Vitamin D deficiency and seasonal variation over the years in São Paulo, Brazil.

Brazil is a tropical/subtropical geographic area with elevated ultraviolet (UV) radiation. We report very high prevalence of vitamin D deficiency in a large database of Brazilian subjects and show seasonal and reciprocal relationship between vitamin D and parathyroid hormone (PTH) over the years in this tropical area. INTRODUCTION: We aim to examine the prevalence of vitamin D deficiency, characterize the temporal relationship between 25-hydroxyvitamin D levels (25(OH)D) and intact PTH (iPTH) according to seasons, and investigate potential associations between 25(OH)D levels and extra-skeletal outcomes in a Brazilian population. METHODS: We retrospectively determined population weekly mean concentrations of unpaired 25(OH)D and iPTH using 39,004 laboratory results of Brazilian individuals of both genders aged 2 to 95 years. The 25(OH)D and iPTH distributions were normalized, and the means fit with a sinusoidal function. Potential associations between 25(OH)D serum levels and inflammatory markers, fasting glucose, HbA1c and Homeostasis Model Assessment index (HOMA) were examined. RESULTS: Of the samples, 33.9 % had 25(OH)D serum concentrations lower than 20 ng/mL, while the vast majority (70.7 %) were found to be vitamin D deficient or insufficient (<30 ng/mL). Vitamin D deficiency was significantly higher during the winter as compared to the summer (38.4 % <20 ng/mL and 75.5 % <30 ng/mL versus 23.3 % <20 ng/mL and 62.5 % <30 ng/mL, respectively; p < 0.001). Seasonal variation was observed for both 25(OH)D and iPTH. 25(OH)D peaks occurred in March and troughs in September. iPTH levels showed an inverted pattern of peaks and troughs with a delay of 1 ± 5 week. 25(OH)D was significantly associated with inflammatory markers but not with glucose homeostasis. CONCLUSIONS: A sinusoidal interrelationship has been detected between vitamin D and PTH in this tropical population. A large percentage of the individuals showed vitamin D deficiency. Public health strategies are needed to better understand and manage this very high and apparently contradictory prevalence of vitamin D deficiency.

Development and validation of a tool for identifying women with low bone mineral density and low-impact fractures: the São Paulo Osteoporosis Risk Index (SAPORI).

UNLABELLED: The performance of the São Paulo Osteoporosis Risk Index (SAPORI) was tested in 1,915 women from the original cohort, São Paulo Osteoporosis Study (SAPOS) (N = 4332). This new tool was able to identify women with low bone density (spine and hip) and low-impact fracture, with an area under the receiving operator curve (ROC) of 0.831, 0.724, and 0.689, respectively. INTRODUCTION: A number of studies have demonstrated the clinical relevance of risk factors for identifying individuals at risk of fracture (Fx) and osteoporosis (OP). The SAPOS is an epidemiological study for the assessment of risk factors for Fx and low bone density in women from the community of the metropolitan area of São Paulo, Brazil. The aim of the present study was to develop and validate a tool for identifying women at higher risk for OP and low-impact Fx. METHODS: A total of 4,332 pre-, peri-, and postmenopausal women were analyzed through a questionnaire addressing risk factors for OP and Fx. All of them performed bone densitometry at the lumbar spine and proximal femur (DPX NT, GE-Lunar). Following the identification of the main risk factors for OP and Fx through multivariate and logistic regression, respectively, the SAPORI was designed and subsequently validated on a second cohort of 1,915 women from the metropolitan community of São Paulo. The performance of this tool was assessed through ROC analysis. RESULTS: The main and significant risk factors associated with low bone density and low-impact Fx were low body weight, advanced age, Caucasian ethnicity, family history of hip Fx, current smoking, and chronic use of glucocorticosteroids. Hormonal replacement therapy and regular physical activity in the previous year played a protective role (p < 0.05). After the statistical adjustments, the SAPORI was able to identify women with low bone density (T-score ≤ -2 standard deviations) in the femur, with 91.4% sensitivity, 52% specificity, and an area under the ROC of 0.831 (p < 0.001). At the lumbar spine, the performance was similar (81.5% sensitivity, 50% specificity, and area under ROC of 0.724; p < 0.001). Regarding the identification of low-impact Fx, the sensitivity was 71%, the specificity was 52%, and the area under the ROC was 0.689 (p < 0.001). CONCLUSION: The SAPORI is a simple, useful, fast, practice, and valid tool for identifying women at higher risk for low bone density and osteoporotic fractures.

Hormonal influence on periurethral vessels in postmenopausal incontinent women using Doppler velocimetry analysis.

UNLABELLED: The lack of estrogen affects the urinary tract mainly by diminishing vascular, muscular and epithelial trophism, resulting in negative effects on continence in postmenopausal women. OBJECTIVE: Study the effect of hormone therapy (estrogen and progesterone) in periurethral vessels detected by Doppler velocimetric analysis using, as parameters, the number of vessels, resistance and pulsatility indexes, as well as the minimum diastolic value. METHODS: Thirty-eight postmenopausal women with stress urinary incontinence were randomized into two groups. The first consisted of women receiving 3 months of estrogen therapy previous to 3 months of continuous estrogen and progesterone combined therapy. The second comprised of women receiving 3 months of continuous estrogen and progesterone therapy. Periurethral Doppler velocimetric analysis was done before hormone administration and during treatment in both groups. RESULTS: We observed a statistically significant increased number of periurethral vessels during treatment in both groups. There was an increase in value of the mean minimum diastolic value during estrogen and progesterone therapy in Group 2. The resistance indexes diminished in both groups. However, they were not statistically significant. CONCLUSION: Hormonal therapy of short duration (3-6 months) had a positive effect on the urethral continence mechanism increasing the number of periurethral vessels either with estrogen alone or combined therapy (estrogen and progesterone).

A randomized double-blind study of the short-time treatment of obese patients with nonalcoholic fatty liver disease with ursodeoxycholic acid.

In order to determine the effect of ursodeoxycholic acid on nonalcoholic fatty liver disease, 30 patients with body mass indices higher than 25, serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST) or gamma-glutamyltransferase (gamma-GT) at least more than 1.5 times the upper limit of normality, and hepatic steatosis demonstrated by ultrasonography were randomized into two groups of 15 patients to receive placebo or 10 mg kg-1 day-1 ursodeoxycholic acid for three months. Abdominal computed tomography was performed to quantify hepatic fat content, which was significantly correlated with histological grading of steatosis (r s = -0.83, P < 0.01). Patient body mass index remained stable for both groups throughout the study, but a significant reduction in mean ( +/- SEM) serum levels of ALT, AST and gamma-GT was observed only in the treated group (ALT = 81.2 +/- 9.7, 44.8 +/- 7.7, 48.1 +/- 7.7 and 52.2 +/- 6.3 IU/l at the beginning and after the first, second and third months, respectively, N = 14, P < 0.05). For the placebo group ALT values were 66.4 +/- 9.8, 54.5 +/- 7, 60 +/- 7.6 and 43.7 5 IU/l, respectively. No alterations in hepatic lipid content were observed in these patients by computed tomography examination (50.2 +/- 4.2 Hounsfield units (HU) at the beginning versus 51.1 +/- 4.1 HU at the third month). These results show that ursodeoxycholic acid is able to reduce serum levels of hepatic enzymes in patients with nonalcoholic fatty liver disease, but this effect is not related to modifications in liver fat content.

Magnetic resonance cholangiography in the diagnosis of biliary complications after orthotopic liver transplantation.

OBJECTIVE: The aim of our study was to evaluate the role of magnetic resonance cholangiography (MRC) in the diagnosis of biliary tract complications (BC) after orthotopic liver transplantation (OLT). MATERIALS AND METHODS: Among 21 OLT patients who underwent routine follow-up MRC using a breath-hold T2-weighted turbo spin-echo sequence with half-Fourier acquisition (HASTE), 5 had an elevated serum alkaline phosphatase level. Diagnostic confirmation was obtained with endoscopic retrograde cholangiography (ERC) (n = 11), surgery (n = 3), or clinical and laboratory follow-up of at least 1 year (n = 8). RESULTS: In 13 patients, no abnormality of the biliary tract was detected using MRC. In 8 patients, anastomotic strictures were diagnosed, 7 of which were confirmed at surgery or using ERC. One patient with normal findings at MRC and abnormal liver function test results was found to have a stricture at ERC. All patients with normal MRC and liver function tests had 1 year of uneventful follow-up and were considered true-negative cases. We found that MRC had 87.5% sensitivity, 92.3% specificity, 87.5% positive predictive value, 92.3% negative predictive value, and 90.4% accuracy for the diagnosis of BC. CONCLUSION: MRC is a valuable examination to detect BC after OLT. It provides useful information for planning interventional procedures.

The value of unenhanced CT in the diagnosis of acute appendicitis.

OBJECTIVE: To establish the accuracy of unenhanced CT in the preoperative diagnosis of acute appendicitis. DESIGN: Accuracy study, prospective and blinded. SETTING: The University Hospital. PARTICIPANTS: 52 patients with clinical and laboratorial manifestations of acute appendicitis. CT diagnosis was made by: presence of an abnormal appendix, appendiceal calculi with pericecal phlegmon or alterations in the pericecal appendicular site and absence of signs that may lead to other diagnosis. MAIN OUTCOME MEASURES: Overall accuracy, comparing the tomographic aspects with the intra-operative findings and pathological reports ("gold standard"). RESULTS: Acute appendicitis was confirmed in 44 cases. Efficacy was 92%, sensitivity was 91%, specificity was 100%, positive predictive value was 100% and negative predictive value was 67%. CONCLUSIONS: Unenhanced CT presents a similar overall accuracy to that reported by other authors who studied enhanced CT diagnosis of acute appendicitis.

Chronic hepatosplenic schistosomiasis mansoni: magnetic resonance imaging and magnetic resonance angiography findings.

PURPOSE: To evaluate the hepatosplenic manifestations and the portal venous system in patients with chronic infection by Schistosoma mansoni. MATERIAL AND METHODS: A cross-sectional observational study was performed in 28 patients with chronic hepatosplenic schistosomiasis submitted to magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the abdomen. Images were interpreted independently by two radiologists to determine the reproducibility of image interpretation and who evaluated the presence of morphological alterations in the liver and spleen, such as hepatosplenomegaly, hepatic fissure widening, periportal fibrosis, and the presence of siderotic nodules. Interobserver and intra-observer agreement were measured with the kappa and intraclass correlation tests. Evaluation of venous collateral pathways and portal and splenic veins was done in consensus by both examiners. RESULTS: Observers identified enlargement of the left lobe (78.5-92.8%) and caudate-to-right-lobe ratio (78.5-92.8%), irregularity of hepatic contours (89.2-96.4%), fissure widening (89.2-100%), and splenic siderotic nodules (84.2%). Splenomegaly, heterogeneity of hepatic parenchyma, peripheral hepatic vessels, and periportal fibrosis were observed in 100% of patients. MRI findings presented almost perfect interobserver (kappa = 0.65-1) and intra-observer (kappa = 0.73-1 for observer 1, and kappa = 0.65-1 for observer 2) agreement for the variables analyzed. MRA showed the presence of collateral pathways in the majority of patients (71.4%) along with widening of portal and splenic veins. CONCLUSION: Using MRI, hepatosplenic alterations in schistosomiasis are characterized by heterogeneity of hepatic parenchyma, presence of peripheral perihepatic vessels, periportal fibrosis, splenomegaly, siderotic nodules, and the presence of venous collateral pathways.

Endoscopic, ultrasonographic, and US-Doppler parameters as indicators of variceal bleeding in patients with schistosomiasis.

Bleeding from esophagogastric varices is a potentially deadly complication in patients with hepatosplenic schistosomiasis. The aim of this study is to establish indicators of variceal bleeding. We studied 40 patients with compensated hepatosplenic schistosomiasis and varices, analyzing four endoscopic (variceal size, red color signs, fundic varices, and congestive gastropathy), nine ultrasonographic (right and left hepatic lobe size, periportal and gallbladder wall thickness, portal and splenic veins diameter, spleen longitudinal axis and volume, and presence of collateral circulation), and five US-Doppler parameters (portal and splenic veins velocity and flow and portal vein congestion index). Patients were divided in two groups according to previous history of variceal bleeding. The group with bleeding episodes was again divided in two groups: with and without treatment, namely endoscopic sclerotherapy. All endoscopic parameters and two ultrasonographic (periportal thickness and portal vein diameter) were statistically different between the groups with and without previous bleeding. The likelihood index, adopted to determine the best parameters related to previous bleeding showed that the most important combinations are: gastropathy and red signs followed by portal vein diameter and variceal size. In conclusion, although aware of the limits of the statistical analysis due to the small number of patients, our results demonstrated that endoscopic and US parameters (isolated or combined) can identify patients with a high risk of variceal bleeding, allowing physicians to optimize prophylactic therapy.

A randomized double-blind study of the short-time treatment of obese patients with nonalcoholic fatty liver disease with ursodeoxycholic acid

In order to determine the effect of ursodeoxycholic acid on nonalcoholic fatty liver disease, 30 patients with body mass indices higher than 25, serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST) or gamma-glutamyltransferase (gamma-GT) at least more than 1.5 times the upper limit of normality, and hepatic steatosis demonstrated by ultrasonography were randomized into two groups of 15 patients to receive placebo or 10 mg kg-1 day-1 ursodeoxycholic acid for three months. Abdominal computed tomography was performed to quantify hepatic fat content, which was significantly correlated with histological grading of steatosis (r s = -0.83, P < 0.01). Patient body mass index remained stable for both groups throughout the study, but a significant reduction in mean (+ or - SEM) serum levels of ALT, AST and gamma-GT was observed only in the treated group (ALT = 81.2 + or - 9.7, 44.8 + or - 7,7, 48.1 + or - 7.7 and 52.2 + or - 6.3 IU/l at the beginning and after the first, second and third months, respectively, N = 14, P < 0.05). For the placebo group ALT values were 66.4 + or - 9.8, 54.5 + or - 7, 60 + or - 7.6 and 43.7 + or - 5 IU/l, respectively. No alterations in hepatic lipid content were observed in these patients by computed tomography examination (50.2 + or - 4.2 Hounsfield units (HU) at the beginning versus 51.1 + or - 4.1 HU at the third month). These results show that ursodeoxycholic acid is able to reduce serum levels of hepatic enzymes in patients with nonalcoholic fatty liver disease, but this effect is not related to modifications in liver fat content

Calcificaçöes pancreáticas em criança associada a ingestäo crônica de álcool: relato de caso / Pancreatic calcifications in child with association of chronic ingestiion of alcohol: a case report

Calcificaçöes pancreáticas em crianças tem sido descritas com pouca frequência, sendo a associaçäo com ingestäo crônica de álcool ainda mais rara. Os autores apresentaram o caso de uma criança de nove anos de idade com calcificaçöes pancreáticas e dores abdominais recorrentes, causadas pela pancreatite crônica alcoólica. Essa etiologia foi determinada por anamnese, dados epidemiológicos, exames laboratoriais e diagnóstico por imagem

Fibrossarcoma retroperitoneal. Relato de um caso. / Retroperitoneal fibrosarcoma. Report of a case

Os autores apresentam um caso de fibrossarcoma retroperitoneal bem diferenciado e calcificado, em paciente do sexo feminino, 59 anos cujo principal sintoma foi disfagia e tumor abdominal