ABSTRACT Regional development in the state of Pará (Brazil) continues to be limited by lack of access to energy. This is a problem that is widespread in several rural communities and agricultural regions. Therefore, this study aimed to analyze the potential use of palm oil and cocoa processing waste biomass, which are abundant in the state and whose energy capacities can be used to generate electricity in biomass gasification plants. To do so, a literature review on elementary and calorific value analysis of palm oil (empty fruit bunches, fibers, kernel shell and cake, trunks, and others) and cocoa (pod husks) were conducted. The findings have shown that both waste biomass materials have satisfactory energetic characteristics for use in gasification plants. Thus, palm oil and cocoa processing waste biomasses are alternative energy sources for producers of these fruits in upstate Pará, enabling the development of the region.

ABSTRACT Denosumab (DMAb) is a human monoclonal antibody used as an antiresorptive drug in the treatment of osteoporosis. Approval at a dosage of 60 mg every 6 months was based on the results of the randomized, placebo-controlled trial (FREEDOM). The design of this 3-year study included an extension for up to 10 years. Those who were randomized to DMAb continued on drug, while those who were randomized to placebo transitioned to DMAb. The 10-year experience with DMAb provides data on efficacy of drug in terms of reduced fractures and continued increases in bone mineral density (BMD). The 10-year experience with denosumab also provides information about rare complications associated with the use of DMAb, such as osteonecrosis of the jaw (ONJ), and atypical femoral fractures (AFF). This experience provided new insights into the reversibility of effects upon discontinuation without follow-on therapy with another agent. This review focuses upon prolonged treatment with DMAb, with regard to beneficial effects on fracture reduction and safety. Additionally, its use in patients with impaired renal function, compare its results with those of bisphosphonates (BPs), the occurrence/frequency of complications, in addition to the use of different tools, from imaging techniques to histological findings, to evaluate its effects on bone tissue.

ABSTRACT Primary hyperparathyroidism (PHPT) is an endocrine disorder resulting from the hyperfunction of one or more parathyroid glands, with hypersecretion of parathyroid hormone (PTH). It can be managed by parathyroidectomy (PTX) or non-surgically. Medical therapy with pharmacological agents is an alternative for those patients with asymptomatic PHPT who meet guidelines for surgery but are unable or unwilling to undergo PTX. In this review, we focus upon these non-surgical aspects of PHPT management. We emphasize the most studied and widely used pharmacological alternatives: bisphosphonates, denosumab, cinacalcet and hormone therapy, in addition to combined therapy. We also address the relevant aspects of perioperative management.

Abstract Obesity affects several areas of the human body, leading to increased morbidity and mortality and the likelihood of other diseases, such as type 2 diabetes mellitus, cardiovascular diseases and musculoskeletal disorders. These conditions predispose to bone fractures and sarcopenic obesity, defined by the presence of an obesity-associated decrease in muscle mass and strength. Both bone fragility and sarcopenic obesity disease are consequences of several factors, such as a low degree of chronic inflammation, insulin resistance, hormonal changes, nutritional deficiencies, ectopic fat deposits and sedentary lifestyle. The diagnosis of obesity-related musculoskeletal disorders is limited by the lack of sarcopenia criteria and lower accuracy of bone mineral density measurement by dual-energy X-ray absorptiometry in overweight people. Reducing body weight provides undeniable benefits to this population, however treating cases of severe obesity with bariatric surgery can cause even greater damage to bone and muscle health, especially in the long term. The mechanisms involved in this process are not yet fully understood, but factors related to nutrient malabsorption and mechanical discharge as well as changes in gut hormones, adipokines and bone marrow adiposity should be taken into account. Depending on the surgical technique performed, greater musculoskeletal damage may occur, especially in cases of malabsorptive surgeries such as Roux-en-Y gastric bypass, when compared to restrictive techniques such as sleeve gastrectomy. This difference is probably due to greater weight loss, nutrient malabsorption and important hormonal changes that occur as a consequence of the diversion of intestinal transit and loss of greater absorptive surface. Thus, people undergoing bariatric procedures, especially malabsorptive ones, should have their musculoskeletal health supervised to allow early diagnosis and appropriate therapeutic interventions to prevent osteoporotic fractures and preserve the functionality of the skeletal muscles. Arch Endocrinol Metab. 2022;66(5):621-32

ABSTRACT Several drugs are available for the treatment of osteoporosis in postmenopausal women. Over the last decades, most patients requiring pharmacological intervention were offered antiresorptive drugs as first-line therapy, while anabolic agents were considered a last resource for those with therapeutic failure. However, recent randomized trials in patients with severe osteoporosis have shown that anabolic agents reduce fractures to a greater extent than antiresorptive medications. Additionally, evidence indicates that increases in bone mineral density (BMD) are maximized when patients are treated with anabolic agents first, followed by antiresorptive therapy. This evidence is key, considering that greater increases in BMD during osteoporosis treatment are associated with a more pronounced reduction in fracture risk. Thus, international guidelines have recently proposed an individualized approach to osteoporosis treatment based on fracture risk stratification, in which the stratification risk has been refined to include a category of patients at very high risk of fracture who should be managed with anabolic agents as first-line therapy. In this document, the Brazilian Society of Endocrinology and Metabolism and the Brazilian Association of Bone Assessment and Metabolism propose the definition of very high risk of osteoporotic fracture in postmenopausal women, for whom anabolic agents should be considered as first-line therapy. This document also reviews the factors associated with increased fracture risk, trials comparing anabolic versus antiresorptive agents, efficacy of anabolic agents in patients who are treatment naïve versus those previously treated with antiresorptive agents, and safety of anabolic agents.

ABSTRACT Several drugs are available for the treatment of osteoporosis in postmenopausal women. Over the last decades, most patients requiring pharmacological intervention were offered antiresorptive drugs as first-line therapy, while anabolic agents were considered a last resource for those with therapeutic failure. However, recent randomized trials in patients with severe osteoporosis have shown that anabolic agents reduce fractures to a greater extent than antiresorptive medications. Additionally, evidence indicates that increases in bone mineral density (BMD) are maximized when patients are treated with anabolic agents first, followed by antiresorptive therapy. This evidence is key, considering that greater increases in BMD during osteoporosis treatment are associated with a more pronounced reduction in fracture risk. Thus, international guidelines have recently proposed an individualized approach to osteoporosis treatment based on fracture risk stratification, in which the stratification risk has been refined to include a category of patients at very high risk of fracture who should be managed with anabolic agents as first-line therapy. In this document, the Brazilian Society of Endocrinology and Metabolism and the Brazilian Association of Bone Assessment and Metabolism propose the definition of very high risk of osteoporotic fracture in postmenopausal women, for whom anabolic agents should be considered as first-line therapy. This document also reviews the factors associated with increased fracture risk, trials comparing anabolic versus antiresorptive agents, efficacy of anabolic agents in patients who are treatment naïve versus those previously treated with antiresorptive agents, and safety of anabolic agents.

SUMMARY OBJECTIVE: To evaluated calcification of the coronary arteries and its association with visceral fat and 25-hydroxyvitamin D (25(OH)D) serum levels. METHODS: A cross sectional study involving 140 individuals without any previous diagnosis of cardiovascular disease. A biochemical analysis of vitamin D serum levels was carried out, as well as computed tomography to measure coronary artery calcium score and visceral adipose tissue. RESULTS: The mean age of the individuals was 55.9 (±12.4). Coronary artery calcium was observed in 40.7% of the population. Vitamin D presented median serum levels of 30.4 ng/ml (IQ24.5–39.1), with 14,1 and 33.7% of the individuals presenting deficiency and insufficiency, respectively. In the univariate analysis, the calcium score was more prevalent in aged patients (p<0.01), in hypertensive individuals (p<0.01), in diabetics (p=0.02), and in those with a higher concentration of VAT (p=0.02). In the adjusted analysis, it was found that the highest concentration of VAT (OR: 4.0; 95%CI 1.4–11.7), hypertension (OR: 4.8; 95%CI 1.5–15.3), and age (OR: 10.4; 95%CI 3.9–27.6) were predictors of subclinical atherosclerosis, regardless of body mass index, diabetes, and 25OHD. CONCLUSIONS: Excess visceral fat was associated with subclinical atherosclerosis, regardless of other risk factors for cardiovascular disease. Serum levels of 25OHD were not associated with CAD in its early stages.

SUMMARY OBJECTIVE: To evaluated calcification of the coronary arteries and its association with visceral fat and 25-hydroxyvitamin D (25(OH)D) serum levels. METHODS: A cross sectional study involving 140 individuals without any previous diagnosis of cardiovascular disease. A biochemical analysis of vitamin D serum levels was carried out, as well as computed tomography to measure coronary artery calcium score and visceral adipose tissue. RESULTS: The mean age of the individuals was 55.9 (±12.4). Coronary artery calcium was observed in 40.7% of the population. Vitamin D presented median serum levels of 30.4 ng/ml (IQ24.5–39.1), with 14,1 and 33.7% of the individuals presenting deficiency and insufficiency, respectively. In the univariate analysis, the calcium score was more prevalent in aged patients (p<0.01), in hypertensive individuals (p<0.01), in diabetics (p=0.02), and in those with a higher concentration of VAT (p=0.02). In the adjusted analysis, it was found that the highest concentration of VAT (OR: 4.0; 95%CI 1.4–11.7), hypertension (OR: 4.8; 95%CI 1.5–15.3), and age (OR: 10.4; 95%CI 3.9–27.6) were predictors of subclinical atherosclerosis, regardless of body mass index, diabetes, and 25OHD. CONCLUSIONS: Excess visceral fat was associated with subclinical atherosclerosis, regardless of other risk factors for cardiovascular disease. Serum levels of 25OHD were not associated with CAD in its early stages.

ABSTRACT Antiresorptive therapy is the main form of prevention of osteoporotic or fragility fractures. Medication-related osteonecrosis of the jaw (MRONJ) is a relatively rare but severe adverse reaction to antiresorptive and antiangiogenic drugs. Physicians and dentists caring for patients taking these drugs and requiring invasive procedures face a difficult decision because of the potential risk of MRONJ. The aim of this study was to discuss the risk factors for the development of MRONJ and prevention of this complication in patients with osteoporosis taking antiresorptive drugs and requiring invasive dental treatment. For this goal, a task force with representatives from three professional associations was appointed to review the pertinent literature and discuss systemic and local risk factors, prevention of MRONJ in patients with osteoporosis, and management of established MRONJ. Although scarce evidence links the use of antiresorptive agents in the context of osteoporosis to the development of MRONJ, these agents are considered a risk factor for this complication. Despite the rare reports of MRONJ in patients with osteoporosis, the severity of symptoms and impact of MRONJ in the patients' quality of life make it imperative for health care professionals to consider this complication when planning invasive dental procedures.

ABSTRACT Hypovitaminosis D is a common condition with a negative impact on health. This statement, prepared by experts from the Brazilian Society of Endocrinology and Metabolism and the Brazilian Society of Clinical Pathology/Laboratory Medicine, includes methodological aspects and limitations of the measurement of 25-hydroxyvitamin D [25(OH)D] for identification of vitamin D status, and identifies individuals at increased risk for deficiency of this vitamin in whom 25(OH)D measurement is recommended. For the general population, 25(OH)D levels between 20 and 60 ng/mL are considered normal, while individuals with levels below 20 ng/mL are considered to be vitamin D deficient. This statement identifies potential benefits of maintaining 25(OH)D levels > 30 ng/mL in specific conditions, including patients aged > 65 years or pregnant, those with recurrent falls, fragility fractures, osteoporosis, secondary hyperparathyroidism, chronic kidney disease, or cancer, and individuals using drugs with the potential to affect the vitamin D metabolism. This statement also calls attention to the risk of vitamin D intoxication, a life-threatening condition that occurs at 25(OH)D levels above 100 ng/mL

ABSTRACT Osteoporosis is a systemic skeletal disease characterized by reduced bone mass and deterioration of bone tissue microarchitecture leading to an increased risk of fractures. Fragility fractures, especially hip fractures, are associated with a significant reduction in the physical function and quality of life of affected patients, as well as increased mortality, leading to a major financial impact on health care. Many drugs have been registered for the treatment of osteoporosis and very recently, a new anabolic agent, romosozumab, has been approved in some countries. Despite the expansion of efficacious antiresorptive and anabolic therapies in recent years, a concomitant increase in concerns have been raised by physicians, patients and the lay press about the potential for adverse events, especially atypical femoral fractures (AFF) following prolonged use of bisphosphonates. Whatever the mechanism(s) may be, direct or indirect, linking prolonged bisphosphonate use to atypical femoral fractures, this adverse event is very rare in comparison to the magnitude of risk reduction of typical osteoporotic fractures. An estimated 162 osteoporosis-related fractures are prevented for each atypical femoral fracture associated with an anti-resorptive medication. Until a risk calculator for predicting risk of atypical fractures, becomes available in clinical practice, and we view this as an unlikely scenario, it is up to the physician to consider continuing or discontinuing bisphosphonate use after the critical 3-5 year period of treatment with zoledronic acid or alendronate, but close monitoring for the residual bone effects overtime should be planned. For other bisphosphonates, in which no residual effects are expected, drug holiday is usually not applied.

Resumo O tratamento convencional do aneurisma da artéria poplítea é a cirurgia aberta de exclusão do aneurisma e revascularização do membro acometido. Nos últimos anos, o tratamento endovascular vem ganhando popularidade e interesse. O tratamento endovascular é menos invasivo e de menor morbidade; porém, é de alto custo e sua perviedade é incerta. O objetivo desta revisão é comparar os dois tratamentos através da análise de desfechos abordados em estudos primários e secundários. Realizou-se uma revisão narrativa da literatura publicada nos últimos 5 anos. Foram selecionados seis estudos retrospectivos, duas metanálises, um ensaio clínico e uma revisão sistemática Cochrane. Número limitado de pacientes e curto período de seguimento não nos permitem extrair conclusões consistentes. Não há evidência clara que sugere melhores resultados entre um ou outro tratamento eletivo. Novos ensaios randomizados devem ser realizados para determinar o papel do tratamento endovascular desse aneurisma.

Abstract The conventional treatment for a popliteal artery aneurysm is open surgery to exclude the aneurysm and revascularization of the affected limb. Over recent years, endovascular treatment has grown in popularity and has been attracting increased interest. Endovascular treatment is less invasive and associated with lower rates of morbidity, but it is expensive and patency is uncertain. The aim of this review is to compare these two treatments by analyzing the outcomes reported in primary and secondary studies. A narrative review is conducted of the literature published over the last 5 years. Six retrospective studies, two meta-analyses, one clinical trial and one Cochrane systematic review were selected. We were unable to draw firm conclusions because of small patient samples and short follow-up periods. There is no clear evidence to indicate that the outcomes of one or another elective treatment are superior. New randomized trials should be conducted to determine the role endovascular treatment has to play in management of this type of aneurysm.

ABSTRACT Objective To present an update on the diagnosis and treatment of hypoparathyroidism based on the most recent scientific evidence. Materials and methods The Department of Bone and Mineral Metabolism of the Sociedade Brasileira de Endocrinologia e Metabologia (SBEM; Brazilian Society of Endocrinology and Metabolism) was invited to prepare a document following the rules set by the Guidelines Program of the Associação Médica Brasileira (AMB; Brazilian Medical Association). Relevant papers were retrieved from the databases MEDLINE/PubMed, LILACS, and SciELO, and the evidence derived from each article was classified into recommendation levels according to scientific strength and study type. Conclusion An update on the recent scientific literature addressing hypoparathyroidism is presented to serve as a basis for the diagnosis and treatment of this condition in Brazil.

Abstract Objective: Intimal hyperplasia is associated with graft failure and vascular sutures in the first year after surgery and in postangioplasty restenosis. Allium sativum (common garlic) lowers cholesterol and has antioxidant effects; it also has antiplatelet and antitumor properties and, therefore, has great potential to reduce or inhibit intimal hyperplasia of the arteries. Our objective is to determine if the garlic has an efficacy to inhibit myointimal hyperplasia compared to cilostazol. Methods: Female New Zealand rabbits were divided into the following groups (n=10 each) according to treatment: group A, garlic, 800 µg×kg-1×day-1, orally; group C, cilostazol, 50 mg.day-1, orally; group PS, 10 ml of 0.9% physiological saline solution, orally. Our primary is the difference of the mean of myointimal hyperplasia. Statistical analysis was performed by using ANOVA and Tukey tests, as well as the Chi-square test. We calculated the 95% confidence interval for each point estimate, and the P value was set as < 0.05. Results: Group PS had a mean hyperplasia rate of 35.74% (95% CI, 31.76–39.71%); group C, 16.21% (95% CI, 13.36–19.05%); and group A, 21.12% (95% CI, 17.26–25.01%); P<0.0001. Conclusion: We conclude that Allium sativum had the same efficacy in inhibiting myointimal hyperplasia when compared to the positive control, cilostazol.