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The proceedings contain 343 papers. The topics discussed include: implementation of a disease modifying anti-rheumatic drug blood monitoring software: 8 years of experience in a single center;effectiveness of colchicine among patients with COVID-19 infection: a randomized, open labelled, clinical trial;rheumatic autoimmune diseases following COVID-19 infection: an observational study in Iraqi Kurdistan region;COVID-19 in male elite Irish-based athletes at a national sports institute;the effects of a pain management program for patients with an inflammatory arthritis;a retrospective analysis of the effectiveness safety of platelet rich plasma injections in primary osteoarthritis in knee joint, in patients attending a tertiary care hospital, Sri Lanka;a cohort study;do proformas used in fracture liaison service appointments reflect national osteoporosis clinical standards? a content analysis;calcium pyrophosphate dihydrate crystal in operated rheumatoid arthritis of the knee;cardiac amyloidosis: a case series of 31 patients with a comprehensive literature review;scoping review for the application of center of pressure for patient or intervention assessment in rheumatoid conditions;and four SNPs associated with monocyte/macrophage cell lineage uniquely associated with CRPS-1 in discovery and replication cohorts and suggest predisposition to regional osteopenia and digit misperception.
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Introduction/Background: Primary bone marrow oedema syndrome is an elusive and less well-defined entity. Whether Rheumatologists should consider it as a stand alone diagnosis, is debatable. It possibly would be best described as an MRI feature which could be a finding in a number of diseases which would include the initial phases of Osteonecrosis of the bone, Rheumatoid Arthritis, Spondyloarthritis, Enthesitis related, Post traumatic, OA, Infections and Cancers. The treatment options become constricted due to the paucity of evidence. Rheumatologists need to consider this as an area of unmet need with development of consensus classification criteria and treatment approaches. Description/Method: 27-year-old male, Height 174 cms Weight 90 Kgs BMI 29 Kg/m2, became symptomatic in Jan 2022 with complains of pain in the both hip joints & groin regions, pain became excruciating and he became bed-bound, with early morning stiffness lasting approximately 45 mins. Had received steroids for COVID infection in August 2020. Investigations Hb 13.5gm/dl TLC 7000/mm3 Platelet 400 x 103/mm3 Sr Bil 0.8mg/dl AST 16 IU/L. ALT 24 IU/L Sr Creatininine 1.1mg/dl Blood Sugar Levels, Fasting 89 mg/dl Post Prandial 102 mg/dl ESR 10mm in 1st hour by Wintrobes method CRP Quantitative 29.38mg/L HLA B27 by PCR Negative, RF Negative, ACCP Negative Serum, IgG, Beta2 Glycoprotein 1.44 SGU Serum, IgM, Beta2 Glycoprotein 3.44 SGU Serum, IgG, Cardiolipin antibody 8.4 GPL Serum, IgG, Cardiolipin antibody 17.45 GPL Lupus anticoagulant by DRVVT Negative Sr Cholesterol 211mg/dl HDL 29 mg/dl LDL 156mg/dl TGs 130 mg/dl MRI Hips & SI joints Transient bone marrow oedema/osteopenia of bilateral hip. PET CT Increased metabolic activity in both hip joints Bone Scan (99mTcMDP) Increased vascularity in perfusion phase, increased accumulation in soft tissue in blood pool phase and increased uptake in bilateral Hip joints in skeletal phase scan, suggestive of CRPS Type-I. Management Was initially managed with Tab Etoricoxib 90mg BD, also started on Tab Sulphaslazine and Tab Methotrexate. However, when he had no symptomatic relief he was administered Inj Infliximab on 12 May 2022 and a second dose on 9 June 2022. He had excellent pain relief after the 1st dose, however after 10 days of the administration, he again began experiencing pain especially after walking. He also had pain in the knees on this occasion. He was also administered Inj Zoledronic 4mg on 23 May 2022. He is at present not requiring any NSAIDs over the last 1 month. Discussion/Results: The patient having presented with excruciating and debilitating pain was worked up and evaluation revealed features of bone marrow oedema on MRI which was corroborated with bone scan and PET CT imaging. The acute phase reactant CRP was also significantly elevated. The patient also gave history of early morning stiffness lasting approximately 45 mins. Hence an underlying Inflammatory process such as Spondyloarthritis(Peripheral) with enthesitis was considered. The confounding factors were the pain which worsened on mobilization, HLA B27 negative status, Rheumatoid Factor and ACCP negative status and past history of having received IV Corticosteroids for COVID infection in August 2020. In view of the debilitating pain and aworking diagnosis of Spondyloarthritis, hewas started onNSAIDs alongwith rest, initially, followed by conventional synthetic disease modifying agents in Rheumatic disease followed by biologic synthetic diseasemodifying agent - Inj Infliximab. The thought process was to avoid prolonged NSAID use to prevent the associated side effects. However, since Avascular Necrosis of the Femoral head is a very likely possibility, the patient is planned to be kept under close follow up. Key learning points/Conclusion: Collaborative efforts between the Departments of Nuclear Medicine, Radiology, Orthopaedics and Rheumatology are crucial in the early detection and approach to cases of Bone Marrow oedema. Avascular necrosis of head of Femur is a far more common entity and must be kept in ind even when a diagnosis of Bone Marrow oedema syndrome is being entertained. Diagnosis of Bone Marrow oedema syndrome must be entertained only as a diagnosis of exclusion. Continued follow up and regular imaging must be pursued rigorously in patients diagnosed with Bone Marrow oedema syndromes. There is a requirement to document acute phase reactants such as CRP and ESR in patients diagnosed with Avascular necrosis of bone as this data could help us differentiate AVN from Primary Bone marrow oedema in the early stages.
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Objective: To assess the impact of systemic corticosteroid therapy (SCT) indicated in the treatment of diffuse infiltrating lung disease (DILD) on the BMD assessed by bone densitometry Methods: Prospective study conducted in the pneumology department of Mongi Slim-La Marsa Hospital for one year (2019), involving patients with DILD in whom SCT was indicated in association with preventive measures (calcium and vitamin D). After written consent, each patient had the first measurement of BMDbefore starting SCT and then a control measure between 6 and 12 months after the start of treatment Results: 28 patients were enrolled (medium age=55.8 y;sex ratio F/H=3.5). All had the first measure of BMD and only 12 had a control measure (interruption due to COVID-19 pandemic). In the remaining group, the DILD treated were related to sarcoidosis (n=4), idiopathic nonspecific interstitial lung disease (n=3), Gougerot Sjögren's syndrome (n=2), HSP (n=1), Myositis (n=1), and Systemic Lupus Erythematosus (n=1). The average dose of prescribed SCT was 0.75 mg/kg/d. Based on the measurement of the L1-L4 vertebrae, at the first measurement of the BMD, 4 patients had no abnormalities, 3 had osteopenia and 5 had osteoporosis while at the control measure, 3 patients had no abnormalities, 3 had osteopenia and 6 had osteoporosis. Based on the measurement of the right femur, at the first measurement of the BMD, 5 patients had no abnormalities, 5 had osteopenia and 2 had osteoporosis while at the control measure, 3 patients had no abnormalities, 6 had osteopenia and 3 had osteoporosis. This difference between initial and control BMD was significant for the measurement at the right femur (p=0.001). Age was correlated with the decline of BMD in the L1-L4 vertebrae (p=0.024) Conclusion: SCT is responsible for a significant decrease in BMD despite preventive measures, hence the importance of routine osteoporosis screening and collaborative management with rheumatologists.
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In Mexico, the fragility fractures (FF) represent a public health problem;recent reports state rates of almost 2,000 cases for every 100,000 inhabitants with an expected sevenfold increase by 2050 (Clark.P- 2005). Hip fracture cases will go up from 155,875 to 226,886 in 2050 (5.2 to 7.2 timesmore than those registered in 2005) (Johansson.H-2011). According to ICUROS-Mx study mortality after FF was 20.2%. Quality of life after FF is affected significantly (Borgstrom.F-2013). The costs related with the handling of nonpharmacological low bone mass (osteopenia), osteoporosis and FF are high in our country;they reach over 5,191 million (MXP) in 2010 and $ 7,575 million pesos in 2020 (Carlos.F-2013). TheMexican health care system comprises two sectors: public and private, offers coverage to 82.2% of the 119.5 million inhabitants registered in that year. An example is Instituto Mexicano del Seguro Social (IMSS) Victoriode- la-Fuente-Narváez where the traumatology unit alone will require a budget greater than 315,000,000 million (MXP) per year as per 2050 forecasts. We show the direct costs derived from the most frequent FF according to the Group Related Diagnosis (GRP) published in 2017 by the IMSS with costs updated to 2020 (Gilma.A-2014). Fracture Liaison Services (FLS) with a worldwide successful experience for the care of FF patients offer diverse and feasible models enable to adapt to different Health Systems settings. The aim of this review is to put forward the possible implementation of the International Osteoporosis Foundation (IOF) Capture the Fracture® program) in Mexico. The initial experience in the implementation of the Capture the Fracture program in diverse Mexican institutions shows us that this program is feasible of being adapted for being implemented in countries with fragmented health system such as Mexico. The fishbone diagram below (Figure 1) lists the barriers impacting the development of FLSs inMexico. These barriers include a series of factors required for an effective and efficient FLS. All these factors were exacerbated by the COVID-Sars2. Conclusion: Fragility fractures represent a health problem in Mexico and in the world. This study reviews and puts forward the implementation of FLS as a feasible and cost-effective alternative in health institutions in our country.
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Objective: Ever since the times of ancient physicians and surgeons like Sushruta (600 BC) or Hippocrates (400 BC), it is clear that physical development of individuals with sedentary lifestyle is different from the one of the physically active individuals. Only after the year 2000, with the first discovery of causality of IL-6 and muscular movement, an intensive study of this problematics has begun. Currently, there are about 600 known operations (myokins) that are interrelated with muscle functions. Muscular tissue interrelates with others mechanistically, but it also forms humoral harmony in which the muscular tissue has a dominant and determining role. This phenomenon is relevant for pathophysiology of chronical low-grade inflammation, muscle loss, origin and development of noncommunicable diseases. These cause approx. 75% of deaths in population. Solution of this problem has been considerably affecting cost-effectivity in the health care system today and thus the state economy as well. Therapeutic recommendations together with the whole health care strategy need to be adjusted according to the above mentioned findings, including the patients with osteoporosis and osteopenia. There are, so far, no known suitable medicaments which would be used for solving problematics of muscular loss. This is a reason why more attention needs to be paid to the recommended physical regime (150 min/week, according to WHO) and dietary regime (basic diet + proteins). We have built a complex diagnostic and therapeutic program for our patients. Definition of pathological values follows EWGSOP and WHO. Methods: Patient cohorts: Osteoporosis 60-70 y, 70-80 y, osteopenia 60- 70 y and 70-80 y. Control group for osteopenia 60-80 y. We followed information about the control group during the COVID-19 time period, particularly their physical activity regime. 1) Instructions for patients used to be delivered in a form of lectures for different age groups. Now, during the COVID-19 time period, instructions are provided individually. 2) SarQol (Sarcopenia and Quality of Life) questionnaire (Beaudart 2015). Czech version used with agreement from sarqol.org. Assessment is now done individually only. 3) Measuring hand-grip is standardised according to Southampton protocol with a dynamometer Jamar. Values of 20 kg are found pathological (female values). 4) Determination of BMI, according to WHO, the border figure is 25 or 30 kg/m2 . 5) DXA method determination of selective muscle index as a measure for muscle mass. ALM/Ht2 for age above 60 y, border value for sarcopenia is ≤5.45 kg/m2 . 6) From laboratory examinations we aimed at IL-6 and CRP(hs) - these are not a subject of this report. Results: Conclusion: We have been running a physical activity and dietary program for our patients for more than 2 y. Physical activity is aimed at 150 min/week (WHO) and basic diet aims at the Mediterranean type + protein saturation, considerable stress is given to whey proteins enriched with Leucin. Patients have been instructed. Due to adherence to this regime we are able to report on statistically relevant changes in muscle power and also in complex muscle mass, even during the current pandemic situation. (Table Presented).
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PURPOSE: In patients with a cardiac pacemaker, pocket-related complications such as nerve impairment or bone fractures are infrequent. We present a man with a fracture of the 4th rib several months after pacemaker implantation. CASE PRESENTATION: A 74-year-old man, with a left prepectoral pacemaker implanted 13 months ago, presented complaining of chest pain. The pain started after a sudden trunk rotation and right arm flexion movement with a crack. There was tenderness to palpation and crepitation over the left upper ribs. Computed tomography identified a non-displaced fracture line in the anterior aspect of the left 4th rib. After kinesiotaping and activity restriction, pain alleviated. CONCLUSION: Pacemaker implantation might have caused shoulder dysfunction and pectoral tightness resulting in reduced flexibility of the trunk. Consequently, a reaching motion of the arm with a trunk rotation might have directed rotational force vectors towards the osteopenic left 4th rib causing a fragility fracture. In elderly with a pacemaker, osteopenia and concomitant sarcopenia may create a predisposition to this atypical complication.