Dacia Cerdá

Low Bone Mass and Severity of Cholestasis Affect Fracture Risk in Patients With Primary Biliary Cirrhosis

BACKGROUND & AIMS The influence of osteoporosis and liver disease on fracture risk is not well characterized in patients with primary biliary cirrhosis (PBC). We studied a large series of women with PBC to assess the prevalence and risk factors for fractures and the fracture threshold. METHODS In female patients with PBC (n = 185; age, 55.7 +/- 0.7 years; range 28-79 years), age, duration of PBC, menopausal status, and histologic stage and severity of liver disease were assessed. Vertebral and non-vertebral fractures were recorded in 170 and 172 patients, respectively. Osteoporosis and osteopenia were diagnosed based on densitometry analysis. RESULTS The prevalences of vertebral, non-vertebral, and overall fractures were 11.2%, 12.2%, 20.8%, respectively. Osteoporosis was significantly more frequent in patients with PBC than in normal women. Osteoporosis was associated with age, weight, height, histologic stage, severity, and duration of liver damage; fractures were associated with osteoporosis, menopause, age, and height but not with severity of PBC. Osteoporosis was a risk factor for vertebral fracture (odds ratio [OR], 8.48; 95% confidence interval [CI]: 2.67-26.95). Lumbar T score <-1.5 (OR, 8.27; 95% CI: 1.84-37.08) and femoral neck T score <-1.5 (OR, 6.83; 95% CI: 1.48-31.63) were significant risk factors for vertebral fractures. CONCLUSIONS Fractures, particularly vertebral fractures, are associated with osteoporosis, osteopenia, and T scores less than -1.5, whereas osteoporosis and osteopenia are associated with the severity of liver damage. Patients with T scores less than -1.5 might require additional monitoring and be considered for therapy to prevent fractures.

Actualización 2011 del consenso Sociedad Española de Reumatología de osteoporosis

OBJECTIVE Due to increasing improvement in the diagnosis, evaluation and management of osteoporosis and the development of new tools and drugs, the Spanish Society of Rheumatology (SER) has promoted the development of recommendations based on the best evidence available. These recommendations should be a reference to rheumatologists and other health professionals involved in the treatment of patients with osteoporosis. METHODS Recommendations were developed following a nominal group methodology and based on a systematic review. The level of evidence and degree of recommendation were classified according to the model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through Delphi technique. Evidence from previous consensus and available clinical guidelines was used. RESULTS We have produced recommendations on diagnosis, evaluation and management of osteoporosis. These recommendations include the glucocorticoid-induced osteoporosis, premenopausal and male osteoporosis. CONCLUSIONS We present the SER recommendations related to the biologic therapy risk management.

Randomized trial comparing monthly ibandronate and weekly alendronate for osteoporosis in patients with primary biliary cirrhosis

Osteoporosis resulting in bone fractures is a complication in patients with primary biliary cirrhosis (PBC). Once‐weekly alendronate improves bone mass and is well tolerated in these patients, but there is a concern because of poor compliance. Therefore, the efficacy, adherence, and safety of monthly ibandronate (150 mg) with weekly alendronate (70 mg) were compared in a randomized, 2‐year study in 42 postmenopausal women with PBC and osteoporosis. Bone mineral density (BMD) of the lumbar spine and proximal femur (by DXA), liver function, and bone markers were measured at entry and every 6 months over 2 years. Adherence to therapy was assessed by the Morisky‐Green score. At enrollment, the two groups were similar with respect to age, BMD, severity of cholestasis, previous fractures, and bone markers. Thirty‐three patients, 14 in the ibandronate group and 19 in the alendronate group, completed the trial. At 2 years both treatments resulted in a significant increase in BMD at the lumbar spine (from 0.875 ± 0.025 to 0.913 ± 0.026 g/cm2, P < 0.001 with alendronate, and from 0.898 ± 0.024 to 0.949 ± 0.027 g/cm2, P < 0.001 with ibandronate). The mean percentage change was 4.5% and 5.7%, respectively (P = not significant). BMD increased at the total hip by 2.0% and 1.2%, respectively. Changes in bone markers were similar in both groups and one patient with alendronate developed a new vertebral fracture. Adherence to therapy was higher with ibandronate (P = 0.009). Neither treatment impaired liver function or cholestasis. Conclusion: Both regimens, weekly alendronate and monthly ibandronate, improve bone mass and are comparable in safety for osteoporosis therapy in patients with PBC, although adherence is higher with the monthly regimen. Further larger studies are needed to assess fracture prevention. (Hepatology 2013; 58:2070–2078)

Hypophosphatemic osteomalacia: a report of five cases and evaluation of bone markers

In this study, we analyzed the changes in biochemical markers of bone turnover in five patients with hypophosphatemic osteomalacia. The following bone markers were evaluated: among bone formation markers, total alkaline phosphatase (TAP), bone alkaline phosphatase (BAP), osteocalcin (bone Gla protein, BGP) and procollagen type I N propeptide (PINP); among bone resorption markers, serum β C-terminal cross-linked telopeptide of type I collagen (s-CTx), urinary hydroxyproline (HYP), and N-terminal and α and β C-terminal cross-linked telopeptides of collagen (NTx and α- and β-CTx). In addition, the α/β-CTx ratio was evaluated. TAP and BAP were the markers with the highest increase in both frequency and magnitude. Conversely, BGP values were low in all patients. Collagen-related markers were slightly increased in nearly half of the patients. Among them, PINP showed the highest proportion of increased values. The α/β-CTx ratio was within normal values in all patients. In conclusion, TAP and BAP seem to be the best bone markers in the diagnostic evaluation of hypophosphatemic osteomalacia. In addition, their high values associated with low levels of BGP provide an even more reliable biochemical profile of this disorder, when associated with the classic mineral and skeletal homeostasis abnormalities.

Reference intervals for bone turnover markers in Spanish premenopausal women.

Abstract Background: The aims of this study were to establish robust reference intervals and to investigate the factors influencing bone turnover markers (BTMs) in healthy premenopausal Spanish women. Methods: A total of 184 women (35–45 years) from 13 centers in Catalonia were analyzed. Blood and second void urine samples were collected between 8 a.m. and 10 a.m. after an overnight fast. Serum procollagen type I amino-terminal propeptide (PINP) and serum cross-linked C-terminal telopeptide of type I collagen (CTX-I) were measured by two automated assays (Roche and IDS), bone alkaline phosphatase (bone ALP) by ELISA, osteocalcin (OC) by IRMA and urinary NTX-I by ELISA. PTH and 25-hydroxyvitamin D (25OHD) levels were measured. All participants completed a questionnaire on lifestyle factors. Results: Reference intervals were: PINP: 22.7–63.1 and 21.8–65.5 μg/L, bone ALP: 6.0–13.6 μg/L, OC: 8.0–23.0 μg/L, CTX-I: 137–484 and 109–544 ng/L and NTX-I: 19.6–68.9 nM/mM. Oral contraceptive pills (OCPs) influenced PINP (p=0.007), and low body mass index (BMI) was associated with higher BTMs except for bone ALP. Women under 40 had higher median values of most BTMs. CTX-I was influenced by calcium intake (p=0.010) and PTH (p=0.007). 25OHD levels did not influence BTMs. Concordance between the two automated assays for PINP and particularly CTX-I was poor. Conclusions: Robust reference intervals for BTMs in a Southern European country are provided. The effects of OCPs and BMI on their levels are significant, whilst serum 25OHD levels did not influence BTMs. Age, calcium intake, BMI and PTH influenced CTX-I. The two automated assays for measuring PINP and CTX-I are not interchangeable.

Síndrome de Sweet asociado a síndrome mielodisplásico: a propósito de un caso. Revisión de la literatura

Sweets syndrome or acute neutrophilic febrile dermatosis is a systemic disease of unknown etiology characterized by the appearance of skin lesions produced by a neutrophilic dermal infiltrate, fever and peripheral leukocytosis. It may be associated with hematologic diseases, including leukemia, with immune diseases as rheumatoid arthritis, or can occur in isolation. The myelodysplasias are hematological disorders characterized by one or more cytopenias secondary to bone marrow dysfunction. We present the case of a patient with Sweets syndrome associated with myelodysplastic syndrome and treated with glucocorticoids who did not present a good clinical outcome. We discuss the different treatment of these diseases because in most cases glucocorticoids, which are the treatment of choice in Sweets syndrome, may be insufficient.

Aumento de los valores de PTH en la mujer con osteoporosis posmenopáusica

AIMS Increased parathyroid values (PTH) serum values can be observed in postmenopausal women. However, the clinical repercussion and causes of this finding are poorly understood. This study has aimed to analyze the prevalence and conditions associated to the increased serum PTH levels in postmenopausal women with osteoporosis as well as their clinical characteristics. METHODS Post-menopausal women with osteoporosis were included in the study. PTH, 25-hydroxyvitamin D (25OHD), 24-h urinary calcium, glomerular filtration rate (GFR) and calcium intake were evaluated. The prevalence of increased PTH serum values and its relationship with vitamin D deficiency and insufficiency, kidney failure, hypercalciuria and calcium intake deficiency were evaluated, these being conditions that may increase PTH secretion. RESULTS A total of 204 postmenopausal women with osteoporosis with a mean age of 64 years were included. Increase PTH levels (>65 pg/ml) were observed in 35% and 5 women had primary hyperparathyroidism. Women with increased serum PTH levels were older (67 ± 9 years) were old than those with normal PTH levels (63 ± 11 years) (P=0.03). PTH elevation was associated to calcium intake deficiency (<800 mg/d) in 81% of the women, to a vitamin D deficiency and insufficiency in 55% and 86%, respectively, renal insufficiency in 35% and hypercalciuria in 17% of the patients. These values, however, did not differ when compared with patients with normal PTH serum levels. Serum PTH levels were related to age (r=0.19, P=0.01) but not to 25OHD or GFR values. CONCLUSIONS One third of the post-menopausal women with osteoporosis had elevated PTH levels. This was due to primary hyperparathyroidism in 10%. The prevalence of conditions associated to the increase in PTH (reduced calcium intake, 25-hydroxyvitamin D, renal failure and hypercalciuria) is similar to that observed in women with normal PTH values.

Kala-azar en un paciente con artritis reumatoide tratada con metotrexato

Patients with rheumatoid arthritis (RA) treated with disease-modifying antirheumatic drugs are susceptible to severe infections such as leishmaniasis. As L. infantum is endemic in the Mediterranean region, it is necessary to rule this infectious process out in any RA patient presenting with fever and pancytopenia. An early diagnosis based on a high suspicion can prevent a fatal outcome.

FRI0634-HPR Non Attending Rheumatology Nursing Consultations, High Resolution of Urgent Demand

Background Patients with rheumatic diseases may require routine control and strict monitoring of their disease and side effects of treatment [1]. The possibility of providing nursing consultations for rheumatology patients via telephone or email rather than at clinic attendance [2], can potentially result in a lower rate of clinic visits, better informed and supported patients and families, more appropriate use of healthcare resources and real cost saving [3-5]. Objectives To describe the content of the non-face consultations with rheumatology nursing. Methods Descriptive study of a cohort of patients treated in the outpatient Rheumatology department at our Hospital. The period analysed was from January 2013 to December 2014. An Access database, specifically developed for this purpose, was used for data collection. The variables studied were age, sex, diagnosis, reason for query (doubts about their illness, medication, blood testing, other tests and/or administrative aspects) and query resolution. Nurses responded as soon as possible by telephone or via email between 8-15hrs Monday–Friday. SPSS v18 was used to analyse the data. Results A total of 377 consultations were received, made by 217 patients, 74% of whom were women, diagnosed with Rheumatoid Arthritis (42%), Spondyloarthropathies (21%), Osteoporosis (15%), Systemic Lupus Erythematosus (2%), Osteoarthritis (2%) and other (18%); with a mean age of 57±14 years. Of these 217 patients, 84 of them consulted on more than one occasion. Of the 377 consultations, 361 consultations were made via telephone, 14 via email and 2 via text message. The reasons for the consultation can be divided into 5 categories (see Image 1). Of the 377 consultations, there were 399 reasons for consultation. 371 out of 377 consultations were resolved by the nurse, (131 without no help). In 240, the medical and/or other professional collaboration was necessary. Image 1. Reasons for consultation (n=399). Conclusions The majority of queries were related to disease (flare up) or to medication. “Non attending” skilled nursing consultation, is shown to be an excellent alternative to face to face consultations, in the management of low complexity processes. It demonstrates a high degree of resolution that does not require an attending visit, thereby decreasing the rate of repeated visits to a rheumatologist. It also provides higher confidence, information and loyalty to patients and because of the overall reduction of patients at clinic visits, enables patients to access specialists when face to face consultations with a nurse or physician is needed. Few patients used email option for consultation and the possibility of promoting this alternative is considered. References Valencian Rheumatology Nursing Society (GESVR), 2013. Najera C, et al. 2014. Hughes RA et al. 2002. Royal College of Nursing, 2006. Ferreira R et al. 2014. Acknowledgements Claire Hale Disclosure of Interest None declared

Reference intervals for bone turnover markers in Spanish premenopausal women

BACKGROUND: The aims of this study were to establish robust reference intervals and to investigate the factors influencing bone turnover markers (BTMs) in healthy premenopausal Spanish women. METHODS: A total of 184 women (35-45 years) from 13 centers in Catalonia were analyzed. Blood and second void urine samples were collected between 8 a.m. and 10 a.m. after an overnight fast. Serum procollagen type I amino-terminal propeptide (PINP) and serum cross-linked C-terminal telopeptide of type I collagen (CTX-I) were measured by two automated assays (Roche and IDS), bone alkaline phosphatase (bone ALP) by ELISA, osteocalcin (OC) by IRMA and urinary NTX-I by ELISA. PTH and 25-hydroxyvitamin D (25OHD) levels were measured. All participants completed a questionnaire on lifestyle factors. RESULTS: Reference intervals were: PINP: 22.7-63.1 and 21.8-65.5 μg/L, bone ALP: 6.0-13.6 μg/L, OC: 8.0-23.0 μg/L, CTX-I: 137-484 and 109-544 ng/L and NTX-I: 19.6-68.9 nM/mM. Oral contraceptive pills (OCPs) influenced PINP (p=0.007), and low body mass index (BMI) was associated with higher BTMs except for bone ALP. Women under 40 had higher median values of most BTMs. CTX-I was influenced by calcium intake (p=0.010) and PTH (p=0.007). 25OHD levels did not influence BTMs. Concordance between the two automated assays for PINP and particularly CTX-I was poor. CONCLUSIONS: Robust reference intervals for BTMs in a Southern European country are provided. The effects of OCPs and BMI on their levels are significant, whilst serum 25OHD levels did not influence BTMs. Age, calcium intake, BMI and PTH influenced CTX-I. The two automated assays for measuring PINP and CTX-I are not interchangeable.