñada inicialmente para su aplicación por los médicos de atención primaria en mujeres posmenopáusicas y hombres sobre 50 años, aunque es válida en general entre 40-90 años. Nos propusimos desarrollar un estudio epidemiológico-clínico sobre osteoporosis y fracturas en la población general y algunos grupos especiales de riesgo que incluyen mujeres posmenopáusicas, pacientes con afecciones reumáticas, endocrinas, cáncer y con infección por VIH, así como describir el papel desempeñado por FRAX como herramienta de medición del riesgo de fractura a los 10 años de ocurrida. Asimismo, constituye un gran reto conocer e identificar los principales grupos vulnerables o de riesgo para osteoporosis y fracturas en la población cubana. Esta aplicación nos resulta prioritaria en los grupos identificados, pues permitirá conocer los riesgos de fracturas a corto y largo plazos e implementar correcta y racionalmente los estudios DXA, disponibles en el país para la toma de decisiones terapéuticas(AU)

The FRAX is a tool that has a computerized algorithm developed by the World Health Organization, based on global models of population cohorts, combined with clinical risk factors, which measures the risk of fracture. The tool was initially designed for use by primary care physicians in postmenopausal women and men over 50 years of age, although it is generally valid between 40-90 years. We set out to develop a clinical epidemiological study on osteoporosis and fractures in the general population and some special risk groups that include post-menopausal women, patients with rheumatic, endocrine, cancer and HIV-infected conditions, as well as the role played by FRAX as a measurement tool. The ten-year risk of fracture related to the importance of knowing and identifying the main vulnerable or risk groups for osteoporosis and fractures in the Cuban population constitutes a great challenge. This application is a priority for those groups previously identified as it will allow us to know the short and long-term risks of fractures and implement the correct use of DXA studies, available in the country with a rational use and therapeutic decision-making(AU)

¿A qué pregunta responde "el hueso"?: una cuestión de direccionalidad estructural y organización biológica (hueso y huesos, del big-bang a la osteoporosis) / To which question is 'bone' the answer?: a matter of structural directionality and biological organization (bone and bones, from the big bang to osteoporosis)

La "razón de ser" de nuestros huesos y esqueletos constituye un dilema centralizado en los conceptos biológicos de "estructura" y "organización", cuya solución necesitamos comprender para interpretar, diagnosticar, tratar y monitorear correctamente las osteopatías fragilizantes. Últimamente se ha reunido conocimiento suficiente para proponer aproximaciones razonables a ese objetivo. La que exponemos aquí requiere la aplicación de no menos de 6 criterios congruentes: 1) Un criterio cosmológico, que propone un origen común para todas las cosas; 2) Un criterio biológico, que explica el origen común de todos los huesos; 3) Un enfoque epistemológico, que desafía nuestra capacidad de comprensión del concepto concreto de estructura y del concepto abstracto de organización, focalizada en la noción rectora de direccionalidad espacial; 4) Una visión ecológica, que destaca la importancia del entorno mecánico de cada organismo para la adecuación de la calidad mecánica de sus huesos a las "funciones de sostén" que les adjudicamos; 5) Una correlación entre todo ese conocimiento y el necesario para optimizar nuestra aptitud para resolver los problemas clínicos implicados y 6) Una jerarquización del papel celular en el manejo de las interacciones genético-ambientales necesario para asimilar todo el problema a una simple cuestión de organización direccional de la estructura de cada hueso. Solo aplicando estos 6 criterios estaríamos en condiciones de responder a la incógnita planteada por el título. La conclusión de esta interpretación de la conducta y función de los huesos debería afectar el fundamento de la mayoría de las indicaciones farmacológicas destinadas al tratamiento de la fragilidad ósea. (AU)

The nature of the general behavior of our bones as weight-bearing structures is a matter of two biological concepts, namely, structure and organization, which are relevant to properly interpret, diagnose, treat, and monitor all boneweakening diseases. Different approaches can be proposed to trace the corresponding relationships. The one we present here involves six congruent criteria, namely, 1) a cosmological proposal of a common origin for everything; 2) a biological acknowledgement of a common origin for all bones; 3) the epistemological questioning of our understanding of the concrete concept of structure and the abstract notion of organization, focused on the lead idea of directionality; 4) the ecological insight that emphasizes the relevance of the mechanical environment of every organism to the naturally-selected adjustment of the mechanical properties of their mobile bones to act as struts or levers; 5) The clinical aspects of all the alluded associations; 6) The central role of bone cells to control the genetics/ environment interactions of any individual as needed to optimize the directionality of the structure of each of his/her bones to keep their mechanical ability within physiological limits. From our point of view, we could only solve the riddle posed by the title by addressing all of these six criteria. The striking conclusion of our analysis suggests that the structure (not the mass) of every bone would be controlled not only to take care of its mechanical ability, but also to cope with other properties which show a higher priority concerning natural selection. The matter would be that this interpretation of bone behavior and 'function' should affect the rationales for most pharmacological indications currently made to take care of bone fragility. (AU)

Intercellular mediators in bone remodeling regulation in the experimental renal pathology / Mediadores intercelulares de la regulación de la remodelación ósea en un modelo experimental de patología renal

Bone metabolism disorders are characterized by an imbalance of bone resorption and formation in the bone remodeling process. Glucocorticoids that are used to treat kidney diseases exacerbate these disorders. P-selectin and galectin-3 are molecules involved in the sclerotic process in kidney, whereas bone resorption is regulated by the interaction between the nuclear factor activator kappa b receptor (RANK), its ligand (RANKL) and the RANKL decoy receptor osteoprotegerin (OPG). The aim of this study was to investigate the cellular and molecular mechanisms of disruption of bone remodeling regulation processes, reflected by intercellular mediators (RANKL, OPG, P-selectin and galectin-3) in chronic kidney disease experimental model treated with glucocorticoids. Rats were divided into four groups of 10 animals each. The first group, the control group, included intact animals. The second group consisted of rats with impaired bone remodeling resulting from chronic kidney disease (experimental group (CKD). The third group was a group of animals with impaired bone remodeling due to exposure to glucocorticoids (experimental group (GCs)). The fourth group consisted of rats with impaired bone remodeling in chronic kidney disease, followed by exposure to glucocorticoids (experimental group (CKD + GCs)). The effects of CKD and glucocorticoid were evaluated biochemically, histologically and by measuring bone density. An enzymelinked immunoassay was used to measure intercellular mediator levels in the serum. The bone density in the experimental groups was reduced compared to the control group. RANKL levels in animals of three experimental groups were higher than in intact animals. Serum levels of OPG were higher in CKD and GCs groups than in intact animals. At the same time, in the animals' blood serum of the CKD + GCs group, the levels of OPG were lower, than those in animals from the control group. The levels of galectin-3 in the serum of the experimental groups GCs and CKD + GCs were lower than in intact animals. The serum levels of galectin-3 in animals of the CKD group were higher than those in animals from the control group. The levels of P-selectin were lower in the serum of the GCs group than in intact animals. At the same time, the levels of P-selectin were higher in the CKD and CKD + GCs groups, than those in animals from the control group. In conclusion, the study of the complex system of bone remodeling regulation, which includes many factors and their interactions, may lead to the development of new methods for treating patients with chronic kidney disease in order to prevent osteoporosis in the future. (AU)

Las enfermedades metabólicas óseas se caracterizan por un desequilibrio en el proceso de remodelación ósea en los que participan mediadores tales como receptor del activador del factor nuclear- kappa- b (RANK), su ligando (RANKL) y la osteoprotegerina (OPG). Los glucocorticoides, recuentemente empleados en el tratamiento de la enfermedad renal crónica, exacerban este desequilibrio. En la enfermedad esclerótica renal, las moléculas de adhesión celular P-selectina and galectina-3 tienen un rol fundamental. El objetivo de esta trabajo fue estudiar las alteraciones en los mediadores de la remodelación ósea (RANKL, OPG, P-selectina and galectina-3) en un modelo de enfermedad renal crónica con tratamiento glucocorticoideo. Ratas Wistar hembras fueron divididos en 4 grupos: control (C); enfermedad renal crónica con afección de la remodelación ósea (ERC); animales con afección de la remodelación ósea expuestos a glucocorticoides (GC); enfermedad renal crónica con afección de la remodelación ósea tratados con glucocorticoides (ERC+GC). Los efectos de la ERC y los GC fueron evaluados bioquímicamente, histológicamente y por medición de la densidad ósea. RANKL, OPG, Pselectina and galectina-3 se cuantificaron en muestras de sangre venosa empleando enzimoinmuno análisis. En los 3 grupos experimentales la densidad ósea se evidenció reducida y los niveles séricos de RANKL elevados respecto al grupo control. Los niveles de OPG en los grupos ERC y GC fueron superiores mientras que en el grupo ERC+GC menores respecto a los animales controles. Galectina 3 plasmática en GC y ERC+GC se encontró reducida y aumentada en los animales ERC, en comparación con los animales controles. La concentración sérica de P-selectina sérica fue mayor en los grupos ERC y ERC+GC, y menor en los animales GC respecto a los niveles plasmáticos de los animales intactos. El avance del conocimiento sobre la regulación de la remodelación ósea a través de la interacción de mediadores sistémicos, en un futuro, puede conducir al desarrollo de nuevas estrategias terapéuticas para la prevención de la osteoporosis en pacientes con enfermedad renal crónica. (AU)

Osteoporosis juvenil idiopática. Presentación de un caso / Idiopathic juvenile osteoporosis. A case presentation

Introdución: la osteoporosis juvenil idiopática (OJI) es el término descriptivo aplicado a la osteoporosis de etiología desconocida en la edad pediátrica. Se caracteriza por la pérdida progresiva de la masa ósea y el deterioro de su microarquitectura, lo que lleva al aumento de la fragilidad ósea y a la mayor susceptibilidad de fracturas. El principal objetivo del tratamiento de los niños y adolescentes con densidad mineral ósea disminuida es la prevención de las fracturas óseas por fragilidad. Como medidas generales, se recomienda una alimentación equilibrada, con aporte óptimo de calcio y vitamina D y la promoción de la mayor actividad física posible. Objetivo: presentar un caso de OJI y enfatizar en aspectos del diagnóstico y tratamiento. Caso clínico: adolescente, femenina, de 17 años de edad, que acudió al Departamento de Endocrinología Pediátrica del Instituto Nacional de Endocrinología a la edad de 9 años por fracturas múltiples desde los 5 años, lo que se asociaba a dolores óseos. Ante la sintomatología se indicaron los complementarios correspondientes confirmándose el diagnóstico de OJI e indicándose tratamiento con calcio y vitamina D; se evidenció una evolución favorable con mejoría clínica y radiológica, sin necesidad de administrar tratamiento con bifosfonatos

Introdution: Juvenile idiopathic osteoporosis (JIO) is the descriptive term applied to osteoporosis of unknown etiology in the pediatric age. It is characterized by the progressive loss of bone mass and the deterioration of its microarchitecture, which leads to increased bone fragility and greater susceptibility to fractures. The main objective of the treatment of children and adolescents with decreased bone mineral density is the prevention of bone fractures due to fragility. As general measures, a balanced diet with an optimal supply of calcium and vitamin D and the promotion of as much physical activity as possible is recommended. Objective: Present a case of JIO and emphasize aspects of diagnosis and treatment. Case report: Adolescent, female, 17 years old, who was attended at the Department of Pediatric Endocrinology of the National Institute of Endocrinology at the age of 9 years for multiple fractures since age 5, which was associated with bone pain. Given the symptoms and results of complementary exams, a diagnosis of JIO was confirmed, indicating treatment with calcium and vitamin D. The patient respond favorably, with clinical and radiological improvement, with no need to administer bisphosphonates

Distrofia ósea esclerosante mixta / Mixed-sclerosing-bone-dystrophy

El término "distrofia ósea esclerosante mixta" describe la combinación de las características radiológicas correspondientes a melorreostosis, osteopoiquilosis y osteopatía estriada, como entidades individuales, que ocurren en un mismo paciente. El objetivo de esta comunicación es presentar el caso clínico de una paciente con diagnóstico de distrofia ósea esclerosante mixta y, a partir de este caso, realizar una revisión sobre el tema. (AU)

The term "mixed-sclerosing-bone-dystrophy" describes the combination of the radiological characteristics corresponding to melorheostosis, osteopoikilosis and osteopathia striata, as individual conditions, ocurring in the same patient. The aim of this communication is to present the clinical case of a patient diagnosed with mixed-sclerosing-bone-dystrophy and, based on this case, to undertake a review of this condition. (AU)

Phosphaturic mesenchymal tumor (PMT): exceptionally rare disease, yet crucial not to miss

Phosphaturic mesenchymal tumors (PMTs) are very rare tumors which are frequently associated with Tumor Induced Osteomalacia (TIO), a paraneoplastic syndrome that manifests as renal phosphate wasting. The tumor cells produce a peptide hormone-like substance known as fibroblast growth factor 23 (FGF23), a physiologic regulator of phosphate levels. FGF23 decreases proximal tubule reabsorption of phosphates and inhibits 1-α-hydroxylase, which reduces levels of 1-α, 25-dihydroxyvitamine D3. Thus, overexpression of FGF23 by the tumor cells leads to increased excretion of phosphate in the urine, mobilization of calcium and phosphate from bones, and the reduction of osteoblastic activity, ultimately resulting in widespread osteomalacia. Patients typically present with gradual muscular weakness and diffuse bone pain from pathologic fractures. The diagnosis is often delayed due to the non-specific nature of the symptoms and lack of clinical suspicion. While serum phosphorus and FGF23 testing can assist in making a clinical diagnosis of PMT, the responsible tumor is often difficult to locate. The pathologic diagnosis is often missed due to the rarity of PMTs and histologic overlap with other mesenchymal neoplasms. While patients can experience severe disabilities without treatment, excision is typically curative and results in a dramatic reversal of symptoms. Histologically, PMT has a variable appearance and can resemble other low grade mesenchymal tumors. Even though very few cases of PMT have been reported in the world literature, it is very important to consider this diagnosis in all patients with hypophosphatemic osteomalacia. Here we present a patient who suffered for almost 5 years without a diagnosis. Ultimately, the PMT was located on a 68Ga-DOTA TATE PET/CT scan and subsequently confirmed by histologic and immunohistologic study. Interestingly, strong positivity for FGFR1 by IHC might be related to the recently described FN1-FGFR1 fusion. Upon surgical removal, the patient's phosphate and FGF23 levels returned to normal and the patient's symptoms resolved.

Hiperparatiroidismo primario asintomático en mujeres / Asymptomatic primary hyperparathyroidism in women

El hiperparatiroidismo primario puede tener diferentes características. Una de ellas es la forma asintomática. Esta es una variante leve del hiperparatiroidismo primario hipercalcémico, que se caracteriza por una calcemia no mayor a 1 mg/dl sobre el límite superior del método, hormona paratiroidea intacta (PTHi) elevada, ausencia de litiasis renal, deterioro de la función renal y de osteoporosis, edad menor de 50 años, y calciuria menor a 400 mg/día. No es una entidad quirúrgica, pero en su evolución puede llegar a serlo. Se estudiaron 24 mujeres postmenopáusicas, todas mayores de 50 años, con diagnóstico de hiperparatiroidismo asintomático, se describieron las manifestaciones clínicas, los cambios densitométricos, los parámetros bioquímicos y del remodelado óseo y se compararon los resultados con las variantes clásica y normocalcémica de la enfermedad. Se establecieron los criterios diagnósticos y se observó que solo 2 (8.3%) de las pacientes, durante un seguimiento de 44 ± 12 meses tuvo necesidad de paratiroidectomía. En definitiva, el hiperparatiroidismo primario asintomático es una alteración benigna, de seguimiento clínico periódico que, en pocas ocasiones, durante el seguimiento puede requerir cirugía.

Primary hyperparathyroidism may have different characteristics. One is the asymptomatic form. This is a mild variant of hypercalcemic hyperparathyroidism, characterized by a calcemia not greater than 1 mg/dl above the upper limit of the method, a high intact parathyroid hormone (iPTH), absence of renal stones, renal function impairement, and osteoporosis, less than 50 years of age, and less than 400 mg/day calciuria. It is not a surgical entity, but its evolution may require it. Twenty-four postmenopausal women, all older than 50 years, with a diagnosis of asymptomatic hyperparathyroidism, were studied. Clinical manifestations, densitometric changes, biochemical parameters and bone remodeling were analyzed and the results were compared with the classic and normocalcemic variants of the disease. Diagnostic criteria were established and observed that only 2 (8.3%) of patients, during a follow up of 44 ± 12 months, had need for a parathyroidectomy. In conclusion, the asymptomatic primary hyperparathyroidism is a benign disorder, of periodic clinical follow-up, which rarely may require surgery.

Factores de riesgo y marcadores bioquímicos de la enfermedad metabólica ósea del recién nacido prematuro / Risk factors and biochemical markers in metabolic bone disease of premature newborns

Introducción: La enfermedad metabólica ósea (EMO) del recién nacido prematuro (RNPT) es una complicación de origen multifactorial, que ha ido en aumento, consecuencia de la disminución progresiva de la mortalidad. El objetivo del estudio fue analizar los factores de riesgo (FR) pre y postnatales relacionados con la EMO severa y sus marcadores analíticos. Pacientes y Métodos: Estudio retrospectivo observacional, descriptivo y analítico, que incluyó RNPT nacidos con menos de 32 semanas y/o peso menor de 1.500 g entre enero de 2012 y diciembre de 2014. Se analizó la muestra en función del desarrollo de EMO severa. Resultados: 139 pacientes, con 25(OH)D3 media de 70,68 ± 25,20 nmol/l, mayor en los nacidos en primavera-verano que en otoño-invierno (80,94 ± 25,33 vs 61,13±21,07; p = 0,000). Los pacientes con EMO severa presentaron valores de 25(OH)D3 similares al resto de pacientes (65,61 ± 26,49 vs 72,07 ± 24,89; p = 0,283), y superiores de fosfatasa alcalina (FA) (1314,19 ± 506,67 vs 476,56 ± 188,85; p = 0,000). Mediante curva ROC se calculó un punto de corte de FA de 796,5 IU/l (S 95,2%, E 92,4%). Los FR más asociados al desarrollo de EMO severa fueron el crecimiento intrauterino restringido, el peso al nacimiento y la duración de ventiloterapia y nutrición parenteral. Conclusiones: Las cifras de FA son las que mejor se relacionan con el desarrollo de EMO severa. El riesgo de ésta aumenta a mayor número de factores de riesgo y menores cifras de vitamina D3. Niveles de 25(OH)D3 por encima de 70 nmol/l parecen proteger del desarrollo de EMO, incluso en pacientes con múltiples factores de riesgo.

Background: Metabolic bone disease (MBD) of prematurity is a complication of multifactorial aetiology, which has been increasing, due to progressive decrease in mortality of preterm newborns. The aim of the study was to analyze risk factors of severe MBD and its analytical markers. Patients and Method: Retrospective study involving preterm infants less than 32 weeks gestational age and/or weight less tan 1,500 g born between january 2012 and december 2014. Comparison was made according to the presence of severe MBD. Results: 139 patients were recruited. Mean value of 25(OH)D3 was 70.68 ± 25.20 nmol/L, being higher in patients born in spring-summer than in autumn-winter (80.94 ± 25.33 vs 61.13 ± 21.07; p = 0.000). Levels of 25(OH)D3 were similar in patients with severe MBD compared with the rest of patients (65.61 ± 26.49 vs 72.07 ± 24.89, P = 0.283). Higher levels of alkaline phosphatase (AP, IU/L ) (1314.19 ± 506.67 vs 476.56 ± 188.85; p = 0.000) were found in these patients. Cutoff point of AP 796.5 IU/L (S 95.2%, specificity 92.4%) was calculated by ROC curve. The risk factors most associated to severe EMO were restricted fetal growth, birth weight, duration of ventilation therapy and parenteral nutrition. Conclusions: AP levels were the best marker of severe MBD development. EMO risk increases with the number of risk factors and lower levels of 25(OH)D3. Levels of 25(OH)D3 higher than 70nmol/L appear to protect from the development of severe MBD, even in patients with multiple risk factors.

Diagnostic performance of fractal dimension and radiomorphometric indices from digital panoramic radiographs for screening low bone mineral density

A number of panoramic radiographic measurements have been associated with osteoporotic alterations. However, little is known about the differences in sensitivity and specificity among these measurements for screening low bone mineral density (BMD). Aim: To correlate and compare precision, sensitivity and specificity of panoramic radiomorphometric indices and fractal dimension (FD) for screening low BMD (i.e. osteopenia and osteoporosis). Methods: Sixty-eight female patients (42.78±15.59 years) were included in this study. Body mass index (BMI), mandibular cortical index (MCI), mandibular cortical width (MCW), FD and connectivity (C) were assessed. Low BMD was diagnosed by peripheral dual-energy X-ray absorptiometry (p-DXA). Non-parametric correlations were assessed among all variables. In addition, sensitivity and specificity of MCI, MCW and FD were estimated for screening low BMD. Results: Significant correlation was found between FD and BMI (p=0.013; r=0.269). In addition, FD was the most sensitive method for screening low BMD (70.8%, p=0.001). FD and MCI presented a significant and relatively high sensitivity, whereas MCW presented a high specificity for screening low systemic BMD Conclusions: Among the analyzed methods, FD and MCI offer a significant and relatively high sensitivity, whereas MCW offers a high specificity for screening low BMD (Au)

One-Year Experience Managing a Cancer Survivorship Clinic Using a Shared-Care Model for Gastric Cancer Survivors in Korea

Given the rapid growth of the population of cancer survivors, increased attention has been paid to their health problems. Although gastric cancer is one of the most common cancers, empirical evidence of survivorship care is limited. The objectives of this study were to describe the health care status of gastric cancer survivors and to report the experience of using the shared-care model during a one-year experience at the cancer survivorship clinic in Seoul National University Hospital. This is a descriptive, single-center study of 250 long-term gastric cancer survivors who were referred to the survivorship clinic. The status of their health behaviors, comorbid conditions, secondary cancer screenings, and survivorship care status were investigated through questionnaires and examining the medical records. Among the survivors, 7.2% were current smokers, 8.8% were at-risk drinkers, and 32.4% were physically inactive. Among the patients who did not know their bone density status, the majority were in the osteopenic (37.1%) or osteoporotic range (24.1%). Screening among the eligible population within the recommended time intervals were 76.3% for colorectal cancer, but only 13.6% for lung cancer. All of the survivors were provided with counseling and medical management at the survivorship clinic, as appropriate. In conclusion, Long-term gastric cancer survivors have various unmet needs. Shared-care through survivorship clinics can be an effective solution for providing comprehensive care to cancer survivors.

Factores de riesgo para alteraciones de la densidad mineral ósea en mujeres posmenopáusicas / Risk factors for alterations in bone mineral density in postmenopausal women

OBJETIVO: Determinar los factores de riesgo para presentar alteraciones de la densidad mineral ósea (DMO) en mujeres posmenopáusicas atendidas en la consulta de Menopausia y Climaterio de la Maternidad "Dr. Armando Castillo Plaza", de Maracaibo, Venezuela. MÉTODOS: Investigación descriptiva, con diseño no experimental y transeccional, donde se evaluó la DMO y los factores de riesgo para presentar osteoporosis en 60 mujeres posmenopáusicas. RESULTADOS: La medición de la DMO resultó en promedio de 957,45 ± 149,95 y 905,00 ± 151,25 gramos, con índices T de -0,52 ± 1,66 y -0,55 ± 2,67 en columna vertebral y cuello femoral, respectivamente. Se estableció una prevalencia de osteoporosis del 10% y 5%, y de osteopenia del 43,3% y 50% en columna vertebral y fémur, respectivamente. La menopausia quirúrgica (OR [95% CI] = 4,75 [1,58-14,25]; p=0,004), el consumo excesivo de café (OR [95% CI] = 3,20 [1,40-7,10 1]; p=0,000) o gaseosas (OR [95% CI] = 2,50 [1,18-5,60]; p=0,002), tabaquismo (OR [95% CI] = 1,70 [1,102,80]; p=0,013) y la ausencia de suplementación de calcio más vitamina D (OR [95% CI] = 1,70 [1,00-2,80]; p=0,019) resultaron ser factores significativamente asociados al diagnóstico de osteoporosis u osteopenia (p<0,05). CONCLUSIÓN: Las mujeres posmenopáusicas evaluadas presentan una alta prevalencia de alteraciones en la DMO, principalmente osteopenia, y factores de riesgo para presentar Osteoporosis.

AIM: To determine risk factors for presenting alterations in bone mineral density (BMD) in postmenopausal women attending the consultation of Menopause and Menopause Maternity "Dr. Armando Castillo Plaza", Maracaibo, Venezuela. METHODS: A descriptive research with non-experimental and transactional design where was evaluated BMD and risk factors for developing osteoporosis in 60 postmenopausal women. RESULTS: The BMD measurement was averaged in 957.45 ± 149.95 and 905.00 ± 151.25 grams; with T indexes of -0.52 ± 1.66 and -0.55 ± 2.67 in spine and femoral neck, respectively. The prevalence of osteoporosis was 10% and 5%, while osteopenia was 43.3% and 50% in spine and femur, respectively. Surgical menopause (OR [95% CI] = 4.75 [1.58 to 14.25]; p=0.004); excessive coffee consumption (OR [95% CI] = 3.20 [1,40- 7.10 1]; p=0.000) or gaseous beverages (OR [95% CI] = 2.50 [1.18 to 5.60]; p=0.002); smoking (OR [95% CI] = 1.70 [1.10 to 2.80]; p=0.013) and the absence of supplemental calcium plus vitamin D (OR [95% CI] = 1.70 [1.00 to 2.80]; p=0.019) were be factors significantly associated with the diagnosis of osteoporosis or osteopenia (p<0.05). CONCLUSION: The evaluated postmenopausal women have a high prevalence of abnormal BMD, especially osteopenia, and risk factors for developing osteoporosis.

Hiperparatiroidismo primario normocalcémico

Presentamos las características clínicas, bioquímicas y densitométricas de 35 pacientes con hiperparatiroidismo primario (HPP) normocalcémico, que se caracteriza por un nivel elevado de hormona paratiroidea intacta (PTHi) con el calcio sérico y iónico persistentemente normales, una vez descartadas posibles causas de hiperparatiroidismo secundario. Del total, 30 fueron mujeres (90%) y 5 varones (10%). Se seleccionó un grupo control de 55 pacientes con hiperparatiroidismo primario hipercalcémico: 51 mujeres (93%) y 4 varones (7%). El promedio de edad al diagnóstico de HPP normocalcémico fue de 61.4 ± 11.7 años y del HPP hipercalcémico de 56.4 ± 11.3 años. Además de las diferencias esperables de la calcemia, el calcio iónico, el fósforo y la calciuria de 24 horas, no encontramos cambios significativos en el resto de las variables bioquímicas. Tampoco encontramos diferencias en los valores densitométricos, la presencia de osteopenia u osteoporosis y el número de fracturas entre ambos tipos de HPP. Sí hubo una diferencia significativa en la presencia de litiasis renal entre el HPP normocalcémico (11.4%) vs el HPP clásico (49.1%), p < 0.0005, en parte vinculada a la presencia de hipercalciuria en el HPP clásico. Dos de los 35 pacientes con HPP normocalcémico evolucionaron al HPP hipercalcémico durante un seguimiento de 4 años. Nuestros resultados apoyan la hipótesis que el HPP normocalcémico podría ser una forma temprana del HPP clásico, teniendo ambos similares repercusiones clínicas a nivel renal y óseo.

This report shows our conclusions on the clinical, biochemical and densitometry characteristics of 35 normocalcemic primary hyperparathyroidism (PHPT) patients. This condition is defined by a high level of intact parathyroid hormone (iPTHI) with persistently normal serum and ionized calcium in the absence of secondary hyperparathyroidism. Our selection consisted of 30 women (90%) and 5 men (10%). The control group of 55 hypercalcemic patients with primary hyperparathyroidism included 51 women (93%) and 4 men (7%). The average age at diagnosis of normocalcemic PHPT was 61.4 ± 11.7 years and 56.4 ± 11.3 years in hypercalcemic PHPT. Besides the expected differences in serum calcium, ionized calcium, phosphorus and 24 h urinary calcium, we found no significant changes in other biochemical variables, and no differences in densitometry evaluations such as the presence of osteopenia or osteoporosis and the number of fractures in the two types of PHPT. But there was a significant difference in the presence of renal lithiasis between normocalcemic PHPT (11.4%) and clasic PHPT (49.1%) p < 0.0005, to some extent associated to the presence of hypercalciuria in classic PHPT. Two of the 35 patients with normocalcemic PHPT became classic hypercalcemic PHPT over a 4 year follow-up period. Our findings support the hypothesis that the normocalcemic PHPT could be an early stage of the classic PHPT, both having similar clinical effects to metabolic renal and bone levels.

Caso atípico de osteoporosis idiopática juvenil / Atypical case of juvenile idiopathic osteoporosis

La osteoporosis idiopática juvenil es una enfermedad que aparece en niños y adolescentes, autolimitada, caracterizada por osteoporosis axial y de extremidades, en ocasiones asociada a colapso vertebral, lo que resulta finalmente en cifosis torácica. No se tiene conocimiento, hasta la fecha, de su asociación a alteraciones de la dentición. Se presenta el caso de un adolescente masculino, con historia de retraso en el cambio a la dentición permanente y osteopenia, valorado por varias especialidades médicas como: Medicina Interna, Estomatología, Ortopedia, Endocrinología y Nefrología. Se plantea el diagnóstico de osteoporosis idiopática juvenil, y se descartan, a partir del cuadro sintomatológico y los numerosos complementarios realizados, varias enfermedades hereditarias y adquiridas, entre ellas, la osteogénesis imperfecta tardía y el hiperparatiroidismo. Se destacan en este caso la presencia de alteraciones en la dentición y la poca afectación vertebral

Juvenile idiopathic osteoporosis is a disease seen in children and adolescents, it is self-limited, characterized by axial and limb osteoporosis, occasionally related to vertebral collapse, which finally resulted in thoracic kyphosis. To date, the association between this disease and dental impairments is not known. Here is the case of a male adolescent, with history of delayed change to permanent dentition and osteopenia; he was evaluated by several medical specialists as internal medicine, odontology, orthopedics, endocrinology and nephrology. He was diagnosed as juvenile idiopathic osteoporosis case, and on the basis of the symptom picture and the numerous supplementary tests, it was possible to rule out several hereditary and acquired illnesses such as late imperfect osteogenesis and hyperparathyroidism. This case stressed the presence of dentition impairments and little vertebral effect

Defeito osteoporótico focal do adulto: conceito, diagnóstico e os implantes osseointegráveis / Focal osteoporotic bone marrow defect: concept, diagnosis and osseointegrated implants

O Defeito Osteoporótico Focal do Adulto deve constar na lista de diagnósticos diferenciais de lesões radiolúcidas uni e multiloculares, especialmente as mandibulares, pequenas e médias. O diagnóstico clínico e imaginológico pode ser seguro, mas, se houver uma dúvida mínima, deve-se providenciar biópsia e o laudo revelará um tecido medular hematopoieticamente ativo. O Defeito Osteoporótico Focal do Adulto não inviabiliza os implantes osseointegráveis na região, pois biologicamente não impede o reparo ósseo, e até pode favorecê-lo, pela medula óssea ter numerosas células-tronco e ser rica em células osteoprogenitoras. O diagnóstico deve ser seguro para diferenciá-lo de outras lesões semelhantes na mandíbula, mas agressivas. As principais características do Defeito Osteoporótico Focal do Adulto são ressaltadas neste trabalho, considerando-o uma variável do trabeculado ósseo e medular em um contexto de normalidade

Focal osteoporotic defects in adult patients must be on the list of differential diagnosis of small and medium uni and multiocular radiolucent lesions, especially in the mandible. Clinical and imaginologic diagnoses are safe, however, a biopsy must be performed in case of doubt, in which case the report will include hematopoietically active medullary tissue. Focal osteoporotic defects in adult patients does not hinder osseointegrated implant placement because, biologically speaking, it does not hamper bone repair. In fact, it may even favor it as a result of the large number of stem and osteoprogenitor cells comprising the bone marrow. Safe diagnosis is essential to differentiate focal osteoporotic defects from more severe lesions also found in the mandible. Focal osteoporotic defects in adult patients is considered a variation of normal bone and medullary trabecula, and its main characteristics are highlight herein

Diagnostic and screening utility of biochemical markers for osteoporosis and osteopenia in Saudi women

Postmenopausal osteoporosis is a major health problem worldwide and in Saudi Arabia as it leads to bone fragility and increased liability for fragile fractures, particularly in neck of femur and vertebrae. The present study was designed to determine the value of different screening tests to find out the most sensitive serum and urinary markers of osteoporosis among Saudi women and to clarify the relationship between E[2] deficiency and these markers in peri-menopause, early or postmenopausal women without hormonal replacement therapy. This study included 37 Saudi women aged 40 to 60 years. They were categorized into 3 groups according to their bone mineral density [BMD]: Group I: 15 Normal control [T-score up to -1.5], Group II: 12 Osteopenic women [T-score between -1.5 to 2.5]and Group III:10 Osteoporotic women [T-score below 2.5]. For all subjects, dual energy X-ray absorptiometry [DEXA] was performed. Osteocalcin [OC], alkaline phosphatase [ALP], free galactosyl hydroxylysine [Gal-Hyl], calcium [Ca], inorganic phosphorus [P] and estradiol [E[2]] were measured in serum, whereas, deoxypyridinoline [Dpd] and creatinine levels were measured in urine. Simultaneously both osteopenic and osteoporotic groups showed significant decreases in BMD when compared to the controls. Osteocalcin, ALP and Gal-Hyl showed significant increase [p<0.0001] among the osteopenic and osteoporotic groups versus the control group. Significant decrease in E[2] levels were obvious among the osteopenic [p<0.0001] and osteoporotic [p<0.0001] women when judged against the controls. Urinary Dpd was significantly increased in the osteopenic and osteoporotic groups [p<0.001]. In osteoporotic group, significant negative correlations were observed between OC and BMD. Positive correlations were detected among the osteoporotic group between OC and ALP and between OC and Gal-Hyl. High significant negative correlations were confirmed between E[2] and OC among both the osteopenic and the osteoporotic groups. Also, a significant negative correlation was established between E[2] and Dpd in the osteoporotic group. In comparing between osteopenic and osteoporotic groups, significant decrease was recognized in BMD and significant increase was predicted regarding ALP, [p<0.05], Gal-Hyl [p<0.0001] and Dpd [p< 0.001]. Urinary Dpd may be a simple indicator for osteoporosis in postmenopausal women; however, screening should include the measurement of serum estradiol, galactosyl hydroxylysine, alkaline phosphatase and Osteocalcin to increase the sensitivity and specificity of primary screening to identify the groups at higher risk of osteoporosis which is the keystone in prevention of disabling fragility fractures