Argentine Guidelines for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Postmenopausal Women and Men Aged 50 Years and Older.

OBJECTIVE: The aim of this study was to provide an evidence-based framework to guide health care professionals treating patients under glucocorticoid (GC) therapy and develop guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis (GIO) in postmenopausal women and men aged ≥50 years. METHODS: An expert panel on bone diseases designed a series of clinically meaningful questions following the PICO (Population, Intervention, Comparator, and Outcome) structure. Using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology, we made a systematic literature review, extracted and summarized the effect estimates, and graded the quality of the evidence. The expert panel voted each PICO question and made recommendations after reaching an agreement of at least 70%. RESULTS: Seventeen recommendations (9 strong and 8 conditional) and 8 general principles were developed for postmenopausal women and men aged ≥50 years under GC treatment. Bone mineral density (BMD), occurrence of fragility fractures, probability of fracture at 10 years by Fracture Risk Assessment Tool, and other screening factors for low BMD are recommended for patient evaluation and stratification according to fragility fracture risk. The treatment of patients under GC therapy should include counseling on lifestyle habits and strict control of comorbidities. The goal of GIO treatment is the nonoccurrence of new fragility fractures as well as to increase or maintain BMD in certain clinical situations. This was considered for the therapeutic approach in different clinical scenarios. CONCLUSIONS: This GIO guideline provides evidence-based guidance for health care providers treating patients.

Metabolic risk factors in children with asymptomatic hematuria.

BACKGROUND: Idiopathic or benign hematuria is diagnosed in children after all other possible causes have been ruled out and test results for renal or urologic pathologies are negative. METHODS: To identify possible urinary risk factors for hematuria in children, we retrospectively evaluated clinical onset, family history, and metabolic risk factors of 60 children with idiopathic hematuria but without renal stones or other pathologic conditions that could explain the hematuria. All patients followed the same ambulatory protocol at that used to evaluate kidney stone-formers. RESULTS: Seven patients had microhematuria, three patients each had microhematuria and gross hematuria, and the remaining 50 patients had gross hematuria onset. A family history of stone disease was found in 63 % of the children. At least one urinary metabolic abnormality was present in 49 patients, while 11 patients had no metabolic abnormality. The most common urinary risk factor was idiopathic hypercalciuria (single or associated), which was found in 43.5 % of patients, followed by hypocitraturia (single or associated), present in 31.7 %. Unduly acidic urine pH as a single abnormality was found in 10 % of this pediatric patient population. We also found hyperoxaluria and, less frequently, hypomagnesuria, and hyperuricosuria. CONCLUSIONS: Asymptomatic idiopathic hematuria in pediatric patients may often be associated to different urinary biochemical abnormalities, similar to what is observed in pediatric kidney stone-formers.

Kidney stones: Composition, frequency and relation to metabolic diagnosis.

Nephrolithiasis is one of the most frequent urologic diseases. The aim of this paper is to study the composition and frequency of 8854 patient kidney stones and in a subset of them their metabolic risk factors to be related to their type of calculi. Physicochemical and crystallographic methods were used to assess kidney stone composition. In a subset of 715 patients, we performed an ambulatory metabolic protocol with diagnostic purposes. From the total sample 79% of stones were made of calcium salts (oxalate and phosphate), followed by uric acid stones in 16.5%, calcium salts and uric acid in 2%, other salts in 1.9% and cystine in 0.6%. Male to female ratio was almost three times higher in calcium salts and other types of stones, reaching a marked male predominance in uric acid stones, M/F 18.8 /1.0. The major risk factors for calcium stones are idiopathic hypercalciuria, followed by unduly acidic urine pH and hyperuricosuria. In uric acid stones unduly acidic urine pH and less commonly hyperuricosuria are the most frequent biochemical diagnosis. Our results show that analysis of kidney stones composition and the corresponding metabolic diagnosis may provide a scientific basis for the best management and prevention of kidney stone formation, as well as it may help us to study the mechanisms of urine stone formation.

[Severe osteoporosis treatment with teriparatide]. / Tratamiento de la osteoporosis grave con teriparatide.

The primary objective of this retrospective study was to evaluate the treatment of severe osteoporosis with teriparatide (PTH) and to compare our results with those published in the literature. We included 46 patients, 42 women and four men, mean age: 69.15 ± 9.43 years. Six patients were treatment naive and forty previously treated with bisphosphonates. Thirty-two patients had had 93 fractures of which 86 vertebral. Forty-six received PTH for 6 months, twenty-nine for 12 months and twenty completed the 18 months suggested. Bone mineral density (BMD) of the lumbar spine increased significantly at the first control performed at six months of treatment (p < 0.0001), and the femoral neck BMD reached a significant increase at the end of treatment (p = 0.002). Serum osteocalcin values significantly increased from the first month of treatment, followed by Β crosslaps (beta-CTx, serum test) and bone-specific alkaline phosphatase, returning all the markers of bone turnover to baseline levels at 18 months. Serum and urinary calcium did not change significantly at any time, but 8 (17.9%) patients developed mild hypercalcemia and 3 (6.5%) asymptomatic hypercalciuria. The treatment was well tolerated and there were no serious adverse events requiring discontinuation. In conclusion, PTH is a safe and useful alternative for the treatment of primary severe osteoporosis. Our results agree with those previously reported in the literature.

[Guidelines for the diagnosis, prevention and treatment of osteoporosis, 2012]. / Guías 2012 para el diagnóstico, la prevención y el tratamiento de la osteoporosis.

Osteoporosis is a constantly growing disease which affects over 200 million people worldwide. The present recommendations are guidelines for its diagnosis, prevention and treatment, but they do not constitute standards for clinical decisions in individual patients. The physician must adapt them to individual patients and special situations, incorporating personal factors that transcend the limits of these guidelines and are dependent on the knowledge and art of the physician. These guidelines should be reviewed and updated periodically as new, better and more effective diagnostic and therapeutic tools become available.

Clinical features, diagnostic evaluation and responses to treatment in Paget's disease of bone in a center specialized in bone metabolism.

The epidemiology of Paget's disease of bone (PDB) has changed in the last years but there is no update data on its clinical presentation, diagnosis and management in Latin America. Our aim was to describe its clinical features, diagnostic evaluation and responses to treatment in a group of PDB patients treated between June 2012 and December 2019 in an institution specialized in bone diseases, in Buenos Aires, Argentina. The frequency of PDB (180/10 714) was 1.68%. Median age was 67 (range 39-97) years and 59.5% were women. Most patients were asymptomatic (58.6%) and had monostotic disease (54.3%). Favorable responses were obtained in all patients who were treated with zoledronate (n = 36), in 10 out of 14 treated with pamidronate, in 9 out of 10 who received intravenous ibandronate and in 12 out of 13 who received oral bisphosphonates. The response rates were not significantly different when we compared monostotic vs. polyostotic disease. Among the biochemical parameters, mean values of bone specific and total alkaline phosphatase, and C-terminal crosslinked telopeptide of type I collagen decreased significantly after treatment with bisphosphonates. It seems that our results reflect the change in PDB epidemiology towards a more indolent disease. In the future, this would probably allow physicians to use lower doses of bisphosphonates than the ones historically recommended for these patients.

La epidemiología de la enfermedad de Paget ósea (EPO) ha cambiado en los últimos años. Son necesarios datos actualizados sobre su forma de presentación clínica, diagnóstico y tratamiento en nuestra región. Nuestro objetivo fue describir las características clínicas, evaluación diagnóstica y respuestas al tratamiento de un grupo de pacientes con EPO en un centro especializado en salud ósea de Buenos Aires, Argentina. Se evaluaron todos los pacientes que fueron atendidos en nuestra institución por enfermedades óseas entre junio de 2012 y diciembre de 2019. La frecuencia de EPO (180/10 714) fue de 1.68%. La mediana de edad fue de 67 (rango 39-97) años. El 59.5% eran mujeres. La mayoría se encontraba asintomático (58.6%) y tenían enfermedad monostótica (54.3%). Se objetivaron respuestas favorables en todos los que recibieron zoledronato (n = 36), en 10 de 14 pacientes que recibieron pamidronato, en 9 de 10 que utilizaron ibandronato endovenoso y en 12 de 13 con bifosfonatos orales. Los porcentajes de respuesta no variaron significativamente entre pacientes con formas monostóticas y poliostóticas. Entre los parámetros bioquímicos, los valores de fosfatasa alcalina total y ósea y de Β cross-laps disminuyeron significativamente luego del tratamiento con bifosfonatos. Nuestros resultados reflejarían un cambio en la epidemiología de la EPO hacia una forma de presentación más indolente. Esto permitiría probablemente el uso de dosis más bajas de bifosfonatos que las históricamente recomendadas para estos pacientes.

The Brief Esophageal Dysphagia Questionnaire shows better discriminative capacity for clinical and manometric findings than the Eckardt score: Results from a multicenter study.

INTRODUCTION: Grading dysphagia is crucial for clinical management of patients. The Eckardt score (ES) is the most commonly used for this purpose. We aimed to compare the ES with the recently developed Brief Esophageal Dysphagia Questionnaire (BEDQ) in terms of their correlation and discriminative capacity for clinical and manometric findings and evaluate the effect of gastroesophageal reflux symptoms on both. METHODS: Symptomatic patients referred for high-resolution manometry (HRM) were prospectively recruited from seven centers in Spain and Latin America. Clinical data and several scores (ES, BEDQ, GERDQ) were collected and contrasted to HRM findings. Standard statistical analysis was performed. KEY RESULTS: 426 patients were recruited, 31.2% and 41.5% being referred exclusively for dysphagia and GERD symptoms, respectively. Both BEDQ and ES were independently associated with achalasia. Only BEDQ was independently associated with being referred for dysphagia and with relevant HRM findings. ROC curve analysis for achalasia diagnosis showed AUC of 0.809 for BEDQ and 0.765 for ES, with the main difference being higher BEDQ sensitivity (80.0% vs 70.8% for ES). GERDQ independently predicted ES but not BEDQ. In the absence of dysphagia (BEDQ = 0), GERD symptoms significantly determine ES. CONCLUSIONS AND INFERENCES: Our study suggests both the BEDQ and ES can complementarily describe symptomatic burden in achalasia. BEDQ has several advantages over the ES in the dysphagia evaluation, basically due to its higher sensitivity for manometric diagnosis and independence of GERD symptoms. ES should be used as an achalasia-specific metric, while BEDQ is a better symptom-generic evaluating tool.

Alliance for the development of the Argentinian Hip Fracture Registry.

Age expectancy has significantly increased over the last 50 years, as well as some age-related health conditions such as hip fractures. The development of hip fracture registries has shown enhanced patient outcomes through quality improvement strategies. The development of the Argentinian Hip Fracture Registry is going in the same direction. INTRODUCTION: Age expectancy has increased worldwide in the last 50 years, with the population over 64 growing from 4.9 to 9.1%. As fractures are an important problem in this age group, specific approaches such as hip fracture registries (HFR) are needed. Our aim is to communicate the Argentinian HFR (AHFR) development resulting from an alliance between Fundación Trauma, Fundación Navarro Viola, and the Argentinian Network of Hip Fracture in the elderly. METHODS: Between October 2020 and May 2021, an iterative consensus process involving 5 specialty-focused meetings and 8 general meetings with more than 20 specialists was conducted. This process comprised inclusion criteria definitions, dataset proposals, website deployment with data protection and user validation, the definition of hospital-adjusted registry levels, implementation planning, and sustainability strategies. RESULTS: By June 2021, we were able to (1) outline data fields, including epidemiological, clinical, and functional dimensions for the pre-admission, hospitalization, discharge, and follow-up stages; (2) define three levels: basic (53 fields), intermediate (85), and advanced (99); (3) identify 21 benchmarking indicators; and (4) make a correlation scheme among fracture classifications. Simultaneously, we launched a fundraising campaign to implement the AHFR in 30 centers, having completed 18. CONCLUSION: AHFR development was based on four pillars: (1) representativeness and support, (2) solid definitions from onset, (3) committed teams, and (4) stable funding. This tool may contribute to the design of evidence-based health policies to improve patient outcomes, and we hope this experience will help other LMICs to develop their own tailored-to-their-needs registries.

Postmenopausal women with sarcopenia have higher prevalence of falls and vertebral fractures.

Recently, a new consensus of the European Working Group on Sarcopenia in Older People (EWSOP2) recommended new cut-off points for the diagnosis of sarcopenia. The aim of the present manuscript was to assess the prevalence of sarcopenia in postmenopausal women and its relationship with bone mineral density, falls and fragility fractures according to EWGSOP2. In this cross-sectional study, 250 ambulatory postmenopausal women over 60 years of age were included. Lumbar spine and hip bone mineral density (BMD) and whole-body composition were assessed by dual-energy X-ray absorptiometry (DXA). Muscle strength was evaluated by handgrip dynamometry and physical performance by a 4-m walk gait speed and five-repetition sit-to-stand test. Sarcopenia was defined according to EWGSOP2 as low muscle strength (handgrip) and low muscle mass (appendicular skeletal muscle mass index by DXA). A sarcopenia prevalence of 4% was found in the whole group increasing with age being 12.5% in = 80- year-old. A higher percentage of falls, prevalence of osteoporosis and vertebral fractures were found in the sarcopenic group. Sarcopenia increased 6.0-fold the likelihood of having a fragility fracture. Women with sarcopenia had significantly lower femoral neck BMD and higher frequency of falls and vertebral fractures. According to our results, identifying patients with sarcopenia might be a useful tool to detect adults at higher risk of falls and fractures.

Recientemente el grupo de trabajo europeo sobre sarcopenia en adultos mayores (EWGSOP2) recomendó nuevos criterios y valores de referencia para el diagnóstico de sarcopenia. El objetivo del presente trabajo fue evaluar la prevalencia de sarcopenia en mujeres postmenopáusicas en nuestro medio y su relación con densidad mineral ósea, caídas y fracturas por fragilidad. Este es un estudio de diseño transversal en el cual se incluyeron un total de 250 mujeres ambulatorias mayores de 60 años. La densidad mineral ósea (DMO) de columna lumbar y cadera y la composición corporal fueron evaluados por absorciometría dual de rayos X (DXA). La fuerza fue evaluada por dinamometría de puño; para el rendimiento físico se utilizó caminata de 4 m y la prueba de levantarse y sentarse de una silla (5 repeticiones). La sarcopenia se definió de acuerdo a EWGSOP2 como baja fuerza muscular (dinamometría) y baja masa muscular (índice de masa muscular esquelética por DXA). El 4% de las mujeres cumplía con los criterios de sarcopenia siendo aún mayor en aquellas = 80 años. Las mujeres con sarcopenia presentaron significativamente mayor frecuencia de caídas, osteoporosis y fracturas vertebrales. El riesgo de fracturas por fragilidad se vio incrementado 6 veces en las mujeres con sarcopenia. El diagnóstico de sarcopenia podría considerarse una herramienta útil para identificar a aquellos adultos con riesgo incrementado de caídas y fracturas.

Validation and psychometric evaluation of the Spanish version of Brief Esophageal Dysphagia Questionnaire (BEDQ): Results of a multicentric study.

BACKGROUND: The recently developed Brief Esophageal Dysphagia Questionnaire (BEDQ) evaluates esophageal obstructive symptoms. Its initial evaluation showed strong psychometric properties. The aims of this study were to (a) translate and validate an international Spanish version of BEDQ and (b) evaluate its psychometric properties in a large Hispano-American sample of symptomatic individuals. METHODS: A Spanish BEDQ version was performed by Hispano-American experts using a Delphi process and reverse translation. Patients were prospectively recruited from seven centers in Spain and Latin America among individuals referred for high-resolution manometry (HRM). Patients completed several scores: Hospital Anxiety & Depression Scale (HADS), Eckardt score (ES), Gastroesophageal Reflux Questionnaire (GERDQ), and the BEDQ. Standardized psychometric analyses were performed. KEY RESULTS: A total of 426 patients were recruited. Spanish BEDQ showed excellent reliability (Cronbach's alpha = 0.91). Factor analysis confirmed its unidimensional character. Moderate significant correlations between BEDQ and other symptomatic scores were found, suggesting sufficient convergent validity. Patients with abnormal or obstructive HRM findings scored significantly higher when compared to normal or non-obstructive findings, respectively. Using a cutoff of 10, BEDQ showed a sensitivity of 65.38% and a specificity of 66.21% and an area under the curve of 0.71 for obstructive or major manometric diagnosis. CONCLUSIONS AND INFERENCES: A widely usable Spanish BEDQ version has been validated. We confirm its excellent psychometric properties in our patients, confirming the appropriateness of its use in different populations.

The Spanish version of the esophageal hypervigilance and anxiety score shows strong psychometric properties: Results of a large prospective multicenter study in Spain and Latin America.

BACKGROUND: Anxiety is a significant modulator of sensitivity along the GI tract. The recently described Esophageal Hypervigilance and Anxiety Score (EHAS) evaluates esophageal-specific anxiety. The aims of this study were as follows: 1. translate and validate an international Spanish version of EHAS. 2. Evaluate its psychometric properties in a large Hispano-American sample of symptomatic individuals. METHODS: A Spanish EHAS version was developed by a Delphi process and reverse translation. Patients referred for high-resolution manometry (HRM) were recruited prospectively from seven Spanish and Latin American centers. Several scores were used: EHAS, Hospital Anxiety and Depression Scale (HADS), Eckardt score (ES), Gastroesophageal Reflux Questionnaire (GERDQ), and the Brief Esophageal Dysphagia Questionnaire (BEDQ). Standardized psychometric analyses were performed. KEY RESULTS: A total of 443 patients were recruited. Spanish EHAS showed excellent reliability (Cronbach´s alpha = 0.94). Factor analysis confirmed the presence of two factors, corresponding to the visceral anxiety and hypervigilance subscales. Sufficient convergent validity was shown by moderate significant correlations between EHAS and other symptomatic scores. Patients with high EHAS scores had significantly more dysphagia. There was no difference in EHAS scores when compared normal vs abnormal or major manometric diagnosis. CONCLUSIONS AND INFERENCES: A widely usable Spanish EHAS version has been validated. We confirm its excellent psychometric properties in our patients, confirming the appropriateness of its use in different populations. Our findings support the appropriateness of evaluating esophageal anxiety across the whole manometric diagnosis spectrum.

Unsuspected polymicrobial brain abscess arising from an intra-abdominal source in a patient with hereditary hemorrhagic telangiectasia.

The unusual and unprecedented occurrence of a patient with hereditary hemorrhagic telangiectasia (HHT) and a polymicrobial abscess with three different organisms, including fungi, is reported. The patient was a 48-year-old woman with human immunodeficiency virus (HIV) infection and HHT who was brought to the hospital after a motor vehicle accident with altered mental status. Computed tomography did not reveal evidence of acute brain injury but showed a left frontal brain abscess. The patient underwent neurosurgical drainage of the abscess. On culture the abscess yielded methicillin-resistant Staphylococcus aureus, Streptococcus intermedius, and Candida guilliermondii.

Clinical features, diagnostic evaluation and responses to treatment in Paget's disease of bone in a center specialized in bone metabolism / Características clínicas, evaluación diagnóstica y respuestas al tratamiento de la enfermedad de Paget ósea en un centro especializado en metabolismo óseo

Abstract The epidemiology of Paget's disease of bone (PDB) has changed in the last years but there is no update data on its clinical presentation, diagnosis and management in Latin America. Our aim was to describe its clinical features, diagnostic evaluation and responses to treatment in a group of PDB patients treated between June 2012 and December 2019 in an institution specialized in bone diseases, in Buenos Aires, Argentina. The frequency of PDB (180/10 714) was 1.68%. Median age was 67 (range 39-97) years and 59.5% were women. Most patients were asymptomatic (58.6%) and had monostotic disease (54.3%). Favorable responses were obtained in all patients who were treated with zoledronate (n = 36), in 10 out of 14 treated with pamidronate, in 9 out of 10 who received intravenous ibandronate and in 12 out of 13 who received oral bisphosphonates. The response rates were not significantly different when we compared monostotic vs. polyostotic disease. Among the biochemical parameters, mean values of bone specific and total alkaline phosphatase, and C-terminal cross-linked telopeptide of type I collagen decreased significantly after treatment with bisphosphonates. It seems that our results reflect the change in PDB epidemiology towards a more indolent disease. In the future, this would probably allow physicians to use lower doses of bisphosphonates than the ones historically recommended for these patients.

Resumen La epidemiología de la en fermedad de Paget ósea (EPO) ha cambiado en los últimos años. Son necesarios datos actualizados sobre su forma de presentación clínica, diagnóstico y tratamiento en nuestra región. Nuestro objetivo fue describir las características clínicas, evaluación diagnóstica y respuestas al tratamiento de un grupo de pacientes con EPO en un centro especializado en salud ósea de Buenos Aires, Argentina. Se evaluaron todos los pacientes que fueron atendidos en nuestra institución por enfermedades óseas entre junio de 2012 y diciembre de 2019. La frecuencia de EPO (180/10 714) fue de 1.68%. La mediana de edad fue de 67 (rango 39-97) años. El 59.5% eran mujeres. La mayoría se encontraba asintomático (58.6%) y tenían enfermedad monostótica (54.3%). Se objetivaron respuestas favorables en todos los que recibieron zoledronato (n = 36), en 10 de 14 pacientes que recibieron pamidronato, en 9 de 10 que utilizaron ibandronato endovenoso y en 12 de 13 con bifosfonatos orales. Los porcentajes de respuesta no variaron significativamente entre pacientes con formas monostóticas y poliostóticas. Entre los parámetros bioquímicos, los valores de fosfatasa alcalina total y ósea y de β cross-laps disminuyeron significativamente luego del tratamiento con bifosfonatos. Nuestros resultados reflejarían un cambio en la epidemiología de la EPO hacia una forma de presentación más indolente. Esto permitiría probablemente el uso de dosis más bajas de bifosfonatos que las históricamente recomendadas para estos pacientes.

Pulmonary Cryptococcosis in the Immunocompetent Patient-Many Questions, Some Answers.

Background. There are no prospective data regarding the management of pulmonary cryptococcosis in the immunocompetent patient. Clinical guidelines recommend oral fluconazole for patients with mild to moderate symptoms and amphotericin B plus flucytosine followed by fluconazole for severe disease. It is unclear whether patients who have histological evidence of Cryptococcus neoformans but negative cultures will even respond to drug treatment. We evaluated and managed a patient whose presentation and course raised important questions regarding the significance of negative cultures, antifungal choices, duration of therapy, and resolution of clinical, serologic, and radiographic findings. Methods. In addition to our experience, to answer these questions we reviewed available case reports and case series regarding immunocompetent patients with pulmonary cryptococcosis for the last 55 years using the following definitions: Definite - Clinical and/or radiographic findings of pulmonary infection and respiratory tract isolation of C. neoformans without other suspected etiologies; Probable - Clinical and radiographic findings of pulmonary infection, histopathologic evidence of C. neoformans, and negative fungal cultures with or without a positive cryptococcal polysaccharide antigen. Results. Pulmonary cryptococcosis resolves in most patients with or without specific antifungal therapy. Clinical, radiographic, and serologic resolution is slow and may take years. Conclusions. Persistently positive antigen titers are most common in untreated patients and may remain strongly positive despite complete or partial resolution of disease. Respiratory fungal cultures are often negative and may indicate nonviable organisms.

Postmenopausal women with sarcopenia have higher prevalence of falls and vertebral fractures / Las mujeres postmenopáusicas con sarcopenia tienen mayor prevalencia de caídas y fracturas vertebrales

Abstract Recently, a new consensus of the European Working Group on Sarcopenia in Older People (EWSOP2) recommended new cut-off points for the diagnosis of sarcopenia. The aim of the present manuscript was to assess the prevalence of sarcopenia in postmenopausal women and its relationship with bone mineral density, falls and fragility fractures according to EWGSOP2. In this cross-sectional study, 250 ambulatory postmenopausal women over 60 years of age were included. Lumbar spine and hip bone mineral density (BMD) and whole-body composition were assessed by dual-energy X-ray absorptiometry (DXA). Muscle strength was evaluated by handgrip dynamometry and physical performance by a 4-m walk gait speed and five-repetition sit-to-stand test. Sarcopenia was defined according to EWGSOP2 as low muscle strength (handgrip) and low muscle mass (appendicular skeletal muscle mass index by DXA). A sarcopenia prevalence of 4% was found in the whole group increasing with age being 12.5% in ≥ 80year-old. A higher percentage of falls, prevalence of osteoporosis and vertebral fractures were found in the sarcopenic group. Sarcopenia increased 6.0-fold the likelihood of having a fragility fracture. Women with sarcopenia had significantly lower femoral neck BMD and higher frequency of falls and vertebral fractures. According to our results, identifying patients with sarcopenia might be a useful tool to detect adults at higher risk of falls and fractures.

Resumen Recientemente el grupo de trabajo europeo sobre sarcopenia en adultos mayores (EWGSOP2) recomendó nuevos criterios y valores de referencia para el diagnóstico de sarcopenia. El objetivo del presente trabajo fue evaluar la prevalencia de sarcopenia en mujeres postmenopáusicas en nuestro medio y su relación con densidad mineral ósea, caídas y fracturas por fragilidad. Este es un estudio de diseño transversal en el cual se incluyeron un total de 250 mujeres ambulatorias mayores de 60 años. La densidad mineral ósea (DMO) de columna lumbar y cadera y la composición corporal fueron evaluados por absorciometría dual de rayos X (DXA). La fuerza fue evaluada por dinamometría de puño; para el rendimiento físico se utilizó caminata de 4 m y la prueba de levantarse y sentarse de una silla (5 repeticiones). La sarcopenia se definió de acuerdo a EWGSOP2 como baja fuerza muscular (dinamometría) y baja masa muscular (índice de masa muscular esquelética por DXA). El 4% de las mujeres cumplía con los criterios de sarcopenia siendo aún mayor en aquellas ≥ 80 años. Las mujeres con sarcopenia presentaron significativamente mayor frecuencia de caídas, osteoporosis y fracturas vertebrales. El riesgo de fracturas por fragilidad se vio incrementado 6 veces en las mujeres con sarcopenia. El diagnóstico de sarcopenia podría considerarse una herramienta útil para identificar a aquellos adultos con riesgo incrementado de caídas y fracturas.

[Osteoporosis during pregnancy and lactation. Report of eight cases]. / Osteoporosis del embarazo y la lactancia. Estudio de 8 casos.

Both generalized and regional osteoporosis exceptionally occur during pregnancy and lactation. The aim of this paper is to show our experience in the diagnosis and treatment of these diseases. From 1984 to 2004 six lactating women with osteoporosis and two with regional osteoporosis consulted us. In the former group, three patients had vertebral fractures and the others experienced substantial demineralization detected by dual-energy X-ray absorptiometry (DXA). In all cases, symptoms began during the third trimester of pregnancy or immediately after delivery. Five of them were primiparous and one was multiparous with a long period of lactation. Risk factors were: low calcium intake, low weight, family history of osteoporosis, amenorrhea, cigarette consumption and corticosteroid therapy. Laboratory tests evidenced increased bone turnover. DXA scan showed substantial demineralization, particularly in axial skeleton. Lactation was interrupted in all women and four received anti-resorptive drugs, one estrogen and only calcium plus vitamin D the remaining. All of them, but one, evolved successfully. The women affected by regional osteoporosis complained of unilateral pain and progressive functional limitation of right foot and left hip respectively. Reduced bone mineral density at symptomatic sites was seen by DXA. Diagnosis was confirmed by typical magnetic resonance imaging pattern. Both patients cured with rest and bisphosfonates treatment.

[Osteoporosis during pregnancy and lactation]. / Osteoporosis del embarazo y la lactancia.

During pregnancy and lactation women have to form and maintain fetus and newborn skeleton. These processes require maternal hormonal and metabolic adjustments. During the first weeks of pregnancy, calcium intestinal absorption rise and reach a maximum in the last trimester. Hypercalciuria can be detected until lactation is stopped. During lactation, calcium that is present in maternal milk, results from lowering maternal calcium excretion and increasing bone resorption. Plasma 1,25 (OH)(2) D(3) levels increase two-fold early in pregnancy due to high placental 1-alpha-hydroxilase activity, remain high until delivery and decline to normal values during lactation. Estrogen, prolactin and placental lactogen, which are involved in calcium absorption, increase at the same time. Normal or even low levels of parathyroid hormone (PTH) can be detected during pregnancy. This suggests that their physiological actions could be mimicked by the parathyroid- related-peptide (PTHrP), which increases in late stages of pregnancy and remain high during delivery and lactation. Calcitonin levels increase during pregnancy, decline during lactation and return to normal values after lactation is stopped. The physiological roll of tumor necrosis factor, interleukin 6 and osteoprotegerin has not been elucidated yet. The above mentioned changes can exceptionally lead to generalized or regional osteoporosis. The aim of this article is to review the published bibliography concerning the physiopathology of these diseases.

Biochemical diagnosis in 3040 kidney stone formers in Argentina.

Nephrolithiasis is a frequent condition in urology that has an important recurrence and high impact in health economy. Knowing the biochemical abnormalities implicated in its pathogenesis is mandatory to establish therapeutic aims. Our objectives are to present the results in 3040 kidney stone formers in Argentina. All patients were selected after completing an ambulatory metabolic protocol with diagnostic purposes. There were 1717 men, (56.48%), with a mean age of 45±12 years, and 1323 women, (43.52%), mean age 44±12 years. 2781 patients had biochemical abnormalities, (91.49%), and were arbitrarily divided in two groups: those who had only one (single) biochemical abnormality (n=2156) and those who had associated abnormalities (n=625). No biochemical abnormalities were found in 259 patients (8.51%). The abnormalities present, single and associated, in order of frequency, were idiopathic hypercalciuria, (56.88%), hyperuricosuria (21.08%), unduly acidic urine (10.95%), hypocitraturia (10.55%), hypomagnesuria (7.9%), primary hyperparathyroidism (3.01%), hyperoxaluria (2.6%), and cystinuria (0.32%). We performed in 484 patient's stone composition and found calcium oxalate stones related to idiopathic hypercalciuria predominantly while uric acid stones to unduly acidic urine. In conclusion, the biochemical abnormalities described are similar to those found in a previous series of our own and to those reported in the literature. Its diagnosis is important to therapeutic purposes to avoid eventual recurrence.

Coagulase-negative staphylococcal bloodstream infections: Does vancomycin remain appropriate empiric therapy?

OBJECTIVES: It is unknown if vancomycin minimal inhibitory concentrations (MICs) have increased in coagulase-negative staphylococci (CoNS) or whether vancomycin remains appropriate empiric therapy. METHODS: We performed a retrospective study at a single tertiary care center over 8 years. Adult inpatients with ≥2 positive blood cultures for CoNS within a 48-h period were eligible. Susceptibilities were performed by automated broth based-microdilution. Changes in antimicrobial susceptibility were analyzed using logistic regression. The clinical characteristics and outcomes of patients with bloodstream infections (BSI) were compared by MIC. RESULTS: Of 308 episodes of possible CoNS bacteremia, the vancomycin MIC was ≤1 µg/mL in 80 (26%) isolates, 2 µg/mL in 223 (72.4%) isolates and 4 µg/mL in 5 (1.6%) isolates. No isolates were resistant. We observed an 11-fold increased chance of having an isolate with a vancomycin MIC ≤1 µg/mL in 2009-2011 compared with 2004-2008 (OR 10.8, 95% CI 6.0-19.5, p < 0.05). In 152 patients with BSI, the median days of bacteremia, hospital mortality and readmissions at 30 days were similar in BSI caused by isolates with high vancomycin MICs (2-4 µg/mL) and low vancomycin MICs (≤1 µg/mL). CONCLUSIONS: We conclude vancomycin is still appropriate empiric therapy for CoNS BSIs. CoNS vancomycin MICs decreased over the study period despite widespread use of vancomycin.

Survival time of methicillin-resistant Staphylococcus aureus-free status after institutional clearance.

OBJECTIVE: To determine the durability of methicillin-resistant Staphylococcus aureus (MRSA)-free status after patients are removed from contact precautions and the association of specific clearance policy variables with survival. DESIGN: Retrospective cohort study from October 2007 to April 2013. SETTING: Veteran Affairs Boston Healthcare System. PARTICIPANTS: Patients with a prior history of MRSA who were removed from contact precautions after deemed cleared of their MRSA status by infection prevention. METHODS: Active nasal screening results and clinical data from acute, long-term, and outpatient care facilities were evaluated to determine survival of MRSA-free status in a time-to-event analysis. RESULTS: A total of 351 unique patients were followed for 107,112 patient-days. The median age was 68 years. Overall, 249 (71%) of patients remained MRSA-free, and 102 (29%) reverted to MRSA positive. The median MRSA-free survival was 880 days. Comorbidities, presence of indwelling devices, and the use of systemic antibiotics at the time of clearance screening were not associated with MRSA-free survival. More than 21,000 days of inpatient isolation days were avoided during the study period. CONCLUSIONS: The majority of patients removed from contact precautions remained MRSA-free for more than 2 years. Antibiotic use at the time of clearance was not associated with reductions in MRSA-free survival. These findings can be used to simplify clearance criteria, promote clearance policies, and reduce patient isolation days.