[Cost-effectiveness analysis of fracture liaison services in Catalonia]. / Análisis de coste-efectividad de las Unidades de Coordinación de Fracturas en Cataluña.

OBJECTIVE: To assess the cost-effectiveness of Fracture Liaison Service (FLS) compared to the standard of care for secondary prevention of fragility fractures form the perspective of the Catalan Health Service. METHODS: Cost-utility assessment through a Markov model that simulated disease progression of a patients' cohort candidates to initiate antiosteoporotic treatment after a fragility fracture. A time horizon of 10 years and a 6-month duration per cycle was established. Clinical, economics and quality of life parameters were obtained from the literature and derived from four Catalan FLS. The Catalan Health Service perspective was adopted, considering direct health costs expressed in 2022 euros. A 3% discount rate was applied on costs and outcomes. Uncertainty was assessed through multiple sensitivity analyses. RESULTS: Compared to the standard of care, FLS would promote antiosteoporotic initiation and persistence, reducing the incidence and mortality associated with subsequent fragility fractures. This incremental clinical benefit was estimated at 0.055 years and 0.112 quality-adjusted life years (QALYs) per patient. A higher cost (€1,073.79 per patient) was estimated, resulting into an incremental cost-utility ratio of €9,602.72 per QALYs gained. The sensitivity analyses performed were consistent, corroborating the robustness and conservative approach of the base-case. CONCLUSIONS: The introduction of FLS for the secondary prevention of FF would represent a cost-effective strategy from the Catalan Health Service perspective.

Association of orthogeriatric services with long-term mortality in patients with hip fracture.

PURPOSE: To assess the impact of the comprehensive orthogeriatric care model (OGM) on 2-year survival, length of stay (LOS), discharges to nursing homes, and antiosteoporotic treatment (AOT) in patients with hip fracture. METHODS: Retrospective cohort study. Hospitals were classified as OGM if the patient was cared for in a comprehensive orthogeriatric unit. We included data from patients ≥ 65 years old discharged between 2012 and 2013. The main outcome was 12- and 24-month mortality. The variables collected were sex, type of fracture, comorbidities, AOT, LOS, and discharge to nursing homes. Survival analysis was performed with Kaplan-Meier method and comparison with Mantel-Haenszel test. Factors associated with death were determined by logistic regression. RESULTS: First admissions in the 12 (out of 32) hospitals with OGM were 3580 of 9215 (38.8%). Patients in OGM had more comorbidities and discharges to nursing homes, shorter LOS, and less prescription of AOT. Two years after the admission the deceased patients were 3000 (32.6%). The survival was lower in males (p < 0.001), in the older age groups (p < 0.001), and in patients with Charlson > 1 (p < 0.001). Factors associated with increased risk of death at 12 and 24 months (logistic regression) were male gender, age and Charlson > 1, while care in the OGM decreased the risk. OGM benefited more patients > 80 years and those with Charlson < 1. CONCLUSIONS: Patients admitted in OGM have shorter stays, more discharges to nursing homes, lower prescription of AOT, and better 12- and 24-month survival adjusted by sex, age, and comorbidities compared to non-OGM care.

Comparison of total, free and bioavailable 25-OH vitamin D determinations to evaluate its biological activity in healthy adults: the LabOscat study.

Determination of different forms of 25-OHD (total, free and bioavailable) in healthy young women does not offer additional advantages over standard 25-OHDT for evaluating vitamin D deficiency. In these subjects 25-OHDT values <15 ng/ml would be more appropriate for defining this deficiency. INTRODUCTION: Determination of 25-OH vitamin D serum levels (25-OHD) constitutes the method of choice for evaluating vitamin D deficiency. However, vitamin D-binding protein (DBP) may modulate its bioavailability thereby affecting correct evaluation of 25-OHD status. We analysed the impact of the determination of 25-OHD (total, free and bioavailable) on the evaluation its biologic activity (estimated by serum PTH determination) in healthy young women. METHODS: 173 premenopausal women (aged 35-45 yrs.) were included. We analysed serum values of total 25-OHD (25-OHDT), DBP, albumin, PTH and bone formation (PINP,OC) and resorption (NTx,CTx) markers. Free(25-OHDF) and bioavailable (25-OHDB) serum 25-OHD levels were estimated by DBP and albumin determinations and also directly by ELISA (25-OHDF-2). We analysed threshold PTH values for the different forms of 25-OHD and the correlations and differences according to 25-OHDT levels <20 ng/ml. RESULTS: 62% of subjects had 25-OHD values <20 ng/ml and also had significantly lower 25-OHDF and 25-OHDB values, with no significant differences in bone markers and PTH values. The PTH threshold value was similar for all forms of 25-OHD (∼70 pg/ml). Women with PTH values >70 had lower 25-OHDT (15.4 ± 1.4 vs. 18.3 ± 2.7, p < 0.05) and 25OHDB values (1.7 ± 0.2 vs. 2.2 ± 0.09, p < 0.05). The different forms of 25OHD were significantly intercorrelated, with marginal correlations between PTH and 25-OHDT (r = -0.136, p = 0.082). CONCLUSIONS: Determination of different forms of 25-OHD in healthy young women does not offer additional advantages over standard 25-OHDT for evaluating vitamin D deficiency. In these subjects 25-OHDT values <15 ng/ml would be more appropriate for defining this deficiency.

Aumento de los valores de PTH en la mujer con osteoporosis posmenopáusica / Increase of PTH in post-menopausal osteoporosis

Objetivos. Los valores séricos de la hormona paratiroidea (PTH) pueden estar aumentados en las mujeres posmenopáusicas con osteoporosis. Sin embargo, sus causas y repercusión clínica son poco conocidas. El objetivo de este estudio ha sido analizar la prevalencia y los procesos asociados al aumento de PTH en mujeres posmenopáusicas con osteoporosis. Métodos. Se incluyeron mujeres con osteoporosis en las que se determinaron los niveles de PTH, 25-hidroxivitamina D, el filtrado glomerular y la excreción urinaria de calcio. Se evaluó la prevalencia de valores aumentados de PTH y su relación con la deficiencia e insuficiencia de vitamina D, insuficiencia renal, hipercalciuria e ingesta de calcio deficiente, condiciones que pueden aumentar la secreción de PTH. Resultados. Incluimos un total de 204 mujeres con una edad media de 64 años. Observamos valores aumentados de PTH (> 65 pg/ml) en un 35%. Cinco mujeres padecían un hiperparatiroidismo primario. Las mujeres con valores aumentados de PTH eran mayores (67±9 años) que las mujeres con niveles de PTH normales (63±11 años; p=0,03). La elevación de PTH se asoció a una ingesta de calcio deficiente (< 800mg/24h) en el 81% de las mujeres, a una deficiencia e insuficiencia de 25-hidroxivitamina D en el 55 y 86% respectivamente; a insuficiencia renal en el 35% y a hipercalciuria en el 17%. Las frecuencias de dichos procesos fueron similares en las mujeres con valores normales de PTH. Los valores de PTH se relacionaron con la edad (r=0,19; p=0,01), pero no con los valores de 25-hidroxivitamina D o con el FG. Conclusiones. Un tercio de las mujeres posmenopáusicas con osteoporosis presentan valores elevados de PTH. En un 10% se debe a un hiperparatiroidismo primario. La prevalencia de procesos asociados al aumento de PTH (ingesta reducida de calcio, déficit de 25-hidroxivitamina D, insuficiencia renal e hipercalciuria) es similar a la observada en mujeres con valores normales de PTH(AU)

Aims. Increased parathyroid values (PTH) serum values can be observed in postmenopausal women. However, the clinical repercussion and causes of this finding are poorly understood. This study has aimed to analyze the prevalence and conditions associated to the increased serum PTH levels in postmenopausal women with osteoporosis as well as their clinical characteristics. Methods. Post-menopausal women with osteoporosis were included in the study. PTH, 25-hydroxyvitamin D (25OHD), 24-h urinary calcium, glomerular filtration rate (GFR) and calcium intake were evaluated. The prevalence of increased PTH serum values and its relationship with vitamin D deficiency and insufficiency, kidney failure, hypercalciuria and calcium intake deficiency were evaluated, these being conditions that may increase PTH secretion. Results. A total of 204 postmenopausal women with osteoporosis with a mean age of 64 years were included. Increase PTH levels (>65 pg/ml) were observed in 35% and 5 women had primary hyperparathyroidism. Women with increased serum PTH levels were older (67±9 years) were old than those with normal PTH levels (63±11 years) (P=0.03). PTH elevation was associated to calcium intake deficiency (<800mg/d) in 81% of the women, to a vitamin D deficiency and insufficiency in 55% and 86%, respectively, renal insufficiency in 35% and hypercalciuria in 17% of the patients. These values, however, did not differ when compared with patients with normal PTH serum levels. Serum PTH levels were related to age (r=0.19, P=0.01) but not to 25OHD or GFR values. Conclusions. One third of the post-menopausal women with osteoporosis had elevated PTH levels. This was due to primary hyperparathyroidism in 10%. The prevalence of conditions associated to the increase in PTH (reduced calcium intake, 25-hydroxyvitamin D, renal failure and hypercalciuria) is similar to that observed in women with normal PTH values(AU)

[Increase of PTH in post-menopausal osteoporosis]. / Aumento de los valores de PTH en la mujer con osteoporosis posmenopáusica.

AIMS: Increased parathyroid values (PTH) serum values can be observed in postmenopausal women. However, the clinical repercussion and causes of this finding are poorly understood. This study has aimed to analyze the prevalence and conditions associated to the increased serum PTH levels in postmenopausal women with osteoporosis as well as their clinical characteristics. METHODS: Post-menopausal women with osteoporosis were included in the study. PTH, 25-hydroxyvitamin D (25OHD), 24-h urinary calcium, glomerular filtration rate (GFR) and calcium intake were evaluated. The prevalence of increased PTH serum values and its relationship with vitamin D deficiency and insufficiency, kidney failure, hypercalciuria and calcium intake deficiency were evaluated, these being conditions that may increase PTH secretion. RESULTS: A total of 204 postmenopausal women with osteoporosis with a mean age of 64 years were included. Increase PTH levels (>65 pg/ml) were observed in 35% and 5 women had primary hyperparathyroidism. Women with increased serum PTH levels were older (67 ± 9 years) were old than those with normal PTH levels (63 ± 11 years) (P=0.03). PTH elevation was associated to calcium intake deficiency (<800 mg/d) in 81% of the women, to a vitamin D deficiency and insufficiency in 55% and 86%, respectively, renal insufficiency in 35% and hypercalciuria in 17% of the patients. These values, however, did not differ when compared with patients with normal PTH serum levels. Serum PTH levels were related to age (r=0.19, P=0.01) but not to 25OHD or GFR values. CONCLUSIONS: One third of the post-menopausal women with osteoporosis had elevated PTH levels. This was due to primary hyperparathyroidism in 10%. The prevalence of conditions associated to the increase in PTH (reduced calcium intake, 25-hydroxyvitamin D, renal failure and hypercalciuria) is similar to that observed in women with normal PTH values.

Análisis retrospectivo de biopsias de arteria temporal en un hospital comarcal / Retrospetive analysis of temporal artery biopsies in a district hospital

Antecedentes: La arteritis de células gigantes (ACG) o enfermedad de Horton es una vasculitis de arterias de mediano y gran calibre cuyo diagnóstico se basa en la presencia de datos clínicos, analíticos y alteraciones histológicas características. El rendimiento de la biopsia de arteria temporal (BAT) en diferentes series es muy variable. Material y método: Se trata de un trabajo retrospectivo mediante revisión sistemática de historias clínicas de 180 pacientes (185 BAT) biopsiados en nuestro centro entre enero de 1989 y marzo del 2001. Se han recogido las siguientes variables: edad, sexo, servicio de procedencia, síntomas sistémicos, síntomas vasculares, polimialgia reumática (PMR), exploración vascular, velocidad de sedimentación globular (VSG), criterios clínicos del American College of Rheumatology (ACR) para la clasificación de la ACG (CCACR) y resultado de la BAT. Dichas variables se han comparado en dos grupos de pacientes: los que tenían diagnóstico final de ACG (grupo ACG), y los que no tenían diagnóstico de ACG (no ACG).Resultados: Un total de 31 pacientes fueron diagnosticados de enfermedad de Horton, 19 con biopsia positiva. El tamaño medio de las BAT obtenidas fue de 9,5 mm. De las variables analizadas, sólo las manifestaciones dependientes de isquemia del territorio vascular y la alteración de la exploración arterial fueron significativamente más frecuentes en el grupo ACG. De los pacientes con enfermedad de Horton, 30 reunían tres o más CCACR. De los 149 pacientes sin ACG, 70 reunían tres o más CCACR. El valor predictivo positivo de los CCACR fue del 30 por ciento. Discusión: El rendimiento de la BAT en nuestro hospital es bajo. La sintomatología vascular y la alteración de la exploración arterial fueron más frecuentes en el grupo ACG. El valor predictivo positivo de los CCACR fue bajo. Es necesario limitar la indicación de BAT a pacientes con datos clínicos más específicos y mejorar la técnica de BAT en nuestro centro (AU)

Radiological progression in early rheumatoid arthritis after DMARDS: a one-year follow-up study in a clinical setting.

OBJECTIVE: To analyse the frequency and prognostic factors of radiographic progression in a series of Spanish patients with early rheumatoid arthritis (RA) after 1 yr of treatment with disease-modifying anti-rheumatic drugs (DMARDs). METHODS: Sixty patients (47 females, 13 males) with RA with a disease duration shorter than 2 yr [mean (s.d.) duration 9.5+/-6.6 months] were treated with the same therapeutic protocol using gold salts as the first DMARD and methotrexate as a second option, and were followed up for 1 yr. Radiographic progression in the hands and feet (total radiographic Larsen score and the erosion joint count) was used as the outcome variable. Clinical, laboratory, immunogenetic and radiographic data were obtained at study entry. Disease activity and response to therapy were measured at 6 and 12 months. RESULTS: Erosive disease was found in 21.7% of patients at baseline and in 38.3% after 1 yr. Although a substantial reduction in disease activity was observed during the 1 yr follow-up [disease activity score (DAS28) 5.8+/-0.8 at entry and 3.9+/-1.3 at 12 months, P < 0.001], the Larsen score rose from 1.9+/-3.3 to 5.6+/-9.8 after 1 yr. In 26.6% of patients, a raised erosion joint count was observed after 1 yr. Radiographic progression in the total joint radiographic damage (increase in Larsen score of >or=2) was observed in 36.6%. In the multivariate analysis, baseline pain [visual analogue scale (VAS)] and the presence of two copies of the shared epitope were associated with radiographic progression in the erosion joint count. Disease duration before study entry, VAS pain and Larsen score at baseline were significant predictors of radiographic progression in total damage (Larsen score). Baseline radiographic damage had the highest positive predictive value for progression. CONCLUSIONS: Radiographic progression was observed in up to 36.6% of patients with early RA after 1 yr of DMARD therapy in spite of a significant reduction in disease activity. Baseline factors, such as VAS pain, disease duration until DMARD therapy, damage score at baseline and the presence of two copies of the shared epitope, were associated with radiographic progression.

Aetiology and presenting symptoms in male osteoporosis.

In order to analyse the clinical characteristics and the principal causes of osteoporosis in men, 81 osteoporotic males from an out-patient rheumatology department were studied. Bone mass assessment, automated biochemical profile and biochemical markers of bone turnover were performed in all patients, and hormonal measurements were taken when a specific aetiology was not readily apparent. Sixty-three men (78%) had secondary osteoporosis and 18 (22%) primary osteoporosis. Secondary causes of osteoporosis included hypogonadism (12 patients), corticosteroid therapy (10 patients) and alcoholism (10 patients); the remaining patients had various causes of osteoporosis. Eighteen patients had primary osteoporosis, eight of them with associated hypercalciuria. Normocalciuric patients showed lower 25-hydroxyvitamin D and 1-25-hydroxyvitamin D levels than the control group, whereas hypercalciuric patients had lower parathyroid hormone and renal threshold for phosphate excretion. In 69 patients (85%), back pain was the chief complaint. Forty-five of these 69 patients (65%) had chronic back pain and 24 (35%) had subacute episodes. Fifty per cent of the patients with chronic back pain had vertebral fractures. Both patients with and without chronic back pain were found to have a similar number of vertebral fractures. In conclusion, male osteoporosis is frequently associated with major risk factors. Patients with primary osteoporosis may have associated hypercalciuria or decreased vitamin D levels. However, not all the patients for whom back pain was the chief complaint were found to have vertebral fractures.

Vertebral fractures and osteopenia in chronic alcoholic patients.

To assess whether vertebral fractures are associated with osteopenia in chronic alcoholic patients, a transversal study was carried out in 76 chronic alcoholic males and 62 age-matched healthy males. Lumbar bone mineral density (BMD) by dual photon absorptiometry and spinal chest X-ray films were done in all patients. Twenty-seven patients (36%) had vertebral fractures, but only 5 of them had a BMD below the fracture threshold. Twenty-two patients (29%) had osteoporosis by densitometric criteria. There were no significant differences in lumbar BMD between alcoholic patients with and without vertebral fractures (1.11 +/- 0.2 versus 1.13 +/- 0.2, P = ns). Previous trauma was recorded in 24 of the 27 patients with vertebral fractures and in 28 of the 49 patients without vertebral fractures (P < 0.001). Moreover, patients with vertebral fractures had more peripheral fractures than patients without vertebral fractures (81% versus 49%, P = 0.01). Only one patient was aware of a previous episode of traumatic vertebral fracture. In conclusion, chronic alcoholics frequently have traumas and vertebral fractures, the latter despite having a lumbar BMD above the fracture threshold, suggesting a frequent but unrecognized association between both processes. These results suggest that both spine films and BMD measurements should be obtained for diagnosis of osteoporosis in alcoholic patients.

Haemophilus paraphrophilus endocarditis: case report and review.

Endocarditis due to Haemophilus paraphrophilus is an uncommon disease. We report a case of H. paraphrophilus endocarditis with embolic complications in which the causative organism was resistant to beta-lactam antibiotics. Before April 1994, 16 cases of H. paraphrophilus endocarditis had been reported. Infection by this organism usually affects a previously damaged mitral valve. We emphasize the fastidiousness of the organism and the high incidence of embolic complications, which determine the outcome. To our knowledge we describe the first patient with endocarditis due to beta-lactam-resistant H. paraphrophilus.

[Arthropathy associated with infection by parvovirus B19. Description of 4 cases]. / Artropatía asociada a la infección por parvovirus B19. Descripción de cuatro casos.

Four cases of human parvovirus infection in which the main clinical manifestation was a polyarthritis are described. Four females with ages ranging from 30 to 32 years presented with acute symmetrical polyarthralgias involving hands and knees. In addition, evidence of synovitis in the ankles and tenosynovitis of the fingers was found in two and three cases respectively. Half of the patients noticed an erythematous rash in the preceding days. Laboratory studies were normal in all cases. Antinuclear antibodies and rheumatoid factor were not detected in any case. All patients had significant levels of IgG and IgM antibodies to parvovirus B19 at the time of presentation and a rise in IgG and a fall in IgM levels were seen at two months. All cases cleared up within two weeks without treatment.

Clinical evolution of sacral stress fractures: influence of additional pelvic fractures.

OBJECTIVES: To evaluate the clinical evolution of sacral stress fractures in relation to the scintigraphic pattern and the presence of additional pelvic fractures. METHODS: This was a retrospective study of 14 patients with sacral fractures. RESULTS: Six patients had additional pelvic fractures. Four bone scintigraphic patterns were found. The resolution of symptoms was longer in patients with associated pelvic fractures (30 weeks v three weeks). No relation was found between the bone scintigraphic pattern and the time of evolution. CONCLUSION: Associated pelvic fractures delay the resolution of symptoms in patients with sacral fractures, regardless of scintigraphic pattern.