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

The aim of this study was to determine factors that influence unsuccessful peripheral blood stem cell (PBSC) harvesting in patients with multiple myeloma (MM). Retrospective data of 186 MM patients who received G-CSF as mobilization were analyzed. Patients with successful harvest were compared with those who failed (using 2 definitions of failure <2 and <4 CD34 cells×10(6)/mm(3)). The groups were compared regarding age, gender, body weight, baseline platelet count, receipt of radiotherapy, number of prior chemotherapy regimens, PBSC count before collection, processed and collected volume, collect replace, number of sessions and final number of PBSC collected. By multivariate analysis, a baseline platelet count <161,000 cells/mm(3) was associated with PBSC harvest lower than 2×10(6)/kg, and age >58 years was related to PBSC harvest lower than 4×10(6)/kg CD34 cells/kg. Patients with these parameters should not receive mobilization protocols with G-CSF alone. Alternative protocols should be tested in this high risk harvest failure population., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

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

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

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

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

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

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

Brown tumors are relatively uncommon but they are serious complications of renal osteodystrophy. We describe a 31-year-old woman with end-stage renal disease who had undergone hemodialysis for nine years and developed severe secondary hyperparathyroidism and a maxilla brown tumor despite increasing doses of oral calcitriol and calcium carbonate. The fast increase of the right maxillary bone tumor led to indication of parathyroidectomy (PTx). Despite normalization of serum PTH there was a slow regression of the mass and the patient still complained about her appearance after two-years of follow-up. Excision of the maxillary mass followed by recontouring of the maxilla was then performed, with adequate masticator rehabilitation.

Osteoporosis is a metabolic disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. Bone fragility depends on bone density, turnover and microarchitectural features, such as relative trabecular volume, spacing, number and connectivity. Previous fragility fractures increase the fracture risk irrespective of bone density. Other risk factors must also be considered as many fractures occur in patients with osteopenia on densitometry. On the other hand, the diagnosis of osteoporosis and increased fracture risk should not be based on densitometric data alone when young populations such as men below 65 years, premenopausal women, adolescents and children are considered.

Glucocorticoid-induced osteoporosis is the most frequent cause of secondary osteoporosis. Glucocorticoids cause a rapid bone loss in the first few months of use, but the most important effect of the drug is suppression of bone formation. The administration of oral glucocorticoid is associated with an increased risk of fractures at the spine and hip. The risk is related to the dose, but even small doses can increase the risk. Patients on glucocorticoid therapy lose more trabecular than cortical bone and the fractures are more frequent at the spine than at the hip. Calcium, vitamin D and activated forms of vitamin D can prevent bone loss and antiresorptive agents are effective for prevention and treatment of bone loss and to decrease fracture risk. Despite the known effects of glucocorticoids on bone, only a few patients are advised to take preventive measures and treat glucocorticoid-induced osteoporosis.

The aim of this study was to investigate if the omission of one of the glucose measurements in the 100-g oral glucose tolerance test (100-g OGTT) would have influenced the final diagnosis of GDM in a Brazilian cohort. We performed a retrospective study with 75 patients with GDM. The 100-g OGTT test was performed in 65 of these women. Twenty (30.76%), 24 (36.92%) and 21 (32.32%), respectively, had two, three and four values above the normal range. The mean fasting, 1, 2 and 3h glycemia were 109.81 +/- 33.34, 206.55 +/- 44.09, 188.13 +/- 46.52 and 142.12 +/- 49.53 mg/dl, respectively. They were above the cut-off values in 52 (80%), 55 (84.61%), 56 (86.1%) and 31 (47.6%) tests. The exclusion of the 1st, 2nd and 3rd measurements would have missed, respectively, 9 (10.5%), 16 (18.8%) and 13 (15.2%) cases. The omission of the 4th measurement would miss one case (1.17%). In conclusion, in our study, the omission of the last glucose measurement in the 3 h 100-g OGTT would not have caused a significant impact on the final diagnosis of GDM. Therefore, given the potential advantages of simplifying the test in terms of cost and convenience, the abbreviation of the 100-g OGTT should be considered.

Adult-onset hypophosphatemic osteomalacia is a rare disease characterized by hypophosphatemia, increased levels of alkaline phosphatase and decreased bone mass. Oral supplementation with phosphate and vitamin D is the main treatment and, in cases of oncogenic osteomalacia, tumor resection is mandatory. We report the case of a patient with hypophosphatemic osteomalacia of an unknown cause. Despite extensive search, no tumor was found. The patient was treated with phosphate for a long period and developed tertiary hyperparathyroidism. Serum PTH levels did not return to normal after surgical excision of three parathyroids and the patient refused to continue clinical investigation and treatment. After ten years absent from the hospital, during which medications were used irregularly, she was admitted with multiple fractures and respiratory insufficiency caused by severe thoracic deformities, and died. The authors discuss the relationship between osteomalacia and hyperparathyroidism and the aggressive course of the disease.

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

Opportunistic infections in endogenous Cushing's syndrome are associated with severe cortisol excess and carry a high mortality. Pulmonary cryptococcosis is one of these opportunistic infections and can mimic a lung neoplasm, therefore making its diagnosis difficult. We report a case of a young male with ACTH-dependent Cushing's syndrome and severe hypercortisolism. The patient achieved cure after the transfenoidal surgery, but developed a febrile state. A chest computed tomography showed a pulmonary nodule that did not change in serial chest radiographs. Diagnosis of tuberculosis, fungal and bacterial infections were inconclusive, so the hypothesis of lung neoplasm became more probable. The necropsy, however, disclosed a pseudotumoral cryptococcosis. Opportunistic infections, like Cryptococcus neoformans, should be considered in patients with Cushing's syndrome and a pulmonary infiltrate.