Avaliação histomorfométrica do efeito do ultrasom pulsado nas falhas ósseas provocadas em fêmures de rato: estudo experimental

SILVA, J. S. P. Avaliação histomorfométrica do efeito do ultrasom pulsado nas falhas ósseas provocadas em fêmures de rato: estudo experimental . 2000. 85 f. Dissertação (Mestrado) – Faculdade de Medicina, Universidade de São Paulo. São Paulo, 2000.

An Intriguing Case of Anaemia and Splenomegaly

Objectives: Thrombocytopenia and splenomegaly are common features in several haematological disorders. Gaucher disease (GD) is a rare lysosomal storage disorder frequently characterized by thrombocytopenia and splenomegaly, which represents a clinical challenge for haematologists and internists. Case: We describe the case of a 37-year-old patient with a diagnosis of spherocytosis since childhood, who developed hepatic failure and presented striking features of GD including hepatosplenomegaly, bone fractures and post-partum bleeding. We reconsidered the diagnosis of spherocytosis and investigated Gaucher disease. Conclusion: GD should be considered in the differential diagnosis of thrombocytopenia and splenomegaly.

Proton-pump inhibitors adverse effects: a review of the evidence and position statement by the Sociedad Española de Patología Digestiva

Introduction: In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest. Objective: The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use. Material and methods: A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients. Results: Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis. Conclusions: PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate.

Fratura traumática do osso temporal : diagnóstico, sequelas e tratamento

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Clínica e cirurgia de equinos

O presente relatório de conclusão do curso de Mestrado Integrado em Medicina Veterinária da Universidade de Évora é baseado no estágio curricular realizado no hospital de equinos “Pferdeklinik in Kirchheim” na Alemanha e em clínica ambulatória com a Dra. Rita Rocha Pires na zona da Grande Lisboa e no concurso de saltos de obstáculos internacional de Vilamoura. O presente relatório é dividido em duas partes. A primeira parte apresenta a casuística nos dois locais do estágio e descreve alguns dos casos clínicos e cirúrgicos acompanhados nas diferentes áreas da clínica de equinos. A segunda parte aborda uma monografia sobre as vantagens e desvantagens de diferentes tipos de tratamento de fraturas completas do terceiro osso do metacarpo/tarso e apresenta um caso clinico de fratura cominutiva do terceiro osso do metatarso, o qual foi acompanhado durante o estágio na Alemanha; EQUINE CLINICS AND SURGERY ABSTRACT: The present report is based on the curricular internship, integrated on the Master´s degree in veterinary medicine at the University of Évora, which took place at the equine hospital “Pferdeklinik in Kirchheim” in Germany and at outpatient clinic with Dr. Rita Rocha Pires in the Greater Lisbon area and at the international show jumping competition in Vilamoura. This report is divided into two sections. The first section presents the casuistry at the two internship sites and describes some of the clinical and surgical cases followed in different areas of equine clinics. The second section develops a monograph on the advantages and disadvantages of different types of treatment for complete third metacarpal/tarsal bone fractures and presents a clinical case of a comminuted third metatarsal bone fracture, which was accompanied during the internship in Germany.

Use of calcium or calcuim in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis

Background:  Whether calcium supplementation can reduce osteoporotic fractures is uncertain. We did a meta-analysis to include all the randomised trials in which calcium, or calcium in combination with vitamin D, was used to prevent fracture and osteoporotic bone loss.

Methods:  We identified 29 randomised trials (n=63 897) using electronic databases, supplemented by a hand-search of reference lists, review articles, and conference abstracts. All randomised trials that recruited people aged 50 years or older were eligible. The main outcomes were fractures of all types and percentage change of bone-mineral density from baseline. Data were pooled by use of a random-effect model.

Findings:  In trials that reported fracture as an outcome (17 trials, n=52 625), treatment was associated with a 12% risk reduction in fractures of all types (risk ratio 0·88, 95% CI 0·83–0·95; p=0·0004). In trials that reported bone-mineral density as an outcome (23 trials, n=41 419), the treatment was associated with a reduced rate of bone loss of 0·54% (0·35–0·73; p<0·0001) at the hip and 1·19% (0·76–1·61%; p<0·0001) in the spine. The fracture risk reduction was significantly greater (24%) in trials in which the compliance rate was high (p<0·0001). The treatment effect was better with calcium doses of 1200 mg or more than with doses less than 1200 mg (0·80 vs 0·94; p=0·006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0·84 vs 0·87; p=0·03).

Interpretation:  Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older. For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation).

Overweight children have poor bone strength relative to body weight, placing them at greater risk for forearm fractures

Introduction: Obesity is thought to be a protective factor for bones in adults but not in children based on the evidence of the greater incidence of forearm fractures in obese children. Our objective was to investigate the effect of adiposity on bone strength in relation to the mechanical challenge placed onto the forearm bones in case of a fall.

Methods: Cross sectional areas (CSA) were obtained at the mid- and distal radius by peripheral quantitative computed tomography in 486 children (241 boys), mean age 8.3 years (range 6.9–9.7), participating in the LOOK Project. The following parameters were measured: bone mass and bone CSA (both sites), and muscle and fat CSA (mid-forearm only). Bone strength indices combining bone size and total volumetric density were calculated at each site.

Results/Discussion: Overweight children (BMI > percentile equivalent to 25 kg/m² in adults) have higher bone parameters than normal-weight peers (Z-scores +0.6 to +0.9SD, p < 0.0001). These differences disappear after adjustment for muscle CSA. Adiposity (fat CSA/muscle CSA) was negatively correlated with bone mass, size and strength at the distal radius only (r = −0.1, p < 0.05). After adjustment for body weight (estimate of the load during a fall), the negative correlations were stronger and observed at both the mid- and distal radius (r = −0.37 to −0.55, p < 0.0001).

Conclusion. Overweight children have stronger bones due to greater muscle size. However, children with high fat mass relative to muscle mass (increased adiposity) have poorer bone strength, independent of weight, which may contribute to the increased risk of fracture in obese children.

Seasonal periodicity of serum vitamin D and parathyroid hormone, bone resorption, and fractures : the Geelong Osteoporosis Study

In this population-based study, seasonal periodicity was seen with reduced serum vitamin D, increased serum PTH, and increased bone resorption in winter. This was associated with an increased proportion of falls resulting in fracture and an increased risk of wrist and hip fractures.

Introduction: In a population of women who reside in a temperate climate and do not generally receive dietary vitamin D supplementation, we investigated whether seasonal vitamin D insufficiency is associated with increased risk of fracture.

Materials and Methods: An observational, cross-sectional, population-based study set in southeastern Australia (latitude 38–39° S). Participants were drawn from a well-defined community of 27,203 women ≥55 years old: 287 randomly selected from electoral rolls, 1635 with incident fractures, and 1358 presenting to a university hospital with falls. The main outcome measures were annual periodicities of ultraviolet radiation, serum 25-hydroxyvitamin D [25(OH)D], serum parathyroid hormone (PTH), serum C-telopeptide (CTx), BMD, falls, and fractures.

Results: Cyclic variations in serum 25(OH)D lagged 1 month behind ultraviolet radiation, peaking in summer and dipping in winter (p < 0.001). Periodicity of serum PTH was the inverse of serum 25(OH)D, with a phase shift delay of 1 month (p = 0.004). Peak serum CTx lagged peak serum PTH by 1–2 months. In late winter, a greater proportion of falls resulted in fracture (p < 0.001). Seasonal periodicity in 439 hip and 307 wrist fractures also followed a simple harmonic model (p = 0.078 and 0.002, respectively), peaking 1.5–3 months after the trough in 25(OH)D.

Conclusions: A fall in 25(OH)D in winter is accompanied by increases in (1) PTH levels, (2) bone resorption, (3) the proportion of falls resulting in fracture, and (4) the frequency of hip and wrist fracture. Whether vitamin D supplementation in winter can reduce the population burden of fractures requires further investigation.

The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community : the Geelong Osteoporosis Study

Fractures associated with severe trauma are generally excluded from estimates of the prevalence of osteoporotic fractures in the community. Because the degree of trauma is difficult to quantitate, low bone mass may contribute to fractures following severe trauma. We ascertained all fractures in a defined population and compared the bone mineral density (BMD) of women who sustained fractures in either 'low' or 'high' trauma events with the BMD of a random sample of women from the same population. BMD was measured by dual-energy X-ray absorptiometry and expressed as a standardized deviation (Z score) adjusted for age. The BMD Z scores (mean ± SEM) were reduced in both the low and high trauma groups, respectively: spine-posterior-anterior (- 0.50 ± 0.05 and -0.21 ± 0.08), spine-lateral (-0.28 ± 0.06 and -0.19 ± 0.10), femoral neck (-0.42 ± 0.04 and -0.26 ± 0.09), Ward's triangle (- 0.44 ± 0.04 and -0.28 ± 0.08), trochanter (-0.44 ± 0.05 and -0.32 ± 0.08), total body (-0.46 ± 0.06 and -0.32 ± 0.08), ultradistal radius (- 0.47 ± 0.05 and -0.42 ± 0.07), and midradius (-0.52 ± 0.06 and -0.33 ± 0.09). Except at the PA spine, the deficits were no smaller in the high trauma group. Compared with the population, the age-adjusted odds ratio for osteoporosis (t-score < -2.5) at one or more scanning sites was 3.1 (95% confidence interval 1.9, 5.0) in the high trauma group and 2.7 (1.9, 3.8) in the low trauma group. The data suggest that the exclusion of high trauma fractures in women over 50 years of age may result in underestimation of the contribution of osteoporosis to fractures in the community. Bone density measurement of women over 50 years of age who sustain fractures may be warranted irrespective of the classification of trauma.

Forearm bone mineral density and incidence of hip fractures in Swedish urban and rural men 1987-2002

Background: It is not known whether the recently described break in the trend in hip fracture incidence in many settings applies in both women and men, depends on changes in bone mineral density (BMD) or changes in other risk factors, or whether it is apparent in both urban and rural settings. Methods: We evaluated changes in annual hip fracture incidence from 1987 to 2002 in Swedish men aged ≥60 years in one urban (n=25,491) and one rural population (n=16,432) and also secular differences in BMD, measured by single-photon absorptiometry at the distal radius and multiple other risk factors for hip fracture in a population-based sub-sample of the urban and the rural men aged 60–80 years in 1988/89 (n=202 vs. 121) and in 1998/99 (n=79 vs. 69). Results: No statistically significant changes in the annual age-adjusted hip fracture incidence per 10,000 were apparent from 1987 to 2002 in urban (0.38 per year, 95% CI-0.12 to 0.88) or rural men (-0.05 per year, 95% CI -0.63 to 0.53). BMD was similar in 1988/89 and 1998/99 when examining both urban (-19.6 mg/cm², 95% CI -42.6 to 3.5) and rural (-23.0 mg/cm², 95% CI -52.1 to 6.1) men. Conclusions: Since no secular change in age-adjusted hip fracture incidence was found during the study period, a levelling off in hip fracture incidence is present also in Swedish men. Because BMD on a group level was similar in 1988/89 and 1998/99, changes in other risk factors ought to be either of minor importance or counteracted by changes in different risk factors.

Treatment of radius, ulna and humerus fractures with the aid of a bone morphogenetic protein in a giant anteater (Myrmecophaga tridactyla)

A giant anteater (Myrmecophaga tridactyla) was found with closed comminuted fractures on the fight radius and ulna and left humerus he duration of which was unknown. The animal was unable to use either of he thoracic limbs. The fractures were stabilized with 3.5-mm titanium plates and a commercially available mixture of micro lyophilized bovine cortical osseous and bovine BMP (Gen-tech(R), Baumer, Brazil) was implanted into the fractures sites. Postoperative radiographic evaluations were performed every 30 days and after four months. Bone healing was observed in all of he fractures. The animal was able to be reintroduced into its natural habitat. From his case we conclude that despite he low metabolic fate of the giant anteater, which is an inherent characteristic of this species, he treatment of radius, ulna and humerus fractures by means of plates and screws, associated with BMP on the Myrmecophaga tridactyla, was a success.

Synthesis Pengo System plates for the treatment of long-bone diaphyseal fractures in dogs

A Brazilian orthopaedic company designed a stainless steel plate called Synthesis Pengo System (S.P.S.), which has one fixed and one changeable extremity. According to the assembly of the changeable extremity, it is possible to obtain dynamization or neutralization of the fracture site. Since the S.P.S. plate was developed for use in human patients, the aim of this study was to evaluate this system in long-bone diaphyseal fractures in dogs. Eight dogs with closed diaphyseal fractures of the femur (n = 1), radius and ulna (n = 5), and tibia (n = 2) were used. Patients were aged seven months to three years and weighed 18 to 31.2 kg. The S.P.S. plate was assembled with one fixed extremity and one changeable extremity in dynamization mode. The trail bar was positioned for synthesis modules with holes for cortical screws. The modules were positioned close to one another in two fractures and for away from the fracture site in the others. The bone healing occurred by external callus. Since motion at the fracture site determines the amount of callus required, the secondary bone healing that was observed in all of the cases indicated less rigid fixation of this system. A potential benefit of this system was a lesser interface contact with the bone since it was only done by trail bar. The major disadvantage was the prominence of the implant. It was possible to conclude that the S.P.S. plate appears to be a suitable method for the treatment of diaphyseal fractures in dogs.

Bone images from dual-energy subtraction chest radiography in the detection of rib fractures

To assess the sensitivity and image quality of chest radiography (CXR) with or without dual-energy subtracted (ES) bone images in the detection of rib fractures.