A. Del Puente

Determinants of bone mineral density in immobilization: A study on hemiplegic patients

Osteoporosis that develops during immobli-zation is a severe condition that confers increased risk of fractures with their burden of mortality and disability. The aim of this study was to investigate the determinants of immobilization osteoporosis. As a model of this condition we studied hemiplegic subjects, measuring bone mineral density in the paralyzed lower limb as compared with the non-paralyzed one. In spite of the limits related to the loss of nervous stimulation, this model offers the advantage of a proper control for the complex genetic and environmental cofactors involved. We examined 48 hemiplegic subjects (31 men, 17 women in menopause) admitted consecutively over a 9-month period. Mean length of immobilization was 10.9 months for men (range 1–48 months) and 7.8 months for women (range 1–40 months). The average time since menopause was 14.9 years (range 1.7–23.9 years). For each subject the following were performed: questionnaire, medical examination, anthropometric measurements, evaluation of the scores for spasticity and for lower limb motor capacity in order to account for the different degrees of disability among patients. Bone mineral density was measured using dual-energy X-ray absorptiometry (DXA) at both femoral necks. For each patient we defined a percentage difference in bone loss between the paralyzed and non-paralyzed limb. Regression coefficient were calculated by multiple logistic regression. There was significant bone loss in the paralyzed limb in both sexes, accounting for up to 6.3% in women. Multiple regression analysis showed that the degree of bone loss depends significantly and directly on the length of immobilization, even when controlling for age and sex in the regression model (R=0.193,p=0.034). However, when time since menopause was included in the regression model, with length of immobility as a covariate, it was the only significant determinant of bone loss (R=0.312,p=0.039). No additional factors were observed among men. No differences were shown with regard to anthropometric measurements or functional scores. Length of immobilization accounts only for a small fraction of bone loss, which does not exceed 5% of the total variance. Our data show that postmenopausal women should be considered at highest risk for osteoporosis in cases of immobility and that different factors, other than length of immobility, might come into play in determining bone loss in this condition.

Interplay between environmental factors, articular involvement, and HLA-B27 in patients with psoriatic arthritis.

Medical records of 138 patients with psoriatic arthritis and 138 with rheumatoid arthritis were reviewed for the occurrence of an environmental factor triggering arthritis. Twelve (9%) of the patients with psoriatic arthritis had had an acute disorder immediately preceding onset of arthritis (an operation in four cases, articular trauma in three, abortion in two, myocardial infarction, thrombophlebitis, and phosphoric ester intoxication in one case each). Peripheral arthritis occurred in all these patients. Among the rheumatoid patients, an acute event immediately preceding the onset of the disease was recorded in two cases (1%) only (chi 2 = 7.52; p = 0.006). No significant association was found in the arthritic patients between the incidence of acute events preceding arthritis onset and positivity of the HLA-B27 phenotype.

Diffuse idiopathic skeletal hyperostosis (DISH): a retrospective analysis.

SummaryDiffuse idiopathic skeletal hyperostosis (DISH) is a skeletal disease characterized by ligamentous ossification of the anterolateral side of the spine. The radiographs of the spine of 69 patients (22 males, 47 females, mean age 64.97±8.83 years) affected by DISH according to Resnicks criteria were selected. A lower rate of lumbar spine involvement (71%) and a different distribution between sexes were demonstrated, as compared to the data from the literature. Data on relationships among extent of hyperostosis, occupation and metabolic disorders suggest that an important role might be played by the exposure to microtrauma, while, in subjects affected by a metabolic disorder, this condition would represent a prevalent pathogenetic factor. These data underline some peculiarities in the clinical picture of DISH in the population from Campania, that could depend on genetic factors.

Impaired Bone Metabolism in Glycogen Storage Disease Type 1 Is Associated with Poor Metabolic Control in Type 1a and with Granulocyte Colony-Stimulating Factor Therapy in Type 1b

Background: Glycogen storage disease type 1 (GSD1) is a rare and genetically heterogeneous metabolic defect of gluconeogenesis due to mutations of either the G6PC gene (GSD1a) or the SLC37A4 gene (GSD1b). Osteopenia is a known complication of GSD1. Objectives: The aim of this study was to investigate the effects of poor metabolic control and/or use of GSD1-specific treatments on bone mineral density (BMD) and metabolism in GSD1 patients. Methods: In a multicenter, cross-sectional case-control study, we studied 38 GSD1 (29 GSD1a and 9 GSD1b) patients. Clinical, biochemical and instrumental parameters indicative of bone metabolism were analyzed; BMD was evaluated by dual-emission X-ray absorptiometry and quantitative ultrasound. Results: Both GSD1a and GSD1b patients showed reduced BMD compared with age-matched controls. In GSD1a patients, these abnormalities correlated with compliance to diet and biochemical indicators of metabolic control. In GSD1b patients, BMD correlated with the age at first administration and the duration of granulocyte colony-stimulating factor (G-CSF) therapy. Conclusions: Our data indicate that good metabolic control and compliance with diet are highly recommended to improve bone metabolism in GSD1a patients. GSD1b patients on G-CSF treatment should be carefully monitored for the risk of osteopenia/osteoporosis.

Progressive systemic sclerosis and S-adenosylmethionine

Cutaneous inelasticity is one of the most persisting clinical features of Progressive Systemic Sclerosis (PSS), despite diverse pharmacological treatment. In this regard, many therapeutic attempts have been effected to interfere with dermal fibroblastic activity, including therapies with D-penicillamine (1), N-acetylcysteine (2), and other drugs (3), but the results have been partial and controversial. Moreover, the use of these drugs, particularly D-penicillamine, is often limited by adverse effects in long-term treatments. Recently, we have obtained significant subjective and objective improvement in symptoms of sclerosis using S-adenosylmethionine (SAMe) in a group of 10 females (6 with PSS with Raynauds phenomenon and ~sophageal involvement, 3 with morphea and 1 presenting only sclerodactyly). SAMe is a physiological molecule involved as a donor of the methyl group and sulphydrilant agent in many organic reactions, particularly in the phospholipid methylation process and in the synthesis of glutathione. Its antiflogistic effect has been demonstrated in several conditions of acute inflammation,

PREVALENCE AND INCIDENCE OF OSTEOPOROTIC FRACTURES IN PATIENTS ON LONG-TERM GLUCOCORTICOID TREATMENT FOR RHEUMATIC DISEASES: The Glucocorticoid Induced Osteoporosis Tool, GIOTTO STUDY.

Osteoporosis and fractures are common and invalidating consequences of chronic glucorticoid (GC) treatment. Reliable information regarding the epidemiology of GC induced osteoporosis (GIOP) comes exclusively from the placebo group of randomized clinical trials while observational studies are generally lacking data on the real prevalence of vertebral fractures, GC dosage and primary diagnosis. The objective of this study was to evaluate the prevalence and incidence of osteoporotic fractures and to identify their major determinants (primary disease, GC dosage, bone mineral density, risk factors, specific treatment for GIOP) in a large cohort of consecutive patients aged >21 years, on chronic treatment with GC (≥5 mg prednisone - PN - equivalent) and attending rheumatology centers located all over Italy. Glucocorticoid Induced OsTeoporosis TOol (GIOTTO) is a national multicenter cross-sectional and longitudinal observational study. 553 patients suffering from Rheumatoid Arthritis (RA), Polymyalgia Rheumatica (PMR) and Connective Tissue Diseases (CTDs) and in chronic treatment with GCs were enrolled. Osteoporotic BMD values (T score <-2.5) were observed in 28%, 38% and 35% of patients with CTDs, PMR or RA at the lumbar spine, and in 18%, 29% and 26% at the femoral neck, respectively. Before GC treatment, prevalent clinical fractures were reported by 12%, 37% and 17% of patients with CTDs, PMR, or RA, respectively. New clinical fragility fractures during GC treatment were reported by 12%, 10% and 23% of CTDs, PMR and RA patients, respectively. Vertebral fractures were the prevailing type of fragility fracture. More than 30% of patients had recurrence of fracture. An average of 80% of patients were in supplementation with calcium and/or vitamin D during treatment with GCs. Respectively, 64%, 80%, and 72% of the CTDs, PMR and RA patients were on pharmacological treatment for GIOP, almost exclusively with bisphosphonates. The GIOTTO study might provide relevant contributions to clinical practice, in particular by highlighting and quantifying in real life the prevalence of GIOP and relative fractures, the frequency of the main risk factors, and the currently sub-optimal prevention. Moreover, these results emphasize the importance of the underlying rheumatic disease on the risk of GIOP associated fractures.

THU0412 Prevalence and Incidence of Osteoporotic Fractures in Patients on Long-Term Glucocorticoid Treatment for Rheumatic Diseases: The Glucocorticoid Induced Osteoporosis Tool, Giotto Study.

Background Osteoporosis and fractures are common and invalidating consequences of chronic glucorticoid (GC) treatment. Reliable information regarding the epidemiology of GC induced osteoporosis (GIOP) are coming exclusively from the placebo group of randomized clinical trials while observational studies are generally lacking data on the real prevalence of vertebral fractures, GC dose and primary diagnosis. Objectives The objective of this study was to evaluate the incidence of osteoporotic fractures and to identify their major determinants (primary disease, GC dose, BMD values, specific treatment for GIOP, etc.) in a large cohort of consecutive patients aged > 21 years, on chronic treatment with GC (≥5 mg prednisone –PN- equivalent), attending rheumatology centres located all over Italy. Methods Here the results of an interim analysis of the first 553 enrolled patients are presented. Systemic Lupus Erythematosus or other Connectivites (CON), Polymialgia Rheumatica (PMR), and Rheumatoid arthritis (RA) were the underlying diseases. Results In the table are shown the main clinical characteristics : Conclusions In real life the prevalence of clinical fractures in patients with rheumatic diseases is high even before GC treatment and the incidence of new clinical fractures while on chronic GC treatment (PN- equivalent ≥ 5 mg/day) is somewhat lower than hitherto assumed. These results emphasize the importance of the underlying disease in the risk of GIOP associated fractures. Disclosure of Interest None Declared