Bone mineral density in patients with type 1 diabetes mellitus.

Although osteopenia is often reported as a complication of type 1 diabetes mellitus, its frequency and severity remain unclear, and studies of bone mineral density in type 1 diabetics have yielded conflicting results. We measured bone mineral density at the lumbar spine and femoral neck in 88 Spanish adults with type 1 diabetes mellitus responsible for moderately severe complications. Mean age (+/- SD) was 28.9 +/- 8.8 years, and mean disease duration was 11.2 +/- 6.4 years. As compared to normal Spanish adults, bone mineral density was decreased in the patients at the lumbar spine (Z-score, -0.32 +/- 1.08; P < 0.001) but not at the femoral neck (Z-score, -0.21 +/- 1.03; P non-significant). The magnitude of bone loss in the diabetics was small (T-score, -0.38 +/- 1.13 at the lumbar spine and -0.37 +/- 1.08 at the femoral neck). Only three patients met WHO criteria for osteoporosis at one or both measurement sites. Patients with retinopathy (n = 37) had lower lumbar spine bone mineral density values than patients without retinopathy; however, this difference was no longer present after adjustment for age and disease duration. Bone mineral density values were similar in patients with (n = 13) and without microalbuminuria. Our findings suggest that bone loss is not a major problem in younger type 1 diabetics with short disease durations and no severe diabetic complications.

[Septic arthritis induced by pyogenic germs in patients without parenteral drug addiction. Analysis of 44 cases]. / Artritis séptica inducida por gérmenes piógenos en pacientes sin adicción a drogas por vía parenteral. Análisis de 44 casos.

BACKGROUND: The aim of this study was to evaluate the clinical-microbiological characteristics presented in the area of influence of the Hospital de Bellvitge-Prínceps d'Espanya, of articular infection induced by pyogenic germs in patients without intravenous drug addiction. METHODS: All the cases of microbiologically confirmed articular infection in patients without intravenous drug addiction diagnosed during the period of 1981-1990 were evaluated by protocol. RESULTS: Five cases (11%) with gonococcal arthritis and 39 cases (89%) of non gonococcal arthritis were observed with Staphylococcus aureus being the causal germ in 27 cases. Sixty percent of the patients presented one or more predisposing factors for the appearance of infectious arthritis. Monoarticular involvement was seen in 84% of the cases. At the time of diagnosis fourteen patients presented radiological signs compatible with septic involvement, with the isotopic study with 99mTc being positive in the 27 cases in which it was carried out. Delay in diagnosis was of 20 +/- 25 days. Functional results were considered as satisfactory in 57% of the cases. CONCLUSION: In the area of influence of the Hospital de Bellvitge-Prínceps d'Espanya, the prevalence of gonococcal arthritis is low. Gram positive germ are the most frequent causal agents in all the age groups studied. Gammagraphy with 99mTc presented high profitability in the diagnosis of articular infections. The functional results observed were not optimal and improvement of the same probably requires a shortening in the time of delay in diagnosis.

[Limitations of joint mobility in patients with type 1 diabetes mellitus]. / Limitación de la movilidad articular en pacientes con diabetes mellitus tipo I.

BACKGROUND: To assess limitation of joint mobility in patients with type I diabetes mellitus and to evaluate its relation with retinopathy, joint mobility was prospectively assessed in 96 diabetic patients and 68 healthy controls. METHODS: Joint mobility was explored with the praying maneuver and the measurement in mobility degrees of the third and fifth metacarpophalangeal joints, wrists and elbows. The degree of metabolic control was assessed with the mean glycosylated hemoglobin in the last two years. Retinopathy was investigated with direct funduscopy. The results were statistically evaluated with chi-square and Student's t tests and the linear coefficient. RESULTS: A reduced joint mobility was found in 41 diabetics and 5 controls (p less than 0.0001). The reduction in joint mobility was related with the patients' age but not with the degree of metabolic control. 85% of diabetics with joint involvement had retinopathy of some degree. CONCLUSIONS: A limited joint mobility is a common complication of type I diabetes mellitus. The demonstration of this abnormality in diabetic patients might represent a first and simple marker of microangiopathy.

[Prevalence of criteria indicating bone densitometry and risk factors for low bone mass and fracture in rheumatology outpatient units]. / Prevalencia de los criterios de indicación de densitometría ósea y de los factores de riesgo de baja masa ósea y fractura en unidades extrahospitalarias de reumatología.

Many organisms have proposed criteria to identify individuals with low bone mass or increased risk for osteoporotic fracture in order to provide them with the available diagnostic and therapeutic resources. Among these organisms are the WHO, the Catalan Agency for Health Technology Assessment (CAHTA) and the International Committee for Osteoporosis Clinical Guidelines (ICOCG). We designed a prospective multicenter study to determine the prevalence of indications for bone densitometry in rheumatology outpatient clinics by applying the criteria of these three organisms. Two hundred sixty-two women and 98 men aged 18 years or older who attended five rheumatology outpatient clinics were interviewed and their medical records were reviewed. The mean age was 58.3±13.4 years. Bone densitometry was indicated in 45% of the patients interviewed according to the CAHTA criteria, in 77% according to the WHO criteria and in 62% according to the ICOCG criteria (applicable only to women). The proportion of patients with indications for bone densitometry increased with age, and was higher in women. The concordance among criteria was low.

[Pseudopodagra caused by hydroxyapatite. Report of 3 cases]. / Pseudopodagra por hidroxiapatita. A propósito de tres casos.

Calcium hydroxyapatite crystals deposit in periarticular soft tissues usually translates itself clinically through pain and mobility limitation of affected joint. Compromise of small joints in feet is infrequent, less than 1% of all cases. Recently pseudopodagra crises have been described due to the deposit of this material in soft tissues adjacent to metatarsal or phalangeal first joint. Its clinical expression is practically undistinguishable from gout crises. Three new cases of pseudopodagra due to hidroxyamatite are presented and some considerations are made concerning this clinical entity and its differential diagnosis in relation to gout.

Microalbuminuria is associated with limited joint mobility in type I diabetes mellitus.

OBJECTIVE: To determine whether limited joint mobility (LJM) is associated with microalbuminuria in type I diabetes mellitus. METHODS: Joint mobility was measured in a control group of 63 healthy subjects and in 63 type I diabetic patients, older than 18 years (mean 31.7 years, range 18-57), recruited from the outpatient clinic of the Endocrine Unit. Patients with established diabetic nephropathy (proteinuria or increased creatinine) were excluded. Joint mobility was assessed qualitatively with the prayer manoeuvre and quantitatively by measuring the angles of maximal flexion and extension of the fifth and third metacarpophalangeal (MCP) joints and wrist. Diabetic retinopathy was assessed by direct ophthalmoscopy. Urinary albumin excretion (UAE) was determined in at least two 24 hour urine samples. RESULTS: Joint mobility was limited in diabetic patients compared with control subjects. Diabetic patients with LJM had longer duration of diabetes (12.1 (SD 6.4) years compared with 6.9 (5.7) years; p < 0.001). Joint mobility was limited in patients with retinopathy: prayer manoeuvre was positive in 96.4% of patients with retinopathy, but in only 40.0% of patients with no retinopathy (p < 0.001); mobility of MCP joints and wrist was limited in diabetic patients with retinopathy even when the longer duration of their diabetes was taken into consideration. Microalbuminuria, present in 11 patients (17.5%), was associated with LJM: prayer manoeuvre was positive in 90.9% of patients with microalbuminuria, but in only 57.4% of patients with normal UAE (p < 0.05). Maximal flexion of MCP joints was reduced in patients with microalbuminuria. Microalbuminuria, but not LJM, was associated with risk factors of cardiovascular disease. CONCLUSION: LJM is associated with microalbuminuria and retinopathy in type I diabetes. The association is independent of age and duration of diabetes.

Munchausen's syndrome simulating reflex sympathetic dystrophy.

A 15 year old girl who had pain, oedema of her left hand, and fever of four months' duration is described. Marked demineralisation of her hand was shown by radiography, and increased articular uptake by technetium-99m bone scan. All these changes were indistinguishable from reflex sympathetic dystrophy. After two admissions to hospital and multiple explorations we discovered that she had induced her symptoms herself and a diagnosis of Munchausen's syndrome was made. As far as we know this presentation has not been previously reported and might help to explain the physiopathology of some signs of reflex sympathetic dystrophy.

Bone mineral density in patients with temporal arteritis and polymyalgia rheumatica.

OBJECTIVE: To assess the influence of corticosteroids in the mineral content of patients with giant cell arteritis (GCA), 56 patients, 28 with polymyalgia rheumatica (PMR) and 28 with temporal arteritis (TA) were studied. METHODS: The bone mineral density (BMD) in the lumbar spine and the femoral neck was measured by dual photon X-ray absorptiometry. A control group (48 people) comparable in age and sex was also evaluated. RESULTS: Compared with the controls, the patients with GCA had lower values of BMD in the femoral neck (men: p < 0.03; women: p < 0.001). In the lumbar spine differences were significant in women (p < 0.05) but not in men (p < 0.1). Multiple regression analysis showed that the BMD at L2-L4 in men correlated with height and weight and was inversely related to the cumulative dose of corticosteroids and the duration of treatment. The BMD at L2-L4 in women correlated with height and weight, but not with corticosteroids. Multiple regression analysis in men showed that age and the total dose of corticosteroids were significant independent predictors of femoral BMD. In women BMD in the femoral neck was correlated with age and weight, but not with corticosteroid treatment. CONCLUSION: The total dose and duration of corticosteroid treatment have been shown to be determinant factors of bone mass in patients with GCA who received corticosteroids.

Bone mineral density in patients with peripheral psoriatic arthritis.

BACKGROUND: Little information is available on the occurrence of generalized osteopenia in psoriatic arthritis. The only two published studies of bone mass in psoriatic arthritis produced conflicting results. METHODS: We compared bone mineral density measured at the lumbar spine and femoral neck using dual-energy X-ray absorptiometry in 52 patients with active peripheral psoriatic arthritis and in 52 controls. The psoriatic arthritis group included 19 males, 14 premenopausal women, and 19 post-menopausal women. Controls were matched to the patients on sex, age, and menopausal status. RESULTS: In the overall study population no significant differences were found between psoriatic arthritis patients and controls. Postmenopausal psoriatic arthritis patients had a lower femoral neck bone mineral density than the relevant subgroup of controls. No significant differences in lumbar spine bone mineral density were found in the analyses of the male, premenopausal female, and postmenopausal female subgroups. Neither was femoral neck density significantly different between male or premenopausal female psoriatic arthritis patients and controls. CONCLUSION: These results suggest that peripheral psoriatic arthritis is not associated with significant generalized bone loss.

Usefulness of bone densitometry in postmenopausal women with clinically diagnosed vertebral fractures.

OBJECTIVE: To analyse whether bone mineral density (BMD) assessment is required in postmenopausal women presenting with low trauma vertebral fracture. METHODS: Women with vertebral fracture diagnosed over a 10 year period were recruited from our database. The following were excluded: (a) patients with high energy trauma; (b) patients with malignancies; (c) patients with a metabolic bone disease other than osteoporosis. All postmenopausal women were included in whom BMD had been evaluated at both the lumbar spine and femoral neck by dual energy x ray absorptiometry during the six months after the diagnosis. Patients with a potential cause of osteoporosis other than age and menopause were not considered. A total of 215 patients were identified. RESULTS: The mean (SD) age of the patients was 65.9 (6.9) years. BMD at the lumbar spine was 0.725 (0.128) g/cm(2) and the T score was -2.94 (1.22); BMD at the femoral neck was 0.598 (0.095) g/cm(2) and the T score was -2.22 (0.89). The BMD of the patients was significantly lower than that of the general population at both the lumbar spine and femoral neck. When the lowest value of the two analysed zones was considered, six patients (3%) showed a normal BMD, 51 (23.5%) osteopenia, and 158 (73.5%) osteoporosis. The prevalence of osteoporosis at the femoral neck increased with age; it was 25% in patients under 60, 35% in patients aged 60-70, and 60% in patients over 70. CONCLUSION: These results indicate that bone densitometry is not required in postmenopausal women with clinically diagnosed vertebral fractures if it is performed only to confirm the existence of a low BMD.

Osteoporotic vertebral fracture in clinical practice. 669 Patients diagnosed over a 10 year period.

OBJECTIVE: Few data are available on clinically diagnosed vertebral fracture. Information about osteoporotic vertebral fracture has mainly been obtained via inferences from epidemiological studies of vertebral deformity. We evaluated the characteristics of patients with osteoporotic vertebral fracture diagnosed in a rheumatology department over a 10 year period. METHODS: Patients with back pain and vertebral fracture diagnosed between January 1990 and December 1999 were recruited from our data base. Patients with high energy trauma, malignancies, and metabolic bone diseases other than osteoporosis were excluded. These variables were analyzed: sex, age at diagnosis, type of osteoporosis (primary vs secondary), number of fractures at diagnosis (single vs multiple), and percentage of admissions and length of stay. RESULTS: Of the 669 patients, 534 (80%) were women and 135 (20%) were men. Age at diagnosis ranged from 30 to 91 yrs, mean 67.1 +/- 9.1. Secondary osteoporosis was diagnosed in 177 (26%) patients and the frequency was significantly higher in men than women (55% vs 19%; p < 0.001); the most common associations for secondary osteoporosis were oral corticosteroids, chronic obstructive airway disease, and rheumatoid arthritis. At diagnosis, half of the patients presented with multiple fractures. One hundred twenty (18%) patients were admitted; length of stay ranged from 5 to 56 days, mean 15.9 +/- 7.7. The frequency of admissions was higher in men than women (27% vs 16%; p < 0.001), higher in patients with secondary osteoporosis than in those with primary osteoporosis (33% vs 12%; p < 0.001), and higher in patients with multiple fractures than in those with single fractures (27% vs 8%; p < 0.001). CONCLUSION: Characteristics of patients recruited from a clinical setting differ significantly from those of subjects included in the epidemiological studies. In a rheumatology practice, frequency of secondary osteoporosis, mainly associated with corticosteroid treatment, is notably high. Admission is by no means a rare event.