Osteoporosis and Fragility Fractures in Patients with Liver Cirrhosis: Usefulness of FRAX® as a Screening Tool.

PURPOSE: The purpose of this study is to assess the prevalence of osteoporosis and fragility fractures in patients with liver cirrhosis (LC) and determine the associated risk factors, evaluating the usefulness of FRAX® as a screening method to identify patients at a higher risk of fracture. METHODS: This was a cross-sectional study. Demographic, clinical, and analytical data were collected in a randomized sample of LC patients attending the Hepatology Department of a university hospital. We assessed the absolute risk of fracture at 10 years (FRAX®) and based on the bone mineral density (BMD), the presence of morphometric vertebral fracture with a vertebral fracture assessment (VFA), or a thoracic and lumbar X-ray and bone microarchitecture with a trabecular bone score (TBS). RESULTS: Ninety-two patients were included (71% male); the mean age was 63 ± 11.3 years. The main etiology of LC was alcoholism (52.2%), and most patients were Child-Pugh A (80.4%), with a mean model for end-stage liver disease (MELD) score of 10.1 ± 3.6. Sixteen patients (17.4%) had osteoporosis, and fifty-four (58.7%) had osteopenia. Eight patients (8.7%) had suffered at least one fragility fracture. The absolute risk of a major fracture according to FRAX without the BMD was 5.7 ± 4.5%. Risk factors associated with osteoporosis were age and the female sex. BMI > 30 was a protective factor. A FRAX cut-off point for a major fracture > 6.6% had a sensitivity of 69% and a specificity of 85% for a diagnosis of osteoporosis. CONCLUSIONS: The prevalence of osteoporosis and fractures in patients with LC is high, particularly in older women. FRAX® may be a useful method to identify candidates for bone densitometry. A FRAX value below 6.6% without the BMD can avoid unnecessary testing.

Interobserver reliability of Masei index validation by a multicenter collaborative group of rheumatologists.

MASEI is the main validated ultrasound score for the evaluation of enthesis. The lack of studies facing the agreement to achieve for the interpretation of the MAdrid Sonographic Enthesis Index (MASEI) among researchers from different centers in multicenter studies is of concern. The aim of this multicenter was to evaluate the interobserver reliability of MASEI. An experienced ultrasonographer-rheumatologist performed ultrasound scans of the areas included in MASEI index in three patients with Ankylosing Spondylitis and Psoriatic Arthritis. Videos were captured. The videos were then evaluated by 24 rheumatologists of the ultrasound working group of the Catalan Society of Rheumatology (EcoCAT). A face-to-face training meeting was held. Ten days after the workshop, the study participants evaluated the videos. A reliability assessment was performed. The ICC for the MASEI scores after the workshop was of 0.97 (95% CI 89-99). Reliability did not vary statistically with examiner experience. Globally, no problems of reliability by structures were seen, and all the ICCs were above 0.90 and improved slightly after the educational program. However, the correlation observed between examiners at plantar aponeursis and triceps tendon was weak. The small variability observed in the results of the index validation in our study, suggests that the MASEI index is reproducible by different observers when those are well trained and show awesome results of the enthesis when examined by ultrasound.

Respuesta a la Editorial «Vitamina D: el traje nuevo del Rey Sol» / Response to the Editorial «Vitamin D: The new suit of the Sun King»

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Recomendaciones de la Sociedad Española de Reumatología sobre osteoporosis / Recommendations by the Spanish Society of Rheumatology on Osteoporosis

Objetivo: Actualizar las recomendaciones sobre osteoporosis (OP) de la Sociedad Española de Reumatología (SER) basadas en la mejor evidencia posible. Métodos: Se creó un panel formado por nueve reumatólogos expertos en OP previamente seleccionados por la SER mediante una convocatoria abierta. Las fases del trabajo fueron: identificación de las áreas claves para la actualización del consenso anterior, análisis y síntesis de la evidencia científica (utilizando los niveles de evidencia del SIGN) y formulación de recomendaciones a partir de esta evidencia y de técnicas de consenso. Resultados: Esta revisión de las recomendaciones comporta una actualización en la evaluación diagnóstica de la OP y de su tratamiento. Propone unos criterios para considerar alto riesgo de fractura y unas indicaciones para iniciar tratamiento. Las recomendaciones abordan también cuestiones relativas a la seguridad de los tratamientos y al manejo de situaciones especiales como las enfermedades inflamatorias y el tratamiento con glucocorticoides. Conclusiones: Se presenta la actualización de las recomendaciones SER sobre OP

Objective: To update the recommendations on osteoporosis (OP) of the Spanish Society of Rheumatology (SER) based on the best possible evidence. Methods: A panel of nine expert rheumatologists in OP was created, previously selected by the SER through an open call. The phases of the work were: identification of the key areas for updating the previous consensus, analysis and synthesis of the scientific evidence (using the SIGN levels of evidence) and formulation of recommendations based on this evidence and consensus techniques. Results: This revision of the recommendations implies an update in the diagnostic evaluation and treatment of OP. It proposes some criteria to consider the high risk of fracture and some indications to start treatment. The recommendations also address issues related to the safety of treatments and the management of special situations such as inflammatory diseases and treatment with glucocorticoids. Conclusions: We present an update of SER recommendations on OP

Recommendations by the Spanish Society of Rheumatology on Osteoporosis. / Recomendaciones de la Sociedad Española de Reumatología sobre osteoporosis.

OBJECTIVE: To update the recommendations on osteoporosis (OP) of the Spanish Society of Rheumatology (SER) based on the best possible evidence. METHODS: A panel of nine expert rheumatologists in OP was created, previously selected by the SER through an open call. The phases of the work were: identification of the key areas for updating the previous consensus, analysis and synthesis of the scientific evidence (using the SIGN levels of evidence) and formulation of recommendations based on this evidence and consensus techniques. RESULTS: This revision of the recommendations implies an update in the diagnostic evaluation and treatment of OP. It proposes some criteria to consider the high risk of fracture and some indications to start treatment. The recommendations also address issues related to the safety of treatments and the management of special situations such as inflammatory diseases and treatment with glucocorticoids. CONCLUSIONS: We present an update of SER recommendations on OP.

Funciones de la vitamina D: beneficios óseos y extraóseos / No disponible

Además de los beneficios bien conocidos sobre el hueso, especialmente en lo que se refiere a la disminución del riesgo de fractura no vertebral y de fémur, la vitamina D tiene también otros efectos favorables en multitud de órganos. Destacan sus efectos antitumorales, antimicrobianos, inmunomoduladores, antiinflamatorios, así como sus efectos sobre el metabolismo glucídico, el sistema cardiovascular y el músculo. A pesar de que parece clara la asociación de hipovitaminosis D con muchas enfermedades, así como los beneficios de la suplementación, no es fácil establecer una relación causa-efecto. Son necesarios estudios observacionales con mayor número de pacientes y ensayos clínicos aleatorizados bien diseñados, con determinación de los valores basales de vitamina D y una estricta monitorización de estos

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[New data on biphosphonate therapy: are therapeutic holidays advisable?]. / Nuevos datos sobre el tratamiento con bisfosfonatos: ¿son aconsejables unas vacaciones terapéuticas?

Bisphosphonates are potent antiresorptive agents proven to be highly effective in vertebral and non-vertebral fractures. However, the reported complications associated with long-term use have led to questions on indefinite treatment. After administration of alendronate there is a high retention of the drug due to slow skeletal release as a result of bone resorption (half-life of more than 10 years), and it seems logical to propose a cessation of treatment (drug holidays) after prolonged treatment. The largest study published to date that assesses the effects on bone mineral density (BMD) and fractures with maintained or discontinued alendronate treatment is the FLEX (Fracture Intervention Trial Long-term Extension) trial. This study showed that discontinuation of alendronate for up to 5 years, after 5 years of treatment, the anti-resorptive effect is slowly lost, mainly in the lumbar spine (approximately 1.5% in 5 years), as well as a slow and progressive loss of femur BMD (<3% in 5 years), but maintains its vertebral (morphometric) and non-vertebral anti-fracture efficacy. In this context, the American Society for Bone and Mineral Research recommended that continued use of bisphosphonates beyond 5 years should be reevaluated annually, assessing factors such as BMD, particularly in the hip region, fracture history, newly diagnosed underlying conditions or initiation of other medications known to affect skeletal status, and new research findings in a rapidly evolving field. However, the molecular differences between bisphosphonates, provides them different affinity and antiresorptive potency, so we can not extrapolate these recommendations to bisphosphonates other than alendronate.

Nuevos datos sobre el tratamiento con bisfosfonatos: ¿son aconsejables unas vacaciones terapéuticas? / New data on biphosphonate therapy: are therapeutic holidays advisable?

Los bisfosfonatos son antirresortivos potentes que han demostrado una alta eficacia antifractura vertebral y no vertebral. Sin embargo, las complicaciones descritas asociadas a su uso a largo plazo han puesto en alerta y cuestionado un tratamiento indefinido. Después de la administración de alendronato se produce una alta retención esquelética con una lenta liberación a consecuencia de la resorción ósea (vida media terminal de más de 10 años), por lo que parece lógico plantear una interrupción del tratamiento (vacaciones terapéuticas) después de un tratamiento prolongado previo. El estudio más importante publicado hasta la fecha donde se evalúan las consecuencias sobre la densidad mineral ósea (DMO) y las fracturas del tratamiento mantenido o discontinuado con alendronato es el FLEX (Fracture Intervention Trial Long-term Extension). En este estudio después de 5 años de tratamiento con alendronato, retirarlo durante otros 5 supone perder lentamente el efecto antirresortivo, aumentar la DMO en la columna lumbar (aproximadamente 1,5% en 5 años), perder lenta y progresivamente la DMO en el fémur (<3% en 5 años), pero sin embargo supone mantener la eficacia antifractura vertebral (morfométrica) y periférica. A la luz de estos resultados, la American Society for Bone and Mineral Research recomienda que el tratamiento continuado con bisfosfonatos más allá de 5 años debería reevaluarse anualmente, investigando factores como la DMO (sobre todo en cadera), la historia de fractura, la presencia de enfermedades o fármacos osteopenizantes y, muy especialmente, recomienda estar alerta a los nuevos datos de investigación en este campo de tan rápida evolución. Sin embargo, las diferencias moleculares entre los distintos bisfosfonatos, que les confieren una diferente afinidad y potencia antirresortiva, hacen que no podamos extrapolar estas recomendaciones sobre alendronato al resto de los bisfosfonatos (AU)

Bisphosphonates are potent antiresorptive agents proven to be highly effective in vertebral and non-vertebral fractures. However, the reported complications associated with long-term use have led to questions on indefinite treatment. After administration of alendronate there is a high retention of the drug due to slow skeletal release as a result of bone resorption (half-life of more than 10 years), and it seems logical to propose a cessation of treatment (drug holidays) after prolonged treatment. The largest study published to date that assesses the effects on bone mineral density (BMD) and fractures with maintained or discontinued alendronate treatment is the FLEX (Fracture Intervention Trial Long-term Extension) trial. This study showed that discontinuation of alendronate for up to 5 years, after 5 years of treatment, the anti-resorptive effect is slowly lost, mainly in the lumbar spine (approximately 1.5% in 5 years), as well as a slow and progressive loss of femur BMD (<3% in 5 years), but maintains its vertebral (morphometric) and non-vertebral anti-fracture efficacy. In this context, the American Society for Bone and Mineral Research recommended that continued use of bisphosphonates beyond 5 years should be reevaluated annually, assessing factors such as BMD, particularly in the hip region, fracture history, newly diagnosed underlying conditions or initiation of other medications known to affect skeletal status, and new research findings in a rapidly evolving field. However, the molecular differences between bisphosphonates, provides them different affinity and antiresorptive potency, so we can not extrapolate these recommendations to bisphosphonates other than alendronate (AU)

Utilidad de la herramienta FRAX en el tratamiento de la osteoporosis en población femenina española / Usefulness of FRAX tool for the management of osteoporosis in the Spanish female population

Fundamento y objetivo: Las fracturas osteoporóticas conllevan un importante consumo de recursos sanitarios. La densitometría ósea ha sido básica en el manejo de la osteoporosis, pero en la predicción del riesgo absoluto de fractura también son importantes otros factores de riesgo. La Organización Mundial de la Salud (OMS) publicó la herramienta FRAX y la National Osteoporosis Guideline Group (NOGG), más recientemente, los umbrales coste-efectivos para solicitar densitometría. Nuestro objetivo es conocer la capacidad predictiva para detectar osteoporosis del FRAX en nuestra población y conocer cómo se modificarían las derivaciones para densitometría aplicando las guías NOGG. Sujetos y método: Estudio de validación diagnóstica en 1.650 mujeres entre 50 y 90 años, sin tratamiento antirresortivo previo de la cohorte FRIDEX. Se realizó densitometría y cuestionario de factores de riesgo. Se compararon los resultados pre y posdensitometría. Se analizó la curva ROC y el área bajo la curva de FRAX predensitometría para predecir osteoporosis. Se calculó el riesgo FRAX predensitometría aplicando umbrales NOGG para determinar a quién debería habérsele realizado densitometría.Resultados: El área bajo la curva para validez diagnóstica de osteoporosis densitométrica de FRAX predensitometría fue 81,2% para fractura principal y 83,1% para fractura de cadera. Aplicando umbrales NOGG a FRAX predensitometría, se derivarían a densitometría el 25,2% de las realizadas. Si añadimos el 24,2% con fractura previa, llegarían al 49,4% de los casos analizados.Conclusión: FRAX es útil para predecir la presencia de osteoporosis. La utilización de los umbrales de las guías NOGG a la herramienta FRAX reduciría al 50% el número de densitometrías realizadas en nuestra práctica clínica actual (AU)

Background and objective: Osteoporotic fractures involve a significant consumption of health resources. Bone densitometry has been essential in the management of osteoporosis. However, for fracture absolute risk prediction, other important clinical risk factors are also important. WHO published a risk estimation tool (FRAX), and the National Osteoporosis Guideline Group (NOGG) reported thresholds for densitometry assessment based on cost-effectivity criteria. Our goal is to determine the diagnostic predictive validity of FRAX in our population, and to assess how its use (according to NOGG guidelines) would modify the current number of referrals to DXA scan in our health system. Subjects and methods:Diagnostic validation study in a consecutive sample of 1,650 women, 50 to 90 years old, under no treatment with anti-resortives, from the FRIDEX cohort. DXA and a questionnaire regarding risk factors were performed. ROC curve and area under the curve (AUC) were used to assess FRAX's diagnostic validity for femoral neck osteoporosis (FNOP). Risk of fracture was calculated using FRAX pre and postDXA, and women were classified according to their risk, following NOGG recommendations.Results: FRAX's ROC AUC for FNOP was 0.812 for major fracture and 0.832 for hip fracture. Using FRAX according to NOGG would result in performing only 25.2% of the current tests. If we added previous fracture antecedent to the algorithm, 49.4% of the tests performed would be advised.Conclusions: The use of NOGG thresholds applied to FRAX would reduce about 50% the current number of referrals to DXA scan in our population. FRAX has a good diagnostic validity for FNOP (AU)

[Usefulness of FRAX tool for the management of osteoporosis in the Spanish female population]. / Utilidad de la herramienta FRAX en el tratamiento de la osteoporosis en población femenina española.

BACKGROUND AND OBJECTIVE: Osteoporotic fractures involve a significant consumption of health resources. Bone densitometry has been essential in the management of osteoporosis. However, for fracture absolute risk prediction, other important clinical risk factors are also important. WHO published a risk estimation tool (FRAX), and the National Osteoporosis Guideline Group (NOGG) reported thresholds for densitometry assessment based on cost-effectivity criteria. Our goal is to determine the diagnostic predictive validity of FRAX in our population, and to assess how its use (according to NOGG guidelines) would modify the current number of referrals to DXA scan in our health system. SUBJECTS AND METHODS: Diagnostic validation study in a consecutive sample of 1,650 women, 50 to 90 years old, under no treatment with anti-resortives, from the FRIDEX cohort. DXA and a questionnaire regarding risk factors were performed. ROC curve and area under the curve (AUC) were used to assess FRAX's diagnostic validity for femoral neck osteoporosis (FNOP). Risk of fracture was calculated using FRAX pre and postDXA, and women were classified according to their risk, following NOGG recommendations. RESULTS: FRAX's ROC AUC for FNOP was 0.812 for major fracture and 0.832 for hip fracture. Using FRAX according to NOGG would result in performing only 25.2% of the current tests. If we added previous fracture antecedent to the algorithm, 49.4% of the tests performed would be advised. CONCLUSIONS: The use of NOGG thresholds applied to FRAX would reduce about 50% the current number of referrals to DXA scan in our population. FRAX has a good diagnostic validity for FNOP.

Artritis infecciosa por mycobacterium kansasii en un paciente con infección por el virus de la inmunodeficiencia humana / Infectious arthritis by Mycobacterium kansasii in a patient with human immunodeficiency virus

No disponible

Tendinitis por levofloxacino / Tendinitis associated with levofloxacin

No disponible