The Impact of Disease Activity on Quality of Life, Fatigue, Functional Status and Physical Activity in Patients with Ankylosing Spondylitis.

BACKGROUND: Inflammatory back pain and stiffness are the leading symptoms of ankylosing spondylitis (AS). AS progression leads to substantial functional impairment and can reduce quality of life (QoL). The aim of this study was to determine the impact of disease activity on QoL, fatigue, functional status and physical activity. SUBJECTS AND METHODS: One hundred and fifty AS patients were included in the study, their body mass index (BMI) was calculated and they completed questionnaires regarding disease activity (The Bath Ankylosing Spondylitis Disease Activity Index, BASDAI) functional status (The Bath Ankylosing Spondylitis Functional Index, BASFI) spinal mobility (The Bath Ankylosing Spondylitis Metrology Index, BASMI), physical activity (the International Physical Activity Questionnaire, IPAQ), functional disability (The Health Assessment Questionnaire Disability Index, HAQ-DI), fatigue (The Functional Assessment of Chronic Illness Therapy - fatigue, FACIT-F) and QoL (The Short Form Survey-36, SF-36). RESULTS: Patients with inactive disease (BASDAI<4) had significantly better HAQ scores (p=0.001), SF-36 mental component scores - MCS (65.68±19.54 inactive vs. 46.89±21.78 active disease, p=0.001), SF-36 physical component scores - PCS (median score 56.25 inactive vs. 30.00 active disease, p=0.001) and FACIT-F scores (38.49±10.62 inactive vs. 26.21±10.81 active disease, p=0.001). There was no significant difference in patient's physical activity or BMI regarding disease activity (p=0.564 and p=0.162 respectively). Also, there was no significant difference in BASDAI, BASMI or BASFI scores regarding different BMI categories (p=0.818, p=0.474, p=0.436, respectively). CONCLUSION: AS activity increased fatigue, impaired functional ability and QoL, especially the physical component. Although more than half (61.4%) of our patients were categorized as pre-obese or obese according to BMI, this was not related to disease activity, spinal mobility or daily functioning scores. Reported physical activity level had no effect on disease activity. Disease activity influences the course of AS and QoL assessment should be implemented into regular AS evaluation in order to improve treatment outcome.

Anti-TNF Therapy and the Risk of Malignancies and Infections in Inflammatory Rheumatic Diseases - Our Experience.

BACKGROUND: Early diagnosis is the key to successful treatment of inflammatory rheumatic diseases and the use of conventional disease-modifying antirheumatic drugs (csDMARD) and biologic disease-modifying antirheumatic drugs (bDMARD) or biologics have substantially contributed to better disease control. Biological drugs have been approved for the treatment of rheumatoid arthritis (RA), juvenile arthritis (JIA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA). SUBJECTS AND METHODS: The study involved 79 adult patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS), psoriatic arthritis (PsA) or undifferentiated spondyloarthropathy (USpA) - the last three clinical entities belong to a common group called spondyloarthropathies (SpA); receiving anti-TNF therapy at the department of Rheumatology and Rehabilitation, Clinical Hospital Center Zagreb. The duration of therapy was a minimum of 1 month, with the mean duration of 32.0±24.0 months. The infections recorded were infections that appeared during treatment or soon after the treatment was stopped. RESULTS: During the course of therapy 17 patients (21.5%) experienced an infection, with the total number of 21 infections. This resulted in an overall incidence rate (IR) of 9.9/100 patient-years. Of the patients with RA 76.5% developed an infection, which was significantly higher than for patients with SpA (p<0.001). The IR/100 patient-years for all infections in RA patients was 23.7 compared to 2.8 in patients with SpA. Female gender was associated with a significantly higher infection rate (70.6%, p=0.005). There were 8 infections that were considered serious, yielding an IR of 3.8/100 patient-years. There was only one malignancy case in our study. CONCLUSION: Every fifth patient developed an infection during the course of anti-TNF therapy, and more than one third of all infections were serious. RA and female gender was associated with a significantly increased number of infections.

Local Cryotherapy, Comparison of Cold Air and Ice Massage on Pain and Handgrip Strength in Patients with Rheumatoid Arthritis.

BACKGROUND: The main benefits of cryotherapy in rheumatoid arthritis (RA) are in reducing inflammation and swelling and in relieving joint pain. This study aimed to compare the short-term effects of cold air therapy vs. ice massage, on pain and handgrip strength (HGS) in patients with RA. SUBJECTS AND METHODS: The study is a non-randomized clinical trial. Patients were recruited if they had disease activity score (DAS28) ≥3.2 with at least 2 swollen joints on the dominant hand and were consecutively divided into two groups of 15 patients. There was no statistically significant difference in DAS28 score between groups. The first group received cold air therapy at -30°C and the second ice massage of the hands. The pain (visual analogue scale, 0-10), and HGS (kg) were measured immediately prior and after cryotherapy, and 30 and 60 minutes after cryotherapy. Descriptive statistics, Independent Samples T-test, and Paired Samples T-test were used for statistical analysis. RESULTS: Pain intensities for cold air therapy were as follows: 5.33 (±2.44), 3.13 (±2.67), 2.87 (±2.56), 2.80 (±2.73), and for ice massage were: 5.20 (±2.37), 2.87 (±2.42), 2.60 (±2.23), 2.67 (±2.28). In both groups pain was significantly lower immediately after, 30 and 60 minutes after the treatment compared to the baseline (p=0.001). There was no significant difference in pain alleviation between the groups regarding the used method of cryotherapy on all three measured time points. Nonsignificant improvement in HGS occurred after both methods of cryotherapy. There was no significant correlation between pain intensity and HGS. CONCLUSIONS: A single application of cold air therapy and ice massage equally provides immediate and significant pain alleviation in patients with active RA, which is maintained for one hour. There is scientific evidence that HGS is influenced greatly by the disease activity. A single application of cryotherapy could not reduce disease activity explaining recorded nonsignificant effect on HGS.

Correspondence of vitamin D status with functional scores and disease activity among Croatian patients with ankylosing spondylitis: a preliminary study.

BACKGROUND: Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease which primarily affects the axial spine and sacroiliac joints. Over the past several years Vitamin D has been recognized as a hormone with significant immunomodulatory effect due to the fact that it inhibits T-cell proliferation and decreases the production of interleukin-2, interferon-γ, and tumor necrosis factor-α. Therefore, vitamin D may play a role in the development and progression of inflammatory diseases. Our aim was to estimate and evaluate the correspondence of vitamin D status with functional scores, spinal mobility and disease activity among patients with AS in Croatia. SUBJECTS AND METHODS: One hundred and fifty (150) AS patients were prospectively enrolled and assessed for disease activity, spinal mobility and functional disability. Blood samples were obtained from all patients and 25(OH)D concentration and inflammatory markers were determined. All patients underwent bone mineral density measurement at the lumbar spine (L1-L4) and proximal femur (total hip and femoral neck) with dual-energy x-ray absorptiometry. RESULTS: The prevalence of 25(OH)D inadequacy considering cut-offs of 75, 50 and 30 nmol/L was 80, 46.7 and 16.7% respectively. The mean 25(OH)D serum concentration was 52.63±23.45 nmol/L. There was no significant difference in mean 25(OH)D concentration regarding patient's age, sex, smoking status, season change, disease activity, spinal mobility or functional scores. However, there was a trend towards lower 25(OH)D concentration in patients with higher disease activity, worse spinal mobility and worse functional scores. CONCLUSION: Our results showed that there is no significant association between serum 25(OH)D concentration and activity of AS. Given that significant proportion of our patients had inadequate vitamin D status, the role of vitamin D in pathophysiology of AS still remains to be elucidated.

Prevalence and Correlation of Depressive Symptoms with Functional Scores, Therapy and Disease Activity among Croatian Patients with Rheumatoid Arthritis: A Preliminary Study.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic, autoimmune and disabling disease that significantly affects the quality of life. Additionally, significant number of patients with RA suffer from depressive disorders, which are commonly underrecognised and undertreated. We aimed to estimate the prevalence of depressive symptoms in Croatian RA patients and to assess the relationship between them and clinical correlates. SUBJECTS AND METHODS: Fifty-four RA patients treated at the Clinic for Rheumatic Diseases and Rehabilitation at the University Hospital Centre Zagreb were prospectively enrolled in the study and evaluated for functional status using the Disease Activity Score 28 (DAS-28), Health Assessment Questionnaire (HAQ), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and Visual Analogue Scale (VAS) for pain and health related quality of life (HRQL) measurement. The depressive symptoms were assessed using the Beck Depression Inventory-II (BDI-II) questionnaire. RESULTS: Thirty RA patients (55.6%) had some sort of mood disorder, with 10 (18.5%) patients accounting as depressed. Positive correlation was found between depressive symptoms, higher disease activity and disablity during daily activities (τb=0.385, p=0.001 and τb=0.282, p=0.024 respectively). We found no significant association between depression and disease activity in the whole sample of RA patients, but for postmenopausal patients, the disease activity correlated with postmenopausal patients accounting as depressed (BDI-II score moderate or severe; τb=0.363, p=0.021). The use of biologic therapy correlated negatively with the disease acitivity, pain intensity and worse health related quality of life score (τb=-0.360, p=0.06; τb=-0.310, p=0.07; τb=-0.380, p=0.01 respectively). CONCLUSION: Considering the high prevalence of depressive sympoms in RA patients and the effect on functional disability and quality of life, we wanted to emphasize the importance of recognizing and optimizing depression treatment through multidisciplinary approach in RA patients.

GUIDELINES FOR THE PREVENTION, DETECTION AND THERAPY OF VITAMIN D DEFICIENCY IN ADULTS.

It is estimated that over one billion of people around the globe have low serum values of vitamin D, therefore, we can consider vitamin D deficiency as a pandemic and public health problem. Geographic position of Croatia, especially the continental part of the country, is a risk factor for the development of deficiency of vitamin D in the population. The aim of these guidelines is to provide the clinicians with easy and comprehensive tool for prevention, detection and therapy of vitamin D deficienney in healthy population and various groups of patients. They were made as a result of collaboration of clinicians of different backgrounds who are dealing with patients at risk of vitamin D deficiency. These guidelines are evi- dence-based, according to GRADE-system (Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendation. The main conclusions address the recommended serum vitamin D values in the population which should be between 75 and 125 nmol/L and defining recommended preven- tive and therapeutic dosages of vitamin D in order to reach the adequate levels of serum vitamin D.

[DIAGNOSTIC ULTRASOUND OF MUSCULOSKELETAL SYSTEM IN RHEUMATOLOGY IN CROATIA ­ CURRENT STATUS AND NEW PERSPECTIVES].

In recent years, diagnostic ultrasound of the musculoskeletal system (MSUS) has become almost inevitable in everyday clinical practice in rheumatology. Due to the efforts of the European League Against Rheumatism (EULAR), the use of MSUS has significantly increased in Europe. Unfortunately, there are still certain open issues related to MSUS, primarily regarding different ways of interpretation of US findings, the standardization of MSUS findings, and the lack of clear criteria for assessing the competency of sonographers and their certification.

[The role of vitamin D and calcium in the management of osteoporosis]. / Uloga vitamina D i kalcija u lijecenju osteoporoze.

This paper reviews two cornerstones of bone health: calcium and vitamin D. Recent recommendations on dietary intake and supplementation of calcium and vitamin D for prevention and treatment of osteoporosis are given.

[Relationship between vitamin D status and bone mineral density in Croatian postmenopausal women]. / Povezanost statusa vitamina D s mineralnom gustocom kosti u hrvatskih zena u postmenopauzi.

The aim of the study was to investigate correlation of vitamin D status meassured as 25-hydoxyvitamin D (25(OH)D) concentration with bone mineral density (BMD) in Croatian postmenopausal women. This study was based on the sample of 194 adult, postmenopausal women aged 50 years or over from Croatia. Assessment of 25(OH)D concentration and BMD by dual-energy xray absorptiometry (DXA) was performed to all participants. The average age of the participants in this study was 60.6 years. The average menopause duration was 11.4 years. Among the included participants only 13.9% of women complied with diagnostic criteria for osteoporosis. Mean serum concentration of 25(OH)D was 49.1 nmol/L (+/-17.1 SD). The prevalence of severe vitamin D deficiency was significantly higher in participants with osteoporosis compared with participants with normal BMD (<30 nmol/L; 29.6% vs. 9.8%). Correlation between serum 25(OH)D concentration and BMD was significant and positive at the proximal femur (r=0.18; p=0.026), and at the femoral neck (r=0.15; p<0.001). The results of this study indicate significant and positive correlation between serum 25(OH)D concentration and BMD meassured at the proximal femur and at the femoral neck in Croatian postmenopausal women.

Efficacy of therapeutic ultrasound in the treatment of chronic calcific shoulder tendinitis: a randomized trial.

BACKGROUND: Calcific shoulder tendinitis (CST) is characterized by hydroxyapatite crystals deposition in the rotator cuff tendons. Therapeutic exercises have been the mainstay of CST treatment, and evidence for therapeutic ultrasound (T-US) utilization and efficacy is lacking. AIM: This study aimed to determine whether 4500 J T-US combined with therapeutic exercises is superior to therapeutic exercises alone regarding calcification size reduction and symptom improvement in chronic symptomatic CST. DESIGN: This is a double-blind, placebo-controlled study. SETTING: This study was conducted at a University Department for Rheumatic Diseases and Rehabilitation of a University Hospital. POPULATION: Patients with chronic CST were analyzed. METHODS: After eligibility allocation, 46 patients with sonographically confirmed CST were divided into two groups (56 shoulders, 26 per group). Both groups performed the same therapeutic exercises for half an hour under physiotherapist supervision. In the treatment group T-US (4500 J, 10 minutes per session at a frequency of 1 MHz and an intensity of 1.5 W/cm2), and in the placebo group, sham T-US was applied for 4 weeks. Patients were assessed for: calcification size, shoulder pain, global health (GH), shoulder mobility (ROM), handgrip strength, Health Assessment Questionnaire Disability Index (HAQ-DI), Shoulder Pain and Disability Index (SPADI), and overall rehabilitation satisfaction. RESULTS: All assessed variables improved in both groups. A significantly greater reduction in calcification size was recorded in the treatment group compared to placebo: -10.92% (IQR 4.61% to 19.38%) versus -5.04% (2.30% to 7.22%), P=0.008. There was a significantly greater decrease in HAQ-DI, reduction of VAS GH, and an increase in hand grip strength in the treatment group, while no significant differences were observed for other parameters between the groups. CONCLUSIONS: Our results showed that adding the 4500 J T-US to therapeutic exercises in chronic symptomatic CST therapy resulted in greater calcification size reduction immediately following the treatment, as well as hand grip strength, HAQ-DI, and VAS GH improvement. CLINICAL REHABILITATION IMPACT: 4500 J T-US combined with therapeutic exercises is more effective in reducing calcification size than therapeutic exercises alone in the treatment of chronic symptomatic CST.

[Vitamin D: vitamin from the past and hormone of the future]. / Vitamin D: vitamin proslosti, hormon buducnosti.

In the last decade there has been a rising recognition of potential clinical significance of the vitamin D. Vitamin D regulates about 3% of the human genome. Thus, vitamin D deficiency is common and high in various populations across the world including Croatia. In this paper vitamin D metabolism and up to date knowledge of vitamin D function in calcium metabolism, muscular function and in prevention of infection, malignancy, autoimmune and cardiovascular diseases is presented. Reasons for pandemic vitamin D deficiency and guidelines for vitamin D supplementation are given.

[Ultrasonographic semiology--correlation between anatomy and sonography of musculoskeletal tissue]. / Ultrazvucna semiologija--usporedba anatomskog nalaza i ultrazvucnog prikaza struktura misicnokostanog sustava.

Diagnostic ultrasound (US) as noninvasive, non-ionisating and cost-effective imaging diagnostic technique has emerged as a useful imaging modality in rheumatology for the assessment of joint and soft tissue pathology. It can detect both early inflammatory soft tissue lesions (synovitis, tenosynovitis) and early erosive bone lesions in arthritis. Thus Power Doppler ultrasonography can differentiate active from inactive joint processes allowing monitoring of the new anti-inflammatory drugs used to treat inflammatory rheumatological diseases. In the process of learning the diagnostic technique memorizing and recognition of specific sonografic presentation of the different tissue structures, pathological processes, artifacts and pitfalls known as basic sonografic semiology is essential for appropriate interpretation of ultrasound image. In this paper ultrasound appearance of normal and basic pathological findings of different structures and tissues of musculoskeletal system is described and illustrated.

[The value of sonography and power Doppler in the detection of early arthritis]. / Vrijednost dijagnostickog ultrazvuka i power Dopplera u detekciji ranog artritisa.

Magnetic resonance imaging (MRI) of small joints of the hands and feetis still "the gold standard" in detecting early inflammatory changes in the patients with rheumatoid arthritis (RA). Radiographic assessment has only limited value in early diagnostic of RA. The limited accessibility of MRI makes both ultrasound (US) and Power Doppler (PD) of small joints of hands and feet equally useful tools as they give the same results as MRI in evaluating some of the pathologies such as: bone erosions, intraarticular effusions and changes of tendons. Power Doppler can detect subclinically synovitis of the small joints in the early phase of RA. Nowdays, in the field of rheumatology we talk about US and PD as "a rheumatologist's prolonged finger" or as " a rheumatological stetoscope", exactly because of their accessibility and possibility of getting quick and useful information about the patient himself. Since US and PD are inexpensive and non-invasive procedures, they can greatly improve diagnostics in RA and especially the assessment of the early phase of the inflammatory diseases, which can serve as a reliable indicator of the overal progression of the disease. Some new data show possibility of monitoring patients with RA and their response on disease modifying antirheumatic drugs (DMARDs) or biologicals by US and PD.

[The role of magnetic resonance imaging in seronegative spondyloarthritides]. / Uloga magnetske rezonancije u seronegativnim spondiloartritisima.

Seronegative spondyloarthritides (SpA) is a group of inflammatory rheumatic diseases characterized by inflammation of the sacroiliac joints and/or the spine, enthesitis and peripheral arthritis. MRI is the imaging method of choice for visualization of the sacroiliac joint and spine according to the new ASAS classification criteria for axial SpA. It can visualize both active inflammation and structural damage and is not associated with radiation exposure. MRI findings characteristic for active disease include bone marrow edema and contrast enhancement of the bone marrow and the joint space, while chronic changes include bone erosions, sclerosis, periarticular fatty tissue accumulation, bone spurs and ankylosis. MRI has higher sensitivity comparing to other radiological modalities. MRI.is the most important diagnostic imaging method in early SpA. It is sensitive and reliable for objective monitoring of the disease process and it is essential in the management of patients with SpA.

[Standardised ultrasound scanning of the elbow]. / Standardizirani ultrazvucni pregled lakta.

Musculoskeletal ultrasound (US) is noninvasive, nonionisating and cost-effective imaging diagnostic technique. It is a useful imaging modality for the diagnosis of joint and soft tissue pathology and can be considered as an extension of physical examination. Elbow is easily accessed due to its superficial position. A high resolution, multi-frequency (10-15 MHz) linear transducer should be used. US investigation of the elbow includes scanning of the anterior, medial, lateral and posterior part of the joint. Common flexor and extensor origin at the humearal epicondyles, triceps tendon, distal biceps tendon and ulnar nerve should be analised. The most frequent US finding of the elbow is lateral epicondylitis. In inflammatory arthropaties bursal distension and joint effusion are easily accessed by US. Power Doppler sonography is used for detection of sinovial vascularisation. In this paper standardized techinque for the US examination of the elbow is described. The normal ulrasound anatomy of the elbow is illustrated.

[Standardised ultrasound scanning of the shoulder--normal and basic pathological findings]. / Standardizirani ultrazvucni pregled ramena--normalan nalaz i prikaz osnovnih patoloskih promjena.

Diagnostic ultrasound (US) is noninvasive, non-ionisating and cost-effective imaging diagnostic technique. It has emerged as a useful imaging modality for the diagnosis of joint and soft tissue pathology. The shoulder is probably the most frequently analyzed joint. Diagnostic US can be considered as an extension of physical examination and has better sensitivity and specificity for the detection of rotator cuff tendon tear compared to the physical examination. A high frequency linear probe (7.5-15 MHz) with high resolution transducer should be used. US investigation of the shoulder includes scanning of the long head of the biceps, the subskapularis, the supraspinatus, and the infraspinatus tendon in longitudinal and transverse planes, and scanning of the subacromial-subdeltoid (SA/SD) bursa, glenohumeral (GH) and acromioclavicular (AC)joint. The most frequent US findings of the shoulder are effusion in the long head of the biceps tendon, and in the SA/SD bursa, tendinosis or tear of the supraspinatus tendon, and the degenerative changes of the AC joint. In inflammatory arthopahies synovial effusion and hypertrophy of the GH joint can be evaluated. Power Doppler sonography is used for detection of sinovial vascularisation. In this paper standardized techinque for the US examination of the shoulder is described. Pictures of normal and sam basic phathological findings are presented.

Influence of Non-pharmacological Treatment on Pain, Morning Stiffness, Fatigue, and Physical Function in Patients with Psoriatic Arthritis.

Naphthalanotherapy (NT) is a therapeutic procedure that uses mineral oil obtained from petroleum. The aim of this study was to investigate the influence of the duration of NT combined with an individually adjusted rehabilitation program (IARP) on pain, morning stiffness (MS), fatigue, and physical function in patients with psoriatic arthritis (PsA). A total of 29 consecutive patients with PsA were divided into two groups. Group 1 (n=17) participated in a two-week and Group 2 (n=12) in a three-week intervention program. Pain (using the Visual Analogue Scale - VAS), fatigue (VAS and Functional Assessment of Chronic Illness Therapy-Fatigue - FACIT-F), duration of MS (minutes), and physical function (Health Assessment Questionnaire - HAQ) were assessed before and after therapy. Statistical analysis was performed using SPSS version 20, with P<0.05. There was a significant improvement in VAS-pain, VAS-fatigue, MS, HAQ, and FACIT-F before vs after therapy: Group 1:5.88±1.62 vs 3.94±1.25, P=0.001; 6.59±1.73 vs 4.35±1.73, P=0.001; 35.47±31.64 vs 23.71±29.30, P=0.001; 1.43±0.78 vs 1.23±0.74, P=0.001; 25.88±10.89 vs 30.71±10.65, P=0.009; Group 2: 6.17±1.27 vs 3.92±1.44, P=0.001; 6.50±1.93 vs 3.75±1.71, P=0.001; 38.42±32.00 vs 21.25±17.31, P=0.006; 1.47±0.79 vs 0.93±0.54, P=0.008; 25.00±9.87 vs 36.83±7.20, P=0.001, respectively. Regarding the length of the therapy, significant difference was reached only in FACIT-F (P=0.009). Two-week and three-week NT combined with IARP are equally efficient in reduction of pain and MS, as well as in improving physical function in patients with PsA. The three-week program showed an additional effect on reducing fatigue assessed by the FACIT-F score.

[Leukocytoclastic vasculitis in primary Sjögren syndrome: a case report]. / Leukocitoklasticki vaskulitis u primarnome sjögrenovu sindromu: prikaz bolesnika.

We report a case of primary Sjögren's syndrome (SSjö with cutaneous leukocytoclastic vasculitis. The accurate diagnosis of SSjö was established based on objective signs and symptoms of ocular and oral dryness and characteristic appearance of a biopsy sample from a minor salivary gland, and presence of anti-SS-A autoantibody. Another autoimmune disorder was not present, so diagnosis of primary SSjö was established. Histologic finding of skin biopsy of purpuric lesion was typical for leukocytoclastic vasculitis. The patient was treated with small doses of glucocorticoids and with local symptomatic therapy for ocular and oral dryness. SSjö is one of the most common autoimmune disorders and vasculitis is one of the most characteristic extraglandular manifestations, but wide spectrum of cutaneous involvement in primary SSjö has been little studied.

Septic acromioclavicular arthritis in a patient with diabetes mellitus.

A 44-year-old diabetic man with isolated septic arthritis of the left acromioclavicular joint (A-C) caused by Staphylococcus aureus is described. He was admitted to the Department of Rheumatology with clinical symptoms of left shoulder arthritis and fever. Laboratory findings showed leukocytosis, elevated levels of erythrocyte sedimentation rate and C-reactive protein, all indicating septic arthritis. Blood culture was positive for Staphylococcus aureus. Left A-C joint x-ray and ultrasonography, and whole body scintigraphy with 99 mTc radiolabeled autologous leukocytes pointed to septic arthritis of the A-C joint. The patient was treated for six weeks with antibiotics successfully. Infection of the A-C joint is uncommon, even in conditions such as immunodeficiency, renal dialysis and intravenous drug abuse which are associated with unusual joint infections, and can be differentiated from shoulder joint infection, by maximal tenderness over the A-C joint on examination, and findings of A-C joint widening, effusion, and bony erosions on imaging studies.

Vitamin D status, dependence on age, and seasonal variations in the concentration of vitamin D in Croatian postmenopausal women initially screened for osteoporosis.

Vitamin D deficiency is associated with secondary hyperparathyroidism, increased bone turnover, and bone loss, leading to increased risk for osteoporotic fractures. The objective of this study was to investigate the prevalence of inadequate (insufficient or deficient) serum vitamin D levels in Croatian postmenopausal women initially screened for osteoporosis. Assessment of 25-hydroxyvitamin D (25(OH)D) was performed in 120 Croatian postmenopausal women aged > or =50 years. Three cut-off levels of vitamin D inadequacy were investigated: <75, <50, and <30 nmol/L. Among the included patients, only 14.2% of women complied with diagnostic criteria for osteoporosis. A total of nine (7.5%) had vitamin D levels greater than 75 nmol/L, suggesting that 92.5% of postmenopausal women had inadequate vitamin D status. The prevalence of two different cut-off point groups was 63.3% (<50 nmol/L) and 14.2% (<30 nmol/L). Mean (+/-SD) serum level of 25(OH)D was 46.94 (16.77) nmol/L. Vitamin D was exhibiting declining values with increasing age (r = -0.28; P = 0.002). The prevalence of vitamin D levels below 30 nmol/L was high in patient aged > or =65 years (23.8%). The highest mean level of vitamin D was detected in summer, with significant differences from spring and winter (P = 0.015 and P = 0.022, respectively). The results of this study indicate a high prevalence of vitamin D inadequacy in Croatian postmenopausal women initially screened for osteoporosis. High prevalence coupled with the rising recognition of potential clinical significance of the vitamin D inadequacy makes this highly interesting intervention target, suggesting that the attempts to increase the awareness on this issue are needed.