Diogo S. Domiciano

Osteoarthritis: can anti-cytokine therapy play a role in treatment?

Osteoarthritis (OA) is the most common joint disorder worldwide, and it has an enormous socioeconomic impact both in the United States and throughout the world. The degree of articular inflammation is usually associated with the disease’s progression, indicating that this process could contribute to articular damage. IL-1 beta and anti-TNF alpha are the two major cytokines players in the physiopathology of OA. Hence, we aimed to review the current literature on the effects of IL-1 and TNF-alpha neutralization as a new OA therapy. In vitro and experimental models showed a reduction in cartilage destruction with IL-1 inhibition therapy by IL-1 receptor antagonists (IL-1Ra). Despite this favorable evidence in animal models, studies on the inhibition of IL-1R in humans are still scarce. Although there is clear evidence that TNF-alpha plays a role in the pathophysiology of OA, only a few experimental trials have investigated the efficacy of blocking this pro-inflammatory cytokine in the treatment of OA. So far, the few studies available in humans using anti-TNF-alpha and IL-1 receptor antagonist are not remarkable, suggesting that further investigation and new therapeutic approaches are needed.

Vertebral fracture assessment by dual X-ray absorptiometry: a valid tool to detect vertebral fractures in community-dwelling older adults in a population-based survey.

Vertebral fractures are associated with higher morbidity and mortality. Since 70% of vertebral fractures are clinically silent, a radiologic image of the spine has to be acquired for the diagnosis. The aim of this study was to compare the performance of Vertebral Fracture Assessment (VFA) by dual x‐ray absorptiometry (DXA) with radiographs to identify vertebral fractures in community‐dwelling older adults.

Autoimmune hemolytic anemia in systemic lupus erythematosus: association with thrombocytopenia

Hematological disturbances are common in systemic lupus erythematous (SLE). Specifically, autoimmune hemolytic anemia (AHA) may manifest in SLE patients at the time of diagnosis or within the first year of the disease. AHA is often associated with thrombocytopenia, lupus nephritis, and central nervous system activity. In this study we investigated these associations in Brazilian patients with SLE. Forty-four consecutive SLE patients who had a history of AHA were age, gender, and disease duration matched with 318 SLE patients without AHA who formed the control group. All patients fulfilled the revised American College of Rheumatology criteria for SLE and were followed-up within our Service. Clinical and laboratorial manifestations were similar in both groups, except for the predominance of leukopenia, thrombocytopenia, and anti-dsDNA on univariate analysis in the AHA group. The multivariate logistic regression model revealed risk only for thrombocytopenia in the AHA group compared to the control group (odds ratio, 2.70; 95% confidence interval, 1.32–5.50). Our results corroborate previous data that AHA in SLE increases the risk of thrombocytopenia in individuals with SLE. This association suggests a common mechanism in AHA and SLE pathophysiologies.

Bone Mineral Density and Parathyroid Hormone as Independent Risk Factors for Mortality in Community-Dwelling Older Adults: A Population-Based Prospective Cohort Study in Brazil. The São Paulo Ageing & Health (SPAH) Study

Previous studies have shown a relationship between osteoporosis and increased mortality risk. However, none of these studies performed a concomitant evaluation of the parathyroid hormone (PTH)‐calcium‐vitamin D axis and bone mass to accurately determine the contribution of each of these parameters to survival in older subjects. Thus, we sought to investigate the association between bone parameters and mortality in a longitudinal, prospective, population‐based cohort of 839 elderly subjects. Clinical data (including history of fractures and cardiovascular events) were assessed using a specific questionnaire. Laboratory exams, including serum 25OHD and PTH, were also performed. Bone mineral density (BMD) at the lumbar spine and hip were evaluated using DXA. All analyses were performed at baseline (2005 to 2007). Mortality was recorded during follow‐up. Multivariate Cox proportional regression was used to compute hazard ratios for all‐cause and cardiovascular mortality. Over a mean 4.06 ± 1.07 years, there were 132 (15.7%) deaths. These individuals were compared to 707 subjects who were alive at the end of the coverage period for mortality data collection. In a multivariate Cox proportional hazards model, age (HR 1.32; 95% CI, 1.13 to 1.55; p = 0.001, for each 5‐year increase), male gender (HR 1.90; 95% CI, 1.30 to 2.79; p = 0.001), recurrent falls (more than two in the previous year; HR 1.65; 95% CI, 1.06 to 2.56; p = 0.026), diabetes mellitus (HR 2.17; 95% CI, 1.46 to 3.21; p < 0.001), low physical activity score (HR 1.78; 95% CI, 1.14 to 2.79; p = 0.011), prior cardiovascular event (HR 1.76; 95% CI, 1.18 to 2.63; p = 0.006), total hip BMD (HR 1.41; 95% CI, 1.15 to 1.72; p = 0.001, per each 1 SD decrease), and intact PTH (iPTH) (HR 1.06; 95% CI, 1.04 to 1.08; p < 0.001, per each 10 pg/mL increase) were independently associated with all‐cause mortality. The subjects in the highest quartile of PTH (>49 pg/mL) were at a higher risk of cardiovascular death (HR 3.09; 95% CI, 1.36 to 6.99; p = 0.007) compared with the subjects in the lowest quartile (<26 pg/mL). Low BMD and higher PTH were significantly associated with mortality in community‐dwelling older adults. These findings support the notion that careful screening of these bone parameters might lead to better management of older patients and improve outcomes in this population.

Demographic, clinical, laboratorial, and radiological characteristics of rheumatic fever in Brazil: systematic review

Rheumatic fever (RF) is characterized by a non-suppurative inflammatory process that begins after a group A betahemolytic streptococci infection. Its prevalence is higher in developing countries, such as Brazil. However, in our country, systematic epidemiologic data on the disease are scarce and incomplete. Rheumatic fever has an estimated incidence of 3% among Brazilian children and adolescents. We undertook a systematic review of the main Brazilian studies using the LILACS, Scielo, and Medline databases searching for expressions like Febre Reumatica and Rheumatic Fever. Ten epidemiological studies were selected and comparative analysis did not show a predominance of gender, clinical presentation, and laboratorial and radiological parameters in the different regions of the country.Rheumatic fever (RF) is characterized by a non-suppurative inflammatory process that begins after a group A betahemolytic streptococci infection. Its prevalence is higher in developing countries, such as Brazil. However, in our country, systematic epidemiologic data on the disease are scarce and incomplete. Rheumatic fever has an estimated incidence of 3% among Brazilian children and adolescents. We undertook a systematic review of the main Brazilian studies using the LILACS, Scielo, and Medline databases searching for expressions like Febre Reumática and Rheumatic Fever. Ten epidemiological studies were selected and comparative analysis did not show a predominance of gender, clinical presentation, and laboratorial and radiological parameters in the different regions of the country.

Churg-Strauss syndrome and active chronic hepatitis B virus infection: coincidence or association?

The etiology of Churg-Strauss syndrome (CSS) is not well understood. Some case reports have suggested allergic desensitization,1 exposure to pigeons,2 cocaine use,3 leukotriene receptor antagonist treatment4,5 and hepatitis vaccination6,7 as putative etiological agents. In the present study, we report the case of a patient who developed CSS after becoming infected with hepatitis B virus (HBV).

Brazilian guidelines for the diagnosis and treatment of postmenopausal osteoporosis

Osteoporosis is the leading cause of fractures in the population older than 50 years. This silent disease affects primarily postmenopausal women and the elderly, and the morbidity and mortality rates are high. The main goal of treating osteoporosis is the prevention of fractures. The identification of populations at risk through early diagnosis and treatment is essential. The last Brazilian guideline for the treatment of postmenopausal osteoporosis was elaborated in 2002. Since then, new strategies for diagnosis and risk stratification have been developed, and drugs with novel action mechanisms have been added to the therapeutic arsenal. The Osteoporosis and Osteometabolic Diseases Committee of the Brazilian Society of Rheumatology, in conjunction with the Brazilian Medical Association and other Societies, has developed this update of the guidelines for the treatment of postmenopausal osteoporosis according to the best scientific evidence available. This update is intended for professionals in many medical and health specialties involved in the treatment of osteoporosis, for physicians in general and for health-related organizations.

Prescribed Versus Preferred Intensity Resistance Exercise in Fibromyalgia Pain

Exercise is the treatment of choice for fibromyalgia (FM), but little is known about resistance exercise prescription to modulate pain in this condition. This study aimed to compare the effects of different resistance exercise models, comprising self-selected or prescribed intensity, on pain in FM patients. In a cross-over fashion, 32 patients underwent the following sessions: (i) standard prescription (STD; 3 × 10 repetitions at 60% of maximal strength); (ii) self-selected load with fixed number of repetitions (SS); (iii) self-selected load with volume load (i.e., load × sets × repetitions) matched for STD (SS-VM); and (iv) self-selected load with a free number of repetitions until achieving score 7 of rating perceived exertion (SS-RPE). Pain, assessed by Visual Analogic Scale (VAS) and Short-Form McGill Pain Questionnaire (SF-MPQ), was evaluated before and 0, 24, 48, 72, and 96 h after the sessions. Load was significantly lower in SS, SS-VM, SS-RPE than in STD, whereas rating perceived exertion and volume load were comparable between sessions. VAS scores increased immediately after all sessions (p < 0.0001), and reduced after 48, 72, 96 h (p < 0.0001), remaining elevated compared to pre-values. SF-MPQ scores increased immediately after all exercise sessions (p = 0.025), then gradually reduced across time, reaching baseline levels at 24 h. No significant differences between sessions were observed. Both prescribed and preferred intensity resistance exercises failed in reducing pain in FM patients. The recommendation that FM patients should exercise at preferred intensities to avoid exacerbated pain, which appears to be valid for aerobic exercise, does not apply to resistance exercise.

AB1124 Effect of sarcopenia, subcutaneous adipose tissue and abdominal visceral fat on mortality risk of community-dwelling older adults: a population-based prospective cohort study in brazil

Background Body composition changes resulting from ageing (decreased muscle mass and increased fat tissue) are frequently not accompanied by concomitant changes in body mass index (BMI). Thus, BMI has low accuracy to estimate death risk attributed to changes in body composition in the older adults1. Currently, the best method for body composition analysis in routine clinical practice is dual energy X-ray absorptiometry (DXA)2. However, the few studies on body composition by DXA and mortality risk in elderly have some limitations, such as analysis not compartmentalized (subcutaneous and visceral tissues) of body fat and appendicular muscle mass not adjusted for fat mass3. Objectives We sought to investigate the association between body composition by DXA (including visceral fat measurement) and mortality in a longitudinal, prospective, population-based cohort of elderly subjects. Methods 839 community-dwelling subjects (516 women, 323 men), ≥65 years, were assessed by questionnaire on clinical data, laboratory exams and body composition by DXA using Hologic QDR 4500A equipment. DXA APEX software computes visceral adipose tissue (VAT) by subtracting the subcutaneous adipose tissue (SAT) from the total android fat. All analyses were performed at baseline. Total body fat was expressed by fat mass index (FMI) [(total body fat (kg)/height2 (m)]. Sarcopenia was defined as low appendicular muscle mass adjusted for fat. Mortality was recorded during 4 year-follow-up. Multivariate logistic regression was used to compute odds ratios for all-cause and cardiovascular mortality. Results Over a mean 4.06±1.07 years of follow-up, there were 132 (15.7%) deaths. In men, after adjustment for age, BMI, smoking, physical activity, alcohol, diabetes, dyslipidemia, cardiovascular event, recurrent falls, 25OHD and PTH, the presence of sarcopenia (OR 11.36, 95% CI: 2.21–58.37, p=0.004) and visceral fat mass (OR 1.99 95% CI: 1.38–2.87, p<0.001, for each 100g-increase) significantly increased all-cause mortality risk, while FMI was associated with decreased mortality risk (OR 0.48, 95% CI: 0.33–0.71, p<0.001). Similar results were observed for cardiovascular mortality in men: sarcopenia (OR 14.84, 95% CI: 5.15–47.72, p<0.001), visceral fat mass (OR 1.66, 95% CI: 1.31–2.10, p<0.001) and FMI (OR 0.57,95% CI: 0.43–0.76, p<0.001). In women, only sarcopenia was predictor of all-cause (OR 62.88, 95% CI: 22.59–175.0, p<0.001) and cardiovascular death (OR 74.54, 95% CI: 9.72–571.46, p<0.001). Conclusions Sarcopenia and fat distribution are associated with all cause and cardiovascular mortality risk in elderly, and they are different according to sex. Visceral fat and subcutaneous fat have opposite roles on mortality risk in elderly men, and this is distinct from what is observed in young adults.These findings point to the risk of encouraging weight loss in the elderly aiming young adult goals. Furthermore, DXA seems to be a promising tool for evaluation risk of mortality in elderly, since it is easily applicable in clinical practice. References Thibault R, Pichard C. Ann Nutr Metab 2012. M Zamboni, G Mazzali, E Zoico, et al. International Journal of Obesity 2005. Yves Rolland, Adeline Gallini, Christelle Cristini, et al. Am J Clin Nutr 2014. Disclosure of Interest None declared

OP0004 Visceral Fat Measured by Dual-Energy X-Ray Absorptiometry is Associated with Increased Risk of Non-Spine Fractures in Nonobese Elderly Women: A Population-Based Prospective Cohort Analysis from The São Paulo Ageing & Health (Spah) Study

Background The protective role of obesity on bone health has currently been questioned, since it has been demonstrated that visceral fat have a deleterious effect on bone. However, there are no studies evaluating the association between visceral fat measured by DXA with fracture risk. Objectives The aim of this study was to investigate the association of visceral fat with incident non-spine fractures in community-dwelling elderly women. Methods This is a longitudinal prospective population-based cohort study evaluating 433 community-dwelling women aged 65 years or older. Specific questionnaire (clinical and anthropometric data), including personal history of fragility fracture in non-spine osteoporotic sites (hip, humerus, wrist, rib) was performed at baseline and after an average of 4.3 years. All incident fractures during the study period were confirmed by affected site radiography. Bone mineral density (BMD) and laboratory tests were also performed at baseline. Visceral fat was measured by a new software of dual-energy X-ray absorptiometry (DXA) in the android region of a total body DXA scan. Logistic regression models were used to estimate the relationship between visceral fat and non-spine fractures. Results The mean age was 72.8±4.7 years and 28 incident non-spine osteoporotic fractures were identified after a mean follow-up time of 4.3±0.8 years. According the Lipschitz classification for nutritional status in elderly, 61.4% of women were considered obese/overweigth (BMI >27 kg/m2) and 38.6% were nonobese (7.4% underweight- BMI <22 kg/m2 and 31.2% normal weight- BMI ≥22 and ≤27 kg/m2). After adjusting for age, previous fracture and BMD (parameters with significance at univariate analysis), visceral fat area had a significant association with incident non-spine fractures in nonobese (BMI ≤27 kg/m2) elderly women (p=0.009). Conclusions Higher visceral fat was associated with the risk for non-spine fractures in nonobese elderly women. This study supports a potential negative effect of visceral adiposity on bone health. References Gower BA, Casazza K. Divergent effects of obesity on bone health. J Clin Densitom. 2013;16(4):450-454. Cohen A, Dempster DW, Recker RR, et al. Abdominal fat is associated with lower bone formation and inferior bone quality in healthy premenopausal women: a transiliac bone biopsy study. J Clin Endocrinol Metab. 2013;98(6):2562-2572. Sheu Y, Marshall LM, Holton KF, et al. Abdominal body composition measured by quantitative computed tomography and risk of non-spine fractures: the Osteoporotic Fractures in Men (MrOS) Study. Osteoporos Int. 2013;24(8):2231-2241. Lipschitz DA. Screening for nutritional status in the elderly. Prim Care. 1994; 21(1):55-67. Disclosure of Interest None declared