Vertebral fractures are increased in rheumatoid arthritis despite recent therapeutic advances: a case-control study.

Prevalence and risk factors of vertebral fractures in postmenopausal RA women were assessed in 323 patients and compared with 660 age-matched women. Of patients, 24.15% had at least one vertebral fracture vs.16.06% of controls. Age, glucocorticoids and falls were the main fracture risks. Vertebral fractures were associated with disease severity. INTRODUCTION: There is little quality data on the updated prevalence of fractures in rheumatoid arthritis (RA) that may have changed due to advances in the therapeutic strategy in recent years. This study was aimed at analysing the prevalence and risk factors of vertebral fractures in postmenopausal women with RA and comparing it with that of the general population. METHODS: We included 323 postmenopausal women diagnosed with RA from 19 Spanish Rheumatology Departments, randomly selected and recruited in 2018. Lateral radiographs of the thoracic and lumbar spine were obtained to evaluate morphometric vertebral fractures and the spinal deformity index. We analysed subject characteristics, factors related to RA, and fracture risk factors. The control group consisted of 660 age-matched Spanish postmenopausal women from the population-based Camargo cohort. RESULTS: Seventy-eight (24.15%) RA patients had at least one vertebral fracture. RA patients had increased fracture risk compared with controls (106 of 660, 16.06%) (p = 0.02). Logistic regression analysis showed that age (OR 2.17; 95% CI 1.27-4.00), glucocorticoids (OR 3.83; 95% CI 1.32-14.09) and falls (OR 3.57; 95% CI 1.91-6.86) were the independent predictors of vertebral fractures in RA patients. The subgroup with vertebral fractures had higher disease activity (DAS28: 3.15 vs. 2.78, p = 0.038) and disability (HAQ: 0.96 vs. 0.63, p = 0.049), as compared with those without vertebral fractures. CONCLUSION: The risk of vertebral fracture in RA is still high in recent years, when compared with the general population. The key determinants of fracture risk are age, glucocorticoids and falls. Patients with vertebral fractures have a more severe RA.

Dose escalation of the anti-TNF-alpha agents in patients with rheumatoid arthritis. A systematic review.

OBJECTIVE: To estimate the proportion of rheumatoid arthritis (RA) patients on anti-tumour necrosis factor (anti-TNF) who require dose escalation. METHODS: Systematic review of the scientific literature. Infliximab, etanercept and adalimumab studies in RA were considered. Primary outcome was the proportion of patients requiring dose escalation. American College Rheumatology (ACR) and Disease activity score (DAS) responses post-escalation were assessed when available. RESULTS: From 1801 references, 16 studies with 8510 patients were included. Of all the infliximab patients, 53.7% underwent dose escalation. Fourty-four per cent of the infliximab patients experienced dose increase and 8.3%, frequency increase. The ACR20 response to dose escalation ranged from 27 to 36% and DAS28 improved from 5.2 to 4.5 in one study and from 4.1 to 3.7 in another. Of the etanercept patients, 17.5% experienced a dose increase but changes on the mean dose were not statistically significant. CONCLUSIONS: Dose escalation is common in patients treated with infliximab, and less frequent with etanercept. In a proportion of patients, the dose escalation seems effective. The design and evidence level of the available studies limit the strength of the conclusions.

[Effect of alendronate on bone mineral density and incidence of fractures in postmenopausal women with osteoporosis. A meta-analysis of published studies]. / Efecto del alendronato sobre la densidad mineral ósea y la incidencia de fracturas en mujeres posmenopáusicas con osteoporosis. Un metaanálisis de los estudios publicados.

BACKGROUND: To perform a systematic review, completed with a meta-analysis, of the published evidences about the effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal women with low bone mass. METHODS: We search for all alendronate clinical trials in postmenopausal women with low bone mass which were randomized, double blind, placebo controlled, with a duration of one year or more and with bone mineral density measurement and/or fractures as outcomes. We used the weighted average of individual study results as an estimation of the global effect. RESULTS: Seven studies meet all the inclusion criteria. Relative Risks (RR) with 95% Confidence Intervals (CI 95%) for the combined effect under fixed effects model were: RR 0.54 (CI 95%: 0.45 to 0.66) for vertebral fractures, RR 0.81 (CI 95%: 0.72 to 0.92) for non vertebral fractures and RR 0.64 (CI 95%: 0.40 to 1.01) for hip fractures. CONCLUSIONS: Our results demonstrate that alendronate reduces the risk of vertebral, non vertebral and hip fractures in postmenopausal women with low bone mass. This meta-analysis allows the classification of alendronate anti-fracture evidences in the highest level.

Extramedullary hematopoiesis related to Paget's disease.

Extramedullary hematopoiesis usually occurs in hematological diseases but may also be found as an uncommon complication of Paget's disease, probably due to bone effraction mechanism. We present a case of intrathoracic extramedullary hematopoiesis related to Paget's disease. To our knowledge, this is the seventh case reported in the literature. We describe and correlate the conventional X-ray, CT, MR imaging, and cytological findings.

[Epidemiology of the osteoporotic fracture of the hip in the province of Palencia]. / Epidemiología de la fractura osteoporótica de cadera en la provincia de Palencia.

BACKGROUND: Hip fracture is the most severe consequence of osteoporosis. The aim of the present study was to know the incidence of osteoporotic hip fracture in the Palencia province, its direct economical consequences and characteristics associated with the origin episode. PATIENTS AND METHODS: All patients aged over 49 years who had a nontraumatic hip fracture during the second semester of 1994 and the first semester of 1995 were included in the study. An analysis of costs was performed and each patient received a questionnaire to know the circumstances associated with the episode. RESULTS: During the study period the overall incidence of hip fracture was 83/100,000 inhabitants/year, which corresponds to an adjusted incidence of 240.9/100,000 inhabitants older than 49 years (336.8 women and 120.7 men). There was an exponential growth, with peak values starting at 80 years. The female/male ratio was 2.8 and the mean age 80.8 years. Twenty-four percent of fractures occurred in institutionalized persons, with an adjusted incidence of 1,107/100,000 inhabitants/year, which corresponds to a relative risk of 13.57 (95% CI: 10.06-18.28). No significant differences were observed between trochanteric and neck fractures. Ninety-seven percent of fractures occurred after a fall, usually in the morning or afternoon (86%), with lateral direction and impact on the greater trochanter (89%). The mortality rate during admission was 5.9%. The mean cost of care during admission was 1,170,000 pesetas. CONCLUSIONS: The incidence of hip fracture in Palencia is slightly higher than the national mean, probably due to populational ageing. The risk of fracture reaches alarming proportions in the institutionalized population. The implementation of efficient preventive measures, particularly among the exposed populations, is necessary.

[The treatment of Paget's disease of bone with second-generation bisphosphonates via intravenous infusion]. / Tratamiento de la enfermedad ósea de Paget con bifosfonatos de segunda generación en infusión intravenosa.

We compared the biochemical effects and safety of pamidronate (30 mg a day for 3 consecutive days) versus clodronate (300 mg a day for 3 consecutive days) via intravenous infusion in 14 patients with Paget's disease of bone (PDB). Both drugs induced a decrease in serum alkaline phosphatase levels as well as the elimination of hydroxyproline from urine, an effect most marked in the group treated with pamidronate. The response was maintained for 6 months after the infusion in the majority of the patients. No relevant side effects were found, except post-infusion febricula and in one patient, self-limiting thrombopenia 6 months after the infusion. We conclude that the intravenous infusion of either of the two drugs may constitute a safe and effective alternative for treatment of PDB with marked biochemical activity or resistant to conventional therapy.

Suprascapular nerve entrapment of occupational etiology: clinical and electrophysiological characteristics.

In this paper we report the clinical and electrophysiological study of a patient with suprascapular nerve entrapment. The patient was initially diagnosed as having shoulder pain due to tendinitis, since his job involved continuous loading of the affected shoulder with heavy weights. Later, clinical exploration revealed wasting of the supra and infraspinatus muscles. Electrophysiological study confirmed the diagnosis of a neuropathy of the suprascapular nerve at the level of the coracoid notch, which improved with conservative treatment. This case report stresses the importance of suprascapular nerve entrapment as a causal factor for shoulder pain; it has an occupational origin which should be taken into account in the differential diagnosis of shoulder pain syndromes.

Goodpasture's syndrome in a patient receiving penicillamine and carbimazole.

A 51-year-old woman with advanced rheumatoid arthritis developed a Goodpasture's syndrome during treatment with penicillamine and carbimazole. Circulating antiglomerular basement membrane antibodies (anti-GBM) were present. Renal biopsy showed focal necrotizing glomerulonephritis with crescents, and HLA typing showed the presence of DR3 and DR4. The patient responded dramatically to pulse methylprednisolone and cyclophosphamide, with both clinical remission and disappearance of anti-GBM antibodies.