Frailty in HIV infected people: a new risk factor for bone mineral density loss.

OBJECTIVE: The study aims to assess the association between bone mineral density (BMD) and frailty in a cohort of HIV-infected patients. DESIGN: A cross-sectional study in an HIV outpatient unit where nearly 1000 patients are monitored. METHODS: Study participants undergoing bone densitometry were proposed an evaluation of frailty using criteria of the Cardiovascular Health Study (CHS) and the Study of Osteoporotic Fractures (SOF). Frailty markers were weight-loss, self-reported exhaustion, physical activity, grip strength, chair stands, and slow gait. Patients' characteristics were collected from an electronic medical record. Associations of frailty with BMD and osteoporosis were tested using multivariate linear and logit regression models, respectively. RESULTS: In total, 175 HIV-infected patients, 121 (69.14%) men, were analyzed. Prevalence of frailty markers, osteopenia, and osteoporosis were comparable among sexes. Despite a younger age, spinal and femoral neck BMD were lower in women (P < 0.05). Linear regression model adjusting by age, duration of HIV follow-up, BMI, smoking status, osteoarthritis, osteoporosis treatment, and the age at menopause showed a negative association of spinal and femoral BMD with frailty according to SOF criteria in women (P < 0.05). In men, SOF-defined frailty was associated with osteoporosis (odds ratio 28.79; 95% confidence interval 2.15-386.4) in a model adjusting for age, duration of HIV follow-up, CD4 nadir, CD4 T-cell count, tobacco consumption, exposure to tenofovir (TDF) and protease inhibitors. No significant associations were found between BMD and CHS-defined frailty. CONCLUSION: Our study shows that frailty according to SOF criteria is associated with low spinal BMD values in female and osteoporosis in male HIV-infected patients.

Osteoporosis prevention among chronic glucocorticoid users: results from a public health insurance database.

INTRODUCTION: Long-term glucocorticoid therapy is the leading cause of secondary osteoporosis. The management of glucocorticoid-induced osteoporosis (GIOP) seems to be inadequate in many European countries. OBJECTIVE: To evaluate the rate of screening and treatment of GIOP. DESIGN: Information was collected from a national public health-insurance database in our geographic area of Provence-Alpes-Côte-d'Azur and in Corsica, from September 2009 through August 2011. PATIENTS: We identified participants aged 15 years and over starting glucocorticoid therapy (≥7.5 mg of prednisone equivalent per day during at least 90 days consecutive). This cohort was compared with an age-matched and sex-matched population that did not receive glucocorticoids. MAIN OUTCOME MEASURES: Bone mass, prescription of bone antiresorptive medication and use of calcium and/or vitamin D treatment. RESULTS: We identified 32 812 patients who were prescribed glucocorticoid therapy, yielding 1% prevalence. Incidence of glucocorticoid therapy was 2.8/1000 inhabitants/year. Males represented 44%, the mean age was 58 years. The median prednisone-equivalent dose was 11 mg/day (IQR 9-18 mg/day). 8% underwent bone mass measurement. Calcium and/or vitamin D, and bisphosphonates were prescribed in 18% and 12%, respectively. Results were lower for the control population: 3% underwent bone mass measurement and 3% received bisphosphonate therapy. The rates of osteodensitometry and treatments were higher in women over 55 years of age than in men and women 55 years of age and younger, and also when glucocorticoid therapy was initiated by a rheumatologist versus other physician specialty. CONCLUSIONS: The management of GIOP remains very inadequate, despite the availability of a statutory health insurance system. Targeted interventions are needed to improve the management of GIOP.

Bone infarcts: Unsuspected gray areas?

There is agreement to label as bone infarcts avascular necrosis (AVN) occurring in the metaphyses or diaphyses of long bones, the terms AVN or osteonecrosis being used at the epiphyses. One might expect bone infarction to hold no mysteries. Oddly enough, however, scientific evidence about bone infarcts is extraordinarily scant. The prevalence of bone infarcts is unknown. The main sites of involvement are the distal femur, proximal tibia, and distal tibia. In patients without sickle cell disease or Gaucher's disease, involvement of the upper limbs and lesions confined to the diaphysis are so rare as to warrant a reappraisal of the diagnosis. Although widely viewed as a generally silent event, bone infarcts causes symptoms in half the cases. Standard radiographs are normal initially then show typical high-density lesions in the center of the marrow cavity. A periosteal reaction is common and may be the first and only radiographic change. Magnetic resonance imaging consistently shows typical features and therefore, in principle, obviates the need for other investigations. Bone infarcts are multifocal in over half the cases and, when multifocal, are usually accompanied with multiple foci of epiphyseal avascular necrosis. Thus, bone infarcts, whose prognosis is good per se (with the exception of the very low risk of malignant transformation), are usually a marker for systemic avascular necrosis. Consequently, patients with bone infarcts must be investigated both for known risk factors and for other foci of avascular necrosis, which may, in contrast, have function-threatening effects.

Evaluation of the treatment effect of NSAIDs/TNF blockers according to different domains in ankylosing spondylitis: results of a meta-analysis.

OBJECTIVES: To assess the treatment effect of NSAIDs and TNF blockers in AS according to different domains of interest. METHODS: A systematic literature research was performed in electronic databases up to October 2009. All randomized controlled trials (RCTs) reporting the efficacy (on pain and/or physical function and/or acute-phase reactants) of NSAIDs/anti-TNF vs placebo in AS were selected. Pooled effect sizes were calculated by meta-analysis, using fixed or random-effect models. RESULTS: Optimal data to calculate the effect size were available in 8 out of the 240 selected RCTs evaluating anti-TNF and 5 of the 135 evaluating NSAIDs. For the domains pain, physical function and patient's global assessment, the treatment effect was large or medium for both TNF blockers and NSAIDs. For the domain acute-phase reactants, the effect of TNF blockers was medium [standardized mean difference (SMD) (95% CI) -0.56 (-0.70, -0.42)], whereas NSAIDs had no significant effect on acute-phase reactants {SMD [95% odds ratio (OR)] -0.09 (-0.34, 0.16)}. Finally for the domain mobility, the effect of both TNF blockers and NSAIDs was small and not significant. CONCLUSION: This study suggests that the treatment effect of NSAIDs and anti-TNF are both of relevant magnitude considering the main patient-reported outcomes but with a trend in favour of anti-TNF despite the fact that such drugs are given on top of NSAIDs in refractory patients. Moreover, a statistically significant difference was observed for the domain 'acute-phase reactants' confirming the specificity of such drug category.