Bone Mass Loss and Sarcopenia in Ecuadorian Patients.

OBJECTIVE: To study the association between osteoporosis and sarcopenia and determine the prevalence of osteosarcopenia in patients who attended a rheumatology center in Ecuador. METHODS: A cross-sectional study was conducted in a population of patients who had a densitometric study. The diagnosis of sarcopenia was determined by the DXA standard gold test, screening, and conventional methods (bioimpedance, anthropometric measurements, SARC-F, muscle function, and gait test). RESULTS: A total of 92 patients were studied. The median age was 66 ± 10, 90% females. Using the criteria of SMI, 65% had sarcopenia of which 9% had only sarcopenia and 56% had osteosarcopenia; 22% had only osteopenia/osteoporosis; and 13% none of these conditions. The prevalence of sarcopenia according to handgrip strength was 60%, gait speed 45%, and SARC-F score 40%. The prevalence of osteosarcopenia according to handgrip strength was 51%, gait speed 34%, and SARC-F score 32%. Osteoporosis was associated with a higher prevalence of sarcopenia using the criteria of SMI since 40% had sarcopenia in the normal DXA group, 64% in the osteopenia group, and 76% in the osteoporosis group (p=0.017). Of the women, 69% had sarcopenia compared to 33% of the men (p=0.034). The BMI was lower in the group with sarcopenia (25.1 ± 4.1 kg/m2) compared to the group without sarcopenia (29.4 ± 4.1 kg/m2, p < 0.001). Patients with osteosarcopenia and sarcopenia had lower BMI, handgrip strength, ASM, SMI, and total-body skeletal muscle mass than those with osteopenia/osteoporosis or normal patients. CONCLUSION: 65% of the studied population had sarcopenia. It is clear that the prevalence of sarcopenia is higher in patients with greater loss of bone mass. Identifying pathways that affect both bone and muscle could facilitate the development of treatments that simultaneously improve osteoporosis and sarcopenia.

Recommendations for the conduct of economic evaluations in osteoporosis: outcomes of an experts' consensus meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the US branch of the International Osteoporosis Foundation.

Economic evaluations are increasingly used to assess the value of health interventions, but variable quality and heterogeneity limit the use of these evaluations by decision-makers. These recommendations provide guidance for the design, conduct, and reporting of economic evaluations in osteoporosis to improve their transparency, comparability, and methodologic standards. INTRODUCTION: This paper aims to provide recommendations for the conduct of economic evaluations in osteoporosis in order to improve their transparency, comparability, and methodologic standards. METHODS: A working group was convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis to make recommendations for the design, conduct, and reporting of economic evaluations in osteoporosis, to define an osteoporosis-specific reference case to serve a minimum standard for all economic analyses in osteoporosis, to discuss methodologic challenges and initiate a call for research. A literature review, a face-to-face meeting in New York City (including 11 experts), and a review/approval by a larger group of experts worldwide (including 23 experts in total) were conducted. RESULTS: Recommendations on the type of economic evaluation, methods for economic evaluation, modeling aspects, base-case analysis and population, excess mortality, fracture costs and disutility, treatment characteristics, and model validation were provided. Recommendations for reporting economic evaluations in osteoporosis were also made and an osteoporosis-specific checklist was designed that includes items to report when performing an economic evaluation in osteoporosis. Further, 12 minimum criteria for economic evaluations in osteoporosis were identified and 12 methodologic challenges and need for further research were discussed. CONCLUSION: While the working group acknowledges challenges and the need for further research, these recommendations are intended to supplement general and national guidelines for economic evaluations, improve transparency, quality, and comparability of economic evaluations in osteoporosis, and maintain methodologic standards to increase their use by decision-makers.

Biologic therapies and bone loss in rheumatoid arthritis.

INTRODUCTION: Rheumatoid arthritis (RA) is a common systemic autoimmune disease of unknown cause, characterized by a chronic, symmetric, and progressive inflammatory polyarthritis. One of the most deleterious effects induced by the chronic inflammation of RA is bone loss. During the last 15 years, the better knowledge of the cytokine network involved in RA allowed the development of potent inhibitors of the inflammatory process classified as biological DMARDs. These new drugs are very effective in the inhibition of inflammation, but there are only few studies regarding their role in bone protection. The principal aim of this review was to show the evidence of the principal biologic therapies and bone loss in RA, focusing on their effects on bone mineral density, bone turnover markers, and fragility fractures. METHODS: Using the PICOST methodology, two coauthors (PC, LM-S) conducted the search using the following MESH terms: rheumatoid arthritis, osteoporosis, clinical trials, TNF- antagonists, infliximab, adalimumab, etanercept, certolizumab, golimumab, IL-6 antagonists, IL-1 antagonists, abatacept, tocilizumab, rituximab, bone mineral density, bone markers, and fractures. The search was conducted electronically and manually from the following databases: Medline and Science Direct. The search period included articles from 2003 to 2015. The selection included only original adult human research written in English. Titles were retrieved and the same two authors independently selected the relevant studies for a full text. The retrieved selected studies were also reviewed completing the search for relevant articles. The first search included 904 titles from which 253 titles were selected. The agreement on the selection among researchers resulted in a Kappa statistic of 0.95 (p < 0.000). Only 248 abstracts evaluated were included in the acronym PICOST. The final selection included only 28 studies, derived from the systematic search. Additionally, a manual search in the bibliography of the selected articles was made and included into the text and into the section of "small molecules of new agents." CONCLUSION: Treatment with biologic drugs is associated with the decrease in bone loss. Studies with anti-TNF blocking agents show preservation or increase in spine and hip BMD and also a better profile of bone markers. Most of these studies were performed with infliximab. Only three epidemiological studies analyzed the effect on fractures after anti-TNF blocking agent's treatment. IL-6 blocking agents also showed improvement in localized bone loss not seen with anti-TNF agents. There are a few studies with rituximab and abatacept. Although several studies reported favorable actions of biologic therapies on bone protection, there are still unmet needs for studies regarding their actions on the risk of bone fractures.

An appendix to the 2012 IOF-ECTS guidelines for the management of glucocorticoid-induced osteoporosis.

The use of glucocorticoids in the treatment of medical disorders can lead to rapid bone loss and increased risk of fragility fracture. Updated clinical guidelines are needed that accommodate recent advances in fracture risk assessment and new pharmacological interventions to reduce fracture risk. This document serves as an appendix to the 2012 IOF-ECTS guidelines for the management of glucocorticoid-induced osteoporosis.

A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis.

UNLABELLED: This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for 3 months or longer. INTRODUCTION: The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010. METHODS AND RESULTS: The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review. CONCLUSIONS: Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.

[Diagnosis and pharmacological and nonpharmacological treatment of fibromyalgia. Compendium of the best evidence]. / Diagnóstico y tratamiento farmacológico y no farmacológico de la fibromialgia. Síntesis de la mejor evidencia.

Chronic generalized musculoskeletal pain is one of the most common reasons for consultation in daily medical practice, and it poses a diagnostic and therapeutic challenge. Fibromyalgia is one of the so-called central sensitization syndromes, mainly characterized by generalized pain in the musculoskeletal system. Fibromyalgia diagnosis is basically clinical, and it should be considered whenever patients complain of generalized pain. Patients with chronic inflammatory diseases may also suffer from fibromyalgia, and this condition may be the reason for the pain they complain of in medical consultations. The aim of this review paper has been to provide our readers with a summary of the best available evidence about this disease based upon an updated review of scientific literature on fibromyalgia aspects, such as its diagnostic criteria, pathophysiology, clinical profile and differential diagnosis, followed by an ample systematic review of its pharmacological and non-pharmacological aspects. This systematic review analyses the multidisciplinary aspects in which sufficient evidence was found in the two strongest types of clinical research design, 1) controlled clinical trials and 2) systematic reviews or meta-analysis. This review was developed by a group of Latin American specialists from several countries, recognized as a group of experts in fibromyalgia study.

Site-dependent bone mineral density response to oral pamidronate and calcium in postmenopausal osteoporosis: a preliminary report.

Radiologically diagnosed postmenopausal osteoporotic patients with at least one nontraumatic vertebral flattening were treated for one year with either oral pamidronate (APD), 300 mg/day plus calcium 1 g/day (n=39) or with calcium alone (n=21). Bone mineral density (BMD) was assessed in lumbar spine, femoral neck, trochanter and Ward's triangle by dual X-ray absorptiometry in order to determine the number of responders at each site. As no densitometric inclusion criteria were stipulated, wide inter- and intra-individual variations in both regional basal BMD and response to therapy were found. However, the APD-treated group showed significant mean BMD increases in spine (+3.1%; p < 0.001) and femoral neck (+3.2%; p < 0.002) versus basal level, whereas the calcium only group failed to exhibit significant differences. The entire 60-strong population was then split into two groups, according to whether individual BMD content was greater or less than the mean basal value for each skeletal site evaluated. For either treatment, subpopulations with lower basal BMD tended to achieve greater bone gain, though statistically significant differences were only disclosed at trochanter (p < 0.004) with APD and at femoral neck (p < 0.002) in the calcium only group. Globally speaking, increases in BMD were observed in 60-80% of patients receiving either treatment - who were thus defined as responders - at each particular skeletal area assessed. However, when only skeletal areas with low basal BMD were considered, the number of responders reached 60-100%. Responsive sites varied among patients: out of 56 cases, 9 (24%) on APD and 6 (32%) on calcium alone responded in all 4 areas evaluated, while a single case on the latter treatment failed to show BMD response at any site. Overall, the mean number of responsive sites was 2.7. Odds ratios were calculated considering treatment modality and high or low basal BMD as parameters, but no significant differences were found in the number of responders. It may be concluded that APD induces moderate lumbar and femoral neck bone mass gain in severe postmenopausal osteoporosis, whereas calcium alone leads to non significant variations, both findings being in agreement with reported data. Therefore, evaluated APD doses enhance mineralization in responsive sites alone, but fail to increase the total number of responders. Interestingly, responsive sites seem to be those relitively spared by the course of the disease.

Adult onset Still's disease: clinical features and course.

Fifteen patients with adult onset Still's disease are described, all diagnosed according to recognized criteria. Mean delay in reaching a firm diagnosis was 16 months. Besides the typical clinical picture, there was a high frequency of pruriginous rash, one instance of overlapping polymyositis and recurrent systemic manifestations in most cases. Chronic polyarticular involvement predominated, with radiological progression particularly in wrist, proximal interphalangeal and hip joints. However, functional prognosis at the end of a mean 4.8-year course was satisfactory, as also the response to treatment mainly with steroid drugs and, on occasion, with remitting agents to alleviate arthritis.

Effect of low doses of deflazacort vs prednisone on bone mineral content in premenopausal rheumatoid arthritis.

Longterm administration of steroid drugs, particularly prednisone, is known to induce osteoporosis, as well as bone growth inhibition and delayed fracture union. Recently deflazacort, an oxazoline prednisone derivative, has been developed to reduce such deleterious effects. We carried out a comparative study in premenopausal patients with rheumatoid arthritis (RA). Sixteen cases whose mean age was 36.5 years and mean disease duration 29 months, all fulfilling ARA criteria, were evaluated in a randomized, double blind trial. Visually identical deflazacort or prednisone capsules were given and patients were instructed to maintain an adequate calcium intake. Laboratory tests focussed on bone mineral density in lumbar spine, femoral neck and Ward's triangle and whole body mineral content. Differences between baseline and 12-month values were processed statistically. Persistent synovitis control proved similar for both drugs and features suggestive of Cushing's syndrome were only found in the prednisone group. The difference in whole body bone mineral content between the deflazacort and prednisone groups just failed to reach statistical significance. In the deflazacort group, the difference between the nonsignificant bone mineral density increase at the femoral neck and the significant decrease in the prednisone group proved statistically significant. Ward's triangle was the most sensitive area to bone mineral density changes in patients receiving prednisone, with a highly significant intergroup difference (p < 0.01). We believe this is the first study on corticosteroid induced osteoporosis, as evaluated by whole body mineral content measurements in premenopausal patients with short term RA, showing that deflazacort is a promising alternative in cases severe enough to require steroid therapy.

Clinical and serologic characteristics of patients with overlap syndrome: is mixed connective tissue disease a distinct clinical entity?

We discuss the clinical and serologic features of 27 patients with overlap syndrome followed prospectively by our group. The findings are similar to those of other reports, but we have drawn attention to the presence of peritendinous nodules in these patients and mentioned some peculiar neurologic manifestations. Rheumatoid arthritis was the most common diagnosis in our patients. The presence of high-titer antibodies against the nuclear ribonucleoprotein fraction of extractable nuclear antigen (nRNP) did not allow the identification of a particular subgroup. However, patients with this antibody tended to fulfill more criteria of more diseases than those without it. The findings lead us to conclude that antibodies to nRNP do not identify a particular subgroup within the overlap syndromes and that mixed connective tissue disease does not appear to be a distinct entity.

Enfermedad de Still en el niño y en el adulto: estudio comparativo de sus características clínicas; serológicas y de histocompatibilidad / Still disease in children and adults: comparative study of its clinical, serological and histocompatibility characteristics

Diecisiete pacientes con enfermedad de Still de comienzo juvenil y 6 pacientes con comienzo en la edad adulta fueron analizados comparativamente con el objeto de determinar la influencia de la edad en la expresión clínica de esta afección. Doce de 17 pacientes juveniles y 3 de 6 adultos eran de sexo masculino. Fiebre héctica, rash cutáneo y poliartritis se observaron en todos los pacientes de ambos grupos. Leucocitosis se observó en 13 de 17 pacientes juveniles (76%) y en 5 de 6 (83%) pacientes adultos. Pericarditis, esplenomegalia, adenomegalias, anemia y anquílosis ósea se observaron con mayor frecuencia, aunque no significativamente, en el grupo de pacientes de comienzo juvenil. El antígeno HLA DR4 se encontró en 6 de 11 (54,5%) pacientes juveniles, frecuencia significativamente aumentada con respecto a la población general. En los adulto 1 de 6 tenían HLA DR4. No existió relación entre pronóstico favorable y presencia del antígeno HLA Bw35. En este trabajo no se encontraron diferencias significativas en las manifestaciones clínicas y serológicas entre pacientes juveniles y adultos con enfermedad de Still

Enfermedad de Still en el niño y en el adulto: estudio comparativo de sus características clínicas; serológicas y de histocompatibilidad / Still disease in children and adults: comparative study of its clinical, serological and histocompatibility characteristics

Diecisiete pacientes con enfermedad de Still de comienzo juvenil y 6 pacientes con comienzo en la edad adulta fueron analizados comparativamente con el objeto de determinar la influencia de la edad en la expresión clínica de esta afección. Doce de 17 pacientes juveniles y 3 de 6 adultos eran de sexo masculino. Fiebre héctica, rash cutáneo y poliartritis se observaron en todos los pacientes de ambos grupos. Leucocitosis se observó en 13 de 17 pacientes juveniles (76%) y en 5 de 6 (83%) pacientes adultos. Pericarditis, esplenomegalia, adenomegalias, anemia y anquílosis ósea se observaron con mayor frecuencia, aunque no significativamente, en el grupo de pacientes de comienzo juvenil. El antígeno HLA DR4 se encontró en 6 de 11 (54,5%) pacientes juveniles, frecuencia significativamente aumentada con respecto a la población general. En los adulto 1 de 6 tenían HLA DR4. No existió relación entre pronóstico favorable y presencia del antígeno HLA Bw35. En este trabajo no se encontraron diferencias significativas en las manifestaciones clínicas y serológicas entre pacientes juveniles y adultos con enfermedad de Still (AU)

Enfermedad mista del tejido conectivo.Un caso con afectacion trigeminal e hipertension pulmonar. / Mixed connective tissue disease. A case with trigeminal hypoesthesia and pulmonary hypertension

Presentamos una paciente de 31 anos de edad portadora de una enfermedad mista del tejido conectivo (EMTC). Como hallazgo significativo por su baja frecuencia en esta nosologia,presentaba hipoetesia trigeminal e hipertension pulmonar. El tratamiento con prednisona produjo mejoria de algunos sintomas y signos:artralgias,debilidad muscular, derrame pericardico y ascitis, asi como parcialmente,de las pruebas funcionales respiratorias, sin modificar la evolucion de las manifestaciones cutaneas, neurologicas y esofagicas