High prevalence of prothrombotic abnormalities in multifocal osteonecrosis: description of a series and review of the literature.

Multifocal or multiple osteonecrosis (ON), defined by the involvement of 3 or more anatomic sites, is unusual, being observed in only 3%-10% of patients diagnosed with ON. We report the clinical characteristics of a cohort of 29 patients with multifocal ON from a single center and evaluate the prevalence of associated prothrombotic abnormalities in 26 of these patients. We conducted a retrospective study of all patients diagnosed with multifocal ON evaluated in our institution during the last 20 years. We recorded clinical manifestations and underlying diagnoses. A wide thrombophilic profile was performed, including antithrombin, protein C, protein S, lupus anticoagulant, anticardiolipin antibodies, activated protein C resistance, factor V Leiden, mutation G-20210-A of the prothrombin gene, and factor VIII. Coagulation test results were compared with those in a healthy control group and a group of patients with history of lower-extremity deep venous thrombosis. The mean age of the patients was 49.2 ± 15 years (range, 28-81 yr). The mean number of ON localizations per patient was 5.2 ± 2.3 (range, 3-11). Hips were the most commonly affected joint (82%), followed by knees (58%), shoulders (37%), and ankles (13%). Most patients had an underlying disease process, and 12 of 25 (48%) patients had coagulation test abnormalities. The most common alterations were high factor VIII levels and antiphospholipid antibody (aPL) positivity in 24% and 20% of cases, respectively. These abnormalities were more prevalent in patients with multifocal ON compared with patients in the control groups. Sixty-one percent of patients had a history of corticosteroid treatment. Patients with coagulation abnormalities had a higher number of ON localizations per patient (6.5 ± 2.7 vs. 3.88 ± 0.8; p = 0.002) and a higher prevalence of atypical ON localizations (25% vs. 0%; p = 0.05). In conclusion, in the present cohort of patients with multifocal ON, 48% of the patients had at least 1 prothrombotic factor, especially high levels of factor VIII and aPL. These findings have major implications for the diagnosis and treatment of multifocal ON and clearly indicate the need to perform a thrombophilic profile in these patients.

Risk factors for the development of vertebral fractures after percutaneous vertebroplasty.

We have recently observed an increased risk for vertebral fractures (VF) in a randomized controlled trial comparing the analgesic effect of vertebroplasty (VP) versus conservative treatment in symptomatic VF. The aim of the present study was to evaluate the risk factors related to the development of VF after VP in these patients. We evaluated risk factors including age, gender, bone mineral density, the number, type, and severity of vertebral deformities at baseline, the number of vertebral bodies treated, the presence and location of disk cement leakage, bone remodeling (determining bone turnover markers) and 25 hydroxyvitamin D [25(OH)D] levels at baseline in all patients. Twenty-nine radiologically new VF were observed in 17 of 57 patients undergoing VP, 72% adjacent to the VP. Patients developing VF after VP showed an increased prevalence of 25(OH)D deficiency (<20 ng/mL) and higher P1NP values. The principal factor related to the development of VF after VP in multivariate analysis was 25(OH)D levels < 20 ng/mL (RR, 15.47; 95% CI, 2.99-79.86, p < 0.0001), whereas age >80 years (RR, 3.20; 95% CI, 1.70-6.03, p = 0.0007) and glucocorticoid therapy (RR, 3.64; 95% CI, 1.61-8.26, p = 0.0055) constituted the principal factors in the overall study population. Increased risk of VF after VP was also associated with cement leakage into the inferior disk (RR, 6.14; 95% CI, 1.65-22.78, p = 0.044) and more than one vertebral body treated during VP (RR, 4.19; 95% CI, 1.03-34.3, p = 0.044). In conclusion, nearly 30% of patients with osteoporotic VF treated with VP had a new VF after the procedure. Age, especially >80 years, the presence of inferior disk cement leakage after the procedure, the number of cemented vertebrae, and low 25(OH)D serum levels were related to the development of new VF in these patients, with the latter indicating the need to correct vitamin D deficiency prior to performing VP.

25 hydroxyvitamin D serum levels influence adequate response to bisphosphonate treatment in postmenopausal osteoporosis.

UNLABELLED: It remains unclear whether vitamin D sufficiency optimizes response to bisphosphonate (BP) treatment in postmenopausal osteoporosis. We evaluated the role and possible mechanisms of vitamin D in adequate response to standard BP treatment for postmenopausal osteoporosis. METHODS: We included 120 postmenopausal osteoporotic women (aged 68 ± 8 years) receiving BP (alendronate or risedronate) at their annual follow-up, performing complete anamnesis, including treatment adherence, use of vitamin D supplements, and previous falls and fractures during the last year. We analyzed the evolution of bone mineral density (BMD) during this period and serum PTH and 25 hydroxyvitamin D (25(OH)D) and urinary NTx levels. Patients were classified as inadequate responders to antiosteoporotic treatment based on BMD loss>2% and/or the presence of fragility fractures during the last year. RESULTS: Thirty percent of patients showed inadequate response to BP treatment, with significantly lower levels of 25(OH)D (22.4 ± 1.3 vs. 26.6 ± 0.3 ng/ml, p=0.01), a higher frequency of 25(OH)D levels<30 ng/ml (91% vs. 69%, p=0.019) and higher urinary NTx values (42.2 ± 3.9 vs. 30.9 ± 2.3 nM/mM, p=0.01). Patients with 25(OH)D>30 ng/ml had a greater significant increase in lumbar BMD than women with values <30 ng/ml (3.6% vs. 0.8%, p<0.05). The probability of inadequate response was 4-fold higher in patients with 25(OH)D<30 (OR, 4.42; 95% CI, 1.22-15.97, p=0.02). CONCLUSIONS: Inadequate response to BP treatment is frequent in postmenopausal women with osteoporosis as is vitamin D insufficiency, despite vitamin D supplementation. Maintenance of 25(OH)D levels >30 ng/ml is especially indicated for adequate response to BP treatment.

Effect of vertebroplasty on pain relief, quality of life, and the incidence of new vertebral fractures: a 12-month randomized follow-up, controlled trial.

Uncertainty regarding the benefits of vertebroplasty (VP) for the treatment of acute osteoporotic vertebral fractures has recently arisen. A prospective, controlled, randomized single-center trial (ClinicalTrials.gov registration number NCT00994032) was designed to compare the effects of VP versus conservative treatment on the quality of life and pain in patients with painful osteoporotic vertebral fractures, new fractures and secondary adverse effects were also analyzed during a 12-month follow-up period. A total of 125 patients were randomly assigned to receive conservative treatment or VP. The primary end point was to compare the evolution of the quality of life (Quality of Life Questionnaire of the European Foundation for Osteoporosis [Qualeffo-41] and pain (Visual Analogue Scale [VAS]) during a 12 month follow-up. Secondary outcomes included comparison of analgesic consumption, clinical complications, and radiological vertebral fractures at the same time points. Both arms showed significant improvement in VAS scores at all time points, with greater improvement (p = 0.035) in the VP group at the 2-month follow-up. Significant improvement in Qualeffo total score was seen in the VP group throughout the study, whereas this was not seen in the conservative treatment arm until the 6-month follow-up. VP treatment was associated with a significantly increased incidence of vertebral fractures (odds ratio [OR], 2 · 78; 95% confidence interval [CI], 1.02-7.62, p = 0.0462). VP and conservative treatment are both associated with significant improvement in pain and quality of life in patients with painful osteoporotic vertebral fractures over a 1-year follow-up period. VP achieved faster pain relief with significant improvement in the pain score at the 2-month follow-up but was associated with a higher incidence in vertebral fractures.

[Intake of calcium, magnesium and sodium through water: health implications]. / Aporte de calcio, magnesio y sodio a través del agua embotellada y de las aguas de consumo público: implicaciones para la salud.

BACKGROUND AND OBJECTIVE: Calcium (Ca(2+)) intake through diet is mainly obtained from dairy products. However, there are other sources of Ca(2+), such as water, which can significantly contribute to its intake. Moreover, water also contains other minerals, such as magnesium (Mg(2+)) and sodium (Na(+)), with potential implications for health. Thus, Mg(2+) has been associated with a reduction of sudden death, whereas Na(+) contributes to the occurrence of hypertension. The rise in the consumption of bottled water in the general population clearly indicates the necessity of knowing the possible effects on health. Indeed, there may be a great variation in the content of these minerals depending on the type of water. METHODS: We obtained the mineral content of Ca(2+), Mg(2+) y Na(+) from tap water of 492 Spanish towns and cities (through data given by autonomous communities, city/town halls or municipal water companies) and from 182 commercially available bottled waters (122 available in Spain, 60 available in Europe). The results were compared with the recommended dietary intake of these minerals. RESULTS: There is a great variation in the mineral content among the different bottled waters and also among tap waters. Thus, among bottled waters in our country the Ca(2+) concentration ranges between 0.5-672 mg/l; 16% of these waters had a concentration > 100 mg/l and only two > 300 mg/l; some European waters showed high concentrations of Ca(2+) (459-575 mg/l); Na+ concentrations ranged between 0.1-2.000 mg/l, and Mg(2+) between 0.1-128. In tap water Ca2+ concentrations ranged between 0-337 mg/l, Na+ between 1-332 mg/l, and Mg(2+) between 0.3-315 mg/l. In 33.4% of the analysed tap waters the Ca(2+) concentration was > 100 mg/l, in 4 of them it was > 200 mg/l. CONCLUSIONS: Water, even bottled water or tap water, has a great variability in the concentrations of Ca(2+), Mg(2+) and Na(+). In some occasions, water may even supply the minimum recommended intake of Ca(2+) and Mg(2+) and can exceed the Na+ content. These data should be considered when selecting one for consumption.

Aporte de calcio, magnesio y sodio a través del agua embotellada y de las aguas de consumo público: implicaciones para la salud / Intake of calcium, magnesium and sodium through water: health implications

FUNDAMENTO Y OBJETIVO: El aporte de calcio (Ca2+) en la dieta se obtiene, en su mayor parte, medianteel consumo de productos lácteos. Sin embargo, existen otras fuentes, como el agua, quepueden contribuir en su ingesta. Además, el agua contiene otros minerales, como el magnesio(Mg2+) y el sodio (Na+), con efectos potenciales para la salud. Así, el aumento de Na+ en la ingestacontribuye al desarrollo de hipertensión, mientras que el aumento del Mg2+ se ha relacionadocon una disminución de muerte súbita. El creciente consumo de agua embotellada en lapoblación española indica la necesidad de conocer sus posibles efectos en la salud, ya quepuede haber una gran variabilidad en las concentraciones de los minerales dependiendo deltipo de agua consumida. El objetivo de este trabajo fue revisar las concentraciones de Ca2+,Mg2+ y Na+ en las aguas de consumo público y en las envasadas comercializadas y compararlascon los objetivos nutricionales de estos minerales.METODOLOGÍA: Se revisan los datos analíticos relativos al Ca2+, Mg2+ y Na+ de las aguas de consumopúblico de 492 poblaciones españolas, de 122 aguas envasadas inscritas en el RegistroSanitario de Alimentos de la Dirección General de Salud Pública y de 60 aguas envasadas europeas.Se comparan los resultados con los objetivos nutricionales de estos minerales.RESULTADOS: Hay una gran variabilidad en las concentraciones de minerales de las diferentesaguas envasadas y en las aguas de consumo público. Así, en las aguas envasadas inscritas ennuestro país, la concentración de Ca2+ oscila entre 0,5 y 672 mg/l, el 16% tenía una concentraciónde Ca2+ > 100 mg/l y dos tenían una concentración > 300 mg/l. Algunas aguas europeastenían concentraciones muy altas de Ca2+ (459-575 mg/l); las concentraciones de Na+ oscilanentre 0,1 y 2.000 mg/l y las de Mg2+, entre 0,1 y 128 mg/l. En las aguas de consumopúblico, las concentraciones de Ca2+ oscilan entre 0 y 337 mg/l; las de Na+, entre 1 y 332mg/l, y las de Mg2+, entre 0,3 y 315 mg/l. El 33,4% de las aguas de consumo público teníanuna concentración de Ca2+ > 100 mg/l, y en 4 fue > 200 mg/l.CONCLUSIONES: El agua, tanto envasada como de consumo público, presenta una gran variabilidaden las concentraciones de Ca2+, Mg2+ y Na+. En ocasiones, el agua incluso puede suministrarlos objetivos nutricionales mínimos de Ca2+ y Mg2+ y exceder los de Na+. Estos datos, dadassus repercusiones en la salud, deberían tenerse en cuenta a la hora de seleccionar el agua parael consumo

BACKGROUND AND OBJECTIVE: Calcium (Ca2+) intake through diet is mainly obtained from dairy products.However, there are other sources of Ca2+, such as water, which can significantly contributeto its intake. Moreover, water also contains other minerals, such as magnesium (Mg2+) andsodium (Na+), with potential implications for health. Thus, Mg2+ has been associated with a reductionof sudden death, whereas Na+ contributes to the occurrence of hypertension. The risein the consumption of bottled water in the general population clearly indicates the necessity ofknowing the possible effects on health. Indeed, there may be a great variation in the content ofthese minerals depending on the type of water.METHODS: We obtained the mineral content of Ca2+, Mg2+ y Na+ from tap water of 492 Spanish townsand cities (through data given by autonomous communities, city/town halls or municipal water companies)and from 182 commercially available bottled waters (122 available in Spain, 60 availablein Europe). The results were compared with the recommended dietary intake of these minerals.RESULTS: There is a great variation in the mineral content among the different bottled watersand also among tap waters. Thus, among bottled waters in our country the Ca2+ concentrationranges between 0.5-672 mg/l; 16% of these waters had a concentration > 100 mg/l and onlytwo > 300 mg/l; some European waters showed high concentrations of Ca2+ (459-575 mg/l);Na+ concentrations ranged between 0.1-2.000 mg/l, and Mg2+ between 0.1-128. In tap waterCa2+ concentrations ranged between 0-337 mg/l, Na+ between 1-332 mg/l, and Mg2+ between0.3-315 mg/l. In 33.4% of the analysed tap waters the Ca2+ concentration was > 100 mg/l, in4 of them it was > 200 mg/l.CONCLUSIONS: Water, even bottled water or tap water, has a great variability in the concentrationsof Ca2+, Mg2+ and Na+. In some occasions, water may even supply the minimum recommendedintake of Ca2+ and Mg2+ and can exceed the Na+ content. These data should be consideredwhen selecting one for consumption