Bone mineral density in diabetes and impaired fasting glucose.

We report that compared with normoglycaemia, post-menopausal women (non-obese and obese) with diabetes had higher lumbar spine bone mineral density (LSBMD). Femoral neck bone mineral density (FNBMD) was higher in obese post-menopausal women with diabetes. Only non-obese post-menopausal women with impaired fasting glucose (IFG) had a higher LSBMD than normoglycaemia. No other associations with IFG were observed. INTRODUCTION: Individuals with diabetes have a higher or normal bone mineral density (BMD) compared with those without diabetes. However, paradoxically, they also have a higher fracture risk. It is not clear whether those with IFG also have altered BMD. This study aimed to determine whether individuals with IFG have elevated or normal BMD. METHODS: Women (n = 858) and men (n = 970) (aged 20-80 years) from the Geelong Osteoporosis Study were included. IFG was defined as fasting plasma glucose (FPG) 5.5-6.9 mmol/L and diabetes as FPG ≥ 7.0 mmol/L, use of antihyperglycaemic medication and/or self-report. Using multivariable linear regression, the relationships between glycaemia and BMD at the femoral neck and lumbar spine were examined, and adjusted for age, body mass index (BMI), and other variables. In women, two interaction terms were identified: menopause × glycaemia and BMI × glycaemia, and thus, the analyses were stratified by menopause and obesity status (BMI cut point ≥ 30 kg/m2). RESULTS: There were no associations between glycaemic status and BMD for pre-menopausal women. For non-obese post-menopausal women, there was no association between FNBMD and glycaemic status, but women with IFG or diabetes had higher LSBMD than those with normoglycaemia (7.1% and 9.7%, respectively, both p < 0.01). Obese post-menopausal women with diabetes had a higher FNBMD (8.8%, p = 0.008) and LSBMD (12.2%, p < 0.001), but those with IFG were not different from the normoglycaemia group. There were no associations detected between glycaemic status and BMD in men. CONCLUSIONS: In this study, we report that compared with normoglycaemia, post-menopausal women (non-obese and obese) with diabetes had higher LSBMD. FNBMD was higher in obese post-menopausal women with diabetes. Only non-obese post-menopausal women with IFG had a higher LSBMD than normoglycaemia. No other associations with IFG were observed.

Clinical and Nutritional Factors Associated With Early Mortality After Heart Transplantation.

OBJECTIVE: The aim of this work was to verify the association between clinical and nutritional factors and mortality in the 1st 30 days after heart transplantation. METHODS: This was a retrospective study of patients who underwent heart transplantation in a public hospital in Brazil from January 2013 to August 2015. The clinical and nutritional factors analyzed were: body mass index, body surface area, cachexia, infection, duration of orotracheal intubation, ejection fraction, mean pulmonary pressure, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score, hemoglobin, and diabetes mellitus. The primary outcome was mortality in the 1st 30 days after heart transplantation, and secondary outcomes were infection, acute kidney insufficiency, and duration of orotracheal intubation. We performed chi-square test, unpaired t test, and logistic regression in the analyses. A P value of < .05 was considered to be significant. RESULTS: The sample had 103 patients, of which 16 patients (15.53%) died within 30 days after heart transplantation. We observed a relationship between death and orotracheal intubation duration (P < .01), postoperative creatinine (P < .01), acute kidney injury (P < .01), and INTERMACS score (P = .01) in the bivariate analysis but not in the multivariate model. CONCLUSIONS: Clinical and nutritional factors had no impact on mortality up to 30 days after heart transplantation in this study, although orotracheal intubation duration, postoperative creatinine, acute kidney injury, and INTERMACS score were individually associated with early death.

Dysglycaemia and Other Predictors for Progression or Regression from Impaired Fasting Glucose to Diabetes or Normoglycaemia.

AIMS: Diabetes mellitus is a growing health problem worldwide. This study aimed to describe dysglycaemia and determine the impact of body composition and clinical and lifestyle factors on the risk of progression or regression from impaired fasting glucose (IFG) to diabetes or normoglycaemia in Australian women. METHODS: This study included 1167 women, aged 20-94 years, enrolled in the Geelong Osteoporosis Study. Multivariable logistic regression was used to identify predictors for progression to diabetes or regression to normoglycaemia (from IFG), over 10 years of follow-up. RESULTS: At baseline the proportion of women with IFG was 33.8% and 6.5% had diabetes. Those with fasting dysglycaemia had higher obesity-related factors, lower serum HDL cholesterol, and lower physical activity. Over a decade, the incidence of progression from IFG to diabetes was 18.1 per 1,000 person-years (95% CI, 10.7-28.2). Fasting plasma glucose and serum triglycerides were important factors in both progression to diabetes and regression to normoglycaemia. CONCLUSIONS: Our results show a transitional process; those with IFG had risk factors intermediate to normoglycaemics and those with diabetes. This investigation may help target interventions to those with IFG at high risk of progression to diabetes and thereby prevent cases of diabetes.

Real-time, non-invasive microscopic confirmation of clinical diagnosis of bullous pemphigoid using in vivo reflectance confocal microscopy.

BACKGROUND: Bullous pemphigoid is an autoimmune disease affecting prevalently the elder. In vivo reflectance confocal microscopy is a non-invasive technique for real-time imaging of the skin with cellular-level resolution. No previous data has been reported about confocal microscopy of bullous pemphigoid. Aim of this preliminary study is the evaluation of the potential of in vivo reflectance confocal microscopy for real-time, microscopical confirmation of clinical bullous pemphigoid diagnosis. METHODS: A total of nine lesions from patients affected by pemphigoid underwent in vivo reflectance confocal microscopy before histological examination. RESULTS: In our preliminary study, confocal microscopy showed high grade of correspondence to histopathology. In particular, presence of sub-epidermal cleft and variable amount of oedema of the upper dermis associated with inflammatory cells infiltration were seen as prevalent confocal features in the bullous lesions considered. Differently, in urticarial lesions, no specific features could be appreciated at confocal analysis beside the presence of signs of spongiosis and perivascular inflammation. CONCLUSION: Confocal microscopy seems to be useful for in vivo, microscopical confirmation of the clinical suspect of bullous pemphigoid and for biopsy site selection in urticarial lesions to obtain a more significant specimen for histopathological examination.

Is the trapezius transfer a useful treatment option for irreparable tears of the subscapularis?

INTRODUCTION: When suture of the torn subscapularis could not be performed, a superior trapezius transfer was used for repair of the tendinous defect. The aim of this article is to report the mid-term functional and radiographic outcome of this technique when complete watertight rotator cuff healings were achieved and to investigate the usefulness of the trapezius transfer. The hypothesis of this work was that the trapezius transfer could not be considered as a useful treatment option. MATERIALS: The study included 20 shoulders demonstrating watertight healing of the rotator cuff on arthro CT-scan control performed 13.5 months after open surgery consisting of a trapezius transfer and suture of all other torn tendons. The mean age at surgery was 58.4 years. The trapezius transfer operative technique is described. METHODS: The functional status of the shoulders was assessed preoperatively and at a mean follow-up of 30 months according to the non-weighted Constant score and by measurement of active external rotation, arm at the side. Radiographic and CT-scan assessments were performed preoperatively and at a mean follow-up of 28.5 months. The functional results obtained at last follow-up were compared with those "theoretically estimated" after anatomically successful suture of the torn supra and infraspinatous without associated repair of the torn subscapularis. RESULTS: Between the pre- and postoperative periods, pain, daily activities and Constant score had all statistically improved. Arthritis was not aggravated but the preoperative anterior subluxation of the humeral head persisted in most cases. The reported Constant scores correlated those "theoretically estimated" in case of non-associated subscapularis repair. DISCUSSION: This series is comparable to those evaluating the pectoralis major transfer technique and reports an identical functional outcome. CONCLUSION: Since the Constant scores obtained after trapezius transfer correlate those estimated when not combining a subscapularis repair and taking into account the very frequent lack of improvement regarding the preoperative anterior subluxation of the humeral head, the trapezius transfer does not appear as a recommendable treatment option.

[Geometric index of heart rate variability in chronic obstructive pulmonary disease]. / Índices geométricos de variabilidade da frequência cardíaca na doença pulmonar obstrutiva crônica.

BACKGROUND: It was already evidenced decreased heart rate variability (HRV) in chronic obstructive pulmonary disease (COPD) patients at rest. OBJECTIVE: In order to insert new elements in the literature regarding this issue, we evaluated geometric index of HRV in COPD subjects. METHOD: We analyzed data from 34 volunteers, divided into two groups according to spirometric values: COPD (17 volunteers, FEV1/FVC=47.3±10.2; FEV1=50.8±15.7) and control (17 volunteers, FEV1/FVC=78.8±10.8; FEV1=100.1±14.7). For analysis of HRV indexes the volunteers remained in the supine position for 30 minutes. We analyzed the following indexes: triangular index (RRtri), triangular interpolation of RR intervals (TINN) and Poincaré plot (SD1, SD2 and SD1/SD2). Student t test for unpaired samples and Mann-Whitney test were used for data analysis. RESULTS: We observed statistically significant reductions in geometric indexes in the COPD group: RRtri (0.043±0.01 vs. 0.059±0.02; p=0.018), TINN (105.88±51.82 vs. 151.47±49.9; p=0.014), SD1 (9.76±4.66 vs. 14.55±6.04; p=0.014) and SD2 (34.86±17.02 vs. 51.51±18.38; p=0.010). SD1/SD2 (0.30±0.11 vs. 0.28±0.07; p=0.605) were not significantly different between groups. Patients with COPD presented a visual analysis of Poincaré plot of lower dispersion of RR intervals both beat to beat and the long term. CONCLUSION: Subjects with COPD present reduction of geometric indexes of HRV, indicating reduced heart rate variability.

The variability of baroreflex sensitivity in juvenile, spontaneously hypertensive rats.

In this study the baroreflex sensitivity of conscious, juvenile, spontaneously hypertensive rats (SHRs) was compared. The study population consisted of 19 eight-week-old male SHRs. The baroreflex sensitivity was quantified as the derivative of the variation in heart rate (HR) and the variation of mean arterial pressure (baroreflex sensitivity = ΔHR/ΔMAP). MAP was manipulated with sodium nitroprusside (SNP) and phenylephrine (PHE), administered via an inserted cannula in the right femoral vein. The SHRs were divided into four groups: (1) low bradycardic baroreflex (LB) where the baroreflex gain (BG) was between 0 and -1 bpm/mmHg with PHE; (2) high bradycardic baroreflex (HB), where the BG was < -1 bpm/mmHg with PHE; (3) low tachycardic baroreflex (LT) where the BG was between 0 and 3 bpm/mmHg with SNP; (4) high tachycardic baroreflex (HT) where the BG was > 3 bpm/mmHg with SNP. We noted that 36.8% of the rats presented with an increased bradycardic reflex, while 27.8% demonstrated an attenuated tachycardic reflex. No significant alterations were noted regarding the basal MAP and HR. There were significant differences in the baroreflex sensitivity between SHRs in the same laboratory. One should be careful when interpreting studies employing the SHR as a research model.

The duration of forest stages in southern Europe and interglacial climate variability.

Foraminiferal oxygen isotope and pollen analyses from a deep-sea sequence off southwest Portugal show that the duration of temperate stages on land over the past 350,000 years varied considerably. The record shows forest contractions during intervals of low ice volume, coeval with declines in atmospheric methane, after which tree populations did not always recover. What emerges is that, although the broad timing of interglacials is consistent with orbital theory, their specific duration may be dictated by millennial variability. This complicates the prediction of the natural duration of interglacials, at least until the origin of this climate variability is understood.

Enantioselective HPLC analysis of propafenone and of its main metabolites using polysaccharide and protein-based chiral stationary phases.

HPLC on chiral stationary phases has been used for the enantioselective assay of propafenone (PPF), 5-hydroxypropafenone (PPF-50H) and N-despropylpropafenone (PPF-NOR) enantiomers. The results obtained on Chiralpak AD column showed that it is useful for the resolution of PPF and of its main metabolites, although the peaks obtained for PPF-NOR were not symmetrical under the conditions investigated. This column and circular dichroism-based detection system were used to determine the absolute configuration of the eluates. Furthermore, the influence of the mobile phase composition on the resolution of PPF and of its main metabolites was investigated on cellulose derivatives (Chiralcel OD-H and Chiralcel OD-R) and protein (Chiral AGP and Ultron ES-OVM)-based chiral stationary phases. The enantiomers of PPF were resolved on all the columns, except for the Ultron ES-OVM. This column, the Chiralpak AD and the Chiralcel OD-H columns were suitable for the resolution of the PPF-50H enantiomers. The PPF-NOR enantiomers were resolved on the Chiralpak AD, Chiral AGP and Chiralcel OD-R columns.

Heparan sulfates and heparins: similar compounds performing the same functions in vertebrates and invertebrates?

The distribution and structure of heparan sulfate and heparin are briefly reviewed. Heparan sulfate is a ubiquitous compound of animal cells whose structure has been maintained throughout evolution, showing an enormous variability regarding the relative amounts of its disaccharide units. Heparin, on the other hand, is present only in a few tissues and species of the animal kingdom and in the form of granules inside organelles in the cytoplasm of special cells. Thus, the distribution as well as the main structural features of the molecule, including its main disaccharide unit, have been maintained through evolution. These and other studies led to the proposal that heparan sulfate may be involved in the cell-cell recognition phenomena and control of cell growth, whereas heparin may be involved in defense mechanisms against bacteria and other foreign materials. All indications obtained thus far suggest that these molecules perform the same functions in vertebrates and invertebrates.

Simultaneous determination of propafenone and 5-hydroxypropafenone enantiomers in plasma by chromatography on an amylose derived chiral stationary phase.

An enantioselective liquid chromatography method was developed for the simultaneous determination of propafenone (PPF) and 5-hydroxypropafenone (PPF-5OH) enantiomers in plasma. After liquid liquid extraction with dichloromethane, the enantiomers were resolved on a Chiralpak AD column using hexane-ethanol (88:12, v/v) plus 0.1% diethylamine as the mobile phase and monitored at 315 nm. Under these conditions the enantiomeric fractions of the drug and of its metabolite were analysed within 20 min. The extraction procedure resulted in absolute recoveries of 62.9 and 61.3% for (R)- and (S)-PPF, respectively, and of 57.6 and 56.5% for (R)- and (S)-PPF-5OH, respectively. This procedure was efficient in removing endogenous interferents as well the interference of an other PPF metabolite, N-despropylpropafenone (PPF-NOR). The calibration curves were linear over the concentration range 25-1250 ng/ml. Low values of the coefficients of variation were demonstrated for both within-day and between day assays. The method described in this paper allows the determination of PPF and PPF-5OH enantiomers at plasma levels as low as 25 ng/ml and can be used in clinical pharmacokinetic studies.

Upper extremity nerve lesions (diagnosis, indications, surgical techniques).

OBJECTIVE: Revision and questioning of orthodox principles regarding the conduction of nerve impulse. DESIGN: Retrospective study with clinical analysis of results. SITE: Hospital das Clinicas (HCFMSP), public university institution with research programs and tertiary attention to health. GROUP MEMBERS: Author and a team of residents and trainees. OPERATION: Direct suture of nervous stumps utilizing auxiliary technical procedures:- joint-flexion, nerve transposition, tendon transplants, bone shortening. MEASUREMENT: Clinical evaluation and objective tests for tactile and stereognostic function recovery (Weber Test). RESULTS: Variable, depending on preoperative conditions:- type of lesion, time elapsed since injury. CONCLUSIONS: Neurorrhaphy should be the procedure of choice even for long term lesions, although the expected results may be less favourable. Periodical evaluation from 24 hs. postoperative, checking for early undefined signals of nervous function recovery. Association of specific drugs for chemical biophysics of the nerve.

[Comparative controlled study on the use of benznidazole, nifurtimox and placebo, in the chronic form of Chagas' disease, in a field area with interrupted transmission. I. Preliminary evaluation]. / Estudo comparativo controloado com emprego de benznidazole, nifurtimox e placebo, na forma crônica da doença de Chagas; em uma área de campo com transmissão interrompida. I. Avalição preliminar.

A controlled clinical trial was carried out to evaluate the therapeutic efficacy and tolerance of nifurtimox and benznidazole in patients with chronic Chagas' disease. All patients had immunofluorescence and complement fixation reactions positives for T. cruzi antibodies and at least two xenodiagnoses positives in three performed before treatment, and they were submitted to clinical examinations, ECG and X-ray of the heart and esophagus. Of 77 patients studied, 27 were treated with nifurtimox and 26 with benznidazole in the dosage of 5 m/kg/day for 30 consecutive days, and 24 received a placebo in tablets similar to benznidazole. From the 77 patients, 64 (83.1%) accomplished the treatment: 23 (88.4%) with benznidazole, 19 (70.3%) with nifurtimox and 22 (91.6%) with placebo. The patients were evaluated, clinically, serologically and parasitologically (six xenodiagnoses within one year after treatment). The benznidazole group showed only 1.8% of positive xenodiagnoses post-treatment, the nifurtimox 9.6% and the placebo 34.3%. All serologic reactions continued positive and there were no clinical, ECG or X-ray changes one year after treatment.

Evaluation of the xenodiagnosis of chronic Chagas patients infected ten years or over in an area where transmission has been interrupted--Iguatama and Pains, west Minas Gerais State, Brazil.

To evaluate the results of xenodiagnosis in chronic Chagas patients infected for ten years or over in an area where transmission has been stemmed as well as the performance of these tests applied one or more times to determine the presence of the parasite in serum-positive patients for Trypanosoma cruzi infection, 570 xenodiagnosis were performed in 246 patients by exposing each patient to 40 Triatoma infestans nymphs of 3rd/4th stage once, twice or three times, at 30 days intervals. The 570 xenodiagnosis showed overall positive results in 50.7% with a peak 78% in patients under 20 years of age, and 60.5% in those over 60. Of the 158 patients who underwent three xenodiagnosis, 51 (32.3%) had three positive tests, 48 (30.3%) had all negative results, and the remainder had alternating positive and negative findings. There was no difference in number of positive results between the 1st, 2nd and 3rd tests; however, the 1st and 2nd trials added up to 53.2% and the sum total of all three trials was 57.7%.

[Accident prevention and emergency treatment of traumatic hand injuries in the metropolitan area of São Paulo]. / Prevenção de acidentes e atendimento de emergência de lesões traumáticas da mão na área metropolitana de São Paulo.

The workman's hand is a "tool"; it is his most valuable asset. Worker selection and training, associated with a preventional approach, by employee and employer, humanises work and makes it more effective. The rate of hand injuries in the city of São Paulo is very high (of the order of 500 cases per day) and its aggregate cost is extremely high. The primary care of lesions is so poor that it well deserves the label of "second accident". The CIPAM-SUDS/SP system will provide a simpler and proper treatment by trained surgeons in full time duty in first-aid decentralized stations, located inside the industrial areas.

Early restoration of pinch grip after ulnar nerve repair and tendon transfer.

Restoration of pinch in ulnar nerve lesions may be achieved within three or four weeks by a one-stage operation combining nerve repair and tendon transfer. We have been using this approach for nerve injuries of the upper limb since 1961, to meet the socio-economic needs of patients who would otherwise need splints and long-term physiotherapy. In our experience, the procedure of choice is transfer of E.I.P. to adductor pollicis and E.P.B. to the first dorsal interosseous. The operative technique and its results in 18 patients followed up for 37-515 days are discussed.

[Morbidity in Chagas' disease. IV. Longitudinal study of 10 years in Pains and Iguatama, Minas Gerais, Brazil]. / Morbidade da doenca de Chagas. IV. Estudo longitudinal de dez anos emPains e Iguatama, Minas Gerais, Brasil.

An evolutive study of the "case-control" type was carried out in an endemic area of Chagas' disease in Minas Gerais State, Brazil, using two cross-section evaluations with an interval of ten years between them (1974-1984). Patients were paired for sex and age. In the first cross-section study 264 pairs one with a positive serology and the other with a negative serology for T. cruzi antibodies were included. In the second evaluation, ten years later, 235 patients among those with previous positive serology and 216 with negative serology were located, but only 110 pairs could be recomposed and reexamined (clinical examination, ECG and Rx of the heart and esophagus). The incidence of chagasic cardiopathy in the cases with positive serology but previously assymptomatic was 38.3% during the ten year period. On the other hand there was a deterioration in 24% of the patients with chagasic cardiopathy since the first examination. Considering all clinical forms of the disease in 34.5% of the patients the clinical situation deteriorated, in 57.3% there was no change and in 8.2% the situation improved. The general mortality in the period was 23% in the chagasic group and 10.6% in the control group, but the lethality by cardiopathy was 17% in chagasic group and only 23.3% in the control group. The mortality was twice as high in males than in females, mainly in the age group from 30 to 59 years.

Clinical aspects of muscle imbalance in the hand due to ulnar nerve lesions and a proposed thumb-index finger grip classification.

This study deals with the anatomical and clinical bases of the thumb-index finger grip, emphasizing not only its general importance, but also its ergonomic role. A classification according to the different functions of two muscular groups (extrinsic and intrinsic), with special reference to muscular imbalance due to ulnar nerve lesions is proposed. After some general considerations on the function of the hand practical conclusions are drawn.