Developing fracture liaison service framework based on comparative analysis and scoping review.

This research conducts a comparative analysis and scoping review of 105 studies in the field of Fracture Liaison Service (FLS). The resulting two-dimensional framework represents a significant step toward FLS implementation. PURPOSE: The primary goal is to review interventions in real world settings in order to provide the FLS framework that specifies the essential elements of its implementation and offers different perspectives on that. METHOD: This study encompasses two phases: a comparative analysis of existing FLS models, including "Capture the Fracture," "5IQ," and "Ganda," and a scoping review from 2012 to 2022 in PubMed, Web of Science, Scopus, ProQuest, and IEEE databases limited to publications in English. RESULTS: The resulting model of comparative analysis identifies patient identification, investigation, intervention and integration or continuity of care as the four main stages of FLS. Additionally, the elements of quality and information span across all stages. Following comparative analysis, the framework is designed to be used for content analysis of the included studies in the scoping review. The intersection of columns (Who, Where, When, What, How, Quality) with rows (Identification, Investigation, Intervention, and continuity of care) yields a set of questions, answered in tabular form based on the scoping review. CONCLUSION: The framework offers potential benefits in facilitating the adoption of effective approaches for FLS implementation. It is recommended to undertake an in-depth review of each of these components in order to uncover novel and innovative approaches for improving their implementation.

Prediction of subsequent fragility fractures: application of machine learning.

BACKGROUND: Machine learning (ML) has shown exceptional promise in various domains of medical research. However, its application in predicting subsequent fragility fractures is still largely unknown. In this study, we aim to evaluate the predictive power of different ML algorithms in this area and identify key features associated with the risk of subsequent fragility fractures in osteoporotic patients. METHODS: We retrospectively analyzed data from patients presented with fragility fractures at our Fracture Liaison Service, categorizing them into index fragility fracture (n = 905) and subsequent fragility fracture groups (n = 195). We independently trained ML models using 27 features for both male and female cohorts. The algorithms tested include Random Forest, XGBoost, CatBoost, Logistic Regression, LightGBM, AdaBoost, Multi-Layer Perceptron, and Support Vector Machine. Model performance was evaluated through 10-fold cross-validation. RESULTS: The CatBoost model outperformed other models, achieving 87% accuracy and an AUC of 0.951 for females, and 93.4% accuracy with an AUC of 0.990 for males. The most significant predictors for females included age, serum C-reactive protein (CRP), 25(OH)D, creatinine, blood urea nitrogen (BUN), parathyroid hormone (PTH), femoral neck Z-score, menopause age, number of pregnancies, phosphorus, calcium, and body mass index (BMI); for males, the predictors were serum CRP, femoral neck T-score, PTH, hip T-score, BMI, BUN, creatinine, alkaline phosphatase, and spinal Z-score. CONCLUSION: ML models, especially CatBoost, offer a valuable approach for predicting subsequent fragility fractures in osteoporotic patients. These models hold the potential to enhance clinical decision-making by supporting the development of personalized preventative strategies.

Association of serum vitamin D status with serum pro-inflammatory cytokine levels and clinical severity of fibromyalgia patients.

BACKGROUND & AIM: The role of vitamin D deficiency in fibromyalgia (FM) pathogenesis is not clearly understood. In this study, we evaluated the association of serum vitamin D status of FM patients with laboratory indices of inflammation, as well as clinical indices of FM. MATERIALS & METHODS: Ninety-two female FM patients with a mean age of 42.4 ± 7.4 years were included in this cross-sectional study. Serum vitamin D, serum IL-6, and serum IL-8 levels were evaluated using an enzyme-linked immunosorbent assay. Serum vitamin D levels were categorized as deficient (<20 ng/ml), insufficient (20-30 ng/ml), and sufficient (30-100 ng/ml). The clinical severity of the disease was assessed by the fibromyalgia impact questionnaire (FIQ) and widespread pain index (WPI). RESULTS: The mean serum IL-6 level was significantly higher in vitamin D-deficient patients in comparison with vitamin D-sufficient patients (P = 0.039). The mean serum IL-8 level was also significantly higher in vitamin D-deficient patients in comparison with vitamin D-sufficient patients (P < 0.001). A significant positive correlation was found between the serum IL-8 level and FIQ scores (r = 0.389, p = 0.001) and the WPI of the patients (0.401, p < 0.001). Serum IL-6 level was significantly correlated with the WPI of the patients (r = 0.295, p = 0.004), but not with FIQ scores (r = 0.134, p = 0.066). Serum vitamin D status was not associated with either FIQ scores or WPI. CONCLUSION: In FM patients, serum vitamin D deficiency is associated with higher levels of serum pro-inflammatory cytokines, and higher levels of serum pro-inflammatory cytokines are associated with greater FM impact.

How durable are the effects of cognitive-behavioural therapy in controlling fibromyalgia symptoms? A prospective cohort study.

PURPOSE: Cognitive-behavioural therapy (CBT) is widely used for the treatment of fibromyalgia. However, there is no consensus on the durability of its effects on these patients. In this study, we evaluated how durable are the effects of CBT in controlling fibromyalgia symptoms. METHODS: Forty-eight fibromyalgia patients treated with traditional face-to-face CBT were included. CBT was performed in 20 consecutive group sessions. To evaluate the durability of treatment, the effects of CBT on fibromyalgia symptoms were checked at five time-points: before the CBT, immediately after the CBT, 3 months after the CBT, 6 months after the CBT, and 12 months after the CBT. Outcome measures were the Fibromyalgia impact questionnaire (FIQ) and widespread pain index (WPI). RESULTS: The mean FIQ score of the patients was 68.3 ± 18.8 before the CBT and 50.5 ± 14.1 1 week after the CBT (p < 0.001). The mean post-CBT FIQ score did not significantly change three and 6 months after the CBT (p = 0.11 and p = 0.09, respectively) while the positive effects of CBT significantly diminished after 12 months (p < 0.001). The mean WPI was 10.4 ± 3.6 before the CBT and 8.6 ± 3.1 1 week after the end of CBT (p < 0.001). The mean WPI of three and 6 months was not statistically different from that immediately after the CBT (p = 0.18 and p = 0.15, respectively), while after 12 months, it significantly worsened (p < 0.001). CONCLUSION: CBT's beneficial effects for fibromyalgia patients are durable for 6 months. Complementary CBT sessions could be implemented to boost the CBT effect after this period.

Risk of infection in postmenopausal women with rheumatoid arthritis and osteoporosis taking denosumab and bDMARDS.

Background: There is no clear consensus regarding the potential of denosumab for increasing the risk of infection in patients who concurrently receive biologic disease-modifying anti-rheumatic drugs (bDMARDs). In this study, we compared the rate of infection in postmenopausal women with rheumatoid arthritis who received concurrent bDMARDs and denosumab with those who received bDMARDs alone. Methods: In a case-control study, postmenopausal patients with a confirmed diagnosis of rheumatoid arthritis who received concurrent bDMARDs and denosumab for at least one year were identified and included as the case group (n=40). A total of 44 age-matched postmenopausal rheumatoid arthritis women who received bDMARDs alone were included as the control group of the study. Using a chi-squared test, the incidence of bacterial or viral infections was extracted from the patients' profiles and compared between the two study groups. Statistical analyses were performed by SPSS for Windows, version 16 (Chicago, Illinois, USA). A p-value of fewer than 0.05 was regarded as significant. Results: The clinical and demographic characteristics of the patients of the two study groups were not significantly different. In total, four infections were recorded in the present series, two infections in each group. Accordingly, the rate of infection was 4.5% in the bDMARDs alone group and 5% in bDMARDs + denosumab group. This difference was not statistically significant (p=0.655, 95% CI: 0.121-6.742). Three out of four infections were herpes zoster infection. The other one was osteomyelitis of the first metatarsal bone, which occurred in the bDMARDs+denosumab group. None of the infections needed a hospitalization of IV antibiotics. Conclusion: The risk of infection is comparable between postmenopausal osteoporotic women with rheumatoid arthritis who receive bDMARDS alone and those who receive bDMARDS in combination with denosumab.

The Added Value of Trabecular Bone Score in Fracture Risk Assessment of Kidney Transplant Recipients.

INTRODUCTION: Trabecular Bone Score (TBS) is an index of bone microarchitecture independent of Bone Mineral Density (BMD). Recently, TBS data has been used to optimize the predictive value of the Fracture Risk Assessment Tool (FRAX). The aim of this study was to evaluate the clinical value of FRAX adjustment with TBS in kidney transplant recipients. METHODS: Seventy post-transplant Iranian kidney recipients were included in this study. After the evaluation of BMD and TBS, the risk of major osteoporotic fracture (MOF) and hip fracture (HF) was assessed once with and once without TBS adjustment. The proportion of patients who needed a therapeutic intervention was compared before and after TBS adjustment. The association between TBS and BMD data was also evaluated. RESULTS: The mean age of the patients was 54 ± 8.8 years (range: 40 to 77). The mean TBS of the patients was 1.30 ± 0.12. In multivariate analysis, the TBS was significantly associated with the age (P < .05) and dialysis period (P < .05). A strong correlation was found between the spine BMD and TBS data (r = 0.612, P < .001). A significant correlation was found between the MOF and HF of the patients before and after adjustment for TBS. The proportion of patients needed a therapeutic intervention significantly increased from 17.1% to 25.7% after TBS adjustment of FRAX. CONCLUSION: Adjustment of FRAX with TBS will reclassify the treatment decision in a considerable number of kidney transplant recipients. This clinical value warrants the adjustment of FRAX data with TBS in future workouts.

Melatonin in the treatment of fibromyalgia symptoms: A systematic review.

The available pharmacological modalities for the treatment of fibromyalgia (FM) are associated with a variety of adverse effects and limited benefits. In this study, we systematically reviewed the impact of melatonin in the treatment of FM. Interventional studies, either controlled or uncontrolled and randomized or non-randomized, were included. PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library were searched without time limitation. Primary outcome measures were the effect of melatonin on the disease impact, pain, sleep quality, tender point count, fatigue, anxiety, stiffness, and depression in FM patients. Four studies, reporting the effect of melatonin on 98 patients, were eligible to include. All the studies reported the positive effect of melatonin on the FM symptoms. No major adverse event was reported. A significant level of heterogeneity was observed between the studies. Therefore, further high-quality controlled clinical trials are needed to understand the role of melatonin in FM treatment fully.

The effect of cognitive behavioral therapy on the circulating proinflammatory cytokines of fibromyalgia patients: A pilot controlled clinical trial.

OBJECTIVES: There is no consensus over the effect size of cognitive behavioral therapy (CBT) in the treatment of fibromyalgia (FM). This study aims to evaluate the effect of CBT on FM patients, through assessing circulating proinflammatory cytokines. METHODS: A controlled, single-blind, parallel clinical trial was performed with 21 FM patients in each group. Sixteen FM patients in the intervention group (CBT) and 17 FM patients in the control group (waiting-list) completed the study. For the intervention group, traditional face-to-face CBT was performed for groups of 10 and 11 patients in 20 sessions. Fibromyalgia Impact Questionnaire (FIQ), widespread pain index (WPI), circulating IL-6, IL-8, and TNF-α level were evaluated before and after the intervention using enzyme-linked immunosorbent assay. Intention-to-treat analysis was performed as the primary analysis. RESULTS: The average changes of factors examined were as follows: FIQ score -0.61 ±â€¯5.5 in the waiting-list group and 10.2 ±â€¯14.9 in the CBT group (p = 0.012); WPI -0.33 ±â€¯1.1 in the waiting-list group and 2.4 ±â€¯3.1 in the CBT group (p = 0.002); serum IL-6 level -0.05 ±â€¯0.86 pg/ml in the waiting-list group and 1.5 ±â€¯2.4 pg/ml in the CBT group (p = 0.002); serum IL-8 level - 0.55 ±â€¯0.2.5 pg/ml in the waiting-list group and 5 ±â€¯5.9 pg/ml in the CBT group (p = 0.002); serum TNF-α level 0.67 ±â€¯1.8 pg/ml in the waiting-list group and 0.7 ±â€¯1.6 pg/ml in the CBT group (p = 0.89). CONCLUSION: Reductions in proinflammatory cytokines after CBT compared with a waiting-list control group confirm the potential value of these biomarkers as surrogate outcome measures in FM.

Differentiation of Cocaine-Induced Midline Destructive Lesions from ANCA-Associated Vasculitis.

INTRODUCTION: Cocaine-induced midline destructive lesions (CIMDL) are complications of regular nasal cocaine inhalation. CIMDL can mimic systemic diseases with positive anti-neutrophil cytoplasmic antibodies (ANCA), such as granulomatosis with polyangiitis (GPA). CASE REPORT: In this article, we describe the case of a young woman who presented with nasal perforation induced by cocaine, along with positive perinuclear ANCA test (proteinase 3 antigen), misdiagnosed as limited GPA. The patient was treated with immunosuppressive therapy, which partially improved her symptoms. Admittance of cocaine use aided in the diagnosis of CIMDL. This patient was advised to stop cocaine use. Three-month follow-up revealed no further complications. CONCLUSION: Considering the seropositivity of ANCA in both CIMDL and GPA, early diagnosis of CIMDL and its differentiation from GPA is crucial, and clinicians play an important role in this regard. Lack of distinct histologic characteristics of vasculitis or unresponsiveness to standard therapeutic regimens may favor the diagnosis of CIMDL syndrome. It is crucial to recognize that these conditions may have similar presentations, so that undesired and potentially toxic treatments can be prevented.

Effects of vitamin D optimization on quality of life of patients with fibromyalgia: A randomized controlled trial.

Background: Numerous studies have been conducted to evaluate the frequency of hypovitaminosis D in patients with fibromyalgia syndrome (FMS) and its association with FMS symptoms. This study aimed at assessing the effect of hypovitaminosis D on the symptoms and quality of life of patients with fibromyalgia. Methods: A total of 74 FMS patients with hypovitaminosis D were randomly assigned into group A (Trazodone 25 mg at bedtime + vitamin D 50 000 IU weekly) and group B (Trazodone 25 mg at bedtime + placebo). Serum vitamin D level, Widespread Pain Index (WPI), Fibromyalgia Impact Questionnaire (FIQ), Pittsburgh Sleep Quality Index (PSQI), and Short Form Health Survey (SF-36) were used at the beginning of the treatment and 4 and 8 weeks post treatment. Results: Significant improvements were observed in WPI, FIQ, and PSQI scores in both groups. Moreover, combination of vitamin D and Trazodone resulted in significant improvement of SF-36 scores compared to Trazodone therapy. Improvement in pain-related indices including the WPI and the physical component score (PCS) fraction of SF-36 was more noticeable in vitamin D/Trazodone combination therapy. Conclusion: This study suggests that vitamin D supplementation has significant therapeutic benefits in the management of FMS, especially in pain reduction of patients with fibromyalgia. According to our results, a combination of vitamin D supplements and a conventional antidepressant, when given to vitamin D-deficient fibromyalgia patients, could significantly improve both physical and psychological symptoms.

A study of the value of trabecular bone score in fracture risk assessment of postmenopausal women.

OBJECTIVE: Trabecular Bone Score (TBS) is an index of bone microarchitecture that provides additional skeletal information to areal Bone Mineral Density (aBMD). Recently TBS data has been used to optimize the Fracture Risk Assessment Tool (FRAX) predictive value. The aim of this study was to evaluate the clinical value of TBS on FRAX algorithm. MATERIALS AND METHODS: Among total of 358 postmenopausal Iranian women (mean age 61.3 ± 9.5 years) tested for aBMD and TBS, 184 osteopenic women were identified. Thoracolumbar spine X-ray done in all participants revealed twenty-one vertebral fractures. For the osteopenic group, FRAX and TBS adjusted FRAX (FRAX-TBS) were calculated and compared. RESULTS: Mean TBS of the patients was 1.31 (±0.11). A significant correlation was found between TBS and spine aBMD (r = 0.50, p < 0.001) and TBS and femoral neck aBMD (r = 0.37, p < 0.0001). A strong positive correlation was observed between aBMD adjusted FRAX and FRAX-TBS in predicting the risk of major osteoporotic fracture (r = 0.90, p < 0.0001), and hip fracture (r = 0.97, p < 0.0001). According to the area under the receiver operating characteristics curve, the predictive value of the three different models using aBMD, TBS, and combination of aBMD and TBS were similar (0.765, 0.776, and 0.781, respectively; p = 0.19). The proportion of the women needed treatment remained unchanged using FRAX or FRAX-TBS. CONCLUSION: This study showed no clinical benefit for TBS in postmenopausal women. Adding TBS data to aBMD or FRAX neither improved aBMD predictive value for vertebral fracture nor changed the decision on treatment based on FRAX.

Undesired effect of excessive betamethasone administration during pregnancy: A rare case.

BACKGROUND: Postpartum bilateral femoral neck fracture (BFNF) is a rare condition. We here report a case of BFNF due to excessive corticosteroid consumption, twin pregnancy, immobility, and vitamin D deficiency. CASE: This is a report of a 32-yr-old woman with bilateral femoral insufficiency fracture five days after emergency cesarean section due to preterm labor, twin pregnancy, and the history of a previous cesarean section at 33 wk. Antenatal repeated courses of betamethasone injections for fetal lung maturity, daily oral use of prednisolone for the history of miscarriage, immobilization, and vitamin D deficiency were the important contributing factors in her past medical history and lab investigations. The bone mineral density examination showed low bone density for the expected age. CONCLUSION: Clinicians, who deal with pregnant women, should consider the diagnosis of bilateral femoral insufficiency fracture in any pregnant women with pelvic pain. Awareness of risk factors of BFNF might help to reduce the rate of this complication.

Seropositivity of Rheumatoid Arthritis Specific Tests in a Patient With Nephrotic Syndrome: Successful Treatment With Rituximab.

Presentation of rheumatoid arthritis (RA) with renal complications is very rare without articular symptoms. We here report a case of a 23-year-old woman, presenting with the edema of the extremities, no relevant previous medical history, and the features of acute tubular injury in her percutaneous kidney biopsy. Following the incidental notification of a positive rheumatoid factor test, other immunologic tests including anticyclic citrullinated peptide and antimutated citrullinated vimentin were performed, the positive results of which favored the diagnosis of RA. Administration of rituximab led to the complete remission of the disease. Six weeks later, along with steroid dose reduction, the symptoms of arthralgia was observed, which was managed with methotrexate. Nephrotic syndrome could be rarely the first manifestation of RA, and screening of specific RA autoantibodies might be considered as part of diagnostic evaluations in nephrotic syndrome workup.

Adalimumab-Responsive Refractory Sarcoidosis Following Multiple Eyebrow Tattoos: A Case Report.

Sarcoidosis is a granulomatous disease that can involve multiple organs including the lungs, eyes, nerves, and skin. Cosmetic tattooing can be a predisposing factor for sarcoidosis, and its incidence is likely to increase along with its popularity. A 47-year-old woman with symptoms of fever and polyarthritis along with erythema nodosum lesions on the legs, swollen eyebrows, and a history of multiple eyebrow tattooing was referred to our center. Since the signs and symptoms were positive for Löfgren's syndrome triad including erythema nodosum, bilateral hilar lymphadenopathy, and polyarthritis, a diagnosis of acute sarcoidosis was made, and treatment was started accordingly. The patient was unresponsive to routine therapeutic agents used for sarcoidosis; however, she successfully responded to adalimumab. Our case indicates that systemic sarcoidosis could develop as a reaction to cosmetic tattooing, which might be refractory to conventional therapeutic agents including corticosteroids and non-biologic disease-modifying anti-rheumatic drugs, while tumor necrosis factor antagonists such as adalimumab, could lead to disease remission.

The Effect of Quercetin on Inflammatory Factors and Clinical Symptoms in Women with Rheumatoid Arthritis: A Double-Blind, Randomized Controlled Trial.

OBJECTIVE: Previous studies have shown that the bioflavonoid quercetin has anti-inflammatory and anti-nociceptive effects. We investigated the effect of quercetin supplementation on inflammation, disease severity, and clinical symptoms in women with rheumatoid arthritis (RA). METHODS: The present study was a randomized, double-blind, placebo-controlled clinical trial in which 50 women with RA were allocated into a quercetin (500 mg/day) or placebo group for 8 weeks. Plasma levels of high-sensitivity tumor necrosis factor-α (hs-TNFα), erythrocyte sedimentation rate (ESR), clinical symptoms including early morning stiffness (EMS), morning and after-activity pain, and tender (TSC) and swollen joint counts (SJC) were determined. Disease activity and functional disability were assessed by Disease Activity Score 28 (DAS-28), physician global assessment (PGA), and a health assessment questionnaire (HAQ) at the beginning and end of the study. RESULTS: Quercetin supplementation for 8 weeks significantly reduced EMS, morning pain, and after-activity pain (p < 0.05). DAS-28 and HAQ scores decreased in the quercetin group compared to placebo and the number of patients with active disease significantly decreased in the quercetin group. Plasma hs-TNFα level was significantly reduced in the quercetin group compared to placebo (p < 0.05). There were no significant differences in TJC and SJC between groups but TJC significantly decreased in the quercetin group after the intervention. Supplementation had an effect on ESR but it was not significant (p > 0.05). CONCLUSIONS: Five hundred milligrams per day quercetin supplementation for 8 weeks resulted in significant improvements in clinical symptoms, disease activity, hs-TNFα, and HAQ in women with RA.

Posterior reversible encephalopathy syndrome in a patient with mixed connective tissue disease: a case report.

BACKGROUND: Posterior reversible encephalopathy is a syndrome highly associated with hypertension and cytotoxic therapy. The syndrome typically presents with headache, visual abnormality, seizures and characteristic vasogenic edema on magnetic resonance imaging. The entity warrants a prompt diagnosis to avoid deteriorating consequences. CASE PRESENTATION: In this report, we describe a 15-year-old Iranian boy who was diagnosed with mixed connective tissue disease, and cyclophosphamide pulse therapy was administered. Three days after the second pulse of cyclophosphamide, when he was receiving prednisolone and hydroxycholoroquine, our patient developed generalized tonic-clonic seizures. Magnetic resonance imaging findings showed high signal intensities in the posterior areas of his brain. After 8 days, the brain magnetic resonance imaging abnormalities were resolved following the control of his blood pressure and antiepileptic treatment. These observations have been indicative of posterior reversible encephalopathy syndrome. Nevertheless, our patient developed uncontrollable respiratory distress and eventually died. CONCLUSIONS: To the best of our knowledge, this case is the first report of posterior reversible encephalopathy syndrome in a patient with mixed connective tissue disease. As the patient developed posterior reversible encephalopathy syndrome 3 days after cyclophosphamide pulse therapy to reduce the disease activity, it is hard to accurately determine whether posterior reversible encephalopathy syndrome in this case is a complication of cyclophosphamide or a condition that resulted from the mixed connective tissue disease flare-up.

Hypovitaminosis d: are medical students at risk?

BACKGROUND: Vitamin D deficiency is a pandemic problem mostly diagnosed in elderly. Few studies are available exclusively done on the topic among young adults. Specific professions such as medical students may have higher risk for developing hypovitaminosis D. We aimed to assess the vitamin D status in medical students of Iran University of Medical Sciences; and to define a cut-off point for 25-hydroxyvitamin-D (25(OH)D) level based on secondary hyperparathyroidism. METHODS: This was a cross-sectional study on 100 medical students conducted during October 2012. Serum 25(OH)D, intact parathyroid hormone (iPTH), and calcium were measured. Age, sex, body mass index, daily dietary fish and egg consumption, sun exposure, and sunscreen usage were recorded. The association between serum 25(OH)D and iPTH was assessed. Receiver operating characteristics curve analysis was performed. RESULTS: 25-hydroxyvitamin-D level was <30 ng/ml in 99% of all participants, and <20 ng/ml in 77%. Mean serum 25(OH)D level was 16.8 ± 4.7 ng/ml. iPTH level in the group with 25(OH)D level of <10 ng/ml was significantly higher than in those with serum 25(OH)D level of 10 to <20 ng/ml and 20 to <30 ng/ml (109 ± 47 pg/ml, 47 ± 27 pg/ml and 46 ± 19 pg/ml, respectively; P = 0.0001). There was a significant linear inverse correlation between serum iPTH and 25(OH)D (r = -0.36, P = 0.0001). 25(OH)D level of 15.4 ng/ml was determined as the optimal cut-off point in detecting possible secondary hyperparathyroidism. CONCLUSIONS: To improve the community vitamin D status, in addition to population-based food fortification programs, educational programs seem essential; not only for general population, but also for the more educated groups.

The effect of quercetin on plasma oxidative status, C-reactive protein and blood pressure in women with rheumatoid arthritis.

BACKGROUND: Considering the increased production of free radicals and inflammatory factors in rheumatoid arthritis (RA) and the effects of bioflavonoid quercetin on reducing oxidative stress, inflammation and blood pressure, the present study examined the effects of bioflavonoid quercetin on total antioxidant capacity (TAC) of plasma, lipid peroxidation and blood pressure in women with RA. METHODS: The current study was a randomized double-blind clinical trial in which 51 women with RA aged 19-70 years, were participated. Patients were assigned into quercetin (500 mg/day) or placebo groups for 8 weeks. Dietary intake was recorded using 24-h dietary recall questionnaire and the physical activity was assessed through an international short questionnaire of physical activity at the beginning and end of the study. Plasma TAC and malondialdehyde (MDA) using colorimetric method, oxidized low density lipoprotein (ox-LDL) and high sensitivity C-reactive protein (hs-CRP) using enzyme-linked immunosorbent assay method and also blood pressure were measured at the beginning and end of intervention. RESULTS: After 8 weeks there were no significant differences in TAC of plasma, ox-LDL, MDA, hs-CRP, systolic and diastolic blood pressure between quercetin and placebo groups and in each group comparing before and after. CONCLUSIONS: In this study, quercetin had no effect on oxidative and inflammatory status of plasma and blood pressure in patients with RA. Further studies are needed to ensure the effect of quercetin on oxidative stress and inflammation in human.

Longstanding hypoparathyroidism in a fifty-two-year-old woman misdiagnosed as spondyloarthropathy.

INTRODUCTION: Hypoparathyroidism might cause various musculoskeletal findings, resembling Spondyloarthropathies. CASE PRESENTATION: We described a 52-year-old woman, diagnosed as a case of undifferentiated spondyloarthropathy for ten years, who was unresponsive to classic anti-inflammatory therapies. She developed anterior ischemic optic neuropathy and had elevated muscle enzymes during the course of disease. On a routine checkup, marked hypocalcemia and suppressed parathyroid hormone levels were found. Calcium and calcitriol therapy led to clinical and laboratory improvement. CONCLUSIONS: This case emphasizes the importance of recognizing rheumatic manifestations of hypoparathyroidism to preclude unnecessary treatments. Serum calcium should be included in the diagnostic workup of these patients.