Prevalencia de osteopenia del prematuro antes y después de la implementación de una estrategia temprana de manejo fosfocálcico / Prevalence of osteopenia of prematurity before and after implementing an early strategy with the use of calcium and phosphate

Introducción. Con el uso de la nutrición parenteral agresiva en recién nacidos de muy bajo peso, se detectaron alteraciones del metabolismo fosfocálcico. En 2016 se implementó una estrategia de prevención a través del monitoreo fosfocálcico y su suplementación temprana. El objetivo fue estudiar si esta estrategia disminuye la prevalencia de osteopenia e identificar factores de riesgo asociados. Población y métodos. Estudio cuasiexperimental que comparó la prevalencia de osteopenia entre dos grupos: uno después de implementar la estrategia de monitoreo y suplementación fosfocálcica (01/01/2017-31/12/2019), y otro previo a dicha intervención (01/01/2013-31/12/2015). Resultados. Se incluyeron 226 pacientes: 133 pertenecen al período preintervención y 93 al posintervención. La prevalencia de osteopenia global fue del 26,1 % (IC95% 20,5-32,3) y disminuyó del 29,3 % (IC95% 21,7-37,8) en el período preintervención al 21,5 % (IC95% 13,6-31,2) en el posintervención, sin significancia estadística (p = 0,19). En el análisis multivariado, el puntaje NEOCOSUR de riesgo de muerte al nacer, recibir corticoides posnatales y el período de intervención se asociaron de manera independiente a osteopenia. Haber nacido luego de la intervención disminuyó un 71 % la probabilidad de presentar fosfatasa alcalina >500 UI/L independientemente de las restantes variables incluidas en el modelo. Conclusión. La monitorización y suplementación fosfocálcica precoz constituye un factor protector para el desarrollo de osteopenia en recién nacidos con muy bajo peso al nacer.

Introduction. With the use of aggressive parenteral nutrition in very low birth weight infants, alterations in calcium and phosphate metabolism were detected. In 2016, a prevention strategy was implemented through calcium phosphate monitoring and early supplementation. Our objective was to study whether this strategy reduces the prevalence of osteopenia and to identify associated risk factors. Population and methods. Quasi-experiment comparing the prevalence of osteopenia between two groups: one after implementing the calcium phosphate monitoring and supplementation strategy (01/01/2017­12/31/2019) and another prior to such intervention (01/01/2013­12/31/2015). Results. A total of 226 patients were included: 133 in the pre-intervention period and 93 in the post-intervention period. The overall prevalence of osteopenia was 26.1% (95% CI: 20.5­32.3) and it was reduced from 29.3% (95% CI: 21.7­37.8) in the pre-intervention period to 21.5% (95% CI: 13.6­31.2) in the post-intervention period, with no statistical significance (p = 0.19). In the multivariate analysis, the NEOCOSUR score for risk of death at birth, use of postnatal corticosteroids, and the intervention period were independently associated with osteopenia. Being born after the intervention reduced the probability of alkaline phosphatase > 500 IU/L by 71%, regardless of the other variables included in the model. Conclusion. Calcium phosphate monitoring and early supplementation is a protective factor against the development of osteopenia in very low birth weight infants.

VIH y salud ósea / HIV and bone health

Con el advenimiento de la terapia antirretroviral, el pronóstico y la sobrevida de los pacientes infectados con el virus de la inmunodeficiencia humana (VIH) han cambiado de manera radical, por lo cual en la actualidad se evidencia un aumento en el riesgo de padecer enfermedades no relacionadas con el VIH como, por ejemplo, la osteoporosis. La disminución de la densidad mineral ósea (DMO) se observa en el 40-90% de las personas infectadas por el VIH, con una prevalencia de osteopenia y osteoporosis del 52 y 15%, respectivamente. Esta población de pacientes tiene un mayor riesgo de fracturas (60%) en comparación con personas no infectadas y un riesgo de fracturas vertebrales 2,3 veces mayor que en la población general. El tenofovir fumarato se asoció con un aumento de pérdida renal de fósforo e hiperparatiroidismo secundario. El efavirenz y los inhibidores de proteasas (IP) afectan el metabolismo de la vitamina D; actúan a nivel enzimático aumentando la expresión de la enzima CYP24 que lleva a producción de vitamina D inactiva. El FRAX es una herramienta sencilla y accesible, por lo que su uso está recomendado en pacientes con VIH. Además de las medidas higiénico-dietéticas, actividad física, calcio y vitamina D, el uso de bifosfonatos está indicado en el tratamiento de la osteoporosis en estos pacientes. (AU)

With the advent of antiretroviral therapy, the prognosis and survival of patients infected with the human immunodeficiency virus (HIV) have radically changed, which is why there is now evidence of an increased risk of suffering from diseases not related to HIV such as osteoporosis. The decrease in bone mineral density (BMD) is observed in 40-90% of people infected with HIV, with a prevalence of osteopenia and osteoporosis of 52 and 15%, respectively. This patient population has a 60% higher risk of fractures compared to uninfected people and a risk of vertebral fractures 2.3 times higher than in the general population. Tenofovir fumarate administration is associated with increased renal phosphorus loss and secondary hyperparathyroidism. Efavirenz and protease inhibitors (IP) affect the metabolism of vitamin D, they act at the enzymatic level by increasing the expression of the CYP24 enzyme that leads to the production of inactive vitamin D. The FRAX is a simple and accessible tool, so its use is recommended in patients with HIV and in addition to dietary hygiene measures, physical activity, calcium, and vitamin D, the use of bisphosphonates is indicated in the treatment of osteoporosis in these patients. (AU)

Cuidados médicos en EII: más allá de la terapia convencional / Medical care in IBD: more than conventional therapy

The management of Inflammatory Bowel Disease has progressed over the years largely due to better therapeutic options. These current management is guided by the primary goal in achieving clinical and endoscopic remission (deep remission), thus improving the quality of life of patients. In order to achieve these objectives however, there are risks associated which must always be considered. It is important to recognize that IBD patients are at risk of infection and neoplastic lesions for the natural history of the disease or the therapies that we used. Prevention of possible complications must be carried out. Options in therapeutic management not only include pharmacological therapy, but also include an adequate nutritional setting and an optimal correction of nutritional deficits. These alternative nutritional strategies can and should be considered as an effective therapeutic strategy aimed at improving the quality of life of IBD patients.

El manejo de la enfermedad inflamatoria intestinal ha progresado con el paso de los años dado a mayores opciones terapéuticas. El manejo actual se guía por objetivos para lograr remisión clínica y endoscópica (remisión profunda) mejorando así la calidad de vida de estos pacientes. Sin embargo, para lograr estos objetivos, se debe considerar siempre los riesgos asociados a las nuevas terapias. Es importante reconocer que los pacientes con EII son personas en riesgo tanto de infecciones como de lesiones neoplásicas por la historia natural de la enfermedad y/o por las terapias utilizadas, por lo tanto, la prevención de posibles complicaciones debe ser realizada en forma periódica. Por otro parte, el manejo terapéutico, no solo incluye la terapia farmacológica, sino también una adecuada optimización nutricional y una adecuada corrección de los déficit nutricionales secundarios. En este mismo sentido terapias alternativas, pueden ser consideradas como estrategia terapéuticas complementarias destinadas a mejorar la calidad de vida de estos pacientes.

Low-level laser therapy associated to a resistance training protocol on bone tissue in diabetic rats

ABSTRACT Objective The present study aimed to evaluate the in vivo response of a resistance training and low-level laser therapy (LLLT) on tibias and femurs of rats with diabetes mellitus (DM). Materials and methods Forty male Wistar rats were randomly distributed into four experimental groups: control group (CG), diabetic group (DG), diabetic trained group (TG) and diabetic trained and laser irradiated group (TLG). DM was induced by streptozotocin (STZ) and after two weeks laser and resistance training started, performed for 24 sessions, during eight weeks. At the end of the experiment, animals were euthanized and tibias and femurs were removed for analysis. Histological, histomorphometrical, immunohistochemistry and mechanical analyses were performed. Results Trained groups, with or without laser irradiation, showed increased cortical area, bone density and biomechanical properties. The immunohistochemical analysis revealed that TG and TLG demonstrated an increased RUNX2 expression. RANK-L immunoexpression was similar for all experimental groups. Conclusion In conclusion, it can be suggested that the resistance exercise program stimulated bone metabolism, culminating in increased cortical tibial area, bone mineral content, bone mineral density and biomechanical properties. Furthermore, the association of physical exercises and LLLT produced higher values for bone mineral content and stiffness. Consequently, these data highlight the potential of physical exercise in the management of bone loss due to DM and the possible extra osteogenic stimulus offered by lasertherapy. Further long-term studies should be carried out to provide additional information.

High-impact exercise in rats prior to and during suspension can prevent bone loss

High-impact exercise has been considered an important method for treating bone loss in osteopenic experimental models. In this study, we investigated the effects of osteopenia caused by inactivity in femora and tibiae of rats subjected to jump training using the rat tail suspension model. Eight-week-old female Wistar rats were divided into five groups (n=10 each group): jump training for 2 weeks before suspension and training during 3 weeks of suspension; jump training for 2 weeks before suspension; jump training only during suspension; suspension without any training; and a control group. The exercise protocol consisted of 20 jumps/day, 5 days/week, with a jump height of 40 cm. The bone mineral density of the femora and tibiae was measured by double energy X-ray absorptiometry and the same bones were evaluated by mechanical tests. Bone microarchitecture was evaluated by scanning electron microscopy. One-way ANOVA was used to compare groups. Significance was determined as P<0.05. Regarding bone mineral density, mechanical properties and bone microarchitecture, the beneficial effects were greater in the bones of animals subjected to pre-suspension training and subsequently to training during suspension, compared with the bones of animals subjected to pre-suspension training or to training during suspension. Our results indicate that a period of high impact exercise prior to tail suspension in rats can prevent the installation of osteopenia if there is also training during the tail suspension.

Role of pitavastatin in prevention of osteopenic changes in ovariectomized rats

Objective: To determine the effect of pitavastatin, a third generation statin, on development of osteopenia in ovariectomized rats

Study Design: Experimental study

Place and Duration of Study: Department of Pharmacology, Basic Medical Sciences Institute, Jinnah Postgraduate Medical Center, Karachi, from January to July 2013

Methodology: Forty female Sprague Dawley rats were divided into ovariectomized [OVX], Sham OVX and OVX given pitavastatin 0.4 mg/kg/day, 0.8 mg/kg/day, for 8 weeks. Bone density measurements using CT scan and Archimedes' principle were made on femora and tibiae. Blood samples were analyzed for acid phosphatase [ACP] and alkaline phosphatase [ALP] levels

Results: Ovariectomy-induced osteopenic changes were indicated by significant decrease in bone densities and Hounsfield [HU] index of distal femoral and proximal tibial metaphyses and elevation of ACP and ALP levels. 0.4 mg/kg pitavastatin did not significantly alter the evaluated parameters. 0.8 mg/kg produced a restoration of HU of lower femur and femoral density comparable to Sham. HU of upper tibia and tibial density following 0.8 mg/kg was significantly higher than OVX but was not approximate to Sham. ALP and ACP with 0.8 mg/kg were comparable to Sham

Conclusion: Supra-therapeutic dose of pitavastatin was effective in preventing estrogen deficiency-induced decrease in bone density of ovariectomized rates, over an 8-week period

Efectos óseos de la cirugía bariátrica / Effects of bariatric surgery on bone

La cirugía bariátrica es un recurso terapéutico cuyo uso para el manejo de la obesidad mórbida crece rápidamente. La intervención induce varios cambios en el perfil hormono-metabólico de los pacientes: disminuye la absorción de calcio, caen los niveles de vitamina D, se produce un hiperparatiroidismo secundario que acelera el recambio óseo, aumentan algunas citoquinas como la adiponectina, el GLP-1 y la esclerostina, y disminuyen otras como la leptina, la ghrelina, el GIP y la amilina. El estradiol cae por disminución de la aromatización periférica de la testosterona. Hay disminución de la carga mecánica en el esqueleto, especialmente en los miembros inferiores. Todo esto lleva a pérdida de la masa ósea, que es variable y más marcada en el fémur proximal que en la columna. El riesgo de fractura aumenta, aunque no todas las series lo han demostrado. Los pacientes con marcada disminución del peso corporal poscirugía deberían ser controlados, procurandoun buen aporte de calcio y otros nutrientes, la suplementación con vitamina D y el monitoreo de la densitometría ósea. (AU)

Bariatric surgery is a therapeutic resource for the management of morbid obesity; its use is growing rapidly. The intervention induces several changes in the hormonal and metabolic profile of patients: decreased calcium absorption, falling levels of vitamin D, secondary hyperparathyroidism which accelerates bone turnover; increased level of some cytokines such as adiponectin, GLP-1 and sclerostin, and decreased levels of others such as leptin, ghrelin, GIP and amylin. Estradiol falls due to decreased peripheral aromatization of testosterone. There is a decrease in the mechanical load on the skeleton, especially in the lower limbs. All this leads to loss of bone mass, which is variable and more marked in the proximal femur than in the spine. The risk of fracture increases, although it has not been shown in all series. Patients with marked decrease in body weight after bariatric surgery should be controlled carefully to insure a good supply of calcium and other nutrients, vitamin D supplementation, and the monitoring of bone mineral density. (AU)

[Effects of aerobic training on some inflammatory markers in patients with rheumatoid arthritis]

Rheumatoid arthritis [RA] is more prevalent in women than men and its incidence is in all age group. Patient with RA significantly experience more disability and co-morbidities including cardiovascular diseases in compared with people without RA and this is due to reduced physical activities in the patients. The effect of aerobic training on patients with RA is still unclear. Thus, the aim of this study was to investigate the effects of 8 weeks aerobic training in patients with RA. Twenty three women [mean age 51.96 +/- 7.73 yr and mean weight 72.37 +/- 10 kg] with a diagnosis of RA for more than three years and without any known cardiovascular and brain symptoms were voluntarily enrolled in the study. The patients were divided into aerobic training [n=11] and control groups [n=12]. The patients in the aerobic group performed an aerobic training using a stationary bike [3 d/wk for 8 weeks]. All subjects in this group were administered the same medicine at the same dose. A fasting blood sample was collected prior to and after 8 weeks of aerobic training from the patients. Serum C-reactive protein [CRP], fibrinogen and rheumatoid factor [RF] were measured using standard methods. There was a significant difference in CRP, fibrinogen and body mass index before and after 8 weeks of aerobic training in the experimental group [P

O alendronato de sódio na prevenção da osteopenia secundária à imobilização gessada, em ratas: avaliação histomorfométrica / Alendronate sodium to prevent osteopenia caused by cast immobilization in female rats: histomorphometric evaluation

OBJETIVO: Analisar, por meio da histomorfometria, o efeito do alendronato de sódio sobre o trabeculado ósseo de ratos, quando administrado simultaneamente com imobilização gessada. MÉTODOS: Foram utilizados quatro grupos com cinco fêmeas de ratos Wistar: 1) imobilizado; 2) não imobilizado + alendronato; 3) imobilizado + alendronato; e 4) controle. A imobilização foi feita com gesso pelvipodálico aplicado até o membro posterior direito e o alendronato foi administrado em doses semanais. O período de observação foi de 28 dias e realizada histomorfometria da metáfise proximal da tíbia, com análise do número de trabéculas, volume ósseo, espessura trabecular e separação trabecular. RESULTADOS: O grupo imobilizado apresentou volume ósseo menor que os demais grupos. Os animais que receberam alendronato semanal, tanto imobilizados, quanto não imobilizados, apresentaram volume ósseo maior que o controle. A espessura trabecular no grupo imobilizado foi menor do que nos grupos controle e não imobilizado que recebeu alendronato, mas não apresentou diferença significativa em relação ao imobilizado com alendronato. O grupo imobilizado apresentou separação trabecular maior que os demais grupos. Os grupos não imobilizado, sem imobilização que recebeu alendronato e imobilizado que recebeu alendronato apresentaram aumento no número de trabéculas em relação ao grupo imobilizado. CONCLUSÃO: A imobilização empregada efetivamente levou à osteopenia, verificada pela diminuição de todos os principais parâmetros histomorfométricos estudados. Estas alterações foram prevenidas pela administração concomitante de alendronato sódico, exceto com relação à espessura trabecular. O alendronato de sódio foi capaz de aumentar os parâmetros morfométricos, mesmo em animais não imobilizados.

OBJECTIVE: Using histomorphometric means to analyze the effect of alendronate sodium on the bone trabeculate of rats administered concomitantly with cast immobilization. METHODS: Female Wistar rats were distributed in four groups with five animals each: 1) cast-immobilized; 2) no immobilization + alendronate; 3) cast-immobilized + alendronate; and 4) control. Immobilization was done with pelvipodalic cast applied till the right hind limb and alendronate was administered in weekly doses. The observation period was 28 days and histomorphometric evaluations were performed in the proximal tibial metaphysis, analyzing the number of trabeculae, bone volume, trabecular thickness, and trabecular separation. RESULTS: The immobilized group presented less bone volume than the other groups. The animals receiving alendronate every week, whether or not immobilized, presented a greater bone volume than the control group. Trabecular thickness in the immobilized group was less than in the control and in the non-immobilized groups that received alendronate, but had no significant difference when compared to the immobilized with alendronate group. The immobilized group presented greater trabecular separation than the other groups. In the non-immobilized groups, the non-immobilized group that received alendronate and the immobilized group that received alendronate presented an increased number of trabeculae when compared to the immobilized group. CONCLUSION: The immobilization used led to osteopenia, as confirmed by the decrease in all of the main histomorphometric parameters studied. Such changes were prevented with the concomitant administration of alendronate sodium, exception being made to the trabecular thickness. Alendronate sodium was able to increase morphometric parameters, even in non-immobilized animals.

Análise da topologia óssea em 2.140 pacientes no período de climatério. Predição do risco de fraturas osteoporóticas da senilidade / Analysis of bone topology in 2.140 patients during the climateric period. Prediction of the risk osteoporotic fractures of old age

Objetivo: O tarbalho teve como propósito analisar simultaneamente o estado da matriz mesenquimal protéica e a quantidade de massa óssea em 2.140 mulheres do climatério. Correlacionou o parâmetro protéico (UBPI) com a massa óssea (AD-SoS) normal, osteopenia e osteoporose, configurando uma avaliação completa de tecido ósseo. Material e Métodos: Utilizando a tecnologia com Inteligência Artificial, DBM Sonic BP, as pacientes foram subdivididas nos seguintes grupos: 476 pacientes normais, 729 com osteoponia e 935 com osteoporose. Resultados: Entre as 476 pacientes com massa óssea normal, 98 (20,6%) revelaram matriz protéica inadequada. Entre as 729 pacientes com osteopenia, 310 (42,4%) apresentaram matriz protéica inadequada. Entre as 935 pacientes com o diagnóstico de osteoporose, 935 (100%) todas apresentaram matriz protéica inadequada. De acordo com a fisiopatologia atual da osteoporose, as pacientes portadoras de osteopenia e osteoporose registraram substancial elevação no grau de deterioração na matriz protéica óssea (UBPI). A ferramenta que analisa a matriz protéica (UBPI) revelou-se um marcador biológico precoce para avaliação da resistência tensil e do risco de fratura. A diferença estatística significante (p menor que 0,001) a favor da deterioração da matriz mesenquimal protéica (UBPI) demostrou sua precedência aos quadros de osteopenia e osteoporose. Conclusões: A pesquisa realça a importência da avaliação da topologia óssea ao longo do climatério e enfatiza o valor do rastreamento sequencial da deterioração da micro-arquitetura óssea dos ossos endostal, trabecular e cortical. As análises através da topologia óssea se revelaram mais abrangentes e adicionam minunciosas ferramentas que perfazem os atuais conceitos da osteoporose, segundo o projeto do genoma.

Efecto del calcio dietético vs el citrato de calcio sobre marcadores bioquímicos convencionales en mujeres perimenopáusicas / Effect of dietary calcium vs. calcium citrate on conventional biochemical markers in perimenopausal women

OBJETIVO: Comparación del efecto del citrato de calcio y una dieta con calcio en los alimentos sobre marcadores bioquímicos convencionales. MATERIAL Y MÉTODOS: Se estudiaron 82 mujeres de 30 a 35 años de edad divididas al azar en tres grupos: grupo control: 23 mujeres sin modificación de sus hábitos alimenticios ni actividad física. Grupo con calcio dietético: 28 mujeres con un régimen de 1 000 mg de calcio más actividad física de 30 minutos tres veces por semana. Grupo con citrato de calcio: 31 mujeres suplementadas con citrato de calcio (600 mg), más 500 mg de calcio dietético, y actividad física de 30 minutos tres veces por semana durante siete meses. Se hizo densitometría ósea de calcáneo para clasificarlas en normal y osteopenia, se determinaron parámetros bioquímicos al inicio y final del estudio: fosfatasa alcalina, magnesio, calcio y fósforo séricos, y relación calcio/creatinina en orina. RESULTADOS: El 34 por ciento de las mujeres presentaron osteopenia; éstas tuvieron una reducción significativa en el calcio final en el grupo de citrato de calcio en comparación con el grupo de calcio dietético (p<0.05, 7.4 mg/dl vs 8.8 mg/dl). En la valoración final se observó hipermagnesemia significativa en el grupo de calcio dietético, en comparación con el grupo de citrato de calcio (p<0.05). El fósforo disminuyó en el grupo con calcio dietético (3.5 a 3.2 mg/dl) (p>0.05). La relación calcio/creatinina fue normal en todos los grupos. CONCLUSIONES: El grupo con calcio dietético presentó mayor formación ósea que el grupo con citrato de calcio; en ninguno de ellos se observó resorción ósea.

Osteoporosis: detección, prevención, tratamiento / Osteoporosis: detection, prevention and treatment

El síndrome osteoporótico se caracteriza por una merma en la cantidad (osteopenia) y deterioro de la calidad (microarquitectura) de la mineralización ósea. Se trata de trastornos heterogénos originados por múltiples causas metabólicas, poco conocidas. Se diagnostica por la presencia de deformaciones óseas o fracturas de origen no traumático. La detección precoz de la osteopenia es importante y se considera que los individuos cuya densidad mineral ósea (BMD) es inferior al 80// del normal están más expuestos a fracturas. La fosfatasa alcalina sérica, la hidroxiprolina y las piridinolinas urinarias son marcadores bioquimicos. Se insiste en los aspectos nutricionales y de movimientos físicos, para obtener una mayor masa ósea, especialmente durante el período de crecimiento. Es fundamental ingerir suficiente cantidad de calcio, y en las zonas más australes del país debe aumentarse el consumo de vitamina D. Los recursos terapéuticos tienden a prevenir la osteopenia de un modo más activo. Los estrógenos son muy utilizados en las mujeres postmenopáusicas. Son eficaces pero no para tratar la osteoporosis establecida y persisten todavía algunas dudas sobre su inocuidad a largo plazo. Las calcitoninas aumentan transitoriamente la mineralización vertebral y pueden ser utilizadas como alternativas de las terapias hormonales de reemplaxo. Los bifosfonatos presentan diferentes mecanismos de acción, p.ej., el pamidronato no es citotóxico por lo que no interfiere en el proceso de remodelación fundamental para mantener o mejorar la calidad arquitectónica del hueso. El efecto de los bisfosfonatos sobre la mineralización es duradero. Por ser drogas nuevas aún no han sido aprobadas en todos los países. Las sales de flúor han producido siempre resultados desconcertantes; algunos efectos benéficos iniciales no previenen las consecuencias adversas del uso prolongado. Las vitaminas D, el nitrato de galio y la ipriflavona producen resultados discretos que aún deben compararse con el de los agentes más activos. El empleo de otras drogas (tamoxifeno, los derivados de la parthormona, los factores de crecimiento, las tiazidas y los inhibidores de la bomba de protones) aún está en desarrollo. Se concluye que la osteoporisis es un proceso patológico que acompaña al envejecimiento y para el cual ya existen fármacos disponibles, en especial para prevenir la osteopenia y el deterioro de la calidad del hueso