M. Ghazi

Prevalence and risk factors of osteoporosis and vertebral fractures in patients with ankylosing spondylitis

UNLABELLEDnAnkylosing spondylitis (AS) is characterized by inflammation of the entheses and paravertebral structures, leading in time to bone formation at those sites. As well, vertebral bone loss is also a recognized feature of AS Objective: To calculate the prevalence and risk factors of osteoporosis and vertebral fractures in patients with AS.nnnMETHODSnEighty patients with AS were enrolled in the study. Clinical, biological and radiological status was assessed by the Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), ESR and C-reactive protein (CRP), Bath AS Radiology Index (BASRI) and modified stoke AS spine score (mSASSS). BMD of the hip and spine was measured and vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry by VFA (fracture vertebral assessment).nnnRESULTSnThe years+/-11.8. The mean BMI was 22.8 kg/m(2)+/-4.1 and the mean disease duration was 10.8 years+/-6.6. Prevalence of osteoporosis was 25%. 18.8% of patients had a vertebral fracture (grades 2 and 3). Factors associated with osteoporosis were low weight and BMI and longer disease duration, higher ESR, CRP, BASFI and BASDAI. Vertebral fractures were associated with advanced age, longer disease duration, higher BASFI, BASRI and mSASSS and reduced BMD and T-score at the hip site, presence of osteoporosis at any site. Multiple logistic regression analysis (Table 4) revealed that parameters significantly associated with osteoporosis were BASDAI (OR=1.05, 95% confidence interval [CI]: 1.03-1.09); disease duration (OR=1.13, 95%CI: 1.03-1.25); and BMI (OR=0.82, 95%CI: 0.69-0.93). The presence of VFs (grades 2 and 3) were independently associated with disease duration (OR=1.50, 95%CI: 1.07-2.10); and mSASSS (OR=1.17, 95%CI: 1.05-1.30).nnnCONCLUSIONnOsteoporosis is common in patients with AS and seems to be related to disease activity while vertebral fractures appear to be related to the duration and structural severity of the disease rather than BMD.

Reproducibility of bone mineral density measurements using dual X-ray absorptiometry in daily clinical practice

Bone mineral density (BMD) measurements are frequently performed repeatedly for each patient. Subsequent BMD measurements allow reproducibility to be assessed. Previous studies have suggested that reproducibility may be influenced by age and clinical status. The purpose of the study was to examine the reproducibility of BMD by dual energy X-ray absorptiometry (DXA) and to investigate the practical value of different measures of reproducibility in three distinct groups of subjects: healthy young volunteers, postmenopausal women and patients with chronic rheumatic diseases. Two hundred twenty-two subjects underwent two subsequent BMD measurements of the spine and hip. There were 60 young healthy subjects, 102 postmenopausal women and 60 patients with chronic rheumatic diseases (33 rheumatoid arthritis, 10 ankylosing spondylitis and 10 other systemic diseases). Forty-five patients (75%) among the third group were receiving corticosteroids. Reproducibility was expressed as the smallest detectable difference (SDD), coefficient of variation (CV), least significant change (LSC) and intraclass correlation coefficient (ICC). Sources of variation were investigated by linear regression analysis. The median interval between measurements was 0xa0days (range 0–7). The mean difference (SD) between the measurements (g/cm2) was −0.0001 (±0.003) and −0.0004 (±0.002) at L1-L4 and the total hip, respectively. At L1-L4 and the total hip, SDD (g/cm2) was ±0.04 and ±0.02, CV (%) was 2.02 and 1.29, and LSC (%) 5.60 and 3.56, respectively. The ICC at the spine and hip was 0.99 and 0.99, respectively. Only a minimal difference existed between the groups. Reproducibility in the three groups studied was good. In a repeated DXA scan, a BMD change, the least significant change (LSC) or the SDD should be regarded as significant. Use of the SDD is preferable to use of the CV and LSC because of its independence from BMD and its expression in absolute units. Expressed as SDD, a BMD change of at least ±0.04 g/cm2 at L1-L4 and ±0.02xa0g/cm2 at the total hip should be considered significant. This reproducibility seems independent from age and clinical status and improved in the hips by measuring the dual femur.

Vertebral fracture assessment in healthy men: Prevalence and risk factors

INTRODUCTIONnVertebral fracture assessment (VFA) is a technology that can reliably and accurately diagnose vertebral fractures with greater patient convenience, less radiation exposure, and lower cost than standard spine radiography.nnnOBJECTIVEnTo study prevalence and risk factors of vertebral fractures using VFA in healthy men.nnnMETHODSnThe study cohort consists of a population of 216 healthy men aged between 50 and 79 (mean age, weight and BMI of 63.8 years, 73.3 kg and 25.7 kg/m2, respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. Vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry.nnnRESULTSnNinety-three percent of vertebrae from T4-L4 and 98% from T8-L4 were adequately visualized on VFA. Vertebral fractures were detected in 29.6% (64/216) of these men: 34/216 (15.7%) had grade 1 and 30/216 (13.8%) had grades 2 or 3. Twenty one of men with VFA-identified fracture (32.8%) had only a single vertebral fracture, while the other 67.2% had two or more. Fractures were most common in the mid-thoracic spine and at the thoraco-lumbar junction. As would be expected, the prevalence of VFA-detected fractures increased with age and as BMD declined. This group of men had a statistically significant lower weight, height, calcium consumption and T-score than those without a VFA-identified vertebral fracture. Regression analysis showed that presence of vertebral fracture was mainly related to the osteoporotic status (OR: 9.0; 95% CI: 3.5-22.8).nnnCONCLUSIONnVFA allows evaluation of the majority of vertebral bodies in men. Vertebral fractures are common in healthy men and are related to low BMD.

Discordance Between Hip and Spine Bone Mineral Density Measurement Using DXA: Prevalence and Risk Factors

BACKGROUNDnDiagnostic discordance for osteoporosis is the presence of different categories of T-scores in 2 skeletal sites of an individual patient, falling into 2 different diagnostic categories identified by the World Health Organization classification system.nnnOBJECTIVESnTo evaluate the prevalence and risk factors for T-score discordance between spine and total hip measurement sites.nnnMETHODSnDemographic data, anthropometric measurements, and risk factors for osteoporosis were derived from a database of 3479 patients referred to a community-based outpatient osteoporosis testing center. Dual-energy x-ray absorptiometry (DXA) was performed on L1-L4 lumbar spine and total hips for all cases. Minor discordance was defined as present when the difference between 2 sites was no more than 1 World Health Organization diagnostic class. Major discordance was present when 1 site is osteoporotic and the other is normal. Subjects with incomplete data were excluded.nnnRESULTSnIn 3479 participants (2871 women; mean age, 55.7 +/- 11.9 years), concordance of T-scores, minor discordance, and major discordance were seen in 54, 42, and 4%, respectively. In multivariate logistic regression analysis, age, menopause, and obesity were identified as risk factors against T-score discordance.nnnCONCLUSIONnDensitometrists and clinicians should expect that at least 4 of every 10 patients tested by DXA to demonstrate T-score discordance between spine and total hip measurement sites. T-score discordance can occur for a variety of reasons related to physiologic and pathologic patient factors as well as the performance or analysis of DXA itself.

Prevalence and risk factors of discordance in diagnosis of osteoporosis using spine and hip bone densitometry

Dual x ray absorptiometry is the reference method to measure bone mineral density (BMD) accurately and reproducibly. The World Health Organization defines osteoporosis on the basis of the T score (which is the difference between the measured BMD and the mean value of young adults, expressed in standard deviations for a normative population of the same ethnicity).1 Although the BMD at different anatomical regions is correlated, the agreement between sites is low when it comes to classifying individual subjects as having osteoporosis.2 Various studies have analysed the prevalence and effect of T score discordance on the management of osteoporosis.3–7 However, most of these studies did not evaluate risk factors for this phenomenon. Thus, …

Bone mineral density of the spine and femur in a group of healthy Moroccan men.

BACKGROUNDnBone mineral density (BMD) measurements using dual-energy X-rays absorptiometry (DXA) are widely used to diagnose osteoporosis and to assess its severity. Previous studies show the necessity to establish reference data for bone mass measurements for each particular population. Such data are lacking for the male Moroccan population.nnnAIMnTo establish reference values for the healthy Moroccan male population and to compare them with those for Caucasian and Arab males, and to study the impact of different curves implemented in the DXA system on the diagnosis of osteoporosis.nnnMETHODSnA cross-sectional study of 592 Moroccan men, recruited from the area of Rabat, the capital of Morocco, aged between 20 and 79 years was carried to establish reference values of bone mineral density. Measurements were taken at the lumbar spine and proximal femurs using DXA (Lunar Prodigy Vision, GE). The data were compared with published normative taken by US, European, Iranian, Lebanese, and Saudi men over six decades of age. Impact on osteoporosis diagnosis according to the WHO criteria using the personalized curve and US (NHANES), European and Middle-East reference curves (as implemented in the Lunar densitometers) was studied.nnnRESULTSnOur results showed that the Moroccan men showed the expected decline in BMD at both sites with age after peaking at 20-29 years age group. Every anatomical region has a different rate of bone loss: lumbar spine (0.3% per year) femoral neck (0.6%), trochanter (0.3%), and total hip (0.4%). The lumbar spine and femoral subregions BMD exhibited increases from 0.3 to 0.5% per kilogram of body weight. In the spine, the US/European Lunar reference values classified a larger proportion of men as osteoporotic (18.1% vs. 7.4%) while using the Arabic Lunar reference values, only 7.8% were classified as osteoporotic. However, using Arabic curve for the femurs resulted in underdiagnosis of osteoporosis (1.8% vs. 6.0%), whereas the US/European Lunar reference values classified men as osteoporotic in 3.9% and 5.3% respectively.nnnDISCUSSIONnIn comparison with the other Countries, the spine BMD of Moroccan men were slightly lower than Iranians, Europeans and Brazilians but higher than the Saudi and Lebanese males. We found BMD values taken at the lumbar spine to be around 4% lower than European values between ages 50 and 59 years, and 10% lower for older subjects. These values were 4-6% higher than Saudis/Lebanese values between ages 20-39. For older subjects, Moroccan values were more than 10% higher than Saudis and almost similar to Lebanese. Femoral neck BMD values were 8% higher in young adults (age 20-39 years) to US/Saudis/Lebanese values, but about 10% lower in ages over 60 to US values whereas it was similar to Saudis and Lebanese values.nnnCONCLUSIONnOur study emphasises the importance of using population-specific reference values for BMD measurements to avoid over or underdiagnosis of osteoporosis.

Performance of calcaneus quantitative ultrasound and dual-energy X-ray absorptiometry in the discrimination of prevalent asymptomatic osteoporotic fractures in postmenopausal women

Due to its low cost, portability, and nonionizing radiation, quantitative ultrasound (QUS) of the heel is an alternative to the measurement with dual X-ray absorptiometry (DXA) in the evaluation of bone status. The objective of the study is to compare in asymptomatic postmenopausal women the ability of QUS and DXA to discriminate between those with and without prevalent vertebral fractures (VFs). The study cohort consists of a population of 295 postmenopausal women aged between 60 and 84 (mean age, weight and BMI of 66.3xa0years, 72.0xa0kg and 29.4xa0kg/m2, respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. All women had a calcaneous QUS examination. The mean age of the women in our sample was 66.3 (±5.3)xa0years, ranging from 60 to 84xa0years. Eighty-seven (29.3%) women had VFs Genant grade 2 and 3. Patients with VFs had an age and a number of years of menopause higher to those without VFs, but showed lower height, weight, and BMI. All densitometric and ultrasonometric measurements were significantly reduced in women with VFs. The intercorrelations of BMD at different sites were high, and the correlations of BUA with BMD were lower. BUA correlated weakly with total hip BMD (rxa0=xa00.36), lumbar spine BMD (rxa0=xa00.32), and much less with femur BMD (rxa0=xa00.30); all correlations were significant (Pxa0<xa00.01). Analysis of the AUC for the ROC curves showed lumbar spine T-score below −2.5 to provide consistently the highest AUC (0.64). Age-adjusted ORs after correction for confounding variables (years of menopause, weight, height, and BMI) for QUS and BMD measurements showed that only lumbar spine T-score below −2.5 could predict significantly the presence of VFs (OR, 1.94; 95%CI, 1.02–3.41). Lumbar spine BMD (and not QUS) was able to discriminate asymptomatic postmenopausal women with prevalent VFs from women without VFs and independently contributed to determining the association with fracture. The combination of QUS and BMD did not improve the diagnostic ability of either individual technique.

Targeting Acquired Hemophilia A with Rheumatoid Arthritis by a Rituximab Shot: A Case Report and Review of the Literature

Patient: Male, 66 Final Diagnosis: Acquired hemophilia A Symptoms: Polyarticular flare Medication: — Clinical Procedure: — Specialty: Rheumatology Objective: Challenging differential diagnosis Background: Acquired hemophilia A (AH) is a rare hemorrhagic diathesis, characterized by the presence of autoantibodies directed against the pro-coagulant activity of factor VIII. It is associated with rheumatoid arthritis (RA) in 4% to 8% of cases and its prognosis remains severe. Case Report: A 66-year-old patient has been followed up for 20 years for deforming and severe RA, which was in low-disease activity. However, the patient presented a polyarticular flare involving the metacarpophalangeal and the proximal interphalangeal joints, the left elbow, and the right knee, which was warm and swollen. Articular puncture of this knee yielded a hematic fluid that did not coagulate. Its cytological analysis showed significant presence of red blood cells, which were also abundantly present in the other cell lines. Activated partial thromboplastin time was lengthened and not corrected by the addition of control plasma. Prothrombin time (Quick’s test), fibrinogen level, and vitamin K-dependent factors were without abnormalities. In contrast, factor VIII was collapsed at 7% and the anti-factor VIII antibody was positive. The diagnosis of AH with anti-factor VIII inhibitor was thus retained. With regard to RA, the Disease Activity Score was 6.32 and exhibited a very active RA. Rituximab with methotrexate was begun and the evolution was favorable. After 6 months, the reappearance of the anti-factor VIII inhibitor was found, thus justifying a second cycle of rituximab. Conclusions: AH is not exceptional in RA. Rituximab remains a relevant alternative for managing simultaneous AH with inhibitor and RA.

Étude descriptive de la géométrie de la hanche chez la population féminine marocaine

s / Revue du Rhumatisme 74 (2007) 1039–1208 1105