Official Position of the Brazilian Association of Bone Assessment and Metabolism (ABRASSO) on the evaluation of body composition by densitometry—part II (clinical aspects): interpretation, reporting, and special situations

Abstract Objective: To present an updated and evidence-based guideline for the use of dual-energy x-ray absorptiometry (DXA) to assess body composition in clinical practice. Materials and methods: This Official Position was developed by the Scientific Committee of the Brazilian Association of Bone Assessment and Metabolism ( Associação Brasileira de Avaliação Óssea e Osteometabolismo , ABRASSO) and experts in the field who were invited to contribute to the preparation of this document. The authors searched current databases for relevant publications in the area of body composition assessment. In this second part of the Official Position, the authors discuss the interpretation and reporting of body composition parameters assessed by DXA and the use of DXA for body composition evaluation in special situations, including evaluation of children, persons with HIV, and animals. Conclusion: This document offers recommendations for the use of DXA in body composition evaluation, including indications, interpretation, and applications, to serve as a guiding tool in clinical practice and research for health care professionals in Brazil.

Influence of sleep quality on medical students' academic performance / Influência da qualidade do sono no desempenho acadêmico de estudantes de medicina

Objective: To identify the main factors affecting medical stu- dents' sleep quality and the probable relationship between sleep and academic performance throughout the course. Methods: A cross-sectional qualitative study was carried out at a private higher education institution in the city of Araguari (MG), Brazil. The sample consisted of 110 regularly enrolled medical students. A sociodemographic questionnaire and the Pittsburgh Sleep Quality Index Questionnaire were applied. Statistical analy- sis was performed using the one way analysis of variance test with the post-hoc Tukey test, two way analysis of variance Test, and Student's t-test. Results: Out of the 105 students analyzed, 19.04% (n=20) were classified as "good" sleepers and 80.95% (n=85) as "poor" sleepers. No statistically significant difference was observed between the Pittsburgh Sleep Quality Index Questionnaire scores and the students' grades averages or the students' academic terms. Conclusion: The majority of the students was classified as "poor" sleepers. The use of ener- getic substances and the female sex were the two significant factors that may affect sleep quality. There was no relationship between sleep quality and academic performance.

Objetivo: Identificar os principais fatores que afetam a qualidade do sono de acadêmicos de medicina e a provável relação entre o sono e o desempenho escolar ao longo do curso. Métodos: Estudo transversal de cunho qualiquantitativo realizado em uma institui- ção privada de ensino superior da cidade de Araguari (MG). A amostra foi constituída de 110 acadêmicos do curso de medi- cina regularmente matriculados. Aplicaram-se um questioná- rio sociodemográfico e o Questionário Índice de Qualidade de Sono de Pittsburgh. A análise estatística foi realizada pelo teste de análise de variância one way com post-hoc de Tukey, teste de análise de variância two way e teste t Student. Resultados: Dos 105 estudantes analisados, 19,05% (n=20) foram classificados como bons dormidores e 80,95% (n=85) como maus dormidores. Não houve diferença significativa entre o escore do Questioná- rio Índice de Qualidade de Sono de Pittsburgh e as médias de notas semestrais, tampouco entre o escore do questionário e os períodos letivos. Conclusão: A maioria dos acadêmicos foi clas- sificada como maus dormidores. Uso de substâncias energéticas e sexo feminino foram os fatores significativos que podem afetar a qualidade do sono. Não houve relação entre a qualidade do sono e o desempenho acadêmico.

A two-year follow-up of asfotase alfa replacement in a patient with hypophosphatasia: clinical, biochemical, and radiological evaluation

SUMMARY Hypophosphatasia (HPP) is a rare disease with a high mortality rate in its severe forms. It is caused by mutations within the gene encoding the tissue-nonspecific alkaline phosphatase (TNSALP), an enzyme responsible for bone mineralization. In 2015, the Food and Drug Administration approved the use of asfotase alfa, the first medication showing benefit in the treatment of HPP. We describe a case with a 2-year follow-up of the first Brazilian child treated with asfotase alfa. A 5-year-old boy, born to consanguineous parents, was diagnosed with HPP at the age of 20 months. During prenatal ultrasonography, polyhydramnios and shortening of long bones were detected. After birth, he presented delayed motor development, repeated respiratory infections, and bone deformities. At the age of 2 years and 8 months, he started walking and had already lost his primary teeth. He had reduced levels of alkaline phosphatase (ALP), elevated levels of pyridoxal 5'-phosphate (PLP), and a p.Ala33Val (c.98C>T) missense mutation in homozygosis in the TNSALP gene. His parents and sister also had reduced ALP levels, high PLP levels, and the same mutation in heterozygosis. His father and sister were healthy, and his mother was diagnosed with rickets in childhood, which resulted in short physical stature and lower limb deformities. The patient was started on asfotase alfa at the age of 2 years and 10 months. After 2 years of treatment, he improved his motor skills, had no further episodes of severe respiratory infection, and showed improved radiological findings of rickets, without any severe side effect.

Influence of sleep quality on academic performance of medical students / Influência da qualidade do sono no desempenho acadêmico de estudantes de medicina

Objective: To know the prevalence of "poor" sleepers among medical students, to identify the main factors affecting sleep quality in this population, and the probable relationship between sleep and academic performance throughout the course. Methods: This is a cross-sectional qualitative and quantitative study carried out at a higher education private institution in the city of Araguari (MG) Brazil. The sample consisted of 110 medical students. A sociodemographic questionnaire and the Pittsburgh Sleep Quality Index were applied. Statistical analysis was performed using ANOVA one-way test with the post-hoc Tukey test, two-way ANOVA test and Student's t test. Results: Of the 105 students analyzed, 19.05% (n=20) were classified as "good" sleepers, and 80.95% (n=85) as poor sleepers. No statistically significant difference was observed between the Pittsburgh Sleep Quality Index scores and the students' grade averages or the students' academic terms. Conclusion: The majority of the students was classified as poor sleepers. The consumption of energetic substances and the female sex were the two significant factors that could affect sleep quality. There was no relationship between sleep quality and academic performance.

Objetivo: Conhecer a prevalência de maus dormidores, identificar os principais fatores que afetam a qualidade do sono dessa população e a provável relação entre o sono e o desempenho escolar ao longo do curso de medicina. Métodos: Estudo transversal de cunho qualiquantitativo, realizado em uma instituição privada de Ensino Superior da cidade de Araguari (MG). A amostra foi constituída de 110 acadêmicos do curso de medicina regularmente matriculados. Aplicaram-se um questionário sociodemográfico e o Índice de Qualidade do Sono de Pittsburgh. A análise estatística foi realizada pelo ANOVA one-way com post-hoc de Tukey, teste ANOVA two-way e teste t de Student. Resultados: Dos 105 estudantes analisados, 19,05% (n=20) foram classificados como bons dormidores e 80,95% (n=85) como maus dormidores. Não houve diferença significativa entre o escore do Índice de Qualidade do Sono de Pittsburgh e as médias de notas semestrais, tampouco entre o escore do Índice de Qualidade do Sono de Pittsburgh e os períodos letivos. Conclusão: A maioria dos acadêmicos foi classificada como maus dormidores. O uso de substâncias energéticas e o sexo feminino foram os fatores significativos que podem afetar a qualidade do sono. Não houve relação entre a qualidade do sono e o desempenho acadêmico.

Incidence of vertebral fractures in calcium and vitamin D-supplemented postmenopausal Brazilian women with osteopenia or osteoporosis: data from Arzoxifene Generations Trial

ABSTRACT Objective Vertebral fracture is the most common osteoporotic fracture, affecting quality of life and increasing mortality. Epidemiological data on incidence of vertebral fracture are scarce in Brazil and throughout Latin America. Our aim was to determine vertebral fracture incidence and risk factors in a female Brazilian population. Subjects and methods Postmenopausal women with low bone mass were studied from the Brazilian placebo group of Arzoxifene Generations Trial (n = 974), followed for up to 5 years. The primary endpoint was new vertebral fractures, detected by X-Ray. Experimental design defined two strata: A. Osteoporosis or previous vertebral fracture with osteopenia; B. Osteopenia without previous fracture. Previous fracture, T-score, ionized calcium, alkaline phosphatase, creatinine and glucose were analyzed at baseline. Crude and adjusted incidence rates of vertebral fractures were estimated and Poisson regression model was used. Results Incidence rate was 7.7 (95% CI of 5.4 to 10.9) per 1,000 person-years (PY), increasing as a function of age. Women with new vertebral fractures had higher prevalence of previous nonvertebral fracture after menopause, were older and had lower lumbar spine (LS) T-score. Fracture risk increased by 46% for each unit reduction in LS T-score. Variables correlated with new vertebral fracture were age (p = 0.034), LS T-score, stratum A (p = 0.001 for both) and previous nonvertebral fracture after menopause (p = 0.019). In the final model, LS T-score was the strongest predictor. Conclusions Incidence rate of vertebral fracture of 7.7 per 1,000 PY. Age and previous fractures were associated with new vertebral fracture, but LS T-score was the most important predictor.

Bisphosphonates in the treatment of metabolic bone diseases / Atualização sobre bisfosfonatos nas doenças osteometabólicas

Osteoporosis is a disease characterized by low bone mass associated with the deterioration of microarchitecture, due to an imbalance either in high bone resorption or low bone formation or in both, leading to a high risk of fractures. Bisphosphonates are medications which reduce the ability of osteoclasts to induce bone resorption and consequently improve the balance between resorption and formation. There are bisphosphonates approved for the prevention and treatment of osteoporosis. Administration can be oral (daily, weekly or monthly) or intravenous (quarterly or yearly). These medications are well tolerated and with the correct instructions of administration have a good safety profile. Serious side effects, such as, osteonecrosis of jaw is very rare. Bisphosphonates are the most prescribed medication for the treatment of osteoporosis.

Osteoporose é uma doença caracterizada por baixa massa óssea associada à deterioração da microarquitetura devido ao desbalanço pela alta reabsorção, baixa formação ou ambas, levando a um alto risco de fraturas. Bisfosfonatos são medicamentos que reduzem a capacidade de os osteoclastos induzirem a reabsorção óssea e, consequentemente, melhorar o balanço entre reabsorção e formação. Há bisfosfonatos aprovados para prevenção e tratamento da osteoporose. A administração pode ser via oral (diária, semanal ou mensal) ou intravenosa (trimestral ou anual). Essas medicações são bem toleradas e, seguindo as recomendações adequadas, apresentam alto grau de perfil de segurança. Efeitos colaterais sérios, como osteonecrose de mandíbula, são raros. Bisfosfonatos são as medicações mais prescritas para o tratamento da osteoporose.

Discordância entre IGF-1 e GH pós-sobrecarga de glicose no rastreamento de acromegalia em paciente com macroprolactinoma: relato de caso e revisão sobre o tema / Discrepancy between IGF-1 and GH during 75 g oral glucose tolerance test measures to acromegaly screening in a patient with macroprolactinoma: case report and literature review

Neste artigo, descrevemos o caso de um paciente com diagnóstico de macroprolactinoma, que apresentava valores discordantes entre IGF-1 (elevado) e GH (hormônio de crescimento) pós-teste de tolerância oral à glicose (normal) realizados para pesquisa de co-secreção de GH pelo tumor. Houve normalização dos níveis de prolactina após uso de bromocriptina, porém, durante o acompanhamento, o paciente persistiu com níveis elevados de IGF-1 sem clínica aparente, sugerindo tratar-se de possível forma subclínica de acromegalia. Após o desenvolvimento de novos métodos laboratoriais, mais sensíveis, para a dosagem de GH, casos de discordância entre esses testes vêm sendo observados, levando alguns autores a sugerir que o nadir de GH pós-teste de tolerância à glicose oral (TTGO) para diagnóstico e tratamento da acromegalia pode ser bem menor do que o limite considerado atualmente (1,2). Assim, se isto for confirmado, casos subclínicos ou oligossintomáticos de acromegalia serão diagnosticados mais precocemente.

We describe a patient with macroprolactinoma and discrepant insulin-like growth factor (IGF-1) concentration (elevated) and growth hormone (GH) values during a 75 g oral glucose tolerance test (normal), that were measured to evaluate the co-secretion of GH by tumor. With the bromocriptin use, the patient achieved normalization of prolactin, but persisted with high levels of IGF1, suggesting to be subclinical acromegaly. After the development of new more sensitive GH assays, cases of discrepant GH and IGF-1 results have been observed and taken to some authors to suggest that GH nadir concentration during 75 g OGTT used to acromegaly diagnosis and treatment could be lower than values considered currently normal. Thus, if this is confirmed, subclinical and oligosymptomatic acromegaly cases could have earlier diagnoses.