Impact of previous glucocorticoid therapy on diagnostic accuracy of [18F] FDG PET-CT in giant cell arteritis.

OBJECTIVE: To evaluate the impact of prior glucocorticoid (GC) treatment on the diagnostic accuracy of 18F-FDG PET-CT in giant cell arteritis (GCA). METHODS: Retrospective study of a consecutive cohort of 85 patients with proven GCA who received high-dose GC before PET-CT. RESULTS: Thirty-nine patients previously treated with methylprednisolone (MP) boluses, of whom 37% were PET-CT (uptakes grade 3 or 2) positive. The positivity rate was 80% with MP doses of 125 mg, 33% with 250 or 500 mg, and 0% with doses of 1 g.  If we also classify as positive those cases with a grade 1 uptake (with a circumferencial uptake and smooth linear or long segmental pattern, possibly indicative of "apparently inactive" vasculitis), the positivity rate increases to 62% (100%, 50-60%, and 33% for the different MP doses, respectively). In patients with new-onset GCA treated with high-dose oral GC, PET-CT positivity was 54.5% in patients treated for less than two weeks, 38.5% in those treated for 2 to 4 weeks, and 25% in those treated for 4 to 6 weeks (increasing to 91%, 77%, and 50%, respectively, if we include cases with grade 1 uptake and these characteristics). In patients with relapsing/refractory GCA, or who developed GCA having a prior history of PMR, PET-CT positivity reached 54% despite long-term treatment with low-to-moderate doses of GC (68% including cases with a grade 1 uptake). CONCLUSION: A late 18F-FDG PET-CT (beyond the first 10 days of treatment) can also be informative in a considerable percentage of cases.

A prospective study of lung disease in a cohort of early rheumatoid arthritis patients.

Lung disease is common in patients with rheumatoid arthritis (RA). The onset of lung involvement in RA is not well known. The objective is to describe the features and evolution of lung involvement in early RA, its relationship with disease activity parameters, smoking and treatments. Consecutive patients with early RA without respiratory symptoms were included and tracked for 5 years. Lung assessment included clinical, radiological and pulmonary function tests at diagnosis and during follow-up. Peripheral blood parameters (erythrocyte sedimentation rate, C reactive protein, rheumatoid factor and anti-citrullinated peptide autoantibodies) and scales of articular involvement, such as DAS28-CRP, were evaluated. 40 patients were included and 32 completed the 5-year follow up. 13 patients presented lung involvement in the initial 5 years after RA diagnosis, 3 of them interstitial lung disease. Significant decrease of diffusion lung transfer capacity of carbon monoxide over time was observed in six patients, 2 of them developed interstitial lung disease. DLCO decrease was correlated with higher values of CRP and ESR at diagnosis. Methotrexate was not associated with DLCO deterioration or lung disease development. Subclinical progressive lung disease correlates with RA activity parameters. Smoking status and methotrexate were not associated with development or progression of lung disease.

Rheumatic immune-related adverse events in patients on anti-PD-1 inhibitors: Fasciitis with myositis syndrome as a new complication of immunotherapy.

OBJECTIVE: To evaluate the prevalence and type of rheumatic immune-related adverse events (IRAEs) in patients receiving programmed cell death protein-1 (PD-1) inhibitors. METHODS: This is a single-center prospective observational study, including all cancer patients receiving PD-1 inhibitors between January 2016 and January 2018. RESULTS: During the period analyzed, we evaluated a total of 11 patients. No patient had pre-existing rheumatic or autoimmune disease. In this period, a total of 220 patients were treated with PD1 inhibitors in our center; therefore, the estimated minimum prevalence of rheumatic IRAEs related to these therapies in our population was 5%. The rheumatic IRAEs evaluated included 5 cases of oligo- or polyarthritis, 1 with a polymialgia rheumatica-type syndrome, 2 cases of immunotherapy-induced sicca syndrome, 2 patients who presented symptomatic inflammatory myositis with fasciitis in lower extremities, and 1 patient with a paraneoplastic acral vascular syndrome. The median time to IRAE after anti-PD1 exposure was 8 weeks (range: 2-24). In 5 patients, immunotherapy was discontinued (due to the adverse effect in three and cancer progression in two). In general terms the symptoms resolved completely with symptomatic treatment. Disease-modifying antirheumatic drugs were needed for 2 patients. CONCLUSION: Rheumatic IRAEs should be kept in mind during the follow-up and evaluation of patients treated with PD-1 inhibitors. The concomitant development of symptomatic inflammatory myositis with fasciitis in lower extremities appears to be a new adverse effect of anti-PD-1 immunotherapy. Additional studies are needed to determine how to adequately control and manage these complications.

La hipovitaminosis D grave al ingreso en el paciente crítico se asocia a fracaso renal agudo y mal pronóstico / Severe vitamin D deficiency upon admission in critically ill patients is related to acute kidney injury and a poor prognosis

OBJETIVOS: Determinar la prevalencia de hipovitaminosis D al ingreso en el Servicio de Medicina Intensiva (SMI), así como su asociación con el pronóstico del paciente crítico. DISEÑO: Análisis observacional prospectivo llevado a cabo desde enero a noviembre de 2015. Los pacientes incluidos fueron seguidos hasta su fallecimiento o alta hospitalaria. Ámbito: SMI polivalente de un hospital universitario. PACIENTES: Todos los individuos adultos que ingresaron en el SMI durante el periodo de estudio y que no presentaban factores conocidos que pudieran alterar los valores sanguíneos de 25(OH)D. INTERVENCIONES: Determinación de los niveles séricos de 25(OH)D en las primeras 24 h de ingreso en el SMI. Principales variables de interés: Prevalencia de hipovitaminosis D al ingreso en UCI y mortalidad a los 28 días. RESULTADOS: Se incluyeron 135 individuos. El 74% de los pacientes presentó niveles bajos de 25(OH)D en el momento de su ingreso en el SMI. El grupo de pacientes que fallecieron presentaba niveles significativamente inferiores al grupo de pacientes que sobrevivieron (8,14 ng/mL [6,17-11,53] vs. 12 ng/mL [7,1-20,30], p = 0,04) y el valor en sangre de 25(OH)D al ingreso se mostró como factor de riesgo independiente en el análisis multivariado (OR 2,86; IC 95% 1,05-7,86, p = 0,04). La curva ROC fue de 0,61 (IC 95% 0,51-0,75) y el mejor punto de corte para predecir mortalidad fue de 10,9 ng/mL. Los pacientes con valores de 25(OH)D < 10,9 ng/mL también presentaron mayores tasas de fracaso renal agudo (13 vs. 29%, p = 0,02). CONCLUSIÓN: Existe una elevada prevalencia de hipovitaminosis D en el momento de ingreso en el SMI. La hipovitaminosis D severa (25[OH]D < 10,9 ng/mL) al ingreso en el SMI se asocia a mayor incidencia de fracaso renal agudo y mayor mortalidad

OBJECTIVES: To evaluate the prevalence of vitamin D deficiency in critically ill patients upon admission to an Intensive Care Unit (ICU) and its prognostic implications. DESIGN: A single-center, prospective observational study was carried out from January to November 2015. Patients were followed-up on until death or hospital discharge. SETTING: The department of Critical Care Medicine of a university hospital. PATIENTS: All adults admitted to the ICU during the study period, without known factors capable of altering serum 25(OH)D concentration. INTERVENTIONS: Determination of serum 25(OH)D levels within the first 24 h following admission to the ICU. Main variables of interest: Prevalence and mortality at 28 days. RESULTS: The study included 135 patients, of which 74% presented deficient serum 25(OH)D levels upon admission to the ICU. Non-survivors showed significantly lower levels than survivors (8.14 ng/ml [6.17-11.53] vs. 12 ng/ml [7.1-20.30]; P = .04], and the serum 25(OH)D levels were independently associated to mortality (OR 2.86; 95% CI 1.05-7.86; P = .04]. The area under the ROC curve was 0.61 (95% CI 0.51-0.75), and the best cut-off point for predicting mortality was 10.9 ng/ml. Patients with serum 25(OH)D < 10.9 ng/ml also showed higher acute kidney injury rates (13 vs. 29%; P = .02). CONCLUSION: Vitamin D deficiency is highly prevalent upon admission to the ICU. Severe Vitamin D deficiency (25[OH]D < 10.9 ng/ml) upon admission to the ICU is associated to acute kidney injury and mortality

Severe vitamin D deficiency upon admission in critically ill patients is related to acute kidney injury and a poor prognosis. / La hipovitaminosis D grave al ingreso en el paciente crítico se asocia a fracaso renal agudo y mal pronóstico.

OBJECTIVES: To evaluate the prevalence of vitamin D deficiency in critically ill patients upon admission to an Intensive Care Unit (ICU) and its prognostic implications. DESIGN: A single-center, prospective observational study was carried out from January to November 2015. Patients were followed-up on until death or hospital discharge. SETTING: The department of Critical Care Medicine of a university hospital. PATIENTS: All adults admitted to the ICU during the study period, without known factors capable of altering serum 25(OH)D concentration. INTERVENTIONS: Determination of serum 25(OH)D levels within the first 24h following admission to the ICU. MAIN VARIABLES OF INTEREST: Prevalence and mortality at 28 days. RESULTS: The study included 135 patients, of which 74% presented deficient serum 25(OH)D levels upon admission to the ICU. Non-survivors showed significantly lower levels than survivors (8.14ng/ml [6.17-11.53] vs. 12ng/ml [7.1-20.30]; P=.04], and the serum 25(OH)D levels were independently associated to mortality (OR 2.86; 95% CI 1.05-7.86; P=.04]. The area under the ROC curve was 0.61 (95% CI 0.51-0.75), and the best cut-off point for predicting mortality was 10.9ng/ml. Patients with serum 25(OH)D<10.9ng/ml also showed higher acute kidney injury rates (13 vs. 29%; P=.02). CONCLUSION: Vitamin D deficiency is highly prevalent upon admission to the ICU. Severe Vitamin D deficiency (25[OH]D<10.9ng/ml) upon admission to the ICU is associated to acute kidney injury and mortality.

Spanish consensus on treat to target for osteoporosis.

To reach a Spanish expert consensus on a treat-to-target strategy in osteoporosis, a Delphi Consensus Study has been developed. Most of the experts (59.8%) were rheumatologist with a mean clinical experience of 21.3 years (SD 8.5). Consensus was achieved for 70% of the items. Therapeutic objectives, patient follow-up scheme, treatment failure criteria, and appropriate treatment choice for use in T2T strategy in Spain have been defined. INTRODUCTION: The paper aims to achieve a Spanish expert consensus on a treat-to-target (T2T) strategy in osteoporosis. METHODS: A scientific committee led the project and was involved in expert panel identification and Delphi questionnaire development. Two Delphi rounds were completed. The first-round questionnaire included 24 items and assessed, using a seven-point Likert scale, the experts' wish (W) and prognosis (P) in 5 years for each topic (applicability, therapeutic objectives, patient follow-up, and possible treatment to be prescribed). Items for which there was no consensus in the first round were included in the second round. Consensus was defined as ≥75% agreement (somewhat/mostly/entirely agree) or disagreement (somewhat/mostly/entirely disagree) responses. RESULTS: Of the experts, 112 and 106 completed the first and second rounds, respectively. 59.8% were rheumatologists with a mean clinical experience of 21.3 years (SD 8.5). Consensus was achieved for 70% of the items, and was established regarding the utility of a T2T strategy to define therapeutic objectives, optimal follow-up, and therapeutic algorithm. Participants agreed on the utility of the bone mineral density (BMD) value (T-score >-2.5 SD for spine and >-2.5/-2.0 SD for femoral neck), lack of fractures, and fracture risk (FRAX) as therapeutic objectives. For measuring BMD changes, consensus was achieved on the suitability of hip and femoral neck locations. Experts agreed to consider treatment failure as when a significant BMD gain could not be achieved, or when a new fracture occurs within 2-3 years. There was consensus that all proposed therapies should achieve a therapeutic target through T2T strategy (treatments with the highest consensus scores were denosumab and teriparatide). CONCLUSION: The therapeutic objectives, patient follow-up scheme, treatment failure criteria, and appropriate treatment choice for use in T2T strategy in Spain have been established by a panel of experts. Some aspects nevertheless still require further analysis.

The global burden attributable to low bone mineral density.

INTRODUCTION: The Global Burden of Disease Study 2010 estimated the worldwide health burden of 291 diseases and injuries and 67 risk factors by calculating disability-adjusted life years (DALYs). Osteoporosis was not considered as a disease, and bone mineral density (BMD) was analysed as a risk factor for fractures, which formed part of the health burden due to falls. OBJECTIVES: To calculate (1) the global distribution of BMD, (2) its population attributable fraction (PAF) for fractures and subsequently for falls, and (3) the number of DALYs due to BMD. METHODS: A systematic review was performed seeking population-based studies in which BMD was measured by dual-energy X-ray absorptiometry at the femoral neck in people aged 50 years and over. Age- and sex-specific mean ± SD BMD values (g/cm(2)) were extracted from eligible studies. Comparative risk assessment methodology was used to calculate PAFs of BMD for fractures. The theoretical minimum risk exposure distribution was estimated as the age- and sex-specific 90th centile from the Third National Health and Nutrition Examination Survey (NHANES III). Relative risks of fractures were obtained from a previous meta-analysis. Hospital data were used to calculate the fraction of the health burden of falls that was due to fractures. RESULTS: Global deaths and DALYs attributable to low BMD increased from 103 000 and 3 125 000 in 1990 to 188 000 and 5 216 000 in 2010, respectively. The percentage of low BMD in the total global burden almost doubled from 1990 (0.12%) to 2010 (0.21%). Around one-third of falls-related deaths were attributable to low BMD. CONCLUSIONS: Low BMD is responsible for a growing global health burden, only partially representative of the real burden of osteoporosis.

Características clínicas y económicas asociadas a la diabetes tipo 2 / Clinical and economic characteristics associated with type 2 diabetes

Objetivos. La diabetes mellitus tipo 2 (DM2) suele acompañarse de diversas comorbilidades que pueden incrementar el coste de su tratamiento. No conocemos estudios que hayan determinado los costes asociados al tratamiento de los enfermos con DM2 que, además padecen sobrepeso (SP), obesidad (OBE) o hipertensión arterial (HTA). Hemos examinado el gasto sanitario y la incidencia de enfermedad cardiovascular (ECV) en estos enfermos. Pacientes y métodos. Diseño observacional-multicéntrico de carácter retrospectivo. Se incluyeron pacientes entre 40-99 años que demandaron atención durante 2010 en Badalona (Barcelona, España). Se establecieron 2 grupos de estudio: presencia-DM2 y ausencia-DM2 (referencia/control), y 6 subgrupos: DM2-solo, DM2-HTA, DM2-SP, DM2-OBE; DM2-HTA-SP y DM2-HTA-OBE. Las principales medidas fueron: comorbilidad, síndrome metabólico (SM), complicaciones (hipoglucemias, ECV) y costes (sanitarios; no-sanitarios). El seguimiento se realizó durante 2 años. Resultados. Se reclutaron 26.845 pacientes. La prevalencia de DM2 fue del 14,0%. Los sujetos con DM2 mostraron mayor edad (67,8 vs. 59,7 años) y porcentaje de varones (51,3 vs. 43,0%), p<0,001. La DM2 se asoció principalmente a OBE (OR:2,8; IC 95%: 2,4-3,1), HTA (OR:2,4; IC 95%: 2,2-2,6) y SP (OR:1,9; IC 95%: 1,7-2,2). La distribución por subgrupos osciló entre el 6,7% para los enfermos que solo presentaban DM2, y el 26,1% para los diagnosticados de DM2-HTA-SP y el 34,1% para los que tenían DM2-HTA-OBE. El SM se identificó en el 75,4% y un 37,5% refirió algún episodio de hipoglucemia. El coste-total/paciente con DM2 al cabo de 2 años fue de 4.458€. Por subgrupos fue de DM2: 3.431€; DM2-HTA: 4.075€; DM2-SP: 4.057€; DM2-OBE: 4.915€; DM2-HTA-SP: 4.203€ y DM2-HTA-OBE: 5.02€ (p<0,001). La tasa de ECV en los enfermos con DM2 fue del 4,7%, y del 1,7% en los que no padecían esta condición (p<0,001). Conclusiones. La OBE es una comorbilidad asociada a la DM2 que origina un mayor gasto sanitario que la HTA. La presencia de estas comorbilidades ocasiona mayores tasas de ECV (AU)

Objectives. Type 2 diabetes mellitus (DM2) is usually accompanied by various comorbidities that can increase the cost of treatment. We are not aware of studies that have determined the costs associated with treating DM2 patients with co-morbidities such as overweight (OW), obesity (OBE) or arterial hypertension (AHT). The aim of the study was to examine the health-related costs and the incidence of cardiovascular disease (CVD) in these patients. Patients and methods. Multicenter, observational retrospective design. We included patients 40-99 years of age who requested medical attention in 2010 in Badalona (Barcelona, Spain). There were two study groups: those with DM2 and without DM2 (reference group/control), and six subgroups: DM2-only, DM2-AHT, DM2-OW, DM2-OBE; DM2-AHT-OW and DM2-AHT-OBE. The main outcome measures were: co-morbidity, metabolic syndrome (MS), complications (hypoglycemia, CVD) and costs (health and non-health). Follow-up was carried out for two years. Results. A total of 26,845 patients were recruited. The prevalence of DM2 was 14.0%. Subjects with DM2 were older (67.8 vs. 59.7 years) and more were men (51.3 vs. 43.0%), P<.001. DM2 status was associated primarily with OBE (OR=2.8, CI=2.4-3.1), AHT (OR=2.4, CI=2.2-2.6) and OW (OR=1.9, CI=1.7-2.2). The distribution by subgroups was: 6.7% of patients had only DM2, 26.1% had DM2, AHT and OW, and 34.1% had DM2, AHT, and OBE. Some 75.4% had MS and 37.5% reported an episode of hypoglycemia. The total cost/patient with DM2 was €4,458. By subgroups the costs were as follows: DM2: €3,431; DM2-AHT: €4,075; DM2-OW: €4,057; DM2-OBE: €4,915; DM2-AHT-OW: €4,203 and DM2-AHT-OBE: €5,021, P<.001. The CVD rate among patients with DM2 was 4.7 vs. 1.7% in those without DM2 P<.001. Conclusions. Obesity is a comorbidity associated with DM2 that leads to greater healthcare costs than AHT. The presence of these comorbidities causes increased rates of CVD (AU)

Streptococcal vertebral osteomyelitis: multiple faces of the same disease.

The role of Streptococcus species as an aetiological microorganism of vertebral osteomyelitis (VO) is considered to be of little relevance. We aimed to describe a large number of cases of streptococcal vertebral osteomyelitis (SVO), to analyze the clinical features associated with different Streptococcus species, and to compare them with a cohort of patients with VO caused by Staphylococcus aureus. An incidence study and a retrospective, multicenter, observational clinical study of cases of SVO (1991-2011) were performed. Statistical comparison of SVO by different species and between them and staphylococcal VO was carried out. Over the whole period there was an increasing incidence in the number of VOs and SVOs per year (p <0.05). Among 58 cases of SVO, those caused by non-viridans streptococcus (Streptococcus pneumoniae, Streptococcus agalactiae and Streptococcus pyogenes; n = 26) mimicked VO by S. aureus, and presented with more fever, neurological symptoms and paravertebral abscesses in comparison with those caused by the viridans group (remaining species). In contrast, the latter have a sub-acute clinical picture and were associated with the presence of endocarditis (p <0.05). Among non-viridans SVOs, concomitant infection was specifically related to S. pneumoniae (p <0.05). In conclusion, SVO presents a wide range of clinical patterns. The relationship between VO and diagnosis of endocarditis was established with SVO caused by the viridans group. Whereas non-viridans SVO mimics acute characteristics of VO caused by S. aureus, cases of viridans SVO are significantly more likely to have a sub-acute clinical presentation. The increased incidence of SVO during the last decades could support a new epidemiological scenario.

Clinical and economic characteristics associated with type 2 diabetes.

OBJECTIVES: Type 2 diabetes mellitus (DM2) is usually accompanied by various comorbidities that can increase the cost of treatment. We are not aware of studies that have determined the costs associated with treating DM2 patients with co-morbidities such as overweight (OW), obesity (OBE) or arterial hypertension (AHT). The aim of the study was to examine the health-related costs and the incidence of cardiovascular disease (CVD) in these patients. PATIENTS AND METHODS: Multicenter, observational retrospective design. We included patients 40-99 years of age who requested medical attention in 2010 in Badalona (Barcelona, Spain). There were two study groups: those with DM2 and without DM2 (reference group/control), and six subgroups: DM2-only, DM2-AHT, DM2-OW, DM2-OBE; DM2-AHT-OW and DM2-AHT-OBE. The main outcome measures were: co-morbidity, metabolic syndrome (MS), complications (hypoglycemia, CVD) and costs (health and non-health). Follow-up was carried out for two years. RESULTS: A total of 26,845 patients were recruited. The prevalence of DM2 was 14.0%. Subjects with DM2 were older (67.8 vs. 59.7 years) and more were men (51.3 vs. 43.0%), P<.001. DM2 status was associated primarily with OBE (OR=2.8, CI=2.4-3.1), AHT (OR=2.4, CI=2.2-2.6) and OW (OR=1.9, CI=1.7-2.2). The distribution by subgroups was: 6.7% of patients had only DM2, 26.1% had DM2, AHT and OW, and 34.1% had DM2, AHT, and OBE. Some 75.4% had MS and 37.5% reported an episode of hypoglycemia. The total cost/patient with DM2 was €4,458. By subgroups the costs were as follows: DM2: €3,431; DM2-AHT: €4,075; DM2-OW: €4,057; DM2-OBE: €4,915; DM2-AHT-OW: €4,203 and DM2-AHT-OBE: €5,021, P<.001. The CVD rate among patients with DM2 was 4.7 vs. 1.7% in those without DM2 P<.001. CONCLUSIONS: Obesity is a comorbidity associated with DM2 that leads to greater healthcare costs than AHT. The presence of these comorbidities causes increased rates of CVD.

Consecuencias clínicas y económicas de la combinación de metformina con inhibidores de la dipeptidilpeptidasa en pacientes con diabetes tipo 2 / Clinical and economical consequences of the combination of metformin with dipeptidyl peptidase inhibitors in type 2 diabetes patients

ANTECEDENTES Y OBJETIVO: Existen diversos tratamientos farmacológicos hipoglucemiantes de segunda línea cuya eficacia, seguridad y perfil económico no se ha precisado en nuestro medio. Hemos analizado las consecuencias clínicas (adherencia al tratamiento antidiabético, control metabólico, hipoglucemias y complicaciones macrovasculares) y económicas (uso de recursos y costes) de la combinación de metformina con inhibidores de la dipeptidilpeptidasa (IDPP4) en pacientes con diabetes tipo 2 en comparación con metformina y otros fármacos hipoglucemiantes. PACIENTES Y MÉTODOS: Estudio observacional multicéntrico de carácter retrospectivo. Se incluyeron pacientes de ≥30 años tratados con metformina que iniciaron un segundo tratamiento antidiabético durante los años 2008-2009. Se establecieron 2 grupos de pacientes: metformina con IDPP4 y metformina con otros fármacos antidiabéticos. Las principales medidas fueron: la comorbilidad, el cumplimiento/persistencia, el control metabólico (hemoglobina glicosilada<7%), complicaciones (hipoglucemias, macrovasculares) y costes totales. El seguimiento se realizó durante 2 años. RESULTADOS: Se reclutaron 2.067 pacientes (edad media: 66,6 años; 53,1% varones). En el grupo metformina+IDPP4 se analizaron 519 pacientes (25,1%) y en el grupo metformina+otros fármacos antidiabéticos: 1.548 pacientes (74,9%). Los enfermos tratados con IDPP4, en comparación con los que recibieron metformina asociada a otros antidiabéticos, mostraron un mejor cumplimiento (70,3 vs. 59,6%), persistencia (63,4 vs. 51,0%) y control metabólico (64,3 vs. 59,6%) (p < 0,001). También presentaron una menor proporción de hipoglucemias (13,9 vs. 44,3%), eventos cardiovasculares (3,7 vs. 7,6%) y costes totales (2.347 vs. 2.682 €) (p < 0,05) durante los 2 años del estudio. CONCLUSIONES: A pesar de las limitaciones del estudio, los pacientes en tratamiento con metformina asociada a IDPP4 mostraron un mayor cumplimiento terapéutico, control metabólico y menores tasas de hipoglucemias que los enfermos tratados con metformina asociada a otros antidiabéticos

BACKGROUNDS AND OBJECTIVE: There are different second line glucose lowering drugs whose efficacy, safety and economic profile have not been established in our setting. We have analyzed the clinical (diabetic treatment adherence, metabolic control, hypoglycemia and macrovascular complications) and economic (resource use and costs) consequences of the combination of metformin with dipeptidyl peptidase inhibitors (DPPIV) in patients with type 2 diabetes. Patients and methods. We conducted a multicenter, observational and retrospective study. Patients ≥30 years treated with metformin who initiated a second antidiabetic treatment during 2008-2009 were enrolled in the study. Two groups of patients were established: a) metformin with DPPIV and metformin with other diabetic drugs. The main measurements were comorbidity, compliance/persistence, metabolic control (glycosylated hemoglobin <7%), complications (hypoglycemia, macrovascular) and total costs. Patients were followed-up for 2 years. Results. A total of 2,067 patients were enrolled (mean age: 66.6 years, 53.1% male). Of these, 519 patients (25.1%) were analyzed in the metformin+DPPIV group and 1,548 patients (74.9%) in the group metformin+other antidiabetic drug. The DPPIV group patients showed better compliance (70.3 vs. 59.6%), persistence (63.4 vs. 51.0%) and metabolic control (64.3 vs. 59.6%), respectively (P<.001) compared to the other group. They also showed a lower proportion of hypoglycemia (13.9 vs. 44.3%), cardiovascular events (3.7 vs. 7.6%) and total costs (2,347 vs. € 2,682), P<.05. Conclusions. Despite the limitations of the study, patients treated with metformin associated to DPPIV were more likely to show increased adherence, metabolic control and lower rates of hypoglycemia than those treated with metformin associated to other antidiabetics

Clinical and economical consequences of the combination of metformin with dipeptidyl peptidase inhibitors in type 2 diabetes patients.

BACKGROUNDS AND OBJECTIVE: There are different second line glucose lowering drugs whose efficacy, safety and economic profile have not been established in our setting. We have analyzed the clinical (diabetic treatment adherence, metabolic control, hypoglycemia and macrovascular complications) and economic (resource use and costs) consequences of the combination of metformin with dipeptidyl peptidase inhibitors (DPPIV) in patients with type 2 diabetes. PATIENTS AND METHODS: We conducted a multicenter, observational and retrospective study. Patients ≥30 years treated with metformin who initiated a second antidiabetic treatment during 2008-2009 were enrolled in the study. Two groups of patients were established: a) metformin with DPPIV and metformin with other diabetic drugs. The main measurements were comorbidity, compliance/persistence, metabolic control (glycosylated hemoglobin <7%), complications (hypoglycemia, macrovascular) and total costs. Patients were followed-up for 2 years. RESULTS: A total of 2,067 patients were enrolled (mean age: 66.6 years, 53.1% male). Of these, 519 patients (25.1%) were analyzed in the metformin+DPPIV group and 1,548 patients (74.9%) in the group metformin+other antidiabetic drug. The DPPIV group patients showed better compliance (70.3 vs. 59.6%), persistence (63.4 vs. 51.0%) and metabolic control (64.3 vs. 59.6%), respectively (P<.001) compared to the other group. They also showed a lower proportion of hypoglycemia (13.9 vs. 44.3%), cardiovascular events (3.7 vs. 7.6%) and total costs (2,347 vs. € 2,682), P<.05. CONCLUSIONS: Despite the limitations of the study, patients treated with metformin associated to DPPIV were more likely to show increased adherence, metabolic control and lower rates of hypoglycemia than those treated with metformin associated to other antidiabetics.

Early changes in biochemical markers of bone formation during teriparatide therapy correlate with improvements in vertebral strength in men with glucocorticoid-induced osteoporosis.

UNLABELLED: Changes of the bone formation marker PINP correlated positively with improvements in vertebral strength in men with glucocorticoid-induced osteoporosis (GIO) who received 18-month treatment with teriparatide, but not with risedronate. These results support the use of PINP as a surrogate marker of bone strength in GIO patients treated with teriparatide. INTRODUCTION: To investigate the correlations between biochemical markers of bone turnover and vertebral strength estimated by finite element analysis (FEA) in men with GIO. METHODS: A total of 92 men with GIO were included in an 18-month, randomized, open-label trial of teriparatide (20 µg/day, n = 45) and risedronate (35 mg/week, n = 47). High-resolution quantitative computed tomography images of the 12th thoracic vertebra obtained at baseline, 6 and 18 months were converted into digital nonlinear FE models and subjected to anterior bending, axial compression and torsion. Stiffness and strength were computed for each model and loading mode. Serum biochemical markers of bone formation (amino-terminal-propeptide of type I collagen [PINP]) and bone resorption (type I collagen cross-linked C-telopeptide degradation fragments [CTx]) were measured at baseline, 3 months, 6 months and 18 months. A mixed-model of repeated measures analysed changes from baseline and between-group differences. Spearman correlations assessed the relationship between changes from baseline of bone markers with FEA variables. RESULTS: PINP and CTx levels increased in the teriparatide group and decreased in the risedronate group. FEA-derived parameters increased in both groups, but were significantly higher at 18 months in the teriparatide group. Significant positive correlations were found between changes from baseline of PINP at 3, 6 and 18 months with changes in FE strength in the teriparatide-treated group, but not in the risedronate group. CONCLUSIONS: Positive correlations between changes in a biochemical marker of bone formation and improvement of biomechanical properties support the use of PINP as a surrogate marker of bone strength in teriparatide-treated GIO patients.

Two simultaneous botulism outbreaks in Barcelona: Clostridium baratii and Clostridium botulinum.

Botulism is a severe neuroparalytic disorder that can be potentially life-threatening. In Barcelona, Spain, no outbreaks had been reported in the past 25 years. However, in September 2011, two outbreaks occurred involving two different families. A rare case of Clostridium baratii which produced a neurotoxin F outbreak was detected in five family members who had shared lunch, and several days before that another family was affected by C. botulinum toxin A which was probably present in homemade pâté.

Arthritis related to systemic meningococcal disease: 34 years' experience.

The purpose of this investigation was to assess the clinical characteristics, therapeutic aspects, and outcome of arthritis related to invasive meningococcal disease (IMD). All episodes of bacterial meningitis and IMD are recorded systematically. We selected all episodes of IMD, with or without meningitis, that presented arthritis. From 1977 to 2010, 522 episodes of IMD were treated. Thirty-nine of these (7.5 %, 26 women, mean age 33 years) presented arthritis. Of these 39, 37 (95 %) presented skin lesions and 31 (79 %) had meningitis. Twenty (51 %) had positive blood cultures and six (15 %) had shock. No differences were found in skin lesions, shock, or bacteremia compared to cases without arthritis. In contrast to other septic forms, arthritis related to IMD was cured with short antibiotic therapy and without surgical drainage. There was no mortality. All patients recovered and none presented joint sequelae; however, 13 adult patients (33 %) required long-term treatment with steroids due to persistent symptoms. Arthritis related to IMD most frequently affects the knees and ankles, and may be a cause of fever relapse. Short antibiotic therapy is enough in all cases and surgical drainage is not needed. In some adult patients, especially those over 50 years of age, evolution is torpid and steroid therapy may be required in order to achieve recovery.

Adult onset Still's disease: review of 41 cases.

OBJECTIVES: To describe the clinical, laboratory and radiological features, treatment and prognosis of patients with adult onset Still's disease (AOSD). METHODS: Specific clinical features were retrospectively recorded in 41 patients fulfilling the Yamaguchi criteria. Patients were reviewed in two academic hospitals with a referral area of 700,000-1,000,000 inhabitants. Laboratory tests including haemogram, ferritin, biochemistry and autoimmunity were reviewed. Radiological studies, treatment and ACR functional class were determined. RESULTS: Forty-one patients with AOSD were identified, 25 of whom were female. Mean age at diagnosis: 38.19 years (range 17-68). Feverish polyarthritis was the most common clinical presentation. Acute phase reactants were invariably high in all patients. Serum ferritin levels were elevated in 86% of patients. Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies) were negative in all patients except one. The course of the disease was monocyclic in 44% of the patients, polycyclic in 26%, and chronic articular in 30%. ACR class was as follows: 29 (72.5%) class I, 7 (17.5%) class II, 2 (5%) class III and 2 (5%) class IV. As for the treatment received, aspirin or NSAIDs controlled the disease in eight patients (19.5%) and high-dose corticosteroids (0.5-1 mg/kg/day) in 32 (78%). Almost half of the patients (49%) required an additional diseasemodifying agent, usually methotrexate. Finally, in seven of them (17%) a biological treatment with TNF-α or specially anti-IL-1 had to be added to control the disease. CONCLUSIONS: The clinical and laboratory findings were similar to previous studies. Anti-CCP antibodies were almost always negative. A monocyclic course was associated with a good prognosis. Most of the patients were in ACR functional class I and II. Biological agents were required in 7 patients (17%).