Scielo RSS <![CDATA[Revista médica de Chile]]> http://www.scielo.cl/rss.php?pid=0034-988720160003&lang=es vol. 144 num. 3 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.cl/img/en/fbpelogp.gif http://www.scielo.cl <![CDATA[<strong>El encanto de editar una revista médica y los recuerdos nostálgicos al alejarme</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300001&lng=es&nrm=iso&tlng=es As of March 2016, Humberto Reyes, MD, FACP, steps down as Editor-in-Chief of Revista Médica de Chile. He joined its editorial team in 1971, as a part-time Assistant Editor. A few years later he became Associate Editor and since 1996, Editor-in-Chief. During his tenure the journal improved the peer review system and implemented a web platform to handle the editorial process, while following the recommendations established by acknowledged organizations such as the International Committee of Medical Journal Editors (ICMJE), the World Association of Medical Journal Editors (WAME) and the Committee on Publication Ethics (COPE). Since 2010 he represented Revista Médica de Chile as an ICMJE Member. After an open contest, the Sociedad Médica de Santiago, founder and owner of Revista Médica de Chile since 1872, elected Fernando Florenzano MD as the new Editor-in-Chief. Dr. Reyes leaves this long lasting job with the satisfaction of having conducted an institution considered among mainstream medical journals in spite of being mostly published in Spanish. Revista Médica de Chile receives a high proportion of the research articles that have been generated in the country, subsequently handled by an enthusiastic and solid editorial team whose responsibilities go far beyond selecting the material to be published since they are medical educators striving to help authors to improve their papers before having them published. Conducting this journal has been a fascinating task for this Editor as well as an unforgettable experience. <![CDATA[<strong>Efecto de la incorporación de registros adicionales a la presión arterial en la Encuesta Nacional de Salud, Chile 2010</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300002&lng=es&nrm=iso&tlng=es Background: It is of utmost importance to identify hypertensive subjects in a country, in order to use efficiently public resources. The National Health Survey 2009-10 in Chile incorporated a third measurement of blood pressure (BP) during the home visit performed by a nurse, and a second day of measurement in a representative sub-sample. Aim: To study the effect of these two additional actions over both the average value of BP and the national prevalence of hypertension. Material and Methods: A third blood pressure measurement was carried out in 5,058 subjects, and it was measured in a second day in 930 individuals. The effect of these additional measurements on absolute blood pressure values and the prevalence of hypertension were assessed. Results: A small but statistically significant reduction in mean systolic pressure (0.52 mmHg) and the prevalence of hypertension (1%) was observed after the incorporation of the third blood pressure measurement. No effects in these figures were observed after the measurement performed on a second day. Conclusions: These findings should be considered when designing the new National Health Survey in Chile. <![CDATA[<strong>Clasificación según nivel de morbilidad e intensidad del uso de recursos de una población con patologías crónicas en Atención Primaria de Salud utilizando “<i>Adjusted Clinical Groups</i>” (ACG)</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300003&lng=es&nrm=iso&tlng=es Background: Health care must be provided with strong primary health care models, emphasizing prevention and a continued, integrated and interdisciplinary care. Tools should be used to allow a better planning and more efficient use of resources. Aim: To assess risk adjustment methodologies, such as the Adjusted Clinical Groups (ACG) developed by The Johns Hopkins University, to allow the identification of chronic condition patterns and allocate resources accordingly. Material and Methods: We report the results obtained applying the ACG methodology in primary care systems of 22 counties for three chronic diseases, namely Diabetes Mellitus, Hypertension and Heart Failure. Results: The outcomes show a great variability in the prevalence of these conditions in the different health centers. There is also a great diversity in the use of resources for a given condition in the different health care centers. Conclusions: This methodology should contribute to a better distribution of health care resources, which should be based on the disease burden of each health care center. <![CDATA[<strong>Diferencias de género en la calidad de vida relacionada con la salud en adolescentes escolarizados chilenos</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300004&lng=es&nrm=iso&tlng=es Background: Health-related quality of life (HRQOL) refers to individuals' perception of their subjective well-being, considering various aspects of their life and the impact on their health. Aim: To analyze gender differences in the HRQOL of adolescent students in Chile, by age, type of school attended, and area of residence. Material and Methods: Analytical cross-sectional study conducted in a population of 5th and 12th grade students attending municipal, subsidized and private schools in 11 regions of the country. HRQOL was assessed with the KIDSCREEN-52, an instrument that has been previously adapted and validated in Chile. The database obtained from that adaption and validation process was analyzed. Results: In total, 7,910 students (median age 14 years, 53% female) completed the questionnaire. Compared to males, females had lower HRQOL scores in most of the KIDSCREEN-52 dimensions. However, males were more likely to have lower scores in the “Peers and Social Support” and “School Environment” dimensions. These differences remained valid when the sample was stratified by age, type of school, and area of residence were analyzed. Conclusions: This study supports the existence of inequalities in the self-perceived HRQOL of Chilean adolescent students. The existing differences are not only related to gender but are also evident when stratifying by type of school attended. <![CDATA[<strong>Asociación de la resistina con variables de dimensión y composición corporal en eutróficos y obesos</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300005&lng=es&nrm=iso&tlng=es Background: Resistin is an adipokine secreted in adipose tissue that may be associated with the metabolic and endocrine disorders of obesity. Aim: To assess the association between serum resistin levels and body composition variables, in children and adolescents. Material and Methods: Cross-sectional assessment of 302 subjects, aged 10-16 years. According to body mass index, 124 were classified as eutrophic and 178 as obese. A clinical examination and pubertal assessment were performed. Body weight, height, waist and arm circumferences were measured. Serum resistin levels were measured using an immunoenzymatic assay. Results: Male obese children had significantly higher resistin levels than their eutrophic counterparts. Eutrophic women had higher levels than eutrophic males. No significant association between resistin and pubertal status was observed. In the whole sample and among obese subjects, resistin levels correlated with body mass index, tricipital skinfold, arm circumference, arm fat area and fat mass. Conclusions: There is a significant association between resistin levels and body composition variables, particularly with indicators of fat accretion. <![CDATA[<strong>Acceso a colecistectomía en un programa de tamizaje ecográfico de colelitiasis en centros de medicina familiar</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300006&lng=es&nrm=iso&tlng=es Background: Cholelithiasis (CL) represents a major health burden in Chile, with rates of cholecystectomy (CCT) of ~40.000 per year. The explicit health care guaranties (GES) program includes prioritized CCT for CL carriers between 35 and 49 years of age. Aim: To assess the access and opportunity of CCT in a screening program of CL in Family Medicine Centers, according to the age of the patients. Material and Methods: A systematic ultrasound screening program of CL was developed in Family Medicine Centers ANCORA-UC between March 2009 and March 2013 during which 1.450 individuals were assessed, (80% women) and 281 were identified as having CL (19.4%). After a minimum follow up interval of six months, patients with CL were contacted and surveyed by phone. They were categorized as being beneficiaries of the GES program (those aged between 35 to 49 years) or not (those aged < 35 o &gt; 49 years). Results: Two hundred thirteen patients were contacted (76%), 81 beneficiaries of the program and 132 non-beneficiaries. The attending physician indicated CCT to 191 patients (89.6%). During a mean follow-up time of 641 days/person, 100 patients had CCT, 11% of which were emergency interventions due to complications. A greater proportion of program beneficiaries than non-beneficiaries had an elective CCT (74 and 21% respectively). The waiting interval for elective CCT was longer in non-beneficiaries compared with beneficiaries (340 ± 247 and 229 ± 201 days respectively). Only 46% of the elective CCT in GES patients were done within deadlines determined by the program (≤ 150 days). Conclusions: The age of patients at the moment of CL diagnosis conditions the access and opportunity to CCT. Beneficiaries of the explicit health care guaranties program have higher rates of cholecystectomy with less waiting time. <![CDATA[<strong>Efectividad de la acupuntura en el tratamiento del dolor agudo postquirúrgico en adultos, en comparación con tratamientos activos o con acupuntura simulada</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300007&lng=es&nrm=iso&tlng=es Background: There is evidence that acupuncture may relieve pain. Aim: To assess the evidence about the effectiveness of acupuncture to relieve postoperative pain. Material and Methods: A systematic review of the literature selecting controlled clinical trials and systematic reviews comparing acupuncture with standard pain management. The value and quality of reports were evaluated using Jadad scale and STRICTA protocol. Pain intensity and analgesic consumption were the primary endpoints sought. Results: Five controlled trials and two systematic reviews were selected. A meta-analysis was not feasible due to the heterogeneity of studies. In the postoperative period of tonsillectomy, acupuncture reduced pain by 36 and 22% at 20 minutes and two hours, respectively. In knee replacement, acupuncture reduced pain by 2% and analgesic consumption by 42%. In the postoperative period of dental interventions, acupuncture reduced pain by 24% at two hours. Conclusions: Acupuncture may be useful to manage postoperative pain, but more controlled studies are required. <![CDATA[<strong>Alteraciones tiroideas en pacientes infectados con el virus de inmunodeficiencia humana</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300008&lng=es&nrm=iso&tlng=es Background: Thyroid dysfunction is common among patients infected with human immunodeficiency virus (HIV). It presents in different forms and has a multifactorial etiology. Aim: To determine the prevalence and features of thyroid dysfunction among patients infected with HIV. Material and Methods: A cross-sectional study of 127 patients infected with HIV aged 19 to 75 years (85% males). Patients with previous diagnoses of endocrine diseases and pregnant women were excluded. Participants responded a questionnaire about symptoms and the evolution of HIV infection. A blood sample was obtained to measure thyroid stimulating hormone, free thyroxin, viral load and CD4 count. Results: Hypothyroidism was found 13 cases, hyperthyroidism in one case and hypothyroxinemia in eight cases. No difference in symptoms was found between patients with or without thyroid dysfunction. No significant differences were observed in CD4 count or the prevalence of co-infection with Hepatitis B virus among patients with thyroid dysfunction. No association between antiretroviral agents and thyroid dysfunction was observed. Conclusions: The thyroid abnormalities found in this group of HIV infected patients were usually asymptomatic. It may be advisable to systematically assess thyroid function in HIV infected patients. <![CDATA[<strong>Ultrasonografía bronquial con aspiración por aguja fina en el estudio lesiones adyacentes a la vía aérea central</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300009&lng=es&nrm=iso&tlng=es Background: Endobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield for lesions adjacent to the central airway. Aim: To describe the diagnostic yield of EBUS-TBNA for lesions suspicious of Non-Small Cell Lung Cancer (NSCLC). Material and Methods: Prospective study of 128 patients aged 25 to 87 years (56% males) undergoing EBUS-TBNA. Radiological features of the lesions were recorded by chest CT scan such as morphology, margins of the lesion, lesion size and location based on the International Association for the Study of Lung Cancer (IASLC) map. Definitive pathological results were evaluated. Results: The average size of lesions was 18.5 millimeter and; 68 cases were of less than 20 millimeters. Sensitivity was 96.7%, specificity 100%, and negative predictive value 93.3%. The most common histological diagnosis was adenocarcinoma. Conclusions: EBUS-TBNA is a useful diagnostic tool for NSCLC suspicious lesions adjacent to the central airway. <![CDATA[<strong>Evaluación nutricional de escolares en una ciudad fronteriza entre Estados Unidos y México</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300010&lng=es&nrm=iso&tlng=es Background: Undernutrition and obesity coexist among Mexican children due to poverty, sedentariness and inadequate food intake. Aim: To assess the nutritional status of school age children in a Mexican city located in the frontier with United States. Material and Methods: Cross sectional assessment of children from 28 basic schools in 2005, 2008 and 2013. Using a cluster sampling methodology, 5 children per course were selected in each school, reaching a final sample 840 children aged 7 to 12 years old. Body mass index z scores were calculated. Results: The pre valence of overweight and obesity among these children was 49, 54 and 45% in the assessments performed in 2005, 2008 and 2013 respectively. Conclusions: There is a trend towards a decrease in the frequency of obesity in these children from 2005 to 2013. <![CDATA[<strong>MicroRNAs</strong>: <strong>Marcadores séricos en diabetes mellitus tipo 2 y ejercicio físico</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300011&lng=es&nrm=iso&tlng=es MicroRNAs are small, non-coding molecules with a crucial function in the cell´s biologic regulation. Circulating levels of miRNAs may be useful biomarkers in metabolic diseases such as type 2 Diabetes Mellitus (DM2), which alters the circulating concentrations of several types of miRNA. Specific serum profiles of these molecules have been identified in high-risk patients before the development of DM2 and its chronic complications. Most importantly, these profiles can be modified with physical exercise, which is crucial in the treatment of metabolic diseases. Acute physical activity alone can induce changes in tissue specific miRNAs, and responses are different in aerobic or non-aerobic training. Muscle and cardiovascular miRNAs, which may play an important role in the adap tation to exercise, are predominantly altered. Even further, there is a correlation between serum levels of miRNAs and fitness, suggesting a role for chronic exercise in their regulation. Thus, miRNAs are molecules of growing importance in exercise physiology, and may be involved in the mechanisms behind the beneficial effects of physical activity for patients with metabolic diseases. <![CDATA[<strong>¿Qué son las puntuaciones de propensión?</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300012&lng=es&nrm=iso&tlng=es Medical research is constantly looking for causality. Among study designs, randomized controlled trials are the most reliable way to estimate causal effects but are not always feasible. When this is the case, observational studies must be performed but this type of design unavoidably implies bias. Propensity scores, defined as the probability to receive a treatment conditional to a set of covariables allows to overcome confusion bias when searching for causal effects. <![CDATA[<strong>Problemas éticos y de salud planteados por la reciente epidemia de Ébola</strong>: <strong>¿Qué debemos aprender?</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300013&lng=es&nrm=iso&tlng=es The recent Ebola epidemic that affected several countries in Africa, with very high mortality and a pandemic threat, posed problems of justice, public health, prevention, treatment and research, each of which has relevant ethical issues. Despite severe initial difficulties, an effective international response was achieved, whose outcome has left significant teachings to be considered in order to deal with future epidemics or pandemics. In this article, the authors analyze the main problems faced during the Ebola epidemic, including the unequal distribution of health resources between countries, the need for international collaboration, the requirement for a review of the ethical standards of clinical trials in emergencies, and the necessity of an organized global system of prevention and timely response to these outbreaks. Authors conclude that at the present time health is a global issue without borders, that insufficient healthcare resources in some countries poses risks and affects all countries and that the confrontation of the threats of epidemics requires a solution based in universal solidarity. At the same time, a moral duty to investigate should be acknowledged, seeking a balance between sense of urgency, scientific rigor and involvement of local communities. <![CDATA[<strong>Objeción de conciencia, profesión médica y proyecto sobre despenalización del aborto en Chile</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300014&lng=es&nrm=iso&tlng=es It is usual to understand conscientious objection as a doctor’s refusal to perform a legitimate intervention, for subjective personal reasons unrelated to medicine. It is then accepted only by respect to professional autonomy and freedom of beliefs. Understood in that way it would be thus reasonable to limit it, curtail it or delete it, since the objector would not be willing to grant benefits that correspond to his medical profession. This work aims to show exactly the opposite, taking as an example the project of law that pretends to decriminalize abortion in some situations in Chile. Is the objector who defends medical activity relying on ethic codes that seek to preserve the values and principles of our profession. <![CDATA[<strong>El médico y la objeción de conciencia</strong>: <strong>Opinión del Departamento de Ética del Colegio Médico de Chile A. G.</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300015&lng=es&nrm=iso&tlng=es The Chilean bill that regulates abortion for three cases (Bulletin Nº 9895-11) includes the possibility that health professionals may manifest their conscientious objection (CO) to perform this procedure. Due to the broad impact that the issue of C O had, the Ethics Department of the Chilean College of Physicians considered important to review this concept and its ethical and legal basis, especially in the field of sexual and reproductive health. In the present document, we define the practical limit s of CO, both for the proper fulfillment of the medical profession obligations, and for the due respect and non-discrimination that the professional objector deserves. We analyze the denial of some health institutions to perform abortions if it is legalize d, and we end with recommendations adjusted to the Chilean reality. Specifically, we recognize the right to conscientious objection that all physicians who directly participate in a professional act have. But we a lso recognize that physicians have ineludib le obligations towards their patients, including the obligation to inform about the existence of this service, how to access to it and -as set out in our code of ethics- to ensure that another colleague will continue attending the patient. <![CDATA[<strong>Historia de los terrenos de la Casa de Orates de Santiago de Chile</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300016&lng=es&nrm=iso&tlng=es This work describes the origin of the different locations that Casa de Orates (Madhouse) has occupied in Chile. The locations of this institution at the Yungay and Chimba neighborhoods area are specially analyzed. Moreover, the sad and poorly known incident involving the national Madhouse of Providencia is narrated. <![CDATA[<strong>Tratamiento con sirolimus y prednisona en enfermedad de Erdheim-Chester con compromiso cardiaco</strong>: <strong>Caso clínico</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300017&lng=es&nrm=iso&tlng=es Erdheim-Chester disease (ECD) is a rare non-Langerhans histiocytic disorder. We report a 76-years-old man who suffered a cardiac tamponade secondary to ECD. A pericardial window was made and during the operation the surgeons observed that the myocardium was diffusely infiltrated. Twenty-eight months before, ECD was clinically diagnosed and prednisone and methotrexate were prescribed. Due to disease progression which culminated in the cardiac tamponade, methotrexate was changed to sirolimus aiming to obtain plasma levels between 5-8 ng/ml. This treatment stabilized his cardiac function allowing a survival of 52 months after its initiation, with fewer side effects. <![CDATA[<strong>Compromiso óseo en mastocitosis sistémica</strong>: <strong>una asociación frecuente, pero muchas veces inadvertida</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300018&lng=es&nrm=iso&tlng=es Systemic mastocytosis (SM) is characterized by pathologic expansion and activation of mast cells. The main clinical manifestations of SM include skin involvement, gastrointestinal symptoms and anaphylaxis due to the release of its mediators. Thirty percent of pat ients with SM have a low bone mass and 20% fractures. At the same time, SM affects 10% of male patients with idiopathic osteoporosis. Measuring serum tryptase is essential for the screening of MS. We report two cases of SM with bone involvement. A 25-year- old woman with prior diagnosis of SM, based on skin involvement, flushing, high serum tryptase and compatible bone marrow (BM) biopsy and genetic study. Low bone mass was diagnosed and treatment was started with calcium and vitamin D plus oral bisphosphona tes with adequate response. A 47 years old man who presented with multiple osteoporotic vertebral fractures and low bone mass. Treatment with vitamin D and alendronate was started, but the patient developed new vertebral fractures. The study was extended w ith measurement of serum tryptase that was elevated. Diagnosis of SM was confirmed with BM biopsy and the patient was referred to hematology for specific care. These cases emphasize the importance of bone assessment in SM, as well as the need to rule out S M in patients with osteoporosis and no evident cause. <![CDATA[<strong>Estimación paramétrica de la confiabilidad y diferencias confiables</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300019&lng=es&nrm=iso&tlng=es Systemic mastocytosis (SM) is characterized by pathologic expansion and activation of mast cells. The main clinical manifestations of SM include skin involvement, gastrointestinal symptoms and anaphylaxis due to the release of its mediators. Thirty percent of pat ients with SM have a low bone mass and 20% fractures. At the same time, SM affects 10% of male patients with idiopathic osteoporosis. Measuring serum tryptase is essential for the screening of MS. We report two cases of SM with bone involvement. A 25-year- old woman with prior diagnosis of SM, based on skin involvement, flushing, high serum tryptase and compatible bone marrow (BM) biopsy and genetic study. Low bone mass was diagnosed and treatment was started with calcium and vitamin D plus oral bisphosphona tes with adequate response. A 47 years old man who presented with multiple osteoporotic vertebral fractures and low bone mass. Treatment with vitamin D and alendronate was started, but the patient developed new vertebral fractures. The study was extended w ith measurement of serum tryptase that was elevated. Diagnosis of SM was confirmed with BM biopsy and the patient was referred to hematology for specific care. These cases emphasize the importance of bone assessment in SM, as well as the need to rule out S M in patients with osteoporosis and no evident cause. <![CDATA[<strong>Impacto del Día Mundial de la Tuberculosis en las búsquedas realizadas en Google en países sudamericanos</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300020&lng=es&nrm=iso&tlng=es Systemic mastocytosis (SM) is characterized by pathologic expansion and activation of mast cells. The main clinical manifestations of SM include skin involvement, gastrointestinal symptoms and anaphylaxis due to the release of its mediators. Thirty percent of pat ients with SM have a low bone mass and 20% fractures. At the same time, SM affects 10% of male patients with idiopathic osteoporosis. Measuring serum tryptase is essential for the screening of MS. We report two cases of SM with bone involvement. A 25-year- old woman with prior diagnosis of SM, based on skin involvement, flushing, high serum tryptase and compatible bone marrow (BM) biopsy and genetic study. Low bone mass was diagnosed and treatment was started with calcium and vitamin D plus oral bisphosphona tes with adequate response. A 47 years old man who presented with multiple osteoporotic vertebral fractures and low bone mass. Treatment with vitamin D and alendronate was started, but the patient developed new vertebral fractures. The study was extended w ith measurement of serum tryptase that was elevated. Diagnosis of SM was confirmed with BM biopsy and the patient was referred to hematology for specific care. These cases emphasize the importance of bone assessment in SM, as well as the need to rule out S M in patients with osteoporosis and no evident cause. <![CDATA[<strong>Falleció Dr. Jaime Duclos Hertzer, ex Presidente Sociedad Médica de Santiago</strong>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872016000300021&lng=es&nrm=iso&tlng=es Systemic mastocytosis (SM) is characterized by pathologic expansion and activation of mast cells. The main clinical manifestations of SM include skin involvement, gastrointestinal symptoms and anaphylaxis due to the release of its mediators. Thirty percent of pat ients with SM have a low bone mass and 20% fractures. At the same time, SM affects 10% of male patients with idiopathic osteoporosis. Measuring serum tryptase is essential for the screening of MS. We report two cases of SM with bone involvement. A 25-year- old woman with prior diagnosis of SM, based on skin involvement, flushing, high serum tryptase and compatible bone marrow (BM) biopsy and genetic study. Low bone mass was diagnosed and treatment was started with calcium and vitamin D plus oral bisphosphona tes with adequate response. A 47 years old man who presented with multiple osteoporotic vertebral fractures and low bone mass. Treatment with vitamin D and alendronate was started, but the patient developed new vertebral fractures. The study was extended w ith measurement of serum tryptase that was elevated. Diagnosis of SM was confirmed with BM biopsy and the patient was referred to hematology for specific care. These cases emphasize the importance of bone assessment in SM, as well as the need to rule out S M in patients with osteoporosis and no evident cause.