Assessing the risk of rapid radiographic progression in Hungarian rheumatoid arthritis patients.

BACKGROUND: The outcome of rheumatoid arthritis (RA) should be determined early. Rapid radiological progression (RRP) is > or = 5 units increase according to the van der Heijde-Sharp score within a year. The risk of RRP can be estimated by a matrix model using non-radiographic indicators, such as C-reactive protein (CRP), rheumatoid factor (RF) and swollen joint count (SJC). PATIENTS AND METHODS: A non-interventional, cross-sectional, retrospective study was conducted in eleven Hungarian arthritis centres. We assessed RRP risk in biologic-naïve RA patients with the prevalence of high RRP risk as primary endpoint. RRP was calculated according to this matrix model. As a secondary endpoint, we compared RRP in methotrexate (MTX) responders vs non-responders. RESULTS: We analyzed data from 1356 patients. Mean CRP was 17.7 mg/l, RF was 139.3 IU/ml, mean 28-joint disease activity score (DAS28) was 5.00 and mean SJC was 6.56. Altogether 18.2% of patients had high risk (≥40%) of RRP. RA patients with high RRP risk of RRP (n = 247) had significantly lower age compared to those with RRP < 40% (n = 1109). MTX non-response (OR: 16.84), male gender (OR: 1.67), erosions at baseline (OR: 1.50) and ACPA seropositivity (OR: 2.18) were independent predictors of high-risk RRP. Male gender (OR: 5.20), ACPA seropositivity (OR: 4.67) and erosions (OR: 7.98) were independent predictors of high RRP risk in MTX responders. CONCLUSIONS: In this Hungarian study, high RRP risk occurred in 18% of RA patients. These patients differ from others in various parameters. RRP was associated with non-response to MTX.

[Ten-year fracture risk by FRAX(®) of women with osteoporosis attending osteoporosis care in Hungary]. / A szakellátásban megjeleno osteoporosisos nok 10 éves csonttöréskockázata a FRAX(®) alapján.

INTRODUCTION: Identification of patients with high fracture risk is a key-point in osteoporosis care. AIM: To assess the fracture risk among osteoporotic women attending osteoporosis care in Hungary. METHOD: A cross-sectional survey was conducted in 2009 in 11 centres among women with osteoporosis aged ≥50 years. Main risk factors were recorded and 10-year fracture risk was calculated using the FRAX(®) for Hungary. Health status was assessed by EQ VAS. RESULTS: 1301 patients with mean age of 68.5 (SD = 8.3) years and EQ VAS of 62.0 (SD = 17.2) participated, of whom 690 (53.0%) have already had previous fracture. Major osteoporotic and hip fracture FRAX(®) scores were 20.1 (SD = 13.9) and 10.6 (SD = 12.5), respectively (by 10-year age groups, mean: 18.5/9.3; 16.2/6.7; 23/13.5; 28.9/18.3). Patients with previous fracture had significantly higher scores (p<0.05). CONCLUSIONS: Similar rate of patients attend osteoporosis care for primary and secondary prevention. FRAX(®) score was higher than 7% in the majority of patients. The findings provide inputs for cost-effectiveness analyses and development of intervention thresholds in Hungary.

Application of ionomer cement onto the stapedial footplate: impact on the perilymphatic aluminum level.

OBJECTIVES/HYPOTHESIS: From an acoustic aspect, fixation of the medial end of an ossicular replacement prosthesis to the stapedial footplate would be desirable. Technically, ionomer cement seems an ideal material for this purpose. The objective was to determine the aluminum level of the perilymph after the application of ionomer cement on the stapedial footplate. STUDY DESIGN: An experimental study on rabbits. METHODS: A total of 25 Pannon White rabbits were divided into three groups. Five rabbits (group I) underwent sham operation; in 15 animals (group II) ionomer cement was applied onto the stapedial footplate; and in 5 cases (group III) the application of the cement onto the footplate was followed by opening of the vestibulum. In groups of 5, the animals were killed on day 1, 7, 30, 180, or 365 postoperatively. Fluid samples were taken from the vestibulum and their aluminum levels were determined. RESULTS: The average aluminum level in the fluid was insignificantly lower in group II than in group I, but significantly lower in groups I and II than in group III. CONCLUSION: As a glue, ionomer cement safely can be applied directly onto the footplate without the threat of raising the perilymphatic aluminum level, provided that there is no perilymph leakage. However, in the event of an open vestibulum, the application of cement onto the footplate is to be strongly discouraged due to the danger of a consequent increase in the aluminum level in the perilymph and the cerebrospinal fluid. LEVEL OF EVIDENCE: NA.

[Convulsions in neonatal period and infancy with rare etiology (neurogenetic disease)]. / Ujszülött- ves csecsemokori görcsrohamok hatterében alló ritka neurogenetikai betegségek.

Authors summarized the etiology of convulsions in neonatal period and infancy (hypoxia, intracranial hemorrhage, infections of central nervous system, metabolic background, chromosomal abnormalities, brain developmental abnormalities, benign neonatal convulsions, benign neonatal familial convulsions, drug withdrawal, inborn error of metabolism). They suggest screening examinations after convulsion, summarized the basic principle of tandem examination and review a proposal at suspicion of inborn error of enzyme defects (aminoacidemias, defects of fatty acid oxidation, organic acidemias). They present case history of two patients suffered in extraordinary inborn error of enzyme defect (SCO2 gene mutation, propionic acidemia). Diagnosis originated in Helm P61 Hospital (settlement Madarász Hospital) with a Hungarian and international cooperation.

Calcaneous quantitative ultrasound measurements predicts vertebral fractures in idiopathic male osteoporosis.

OBJECTIVES: The aim of this study was to identify the differences in ultrasound bone variables (QUS) and to test the ability to discriminate male patients with and without vertebral fractures. METHODS: We therefore measured broadband ultrasound attenuation (BUA) and speed of sound (SOS) matched for bone mineral density (BMD) and vertebral deformity in idiopathic male osteoporosis. RESULTS: One hundred and seventeen men (age 56.6 range 27-78) were divided into three groups (osteoporosis n=25, osteopenia n=58 and age-matched control n=34) according to BMD T-score by WHO criteria. We found 66 patients (56%) with at least one vertebral deformity during the study. BMD and BUA did not differ, while SOS was lower in osteoporosis (p<0.001) and control group (p<0.001) between the patients with and without vertebral compression. Strong positive correlation was demonstrated between BUA and BMD (lumbar spine r=0.44, p<0.001, femoral neck r=0.56, p<0.001, radius r=0.40, p<0.001), while similar association between SOS and BMD values was not shown. There was no relationship between the BUA and vertebral fracture risk (Odds ratio: 1.14 95% CI: 0.80-1.61). However, the relative risk of vertebral fracture by SOS was 1.56 (95% CI: 1.08-2.62). Adjusting for age and BMI the risk of vertebral fracture did not change (odds ratio for SOS 1.50 95% CI: 1.02-2.22). After adjustment for BMD SOS was still associated with fracture risk at all measured sites (odds ratio: 1.43, 95% CI: 1.02-2.22; 1.41, 95% CI: 1.02-2.17 and 1.32, 95% CI: 1.02-2.0). CONCLUSION: Our results suggest that BUA values are more closely related to density and structure while SOS values are able to predict fractures.

Comparison of the femoral neck bone density, quantitative ultrasound and bone density of the heel between dominant and non-dominant side.

Our study was initiated to evaluate whether there are differences between the two sides, depending on hand dominance, in densitometry values and quantitative ultrasound parameters (QUS) of the lower limb. One hundred and six women and 44 men were involved. The hand dominance was determined by interview. The bone mineral density (BMD) of the left and the right femoral necks and the calcanei were measured by dual-energy X-ray absorptiometry (DXA). The QUS examination consisted of measuring the attenuation (BUA), the speed of the ultrasound (SOS) and quantitative ultrasound index (QUI) transversing the left and right calcanei. The density of the neck of femur of the non-dominant side did not differ from that of the dominant side. On the other hand, BMD, BUA and the QUI of the calcaneus were higher on the non-dominant side in both genders (p<0.05 for each parameter). No similar differences were seen for the SOS values. Our study has confirmed the side-to-side differences of the calcaneus in both genders, lower values were found on the dominant side. No similar differences were seen on the femur. The AUC values seemed to be higher on the dominant side, however, these differences were not strictly significant. In the case of peripheral site (heel) measurements, the practical significance of our observations is that they raise the possibility of performing peripheral DXA and QUS examinations of the calcaneus on the dominant side of the patient according to handedness.

[The role of biologic agents in the therapy of ankylosing spondylitis]. / A biológiai szerek szerepe a spondylitis ankylopoetica gyógykezelésében.

Ankylosing spondylitis is a chronic, inflammatory rheumatic disease which etiology and pathogenesis are not yet fully understood. The inflammation involves the spine and also the peripheral joints might be affected in some cases resulting in a progressive ankylosis, restricted mobility, significant disability, loss of productivity and decreased quality of life. Gene technology based new drugs of the past decade, the biologic agents, offer an alternative opportunity for the treatment of ankylosing spondylitis in comparison with the previous drugs with doubtful efficiency. In Hungary infliximab and etanercept has been registered for ankylosing spondylitis. The aim of this study was to evaluate the efficacy of infliximab and etanercept by the available randomised controlled trials. A systematic search of the literature was performed from 01. 01. 2000 to 08. 31. 2005. and the relevant publications were analysed following the concepts of evidence based medicine. 7 double blind, randomised, placebo controlled trials were identified, three for infliximab (n = 389) and four for etanercept (n = 431). Although the inclusion criteria, the duration of the trials and the primary endpoints were different, the results confirm that both drugs significantly decrease symptoms and disease activity, and this effect is sustained during the therapy, nevertheless half of the patients did not achieve the standardised criteria of 50% decrease in disease activity. Both agents are well tolerated by patients. The outcomes of long-term therapy are reassuring by open extension studies of three years. Guidelines for biologic therapy has been developed in Hungary determining the target patient group, the conditions of the therapy and also an arthritis centre network has been established. Though individual admission is feasible, biologic drugs are not under reimbursement in Hungary. High drug costs makes the implementation of this new therapeutic opportunity difficult in the daily medical practice.

[Effect of cigarette smoking on bone quality parameters in women]. / A dohányzás hatása a nok csontjának minoségi jellemzoire.

INTRODUCTION: Smoking is a risk factor for osteoporosis. In a previous study, the authors showed lower bone density among smokers in a group of postmenopausal women. AIMS: After this finding, the primary goal of current research was to investigate how smoking could influence bone quality. METHODS: Forty-five (age range: 25-72 ys) smoker women were compared with 45 nonsmoker women adjusted for age and anthropometric parameters. Quantitative ultrasound method was used to determine the speed of ultrasound and the ultrasound attenuation transmitting the left heel (Achilles In Sight, GE Lunar). Dual photon absorptiometry method was applied to investigate the bone mineral density of lumbar spine and left femoral neck (Prodigy, GE Lunar) and single photon absorptiometry was used to determine the bone mineral content of radius at the non dominant side (NK-364, Gamma). RESULTS: No difference was found between smokers and non-smokers among the premenopausal group, however, postmenopausal smoker women had slightly lower speed of ultrasound and ultrasound attenuation values than non-smoker women. Postmenopausal smoker women suffering from bone fracture had significantly lower speed of ultrasound than postmenopausal non-smoker women (1508.9 vs. 1525.3 m/s, respectively), despite their bone density did not differ from each other. CONCLUSION: These data augment the knowledge about the injurious effect of smoking. The increased risk for bone fracture among smokers could be explained not only with the decrease of bone mass, which was previously described, but also with a decreased bone elasticity.

Increased bone fracture prevalence in postmenopausal women suffering from pollen-allergy.

INTRODUCTION: Our aim was to investigate whether pollen-allergy can affect bone mass and fractures in postmenopausal women. METHODS: A total of 125 postmenopausal pollen-allergic women (mean age: 61.26 yr) were split into four groups: (1) treated with neither H1 histamine receptor (H1R) antagonist nor inhaled corticosteroid (n=43); (2) treated only with H1R antagonist (n=53); (3) treated with both H1R antagonist and inhaled corticosteroid (n=17); (4) treated with only inhaled corticosteroid (n=12). Treatment, in the appropriate groups, had occurred for at least 5 years, seasonally. One-hundred non-allergic postmenopausal subjects matched for age, body mass index (BMI), and age at menopause served as controls. RESULTS: Overweight and obesity (25 kg/m(2) < or =BMI) were common among the allergic women (76%). Allergic patients without treatment had a slightly lower bone density than their non-allergic counterparts. The rate (34.9%) of prevalent low-energy fractures (distal forearm, hip, and clinical vertebral fractures) in untreated allergic patients was almost triple that observed in non-allergic women (13%, chi(2) p=0.003). Bone fracture occurred more often in H1R-only treated patients (30.19%) than in controls (chi(2) p=0.01); however, clinical vertebral or hip fractures developed neither in those treated only with H1R antagonist nor in those who received both H1R antagonist and inhaled corticosteroid. Bone fractures were more frequent among patients with inhaled steroid treatment than among patients with a combined treatment of inhaled steroid and antihistamine (50 versus 29.4%). BMI predicted prevalent fractures at 1.278 (95% CI: 1.047-1.559, p=0.016) for a 1 kg/m(2) increase among untreated allergic patients. CONCLUSION: In conclusion, we found a high prevalence of low-energy fractures among pollen-allergic postmenopausal women which was associated with obesity. It is possible that the H1R antagonists compensate for both the negative effect of pollen-allergy and the adverse effect of inhaled corticosteroid treatment on bone fracture risk.

[Effects of body mass index on bone mineral density in men]. / Testtömeg hatása a férfiak csonttömegére.

INTRODUCTION: A strong positive association between body mass index and bone mineral density is well defined in postmenopausal osteoporosis, but not in men. AIMS: The primary goal of the current research was to investigate this association in case of men. METHODS: According to WHO criteria (T-score below -1.0 at all measure site) seventy-two (mean age 55.7 +/- 0.99, range 38-78 yr normal density) healthy male with normal density were recruited. Exclusion criteria were the absence of any risk factors or signs of metabolic disease. Bone mineral measurements at the lumbar spine (L2-4) and femoral neck were performed by the dual-energy X-ray absorptiometry (DEXA, Lunar DPX-L, USA), bone mineral content of the non-dominant radius was measured with single photon absorptiometry (SPA, NK-364, Hungary). Participants were divided into three groups according to body mass index normal weight (18.5-24.9 kg/m2), moderate overweight (25-29.9 kg/m2) and obese subjects (> 30 kg/m2). RESULTS: Femur neck density was significantly lower in the normal weight than in the overweight counterparts (0.969 +/- 0.03 vs 1.062 +/- 0.02 p = 0.01). There was a strong positive association between BMI and femur neck BMD (r = 0.412 p < 0.001). Body mass was an independent predictor of femur neck bone mineral density (regression coefficients 0.382, p = 0.001). There was not correlation at the lumbar spine and the radius sites. CONCLUSION: Bone density at femur neck sites is lower in the normal weight men than in obese subjects, therefore the risk factors for proximal femur osteoporosis are higher in these cases. Prevention strategy is needed for men in the lowest quintile of body mass to prevent further decrease in BMD and reduce the risk of hip fracture.

The effect of intranasal salmon calcitonin therapy on bone mineral density in idiopathic male osteoporosis without vertebral fractures--an open label study.

The aim of this study was to examine the effect of intranasal salmon calcitonin therapy on bone mineral density (BMD) in idiopathic male osteoporosis without vertebral fractures. We conducted a randomized, open label, controlled trial in 71 male patients (mean age 59 +/- 6 years) suffering from idiopathic osteoporosis (femoral neck T-score < -2.5) without vertebral deformity. Patients in the control group (n = 31) received 400 IU Vitamin D + 1000 mg elemental calcium daily while the treatment group (n = 40) received 400 IU Vitamin D, 1000 mg elemental calcium plus 200 IU calcitonin nasal spray daily during alternate months. The study period was 18 months. Compared to controls, nasal calcitonin was associated with significant increases in bone mineral density at the lumbar spine (+3.5 +/- (-4.3%) vs. +0.83 +/- 6.4%, P = 0.04) and the femoral neck (+3.2 +/- 3.9% vs. +0.68 +/- 5.7%, P = 0.004). No significant difference was observed at the radius between the treatment groups (+1.4 +/- 8.8% vs. +1.4 +/- 10.9%, P = 0.98). Treatment was well tolerated with no premature discontinuations or significant side effects compared to the control group. We conclude that 200 IU salmon calcitonin nasal spray used daily, intermittently proved to be an effective and safe therapy in male idiopathic osteoporosis.

[Vertebral deformities and the underlying diseases]. / A csigolyadeformitások és a hátterükben meghúzódó betegségek.

The purpose of this review was to summarise the causes of vertebral deformity. Osteoporosis as the most frequent disease lies in the background of vertebral deformity which is the most common type of fractures. Vertebrae cannot resist mechanical loadings so they deform and/or break because of their decreased mineral density and changed trebecular microarchitecture. The diagnosis of vertebral deformity presents several problems in the practice. For example, patients with vertebral fractures do not report having symptoms even when present (asymptomatic deformity), moreover plain radiograph does not show high enough sensitivity to diagnose vertebral fractures. The two methods most likely used in clinical research would be the semiquantitative assessment of vertebral deformities, which is based on visual evaluation, and the quantitative approach, which is based on different morphometric criteria. Absorptiometric morphometry and digital technology are developing, though presently they are not widespread. The compression of vertebrae is followed by heavy pain and functional disability (symptomatic deformity), and in these cases plain radiographs show the following pictures: wedge, biconcave and crush deformity, which enable us to make the diagnosis. Its high occurrence, the increased mortality rate, the decreasing quality of life and the prevalence of subsequent fracture make osteoporotic vertebral deformity so significant. The bone strength is determined not only by bone mass and bone microarchitecture, but also by its quality and turnover. From this follows that besides osteoporosis there are several diseases with vertebral deformity and increased fragilibility. The main diseases are: developmental disorders, osteochondrosis, heritable disorders, postural conditions, traumas, inflammatory diseases, storage diseases, other metabolic bone diseases, hematological diseases and spondyloarthropathy.

[The role of adrenal and gonadal hormones in the pathogenesis of autoimmune polyarthritis]. / Az adrenalis és a gonadális hormonok szerepe az autoimmun polyarthritisek patogenezisében.

A growing body of recently published results suggest the role of adrenal androgens in the onset and development of chronic inflammatory process due to autoantigens. Dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulphate (DHEA)--the major androgen products of the adrenal gland--have immunosuppressive effect inhibiting interleukin-6 production and substantially determining acute phase reaction. Decreased serum levels of DHEA and DHEAS has been observed in most of autoimmune diseases. Recent data suggest that adrenal hypoandrogenism comes from disturbed neuroendocrine, regulation due to hypothalamic effect of the inflammatory cytokines. On the other side, decreased adrenal androgen activity negatively influences the anabolic tonus of steroid hormone system while a relative enhancement of catabolic pressure occurs by the glucocorticoids. Moreover, the hypothalamus-hypophysis-gonadal axis can also be involved, resulting shifts in serum levels of prolactin, estrogens and gonadal androgens. All these hormonal changes can be summarised in decreasing the immunosuppressive tonus. This hypothesis connects the endocrine dysregulation with the development of autoimmune disorders. The new results promise not only a basically different theory of chronic inflammation but they will permit using new diagnostic tools as well as inducing substantially new and more effective therapeutic approaches.