Joan M. Nolla

Loss of bone mineral density in premenopausal women with systemic lupus erythematosus.

OBJECTIVE--To evaluate bone mineral density (BMD) in premenopausal patients with systemic lupus erythematosus (SLE). METHODS--We measured BMD by dual energy x ray absorptiometry at lumbar vertebrae L2-4 and at the right femoral neck in 74 premenopausal white patients (mean age 30.8 years) with SLE who were receiving glucocorticoid therapy, and in a control group. RESULTS--The mean cumulative dose of prednisone was 32.5 (SD 28) g. The mean dose at the time of absorptiometry was 13.7 (6.9) mg. BMD was significantly reduced at the spine and at the femoral neck in SLE patients when compared with the control group: L2-4 = 0.943 (0.1) g/cm2 v 1.038 (0.1) g/cm2 (p < 0.001); femoral neck = 0.766 (0.09) g/cm2 v 0.864 (0.1) g/cm2 (p < 0.001). Nine patients (12.1%), but none of the control group, had a BMD less than the reference range. CONCLUSION--BMD in premenopausal patients with SLE was less than that in a control group and less than the reference range of values defining the presence of osteoporosis in 12.1%. We did not find a relationship between BMD and either cumulative or baseline dose of corticosteroid therapy.

Group B streptococcus (Streptococcus agalactiae) pyogenic arthritis in nonpregnant adults.

We analyzed the cases of pyogenic arthritis from group B streptococcus (GBS), or Streptococcus agalactiae, in nonpregnant adults diagnosed in the Hospital Universitari de Bellvitge, a 1,000-bed tertiary care teaching hospital in Barcelona, Spain, during a 10-year period, and we reviewed the available literature to summarize the experience with this infectious entity. From the database of our institution, which does not attend pediatric, obstetric, or burn patients, we collected all microbiologically proven cases of infectious arthritis seen from January 1992 to December 2001. We excluded patients with infection limited to spine; patients with prosthetic joint infection; patients undergoing articular surgery during the year before diagnosis; and those with tuberculous, brucellar, or fungal arthritis. Of a total of 112 patients identified, GBS was the causative organism in 11 (10%) cases. We reviewed the literature using a MEDLINE search (1972–2001), and found 64 additional cases.Of the 75 patients, 34 (45%) were men and 41 (55%) women, with ages ranging from 20 to 87 years (mean age, 57.9 ± 14.9 yr); 37 patients (49%) were over 60 years. Sixty-eight percent (51/75) of the patients presented with monoarthritis, while in 32% (24/75) more than 1 joint was involved. The most common location was the knee (36%), followed by the shoulder (25%). In 66% (43/65) of cases, bacteremia was documented. In 64% (47/74) of patients, a systemic predisposing factor for infection was noted; the most common conditions were diabetes mellitus, malignancies, and chronic liver diseases. In 31% (23/75) of patients, a concomitant infectious process due to the same microorganism was found, mainly vertebral osteomyelitis and urinary tract infection. Penicillin was the main antibiotic used after bacterial identification; surgical drainage was performed in 36% (27/75) of cases. The overall mortality rate was 9% (7/75).GBS is now a significant causative agent of pyogenic arthritis in nonpregnant adults. In this population, joint infection by GBS is a disease that mainly affects aged patients with underlying medical illnesses; polyarticular involvement, bacteremia, and the presence of a concomitant infectious process are frequent conditions. The case-fatality rate is substantial.

The global burden attributable to low bone mineral density

Introduction The Global Burden of Disease Study 2010 estimated the worldwide health burden of 291 diseases and injuries and 67 risk factors by calculating disability-adjusted life years (DALYs). Osteoporosis was not considered as a disease, and bone mineral density (BMD) was analysed as a risk factor for fractures, which formed part of the health burden due to falls. Objectives To calculate (1) the global distribution of BMD, (2) its population attributable fraction (PAF) for fractures and subsequently for falls, and (3) the number of DALYs due to BMD. Methods A systematic review was performed seeking population-based studies in which BMD was measured by dual-energy X-ray absorptiometry at the femoral neck in people aged 50 years and over. Age- and sex-specific mean ± SD BMD values (g/cm2) were extracted from eligible studies. Comparative risk assessment methodology was used to calculate PAFs of BMD for fractures. The theoretical minimum risk exposure distribution was estimated as the age- and sex-specific 90th centile from the Third National Health and Nutrition Examination Survey (NHANES III). Relative risks of fractures were obtained from a previous meta-analysis. Hospital data were used to calculate the fraction of the health burden of falls that was due to fractures. Results Global deaths and DALYs attributable to low BMD increased from 103 000 and 3 125 000 in 1990 to 188 000 and 5 216 000 in 2010, respectively. The percentage of low BMD in the total global burden almost doubled from 1990 (0.12%) to 2010 (0.21%). Around one-third of falls-related deaths were attributable to low BMD. Conclusions Low BMD is responsible for a growing global health burden, only partially representative of the real burden of osteoporosis.

Pancreatitis, Panniculitis, and Polyarthritis

BACKGROUND AND OBJECTIVE Lobular panniculitis, together with polyarthritis and intraosseous fat necrosis, may occasionally complicate pancreatic disease. This triad is known in the literature as the pancreatitis, panniculitis, and polyarthritis (PPP syndrome). We describe a case of the PPP syndrome and review the available literature to summarize the clinical characteristics of patients with this condition. METHODS A patient with the PPP syndrome, with evidence of extensive intraosseous fat necrosis in the joints involved revealed by magnetic resonance imaging, is described and the relevant literature based on a PubMed search from 1970 to February 2008 is reviewed. The keywords used were pancreatitis or pancreatic disease, panniculitis, arthritis, and intraosseous fat necrosis. RESULTS Including our case, 25 well-documented patients with the PPP syndrome have been reported. Our patient had few abdominal symptoms despite high serum levels of pancreatic enzymes. In our review of the literature, almost 2/3 of patients had absent or mild abdominal symptoms, leading to misdiagnosis. The delay in diagnosis and specific treatment of the underlying pancreatitis worsens the prognosis of this condition, which has a mortality rate as high as 24%. In nearly 45% of the patients, the arthritis follows a chronic course with a poor response to nonsteroidal anti-inflammatory drugs and corticosteroids, and the rapid development of radiographic joint damage. CONCLUSION Certain forms of pancreatic disease can very occasionally cause arthritis and panniculitis. Although uncommon, physicians should be alert to the possible presence of this syndrome for 2 reasons: first, unrecognized pancreatic disease can be fatal if not treated promptly; second, to avoid inappropriate and risky therapy to improve joint symptoms.

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.

Usefulness of Magnetic Resonance Imaging of the Hand versus Anticyclic Citrullinated Peptide Antibody Testing to Confirm the Diagnosis of Clinically Suspected Early Rheumatoid Arthritis in the Absence of Rheumatoid Factor and Radiographic Erosions

OBJECTIVE The diagnosis of rheumatoid arthritis (RA) is sometimes difficult to establish early in the disease process, particularly in the absence of its classic hallmarks. Our aim was to compare the practical usefulness of magnetic resonance imaging (MRI) of the hand versus anticyclic citrullinated peptide (anti-CCP) antibody testing to confirm the diagnosis of clinically suspected RA in the absence of rheumatoid factor (RF) and radiographic erosions. METHODS We prospectively included patients with early inflammatory arthritis and strong clinical suspicion of RA, in whom initial complementary tests (RF and radiographs of hands, wrists, and feet) did not provide unequivocal confirmation of the diagnosis. In all patients, anti-CCP antibodies were assessed and contrast-enhanced MRI of the most affected hand was performed according to a specifically designed protocol. The MRI criterion for the diagnosis of RA was either the presence of synovitis with bone erosions or bone marrow edema, which is currently considered to be a forerunner of erosions. RESULTS In the 40 patients (28 women), the mean age at diagnosis was 54 +/- 6 years and the median duration of symptoms was 4 +/- 2.6 months (range 1.5 to 12). Final diagnoses at 1-year follow-up were RA in 31 patients, undifferentiated arthritis in 7 (5 self-limiting), and psoriatic arthropathy (PsA) and antisynthetase syndrome in 1 patient each. Anti-CCP antibodies were positive only in 7 patients, all of whom were finally diagnosed with RA. The prevalence of anti-CCP positivity in our series of seronegative RA patients was thus 23% (7/31); in these patients the anti-CCP antibodies had a specificity of 100% (95% CI: 71.7 to 100) and sensitivity of 23% (95% CI: 9.6 to 41.1). Use of the MRI criterion led to the correct diagnosis in 100% of patients with RA and to false-positive results (1 with PsA and 1 with antisynthetase syndrome). The MRI criterion had a specificity of 78% (95% CI: 40.0 to 97.2) and sensitivity of 100% (95% CI: 90.8 to 100) for identification of seronegative RA. CONCLUSION Although the tests are not mutually exclusive, in our experience MRI is more helpful than anti-CCP antibody determination in confirming the diagnosis of clinically suspected early RA in patients in whom the diagnosis cannot be confirmed using conventional methods.

Changing Trends in the Epidemiology of Pyogenic Vertebral Osteomyelitis: The Impact of Cases with No Microbiologic Diagnosis

OBJECTIVES The observed higher incidence of pyogenic vertebral osteomyelitis (PVO) may entail an increasing number of patients with no microbiologic diagnosis. The true incidence of these cases, how exhaustive the etiologic diagnostic efforts must be, and the usefulness of an empirical antibiotic therapy are not well defined. METHODS Retrospective analysis of all cases of vertebral osteomyelitis in our center (1991-2009) and retrospective analysis of cases of PVO (2005-2009). Clinical data, diagnostic procedures, treatment, and outcome were reviewed. A comparative analysis between microbiologically confirmed PVO (MCPVO) and probable PVO (PPVO) was performed. RESULTS Increasing incidence of PVO (+0.047 episodes/100,000 inhabitants-year). During the last decade, there was an increase of PPVO (+0.059 episodes/100,000 inhabitants-year) with stable incidence of MCPVO. During 2005-2009, there were 72 patients [47 (65%) MCPVO and 25 (35%) PPVO]. 60% men; mean age was 66 years. Bacteremia was found in 59%. Computed tomographic guided vertebral biopsy, positive in 7/36 (19%), was more successful among patients with bacteremia. Among MCPVO, there was an increasing proportion of less virulent bacteria. Cases of MCPVO presented more frequently with sepsis, fever, and high acute-phase reactants, and PPVO cases were mostly treated with oral fluoroquinolones plus rifampin. No differences were found between both groups in outcome (93% success, 22% sequelae). CONCLUSIONS An epidemiologic change of PVO is suggested by a higher incidence of PPVO and the isolation of less virulent microorganisms among MCPVO. In this setting, the availability of an oral and effective empirical antibiotic therapy may challenge an exhaustive prosecution of the etiology.

High HDL-cholesterol in women with rheumatoid arthritis on low-dose glucocorticoid therapy

Background  Dyslipidaemia has been described in non‐treated rheumatoid arthritis (RA), and improves after therapy with disease modifying anti‐rheumatic drugs or glucocorticoids; however, it has generally been perceived that glucocorticoids adversely affect lipid metabolism. The association of low dose glucocorticoid therapy with plasma lipid levels was evaluated in female RA patients.

Nutritional status in patients with rheumatoid arthritis

BACKGROUND Some chronic diseases have been associated to an impairment of nutritional status. OBJECTIVE To analyze nutritional status and its relation to dietary intake, disease activity and treatment in rheumatoid arthritis. PATIENTS AND METHODS We have included 93 patients (43 men and 50 women) and 93 age- and sex-matched healthy controls. The assessment of nutritional status included anthropometric (body mass index, tricipital skin fold and midarm muscular circumference) and biochemical (serum albumin, prealbumin and retinol binding protein) parameters. Dietary intake was calculated from a food frequency questionnaire. As a measure of disease activity, we used the Health Assessment Questionnaire, Ritchie index, tender and swollen joint count and C-reactive protein. Statistical analysis was performed in the whole series and in every functional class. RESULTS In the whole series, midarm muscular circumference and serum albumin were significantly lower in patients than in controls. All anthropometric parameters and serum albumin were significantly lower in patients in functional class IV than in their respective controls. The dietary intake of energy, carbohydrates, vegetal proteins and lipids was higher in patients than in controls. Midarm muscular circumference and serum albumin had a significant inverse relation with disease activity parameters; body mass index, midarm muscular circumference and serum albumin correlated inversely with the cumulative dose of glucocorticoids. CONCLUSIONS Patients with rheumatoid arthritis in functional class IV have an impairment of nutritional status without a deficient dietary intake. The differences found in other functional classes are explained by rheumatoid arthritis itself. Nutritional parameters are related to disease activity and glucocorticoid treatment.

Correction of allopurinol dosing should be based on clearance of creatinine, but not plasma creatinine levels: another insight to allopurinol-related toxicity.

Background:Dosing of allopurinol should be corrected depending on renal function, but corrections based on either plasma creatinine (Pcr) or creatinine clearance (CrCl) have been suggested to be minimal standards of care. Methods:Data from a cohort database of 484 gouty patients were used to calculate estimated allopurinol doses using CrCl and estimation of the clearance of creatinine using the equation of Cockroft and Gault (CrCl-CG) if, as a hypothesis, a dosage of 300 mg/d would be prescribed in any patient with Pcr <2.0 mg/dL. Also, allopurinol-related toxicity previous to rheumatologic consultation, during previous allopurinol therapy, and the relationship between both and estimated allopurinol doses were reviewed. Results:The cutoff point of plasma creatinine <2 showed 13% sensitivity and 100% specificity to detect CrCl <50 mL/min. Correlation and agreement between CrCl and CrCl-CG were good, as was the correlation between corrected doses using CrCl and CrCl-CG. One third of patients with Pcr 1.0–1.5 mg/dL and 90% of those with Pcr 1.5–2.0 mg/dL would receive estimated doses over 400 mg/dL/d CrCl. Also, 10% and 34% would receive estimated doses over 600 mg/dL/d CrCl, respectively. Allopurinol-related toxicity previous to consultation (11%) was associated with estimated doses over 400 mg/dL/d CrCl and severe toxicity with estimated doses over 600 mg/dL/d CrCl. When patients were given doses corrected on CrCl, few side effects were observed during follow up (6.7%), and the only severe one was associated with corrected dose over 600 mg/d. Conclusions:Dosage adjustment of allopurinol should be based on clearance of creatinine or estimation of glomerular filtration using the Cockcroft-Gault equation. Pcr is insensitive enough to detect renal function impairment so that patients may be placed at risk for overdosing side effects. Corrected doses over 600 mg/dL/d CrCl may be associated with increased risk of severe toxicity.