Risk factors associated with osteoporosis and fracture in psoriatic arthritis.

BACKGROUND: Although there are few studies mentioned there may be some relationship between psoriatic arthritis (PsA) and osteoporosis, clinical data in real world still need to be clarified in China. The aim of this study was to assess the areal and volumetric bone mineral density (BMD), frequency of fracture, and risk factors in patients with PsA. METHODS: A total of one hundred PsA patients who visited Peking University First Hospital and one hundred age- and sex-matched healthy controls with DXA data were enrolled in the study. Patients with clinical fractures confirmed by X-ray during follow-up were also recorded. Clinical characteristics of the patients were recorded and compared between the abnormal BMD group and the normal BMD group, as well as between the fracture and non-fracture groups. Risk factors for fracture and low BMD were analyzed. RESULTS: Mean BMD at the total hip and femoral neck was significantly lower in PsA patients than that in healthy controls (0.809 ±â€Š0.193 vs. 0.901 ±â€Š0.152 g/cm2, P  = 0.041; 0.780 ±â€Š0.146 vs. 0.865 ±â€Š0.166 g/cm2, P  = 0.037, respectively). Moreover, lumbar spine BMD was negatively correlated with psoriasis duration, swollen joint count and DAS28-CRP (r = -0.503, -0.580, -0.438; P < 0.05). Total hip BMD and femoral neck BMD were negatively correlated with HAQ (r = -0.521, -0.335; P < 0.05). Fractures occurred in 29 patients during the follow-up period. Logistic regression analysis showed that older age (OR 1.132 [95%CI: 1.026-1.248), P < 0.05], higher HAQ score (OR 1.493, 95%CI: 1.214-1.836, P < 0.01), higher disease activity index for psoriatic arthritis (OR 1.033, 95% CI: 1.002-1.679, P < 0.05) and hip joint involvement (OR 6.401, 95% CI: 4.012-44.180, P < 0.05) were risk factors for fracture in the multivariate model. CONCLUSIONS: Increased risks of osteoporosis and fracture were found in PsA patients compared to healthy controls. Besides age, high disease activity and hip joint involvement were risk factors for decreased BMD and fracture.

High remission and low relapse with prolonged intensive DMARD therapy in rheumatoid arthritis (PRINT): A multicenter randomized clinical trial.

OBJECTIVES: To determine whether prolonged intensive disease-modifying antirheumatic drug (DMARD) treatment (PRINT) leads to high remission and low relapse rates in patients with severe rheumatoid arthritis (RA). METHODS: In this multicenter, randomized and parallel treatment trial, 346 patients with active RA (disease activity score (28 joints) [DAS28] (erythrocyte sedimentation rate [ESR]) > 5.1) were enrolled from 9 centers. In phase 1, patients received intensive treatment with methotrexate, leflunomide, and hydroxychloroquine, up to 36 weeks, until remission (DAS28 ≤ 2.6) or a low disease activity (2.6 < DAS28 ≤ 3.2) was achieved. In phase 2, patients achieving remission or low disease activity were followed up with randomization to 1 of 2 step-down protocols: leflunomide plus hydroxychloroquine combination or leflunomide monotherapy. The primary endpoints were good European League Against Rheumatism (EULAR) response (DAS28 (ESR) < 3.2 and a decrease of DAS28 by at least 1.2) during the intensive treatment and the disease state retention rate during step-down maintenance treatment. Predictors of a good EULAR response in the intensive treatment period and disease flare in the maintenance period were sought. RESULTS: A good EULAR response was achieved in 18.7%, 36.9%, and 54.1% of patients at 12, 24, and 36 weeks, respectively. By 36 weeks, 75.4% of patients achieved good and moderate EULAR responses. Compared with those achieving low disease activity and a high health assessment questionnaire (HAQ > 0.5), patients achieving remission (DAS28 ≤ 2.6) and low HAQ (≤ 0.5) had a significantly higher retention rate when tapering the DMARDs treatment (P = 0.046 and P = 0.01, respectively). There was no advantage on tapering to combination rather than monotherapy. CONCLUSIONS: Remission was achieved in a proportion of patients with RA receiving prolonged intensive DMARD therapy. Low disease activity at the start of disease taper leads to less subsequent flares. Leflunomide is a good maintenance treatment as single treatment.

[Risk factors for bone mineral density changes in patients with rheumatoid arthritis and fracture risk assessment].

OBJECTIVE: To verify the fracture risk assessment tool (FRAX) to estimate the probability of osteoporotic fracture in patients with rheumatoid arthritis (RA) with or without bone mineral density (BMD), and identify associated risk factors of osteoporosis. METHODS: In the study, 200 patients with rheumatoid arthritis aged more than 40 years in Peking University First Hospital from Dec. 2009 to Dec. 2012 were recruited. Clinical information was obtained from a questionnaire of their case history and medical records. FRAX tool was administered. Their lumber spine and left femoral BMD were determined by dual energy X ray absorptiometry. The gender, age, disease duration, menopause status, body mass index (BMI) and accumulative dose of glucocorticoid were obtained in retrospect. Correlation analysis was conducted between the BMD and clinical information. RESULTS: The study population (female, 77.5%) had a mean age of 59.4 years, in which 10 (13%) patients showed a normal BMD, 67 (87%) were osteopenia or osteoporosis, while 32 patients (16%) had fragile fracture. Compared with the patients with normal BMD, the subjects with low BMD had significantly older age, longer period for corticoids usage, higher day dose and accumulated dose of corticoids.The 10-year fracture risk of sustaining major osteoporotic fractures and hip fracture was higher. No significant difference was observed between the 10-year fracture risks calculated with BMD and without BMD. The values of the different area under the receiver operating characteristic (ROC) curve (AUC) for major and hip fractures calculated in three ways: without BMD, with the femoral neck BMD, and with T-score. The best result was for FRAX tool for hip fracture with the T-score (AUC 0.899). A stepwise multivariate linear regression model was constructed to explore the relationship between the different clinical factors studied and a low BMD. Three statistically significant variables for lumber BMD were pain on visual assessment scale (VAS) (P=0.02), fracture history (P=0.003) and a higher steroid accumulated dose (P=0.008). Three statistically significant variables for left hip BMD were age (P<0.001), fracture history (P=0.05) and lower BMI (P=0.03). CONCLUSION: Low BMD is a common complication in RA patients. Risk factors for major fracture and hip fracture are increased. There is a positive correlation between FRAX calculated with and without BMD or T score. FRAX with the femoral neck T score or BMD presents a discriminatory capacity better than FRAX without BMD, according to the AUC ROC.

[Relationship between wrist bone mineral density and synovitis, erosion by ultrasonography in female rheumatoid arthritis patients].

OBJECTIVE: To find the correlation of wrist bone mineral density (BMD) to wrist synovitis and erosion, by comparing wrist BMD and ultrasonography. METHODS: A number of 80 female RA patients were examined by BMD measurement of the femoral neck, spine and non-dominant wrist using dual-energy X-ray absorptiometry (DXA). Synovitis of the wrist was examined by ultrasonography. The wrist joint (radiocarpal joint, dorsal midline, and carpoulnar joint) was assessed in the same side of DXA, with transverse and longitudinal scans for USGS synovial hypertrophy and proliferation, tenosynovitis,tendinitis and bone erosion. Colour and power doppler ultrasonography (PDUS) were used to sum the synovitis score. RESULTS: We found: (1) In the study, 80 female RA patients were enrolled, the mean age was 54.6±13.3 (27.0-80.0) years, the disease duration was 48 (12-116) months, and the body Mass Index was 23.0±4.0 (14.8-31.2) kg/m2. The Wrist BMD (g/cm2) in RA significantly reduced, compared with normal controls(0.297±0.121 vs. 0.420±0.180,P<0.01). (2) The Wrist BMD (g/cm2) exceeded in early RA compared with the established RA (0.326±0.103 vs. 0.285±0.132,P<0.01); the positive rate of severe osteoporosis in wrist was lower in early RA compared with the established RA (47.8% vs. 64.9%, P<0.05); the positive rate of bone erosion in wrist by ultrasound was lower in early RA compared with the established RA (39.1% vs. 56.1%, P<0.01). (3) The wrist BMD (g/cm2) in RA with high disease activity reduced compared with moderate and low disease activity (0.267±0.140 vs. 0.280±0.126) and (0.267±0.140 vs. 0.320±0.103) respectively, P<0.05). The percentages of positive ACPA in the high and moderate disease activity groups were significantly higher than those in the remission group (85% vs. 81.8% and 92.6% vs. 81.8%, respectively). DAS28ESR was correlated with wrist BMD (r=-0.288, P<0.01). (4) A significant positive correlation was found between wrist and spine/femur BMD (r=0.634, P<0.01, r=0.795, P<0.01), and a negative correlation between wrist and disease duration and DAS28ESR (r=-0.286, r=-0.301, P<0.01). There was a highly significant positive correlation between wrist BMD and femur BMD (r=0.95, P<0.05). (5) RA patients in wrist osteoporosis group had higher RF positive rate and ACPA rate than wrist osteopenia group (75.5% vs. 55.6%, P<0.05,100% vs. 83.3%, P<0.05). The patients of BMD osteoporosis group had higher DAS28ESR compared with osteopenia group (5.3±1.8 vs. 3.7±1.5, P<0.01). The percentages of synovitis (61.5% vs. 51.7%, P<0.05), tendenitis (14.3% vs. 10.0%, P<0.05) and bone erosion (54.2% vs. 46.2%, P<0.05) in wrist by ultrasonography in osteoporosis group were higher than those of osteopenia group. (6) The wrist BMD in negative bone erosion group by ultrasonography was lower than that in positive bone erosion group [(0.333±0.107) g/cm2 vs. (0.264±0.125) g/cm2, P<0.01], also the PDUS score was higher than positive bone erosion group (4.53±1.40 vs. 2.55±2.66, P<0.01). Compared with negative bone erosion group, the patients in positive bone erosion group had longer disease duration (96.0±104.7) months vs. (66.2±78.0) months, P<0.05), higher percentage of RF (81.0% vs. 53.8%, P<0.01), ACPA (92.7% vs. 79.5%, P<0.05). and higher DAS28ESR (5.4±1.8 vs. 4.2±2.0, P<0.05). The percentage of wrist synovitis in positive bone erosion group was higher (75.6% vs. 30.8%, P<0.01) than that of negative bone erosion group, and moreover, the percentage of severe osteoporosis in the wrist was significantly higher (75.0% vs. 46.4%, P<0.01). (7) A stepwise multivariate linear regression model was constructed to explore the relationship between the different clinical factors studied and a low wrist BMD. Statistically significant variables were age (P=0.001), disease duration (P=0.017), DAS28ESR (P=0.021), and ACPA (P=0.05). CONCLUSION: This study shows a highly significant correlation between hand BMD with disease duration and disease activity, and female RA patients with high titer of ACPA have lower wrist BMD.

[Quantitative ultrasound scans of the calcaneus: a useful tool for screening osteoporosis in patients with connective tissue disease].

OBJECTIVE: To evaluate the ability of calcaneus quantitative ultrasound (QUS) to diagnose osteoporosis in connective tissue disease (CTD) patients. METHODS: In the study, 126 female patients with established CTD underwent dual-energy X-ray absorptiometry (DXA) of the lumber and right hip and QUS of the right heel at the same time. Sensitivity, specificity, as well as positive and negative predictive values were calculated to determine the correlation between cases of osteoporosis detected by the QUS heel scan and by DXA. RESULTS: The mean age of the 126 patients was (43.4 ± 19.8) years (ranging from 30.0 to 80.0 years). Based on their DXA data, 36 (28.6%) patients had normal bone mineral density (BMD, T score ≥ -1.0), 90 (71.4%) patients had abnormal BMD. In abnormal BMD patients, 45 (35.7%) had osteopenia (-2.5 < T score<-1.0), and 42 (33.3%) were osteoporotic (T score ≤ -2.5), while 3 (2.4%) patients had fragile fracture. Broadband ultrasound attenuation (BUA), speed of sound (SOS) and stiffness index (SI) were all significantly different between osteopenia and the normal group when scanning with QUS. QUS T score was positively correlated with DXA T score, both at lumber and right hip respectively (r=0.491, 0.648, P<0.01). After correction by age and BMI, QUS T score remained positively correlated with DXA T score by partial correlation analysis (Pearson partial vertebral r=0.430, P=0.006; right hip r=0.593, P<0.001). The area under the ROC curve for diagnosis of lumber and hip osteoporosis were 0.836 (95%CI: 0.695, 0.977) and 0.647 (95%CI: 0.579, 0.957) separately. The sensitivity and specificity for identifying osteoporosis in lumber were 70% and 83.3% respectively when the T score threshold of QUS was defined as -1.5; however, the sensitivity and the specificity for identifying osteoporosis at right hip were 72.7% and 88.9% when T score threshold of QUS was defined as -1.85. The best SI threshold was defined as 76 for identifying osteoporosis, with sensitivity being 0.800 and specificity 0.741. CONCLUSION: Our study confirmed that QUS measurements performed at calcaneus with quantitative ultrasound bone analysis were capable of screening osteoporosis defined by axial BMD using DXA in female CTD patients.

[Effect of graft-versus-host disease on relapse and survival in 100 patients after allogeneic hematopoietic stem cell transplantation].

The study was aimed to investigate the incidences and risk factors of acute and chronic graft-versus-host diseases (GVHD) and to clarify their effects on relapse and survival of recipients after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The clinical data of 100 cases of allo-HSCT were retrospectively analyzed. The incidences and risk factors of aGVHD and cGVHD, relapse and survival were studied. The results showed that 31 cases developed aGVHD of II - IV grade (34.4%) and 14 cases developed aGVHD of III - IV grade (17.7%). HLA matched or mismatched did not show significant difference in the development of aGVHD of II - IV grade (p > 0.05). Previous occurrence of aGVHD was the risk factor for cGVHD (HR = 2.303, p = 0.088). The female was a favorable factor for cGVHD (HR = 0.401, p = 0.055). The relapse rate was lower in patients who developed cGVHD. The development of aGVHD of II - IV grade was the risk factor for overall survival (p < 0.05). The mortality of patients with aGVHD of III - IV grade and mortality of patients with aGVHD of 0 - I grade were 81.0% and 35.7% respectively, there was very significant difference between them (p = 0.000). In conclusion, till now GVHD and graft-versus-leukemia (GVL) effect can not be separated. The positive effect of GVL could be counteracted by GVHD-related mortality. It is necessary to prevent and control the development of severe aGVHD. The development of local cGVHD may be beneficial to the long-term disease-free survival of patients after allo-HSCT.