Tumay Sozen

Pregnancy- and lactation-associated osteoporosis with severe vertebral deformities: can strontium ranelate be a new alternative for the treatment?

BACKGROUND CONTEXT Pregnancy- and lactation-associated osteoporosis is an uncommon condition that may be a consequence of preexisting low bone density, loss of bone mineral content during pregnancy, and increased bone turnover. PURPOSE To present a case of severe osteoporosis associated with pregnancy and lactation and its treatment protocol. STUDY DESIGN/SETTING A tertiary care hospital. PATIENT SAMPLE A young female after twin pregnancy presenting with severe osteoporosis. METHODS The diagnosis was done on the basis of bone mineral density (BMD) measurement. The patient was treated with first alendronate and then strontium ranelate. She was considered as a candidate for kyphoplasty. RESULTS A dramatic increase in the BMD and palliation of back pain were observed. CONCLUSIONS Strontium ranelate may be a new alternative in the treatment of pregnancy- and lactation-associated osteoporosis.

Investigation of the effect of poorly controlled diabetes mellitus on erythrocyte life

Erythrocyte half-life (Et-1/2) has been measured in 11 patients with poorly controlled blood sugar levels and compared with a normal control group to determine whether decreased red cell deformability, which occurs in diabetic patients, causes shortening of erythrocyte life or not. No difference was seen (Et-1/2 = 28.1 days in diabetic patients and 28.5 days in controls). There was also no correlation between Et-1/2 and glycosylated hemoglobin (HbA1) levels. It has been concluded that poorly controlled diabetes mellitus has no effect upon erythrocyte life.

Mercury vapor inhalation and poisoning of a family

Acute mercury vapor poisoning is a rare but fatal toxicological emergency. People are exposed to mercury in daily life by the way of foods, vaccines, antiseptics, ointments, amalgam or occupation. We present here, the clinical picture and management of four members of the same family who were exposed to elemental mercury. Three of the family members were seen in another hospital with malaise, fever, eritematous rash and pulmonary problems. Their questioning revealed the mercury exposure. Having a suspicion of heavy metal intoxication, blood and urine mercury levels were measured and mercury intoxication was diagnosed. On admission to our hospital, two patients already had chelation therapy. In three of them we found three distinct abnormalities: encephalopathy, nephrotic syndrome and polyneuropathy. The fourth family member had minor symptoms. This family is an example for the inhalation exposure resulting from inappropriate handling of liquid mercury. During the first days, flu like illness ensues. Then, severe pulmonary, neurological, renal, hepatic, hematological and dermatological dysfunctions develop. Blood and urine mercury levels should be tested on suspicion, but it must be kept in mind that blood level is unreliable in predicting the severity of mercury toxicity. The priority in the treatment should be removing the patient from the source of exposure. Then British anti-Lewisite, edetate calcium disodium, penicillamine, Sodium 2,3-dimercaptopropane-1-sulfhonate and 2,3-dimercaptosuccinic acid can be used for binding the mercury. We conclude that since mercury-containing devices are present in daily life, physicians must be able to recognize the clinical manifestations and treatment of mercury poisoning.

Hip fractures in a developing country: osteoporosis frequency, predisposing factors and treatment costs.

Hip fractures are a burden to both society and the individual. The aim of this study was to describe the frequency of osteoporosis and the in-hospital treatment costs of patients with hip fractures admitted to Hacettepe University Faculty of Medicine Hospital. Patients with a hip fracture who were admitted to the Orthopedics and Traumatology wards between April 2003 and December 2006 were interviewed and 50 of them were enrolled prospectively in the study protocol. Patient characteristics, predisposing factors for fractures and hospital costs were recorded as well as laboratory test results and bone mineral density measurements. The mean age was 74.2 years and 72% of the patients were women. Sixty-four percent of them presented with an intertrochanteric fracture. The patient population was significantly debilitated with a high prevalence of vitamin D insufficiency and secondary hyperparathyroidism. No association was shown with T scores and dietary habits and lifestyle characteristics of patients. In 34% of patients in whom measurements were available, no osteoporosis could be documented. The mean hospital expenditure was

Could remembering the prozone phenomenon shorten our diagnostic journey in brucellosis? A case of Brucella spondylodiscitis

5983. Factors affecting the total cost were age and functional status of the patient and the duration of hospital stay, independent of the type of fracture and surgical procedure used.

Decrements in the Thrombin Activatable Fibrinolysis Inhibitor (TAFI) Levels in Association with Orlistat Treatment in Obesity

We reviewed a case of Brucella spondylodiscitis admitted to a referral, university hospital, in Ankara, Turkey. A 75-year-old female was referred to our hospital with low back pain. Previous magnetic resonance imaging yielded cortical destruction of T9–10 and T12–L2 vertebral bodies, focal infectious foci at discs within this range, significant microabscesses at paravertebral areas, which lead to the diagnosis of spondylodiscitis. History of consumption of unpasteurized dairy products led us to first suspect brucellosis yet, the serum agglutination test and blood culture were negative and did mislead us to several other, sometimes invasive, diagnostic tests. The final diagnosis was reached by culturing the specimen obtained through fine-needle aspiration from the paravertebral microabscesses. The exhausting diagnostic journey that started with the suspicion of tuberculosis or malignancy ended with a diagnosis of brucellosis. Brucellosis should be considered in all patients with osteoarthritic complaints in endemic regions, and the “prozone phenomenon” should be kept in mind, before proceeding to high-tech lab tests, imaging, or invasive procedures.

Cold pressor test in diabetic autonomic neuropathy.

Obesity and its associated metabolic complications can impair the physiologic regulation of fibrinolysis, leading to a hyper coagulable state. We aimed to assess circulating thrombin activatable fibrinolysis inhibitor (TAFI) levels in obese female patients and to test the effects of orlistat-induced weight loss on basal TAFI concentrations. Obese female outpatients age 18 and older, with a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of at least 30, were included into the study. Thirteen nonobese (median BMI, 22.60 kg/m2) age-matched females were taken as controls. Plasma TAFI levels were measured before orlistat administration and after 6 months of orlistat treatment in the obese group and only one measurement was done in the control group. Twenty-seven obese patients were recruited into the study. The median TAFI level of the control group was 124.00; this value was significantly lower than the basal TAFI level of the obese group (p < 0.001). TAFI levels after orlistat therapy were statistically significantly lower than basal TAFI levels (p < 0.001) in the obese group. Hemostatic abnormalities including TAFI alterations represent a link between obesity and vascular thrombosis. Effective interventions should be considered in improving the obesity-associated prothrombotic risk profile.

Fenofibrate improves endothelial function and decreases thrombin-activatable fibrinolysis inhibitor concentration in metabolic syndrome

The tests for evaluating sympathetic dysfunction seen in diabetic patients are few and insensitive. For this reason, there are some difficulties in diagnosing sympathetic dysfunction and additional tests are required. The cold pressor test causes a strong sympathetic stimulus and this study investigated whether this test could be helpful in diagnosing sympathetic dysfunction. The cold pressor test was applied to a group of diabetic patients (n = 33) and a control group (n = 15). The mean systolic cold pressor response in diabetic patients was found similar to controls (9 +/- 1.4 vs. 10.6 +/- 1.2 mmHg). However the mean diastolic cold pressor response was significantly lower in diabetic patients as compared with the control group (7.7 +/- 1.0 vs. 12.0 +/- 1.1 mmHg, P < 0.05). Cardiovascular reflex tests were also applied to diabetic patients and deep breathing and orthostatic hypotension test results were used to categorize the patients with parasympathetic and/or sympathetic dysfunction. In patients with autonomic neuropathy the diastolic cold pressor response was smaller than the controls (6.9 +/- 1.3 vs. 12.0 +/- 1.1 mmHg, P < 0.05); however, in patients without autonomic neuropathy it was not significantly different from controls (8.7 +/- 1.8 vs. 12.0 +/- 1.1). The systolic cold pressor test results showed no difference between patients with or without parasympathetic dysfunction but diastolic cold pressor results in patients with sympathetic dysfunction were significantly lower than the results of the patients without sympathetic dysfunction (3.8 +/- 1.3 vs. 9.1 +/- 1.3 mmHg, P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Ten-year follow-up in pregnancy and lactation-associated osteoporosis: sequential therapy with strontium ranelate and ibandronate

Procoagulant state, inflammation, and endothelial dysfunction have been documented in metabolic syndrome. Endothelial dysfunction is a strong predictor of cardiovascular events. Studies on the association of thrombin-activatable fibrinolysis inhibitor and thrombosis are still controversial, but substantial evidence suggests that increased thrombin-activatable fibrinolysis inhibitor or thrombin-activatable fibrinolysis inhibits or protects against arterial thrombosis. This study aimed to assess concomitantly the effects of fenofibrate therapy on thrombin-activatable fibrinolysis inhibitor concentrations and endothelial functions in patients with metabolic syndrome. Twenty-five patients (16 women; mean age 50.4 ± 7.0) were enrolled in the study. Plasma thrombin-activatable fibrinolysis inhibitor, C-reactive protein, and fibrinogen levels were measured before fenofibrate administration and after 8 weeks of fenofibrate treatment. Endothelial function was assessed by endothelial-dependent flow-mediated dilatation from brachial artery. Pretreatment (baseline) thrombin-activatable fibrinolysis inhibitor level was 52.3 (1.2–119.7) decreasing to 7.7 (0.9–51.2; P < 0.001) after 8 weeks of fibrate treatment. Endothelial functions, which were measured with flow-mediated dilatation, were significantly improved after treatment (mean flow-mediated dilatation was 6.76 ± 2.21 at baseline and 10.66 ± 1.17% after 8 week of fenofibrate treatment, P < 0.001). Fenofibrate decreases thrombin-activatable fibrinolysis inhibitor levels and improves endothelial function in metabolic syndrome and, thus, suggests a potential for protection against cardiovascular effects. Further studies are warranted to confirm the effects of fibrates on thrombin-activatable fibrinolysis inhibitor and for conclusive evidence on the association between thrombin-activatable fibrinolysis inhibitor and thrombosis.

Evaluation of bone metabolism and bone mass in patients with type-2 diabetes mellitus.

Pregnancy and lactation-associated osteoporosis (PLO) is a rare but a challenging entity that may result in fragility fractures in postpartum lactating young women. One of the caveats of this condition is the absence of a large case series or a long-term follow-up or adequate evidence to guide clinical management [1]. In 2009, we reported in this journal, a young woman with PLO after delivery of twins [2]. She had a T score of 4.57 at the total lumbar region at the time of diagnosis that regressed to 2.54 after 3 years of treatment with strontium ranelate. Here, we would like to report the 10th year follow-up of the patient. The patient continued to receive strontium ranelate together with vitamin D and calcium replacement and an oral contraceptive. She had severe vertebral deformities, but they did not require kyphoplasty under medical treatment. The patient had lost 5 cm by the 4th year, but thereafter she lost 1 cm. The back pain disappeared by the end of the 6th year when she was still on strontium ranelate. However, by the end of the 7th year, there was no improvement in the bone mineral density (BMD) of the lumbar and femoral regions, but worsening under strontium ranelate (Table). The therapy was switched to an antiresorptive agent, ibandronate. Annual