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1.
G Ital Nefrol ; 36(4)2019 Jul 24.
Artigo em Italiano | MEDLINE | ID: mdl-31373465

RESUMO

Osteoporosis affects a segment of the population in which Chronic Kidney Disease is also greatly represented. Nephropathic patients may present peculiar biochemical abnormalities related to Chronic Kidney Disease, defining the Mineral and Bone Disorder. This kind of anomalies, in the worst scenarios, configure the typical histomorphology patterns of Renal Osteodystrophy. Scientific Societies of Endocrinology have established therapy guidelines for patients with osteoporosis only based on the glomerular filtration rate and recommend avoiding the use of some drugs for the more advanced classes of nephropathy. However, there is no clear therapeutic approach for patients with advanced nephropathy and bone abnormalities. In this paper we propose a systematic review of the literature and present our proposal for managing patients with advanced nephropathy, based on eGFR and on presence of Mineral and Bone Disorder.


Assuntos
Conservadores da Densidade Óssea/uso terapêutico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/tratamento farmacológico , Difosfonatos/uso terapêutico , Osteoporose/tratamento farmacológico , Insuficiência Renal Crônica/complicações , Anticorpos Monoclonais/uso terapêutico , Conservadores da Densidade Óssea/efeitos adversos , Conservadores da Densidade Óssea/química , Distúrbio Mineral e Ósseo na Doença Renal Crônica/etiologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/fisiopatologia , Contraindicações , Denosumab/uso terapêutico , Difosfonatos/efeitos adversos , Difosfonatos/química , Feminino , Fraturas Espontâneas/tratamento farmacológico , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/prevenção & controle , Taxa de Filtração Glomerular , Humanos , Masculino , Osteoporose/complicações , Osteoporose/diagnóstico , Proteína Relacionada ao Hormônio Paratireóideo/uso terapêutico , Guias de Prática Clínica como Assunto , Insuficiência Renal Crônica/fisiopatologia , Fatores de Risco , Teriparatida/uso terapêutico
2.
Cardiovasc Intervent Radiol ; 42(12): 1726-1737, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31444627

RESUMO

INTRODUCTION: To evaluate the long-term consolidation of vertebral metastases (VM) after preventive vertebroplasty (PV) and to report risk factors of pathological fracture despite PV. MATERIALS AND METHODS: Files of 100 consecutives cancer patients referred for PV of VM were retrospectively analyzed. We enumerated 215 VM at the time of the PV procedure (T0): 138 VM were considered at risk of pathological fracture and had PV (treated-VM), and 77 VM were not cemented. We compared the VM characteristics using the spine instability neoplastic score (SINS) at T0 and the rate of pathologic fracture between treated-VM and untreated-VM using Kaplan-Meier method. We analyzed risk factors of pathological fracture despite PV using treated-VM characteristics and quality of cement injection criteria. RESULTS: Despite a lower SINS value at T0 (p < 0.001), the rate of pathological fracture was significantly higher among untreated-VM compared to the treated-VM, (log-rank, p < 0.001). Major risk factors of fracture among treated-VM were: SINS value ≥ 8 (p < 0.012), mechanical pain (p = 0.001), osteolytic lesion (p = 0.033), metastatic vertebral body involvement > 50% with no collapse (p < 0.001) and unilateral posterior involvement by the vertebral metastasis (p = 0.024), Saliou score < 9 (p = 0.008), vertebral metastasis filling with cement < 50% (p = 0.007) and the absence of cement's contact with vertebral endplates (p = 0.014). CONCLUSION: PV is long-term effective for consolidation of VM and must be discussed at the early diagnosed. Quality of cement injection matters, suggesting that techniques that improve the quantity and the quality of cement diffusion into the VM must be developed.


Assuntos
Fraturas Espontâneas/etiologia , Fraturas Espontâneas/prevenção & controle , Fraturas da Coluna Vertebral/etiologia , Fraturas da Coluna Vertebral/prevenção & controle , Neoplasias da Coluna Vertebral/complicações , Vertebroplastia/métodos , Cimentos para Ossos/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Traumatismos da Coluna Vertebral/prevenção & controle , Neoplasias da Coluna Vertebral/secundário , Coluna Vertebral/cirurgia , Resultado do Tratamento
4.
Actas Dermosifiliogr ; 110(8): 642-652, 2019 Oct.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31151668

RESUMO

Psoriasis is a chronic inflammatory disease associated with multiple comorbidities, particularly in patients with arthritis or more severe forms of the disease. The link between all these comorbidities is probably systemic inflammation. Several recent studies have indicated that patients with psoriasis may be at an increased risk of pathologic fractures and osteoporosis. Current guidelines on comorbidities in psoriasis do not recommend assessment of bone health. In this article, we review the available evidence on the association between psoriasis and osteoporosis. We first examine the concept of osteoporosis and the role of vitaminD in bone health and then propose an algorithm for managing and treating this condition in patients with psoriasis.


Assuntos
Osteoporose/etiologia , Psoríase/complicações , Vitamina D/fisiologia , Corticosteroides/efeitos adversos , Densidade Óssea/efeitos dos fármacos , Osso e Ossos/fisiologia , Densitometria/métodos , Feminino , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/prevenção & controle , Humanos , Imunossupressores/efeitos adversos , Masculino , Metotrexato/efeitos adversos , Osteoporose/diagnóstico por imagem , Osteoporose/terapia , Psoríase/tratamento farmacológico , Fatores de Risco
5.
World J Surg Oncol ; 17(1): 73, 2019 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-31014317

RESUMO

BACKGROUND: Giant cell tumor of the bone (GCT) has high local recurrence rates and the prognosis is hard to predict. We therefore retrospectively analyzed clinical outcome and recurrences of 51 GCT cases focusing on the effects of adjuvant local use of hydrogen peroxide. METHODS: The series enclosed 51 advanced GCT cases of the upper and lower extremities (n = 27 Campanacci grade III; n = 24 grade II; n = 39 surgery at our institution, n = 12 elsewhere). Mean follow-up was 88.3 (± 62.0) months. Surgical details, histology, metastases, recurrences, and interview-based data on satisfaction and function including the Musculoskeletal Tumor Society (MSTS) score were evaluated. It was investigated whether hydrogen peroxide was additionally used or not to clean the tumor cavity after curettage as we hypothesized influence on recurrences. To analyze the underlying mechanisms, GCT-derived stromal cell lines were cultured in vitro and tested for cell viability and apoptosis after treatment with hydrogen peroxide. Statistical analysis was performed with Student's t tests, analysis of variance (ANOVA) with post hoc testing, Mann-Whitney U tests, chi-square tests, Kaplan-Meier analysis, and multivariate Cox regression analysis. RESULTS: The whole series had 21 recurrences (41%). Eleven recurrences were found (28%) after surgery at our institution. Kaplan-Meier analysis of cumulative recurrence-free survival revealed at 2 years follow-up 69% (72%, only our institution) and at 10 years follow-up 54% (68%, only our institution). Intralesional resection was performed by vigorous curettage, burring, and defect filling with either polymethylmethacrylate bone cement (n = 45) or cancellous bone from the iliac crest (n = 6). Univariate chi-square analysis showed significantly lower recurrence rate after bone cement filling (2.3-fold, p = 0.024). Cleaning of the lesion cavity with hydrogen peroxide significantly reduced recurrence rate (whole collective 2.9-fold, p = 0.004; our institution 2.8-fold, p = 0.04) and significantly increased cumulative recurrence-free survival rate (whole collective at 10 years follow-up 74% versus 31%, p = 0.002; our institution 79% versus 48%, p = 0.02) compared to cases without hydrogen peroxide treatment. In multivariate analysis, significant risk factors for recurrence were pathological fracture (hazard ratio 3.7; p = 0.04), high mitosis rate (hazard ratio 15.6; p = 0.01), and lack of hydrogen peroxide use (hazard ratio 6.0; p = 0.02). In vitro cell culture analyses found apoptotic nature of hydrogen peroxide induced GCT cell death. CONCLUSIONS: The present series proved for the first time that additional cleaning of the tumor cavity with hydrogen peroxide before defect filling significantly reduced recurrence rate and significantly increased recurrence-free survival in advanced but intralesionally treated GCT cases.


Assuntos
Anti-Infecciosos Locais/administração & dosagem , Neoplasias Ósseas/tratamento farmacológico , Fraturas Espontâneas/prevenção & controle , Tumor de Células Gigantes do Osso/tratamento farmacológico , Peróxido de Hidrogênio/administração & dosagem , Recidiva Local de Neoplasia/prevenção & controle , Adulto , Neoplasias Ósseas/patologia , Quimioterapia Adjuvante , Feminino , Seguimentos , Tumor de Células Gigantes do Osso/patologia , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
6.
J Am Podiatr Med Assoc ; 109(1): 75-79, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30964308

RESUMO

Intraosseous lipomas are rare benign bone neoplasms with an incidence of less than 0.1%; origin in the calcaneus has been reported in only a few patients. First-line treatment remains conservative, but several surgical techniques have also been described. We describe a 44-year-old woman with increasing pain in her left heel for a year and a half, who noticed swelling on the lateral side of the calcaneus. The patient underwent radiography, magnetic resonance imaging, and computed tomography of her left foot, which was suspicious for an intraosseous lipoma with a threatening calcaneal fracture. We performed a surgical procedure, curettage of the tumor, spongioplastics (by autologous bone transplant and ß-tricalcium phosphate), and internal stabilization with a calcaneal plate considering the goal of immediate postoperative weightbearing. Histologic examination confirmed an intraosseous lipoma of the calcaneus. The patient's pain was relieved immediately after surgery. Internal stabilization of the calcaneus allowed the patient to immediately fully weightbear and to return to usual daily activities. Although a benign bone tumor, intraosseous lipoma can cause many complications, such as persistent pain, decreased function, or even pathologic fracture as a result of calcaneal bone weakening. Choosing an appropriate treatment is still controversial. Conservative treatment is the first option, but for patients with severe problems and threatening fracture, surgery is necessary. Internal fixation for stabilization enables immediate postoperative weightbearing and shortens recovery time.


Assuntos
Neoplasias Ósseas/cirurgia , Placas Ósseas , Calcâneo/cirurgia , Fraturas Espontâneas/prevenção & controle , Lipoma/cirurgia , Adulto , Neoplasias Ósseas/complicações , Curetagem , Feminino , Humanos , Ílio/transplante , Lipoma/complicações
8.
Yakugaku Zasshi ; 139(1): 35-38, 2019.
Artigo em Japonês | MEDLINE | ID: mdl-30606925

RESUMO

Fragility fractures associated with osteoporosis can have a major impact on a person's "activities of daily living" (ADL) and life span. Therefore, osteoporosis and its complications must be addressed by early screening and prompt intervention. A Fracture Risk Assessment Tool (FRAX) has been developed by the WHO. FRAX allows the calculation/estimation of absolute fracture risk over a 10-year period. The FRAX can be completed using a free application form, accessible online. The relationship between FRAX and the young adult mean (YAM) was investigated in order to calculate the cut-off value of FRAX for each age group. FRAX can be used by both physicians and other healthcare professionals to pre-screen patients for more detailed subsequent work-ups. Using FRAX in clinical practice has proven to be simple, inexpensive and useful.


Assuntos
Fraturas Espontâneas/etiologia , Fraturas Espontâneas/prevenção & controle , Osteoporose/diagnóstico , Medição de Risco/métodos , Idoso , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osteoporose/complicações , Sensibilidade e Especificidade
9.
Ann Palliat Med ; 8(2): 159-167, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30525770

RESUMO

BACKGROUND: The potential benefit of administering external beam radiation therapy (EBRT) to patients with asymptomatic bone metastases has rarely been addressed in clinical investigations. The aim of this study was to determine if cancer patients who were treated with EBRT for asymptomatic bone metastases experienced later onset of pain and skeletal-related events (SREs) than those who were untreated. METHODS: A retrospective chart review was conducted for prostate, breast, and lung cancer patients with asymptomatic bone metastases treated at a single cancer center from 2007 to 2017. Patients who received EBRT for asymptomatic bone metastases were compared to those who received medical or supportive therapy only. RESULTS: When all cancer groups were combined, the median time from the diagnosis of asymptomatic bone metastases to either moderate-to-severe pain or an SRE was 25 months for the untreated patients and 81 months for the patients receiving EBRT (P<0.001). The delay in the first occurrence of pain or an SRE following EBRT was observed for patients with prostate cancer (P=0.025) and lung cancer (P=0.029) but not for patients with breast cancer. In a multivariate analysis, EBRT was again shown to reduce the risk of developing pain or an SRE when all cancer types were combined (P=0.006). OS was not altered by EBRT. CONCLUSIONS: EBRT administered to a group of prostate, lung, and breast cancer patients with asymptomatic bone metastases was associated with an increase in time to the first occurrence of either pain or an SRE. These data demonstrate that there may be clinical settings in which EBRT should be used to delay or prevent late complications of bone metastases that are asymptomatic at the time of diagnosis.


Assuntos
Neoplasias Ósseas/radioterapia , Fraturas Espontâneas/epidemiologia , Idoso , Neoplasias Ósseas/secundário , Neoplasias da Mama/patologia , Neoplasias da Mama/radioterapia , Feminino , Fraturas Espontâneas/prevenção & controle , Humanos , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/radioterapia , Masculino , Metástase Neoplásica , Cuidados Paliativos , Pennsylvania/epidemiologia , Neoplasias da Próstata/patologia , Neoplasias da Próstata/radioterapia , Análise de Regressão , Estudos Retrospectivos
10.
J Am Acad Orthop Surg ; 27(10): 345-355, 2019 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-30394910

RESUMO

Skeletal metastases exert a profound effect on patients and society, and will be encountered by most orthopedic surgeons. Once a primary malignancy is diagnosed, multidisciplinary management should focus on maximizing the quality of life while minimizing disease- and treatment-related morbidity. This may be best achieved with discerning attention to the unique characteristics of primary cancer types, including pathologic fracture healing rates, longevity, and efficacy of adjuvant therapies. Some lesions may respond well to nonsurgical measures, whereas others may require surgery. A single surgical intervention should allow immediate unrestricted activity and outlive the patient. In certain scenarios, a therapeutic benefit may be provided by excision with a curative intent. In these scenarios, or when endoprosthetic reconstruction is necessary, patients may be best referred to an orthopedic oncologist.


Assuntos
Neoplasias Ósseas/secundário , Neoplasias Ósseas/cirurgia , Neoplasias Renais , Neoplasias Pulmonares , Neoplasias da Glândula Tireoide , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/terapia , Neoplasias da Mama , Terapia Combinada , Feminino , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/prevenção & controle , Humanos , Masculino , Cuidados Paliativos , Neoplasias da Próstata , Próteses e Implantes , Procedimentos Cirúrgicos Reconstrutivos , Encaminhamento e Consulta , Sobrevida
11.
J Bone Joint Surg Am ; 100(24): e153, 2018 Dec 19.
Artigo em Inglês | MEDLINE | ID: mdl-30562300

RESUMO

BACKGROUND: Orthopaedic surgeons must play an important role in the secondary prevention of fragility fractures; however, some surgeons are more aware than others of their responsibility regarding fracture prevention. The purpose of the present study was to identify which factors can lead to a higher sensitivity for fracture prevention. METHODS: A cross-sectional survey was distributed to orthopaedic surgeons via online invitation or at academic conferences in China from July through October 2015. A total of 452 surgeons responded. As the primary outcome measure, we created a sensitivity scoring system for fracture prevention based on the respondents' answers to 5 questions regarding behavior in the following areas: risk-factor evaluation, pharmacologic therapy, nonpharmacologic therapy, patient education, and follow-up. Multivariable linear regression and multivariable logistic regression analyses were used to identify factors related to surgeon sensitivity to fracture prevention. RESULTS: Very few surgeons reported having received adequate training regarding fracture prevention or reading guidelines or other fracture prevention literature (22% and 30%, respectively). Most respondents initiated pharmacologic or nonpharmacologic therapy (82% and 75%, respectively) for the treatment of confirmed osteoporosis among patients with fragility fractures, but only half performed a risk-factor evaluation, patient education, or timely patient follow-up (51%, 52%, and 48%, respectively). In the multivariable linear regression model, the orthopaedic surgeon's age (ß = 0.09, p = 0.003), self-rated knowledge level regarding osteoporosis or related issues (ß = 0.16, p < 0.001), self-perceived effectiveness in using preventive measures for patients with a fragility fracture (ß = 0.62, p < 0.001), and use of clinical pathways for fragility fractures in his or her workplace (ß = 1.24, p < 0.001) were independently associated with sensitivity scores for fracture prevention. Similar results were obtained from a multivariable logistic regression model. CONCLUSIONS: In China, the sensitivity of orthopaedic surgeons to the secondary prevention of fragility fractures is relatively low. Implementation of a comprehensive prevention approach and targeted continuing medical education are required to encourage surgeons to take greater responsibility for screening, treating, educating, and following their patients with fragility fractures.


Assuntos
Fraturas Ósseas/prevenção & controle , Cirurgiões Ortopédicos/normas , Idoso , China , Competência Clínica/normas , Estudos Transversais , Fraturas Espontâneas/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Pessoa de Meia-Idade , Cirurgiões Ortopédicos/educação , Osteoporose/prevenção & controle , Fraturas por Osteoporose/prevenção & controle , Padrões de Prática Médica , Prevenção Secundária , Inquéritos e Questionários
12.
J Surg Orthop Adv ; 27(3): 178-186, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30489242

RESUMO

Mirels scoring system for determining prophylactic stabilization need of skeletal metastases includes a limited number of variables and does not differentiate between procedure types. This study sought to identify additional variables associated with surgical failure, radiographic disease progression, and patient survival. A retrospective review was performed of patients from January 2004 to 2014 who underwent surgical treatment of skeletal metastases of the extremities, were >18 years of age, and had adequate radiographic surveillance. Eighty-nine metastatic bone lesions in 77 patients were included. Mirels score >8 (p = .015) and tumor origin (p = .008) were associated with surgical failure, which was 16.8%. Male gender (p < .001) and use of bone cement (p = .019) were associated with radiographic progression, 43.8% overall. Antiresorptive medications usage (p = .02) was associated with survival. The study concluded that tumor origin may be highly important when considering surgical treatment for metastatic bone disease and antiresorptive medications should be used postoperatively, given an association with survival. (Journal of Surgical Orthopaedic Advances 27(3):178-186, 2018).


Assuntos
Neoplasias Ósseas/cirurgia , Fraturas Espontâneas/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Ósseas/secundário , Placas Ósseas , Neoplasias da Mama/patologia , Calcâneo/cirurgia , Feminino , Neoplasias Femorais/secundário , Neoplasias Femorais/cirurgia , Fixação Intramedular de Fraturas , Humanos , Úmero/cirurgia , Neoplasias Renais/patologia , Linfoma/cirurgia , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/secundário , Mieloma Múltiplo/cirurgia , Rádio (Anatomia)/cirurgia , Estudos Retrospectivos , Fatores de Risco , Tíbia/cirurgia , Falha de Tratamento , Ulna/cirurgia
13.
J Hand Surg Asian Pac Vol ; 23(3): 424-429, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30282534

RESUMO

Unidirectional porous ß-tricalcium phosphate (UDPTCP; Affinos®, Kuraray, Tokyo, Japan) has been in clinical use since 2015. Animal studies have confirmed the excellent potential of UDPTCP with regard to bone formation and material absorption. We present the first three clinical cases using UDPTCP as a bone substitute after curettage of benign bone tumors of the hand. All three patients were males, 29-, 30- and 81-years-old, two having a diagnosis of enchondroma and the other, a bone ganglion, with a pathological fracture identified in one case. Over a mean follow-up of 10 months, all patients achieved satisfactory clinical result, with no adverse events of UDPTCP noted. Radiographic evidence of good bone formation and material absorption was observable over the postoperative course. UDPTCP provided satisfactory clinical results, with good biocompatibility and fast resorption characteristics. Therefore, UDPTCP could provide a safe and reliable filling substitute for bone defects following curettage of small bone tumors.


Assuntos
Neoplasias Ósseas/cirurgia , Substitutos Ósseos/administração & dosagem , Fosfatos de Cálcio/administração & dosagem , Condroma/cirurgia , Adulto , Idoso de 80 Anos ou mais , Materiais Biocompatíveis/administração & dosagem , Biópsia , Neoplasias Ósseas/diagnóstico , Neoplasias Ósseas/tratamento farmacológico , Condroma/diagnóstico , Condroma/tratamento farmacológico , Falanges dos Dedos da Mão , Fraturas Espontâneas/prevenção & controle , Humanos , Masculino , Ossos Metacarpais , Microscopia Eletrônica , Procedimentos Ortopédicos , Cuidados Pós-Operatórios
14.
Clin Orthop Relat Res ; 476(12): 2381-2388, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30260860

RESUMO

BACKGROUND: Prophylactic surgical treatment of the femur is commonly offered to patients with metastatic disease who have a high risk of impending pathologic fracture. Prophylactic fixation is associated with improved functional outcomes in appropriate patients selected based on established criteria, but the perioperative complication profile has received little attention. Given the substantial comorbidity in this population, it is important to characterize surgical risks for surgeons and patients to improve treatment decisions. QUESTIONS/PURPOSES: (1) What is the incidence of postoperative adverse events after prophylactic surgical stabilization of metastatic lesions of the femoral shaft or distal femur? (2) How does this complication profile compare with stabilization of pathologic fractures adjusted for differences in patient demographics and comorbidity? METHODS: We performed a retrospective study using the National Surgical Quality Improvement Program (NSQIP) database. We identified patients undergoing prophylactic treatment of the femoral shaft or distal femur by Current Procedural Terminology (CPT) codes. Patients undergoing treatment of a pathologic fracture were identified by CPT code for femur fracture fixation as well as an International Classification of Diseases code indicating neoplasm or pathologic fracture. We tracked adverse events, operative time, blood transfusion, hospital length of stay, and discharge to a facility within 30 days postoperatively. There were 332 patients included in the prophylactic treatment group and 288 patients in the pathologic fracture group. Patients in the prophylactic treatment group presented with greater body mass index (BMI), whereas the pathologic fracture group presented with a greater incidence of disseminated cancer. The odds of experiencing adverse events were initially compared between the two groups using bivariate logistic regression and then using multivariate regression controlling for age, sex, BMI, and American Society of Anesthesiologists (ASA) class and disseminated cancer causing marked physiological compromise per NSQIP guidelines. RESULTS: With multivariate analysis controlling for age, sex, BMI, and ASA class, patients with pathologic fracture were more likely to experience any adverse event (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.03-2.29; p = 0.036), major adverse events (OR, 1.61; 95% CI, 1.01-2.55; p = 0.043), death (OR, 1.90; 95% CI, 1.07-3.38; p = 0.030), blood transfusion (OR, 1.57; 95% CI, 1.08-2.27; p = 0.017), and hospital stay ≥ 9 days (OR, 1.51; 95% CI, 1.05-2.19; p = 0.028) compared with patients undergoing prophylactic treatment. However, when additionally controlling for disseminated cancer, the only difference was that patients with pathologic fractures were more likely to receive a blood transfusion than were patients undergoing prophylactic fixation (OR, 1.61; 95% CI, 1.12-2.36; p = 0.011). CONCLUSIONS: After controlling for differences in patient characteristics, prophylactic treatment of femoral metastases was associated with a decreased likelihood of blood transfusion and no differences in terms of the frequency of other adverse events. In the context of prior studies supporting the mechanical and functional outcomes of prophylactic treatment, the findings of this cohort suggest that the current guidelines have achieved a reasonable balance of morbidity in patients with femoral lesions and further support the current role of prophylactic treatment of impending femur fractures in appropriately selected patients. LEVEL OF EVIDENCE: Level III, therapeutic study.


Assuntos
Fraturas do Fêmur/prevenção & controle , Fixação de Fratura/efeitos adversos , Fraturas Espontâneas/prevenção & controle , Metástase Neoplásica/prevenção & controle , Complicações Pós-Operatórias/etiologia , Idoso , Transfusão de Sangue/estatística & dados numéricos , Bases de Dados Factuais , Diáfises/patologia , Diáfises/cirurgia , Feminino , Fraturas do Fêmur/etiologia , Fêmur/patologia , Fêmur/cirurgia , Fixação de Fratura/métodos , Fraturas Espontâneas/etiologia , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Duração da Cirurgia , Alta do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/patologia , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
Bone Joint J ; 100-B(8): 1100-1105, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30062934

RESUMO

Aims: The aim of this study was to validate the Mirels score in predicting pathological fractures in metastatic disease of the lower limb. Patients and Methods: A total of 62 patients with confirmed metastatic disease met the inclusion criteria. Of the 62 patients, 32 were female and 30 were male. The mean age of patients was 65 years (35 to 89). The primary malignancy originated from the breast in 27 (44%) patients, prostate in 15 (24%) patients, kidney in seven (11%), and lung in four (6%) of patients. One patient (2%) had metastatic carcinoma from the lacrimal gland, two patients (3%) had multiple myeloma, one patient (2%) had lymphoma of bone, and five patients (8%) had metastatic carcinoma of unknown primary. Plain radiographs at the time of initial presentation were scored using Mirels system by the four authors. The radiographic components of the score (anatomical site, size, and radiographic appearance) were scored two weeks apart. Inter- and intraobserver reliability were calculated with Fleiss' kappa test. Bland-Altman plots were created to compare the variances of the individual components of the score and the total Mirels score. Results: Kappa values for the interobserver variability of the components of the Mirels score were k = 0.554 (95% CI 0.483 to 0.626) for site, k = 0.342 (95% CI 0.285 to 0.400) for size, k = 0.443 (95% CI 0.387 to 0.499) for radiographic appearance, and k = 0.294 (95% CI 0.258 to 0.331)for the total score. Kappa values for the intra-observer reliability were k = 0.608 (95% CI 0.506 to 0.710) for site, k = 0.579 (95% CI 0.487 to 0.670) for size, k = 0.614 (95% CI 0.522 to 0.703) for radiographic appearance, and k = 0.323 (95% CI 0.266 to 0.379) for total score. Conclusion: Our study showed fair to moderate agreement between authors when using the Mirels score, and moderate to substantial agreement when authors rescored radiographs. The Mirels score is subjective and lacks reproducibility in predicting the risk of pathological fracture. Cite this article: Bone Joint J 2018;100-B:1100-5.


Assuntos
Neoplasias Ósseas/secundário , Fraturas Espontâneas/prevenção & controle , Índice de Gravidade de Doença , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Ossos da Perna , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Medição de Risco/métodos
16.
Int J Clin Oncol ; 23(6): 1127-1133, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29959563

RESUMO

BACKGROUND: Skeletal-related events (SRE) are common in patients with renal cell carcinoma (RCC) that includes bone metastasis. The purpose of this study was to clarify the effectiveness of zoledronate with and without sunitinib, combined with radiotherapy, for the treatment of bone metastasis from RCC. METHODS: We retrospectively analyzed 62 RCC patients with bone metastasis, who had been treated with radiotherapy at our institution. We divided the study cohort into two groups: patients treated with radiotherapy alone (RT; n = 27) and those treated with radiotherapy combined with zoledronate (RT + Z; n = 35). We investigated the overall survival and post-irradiation (PI)-SRE-free rate for each group, as well as the effect of sunitinib in the RT + Z treatment group. In addition, we determined treatment effectiveness by imaging assessments and relative response rates. RESULTS: There was no significant difference in the survival rates between the RT and RT + Z treatment groups (p = 0.11). However, the PI-SRE-free rate in the RT + Z group was significantly higher than that in the RT group (p = 0.02). The PI-SRE-free rate was significantly higher in patients who were treated with sunitinib after radiotherapy than in those who were treated without sunitinib (p = 0.03). However, there was no significant difference in the relative response rates, as assessed by imaging, in each group. CONCLUSION: Radiotherapy combined with zoledronate is an effective treatment for RCC with bone metastasis to prevent PI-SRE. Sunitinib may reduce PI-SRE if used after radiotherapy and combined with zoledronate.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Ósseas/terapia , Carcinoma de Células Renais/terapia , Quimiorradioterapia , Fraturas Espontâneas/prevenção & controle , Neoplasias Renais/terapia , Compressão da Medula Espinal/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Ósseas/secundário , Carcinoma de Células Renais/patologia , Feminino , Humanos , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sunitinibe/administração & dosagem , Taxa de Sobrevida , Resultado do Tratamento , Ácido Zoledrônico/administração & dosagem
18.
J Comp Eff Res ; 7(7): 693-707, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29762046

RESUMO

AIM: Randomized controlled trials (RCTs) with clinical outcomes are considered the gold standard for regulatory approval. However, by design they are only able to answer a small number of clinical questions. Other high-quality studies are required for clinical decision-making. The EVOLVE was the largest RCT, evaluating the effects of cinacalcet on clinical outcomes among adult patients receiving maintenance dialysis suffering from secondary hyperparathyroidism. While the EVOLVE trial did not reach its primary end point, imbalance in subjects' age at randomization and discontinuation rates are two of the reasons that the lack of mortality benefit is in question. We undertook a systematic literature review and Bayesian meta-analysis combining randomized and observational studies on the estimated effects of the oral calcimimetic cinacalcet on clinical outcomes including all-cause mortality, cardiovascular-related mortality, hospitalization for cardiovascular events, fracture and parathyroidectomy among patients on maintenance dialysis. METHODS: Data sources included MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases. RCTs and observational studies were included. Data extraction was completed by two authors independently and in duplicate determined the methodological quality of the studies and extracted data. RESULTS: Of 564 unique citations identified, 16 studies were included: six observational studies and ten RCTs. Four high-quality studies (two observational and two RCTs) were deemed suitable for meta-analysis. Results indicated a statistically significant reduction in the risk of death associated with cinacalcet (hazard ratio: 0.83; 95% credible interval: 0.78-0.89). CONCLUSION: The results of this meta-analysis indicate that treatment of secondary hyperparathyroidism with calcimimetic therapy may in fact reduce mortality among patients receiving maintenance dialysis. This finding provides justification for a well-designed and adequately powered randomized trial to definitively address the question.


Assuntos
Calcimiméticos/administração & dosagem , Cinacalcete/administração & dosagem , Hiperparatireoidismo Secundário/tratamento farmacológico , Diálise Renal , Adulto , Idoso , Teorema de Bayes , Feminino , Fraturas Espontâneas/prevenção & controle , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Paratireoidectomia/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Renal Crônica/terapia , Resultado do Tratamento
19.
Clin Orthop Relat Res ; 476(3): 529-534, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29529636

RESUMO

BACKGROUND: Preoperative transarterial embolization has been utilized in the surgical treatment of metastatic renal cell carcinoma of the femur to decrease perioperative blood loss. However, few studies have documented its efficacy in decreasing the proportion of patients receiving transfusions in the setting of prophylactic treatment of impending pathologic femur fractures. QUESTIONS/PURPOSES: In a population of patients with metastatic renal cell carcinoma of the femur who underwent prophylactic fixation, the purpose of this study was to quantify and compare the proportion of patients who received at least one transfused unit of blood between a group treated with preoperative embolization and a group without preoperative embolization. METHODS: A retrospective study was performed using a Medicare claims-based database. International Classification of Diseases, 9 Revision and Current Procedural Terminology codes were used to identify 1285 patients with metastatic renal cell carcinoma of the femur who underwent prophylactic fixation. The proportion of patients who received one or more blood transfusions was compared between 135 patients who underwent preoperative embolization and a group of 1150 concurrent control patients who did not undergo preoperative embolization. The control group was older than the embolization group, with 44% of these patients > 75 years old and 33% of the embolization group > 75 years. There was no difference in the female:male ratio between groups. Statistical comparisons of outcomes related to transfusion percentages were performed using Pearson chi square analysis with p < 0.05 considered significant. With the numbers available, we had 80% power to detect a difference in the percentage of patients transfused of 11% between the study groups at α = 0.05. RESULTS: No difference in transfusion percentage was observed between preoperative transarterial embolization (41 of 135 [30%]) and the control group (359 of 1150 [31%]; relative risk, 0.973; 95% confidence interval, 0.743-1.274; p = 0.84). The percentage of all patients who received a transfusion was 31% (400 of 1285). CONCLUSIONS: Preoperative embolization may not be mandatory in the prophylactic treatment of metastatic renal cell carcinoma of the femur, as demonstrated by the 69% of patients who received zero units of blood despite not receiving embolization. However, assessment of the efficacy of embolization in decreasing blood loss in the current study is limited as a result of biases associated with the database design of the study; the decision of whether to send a patient for embolization should be made on a case-by-case basis. The current study does not identify specific risk factors that should factor into this decision and underscores the need for further research in this regard. A plausible future research design to account for the low numbers and selection bias that limited the current study as well as the existing studies might be a multicenter, retrospective case-control study. LEVEL OF EVIDENCE: Level III, therapeutic study.


Assuntos
Carcinoma de Células Renais/terapia , Embolização Terapêutica/métodos , Fraturas do Fêmur/prevenção & controle , Neoplasias Femorais/terapia , Fixação de Fratura/métodos , Fraturas Espontâneas/prevenção & controle , Neoplasias Renais/patologia , Cuidados Pré-Operatórios/métodos , Idoso , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue , Carcinoma de Células Renais/secundário , Carcinoma de Células Renais/cirurgia , Bases de Dados Factuais , Embolização Terapêutica/efeitos adversos , Feminino , Fraturas do Fêmur/etiologia , Fraturas do Fêmur/patologia , Neoplasias Femorais/secundário , Neoplasias Femorais/cirurgia , Fixação de Fratura/efeitos adversos , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/patologia , Humanos , Masculino , Hemorragia Pós-Operatória/prevenção & controle , Cuidados Pré-Operatórios/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
20.
G Ital Nefrol ; 35(2)2018 Mar.
Artigo em Italiano | MEDLINE | ID: mdl-29582958

RESUMO

CKD-MBD is a systemic disorder of the mineral and bone metabolism as a result of CKD. The clinical relevance of this syndrome has led to the identification of the biochemical targets to be achieved in order to improve the outcome of the patient. However, in hemodialysis (HD) and peritoneal dialysis (DP) patients, these targets are not reached. Hyperphosphatemia is a predictor of cardiovascular and all-cause mortality. In DP the removal of phosphorus (P) occurs by diffusion and convection, with a contribution of ultrafiltration of about 11%. P clearance is time dependent, with differences between CAPD and APD and depending on membrane transport characteristics. Residual renal function plays a key role in the P balance. Calcium (Ca) clearance in PD depends on the calcium levels, calcium concentration in dialysate and ultrafiltration. Positive Ca balance brings to Adynamic Bone Disease. Several bone-derived substances, some of them with hormonal action, have shed new light on the bone- cardiac axis. The hormonal functions of bone are likely to be related to histological lesions that develop during chronic renal failure. Compared to the past, recent data show less obvious differences in bone histomorphometry parameters between HD patients and PD patients. However, in PD patients fewer fractures are reported, probably due to different bone quality.


Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/etiologia , Diálise Peritoneal/efeitos adversos , Osso e Ossos/metabolismo , Cálcio/metabolismo , Sistema Cardiovascular/fisiopatologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/metabolismo , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/prevenção & controle , Hormônios/metabolismo , Humanos , Peptídeos e Proteínas de Sinalização Intercelular/metabolismo , Falência Renal Crônica/complicações , Falência Renal Crônica/metabolismo , Falência Renal Crônica/terapia , Membranas Artificiais , Fósforo/metabolismo , Ultrafiltração , Vitamina D/metabolismo
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