Nada Vujasinovic-Stupar

The relationship among hypertension, antihypertensive medications, and osteoporosis: a narrative review.

Osteoporosis and hypertension are two frequent diseases among the aging population that share a similar etiopathology and often coexist. Moreover, treatment of hypertension affects bone mineral density and, therefore, can worsen osteoporosis. This narrative review considers the influence of the main etiologic factors that contribute to the development of hypertension and osteoporosis and examines the effect of the most often used antihypertensives on bones. A computerized literature search of relevant English publications regarding the etiology of hypertension and osteoporosis as well as the impact of antihypertensives on osteoporosis from 1996 to 2011 was completed in October 2011. The latest update in the search was performed from May to June 2012. The most relevant nongenetic factors in the etiology of osteoporosis and hypertension are low calcium intake, vitamin D and vitamin K deficiency, high consumption of sodium salt, and the effects of different forms of nitric oxide. Thiazide diuretics are the only antihypertensives that have a positive influence on bone mineral density. For other antihypertensive drugs, the data are conflicting, indicating that they may have a potentially negative or positive influence on bone mineral density and fracture risk reduction. Some studies did not find a correlation between the use of antihypertensives and bone mineral density. Due to the frequent coexistence of hypertension and osteoporosis, when selecting long-term antihypertensive therapy the potential effects of antihypertensive drugs on development, worsening, or improvement of osteoporosis should also be considered.

Fatal Sulfasalazine-Induced Eosinophilic Myocarditis in a Patient with Periodic Fever Syndrome

Objective: The aim of this paper is to report the first case of drug-induced eosinophilic myocarditis (EM) in a patient with hereditary periodic fever syndrome (PFS). Case: A 28-year-old man with hyper-IgD syndrome, one of the PFS, developed a sulfasalazine-induced systemic hypersensitivity reaction complicated by EM. Thirteen days after sulfasalazine introduction, which had been given for arthritis, the patient developed fever, facial/neck edema, rash and cardiogenic shock, and died within 8 h. The autopsy revealed hemophagocytosis, while acute heart failure caused by necrotizing EM was established as the cause of death. Conclusion: This was a case of drug-induced EM in a patient with PFS that had an atypical presentation, rapid evolution and poor outcome.

The impact of physical therapy on the quality of life of patients with rheumatoid and psoriatic arthritis

INTRODUCTION This open, uncontrolled study examined the effects of physical therapy and rehabilitation on the quality of life in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA). MATERIAL AND METHODS The study included a total of 109 patients (69 with RA and 40 with PsA). Patients came from Norway for a four-week rehabilitation period at the Institute of Physical Medicine, Rehabilitation & Rheumatology--Igalo from June till October, 2003. This was a self-controlled, pretest/posttest study. All patients had six days of physical therapy per week, during a four-week stay, which made a total of 24 therapy days. Basic therapy included mud packs/baths, kinesitherapy, hydrokinesitherapy and electrotherapy with analgesic effects. Quality of Life measurements were conducted two times (on admission and discharge) using questionnaire EuroQoL (EQ-5D). The research also included evaluation of ACR improvement. RESULTS Pain/disability scale and the well being scale showed that quality of life in patients with PsA was significantly lower in comparison with RA patients. However, after 4 weeks, quality of life was much better in most dimensions of the EuroQoL questionnaire. Patients showed no improvement in self-care activities (in both group.) and daily activities (in group with PsA). Significant improvement was measured also in ACR improvement criteria (around 30%). CONCLUSIONS Physical therapy at the Igalo Institute and good climate conditions have significantly improved the Health-Related-Quality-of-Life in both groups of patients. ACR index showed great

Influence of rituximab–CHOP therapy on clinical course and autoimmune parameters in rheumatoid arthritis associated with diffuse large B cell non-Hodgkin lymphoma

Dear Editor, Patients with rheumatoid arthritis (RA) have an increased risk of developing malignant lymphomas, in particular nonHodgkin lymphoma (NHL) [12]. The addition of rituximab (R), an anti-CD20 antibody, was shown to increase the effectiveness of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy in patients with diffuse large B cell non-Hodgkin lymphoma (DLBCL) [13]. Rituximab is a newly approved therapeutic agent for patients with active RA [11] because the potential decrease or elimination of autoreactive B lymphocytes could improve autoimmune condition. As patients with NHL and concurrent autoimmune disease offer the unique opportunity of monitoring the effects of administered immunochemotherapy on rheumatologic parameters, we have evaluated serologic autoimmune markers and the clinical outcome of a patient with RA who developed DLBCL and received treatment with R-CHOP during the course of her disease. In June 2003, a 51-year-old Caucasian female was referred with 2 months history of tender and swollen joints of the hands and feet, wrists, ankles, and right knee with early morning stiffness of 1-h duration. Physical exam revealed symmetric arthritis affecting wrists; second proximal interphalangeal, fifth proximal interphalangeal, and third metacarpophalangeal joints; and right knee effusion. Her erythrocyte sedimentation rate (ESR) was 83 mm in 1 h and rheumatoid factor (RF) was found positive: Rose– Waaler test 1/80, latex RF 1/640. X-rays of the hands and feet showed narrow radiocarpal articular space (Fig. 1a) and symmetrical subcortical cystic lesions in the fifth metatarsophalangeal joint (MTP5) (Fig. 1b). She fulfilled the American College of Rheumatology (ACR 1987) criteria for diagnosis of RA [1], and therapy with diclofenac started. In February 2004, symptoms of RA worsened and she received additional therapy with chloroquine (250 mg/day) which led to clinical improvement of her RA, while increase of inflammatory and autoimmune markers (ESR 58 mm in 1 h, latex RF 1/320) persisted. In July 2006, 3 years from the diagnosis of RA, she presented with right cervical and axillary lymphadenopathy without B symptoms. Performance status was zero. Laboratory findings showed normal blood cell count, serum LDH level a 1.3 times normal value (597 U/l, referent range <460 U/l) and β2-microglobulin level on the upper limit of the referent range (3.01 mg/l, referent range <3 mg/l). A CT scan and ultrasonography revealed right supraclavicular (20 mm), bilateral axillary (25 mm), retroperitoneal (16 mm), parailiacal, and mediastinal (16 mm) lymphadenopathy and a large focal lesion (43×37 mm) in the spleen. The bone marrow biopsy was unremarkable for a lymphomatous involvement. Morphological and immunohistochemical analysis of the lymph node tissue sections revealed lymphoid proliferation consistent with DLBCL. Namely, Ann Hematol (2008) 87:767–769 DOI 10.1007/s00277-008-0475-y

Matrix Metalloproteinases-3 Baseline Serum Levels in Early Rheumatoid Arthritis Patients Without Initial Radiographic Changes: A Two Year Ultrasonographic Study

Objective: To investigate the association of high baseline serum levels of metalloproteinases-3 (MMP-3) with structural damage to hand and feet joints, assessed by ultrasonography (US), in patients with early, treatment-naïve rheumatoid arthritis (RA), without initial X-ray-visible erosions, during 24 months follow-up. Methods: Sixty-three early RA (European League Against Rheumatism/American College of Rheumatology 2010), disease-modifying anti-rheumatic drugs/glucocorticoid naïve patients (mean age 53.4 ± 14.1) with symptom duration ≤12 months, had baseline serum levels of MMP-3 tested. OMERACT US group definition was used to detect the presence, as well as longitudinal diameter of erosions by US at study entry and after 24 months, at the level of wrists, metacarpophalangeal (MCP2/MCP5) joints of both hands, and fifth metatarsophalangeal joints. Results: Complete data were collected from 52 out of 63 patients. High baseline serum levels of MMP-3 (MMP-3-positive) were found in 46/63 patients. 122 bone erosions in total (1.9 bone erosions/patients) were detected by US at baseline visit and 213 erosions (4.3/patients) after 24 months. MMP-3 positive patients had significantly higher total number of erosions than MMP-3-negative (p = 0.039) and higher increase in size of bone erosions in the feet but not in the hand joints after follow-up (OR 4.82 [1.23–18.9], p = 0.024; OR 1.17 [0.320–4.26], p = 0.816 respectively). Conclusion: After 2 years of follow-up, US assessment showed a higher number of new bone erosions in MMP-3-positive compared to MMP-3-negative patients with early RA and no visible initial radiographic changes. High baseline levels of MMP-3 predict significantly higher structural damage progression at the level of feet, but not at the level of hand joints.

Effects of Alendronate on bone mass in women with osteoporosis.

This paper presents the results of a two-year study of the effects of alendronate (Fosamax) on bone mass in 187 women with osteoporosis, mean age 57.68 years. Bone mass, i.e. bone mineral density (BMD) was measured at the lumbar spine. Measurements were performed prior to treatment, one year and two years after treatment using the DEXA method. The BMD was examined in 65 women, mean age 54.02, taking calcium and vitamin D, and in 75 women mean age 57.16, without any therapy. The baseline BMD (T score) in the alendronate group was -2.87 SD, whereas in the two control groups it measured -1.86 SD and -2.02 SD, respectively. A significant improvement of bone mass, by 5.8%, was registered after a year of treatment with alendronate, and by 8.3% after two years. In patients receiving calcium and vitamin D, a significant increase of bone mass was established as well: by 2.9% after a year, but the values declined back to the baseline after the second year. In patients without any treatment the bone mass decreased by 0.6% after a year, and by 0.9% after the second year.