Comparison of Two- and Three-dimensional Ultrasonography in the Evaluation of Lesion Level in Fetuses with Spina Bifida

Purpose To evaluate the precision of both two- and three-dimensional ultrasonography in determining vertebral lesion level (the first open vertebra) in patients with spina bifida. Methods This was a prospective longitudinal study comprising of fetuses with open spina bifida who were treated in the fetal medicine division of the department of obstetrics of Hospital das Clínicas of the Universidade de São Paulo between 2004 and 2013. Vertebral lesion level was established by using both two- and three-dimensional ultrasonography in 50 fetuses (two examiners in each method). The lesion level in the neonatal period was established by radiological assessment of the spine. All pregnancies were followed in our hospital prenatally, and delivery was scheduled to allow immediate postnatal surgical correction. Results Two-dimensional sonography precisely estimated the spina bifida level in 53% of the cases. The estimate error was within one vertebra in 80% of the cases, in up to two vertebrae in 89%, and in up to three vertebrae in 100%, showing a good interobserver agreement. Three-dimensional ultrasonography precisely estimated the lesion level in 50% of the cases. The estimate error was within one vertebra in 82% of the cases, in up to two vertebrae in 90%, and in up to three vertebrae in 100%, also showing good interobserver agreement. Whenever an estimate error was observed, both two- and three-dimensional ultrasonography scans tended to underestimate the true lesion level (55.3% and 62% of the cases, respectively). Conclusions No relevant difference in diagnostic performance was observed between the two- and three-dimensional ultrasonography. The use of three-dimensional ultrasonography showed no additional benefit in diagnosing the lesion level in the fetuses with spina bifida. Errors in both methods showed a tendency to underestimate lesion level.

The supermassive binary black hole system OJ287

Abstract This doctoral thesis concerns the active galactic nucleus (AGN) most often referred to with the catalogue number OJ287. The publications in the thesis present new discoveries of the system in the context of a supermassive binary black hole model. In addition, the introduction discusses general characteristics of the OJ287 system and the physical fundamentals behind these characteristics. The place of OJ287 in the hierarchy of known types of AGN is also discussed. The introduction presents a large selection of fundamental physics required to have a basic understanding of active galactic nuclei, binary black holes, relativistic jets and accretion disks. Particularly the general relativistic nature of the orbits of close binaries of supermassive black holes is explored with some detail. Analytic estimates of some of the general relativistic effects in such a binary are presented, as well as numerical methods to calculate the effects more precisely. It is also shown how these results can be applied to the OJ287 system. The binary orbit model forms the basis for models of the recurring optical outbursts in the OJ287 system. In the introduction, two physical outburst models are presented in some detail and compared. The radiation hydrodynamics of the outbursts are discussed and optical light curve predictions are derived. The precursor outbursts studied in Paper III are also presented, and tied into the model of OJ287. To complete the discussion of the observable features of OJ287, the nature of the relativistic jets in the system, and in active galactic nuclei in general, is discussed. Basic physics of relativistic jets are presented, with additional detail added in the form of helical jet models. The results of Papers II, IV and V concerning the jet of OJ287 are presented, and their relation to other facets of the binary black hole model is discussed. As a whole, the introduction serves as a guide, though terse, for the physics and numerical methods required to successfully understand and simulate a close binary of supermassive black holes. For this purpose, the introduction necessarily combines a large number of both fundamental and specific results from broad disciplines like general relativity and radiation hydrodynamics. With the material included in the introduction, the publications of the thesis, which present new results with a much narrower focus, can be readily understood. Of the publications, Paper I presents newly discovered optical data points for OJ287, detected on archival astronomical plates from the Harvard College Observatory. These data points show the 1900 outburst of OJ287 for the first time. In addition, new data points covering the 1913 outburst allowed the determination of the start of the outburst with more precision than was possible before. These outbursts were then successfully numerically modelled with an N-body simulation of the OJ287 binary and accretion disc. In Paper II, mechanisms for the spin-up of the secondary black hole in OJ287 via interaction with the primary accretion disc and the magnetic fields in the system are discussed. Timescales for spin-up and alignment via both processes are estimated. It is found that the secondary black hole likely has a high spin. Paper III reports a new outburst of OJ287 in March 2013. The outburst was found to be rather similar to the ones reported in 1993 and 2004. All these outbursts happened just before the main outburst season, and are called precursor outbursts. In this paper, a mechanism was proposed for the precursor outbursts, where the secondary black hole collides with a gas cloud in the primary accretion disc corona. From this, estimates of brightness and timescales for the precursor were derived, as well as a prediction of the timing of the next precursor outburst. In Paper IV, observations from the 2004–2006 OJ287 observing program are used to investigate the existence of short periodicities in OJ287. The existence of a _50 day quasiperiodic component is confirmed. In addition, statistically significant 250 day and 3.5 day periods are found. Primary black hole accretion of a spiral density wave in the accretion disc is proposed as the source of the 50 day period, with numerical simulations supporting these results. Lorentz contracted jet re-emission is then proposed as the reason for the 3.5 day timescale. Paper V fits optical observations and mm and cm radio observations of OJ287 with a helical jet model. The jet is found to have a spine–sheath structure, with the sheath having a much lower Lorentz gamma factor than the spine. The sheath opening angle and Lorentz factor, as well as the helical wavelength of the jet are reported for the first time. Tiivistelmä Tässä väitöskirjatutkimuksessa on keskitytty tutkimaan aktiivista galaksiydintä OJ287. Väitöskirjan osana olevat tieteelliset julkaisut esittelevät OJ287-systeemistä saatuja uusia tuloksia kaksoismusta-aukkomallin kontekstissa. Väitöskirjan johdannossa käsitellään OJ287:n yleisiä ominaisuuksia ja niitä fysikaalisia perusilmiöitä, jotka näiden ominaisuuksien taustalla vaikuttavat. Johdanto selvittää myös OJ287-järjestelmän sijoittumisen aktiivisten galaksiytimien hierarkiassa. Johdannossa käydään läpi joitakin perusfysiikan tuloksia, jotka ovat tarpeen aktiivisten galaksiydinten, mustien aukkojen binäärien, relativististen suihkujen ja kertymäkiekkojen ymmärtämiseksi. Kahden toisiaan kiertävän mustan aukon keskinäisen radan suhteellisuusteoreettiset perusteet käydään läpi yksityiskohtaisemmin. Johdannossa esitetään joitakin analyyttisiä tuloksia tällaisessa binäärissä havaittavista suhteellisuusteoreettisista ilmiöistä. Myös numeerisia menetelmiä näiden ilmiöiden tarkempaan laskemiseen esitellään. Tuloksia sovelletaan OJ287-systeemiin, ja verrataan havaintoihin. OJ287:n mustien aukkojen ratamalli muodostaa pohjan systeemin toistuvien optisten purkausten malleille. Johdannossa esitellään yksityiskohtaisemmin kaksi fysikaalista purkausmallia, ja vertaillaan niitä. Purkausten säteilyhydrodynamiikka käydään läpi, ja myös ennusteet purkausten valokäyrille johdetaan. Johdannossa esitellään myös Julkaisussa III johdettu prekursoripurkausten malli, ja osoitetaan sen sopivan yhteen OJ287:n binäärimallin kanssa. Johdanto esittelee myös relativististen suihkujen fysiikkaa sekä OJ287- systeemiin liittyen että aktiivisten galaksiydinten kontekstissa yleisesti. Relativististen suihkujen perusfysiikka esitellään, kuten myös malleja kierteisistä suihkuista. Julkaisujen II, IV ja V OJ287-systeemin suihkuja koskevat tulokset esitellään binäärimallin kontekstissa. Kokonaisuutena johdanto palvelee suppeana oppaana, joka esittelee tarvittavan fysiikan ja tarpeelliset numeeriset menetelmät mustien aukkojen binäärijärjestelmän ymmärtämiseen ja simulointiin. Tätä tarkoitusta varten johdanto yhdistää sekä perustuloksia että joitakin syvällisempiä tuloksia laajoilta fysiikan osa-alueilta kuten suhteellisuusteoriasta ja säteilyhydrodynamiikasta. Johdannon sisältämän materiaalin avulla väitöskirjan julkaisut, ja niiden esittämät tulokset, ovat hyvin ymmärrettävissä. Väitöskirjan julkaisuista ensimmäinen esittelee uusia OJ287-systeemistä saatuja havaintopisteitä, jotka on paikallistettu Harvardin yliopiston observatorion arkiston valokuvauslevyiltä. OJ287:n vuonna 1900 tapahtunut purkaus nähdään ensimmäistä kertaa näissä havaintopisteissä. Uudet havaintopisteet mahdollistivat myös vuoden 1913 purkauksen alun ajoittamisen tarkemmin kuin aiemmin oli mahdollista. Havaitut purkaukset mallinnettiin onnistuneesti simuloimalla OJ287-järjestelmän mustien aukkojen paria ja kertymäkiekkoa. Julkaisussa II käsitellään mekanismeja OJ287:n sekundäärisen mustan aukon spinin kasvamiseen vuorovaikutuksessa primäärin kertymäkiekon ja systeemin magneettikenttien kanssa. Julkaisussa arvioidaan maksimispinin saavuttamisen ja spinin suunnan vakiintumisen aikaskaalat kummallakin mekanismilla. Tutkimuksessa havaitaan sekundäärin spinin olevan todennäköisesti suuri. Julkaisu III esittelee OJ287-systeemissä maaliskuussa 2013 tapahtuneen purkauksen. Purkauksen havaittiin muistuttavan vuosina 1993 ja 2004 tapahtuneita purkauksia, joita kutsutaan yhteisnimityksellä prekursoripurkaus (precursor outburst). Julkaisussa esitellään purkauksen synnylle mekanismi, jossa OJ287-systeemin sekundäärinen musta aukko osuu primäärisen mustan aukon kertymäkiekon koronassa olevaan kaasupilveen. Mekanismin avulla johdetaan arviot prekursoripurkausten kirkkaudelle ja aikaskaalalle. Julkaisussa johdetaan myös ennuste seuraavan prekursoripurkauksen ajankohdalle. Julkaisussa IV käytetään vuosina 2004–2006 kerättyjä havaintoja OJ287- systeemistä lyhyiden jaksollisuuksien etsintään. Julkaisussa varmennetaan systeemissä esiintyvä n. 50 päivän kvasiperiodisuus. Lisäksi tilastollisesti merkittävät 250 päivän ja 3,5 päivän jaksollisuudet havaitaan. Julkaisussa esitetään malli, jossa primäärisen mustan aukon kertymäkiekossa oleva spiraalitiheysaalto aiheuttaa 50 päivän jaksollisuuden. Mallista tehty numeerinen simulaatio tukee tulosta. Systeemin relativistisen suihkun emittoima aikadilatoitunut säteily esitetään aiheuttajaksi 3,5 päivän jaksollisuusaikaskaalalle. Julkaisussa V sovitetaan kierresuihkumalli OJ287-systeemistä tehtyihin optisiin havaintoihin ja millimetri- sekä senttimetriaallonpituuden radiohavaintoihin. Suihkun rakenteen havaitaan olevan kaksijakoinen ja koostuvan ytimestä ja kuoresta. Suihkun kuorella on merkittävästi pienempi Lorentzin gamma-tekijä kuin suihkun ytimellä. Kuoren avautumiskulma ja Lorentztekijä sekä suihkun kierteen aallonpituus raportoidaan julkaisussa ensimmäistä kertaa.

Vitamin D receptor alleles and bone mineral density in a normal premenopausal Brazilian female population

Studies on the association between vitamin D receptor (VDR) polymorphism and bone mineral density (BMD) in different populations have produced conflicting results probably due to ethnic differences in the populations studied. The Brazilian population is characterized by a very broad genetic background and a high degree of miscegenation. Of an initial group of 164, we studied 127 women from the city of São Paulo, aged 20 to 47 years (median, 31 years), with normal menses, a normal diet and no history of diseases or use of any medication that could alter BMD. VDR genotype was assessed by PCR amplification followed by BsmI digestion of DNA isolated from peripheral leukocytes. BMD was measured using dual energy X-ray absorptiometry (Lunar DPX) at the lumbar site (L2-L4) and femoral neck. Most of the women (77.6%) were considered to be of predominantly European ancestry (20.6% of them reported also native American ancestry), 12.8% were of African-Brazilian ancestry and 9.6% of Asian ancestry, 41.0% (52) were classified as bb, 48.8% (62) as Bb and 10.2% (13) as BB. The BB, Bb and bb groups did not differ in age, height, weight, body mass index or age at menarche. Lumbar spine BMD was significantly higher in the bb group (1.22 ± 0.16 g/cm²) than in the BB group (1.08 ± 0.14; P<0.05), and the Bb group presented an intermediate value (1.17 ± 0.15). Femoral neck BMD was higher in the bb group (0.99 ± 0.11 g/cm²) compared to Bb (0.93 ± 0.12) and BB (0.90 ± 0.09) (P<0.05). These data indicate that there is a significant correlation between the VDR BsmI genotype and BMD in healthy Brazilian premenopausal females.

Risk factors for decreased bone density in premenopausal women

Osteoporosis is a major health problem. Little is known about the risk factors in premenopause. Sixty 40-50-year old patients with regular menses were studied cross-sectionally. None of the patients were on drugs known to interfere with bone mass. Patients answered a dietary inquiry and had their bone mineral density (BMD) measured. The Z scores were used for the comparisons. A blood sample was taken for the determination of FSH, SHBG, estradiol, testosterone, calcium and alkaline phosphatase. Calcium and creatinine were measured in 24-h urine. A Z score less than -1 was observed for the lumbar spine of 14 patients (23.3%), and for the femur of 24 patients (40%). Patients with a Z score less than -1 for the lumbar spine were older than patients with a Z score ³-1 (45.7 vs 43.8 years) and presented higher values of alkaline phosphatase (71.1 ± 18.2 vs 57.1 ± 14.3 IU/l). Multiple regression analysis showed that a lower lumbar spine BMD was associated with higher values of alkaline phosphatase, lower calcium ingestion, a smaller body mass index (BMI), less frequent exercising, and older age. The patients with a Z score less than -1 for the femur were shorter than patients with a Z score ³-1 (158.2 vs 161.3 cm). Multiple regression analysis showed that a lower femoral BMD was associated with lower BMI, higher alkaline phosphatase and caffeine intake, and less frequent exercising. A lower than expected BMD was observed in a significant proportion of premenopausal women and was associated with lower calcium intake, relatively lower physical activity and lower BMI. We conclude that the classical risk factors for osteoporosis may be present before ovarian failure, and their effect may be partly independent of estrogen levels.

Reduced bone mineral density in men after heart transplantation

Heart transplantation is associated with rapid bone loss and an increased prevalence and incidence of fractures. The aim of the present study was to compare the bone mineral density (BMD) of 30 heart transplant (HT) recipients to that of 31 chronic heart failure (CHF) patients waiting for transplantation and to determine their biochemical markers of bone resorption and hormone levels. The BMD of lumbar spine and proximal femur was determined by dual-energy X-ray absorptiometry. Anteroposterior and lateral radiographs of the thoracic and lumbar spine were also obtained. The mean age of the two groups did not differ significantly. Mean time of transplantation was 25.4 ± 21.1 months (6 to 88 months). Except for the albumin levels, which were significantly higher, and magnesium levels, which were significantly lower in HT patients when compared to CHF patients, all other biochemical parameters and hormone levels were within the normal range and similar in the two groups. Both groups had lower BMD of the spine and proximal femur compared to young healthy adults. However, the mean BMD of HT patients was significantly lower than in CHF patients at all sites studied. Bone mass did not correlate with time after transplantation or cumulative dose of cyclosporine A. There was a negative correlation between BMD and the cumulative dose of prednisone. These data suggest that bone loss occurs in HT patients mainly due to the use of corticosteroids and that in 30% of the patients it can be present before transplantation. It seems that cyclosporine A may also play a role in this loss.

Bone mineral density in Brazilian men 50 years and older

Bone mineral density (BMD) in the lumbar spine (LSBMD), femoral neck (FNBMD) and whole body (WBBMD) and whole body tissue composition were evaluated in 288 Brazilian men 50 years and older, 80% white and 20% Mulattoes. Age was inversely correlated with WBBMD (r = -0.20) and FNBMD (r = -0.21) but not with LSBMD (r = 0.03). Body mass index and weight showed a strong positive correlation with WBBMD (r = 0.48 and 0.54), LSBMD (r = 0.37 and 0.45) and FNBMD (r = 0.42 and 0.48). Correlation with height was positive but weaker. No significant bone loss at the lumbar spine level was observed as the population aged. FNBMD and WBBMD decreased significantly only in the last decade (age 70-79) studied. BMD was higher for Brazilian men as compared to Brazilian women at all sites. No significant differences were observed between Brazilian and the US/European male population for BMD in the femoral neck. BMD measured by dual-energy X-ray absorptiometry in South American men is reported here for the first time. A decrease in FNBMD was detected only later in life, with a pattern similar to that described for the US/European male population.

Translation, adaptation and validation of the Roland-Morris questionnaire - Brazil Roland-Morris

The purpose of the present study was to translate the Roland-Morris (RM) questionnaire into Brazilian-Portuguese and adapt and validate it. First 3 English teachers independently translated the original questionnaire into Brazilian-Portuguese and a consensus version was generated. Later, 3 other translators, blind to the original questionnaire, performed a back translation. This version was then compared with the original English questionnaire. Discrepancies were discussed and solved by a panel of 3 rheumatologists and the final Brazilian version was established (Brazil-RM). This version was then pretested on 30 chronic low back pain patients consecutively selected from the spine disorders outpatient clinic. In addition to the traditional clinical outcome measures, the Brazil-RM, a 6-point pain scale (from no pain to unbearable pain), and its numerical pain rating scale (PS) (0 to 5) and a visual analog scale (VAS) (0 to 10) were administered twice by one interviewer (1 week apart) and once by one independent interviewer. Spearman's correlation coefficient (SCC) and intraclass correlation coefficient (ICC) were computed to assess test-retest and interobserver reliability. Cross-sectional construct validity was evaluated using the SCC. In the pretesting session, all questions were well understood by the patients. The mean time of questionnaire administration was 4 min and 53 s. The SCC and ICC were 0.88 (P<0.01) and 0.94, respectively, for the test-retest reliability and 0.86 (P<0.01) and 0.95, respectively, for interobserver reliability. The correlation coefficient was 0.80 (P<0.01) between the PS and Brazil-RM score and 0.79 (P<0.01) between the VAS and Brazil-RM score. We conclude that the Brazil-RM was successfully translated and adapted for application to Brazilian patients, with satisfactory reliability and cross-sectional construct validity.

Parathyroid hormone secretion in chronic human endogenous hypercortisolism

Osteoporosis is a common manifestation of Cushing's syndrome, but the mechanisms responsible for this abnormality have not been defined. With the objective of analyzing parathyroid hormone (PTH) secretion in chronic hypercortisolism (CH), we evaluated 11 healthy subjects and 8 patients with CH, 6 with Cushing's disease and 2 with adrenal adenoma. These volunteers were submitted to tests of PTH stimulation through hypocalcemia (EDTA), PTH suppression through hypercalcemia (iv and oral calcium), and evaluation of bone mineral density (BMD) by DEXA. During the test of PTH stimulation, the calcium and magnesium concentrations of the normal and CH groups were similar. Patients with CH showed an increased PTH response to the hypocalcemic stimulus compared to controls. PTH values were significantly higher in the CH group at 70 (17.5 ± 3.5 vs 10.2 ± 1.3 pmol/l, P = 0.04), and 120 min (26.1 ± 5.9 vs 11.3 ± 1.9 pmol/l, P = 0.008) of EDTA infusion. The area under the curve for PTH during EDTA infusion was also significantly higher in patients with CH than in normal subjects (1867 ± 453 and 805 ± 148 pmol l-1 2 h-1, P = 0.02). During the test of PTH suppression, calcium, magnesium and PTH levels of the patients with hypercortisolism and controls were similar. BMD was decreased in patients with hypercortisolism in the spine (0.977 ± 0.052 vs 1.205 ± 0.038 g/cm² in controls, P<0.01). In conclusion, our results show that subjects with CH present decreased bone mass mainly in trabecular bone. The use of dynamic tests permitted the detection of increased PTH secretion in response to a hypocalcemic stimulus in CH patients that may probably be involved in the occurrence of osteoporosis in this state.

Bone mineral density in young women of the city of São Paulo, Brazil: correlation with both collagen type I alpha 1 gene polymorphism and clinical aspects

Osteoporosis is a multifactorial disease with great impact on morbidity and mortality mainly in postmenopausal women. Although it is recognized that factors related to life-style and habits may influence bone mass formation leading to greater or lower bone mass, more than 85% of the variation in bone mineral density (BMD) is genetically determined. The collagen type I alpha 1 (COLIA1) gene is a possible risk factor for osteoporosis. We studied a population of 220 young women from the city of São Paulo, Brazil, with respect to BMD and its correlation with both COLIA1 genotype and clinical aspects. The distribution of COLIA1 genotype SS, Ss and ss in the population studied was 73.6, 24.1 and 2.3%, respectively. No association between these genotypes and femoral or lumbar spine BMD was detected. There was a positive association between lumbar spine BMD and weight (P<0.0001), height (P<0.0156), and body mass index (BMI) (P<0.0156), and a negative association with age at menarche (P<0.0026). There was also a positive association between femoral BMD and weight (P<0.0001), height (P<0.0001), and BMI (P<0.0001), and a negative correlation with family history for osteoporosis (P<0.041). There was no association between the presence of allele s and reduced BMD. We conclude that a family history of osteoporosis and age at menarche are factors that may influence bone mass in our population.

Bone mineral density in juvenile systemic lupus erythematosus

We evaluated spine bone mineral density (BMD) in Brazilian children with juvenile systemic lupus erythematosus (JSLE) in order to detect potential predictors of reduction in bone mass. A cross-sectional study of BMD at the lumbar spine level (L2-L4) was conducted on 16 female JSLE patients aged 6-17 years. Thirty-two age-matched healthy girls were used as control. BMD at the lumbar spine was measured by dual-energy X-ray absorptiometry. Weight, height and pubertal Tanner stage were determined in patients and controls. Disease duration, mean daily steroid doses, mean cumulative steroid doses and JSLE activity measured by the systemic lupus erythematosus disease activity index (SLEDAI) were determined for all JSLE patients based on their medical charts. All parameters were used as potential determinant factors for bone loss. Lumbar BMD tended to be lower in the JSLE patients, however, this difference was not statistically significant (P = 0.10). No significant correlation was observed in JSLE girls between BMD and age, height, Tanner stage, disease duration, corticosteroid use or disease activity. We found a weak correlation between BMD and weight (r = 0.672). In the JSLE group we found no significant parameters to correlate with reduced bone mass. Disease activity and mean cumulative steroid doses were not related to BMD values. We did not observe reduced bone mass in female JSLE.

Bone mineral density of Brazilian girls with juvenile dermatomyositis

We measured bone mineral density (BMD) in girls with juvenile dermatomyositis (JDM) considering multiple factors in order to determine if it could be used as a predictor of reduction in bone mass. A cross-sectional study of lumbar spine BMD (L2-L4) was conducted on 10 girls aged 7-16 years with JDM. A group of 20 age-matched healthy girls was used as control. Lumbar spine BMD was measured by dual-energy X-ray absorptiometry. Weight, height and pubertal Tanner stage were determined in all patients and controls. Duration of disease and mean daily and cumulative steroid doses were calculated for all patients on the basis of their medical charts. JDM activity was determined on the basis of the presence of muscle weakness, cutaneous vasculitis and/or elevation of serum concentration of one or more skeletal muscle enzymes. Seven patients demonstrated osteopenia or osteoporosis. Lumbar BMD was significantly lower in the JDM patients than the age-matched healthy control girls (0.712 vs 0.878, respectively; Student t-test, P = 0.041). No significant correlation between BMD and age, height, Tanner stage, disease duration, corticosteroid use, or disease activity was observed in JDM girls, but a correlation was observed between BMD and weight (Pearson's correlation coefficient, r = 0.802). Patients with JDM may be at risk for a significant reduction in BMD that might contribute to further skeletal fragility. Our results suggest that reduced bone mass in JDM may be related to other intrinsic mechanisms in addition to steroid treatment and some aspects of the disease itself may contribute to this condition.

Prevalence of low trauma fractures in long-term kidney transplant patients with preserved renal function

We evaluated the prevalence of low bone mineral density (BMD) and osteoporotic fractures in kidney transplantation (KT) patients and determined risk factors associated with osteoporotic fractures. The study was conducted on 191 patients (94 men and 97 women) with first KT for 3 years or more presenting stable and preserved renal function (serum creatinine levels lower than 2.5 mg/dl). KT patients were on immunosuppressive therapy and the cumulative doses of these drugs were also evaluated. BMD was determined by dual-energy X-ray absorptiometry at multiple sites (spine, femur and total body). Quantitative ultrasound of the calcaneus (broadband ultrasound attenuation, speed of sound, and stiffness index, SI) was also performed. Twenty-four percent (46) of all patients had either vertebral (29/46) or appendicular (17/46) fractures. We found osteoporosis and osteopenia in 8.5-13.4 and 30.9-35.1% of KT patients, respectively. Women had more fractures than men. In women, prevalent fractures were associated with diabetes mellitus [OR = 11.5, 95% CI (2.4-55.7)], time since menopause [OR = 3.7, 95% CI (1.2-11.9)], femoral neck BMD [OR = 1.99, 95% CI (1.4-2.8)], cumulative dose of steroids [OR = 1.1, 95% CI (1.02-1.12)] and low SI [OR = 1.1, 95% CI (1.0-1.2)]. In men, fractures were associated with lower lumbar spine BMD [OR = 1.75, 95% CI (1.1-2.7)], lower SI [OR = 1.1, 95% CI (1.03-1.13)], duration of dialysis [OR = 1.3, 95% CI (1.13-2.7)], and lower body mass index [OR = 1.24, 95% CI (1.1-1.4). Our results demonstrate high prevalence of low BMD and osteoporotic fractures in patients receiving a successful kidney transplant and indicate the need for specific intervention to prevent osteoporosis in this population.

Effect of treadmill gait on bone markers and bone mineral density of quadriplegic subjects

Quadriplegic subjects present extensive muscle mass paralysis which is responsible for the dramatic decrease in bone mass, increasing the risk of bone fractures. There has been much effort to find an efficient treatment to prevent or reverse this significant bone loss. We used 21 male subjects, mean age 31.95 ± 8.01 years, with chronic quadriplegia, between C4 and C8, to evaluate the effect of treadmill gait training using neuromuscular electrical stimulation, with 30-50% weight relief, on bone mass, comparing individual dual-energy X-ray absorptiometry responses and biochemical markers of bone metabolism. Subjects were divided into gait (N = 11) and control (N = 10) groups. The gait group underwent gait training for 6 months, twice a week, for 20 min, while the control group did not perform gait. Bone mineral density (BMD) of lumbar spine, femoral neck, trochanteric area, and total femur, and biochemical markers (osteocalcin, bone alkaline phosphatase, pyridinoline, and deoxypyridinoline) were measured at the beginning of the study and 6 months later. In the gait group, 81.8% of the subjects presented a significant increase in bone formation and 66.7% also presented a significant decrease of bone resorption markers, whereas 30% of the controls did not present any change in markers and 20% presented an increase in bone formation. Marker results did not always agree with BMD data. Indeed, many individuals with increased bone formation presented a decrease in BMD. Most individuals in the gait group presented an increase in bone formation markers and a decrease in bone resorption markers, suggesting that gait training, even with 30-50% body weight support, was efficient in improving the bone mass of chronic quadriplegics.

Electrical field stimulation improves bone mineral density in ovariectomized rats

Osteoporosis and its consequent fractures are a great social and medical problem mainly occurring in post-menopausal women. Effective forms of prevention and treatment of osteoporosis associated with lower costs and the least side effects are needed. Electrical fields are able to stimulate osteogenesis in fractures, but little is known about their action on osteoporotic tissue. The aim of the present study was to determine by bone densitometry the effects of electrical stimulation on ovariectomized female Wistar rats. Thirty rats (220 ± 10 g) were divided into three groups: sham surgery (SHAM), bilateral ovariectomy (OVX) and bilateral ovariectomy + electrical stimulation (OVX + ES). The OVX + ES group was submitted to a 20-min session of a low-intensity pulsed electrical field (1.5 MHz, 30 mW/cm²) starting on the 7th day after surgery, five times a week (total = 55 sessions). Global, spine and limb bone mineral density were measured by dual-energy X-ray absorptiometry (DXA Hologic 4500A) before surgery and at the end of protocol (84 days after surgery). Electrical stimulation improved (P < 0.05) global (0.1522 ± 0.002), spine (0.1502 ± 0.003), and limb (0.1294 ± 0.003 g/cm²) bone mineral density compared to OVX group (0.1447 ± 0.001, 0.1393 ± 0.002, and 0.1212 ± 0.001, respectively). The OVX + ES group also showed significantly higher global bone mineral content (9.547 ± 0.114 g) when compared to both SHAM (8.693 ± 0.165 g) and OVX (8.522 ± 0.207 g) groups (P < 0.05). We have demonstrated that electrical fields stimulate osteogenesis in ovariectomized female rats. Their efficacy in osteoporosis remains to be demonstrated.

PCR identification of Mycobacterium tuberculosis complex in a clinical sample from a patient with symptoms of tuberculous spondylodiscitis

A 42-year-old male complaining of thoracic spine pain was admitted to the hospital for evaluation. An X-ray and computer tomography of the thoracic spine showed spondylodiscitis of the L3 lumbar and L2-L3 intervertebral disk. The tuberculin skin test (PPD) was strongly positive. A radioscopy-guided fine needle aspirate of the affected area was cultured but did not reveal the cause of the disease. Two biopsy attempts failed to reveal the cause of the disease by culturing or by acid-fast-resistant staining (Ziehl Neelsen) of the specimens. A third biopsy also failed to detect the infectious agent by using microbiological procedures, but revealed the presence of a 245-bp amplicon characteristic of the Mycobacterium tuberculosis complex after PCR of the sample. The result demonstrates the efficacy of PCR for the identification of M. tuberculosis in situations in which conventional diagnosis by culturing techniques or direct microscopy is unable to detect the microorganism. Following this result the patient was treated with the antituberculous cocktail composed by rifampicin, pirazinamide and isoniazid during a six-month period. At the end of the treatment the dorsalgia symptoms had disappeared.