Multiple vertebral fractures after suspension of denosumab. A series of 56 cases.

BACKGROUND: Denosumab is a monoclonal antibody approved for the treatment of postmenopausal osteoporosis. The withdrawal of denosumab produces an abrupt loss of bone mineral density and may cause multiple vertebral fractures (MVF). OBJECTIVE: The objective of this study is to study the clinical, biochemical, and densitometric characteristics in a large series of postmenopausal women who suffered MVF after denosumab withdrawal. Likewise, we try to identify those factors related to the presence of a greater number of vertebral fractures (VF). PATIENTS AND METHODS: Fifty-six patients (54 women) who suffered MVF after receiving denosumab at least for three consecutive years and abruptly suspended it. A clinical examination was carried out. Biochemical bone remodelling markers (BBRM) and bone densitometry at the lumbar spine and proximal femur were measured. VF were diagnosed by magnetic resonance imaging MRI, X-ray, or both at dorsal and lumbar spine. RESULTS: Fifty-six patients presented a total of 192 VF. 41 patients (73.2%) had not previously suffered VF. After discontinuation of the drug, a statistically significant increase in the BBRM was observed. In the multivariate analysis, only the time that denosumab was previously received was associated with the presence of a greater number of VF (P = .04). CONCLUSIONS: We present the series with the largest number of patients collected to date. 56 patients accumulated 192 new VF. After the suspension of denosumab and the production of MVF, there was an increase in the serum values of the BBRM. The time of denosumab use was the only parameter associated with a greater number of fractures.

Evaluación de los resultados de la cirugía reconstructiva del esqueleto mitroaórtico en la endocarditis infecciosa activa / Evaluation of the results of surgical reconstruction of the mitroaortic skeleton in active infective endocarditis

Resumen Introducción: La cirugía en la endocarditis infecciosa activa con múltiples abscesos y destrucción del cuerpo fibroso intervalvular, representa un procedimiento de alta exigencia técnica y de difícil manejo postoperatorio. Se presenta la experiencia con una técnica original de resección radical y reconstrucción posterior con pericardio bovino. Material y métodos: En los últimos ocho años en nuestro centro se intervinieron 29 pacientes con endocarditis infecciosa activa y abscesos paravalvulares que destruían la unión mitro-aórtica (20 sobre prótesis y 9 sobre válvula nativa): 13 de ellos llegaron al quirófano en situación de sepsis grave. El EuroScore I medio de la serie fue 36 ±22,7%. Para tratarlos se realizó una resección amplia del tejido infectado y posterior reconstrucción del cuerpo fibroso con pericardio bovino fijado en glutaraldehído, mediante una técnica original. Resultados: La mortalidad hospitalaria de la serie fue del 20,7%. El seguimiento medio fue de 34,2 ± 28 meses con un máximo de 8 años. Dos pacientes requirieron reintervención a causa de fugas periprotésicas aórticas. Se registró una sola recidiva del proceso infeccioso. Dos pacientes fallecieron durante el seguimiento posterior al alta, por causas no cardíacas. Conclusiones: La resección amplia de la unión mitro-aórtica y la posterior reconstrucción con pericardio bovino, en algunos casos puede ser la única opción quirúrgica para salvar la vida de un paciente. Los autores consideran que la técnica presentada es un procedimiento reproducible, con morbilidad y mortalidad aceptables, y con el que se minimizaría el riesgo de recidivas futuras.

Abstract Introduction : Surgical intervention of active infective endocarditis with multiple abscesses and destruction of the intervalvular fibrous body represents a technically demanding procedure with a difficult postoperative management. The experience is presented with an original technique for radical resection and subsequent reconstruction using bovine pericardium. Material and methods: During the last eight years in our centre 29 patients with active infective endocarditis and paravalvular abscesses that destroyed the microaortic union underwent surgery (20 over prosthesis and 9 over native valve): 13 of them reached the operating room with severe sepsis. Average EuroScore I of the series was 36 ± 22.7%. Treatment consisted of a broad resection of infected tissue and subsequent reconstruction of the fibrous body with glutaraldehyde fixed bovine pericardium, by means of an original technique. Results: Hospital mortality of the series was 20.7%. Average follow-up was 34.2 ± 28 months, with a maximum of 8 years. Two patients required a reoperation due to periprosthetic aortic valve leaks. Only one relapse of the infectious process was registered. Two patients passed away during follow-up after discharge, for non-cardiac reasons. Conclusion: Broad resection of the mitroaortic union and subsequent reconstruction with bovine pericardium can in some cases be the only surgical option to save a patient's life. The authors consider that the presented technique is a repeatable procedure, with acceptable morbidity and mortality, that would minimise the risk of future recurrence.