[Utility of biochemical markers of bone turnover in diagnosis of osteoporosis and fracture risk prediction]

Currently, for the diagnosis of osteoporosis, we search risk factors and measure bone mineral density [BMD] by DXA. However, bone turnover markers, unused still in practice, have shown an interest especially in the prediction of fracture risk. To determine the relationship between bone markers, BMD and osteoporotic fracture. Prospective study of 65 women referred for measure of BMD during the period between May and August 2010. Each patient had a dosage of serum bone formation markers: osteocalcin [OC] and N-terminal propeptide of type I collagen [P1NP] and bone resorption markers: serum and urinary C-terminal telopeptide of type I collagen [beta-CTX or CrossLaps] as well as parathyroid hormone and calcium. Risk factors of osteoporosis were identified in each case. Our 65 women had a mean age of 58.6 +/- 12.1 years. The majority [83%] were menopausal women. Osteoporosis was found in 52%, osteopenia 26% and normal BMD 22% of cases. An increase in bone turnover markers was correlated with menopause [p = 0. 001 for the OC, p = 0.016 for urinary CTX], a low body mass index [p = 0.015 for OC, p = 0.042 for serum CTX] and osteoporosis [p <0.001 for P1NP, p <0.001 for serum and urinary CTX]. Corticosteroid therapy was correlated with a decrease in bone formation markers [p = 0.002 for P1NP]. The presence of fracture was only associated with increased urinary CTX [p = 0.05]. Bone turnover markers increase in menopausal women and in case of low BMD. However, their contribution in the diagnosis of osteoporosis is low. They are rather an interest in the prediction of fracture risk

[Survival prognosis factors in multiple myeloma]

Outcome in multiple myeloma [MM] is very heterogeneous in survival and therapeutic response, constantly fatale despite her therapy progress. To determine the prognostic factors and survival in MM. We carried out a transversal study of 100 patients in the rheumatology department of hospital Monastir between 1991 and 2010. In each case we determinate the survival delay and also the clinical, laboratory, radiological data at diagnosis and therapeutic response. The mean age was 64.4 years and sex ratio H/F=1.27. MM is IgG type in 57%, IgA in 28% and light chain in 11% of cases. The survival mean is 34 months and the survival median is 26 months. Univariate analysis showed five prognostic factors: age [p = 0.016], anaemia [p=0.033], beta 2 microglobulin [p < 0.0001], CRP [p = 0.0001], albumin [p = 0.002], LDH [p=0.001], plasmocyte proliferation rate [p=0.003] and rapidly therapeutic response [p <0.001]. beta 2 microgrobulin-CRP classification and the international staging system [ISS] presented a high prognosis signification [p < 0.0001]. Multivariate analysis demonstrated two prognostic factors: beta 2 microglobulin and CRP. Our study showed that MM presented many prognostic factors, which easily realized in daily practice. These prognostic factors are essentially to evaluate prognosis and select patients for appropriate therapeutic indication. beta 2 microgrobulin- CRP classification and the international staging system [ISS] are more predictive than Durie Salmon classification in MM survival

[Quality of life in ankylosing spondylitis]

Ankylosing Spondylarthritis [AS] involves by its frequency and its repercussion on the functional capacity an important handicap and deterioration of the patients quality of life. To evaluate the handicap and the quality of life during the AS and to seek the predictive factors of the deterioration of this quality of life. A prospective study relating to 50 patients recruited in the Department of Rheumatology of F. B. Hospital of Monastir during 6 months period [Mars to September 2008]. The studied parameters were the quality of life evaluated by a specific sore [ASQOL] and a generic score [SF-12]. Also the physical, social and economic felt handicap was evaluated using a qualitative scale. Predictive factors [clinical, biological and radiological] of the quality of life were carried out. Our patients are divided in 42 men and 8 women with an average age of 38.9 +/- 10.7 years. The average duration of AS is of 11.9 +/- 7.6 years. The average of ASQOL is of 11.9 +/- 4 [extremes: 0-17]. The average of physical SF12 is of 29.8 +/- 6 [21.7-53.2] and of mental SF-12 of 35.3 +/- 6.6 [22.5-55.8]. The physical, social and economic felt handicap was considered to be average or important in respectively 88%, 72% and 86% of the cases. The predictive factors of a high ASQOL [faded quality of life] are absence of occupation, high BASMI, a high number of painful articulations and high BASFI, BASDAI, BASG, BASRI and EVA total pain. The factors associated to the alteration of the quality of life according to SF-12'S are male sex, professional statute, high number of painful articulations and high BASDAI, BASFI and BASRI. Our study shows the important deterioration of the quality of life in AS patients. The existence of the predictive factors of quality of life primarily related to the functional capacity of the patients and to the disease activity implicates an early and adequate disease management in order to decrease this repercussion

fracture risk assessment tool [FRAXTM], where one is in Tunisia?

The fracture risk assessment tool [FRAXTM], published in February 2008, is developed based on the use of clinical risk factors with or without bone mineral density tests. To calculate the FRAX tool in a cohort of Tunisian patients in whom bone mineral density [BMD] was assessed by dual X ray absorptiometry [DXA]; to correlate this score to osteoporotic fracture and to BMD assessment and to propose a threshold for therapeutic intervention. In a cross sectional study of 582 patients older than 40 years, in whom a BMD measurement by DXA has been performed between January 2006 and December 2009, clinical risk factor for osteoporotic fracture and the occurrence of a prior fragility fracture were assessed. The French version of the FRAX tool was used. Threshold for pharmacological intervention was evaluated by ROC curve. Patients were aged 62.3 +/- 10.4 years. They were female in 91.2% of cases. BMD measurement was under 2.5 standard deviation in 53.2%. Osteopenia was noted in 29.2% of cases and BMD was normal in 17.4% of cases. Osteoporotic fractures were observed in 38.2% of cases. Major osteoporotic fractures [FOM] [hip, vertebra, radius] occurred in 82% of cases. The FRAX score calculated with T-score was 8.55 +/- 8.54% for the FOM and 3.02 +/- 6.37% for femoral neck [FN], while it was 7.81 +/- 6.45% for the FOM and 2.58 +/- 3.97% for the FN if calculated without T-score with a significant difference [p <10[3]]. For the patients having T-score under 2.5 SD, FRAX score was 11.39 +/- 10.32% for the FOM and 4.74 +/- 8.13% for the FN if calculated with T-score and it was 9.18 +/- 6.95% for the FOM and 3.19 +/- 4.11% if calculated without T-score. The score FRAX was correlated to BMD [r=0, 53, p <10-3] and to fracture prevalence [p < 10[3]]. The threshold of therapeutic intervention was fixed to 30% for the FOM and 7% for the FN. Our study confirms the usefulness of the FRAX score in the prediction of fracture risk in Tunisian population. The determination of therapeutic threshold intervention requires other prospective and larger studies with medico-economic analyses

Ochronosis: report of two familial cases

Ochronosis of alkaptonuria is a rare hereditary autosomal recessive disease in wich there is an absence of homogentisic acid oxidase resulting in accumulation of homogentisic acid in tissues. To report a new case of alkaptonuria. A 49-year-old man had been followed for 4 years for chronic lombalgia and arthropaty of two knees. He is married to his cousin and father of 4 girls. His parents are also cousins. The clinical examination has found a cutanuous pigmentation and a lumbar stiffness. At biological checking, creatininemia was at 190 micro mol/L and there are not inflammatory indicators. The radiography have shown a discal dorsolumbar calcifications, anterior inter somatic bridges and bilateral arthritis of knees without articular chondrocalcinosis. The diagnosis of ochronosis have been suspected and confirmed by the blackness of urine and the dosage of alkaptonuria. The patient has been treated symptomatiquely. Familial investigation have revealed that his daughter suffred from the same disease with the notion of blackness of urine. She is 12 year old and she's asymptomatic on the osteoarticular level. Alkaptonuria causes a degenerative arthropaty wich can endanger functional prognosis. Early diagnosis and scanning of this innate error of metabolism by genetic study play a fundamental interest, especially for molecular and genetic advisement

[Adult-onset of Still's disease with atypical articular and skin manifestations]

Adult-onset Still's disease [ASD] is an uncommon clinical entity. It is a diagnosis of exclusion, characterized by a clinical triad of intermittent fever spikes, evanescent rash, and either arthralgia or arthritis. Destructive arthritis more commonly affects the hips, wrists, tarsal joints and cervical spine. To report an unusual case of ASD with severe distal interphalangeal destructive arthritis and finger skin vesiculopustules. A 19 years old girl was followed for 2 year-history of ASD with polycyclic articular involvement. She noted, since 2 months, rapid appearance of painful tumefaction in the distal interphalangeal joints [DIP] with maculopustular eruption distributed exclusively on the hands, in front, only of DIP and few proximal interphalangeal joints [PIP]. Further more, she complained of polyarticular active disease. Hands and wrists X-ray showed narrowed distal-interphalangeal joint space of only DIP joints. RMN imaging revealed in addition carpal, metacarpal and PIP articular inflammatory damage. The infectious investigation remained negative. A surgical skin and DIP biopsy specimens showed disseminated micro-abscesses with polynuclear leukocyte dermal infiltration. There was no signs of osteitis. Bacterial and fungal cultures from the pus failed to reveal any causative organisms. Skin lesions gradually disappeared in response to conventional ASD therapy after intensification. Hence, the diagnosis of distal destructive arthritis of ASD associated with atypical neutrophilic dermatosis [Sweet's syndrome] was made. ASD is rare, heterogeneous, with unpredictable evolution. The distal destructive arthritis represents a possible complication. The presence of pustules as atypical cutaneous features of Sweet's syndrome may be seen in severe forms of ASD and clinicians must be alert to the possibility of a misdiagnosis in these cases

[Usefulness of ultrasonography for the diagnosis of carpal canal syndrome]

Ultrasound is an emerging tool in the diagnosis of carpal tunnel syndrome [CTS]. The aim of this study is to evaluate the diagnostic role of ultrasound in the CTS. Twenty five patients with signs and positive electromyographic of CTS were evaluated with ultrasound. The cross-sectional areas and the flattening ratio of the median nerve as well as the retinaculum bulging were calculated. There were 24 females and 1 male with the mean age of 48 years. Bilateral involvement was noted in 18 cases witch done 43 wrists. The mean cross-sectional areas of the median nerve in the carpal tunnel is 10.54 +/- 3.46 mm2 and it is over 9 mm2 in 93% of the cases. Mean flattening ratio in the carpal tunnel is 1.96 +/- 0.32. Palmer retinaculum bulging is 3.70 +/- 1.03. All theses parameters are over normally. The sensibility of ultrasound in CTS is 93%. Ultrasound measurement of median nerve more its morphologic data is highly predictive for diagnosis of CTS