Abstract Objective: To present an updated and evidence-based guideline for the use of dual-energy x-ray absorptiometry (DXA) to assess body composition in clinical practice. Materials and methods: This Official Position was developed by the Scientific Committee of the Brazilian Association of Bone Assessment and Metabolism ( Associação Brasileira de Avaliação Óssea e Osteometabolismo , ABRASSO) and experts in the field who were invited to contribute to the preparation of this document. The authors searched current databases for relevant publications in the area of body composition assessment. In this second part of the Official Position, the authors discuss the interpretation and reporting of body composition parameters assessed by DXA and the use of DXA for body composition evaluation in special situations, including evaluation of children, persons with HIV, and animals. Conclusion: This document offers recommendations for the use of DXA in body composition evaluation, including indications, interpretation, and applications, to serve as a guiding tool in clinical practice and research for health care professionals in Brazil.

Abstract Background: Osteoporosis is an underdiagnosed condition, and its seriousness is not considered until severe complications arise. This study aimed to evaluate general dentists’ knowledge about osteoporosis and their ability to identify patients with this disease by assessing mandibular cortical width (MCW) and mandibular cortical index (MCI) on panoramic dental radiographs using a visual method. Methods: In this cross-sectional study, an email questionnaire regarding the diagnosis and prevention of osteoporosis was sent to 20,773 dentists in 2016. Those who completed the questionnaire were invited to participate in radiomorphometric training and then to analyze the MCI and MCW of 114 panoramic radiographs of postmenopausal women who underwent both panoramic radiography and bone densitometry. Based on the radiomorphometric indices and while blinded to the densitometry results, the dentists determined whether they would indicate densitometry for these patients. Results: The response rate was 2.3%: 485 dentists completed the questionnaire, and 50 evaluated panoramic radiographs using the MCW and MCI. All of them reported some knowledge about osteoporosis, but 41.6% demonstrated a misleading conceptualization of the disease. Approximately 90% reported minimal access to this information during graduation, and only 27.0% were exposed to the topic during their postgraduate studies. Interest in osteoporosis prevention was expressed by 70.7% of the respondents, and interest in learning the radiomorphometric indices was expressed by 99.0%. The sensitivity in the detection of low bone mineral density through the MCW and MCI was 52.9%, and the specificity was 64%. Conclusions: Brazilian dentists demonstrated insufficient knowledge about osteoporosis and a low ability to detect osteopenia or osteoporosis by applying radiomorphometric indices.

Abstract Background: Trunk pelvic dissociation is fundamental to the compensatory mechanism for muscle weakness during body bending. We carried out an early investigation of gait changes in a sample of community-dwelling women ≥60 years without gait complaints. The primary objective was to correlate spine and pelvic angles with performance tests and accelerometry parameters. The secondary objective was to correlate performance tests with accelerometry. Methods: In this cross-sectional study, 54 community-dwelling women ≥60years were subjected to Falls Efficacy Scale-International (FES-I), performance tests (Berg Balance Scale, Timed Up and Go, and Gait analysis), and radiographic analysis of sagittal alignment (Thoracic and Lumbar Cobb, Pelvic Incidence, Sacral Slope, and Pelvic Tilt angles). Gait speed was assessed in a 10-m comfortable walk, and accelerometry parameters were obtained in a 30m walk distance. Results: The sample, aged 72 ±6 years, exhibited moderate correlation between Sacral Slope and Step Length (+ 0.615). Sacral Slope weakly correlated with FES-I (- 0.339), Berg Balance Scale (+0.367), and with further accelerometry data in the AP plane: RMS, (+ 0.439) and Stride Regularity (+ 0.475), p < 0.05, all. Lumbar Cobb weakly correlated with the following accelerometry data in the AP plane: Step Length (+0.405), RMS, (+0.392), and Stride Regularity (+ 0.345), p < 0.05, all. Additionally, Stride Regularity in AP moderately correlated with FES-I (0,561, p < 0.05), among other weak correlations between performance tests and accelerometry data in AP. Conclusions: Early alterations in Sacral Slope and gait abnormalities in the AP plane may provide understanding of the early gait changes in robust older women.

Abstract Background: It has long been established that obesity plays a positive role against osteoporosis (OP) and low-impact fractures (Fx). However, more recent data has shown higher fracture risk in obese individuals. The aim of this study was to investigate the association between BMI, particularly obesity, OP and low-impact Fx in Brazilian women, as well as to evaluate the SAPORI (Sao Paulo Osteoporosis Risk Index) tool performance to identify low BMD according BMI category. Methods: A total of 6182 women aged over 40 years were included in this cross-sectional analysis using data from two large Brazilian studies. All participants performed hip and spine bone mineral density (BMD) measurements and answered a detailed questionnaire about the presence of clinical risk factors (CRFs) related to low BMD and risk fractures. The World Health Organization (WHO) criteria were used to define obesity. Results: Age-adjusted osteoporosis prevalence was 20.8, 33.6, 47 and 67.1% in obese, overweight, normal and underweight category, respectively. Obesity was present in 29,6% (1.830 women) in the study population and the likelihood of osteoporosis and low-impact Fx compared to a normal BMI in this subgroup was of 0.24 (95% CI 0.20– 0.28; p < 0.001) and of 1.68 (95% CI 1.35–2.11; p < 0.001), respectively. However, the hip Fx likelihood was lower in obese compared with non-obese women (OR = 0.44; 95% CI 0.20–0.97). Using an originally validated cut-off, the SAPORI tool sensitivity was significantly hampered in overweight and obese women although the accuracy had remained suitable because of increasing in specificity. Conclusions: The osteoporosis prevalence reduced as BMI increased and obesity was associated with low-impact Fx, regardless of the BMD measurements. Moreover, the SAPORI performance was impaired in obese women.

Resumo Osteoporose, uma doença metabólica caracterizada por baixa massa óssea, deterioração da microarquitetura do tecido ósseo e aumento da suscetibilidade a fraturas, é comumente vista como um problema de saúde feminino. Essa visão tem fundamentos: em comparação com os homens as mulheres têm densidade mineral óssea menor, têm vida mais longa e perdem massa óssea mais rapidamente, principalmente após a menopausa, devido à diminuição acentuada dos níveis séricos de estrógeno. Entretanto, nos últimos 20 anos a osteoporose no homem tem sido reconhecida como um problema de saúde pública devido à ocorrência cada vez maior de fraturas por fragilidade. Cerca de 30% de todas as fraturas de quadril ocorrem em homens. Estudos recentes mostram que a probabilidade de fratura por fragilidade do quadril, vértebra ou punho em homens brancos após os 50 anos, pelo resto de suas vidas, situa-se em torno de 13%, 40% nas mulheres. Os homens apresentam perda de massa óssea e fraturas mais tardiamente do que as mulheres. Embora os homens mais idosos tenham maior risco de fratura, cerca de metade das fraturas de quadril ocorre antes dos 80 anos. A expectativa de vida tem aumentado para ambos os sexos no Brasil e em todo o mundo, porém em uma velocidade maior para homens do que para mulheres. Esta Diretriz foi baseada em uma revisão sistemática da literatura com relação a prevalência, etiologia, diagnóstico e tratamento da osteoporose em homens.

Abstract Osteoporosis, a metabolic disease characterized by low bone mass, deterioration of the bone tissue microarchitecture and increased susceptibility to fractures, is commonly regarded as a women's health problem. This point of view is based on the fact that compared with men, women have lower bone mineral density and longer lifespans and lose bone mass faster, especially after menopause, due to a marked decrease in serum estrogen levels. However, in the last 20 years, osteoporosis in men has become recognized as a public health problem due to the occurrence of an increasingly higher number of fragility fractures. Approximately 30% of all hip fractures occur in men. Recent studies show that the probability of fracture due to hip, vertebral or wrist fragility in Caucasian men older than fifty years, for the rest of their lives, is approximately 13% versus a 40% probability of fragility fractures in women. Men show bone mass loss and fractures later than women. Although older men have a higher risk of fracture, approximately half of all hip fractures occur before the age of 80. Life expectancy is increasing for both sexes in Brazil and worldwide, albeit at a higher rate for men than for women. This Guideline was based on a systematic review of the literature on the prevalence, etiology, diagnosis and treatment of osteoporosis in men.

Resumo A osteoporose é a principal causa de fraturas na população acima de 50 anos. É uma doença silenciosa que afeta especialmente as mulheres na pós-menopausa e idosos e tem elevada taxa de morbimortalidade. O principal objetivo do tratamento da osteoporose é a prevenção das fraturas. A identificação dessa população de risco através do diagnóstico e tratamento precoces é de fundamental importância. A última diretriz brasileira para tratamento da osteoporose em mulheres na pós-menopausa foi elaborada em 2002. Desde então foram desenvolvidas novas estratégias de diagnóstico da osteoporose, bem como fármacos com novos mecanismos de ação foram adicionados ao arsenal terapêutico. A Comissão de Osteoporose e Doenças Osteometabólicas da Sociedade Brasileira de Reumatologia em conjunto com a Associação Médica Brasileira e sociedades afins desenvolveu esta atualização da diretriz do tratamento da osteoporose em mulheres na pós-menopausa de acordo com as melhores evidências científicas disponíveis. Esta atualização é destinada aos profissionais das várias especialidades médicas e da área da saúde envolvidos no tratamento da osteoporose, médicos em geral e organizações relacionadas à saúde.

Abstract Osteoporosis is the leading cause of fractures in the population older than 50 years. This silent disease affects primarily postmenopausal women and the elderly, and the morbidity and mortality rates are high. The main goal of treating osteoporosis is the prevention of fractures. The identification of populations at risk through early diagnosis and treatment is essential. The last Brazilian guideline for the treatment of postmenopausal osteoporosis was elaborated in 2002. Since then, new strategies for diagnosis and risk stratification have been developed, and drugs with novel action mechanisms have been added to the therapeutic arsenal. The Osteoporosis and Osteometabolic Diseases Committee of the Brazilian Society of Rheumatology, in conjunction with the Brazilian Medical Association and other Societies, has developed this update of the guidelines for the treatment of postmenopausal osteoporosis according to the best scientific evidence available. This update is intended for professionals in many medical and health specialties involved in the treatment of osteoporosis, for physicians in general and for health-related organizations.

ABSTRACT OBJECTIVE: To evaluate bone mass accrual and determine the influence of clinical, anthropometric, dietary and biochemical parameters on bone mass. METHODS: A cohort study including 35 prepubertal HIV-infected children, between 7 and 12 years, attended at a referral center. At time 1 (T1) and time 2 (T2), patients were assessed according to clinical, anthropometric, dietary, biochemical parameters and bone mineral density (BMD). At T2, patients were divided into prepubertal and pubertal. RESULTS: Despite the increase in bone mass absolute values, there was no improvement in lumbar spine BMD (LSBMD) Z-score (p = 0.512) and worsening in total body BMD (TBMD) Z-score (p = 0.040). Pubertal patients (n = 19) showed higher bone mineral content (BMC) (p = 0.001), TBMD (p = 0.006) and LSBMD (p = 0.002) compared to prepubertal patients. After multivariate linear regression analysis, the predictors of bone mass in T1 were age, BMI and HAZ-scores for BMC; BMI Z-score, adequate serum magnesium concentration and dietary calcium intake for TBMD; adequate serum concentration of magnesium, BMI and HAZ-scores for LSBMD. In T2, age, total body fat and lean body mass (kg) for BMC; BMI Z-score and puberty for TBMD; dietary fat intake, BMI Z-score for BMD and puberty for LSBMD. CONCLUSION: HIV-infected children have compromised bone mass and the presence of puberty seems to provide suitability of these parameters. Adequate intake of calcium and fat appears to be protective for proper bone mass accumulation factor, as well as monitoring nutritional status and serum magnesium concentration.

OBJECTIVE: To identify lipodystrophy in prepubertal HIV-infected children using anthropometric parameters and body composition assessment. METHODS: Cross-sectional study including 40 prepubertal HIV-infected children of both genders seen at the Care Center of the Division of Pediatric Infectious Diseases - Universidade Federal de São Paulo, São Paulo city, Brazil, was carried out from August to December 2008. Age, clinical and immunological status, prophylaxis, transmission and highly active antiretroviral therapy were recorded. Body mass index z-score and height-for-age z-score were calculated to characterize the nutritional status. Circumferences were measured with flexible tape and skinfolds were assessed by an adipometry. Fat mass and lean mass were determined by dual-energy X-ray absorptiometry. Presence of clinical signs of lipodystrophy was assessed by a trained clinician. Data were analyzed using SPSS 12.0 software. RESULTS: The mean age and standard deviation were 9.8 (1.2) years, 50% were girls and 82.5% children from B and C categories. Clinical lipodystrophy and dislypidemia were present in 27.5% and 70%, respectively. The trunk to arm ratio and the limb to trunk ratio had positive association with lipodystrophy. Patients with lipodystrophy had short stature, higher triglycerides values and lower HDL-cholesterol. CONCLUSION: The ratios obtained by skinfolds and dual-energy X-ray absorptiometry measurements can be considered as indicators of preclinical lipodystrophy. The cutoff points have not been determined yet; however, continuous assessment may be useful to identify early body composition changes.

RESUMO Objetivos Avaliar a massa mineral óssea de adolescentes com déficit de crescimento, correlacionando-a com alguns aspectos de sua composição corporal. Métodos Estudo caso-controle envolvendo 126 adolescentes (15 a 19 anos de idade), nos estádios finais da puberdade sendo 76 eutróficos e 50 com déficit de crescimento, familiar ou atraso constitucional do crescimento, pareados segundo a idade, o gênero e o grau de estadiamento puberal. Foram medidos o peso, a estatura e calculados escore Z de estatura/idade e o índice de massa corpórea; foram determinados o conteúdo mineral ósseo, a densidade mineral óssea e a densidade mineral óssea ajustada do corpo total, coluna lombar e fêmur; massa magra total e corrigida para a estatura, massa gorda total e corrigida para a estatura. Utilizaram-se os testes t de Student (peso, estatura e composição corporal) e de Mann-Whitney (massa óssea), e a regressão linear múltipla (determinantes da massa óssea). Resultados O peso, a estatura e o Z-estatura/idade foram significativamente maiores entre os eutróficos. Os dois grupos não apresentaram diferença significativa para a massa gorda, percentagem de massa gorda, massa magra total corrigida para estatura e massa gorda total corrigida para estatura. Contudo, a massa magra foi menor para o grupo dom déficit de crescimento. Conclusões Não foi encontrada diferença significativa entre as medidas de massa óssea de adolescentes com déficit de crescimento, contudo os fatores determinantes da formação da massa óssea devem ser mais bem estudados devido à correlação positiva com massa magra total detectada entre estes indivíduos com déficit de crescimento.

ABSTRACT Objective To evaluate bone mineral mass in adolescents with failure to thrive in relation to body composition. Methods A case control study involving 126 adolescents (15 to 19 years), in final puberty maturation being 76 eutrophic and 50 with failure to thrive (genetic or constitutional delay of growth), of matching ages, gender and pubertal maturation. The weight, height and calculated Z score for height/age and body mass index; bone mineral content, bone mineral density and adjusted bone mineral density were established for total body, lower back and femur; total fat-free mass and height-adjusted fat-free mass index, total fat mass and height-adjusted. The statistical analyses were performed using the Student's t-test (weight, height and body composition); Mann-Whitney test (bone mass) and multiple linear regression (bone mass determinants). Results weight, height and height/age Z-score were significantly higher among eutrophic subjects. Both groups did not show statistically significant differences for fat mass, percentage of fat mass, total fat mass height adjusted and fat-free mass index height sadjusted. However, total free fat maass was smaller for the failure to thrive group. Conclusions There was no statistically significant difference for bone mass measurements among adolescents with failure to thrive; however, the factors that determine bone mass formation should be better studied due to the positive correlation with free fat mass detected in these individuals.

OBJETIVOS: investigar o conhecimento de profissionais médicos brasileiros a respeito da osteoporose, estratégias de prevenção e tratamento e o acesso à informação em osteoporose, utilizando-se um questionário desenvolvido para avaliar o conhecimento de profissionais médicos em relação à importância da osteoporose e suas estratégias de tratamento. PACIENTES E MÉTODOS: o questionário foi divulgado a11 mil médicos afiliados à Sociedade Brasileira de Clínica Médica (SBCM). Realizou-se a divulgação da pesquisa e do questionário por meio de anúncios publicados no Jornal do Clínico. Inicialmente, foi disponibilizado na home-page e, em seguida, diretamente enviado via e-mail aos sócios cadastrados da SBCM. RESULTADOS: um total de 329 questionários retornou aos pesquisadores. A maioria dos médicos (55,3%) tinha tempo de graduação superior a 10 anos. Pouco mais que a metade dos profissionais médicos pesquisados (55%) relatou ter fácil acesso à densitometria óssea. A maioria (99%) dos participantes acredita que é importante ou muito importante prevenir a osteoporose. Da mesma forma, 73% dos médicos pesquisados acreditam que a osteoporose possa ser prevenida e 63% deles discutem o assunto com os seus pacientes. Por outro lado, mais da metade dos médicos pesquisados não crê que seus pacientes venham a mudar hábitos de vida e cerca de 50% deles não acreditam que seus pacientes venham a aderir ao tratamento da doença em longo prazo. Apenas 35% dos médicos pesquisados acreditam que os tratamentos para osteoporose sejam efetivos. Cerca de 82% fazem uso da densitometria óssea. Médicos com 10 anos ou mais de graduação utilizam a densitometria óssea mais freqüentemente que seus colegas com menos tempo de graduação. CONCLUSÃO: os autores acreditam que as informações obtidas no presente estudo poderiam ser úteis para o início do desenvolvimento de estratégias educacionais efetivas para a prevenção e o tratamento de pacientes com osteoporose.

OBJECTIVES: Brazilian physicians' knowledge on osteoporosis prevention and treatment strategies was investigated in this cross-sectional study. A specific structured questionnaire was designed to evaluate physicians' knowledge regarding osteoporosis prevention and treatment as well as osteoporosis information access. PATIENTS AND METHODS: the questionnaire was made available to around 11,000physicians affiliated to the Brazilian Society of Internal Medicine (BSIM). The questionnaire was initially presented at the BSIM home-page and subsequently sent by e-mail to all BSIM members. RESULTS: a total of 329 answered questionnaires returned to the researchers. Most of the physicians that answered the questionnaire (55.3%) had time since graduation lougher than 10 years and half of them (55%) reported having easy access to bone densitometry. The great majority of the physicians (99%) believe that preventing osteoporosis is important or very important. Accordingly, 73% of the physicians believe that osteoporosis can be prevented and around 63% of them discuss the issue with their patients regularly. On the other hand, most of the physicians that answered the questionnaire do not believe that their patients are able to change life habits or will adhere to the treatment in the long-term. Only 35% of the physicians believe that current osteoporosis treatment is effective. Around 82% of the physicians make use of bone densitometry to evaluate osteoporosis. Physicians with time since graduation higher than 10 years reported using bone densitometry more often than their colleagues with less time since graduation. CONCLUSION: our results demonstrate that educational programs aiming at the general practitioner are needed in order to provide better care in terms of prevention and treatment of skeletal fragility syndromes.

A prevalência de incapacidade e dependência funcional é maior em idosos e está intimamente associada à redução da massa muscular, que ocorre, até mesmo, em indivíduos saudáveis. A sarcopenia parece decorrer da interação complexa de distúrbios da inervação, diminuição de hormônios, aumento de mediadores inflamatórios e alterações da ingestão protéico-calórica que ocorrem durante o envelhecimento. A perda de massa e força muscular é responsável pela redução de mobilidade e aumento da incapacidade funcional e dependência. Quando associada à fragilidade, esta perda gera custos econômicos e sociais. Neste artigo, pretende-se avaliar aspectos relacionados à gênese da sarcopenia, bem como analisar possíveis opções terapêuticas e de prevenção.

The high prevalence of inability and functional dependence is an important problem in elderly people. It is closely related with aging decrease of lean muscle mass that occurs even in healthy subjects. Skeletal muscle mass deficiency, or sarcopenia, results from complex interactions between innervations disturbances, hormones deficiency, inflammatory cytokines and restriction in caloric-proteic ingestion. Loss of skeletal muscle mass and strength results in disability and functional dependency that are associated to frailty in many elderly people. These conditions represent enormous economic and social budget. In this article, we evaluate pathogenesis of sarcopenia and discuss potential therapies.

OBJETIVO: atividades de promoção de saúde e prevenção direcionadas para osteoporose podem ajudar a reduzir a taxa de fraturas osteoporóticas na população idosa. MÉTODOS: para avaliar se mulheres com osteoporose modificam seus hábitos de vida após a fratura, selecionamos 518 mulheres idosas caucasianas de nosso Serviço Ambulatorial de Reumatologia (122 com fratura), que foram seguidas por um ano. O questionário de avaliação foi baseado no European Vertebral Osteoporosis Study (EVOS) e contém tópicos relacionados com queda, massa óssea e fratura. Radiografias lateral da coluna torácica e lombar foram realizadas de acordo com protocolo padrão para verificar fratura vertebral. Densidade mineral óssea foi medida por meio de densitômetro Lunar DPX, Madison, WI. O comportamento das mulheres foi analisado antes e após a fratura. RESULTADOS: antes da fratura, 34% das mulheres tinham pior percepção da saúde, 40,2% caminhavam pelo menos meia hora por dia, 14,7% usavam bengalas, 56,6% queixavam-se de tonturas, 59,6% possuíam tapetes espalhados pela casa, 78,9% usavam transporte público, 21,1% utilizavam transporte privado (carro) e 36,8% usavam solado de couro e não de borracha. Após a fratura, 66,4% das mulheres tinham pior percepção da saúde; 69,7% ficaram mais sedentárias, 27,9% usavam mais bengalas, 63,4% queixavam-se de mais tonturas, 38,3% tinham retirado os tapetes de casa, 68,1% trocaram o transporte público por privado e 55,7% modificaram o solado dos sapatos de couro para borracha. Fatores de risco relacionados com a massa óssea não foram modificados após a fratura. CONCLUSÕES: estes achados sugerem que mulheres idosas modificam somente os hábitos de vida relacionados com quedas, mas não aqueles relacionados com a massa óssea após a fratura por osteoporose. Pesquisas são necessárias a fim de avaliar quais estratégias de intervenção podem ocasionar melhores resultados na prevenção de fraturas por osteoporose.

OBJECTIVE: health promotion and disease prevention activities directed to osteoporosis might help to reduce the rate of osteoporotic fractures among elderly people. METHODS: in order to check whether osteoporotic women modify their habits after the fracture, 518 postmenopausal white Brazilian elderly women were recruited from the outpatient clinic of the Rheumatology Division (122 of them with fracture) and were followed for one year. Questionnaire of evaluation was based on the European Vertebral Osteoporosis Study (EVOS) and inquiries about topics related to falls, bone mass and fracture. Lateral thoracic and lumbar radiographs were taken according to a standard protocol in order to verify vertebral fracture. Bone mineral density was measured using a bone densitometer (Lunar DPX, Madison, WI). Women's behavior was analyzed before and after the fracture. RESULTS: before the fracture, 34% of them had poor health perception, 40.2% walked at least half an hour per day, 14.7% used canes, 56.6% complained of dizziness, 59.6% scattered rugs, 78.9% used public transportation, 21.1% used car, and 36.8% wore leather instead of rubber sole. After the fracture, 66.4% of those women had worse health perception; 69.7% became more sedentary, 27.9% used more canes, 63.4% complained of more dizziness, 38.3% removed rugs, 68.1% changed from public to private car transportation, and 55.7% modified their shoes from leather to rubber sole. Risk factors related to bone mass did not change before and after the fractures. CONCLUSIONS: these findings suggested that women modify only lifestyle habits related to falls but not those related to bone mass after osteoporotic fracture. Further research is needed in order to check which intervention strategies may lead to better results in preventing osteoporotic fractures.

A osteoporose e os distúrbios neuropsiquiátricos surgem com maior freqüência entre os pacientes idosos, quando comparados com as demais faixas etárias. Manifestações concomitantes destas síndromes podem apresentar causas comuns. Neste artigo, nós descrevemos os casos de duas mulheres com osteoporose estabelecida e idades de 75 e 80 anos, que desenvolveram sinais e sintomas neuropsiquiátricos (apatia, fraqueza, depressão e perda de memória) associados a hipercalcemia [cálcio iônico de 1,43mmol/L e 1,65mmol/L (1,14 - 1,30mmol/L), respectivamente]. Na investigação laboratorial foi observado que os níveis da fração intacta do paratormônio (PTHi) estavam dentro dos limites da normalidade (64 e 63pg/ml, respectivamente) ou não suprimidos. Após exploração cirúrgica cervical foram removidas, de cada paciente, massas tumorais únicas, cujo anátomo-patológico revelou adenoma de paratireóide. As duas pacientes apresentaram melhora dos sintomas e sinais neuropsiquiátricos após a cirurgia e a segunda paciente obteve ganho de massa óssea significativo, sem uso de qualquer droga anti-reabsortiva. A outra paciente não pode ser avaliada através da densitometria óssea, devido às deformidades na coluna torácica. A possibilidade de HPTP deve ser sempre considerada, principalmente em pacientes com níveis de paratormônio dentro da faixa de normalidade, ou não suprimidos apesar de cálcio ionizado elevado. Isso ocorre devido a alguns tumores de paratireóide apresentarem set point alterado em relação aos níveis de cálcio mas sem aumento significativo da produção de paratormônio. Outra correlação observada é que quanto menor forem os adenomas, maior a chance de serem hipersecretores e autônomos. Em conclusão, a aferição do cálcio iônico em pacientes idosos com osteoporose e ou sintomas e sinais neuropsiquiátricos deve ser feita de rotina com o objetivo de se excluir doenças que possam ser tratadas prontamente e com bons resultados.

Osteoporosis and neuropsychiatric disorders occur more frequently in elderly than in young people. When they appear together there is a possibility of a common etiology. We report two cases of elderly women at the ages of 75 and 80y with established osteoporosis and neuropsychiatric manifestations (apathy, weakness, depression and loss of memory) caused by hypercalcemia (ionic calcium of 1.43mmol/L and 1.65mmol/L, respectively) due to primary hyperparathyroidism (PHPT). Other laboratory results showed normal levels of the intact fraction of parathormone (iPTH), i.e. 64 and 63pg/ml, respectively. They were submitted to parathyroidectomy and only one tumoral mass was removed from each woman. Pathologic examination showed parathyroid adenoma. Shortly after the surgery they got better of the neuropsychiatric signs and symptoms. Six months later the bone mineral density (BMD) of the second patient increased whereas the other one was unable to have her BMD evaluated due to thoracic deformities. The possibility of PHPT must be always considered, especially in patients with normal but not suppresible parathormone levels. The reason is that some parathyroid adenomas present an abnormal set point to calcium and no significantly increase in parathormone production. It should be emphasized that there is no satisfactory medical treatment for parathyroid adenoma except for surgical excision, which is effective in the majority of cases. We conclude that ionic calcium must be measured in all elderly patients who present neuropsychiatric disorders and/ or osteoporosis.

No presente estudo foi realizada uma análise retrospectiva de 24 pacientes com osteoporose estabelecida, com 10 ou mais anos de menopausa, tratadas com estrogênio conjugado, progesterona e cálcio, seguidas por um ano. As mulheres tratadas receberam 0,625mg/dia de estrogênio conjugado do 1º ao 259 dia, 5mg/dia de medroxiprogesterona do 13º ao 25º dia, de cada ciclo, e cálcio (500 a 1000mg/dia), durante um ano (12 ciclos). Como grupo controle foram estudadas 18 mulheres pareadas para idade, peso, altura e anos de menopausa, que receberam apenas cálcio (500 a 1000mg/dia). Todas as pacientes tinham pelo menos duas medidas da densidade óssea na coluna e região proximal do fêmur (colo, triângulo de Ward e trocanter), feitas antes e após um ano. O tratamento com estrogênio foi associado com aumento da densidade óssea na coluna e trocanter. O grupo controle não apresentou qualquer mudança estatisticamente significante após um ano, em nenhum dos locais avaliados. Nós concluímos que, mulheres com osteoporose estabelecida, tratadas com terapia de reposição hormonal e cálcio, mesmo quando iniciada com 10 ou mais anos após a menopausa apresentam aumento da densidade óssea. Estes dados comprovam que mulheres com 10 ou mais anos de menopausa respondem á hormonioterapia com aumento absoluto da densidade óssea de forma semelhante à observada em mulheres mais jovens, nos primeiros anos de menopausa.

A retrospective analysis of 24 patients with established osteoporosis and with ten or more years of menopause treated with conjugated estrogen, progesterone and calcium followed for one year has been performed. Treated women received 0.625 mg/day of conjugated estrogen from day 1 to 25, 5 mg/day of medroxiprogesterone from day 13 to 25, of each cycle, plus calcium (500 - 1000 mg/day), during one year (12 cycles). As control group was used 18 age-matched that received only calcium (500 a 1000 mg/day). All patients had at least two dual-photon spine and proximal femur (neck, Ward's triangle and trocanter) densities measurements performed 12 months apart. Estrogen treatment was associated with increased bone mineral density at spine and trocanter. Control group did not present any statistically change after one year in any site studied. We concluded that women with ten or more years of menopause and established osteoporosis treated with replacement hormonal therapy and calcium results in improvement of bone mineral density. These data support that women with ten or more years of menopause respond to estrogen replacement therapy with absolute increments in bone density similar to those seen in younger women, in the early menopause.