Sarcopenia na doença pulmonar obstrutiva crônica

Orientadora : Profa. Dra. Victória Z. Cochenski BorbaDissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências da Saúde, Programa de Pós-Graduação em Medicina Interna. Defesa : Curitiba, 02/09/2016Inclui referências : f. 60-72Resumo: A doença pulmonar obstrutiva crônica (DPOC) é uma doença altamente prevalente, prevenível e tratável. Além do comprometimento pulmonar, diversas condições associadas extrapulmonares são comumente vistas. A redução na densidade mineral óssea (DMO), a presença de fraturas vertebrais e as alterações na composição corporal (CC) que ocorrem nestes pacientes, elevam o risco de exacerbações da doença, pioram a qualidade de vida e aumentam a mortalidade. Este estudo relacionou os dados de DMO, CC, prevalência de fraturas vertebrais morfométricas (FVM), pré-sarcopenia e sarcopenia com os critérios de gravidade e prognóstico de pacientes com DPOC e comparou os resultados com dois grupos controles, além de comparar 4 critérios diagnósticos (Baumgartner, Newman, Misto e FNIH) de pré-sarcopenia e sarcopenia nos três grupos. Todos os pacientes e controles realizaram exame de densitometria óssea, CC e avaliação de FVM no SEMPR (Serviço de Endocrinologia e Metabologia da UFPR). Foram avaliados os dados de 121 pacientes (65 mulheres), média de 67,9 ± 8,6 anos com DPOC (GD), 63 indivíduos tabagistas (GT) (29 mulheres), média de 65,5 ± 8,9 anos e 81 indivíduos não tabagistas (GNT) (47 mulheres), média de 66 ± 8,5 anos. DMO alterada foi observada em 88,4% dos pacientes do GD, com maior número de pacientes com osteoporose neste grupo em relação aos controles (p<0,001). A DMO (g/cm²) nos três sítios avaliados foi menor no GD que nos controles, associado com pior grau de obstrução, estadiamento clínico e índice prognóstico da DPOC (p<0,05). A prevalência de FVM nos pacientes com DPOC foi elevada (57,85%) e maior do que em ambos os grupos controles (GT 23,8% e GNT 14,8%), p<0,001. A CC mostrou menor porcentagem de gordura corporal total no GD em relação aos controles (p=0,04). Pior DMO nos três grupos e nos três sítios avaliados foi associada com menor quantidade de massa magra total (p<0,001). A prevalência de pré-sarcopenia foi maior no GD variando de 19 a 46%, dependendo do critério utilizado, sendo mais prevalente quando utilizado o critério mais atual da literatura (FNIH). No GT a prevalência variou de 20,6 a 39,7% e no GNT de 18,5 a 29,6%. A concordância entre os critérios diagnósticos de pré-sarcopenia foi considerada baixa (kappa <0,40). O diagnóstico de sarcopenia no GD, considerando os 4 critérios, mostrou uma concordância moderada (kappa = 0,57) entre os mesmos e com alta prevalência, variando de 4,9 a 12,4%, também maior pelo FNIH. Existiu uma associação entre sarcopenia e pior prognóstico da doença (OR: 3,50 (1,06 - 11,56), p=0,035), na análise univariada. Concluímos que os pacientes com DPOC apresentaram alterações significativas na massa óssea, na CC e alta prevalência de pré-sarcopenia e sarcopenia quando comparados a controles tabagistas ou não, além de elevado número de FVM. Estas alterações podem levar a pior qualidade de vida, aumento no risco de exacerbações da doença e de mortalidade, também sugerem que a investigação de sarcopenia e de osteoporose deva ser ao diagnóstico da DPOC, para prevenção e tratamento precoces.Abstract: Chronic obstructive pulmonary disease (COPD) is a highly prevalent, preventable and treatable disease. In addition to lung disease, COPD is commonly associated with several extra-pulmonary disorders. The reduction in bone mineral density (BMD), the presence of vertebral fractures and changes in body composition (BC) that occurs in these patients, increase the risk of disease exacerbations, worsen the quality of life and increases mortality. This study linked the BMD data, BC, prevalence of morphometric vertebral fractures (MVF), pre-sarcopenia and sarcopenia with the criteria of severity and prognosis of patients with COPD and compared the results with two control groups. In addition, did a comparison of the 4 criteria (Baumgartner, Newman, Mixed and FNIH) for diagnosis of pre-sarcopenia and sarcopenia in all groups. All patients and controls underwent bone mineral densitometry, body composition exam and evaluation of morphometric vertebral fractures at SEMPR (Serviço de Endocrinologia e Metabologia da UFPR). We evaluated the data of 121 patients (65 women), mean 67.9 ± 8.6 years with COPD (DG), 63 smokers (SG) (29 women), mean 65.5 ± 8.9 years and 81 individuals nonsmokers (NSG) (47 women) mean of 66 ± 8.5 years. Altered BMD was observed in 88.4% of DG patients with a greater number of patients with osteoporosis in this group compared to controls (p <0.001). BMD (g/cm²) in the three sites evaluated was lower in DG than in controls and was associated with worse degree of obstruction, clinical staging and prognostic index of COPD (p <0.05). The prevalence of MVF in COPD patients was high (57.85%) and higher than in both control groups (SG 23.8% and 14.8% NSG), p <0.001. BC showed a lower percentage of total body fat in DG compared to controls (p = 0.04). Worse BMD in the three groups, and in the three sites was associated with lower total lean body mass (p <0.001). The prevalence of pre-sarcopenia was higher in DG ranging from 19 to 46%, depending on the criteria used, being more prevalent when using the most current criteria in the literature (FNIH). In SG the prevalence ranged from 20.6 to 39.7%, and in NSG 18.5 to 29.6%. The agreement between the pre-sarcopenia diagnostic criteria was considered poor (kappa <0.40). The diagnosis of sarcopenia in DG considering the four different criteria showed a moderate agreement between them (kappa = 0.57), with a high prevalence, ranging from 4.9 to 12.4%, also higher by FNIH. Univariate analysis showed an association between sarcopenia and worse prognosis of the disease (OR: 3.50 (1,06 - 11,56), p = 0.035). We conclude that patients with COPD have significant effects on bone mass, BC and high prevalence of pre-sarcopenia and sarcopenia compared to smokers or not smokers. Factors associated with high numbers of MVF, worse quality of life, increased risk of disease exacerbations and mortality, suggesting that initial investigation at the diagnosis of the disease should be done for precocious prevention and treatment

NUTRITIONAL SUPLLEMENTS

The promise of quick results in muscle mass, body definition, fat reduction and body weight is contributing to the abuse of nutritional supplements. However, prior to the prescription of any supplementation, it is necessary to adequate the nutrients intake from the diet. The intake of the right amount of calories, carbohydrates, proteins, fats, vitamins and minerals is the fundamental basis for any physical activity practitioner. And the primary supplementation should occur when you cannot meet the daily requirement of nutrients through food. There are over two hundred and fifty types of food supplements described. The supplements may contain carbohydrates, proteins, fats, minerals, vitamins, herbs, enzymes of the intermediary metabolism substances (such as amino acids) and various types of animal and plant extracts. This article is a review of the nutritional supplements which have consistent scientific studies: carbohydrates, proteins, BCAAs (Branched Chain Amino Acids) and creatine. The aim is to provide clarification and guide the medical community about the indications, benefits and risks of these substances.   A promessa de resultados rápidos e milagrosos no ganho de massa muscular, definição corporal, redução de gordura e peso corporal vem contribuindo para o uso abusivo de suplementos nutricionais. Porém, previamente à indicação de qualquer suplementação, faz-se necessária uma orientação dietética adequada. A ingestão da quantidade correta de calorias, carboidratos, proteínas, gorduras, vitaminas e minerais é a base fundamental para qualquer praticante de atividade física. E a suplementação primária deve ocorrer quando não se consegue suprir a necessidade diária dos nutrientes através da alimentação. Já foram descritos mais de duzentos e cinquenta tipos de suplementos alimentares. Os suplementos podem conter carboidratos, proteínas, gorduras, minerais, vitaminas, ervas, enzimas, substâncias do metabolismo intermediário (como aminoácidos) e vários tipos de extratos vegetais e animais. Este artigo é uma revisão sobre os suplementos nutricionais que apresentam embasamentos científicos consistentes: carboidratos, proteínas, BCAAs (Aminoácidos de Cadeia Ramificada) e creatina. O intuito é de prover um esclarecimento e orientar a população médica quanto à indicação, benefícios e riscos dessas substâncias.  

HIPERPARATIREOIDISMO PRIMÁRIO - DIFERENTES MODALIDADES DE TRATAMENTOS

RESUMOObjetivo: Avaliar a resposta clínica dos portadores de HPTP, submetidos ou não à cirurgia, comparando a evolução de cada grupo.Métodos: Avaliação através dos prontuários dos pacientes com HPTP atendidos no Hospital de Clínicas no período de 1992 a 2014. Os pacientes foram divididos de acordo com o tratamento em grupo cirúrgico (GC) e clínico (GCL). Dados de exames laboratoriais e densitométricos anteriores e após o tratamento foram coletados e posteriormente, realizada uma comparação entre eles.Resultados: Cinquenta e um dos 99 prontuários selecionados compuseram a amostra final, sendo 27 no GC, com idade média de 73±9,8 anos e 24 no GCL, com idade média de 58±12,8 anos, (p=0,0001). Todos os parâmetros avaliados se mantiveram semelhantes no GCL com exceção da DMO de coluna lombar (L1-L4), que aumentou em média 7,5 %. Já o GC apresentou aumento médio na DMO de 22,2% em L1-L4, 14,5% em colo de fêmur e de 11,3% em fêmur total. Neste grupo, cálcio sérico, urinário e PTH diminuíram (p<0,05), embora seis pacientes não apresentaram cura cirúrgica. O GCL apresentou maior comorbidade cardiovascular (p=0,038) que o GC. Os demais parâmetros foram semelhantes entre os grupos.Conclusão: Foi visto uma melhora nos parâmetros laboratoriais e densitométricos dos pacientes do GC, concluindo assim que a cirurgia foi a melhor opção em pacientes mais jovens

Sarcopenia in COPD: relationship with COPD severity and prognosis

Objective: To evaluate the prevalence of sarcopenia in COPD patients, as well as to determine whether sarcopenia correlates with the severity and prognosis of COPD. Methods: A cross-sectional study with COPD patients followed at the pulmonary outpatient clinic of our institution. The patients underwent dual-energy X-ray absorptiometry. The diagnosis of sarcopenia was made on the basis of the skeletal muscle index, defined as appendicular lean mass/height2 only for low-weight subjects and adjusted for fat mass in normal/overweight subjects. Disease severity (COPD stage) was evaluated with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The degree of obstruction and prognosis were determined by the Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity (BODE) index. Results: We recruited 91 patients (50 females), with a mean age of 67.4 ± 8.7 years and a mean BMI of 25.8 ± 6.1 kg/m2. Sarcopenia was observed in 36 (39.6%) of the patients, with no differences related to gender, age, or smoking status. Sarcopenia was not associated with the GOLD stage or with FEV1 (used as an indicator of the degree of obstruction). The BMI, percentage of body fat, and total lean mass were lower in the patients with sarcopenia than in those without (p < 0.001). Sarcopenia was more prevalent among the patients in BODE quartile 3 or 4 than among those in BODE quartile 1 or 2 (p = 0.009). The multivariate analysis showed that the BODE quartile was significantly associated with sarcopenia, regardless of age, gender, smoking status, and GOLD stage. Conclusions: In COPD patients, sarcopenia appears to be associated with unfavorable changes in body composition and with a poor prognosis

Association of primary hyperparathyroidism and humoral hypercalcemia of malignancy in a patient with clear cell renal carcinoma

Hypercalcemia is found frequently in patients with cancer. Besides the etiology related to the malignancy, other causes should be considered in the differential diagnostic, as primary hyperparathyroidism, granulomatous diseases and the use of thiazide diuretics. We present a case report of a severe hypercalcemia due to a rare association and review the relevant literature. A female patient, 57 years old, sent to the Endocrinology Service of Hospital das Clínicas da Universidade do Paraná (SEMPR) in order to investigate severe hypercalcemia with frequent need of hospitalization. The patient was in chemotherapy treatment for recurrence of clear cell renal cancer. During the investigation she presented high level of parathyroid hormone (PTH) and parathyroid scintigraphy suggestive of hyperplasia/ adenoma of parathyroid, histopathological diagnosis was confirmed after parathyroidectomy. After surgery the patient presented undetectable levels of PTH. However, she continued with progressive increase of serum calcium, with no signs of bone metastases or change in vitamin D metabolism. The investigation showed high levels of PTH-related protein (PTHrP), leading us to the diagnosis of hypercalcemia of malignancy. The patient presented severe hypercalcemia due to the rare association of primary hyperparathyroidism and humoral hypercalcemia of malignancy due to secretion of PTHrP by tumor cells. The presence of isolated primary hyperparathyroidism, as a cause of hypercalcemia in cancer patients, has been described in approximately 5-10% of the patients. However, the association of primary hyperparathyroidism and humoral hypercalcemia of malignancy (which means with concomitant elevation of PTH and PTHrP) is rare, only three cases have been described in the literature. Arch Endocrinol Metab. 2015;59(1):84-

Association of primary hyperparathyroidism and humoral hypercalcemia of malignancy in a patient with clear cell renal carcinoma

SUMMARY Hypercalcemia is found frequently in patients with cancer. Besides the etiology related to the malig nancy, other causes should be considered in the differential diagnostic, as primary hyperparathyroid ism, granulomatous diseases and the use of thiazide diuretics. We present a case report of a severe hypercalcemia due to a rare association and review the relevant literature. A female patient, 57 years old, sent to the Endocrinology Service of Hospital das Clínicas da Universidade do Paraná (SEMPR) in order to investigate severe hypercalcemia with frequent need of hospitalization. The patient was in chemotherapy treatment for recurrence of clear cell renal cancer. During the investigation she presen ted high level of parathyroid hormone (PTH) and parathyroid scintigraphy suggestive of hyperplasia/ adenoma of parathyroid, histopathological diagnosis was confirmed after parathyroidectomy. After surgery the patient presented undetectable levels of PTH. However, she continued with progressive increase of serum calcium, with no signs of bone metastases or change in vitamin D metabolism. The investigation showed high levels of PTHrelated protein (PTHrP), leading us to the diagnosis of hypercalcemia of malignancy. The patient presented severe hypercalcemia due to the rare association of primary hyperparathyroidism and humoral hypercalcemia of malignancy due to secretion of PTHrP by tumor cells. The presence of isolated primary hyperparathyroidism, as a cause of hypercalcemia in cancer patients, has been described in approximately 510% of the patients. However, the association of primary hyperparathyroidism and humoral hypercalcemia of malignancy (which means with con comitant elevation of PTH and PTHrP) is rare, only three cases have been described in the literature