Association of back pain with hypovitaminosis D in postmenopausal women with low bone mass.

BACKGROUND: Back pain is a major public health problem due to its high frequency, to the resulting activity constraint, and the need for surgery in many cases. Back pain is more frequent in women than men, mainly in postmenopausal women. High prevalence of hypovitaminosis D has been detected in postmenopausal women, and it is associated with decreased bone mass, sarcopenia, vertebral fractures, and inflammation, which can be related to back pain. METHODS: The relation between back pain and hypovitaminosis D was evaluated in this study, as well the difference regarding the number of bedridden days, number of days away from work, and daily activities limitation between women with and without hypovitaminosis D. This study reviewed baseline data from an interventional phase III multicenter trial in low bone mass postmenopausal women. The study included demographic data, 25OHD determinations, Newitt/Cummings questionnaire on back pain, and vertebral fracture identified thought X-ray evaluation. RESULTS: The trial included 9354 participants, but only 9305 underwent all the evaluations. The age median was 67 (60 - 85 years old) and age at menopause was 49 (18 - 72 years). Hypovitaminosis D was found in 22.5% of the subjects, 15.3% of them had vertebral fractures, 67.5% with back pain, and 14.8% reduced their daily activities in the previous six months. Subjects with hypovitaminosis D, compared to those without hypovitaminosis D, reported more back pain (69.5 v 66.9%, p: 0.022), more cases of severe back pain (8.5% v 6.8%, p: 0,004), higher limitation in their daily activities (17.2 v 14.0%, p: 0.001), and more fractures (17.4 v 14.6%, p: 0,002); also, they had more trouble to perform daily activities addressed in the Newwit/Cummings questionnaire. CONCLUSION: Hypovitaminosis D was related to back pain, to its severity, and to difficulty in perform daily activities. TRIAL REGISTRATION: ClinicalTrial.gov: NCT00088010.

Risk factors for unsuccessful peripheral blood stem cell harvesting using granulocyte-colony stimulating factor mobilization in patients with multiple myeloma.

The aim of this study was to determine factors that influence unsuccessful peripheral blood stem cell (PBSC) harvesting in patients with multiple myeloma (MM). Retrospective data of 186 MM patients who received G-CSF as mobilization were analyzed. Patients with successful harvest were compared with those who failed (using 2 definitions of failure <2 and <4 CD34 cells×10(6)/mm(3)). The groups were compared regarding age, gender, body weight, baseline platelet count, receipt of radiotherapy, number of prior chemotherapy regimens, PBSC count before collection, processed and collected volume, collect replace, number of sessions and final number of PBSC collected. By multivariate analysis, a baseline platelet count <161,000 cells/mm(3) was associated with PBSC harvest lower than 2×10(6)/kg, and age >58 years was related to PBSC harvest lower than 4×10(6)/kg CD34 cells/kg. Patients with these parameters should not receive mobilization protocols with G-CSF alone. Alternative protocols should be tested in this high risk harvest failure population.

[Prevalence of vertebral fractures and risk factors in women over 60 years of age in Chapecó, Santa Catarina State, Brazil]. / Prevalência de fraturas vertebrais e fatores de risco em mulheres com mais de 60 anos de idade na cidade de Chapecó, Santa Catarina, Brasil.

Fractures are the main problems related to bone fragility in postmenopausal women and account for the increase in the risk of new fractures, mortality, and costs. This study's objective was to verify the occurrence of vertebral fragility fracture and correlate it with demographic, behavioral, and clinical factors in a Brazilian population. The cross-sectional study was based on a random sample of elderly women living in Chapecó, Santa Catarina State, Brazil. The sample consisted of 186 white women over 60 years of age. Of these, 48.9% had asymptomatic vertebral fractures, with higher prevalence in T11-12 and L4-5. Adjusted analysis showed a gradient between age and vertebral fracture, while fracture prevalence was 2.3 times higher in women over 80 years. Fracture prevalence was 1.44 times higher in sedentary as compared to non-sedentary women. Due to the high prevalence of asymptomatic vertebral fractures, the authors suggest the use of spinal x-rays in elderly women for fracture screening and prevention.

Prevalência de fraturas vertebrais e fatores de risco em mulheres com mais de 60 anos de idade na cidade de Chapecó, Santa Catarina, Brasil / Prevalence of vertebral fractures and risk factors in women over 60 years of age in Chapecó, Santa Catarina State, Brazil

Fraturas são o principal agravo relacionado à fragilidade óssea na pós-menopausa, representando aumento de risco de novas fraturas, mortalidade e custos. Nosso objetivo foi verificar a ocorrência de fratura vertebral por fragilidade e relacioná-la com fatores demográficos, comportamentais e clínicos em uma população brasileira. Foi feito um estudo transversal com seleção por amostragem aleatória estratificada de mulheres idosas residentes em Chapecó, Santa Catarina, Brasil. A amostra foi constituída por 186 mulheres brancas com idade acima de 60 anos. Destas, 48,9 por cento tinham fraturas vertebrais assintomáticas, com maiores prevalências em T11-12 e L4-5. Na análise ajustada, observa-se que existe gradiente entre idade e fratura vertebral, chegando a ser 2,3 vezes maior a prevalência de fraturas entre as mulheres com idade superior a 80 anos. As sedentárias apresentaram prevalência de fratura 1,44 vez maior do que as não sedentárias. Devido à alta prevalência de fraturas vertebrais encontrada, sugerimos a realização de radiografia de coluna para mulheres idosas para rastreamento e prevenção de agravos.

Fractures are the main problems related to bone fragility in postmenopausal women and account for the increase in the risk of new fractures, mortality, and costs. This study's objective was to verify the occurrence of vertebral fragility fracture and correlate it with demographic, behavioral, and clinical factors in a Brazilian population. The cross-sectional study was based on a random sample of elderly women living in Chapecó, Santa Catarina State, Brazil. The sample consisted of 186 white women over 60 years of age. Of these, 48.9 percent had asymptomatic vertebral fractures, with higher prevalence in T11-12 and L4-5. Adjusted analysis showed a gradient between age and vertebral fracture, while fracture prevalence was 2.3 times higher in women over 80 years. Fracture prevalence was 1.44 times higher in sedentary as compared to non-sedentary women. Due to the high prevalence of asymptomatic vertebral fractures, the authors suggest the use of spinal x-rays in elderly women for fracture screening and prevention.

Osteoporosis and inflammation.

Several inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, celiac disease, cystic fibrosis and chronic obstructive pulmonary disease have been associated to bone resorption. The link between osteoclast, macrophage colony stimulating factor and pro-inflammatory cytokines, especially tumor necrosis factor-alpha and interleukin-1 explain the association between inflammation and osteoporosis. These diseases are related to osteoporosis and high fracture risk independent of other risk factors common to inflammatory diseases such as reduced physical activity, poor nutritional status, hypovitaminosis D, decrease in calcium intake and glucocorticoid treatment. Erythrocyte sedimentation rate and C-reactive protein should always be performed, but the indication about when to perform the densitometry test should be analyzed for each disease. Bisphosphonates are nowadays the best choice of therapy but new medications such as denosumab, IL-1 receptor antagonist, and TNF-alpha antibody have risen as new potential treatments for osteoporosis secondary to inflammation.

Osteoporosis and inflammation / Osteoporose e inflamação

Several inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, celiac disease, cystic fibrosis and chronic obstructive pulmonary disease have been associated to bone resorption. The link between osteoclast, macrophage colony stimulating factor and pro-inflammatory cytokines, especially tumor necrosis factor-α and interleukin-1 explain the association between inflammation and osteoporosis. These diseases are related to osteoporosis and high fracture risk independent of other risk factors common to inflammatory diseases such as reduced physical activity, poor nutritional status, hypovitaminosis D, decrease in calcium intake and glucocorticoid treatment. Erythrocyte sedimentation rate and C-reactive protein should always be performed, but the indication about when to perform the densitometry test should be analyzed for each disease. Bisphosphonates are nowadays the best choice of therapy but new medications such as denosumab, IL-1 receptor antagonist, and TNF-α antibody have risen as new potential treatments for osteoporosis secondary to inflammation.

Diversas doenças inflamatórias têm sido associadas à reabsorção óssea, como a artrite reumatoide, o lúpus eritematoso sistêmico, a doença inflamatória intestinal, a doença celíaca, a fibrose cística e a doença pulmonar obstrutiva crônica. A ligação entre osteoclastos, fator estimulador de colônia de macrófagos e citocinas pró-inflamatórias, principalmente o fator de necrose tumoral-α e interleucina-1, explica a associação entre a inflamação e a osteoporose. Essas doenças estão relacionadas com osteoporose e aumento do risco de fratura, independentemente de outros fatores de risco comuns às doenças inflamatórias, tais como redução da atividade física, estado nutricional, hipovitaminose D, diminuição da ingestão de cálcio e uso de glicocorticoides. A velocidade de hemossedimentação e proteína C-reativa devem ser sempre realizadas, mas a indicação do exame de densitometria óssea deve ser analisada em cada doença. Os bisfosfonatos são atualmente a melhor opção de terapia, mas novos medicamentos, tais como denosumabe, antagonista do receptor de IL-1 e anticorpos anti-TNF-α, surgem como novos potenciais tratamentos para a osteoporose secundária à inflamação.

Concentração plasmática de 25 hidroxivitamina D em mulheres na pós-menopausa com baixa densidade mineral óssea / Concentration of 25-hydroxyvitamin D in postmenopausal women with low bone mineral density

OBJETIVOS: Determinar as concentrações plasmáticas médias de 25 hidroxivitamina D (25OHD) em mulheres na pós-menopausa com baixa densidade mineral óssea (DMO); encontrar o ponto de corte de elevação do paratormônio (PTH); avaliar a correlação entre 25OHD e DMO, parâmetros bioquímicos e presença de fraturas vertebrais. MÉTODOS: Estudo transversal, com dosagem de 25OHD e de PTH, e realização de DMO e radiografia de coluna. RESULTADOS: Houve elevada frequência de concentrações plasmáticas inadequadas de 25OHD (68,3 por cento) e 8 por cento de hiperparatireoidismo secundário. Não foram observadas diferenças significativas entre as concentrações plasmáticas de 25OHD e os parâmetros avaliados, exceto PTH, que apresentou associação inversa. O ponto de corte determinado foi de 61,5 nmol/L. CONCLUSÕES: A alta frequência de hipovitaminose D em idosas com baixa DMO sugere que a avaliação sistemática das concentrações plasmáticas de 25OHD deve ser realizada nessa população. Recomenda-se o uso de ponto de corte de 61,5 nmol/L até a realização de estudo epidemiológico que represente toda a cidade do Rio de Janeiro (RJ).

OBJECTIVES: This study was designed to determine mean serum concentrations of 25-hydroxyvitamin D (25OHD) in postmenopausal women with low bone mineral density (BMD), to find the cutoff of parathormone (PTH) elevation, and to evaluate the correlation 25OHD with BMD, biochemical parameters and vertebral fracture presence. METHODS: Transversal study, with collection of 25OHD and PTH, and determination of DMO and column radiograph. RESULTS: A high incidence of inadequate serum concentrations of 25OHD (68.3 percent) was found and 8 percent of secondary hyperparathyreoidism. No significant differences were found between 25OHD serum concentrations and the evaluated parameters, except for PTH, which showed a negative association. The established cutoff was 61.5 nmol/L. CONCLUSIONS: The elevated incidence of hipovitaminosis D in elderly women with low BMD suggests that a systematic evaluation of 25OHD serum concentrations must be done for this population.The use of 61.5 nmol/L as a cutoff is recommended until the realization of an epidemiologic study that represents all Rio de Janeiro city (RJ, Brazil).

Prevalence of radiological findings among cases of severe secondary hyperparathyroidism.

CONTEXT AND OBJECTIVE: Patients with end stage renal disease (ESRD) and secondary hyperparathyroidism (HPT2) are prone to develop heterotopic calcifications and severe bone disease. Determination of the sites most commonly affected would decrease costs and patients' exposure to X-ray radiation. The aim here was to determine which skeletal sites produce most radiographic findings, in order to evaluate hemodialysis patients with HPT2, and to describe the most prevalent radiographic findings. DESIGN AND SETTING: This study was cross-sectional, conducted in one center, the Hospital Universitário Clementino Fraga Filho (HUCFF), in Rio de Janeiro, Brazil. METHODS: Whole-body radiographs were obtained from 73 chronic hemodialysis patients with indications for parathyroidectomy due to severe HPT2. The regions studied were the skull, hands, wrists, clavicles, thoracic and lumbar column, long bones and pelvis. All the radiographs were analyzed by the same two radiologists, with great experience in bone disease interpretation. RESULTS: The most common abnormality was subperiosteal bone resorption, mostly at the phalanges and distal clavicles (94% of patients, each). 'Rugger jersey spine' sign was found in 27%. Pathological fractures and deformities were seen in 27% and 33%, respectively. Calcifications were presented in 80%, mostly at the forearm fistula (42%), abdominal aorta and lower limb arteries (35% each). Brown tumors were present in 37% of the patients, mostly on the face and lower limbs (9% each). CONCLUSION: The greatest prevalence of bone findings were found on radiographs of the hands, wrists, lateral view of the thoracic and lumbar columns and femurs. The most prevalent findings were bone resorption and ectopic calcifications.

Prevalence of radiological findings among cases of severe secondary hyperparathyroidism / Prevalência de achados radiológicos em pacientes com grave hiperparatireoidismo secundário

CONTEXT AND OBJECTIVE: Patients with end stage renal disease (ESRD) and secondary hyperparathyroidism (HPT2) are prone to develop heterotopic calcifications and severe bone disease. Determination of the sites most commonly affected would decrease costs and patients' exposure to X-ray radiation. The aim here was to determine which skeletal sites produce most radiographic findings, in order to evaluate hemodialysis patients with HPT2, and to describe the most prevalent radiographic findings. DESIGN AND SETTING: This study was cross-sectional, conducted in one center, the Hospital Universitário Clementino Fraga Filho (HUCFF), in Rio de Janeiro, Brazil. METHODS: Whole-body radiographs were obtained from 73 chronic hemodialysis patients with indications for parathyroidectomy due to severe HPT2. The regions studied were the skull, hands, wrists, clavicles, thoracic and lumbar column, long bones and pelvis. All the radiographs were analyzed by the same two radiologists, with great experience in bone disease interpretation. RESULTS: The most common abnormality was subperiosteal bone resorption, mostly at the phalanges and distal clavicles (94 percent of patients, each). "Rugger jersey spine" sign was found in 27 percent. Pathological fractures and deformities were seen in 27 percent and 33 percent, respectively. Calcifications were presented in 80 percent, mostly at the forearm fistula (42 percent), abdominal aorta and lower limb arteries (35 percent each). Brown tumors were present in 37 percent of the patients, mostly on the face and lower limbs (9 percent each). CONCLUSION: The greatest prevalence of bone findings were found on radiographs of the hands, wrists, lateral view of the thoracic and lumbar columns and femurs. The most prevalent findings were bone resorption and ectopic calcifications.

CONTEXTO E OBJETIVO: Pacientes com hiperparatireoidismo secundário (HPT2) à insuficiência renal crônica são propensos a desenvolver calcificações ectópicas e grave doença óssea. A determinação dos sítios mais revelantes pode diminuir o custo e a exposição do paciente a radiação desnecessária. O objetivo foi determinar quais locais radiológicos apresentam mais achados radiográficos para avaliar o HPT2 em pacientes em hemodiálise, assim como os achados mais prevalentes. TIPO DE ESTUDO E LOCAL: Estudo transversal, realizado no Hospital Universitário Clementino Fraga Filho (HUCFF), no Rio de Janeiro, Brasil. MÉTODOS: Radiografias de corpo inteiro foram obtidas de 73 pacientes em hemodiálise crônica que tiveram indicação de paratireoidectomia devido a HPT2 grave. As regiões estudadas foram crânio, mãos e punhos, clavículas, coluna torácica e lombar, ossos longos e pélvis. Todas as imagens foram analisadas pelos mesmos dois radiologistas, com grande experiência na interpretação de doenças do osso. RESULTADOS: A alteração mais comum foi reabsorção óssea subperiosteal, principalmente nas falanges distais e clavículas (ambos em 94 por cento de pacientes). Sinal de "rugger jersey" foi descoberto em 27 por cento. Fratura patológica e deformidades foram visualizadas em 27 por cento e 33 por cento, respectivamente. As calcificações foram encontradas em 80 por cento dos pacientes, principalmente na fístula de antebraço (42 por cento), aorta abdominal e artérias dos membros inferiores (ambos 35 por cento). Tumores marrons estavam presentes em 37 por cento dos pacientes, principalmente na face e nos membros inferiores (ambos 9 por cento). CONCLUSÃO: As radiografias com achados mais prevalentes foram mãos e punhos, radiografia lateral da coluna torácica e lombar e fêmur. Os achados mais prevalentes foram reabsorção óssea e calcificação ectópica.

[Concentration of 25-hydroxyvitamin D in postmenopausal women with low bone mineral density]. / Concentração plasmática de 25 hidroxivitamina D em mulheres na pós-menopausa com baixa densidade mineral óssea.

OBJECTIVES: This study was designed to determine mean serum concentrations of 25-hydroxyvitamin D (25OHD) in postmenopausal women with low bone mineral density (BMD), to find the cutoff of parathormone (PTH) elevation, and to evaluate the correlation 25OHD with BMD, biochemical parameters and vertebral fracture presence. METHODS: Transversal study, with collection of 25OHD and PTH, and determination of DMO and column radiograph. RESULTS: A high incidence of inadequate serum concentrations of 25OHD (68.3%) was found and 8% of secondary hyperparathyreoidism. No significant differences were found between 25OHD serum concentrations and the evaluated parameters, except for PTH, which showed a negative association. The established cutoff was 61.5 nmol/L. CONCLUSIONS: The elevated incidence of hipovitaminosis D in elderly women with low BMD suggests that a systematic evaluation of 25OHD serum concentrations must be done for this population.The use of 61.5 nmol/L as a cutoff is recommended until the realization of an epidemiologic study that represents all Rio de Janeiro city (RJ, Brazil).

[Profile of clinical research subjects in an independent outpatient center]. / Perfil de sujeitos de pesquisa clínica em um centro ambulatorial independente.

This paper assesses the quality of assistance in a clinical trial outpatient center as well as the patients understanding of the informed consent (IC); determine the reasons why they participate and detail socio-economic levels. A cross-sectional study was adopted in a clinical trial outpatient center using a self-explanatory questionnaire. All 100 respondents considered the assistance at the center excellent (86%) or good (9%). Almost all of them were well informed about the content of the IC. Their knowledge about the right to "confidentiality", present in all ICs, was 6 times higher than their knowledge about their right to "access the results", generally not included in the IC. The main reasons for participating were "to know more about ones health" (59%) and to "to benefit other people in the future" (47%). The participants income varied from 3 to 5 minimum wages (48%) and most (66%) concluded at least the 4th grade of basic education in Brazil. The subjects showed the economical characteristics of the average population of Rio de Janeiro. Their level of education allowed them to sign and to understand what they were signing. They were aware of the existence of the IC and its content. The main reason for participating was for one s own benefit and for the benefit of others.

Perfil de sujeitos de pesquisa clínica em um centro ambulatorial independente / Profile of clinical research subjects in an independent outpatient center

Este artigo tem como objetivos avaliar a qualidade de atendimento de um centro de pesquisa clínica e o entendimento do termo de consentimento informado (TCLE); determinar os motivos da participação e detalhar níveis socioeconômicos. Foi feito um estudo transversal em centro de pesquisa ambulatorial, através de questionário auto-explicativo. Dos cem questionários avaliados, todos os sujeitos de pesquisa consideraram o centro como ótimo (86 por cento) ou bom (9 por cento). A quase totalidade foi bem informada do conteúdo do TCLE e o conhecimento do direito "confidencialidade", comum a todos os TCLEs, foi seis vezes maior que " acesso aos dados", que não faz parte. Os principais motivos para participarem foram para "saber mais sobre a sua saúde" (59 por cento) e para "beneficiar outras pessoas no futuro" (47 por cento). A principal faixa de renda salarial dos participantes foi entre dois e cinco salários mínimos (48 por cento) e a maioria (66 por cento) concluiu pelo menos até a 4º série do ensino fundamental. A população possui o mesmo perfil econômico do Rio de Janeiro, nível de escolaridade suficiente para assinar e compreender o que está assinando, conhecendo não só a existência do TCLE, mas demonstrando conhecer seu conteúdo. O motivo principal para participação é para autobenefício e por atitude altruísta.

This paper assesses the quality of assistance in a clinical trial outpatient center as well as the patients´understanding of the informed consent (IC); determine the reasons why they participate and detail socio-economic levels. A cross-sectional study was adopted in a clinical trial outpatient center using a self-explanatory questionnaire. All 100 respondents considered the assistance at the center excellent (86 percent) or good (9 percent). Almost all of them were well informed about the content of the IC. Their knowledge about the right to "confidentiality", present in all ICs, was 6 times higher than their knowledge about their right to "access the results", generally not included in the IC. The main reasons for participating were "to know more about ones health" (59 percent) and to "to benefit other people in the future" (47 percent). The participants´ income varied from 3 to 5 minimum wages (48 percent) and most (66 percent) concluded at least the 4th grade of basic education in Brazil. The subjects showed the economical characteristics of the average population of Rio de Janeiro. Their level of education allowed them to sign and to understand what they were signing. They were aware of the existence of the IC and its content. The main reason for participating was for one´s own benefit and for the benefit of others.

Ectopic and extranumerary parathyroid glands location in patients with hyperparathyroidism secondary to end stage renal disease

Supranumerary or ectopic parathyroid glands are the main cause of persistent hyperparathyroidism (HPT) in patients with end stage renal disease (ESRD) submitted to parathyroidectomy (PTx). PURPOSE: To evaluate the prevalence and location of parathyroid glands in these patients. METHODS: Thirty-five patients with ESRD and severe secondary hyperparathyroidism (HPT2) had been submitted to total PTx at HUCFF from December 2001 to July 2005. Surgery was always performed by the same surgeon, who described in details the location of the glands. RESULTS: Sixteen patients (45.7 percent) had ectopic glands, which were also extranumerary in five of them (14.3 percent). The most common locations were the thyroid parenchyma (33.3 percent), thyroid-thymus conduit (18.5 percent), and thymus (14.8 percent). Before PTx, the sensibility of ultrasonography and scintigraphy with technetium-99m Sestamibi was low (48.3 percent and 35.3 percent, respectively). Moreover, 51.4 percent of the nodules found at US were thyroid nodules. However, 99mTc-Sestamibi was useful to identify ectopic glands in those two patients with persistent HPT after PTx. CONCLUSION: The presence of extranumerary and ectopic parathyroid glands in HPT2 is sufficiently important to justify their exhaustive search. As the preoperative image exams present low sensibility to locate them, it is necessary to develop an exploratory routine embracing the most common sites of location.

A principal causa cirúrgica de persistência da doença após paratireoidectomia no hiperparatireoidismo secundário à insuficiência renal crônica (HPT2) é a existência de paratireóides supranumerárias e/ou ectópicas. OBJETIVO: Avaliar o número, prevalência de ectopia e localizações mais comuns das paratireóides nestes pacientes. MÉTODOS: Acompanhamos prospectivamente pacientes com HPT2, submetidos à paratireoidectomia no HUCFF, entre dezembro/2001 e julho/2005. Todos foram operados pelo mesmo cirurgião, que descreveu detalhadamente a localização das paratireóides encontradas. RESULTADOS: Foram avaliados 35 pacientes: em cinco (14,3 por cento) foi encontrada uma quinta glândula, supranumerária; dezesseis (45,7 por cento) possuíam glândulas ectópicas; as localizações mais comuns foram parênquima intratireoidiano (33,3 por cento), trajeto conduto tireotímico (18,5 por cento) e timo (14,8 por cento). As principais glândulas ausentes na presença de ectopia foram as inferiores esquerdas (29,6 por cento) e direitas (25,9 por cento). A sensibilidade da ultra-sonografia e da cintigrafia com sestamibi na detecção dos nódulos foi baixa (48,3 por cento e 35,3 por cento, respectivamente). Além disso, 51,4 por cento das ultra-sonografias mostraram incidentalomas tireoidianos. CONCLUSÃO: A presença de paratireóides supranumerárias e ectópicas no HPT2 é suficientemente relevante para justificar sua procura exaustiva. Como os exames de imagem pré-operatórios contribuem muito pouco para localizá-los, é necessário que se desenvolva uma rotina de exploração abrangendo as localizações mais comuns.

Ectopic and extranumerary parathyroid glands location in patients with hyperparathyroidism secondary to end stage renal disease.

UNLABELLED: Supranumerary or ectopic parathyroid glands are the main cause of persistent hyperparathyroidism (HPT) in patients with end stage renal disease (ESRD) submitted to parathyroidectomy (PTx). PURPOSE: To evaluate the prevalence and location of parathyroid glands in these patients. METHODS: Thirty-five patients with ESRD and severe secondary hyperparathyroidism (HPT2) had been submitted to total PTx at HUCFF from December 2001 to July 2005. Surgery was always performed by the same surgeon, who described in details the location of the glands. RESULTS: Sixteen patients (45.7%) had ectopic glands, which were also extranumerary in five of them (14.3%). The most common locations were the thyroid parenchyma (33.3%), thyroid-thymus conduit (18.5%), and thymus (14.8%). Before PTx, the sensibility of ultrasonography and scintigraphy with technetium-99m Sestamibi was low (48.3% and 35.3%, respectively). Moreover, 51.4% of the nodules found at US were thyroid nodules. However, 99mTc-Sestamibi was useful to identify ectopic glands in those two patients with persistent HPT after PTx. CONCLUSION: The presence of extranumerary and ectopic parathyroid glands in HPT2 is sufficiently important to justify their exhaustive search. As the preoperative image exams present low sensibility to locate them, it is necessary to develop an exploratory routine embracing the most common sites of location.

Risk factors for decreased total body and regional bone mineral density in hemodialysis patients with severe secondary hyperparathyroidism.

Hyperparathyroidism contributes significantly to decreased bone mineral density (BMD) in end-stage renal disease patients, but this negative influence is not homogeneous throughout the skeleton. We studied the BMD by dual-energy X-ray absorptiometry on total body and on different regions of the skeleton in 42 patients with severe hyperparathyroidism on hemodialysis. We also evaluated the relationship between different risk factors and BMD found on the regions examined in these patients. The legs and other sites where cortical bone predominate were mostly affected, whereas trabecular bone was relatively preserved. This is probably the result of the different effects of hyperparathyroidism on cortical and trabecular bone, but we cannot rule out the interference of ectopic calcifications and sclerotic lesions of vertebral end-plates falsely increasing lumbar spine BMD. The main determinants of low total-body BMD were, in order of importance, immobility, high intact parathyroid hormone levels, low body mass index, and low albumin. Eleven patients presented with pathologic fractures, mainly in the legs, and BMD was lower in this group than in patients without fractures. In conclusion, our study makes clear that hyperparathyroidism is a great threat to bone density in hemodialysis patients, mainly in the legs, the site mostly affected by fragility fractures in our patients. Physicians must worry not only with high parathyroid hormone levels, but also with the nutritional state of these patients.

Metástase ocular de carcinoma de mama: relato de cinco casos / Ocular metastasis of breast cancer: five cases report

Os autores documentam cinco casos de pacientes femininas portadoras de câncer de mama com disseminação ocular. Na série, quatro pacientes já apresentavam doença sistêmica no momento da comprovação de metástase ocular, enquanto uma apresentou lesão orbitária como manifestação inicial de tumor mamário não identificado previamente. A idade na época do diagnóstico de carcinoma de mama variou de 36 a 48 anos. O intervalo entre o diagnóstico de câncer de mama e o surgimento dos sinais e sintomas oculares variou de zero a 128 meses, com média de 60 meses. O intervalo entre o diagnóstico e a recidiva da doença variou de 13 a 132 meses e entre esta e o óbito variou de 4 a 50 meses. Neste estudo duas pacientes receberam quimioterapia; e as demais, a associação de quimioterapia e radioterapia. É importante assinalar que duas mulheres desenvolveram metástases oculares em vigência de quimioterapia. Embora a sensibilidade da metástase à radioterapia esteja bem documentada em vários estudos, há poucas publicações que comprovam a eficácia da quimioterapia.