Correction: Osteoporotic hip fracture-Comorbidities and factors associated with in-hospital mortality in the elderly: A nine-year cohort study in Brazil.

[This corrects the article DOI: 10.1371/journal.pone.0272006.].

Clinical and economic impact of coronary artery bypass graft and percutaneous coronary intervention in young individuals with acute coronary syndromes and multivessel disease: A real-world comparison in a middle-income country.

Background: In recent decades, the world watched a dramatic increase in the incidence of acute coronary syndromes (ACS) among young individuals (≤55 years-old) and a relative decrease in the elderly. The management of ACS in young patients with multivessel disease still needs to be elucidated, as these individuals maintain a long life expectancy. Research Question: To compare clinical outcomes and care costs in individuals with premature ACS and multivessel disease undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). Methods and Results: Participants included all individuals ≤55 years-old admitted with ACS to public hospitals in Brasília (Brazil) between 2013 and 2015 and who underwent cardiac catheterization with SYNTAX score ≥23 or Duke category 6. Outcomes were adjudicated with death certificates and data from medical records. The primary outcome was the occurrence of major adverse cardiovascular events (MACE), defined as death due to cardiovascular causes, recurrent hospitalizations due to cardiovascular ischemic events, and incident heart failure New York Heart Association III-IV. As secondary outcome we assessed indirect and direct costs by evaluating the cost of lost productivity (in international dollars (Int$) per year) due to illness and death, outpatient costs and costs with new hospitalizations. Multivariate and principal components (PC) adjusted analyzes were performed. Results: Among 1,088 subjects (111 CABG and 977 PCI) followed for 6.2 years (IQR: 1.1), 304 primary events were observed. MACE was observed in 20.7% of the CABG group and 28.8% of the PCI group (p = 0.037). In multivariate analyses, PCI was associated with a hazard ratio (HR) = 1.227 (95% CI: 1.004-1.499; p = 0.0457) for MACE, and in PC-adjusted HR = 1.268 (95% CI: 1.048-1.548; p = 0.0271) compared with CABG. Despite direct costs were equivalent, the cost due to the loss of labor productivity was higher in the PCI group (Int$ 4,511 (IQR: 18,062)/year vs Int$ 3,578 (IQR: 13,198)/year; p = 0.049], compared with CABG. Conclusions: Among young individuals with ACS and multivessel disease, surgical strategy was associated with a lower occurrence of MACE and lower indirect costs in the long-term.

Osteoporotic hip fracture-Comorbidities and factors associated with in-hospital mortality in the elderly: A nine-year cohort study in Brazil.

INTRODUCTION: The aim of the study was to identify factors associated with the causes of in-hospital morbidity and mortality in an elderly Brazilian population due to osteoporotic hip fractures. METHOD: Retrospective cohort study involving a population over 60 years of age admitted to hospital due to osteoporotic hip fractures and followed up from hospitalization to outcome (discharge or mortality) from 2010 to 2018, in a public hospital in Brasília, the capital of Brazil. Multivariate analysis was performed using the Poisson regression model with a robust variance, observing the hierarchical model proposed and the receiver operating characteristic (ROC) curve to obtain the cutoff point for mortality incidence in relation the total length of hospital stay. Significance level was set as p < 0.05. The analyses were conducted using the SAS 9.4 software. RESULT: The mean hospital mortality rate among the 402 patients involved was 18.4%, and the associations made with the outcome mortality were per relevance: respiratory infection, age over 90 years, high preoperative cardiovascular risk, chronic obstructive pulmonary disease (COPD) as comorbidity, serum hemoglobin level ≤ 10 and other infections. Mortality also showed association with longer total length of hospital stay, as well as with prolonged postoperative period. CONCLUSION: Hip fractures in the elderly due to osteoporosis indicate a relationship between the sicker profile of the aging elderly population and the prevalence of chronic diseases strongly associated with in-hospital infections, contributing to increased mortality. There were fewer early interventions, and mortality was also associated with prolonged postoperative period. The aim of this study was not to compare independent variables with each other, but suggests the relationship between the presence of comorbidities, which predisposes to the development of infections, directly linked to mortality.

Fractal dimension analysis on CBCT scans for detecting low bone mineral density in postmenopausal women.

Purpose: The aim of this study was to compare the fractal dimension (FD) measured at 2 bone sites (second cervical vertebra and mandible) on cone-beam computed tomography (CBCT). The research question was whether FD could serve as an accessory tool to refer postmenopausal women for densitometric analysis. Therefore, the reliability and accuracy of FD were evaluated. Materials and Methods: In total, 103 postmenopausal women were evaluated, of whom 52 had normal bone mineral density and 51 had osteoporosis, according to dual X-ray absorptiometry of the lumbar spine and hip. On the CBCT scans, 2 regions of interest were selected for FD analysis: 1 at the second cervical vertebra and 1 located at the mandible. The correlations between both measurements, intra- and inter-observer agreement, and the accuracy of the measurements were calculated. A P value less than 0.05 was considered to indicate statistical significance for all tests. Results: The mean FD values were significantly lower at the mandibular region of interest in osteoporotic patients than in individuals with normal bone mineral density. The areas under the curve were 0.644 (P=0.008) and 0.531 (P=0.720) for the mandibular and vertebral sites, respectively. Conclusion: FD at the vertebral site could not be used as an adjuvant tool to refer women for osteoporosis investigation. Although FD differed between women with normal BMD and osteoporosis at the mandibular site, it demonstrated low accuracy and reliability.

Accuracy of Oral 67Gallium Citrate Scintigraphy in assessment of inflammatory activity of Crohn's disease.

AIM: The main goal in Crohn´s disease (CD) is a sustained suppression of inflammatory activity associated with mucosa healing in endoscopic evaluation. During clinical routine, there are small numbers of good markers to monitor inflammatory activity under treatment. We postulated that Oral 67Gallium Citrate Scintigraphy is able to mark inflammatory disease in mucosa and deep inflammation in CD, when used in oral form. OBJECTIVE: Measure the accuracy of Oral 67Gallium Citrate Scintigraphy in intestinal inflammatory activity of Crohn´s disease. PATIENTS AND METHODS: In a prospective consecutive cross-sectional study from January 2018 to June 2019, the ileocolonic region of 32 patients with CD were studied by dividing into four regions of interest (ROI) from the ileum to the rectum. A total of 128 intestinal segments were analyzed in cluster data. Accuracy values of Oral 67Gallium Scintigraphy and colonoscopy tests were evaluated with the histological reference test. Values of the respective receiver operating characteristic (ROC) curves were obtained  and compared. The reliability between the tests was evaluated by Kappa statistical with the segment-level analyses using variance adjustments. All statistical analyses were performed with a test significance level of 0.05. RESULTS: The study population included 32 patients with CD (10 men, 22 women; average age 39 years). Disease time was five years on average. Anti-TNFs treatment was found in 71%. The most found phenotype of the Montreal classification was L3. Differences in ROC curves for colonoscopy (0.94) and Oral 67Ga Scintigraphy (0.96) did not show significant value (p = 0.32). The sensitivity of scintigraphy to detect intestinal inflammatory activity in CD was 64%, specificity of 96% and accuracy of 84%. A high agreement was found between oral scintigraphy and histological measurements with kappa = 0.64. CONCLUSIONS: Oral 67Ga Scintigraphy had similar accuracy and agreement compared to colonoscopy in the identification of inflammatory activity in Crohn´s Disease. This new approach may be useful and less invasive for long term follow-ups.

Correlation and concordance measures between clinical, endoscopic and histological scores activity in Crohn's disease under treatment.

Aim: Our aim was to evaluate the correlation and concordance measures between clinical, endoscopic and histologic remission in Crohn's disease (CD) under treatment. Method: Twenty-four patients with CD under treatment were included in a prospective consecutive cross-sectional study from January to September 2018. Clinical activity was assessed by Crohn's Disease Activity Index (CDAI). All of the patients were submitted an ileocolonoscopy with biopsy and classified by Simple Endoscopic Score (SES-CD). Histologic activity was assessed by Global Histologic Activity Score (GHAS) modified. Remission was considered with CDAI <150; SES-CD ≤2 and GHAS ≤4. Results: Clinical remission was established in 53%, however, only 50% had mucosal healing (MH) and 70% had inflammatory histologic activity. Correlation between endoscopic and histological measures was strong and positive (σ = 0.73, p < .0003). The concordance remission agreement between SES-CD and GHAS was weak with (κ) = 0.3 (IC 95%: -0.09; 0.69). The greatest disparity arose when clinical activity (CDAI) was compared with histological measures (σ = 0.20, p = .45), (κ) = 0.26 (IC = -0.03; 0.56). Conclusion: The score SES-CD correlates well with histological score GHAS in CD under treatment, however, there is low concordance between both mainly in patients with anti-TNFs treatment. CDAI score had low correlation and concordance with histological score GHAS. In this sample, patients under treatment and without symptoms had low MH and histologic healing.

Análise da influência da retirada do leito de idosos na UTI e da continuidade da fisioterapia na enfermaria sobre o tempo de permanência, a readmissão e a mortalidade / Analysis of the influence of bed's withdrawal of the elderly in the ICU and the continuity of physical therapy in the ward on length of stay, readmission and mortality

Objetivo: Analisar a influência da retirada do leito de idosos na UTI e da continuidade da fisioterapia na enfermaria sobre tempo de internação, readmissão e mortalidade. Métodos: Trata-se de um estudo de coorte histórico realizado por meio dos registros de idosos egressos de UTI de um hospital público. Verificou-se as caracterí­sticas clí­nicas e o ní­vel de gravidade dos pacientes pelo escore SAPS 3 (Simplified Acute Physiology Score III). Analisou-se a retirada do leito na UTI, o ní­vel de mobilização alcançado e a continuidade da fisioterapia na enfermaria. Observou-se a relação entre essas variáveis e os desfechos ocorridos. Resultados: Os 133 idosos estudados apresentaram média de idade de 70 ±7 anos; 66,1% eram homens; 78,2% foram retirados do leito na UTI e, após a admissão na enfermaria, 51,9% receberam fisioterapia. O tempo médio de internação após a alta da UTI foi de 27,6 dias; 11,2% dos pacientes foram readmitidos em unidades crí­ticas e 18% foram a óbito. Os idosos que não foram retirados do leito na UTI e aqueles que mantiveram o ní­vel de mobilização após a admissão na enfermaria apresentaram maior readmissão e mortalidade. Conclusão: Parece existir menor risco de readmissão e de mortalidade em pacientes submetidos í terapêutica de retirada do leito na UTI. (AU)

Objective: To analyze the influence of bed's withdrawal of elderly in the ICU and the continuity of the physical therapy in the ward over length of stay, readmission and mortality. Methods: This is a historical cohort study carried out through the registries of elderly patients from the ICU of a public hospital. The clinical characteristics and the level of severity of the patients by the SAPS 3 (Simplified Acute Physiology Score III) were verified. The ICU bed removal, the level of mobilization achieved and the continuity of physical therapy in the ward were analyzed. It was observed whether there was a relationship between these variables and the outcomes. Results: The 133 elderly studied had mean age of 70 ± 7 years; 66.1% were men; 78.2% of the patients were removed from the hospital bed and, after ward admission, 51.9% received physical therapy. The mean length of hospital stay after discharge from the ICU was 27.6 days; 11.2% of the patients were readmitted in critical units and 18% died. The elderly who were not removed from the ICU bed and those who maintained the level of mobilization after admission to the ward presented higher readmission and mortality. Conclusion: There seems to be a lower risk of readmission and mortality in patients undergoing ICU bed removal therapy. (AU)

Can be the cement augmentation an improvement method of preventing hip fractures in osteoporotic patients? / Pode ser a cimentoplastia um método aprimorado para a prevenção de fraturas do quadril em pacientes osteoporóticos?

Introduction: The population around the world is aging. With this, there will be an increased incidence of fractures due to osteoporosis of the hip and this will be a serious global health problem. A World Health Organization (WHO) estimate suggests that the incidence of hip osteoporotic fractures worldwide will triple by 2050. Objective: To present, through a literature review, the main results of the femoral reinforcement, a technique described by scientific articles, with the potential to increase the proximal femoral load for the occurrence of fractures, whether using polymethylmethacrylate (PMMA), phosphate cement calcium (CPC), elastomers and metal implants. Methods : Through electronic search in databases PubMed, Latin American and Caribbean Center of Health Information Information (Bireme), Coordination for the Improvement of Higher Education Personnel (Capes), Scientific Electronic Library Online (SciELO), Google Scholar And Cochrane, using the terms cementoplasty and femororplasty, the studies were selected according to a specific inclusion criterion, describing the main findings of the biomechanical results, type of study and material used to perform the femoral reinforcement. Results : Of the 15 articles analyzed, 14 were experimental analyzes and one was a clinical trial, seven studies used PMMA, two used CPC, four elastomers and two metal implants, 13 of them showed favorable Newton load (N) results for the fracture hip. Conclusion: Most of the studies on femoral reinforcement is experimental, and mostly used the PMMA, presenting an increase in the load in N for fracture occurrence.

Introdução: A população em todo o mundo está envelhecendo. Com isso, haverá aumento da incidência de fraturas por osteoporose do quadril e esse será um grave problema de saúde mundial. Uma previsão da Organização Mundial de Saúde (OMS) mostra que a incidência de fraturas osteoporóticas do quadril em todo o mundo triplicará até o ano 2050. Objetivo : Apresentar por meio de revisão da literatura os principais resultados do reforço femoral, técnica descrita por artigos científicos, com potencial de incrementar a carga do fêmur proximal para a ocorrência de fraturas, seja com uso de polimetilmetacrilato (PMMA), cimento fosfato de cálcio (CPC), elastômeros ou implantes metálicos. Métodos : Por meio de busca eletrônica nas bases de dados PubMed, Latin American and Caribbean Center of Health Science Information (Bireme), Coordination for the Improvement of Higher Education Personnel (Capes), Scientific Electronic Library Online (SciELO), Google Scholar and Cochrane, utilizando os termos Cementoplasty e femororplasty, foram selecionados os trabalhos respeitando um critério de inclusão específico, descrevendo os principais achados dos resultados biomecânicos, o tipo de estudo e o material utilizado na realização do reforço femoral. Resultados : Dos 15 artigos analisados, 14 são análises experimentais e um é ensaio clínico, sete estudos utilizaram PMMA, dois usaram CPC, quatro elastômeros e dois implantes metálicos, 13 deles mostram resultados favoráveis na carga em Newton (N) para a ocorrência da fratura do quadril. Conclusão: A maioria dos estudos sobre reforço femoral é experimental e em sua maioria utilizou o PMMA, apresentando incremento da carga em N para a ocorrência de fratura.

Relationship between pre-sarcopenia, sarcopenia and bone mineral density in elderly men.

OBJECTIVE: Analyze the influence of sarcopenia in bone health of elderly men. SUBJECTS AND METHODS: This cross-sectional study evaluated 198 men aged over 60 years. Body composition was measured by dual energy X-ray absorptiometry. The BMD was measured at the femoral neck, total hip, lumbar spine and 33% radius. The diagnosis of abnormal BMD was defined for men who presented densitometric diagnosis of osteopenia or osteoporosis defined by T-score of femoral neck, total hip and lumbar spine. The pre-sarcopenia and sarcopenia were defined according to the European Working Group on Sarcopenia in Older People. RESULTS: The group diagnosed with normal BMD, compared to the group of abnormal BMD, have significantly higher body weight, body mass index, grip strength, lean mass, fat mass, and relative appendicular skeletal muscle mass (RASM). However, after multiple linear regression analysis, we found that only the RASM, lean mass, and handgrip strength in the dominant hand influenced the variability of the BMD after adjustment for age and weight. Regression analyzes showed a positive association between greater appendicular lean mass and a smaller number of elderly patients with abnormal BMD diagnostic. The regression analyzes showed that elderly men diagnosed with pre-sarcopenia and sarcopenia had more abnormal BMD than non-sarcopenic elderly men. CONCLUSION: We concluded that pre-sarcopenia and sarcopenia were associated with abnormal BMD. The lean mass, compared to fat mass, has a greater positive influence on the BMD of elderly men. This result suggests the importance of the increase in lean mass for the bone health of elderly men.

Treatment of an Acute Fracture of the Femoral Neck in a Young Female Adult with a Transfemoral Amputation: A Case Report.

INTRODUCTION: Fracture of the femoral neck in a young adult with an ipsilateral transfemoral amputation is uncommon, and there is no consensus regarding the best treatment. METHODS: We present a unique case of a displaced right femoral neck fracture treated with closed reduction and percutaneous screw fixation in a twenty-eight-year-old woman with a preexisting ipsilateral transfemoral amputation. RESULTS: We observed satisfactory healing of the fracture with a slight varus deformity and no radiographic signs of osteonecrosis at one year. CONCLUSION: In a young adult with a preexisting transfemoral amputation and an acute femoral neck fracture, reduction and fixation of the fracture may be a reasonable treatment option.

Fractal dimension and mandibular cortical width in normal and osteoporotic men and women.

OBJECTIVE: To verify whether fractal dimensions (FD) on the mandibular trabecular and cortical bone and mandibular cortical width (MCW) differ between patients with normal bone mineral density (BMD) and osteoporosis. STUDY DESIGN: In this retrospective study, 133 dental panoramic radiographs from men aged >60 years and postmenopausal women with a bone densitometry report of the lumbar spine and hip classified as either normal or osteoporotic were selected. Fractal dimensions of five standardized trabecular and cortical mandibular regions of interest and mandibular cortical width were measured on the panoramic radiographs by an experienced oral radiologist, blinded to the densitometric diagnosis. The following statistical analyses were performed: ANOVA and a forward logistic stepwise regression to verify associations between dental panoramic measurements and the densitometric diagnosis. P values less than .05 indicated statistical significance. MAIN OUTCOME MEASURES: Fractal dimension and mandibular cortical width. RESULTS: Differences were found in the FD values on mandibular cortical bone and MCW between patients with normal BMD and with osteoporosis, but not in the FD values of trabecular bone. The odds of having lower mean values of MCW and FD on cortical bone were 2.16, 3125 and 1005 times in osteoporotic patients, respectively, compared with patients with normal BMD. CONCLUSION: The values of FD analysis on mandibular cortical bone and MCW were lower in women with osteoporosis. A well-adjusted logistic regression model showed that cortical bone measurements might be considered as auxiliary tools to referring patients for DXA exam.

Fulfillment of the brazilian agenda of priorities in health research.

This commentary describes how the Brazilian Ministry of Health's (MoH) research support policy fulfilled the National Agenda of Priorities in Health Research (NAPHR). In 2003, the MoH started a democratic process in order to establish a priority agenda in health research involving investigators, health managers and community leaders. The Agenda was launched in 2004 and is guiding budget allocations in an attempt to reduce the gap between scientific knowledge and health practice and activities, aiming to contribute to improving Brazilian quality of life. Many strategies were developed, for instance: Cooperation Agreements between the Ministry of Health and the Ministry of Science and Technology; the decentralization of research support at state levels with the participation of local Health Secretariats and Science and Technology Institutions; Health Technology Assessment; innovation in neglected diseases; research networks and multicenter studies in adult, women's and children's health; cardiovascular risk in adolescents; clinical research and stem cell therapy. The budget allocated by the Ministry of Health and partners was expressive: US$419 million to support almost 3,600 projects. The three sub-agenda with the higher proportion of resources were "industrial health complex", "clinical research" and "communicable diseases", which are considered strategic for innovation and national development. The Southeast region conducted 40.5% of all projects and detained 59.7% of the resources, attributable to the concentration of the most traditional health research institutes and universities in the states of São Paulo and Rio de Janeiro. The second most granted region was the Northeast, which reflects the result of a governmental policy to integrate and modernize this densely populated area and the poorest region in the country. Although Brazil began the design and implementation of the NAPHR in 2003, it has done so in accordance with the 'good practice principles' recently published: inclusive process, information gathering, careful planning and funding policy, transparency and internal evaluation (an external independent evaluation is underway). The effort in guiding the health research policy has achieved and legitimated an unprecedented developmental spurt to support strategic health research. We believe this experience is valuable and applicable to other countries, but different settings and local political circumstances will determine the best course of action to follow.

Relationships between mandibular cortical indexes, bone mineral density, and osteoporotic fractures in Brazilian men over 60 years old.

OBJECTIVE: The aim of this study was to assess relationships between panoramic indexes, bone mineral density (BMD), and osteoporotic fractures in men >60 years old. STUDY DESIGN: Body height and weight, body mass index, lumbar spine and hip BMD, and the presence of osteoporotic fractures were determined in the 127 studied men. Dental panoramic radiographs (DPRs) were used for measuring mandibular cortical indexes. RESULTS: BMDs were lower in patients with thinning and resorption of mandibular cortex. No association was found between mandibular indexes and the presence of osteoporotic fractures. In a forward stepwise logistic regression model, the odds of having a T score ≤-2.5 was increased by 1.97 times for every 1-mm reduction in average mandibular cortical width. CONCLUSIONS: DPRs could show pronounced thinning of the inferior mandibular cortices in men >60 years old. However, there was no apparent association between vertebral fragility fractures and the appearance of mandibular cortex in elderly men.

Non-pharmacological therapy and complementary and alternative medicine in fibromyalgia.

Fibromyalgia is a chronic painful syndrome that affects up to 5% of the world population. It is associated with sleep and mood disorders, fatigue, and functional disability. Its pathogenesis involves a disorder of the central modulation of pain, impairment of the descending inhibitory system, and hyperactivity of substance P. Because of the extensive symptomatology of patients with fibromyalgia and its multifactorial pathogenesis, its ideal treatment requires a multidisciplinary approach including the association of pharmacological and non-pharmacological therapies. The pharmacological therapy currently recommended for the syndrome includes antidepressants, calcium-channel modulators, muscle relaxants, and analgesics. In most cases, the non-pharmacological treatment consists of patient education, supervised aerobic physical activity, and cognitive-behavioral therapy. However, many patients do not respond satisfactorily, or have side effects associated with the long-term use of drugs, in addition to reporting difficulties in adhering to a therapy based on exercises and physical medicine. Thus, physicians and patients are increasingly interested in an alternative and complementary therapy for fibromyalgia. This review approaches the different therapeutic modalities used in fibromyalgia, emphasizing the evidence of non-pharmacological therapy and use of alternative and complementary medicine for these patients.

Correlations between seven panoramic radiomorphometric indices and bone mineral density in postmenopausal women.

OBJECTIVES: The aim was to test for correlations of 7 panoramic radiomorphometric indices with lumbar spine and hip bone mineral densities (BMDs) and to test the accuracy of these indices for predicting osteoporosis and a T-score < or =-2.0. STUDY DESIGN: Mandibular cortical indices, simple visual estimations of cortical widths, mental and antegonial indices, antegonial depth, gonial and antegonial angles, and BMD were measured in 351 postmenopausal women. RESULTS: Associations were demonstrated between BMDs, qualitative indices, and cortical measurements. In the case of severely eroded mandibular cortices, the odds ratio (OR) for osteoporosis (according to the World Health Organization criteria) was 4.82 and the OR for a T-score < or =-2.0, the threshold to begin treatment, was 10.87. In the case of very thin mandibular cortices, the ORs were 8.02 and 5.46 for osteoporosis and a T-score < or =-2.0, respectively. The mental index cutoff for osteoporosis was 3.15 mm. CONCLUSIONS: Antegonial indices and gonial angles cannot be used as osteoporosis predictors. The most accurate indices were the mental index, mandibular cortical index, and visual estimation of cortical width.