Prevalence of fractures in women with rheumatoid arthritis and/or systemic lupus erythematosus on chronic glucocorticoid therapy.

BACKGROUND: Glucocorticoid (GC) therapy is associated with an increased risk of fractures. The main objective of this study was to determine the prevalence of undiagnosed vertebral fractures in women chronically using GC therapy for autoimmune disorders. We also determined the prevalence of non-vertebral fractures, and investigated whether factors such as quality-of-life and future fracture risk are associated with vertebral/non-vertebral fractures. METHODS: This was a multicenter cross-sectional study conducted in Spain. All women had rheumatoid arthritis (RA) and/or systemic lupus erythematosus (SLE). Radiological morphometric vertebral fractures were evaluated centrally (Genant semiquantitative method), whereas non-vertebral fractures were not assessed by radiography. Before radiography, patients were asked whether they had vertebral/non-vertebral fractures, hereafter referred to as 'self-reported' fractures. Assessment tools included the Disease Activity Score (DAS28), the SF-36 questionnaire, and FRAX®. RESULTS: Complete data were obtained for 576 outpatients with RA and/or SLE (83.3 % had RA); mean [SD] age 59.6 [15] years. Of all patients, 6.4 % had self-reported vertebral fractures, whereas 18.9 % had morphometric vertebral fractures (RA: 7.1 % self-reported vs. 20.0 % morphometric; SLE: 3.2 % self-reported vs. 13.7 % morphometric). Non-vertebral fractures were self-reported by 9.8 % of RA and 5.3 % of SLE patients. Low physical functioning was associated with morphometric vertebral fractures (mean [SD] SF-36 score 18.8 [6.0] when present vs. 20.1 [5.9] when absent; p = 0.028) and self-reported non-vertebral fractures (16.7 [5.2] when present vs. 20.1 [5.9] when absent; p < 0.001). Mean [SD] DAS28 was higher (p = 0.013) when any self-reported fractures were present (4.0 [1.3]) than absent (3.6 [1.3]). Based on FRAX® analysis, patients with vs. without morphometric vertebral fractures had higher 10-year probabilities of major osteoporotic fractures (mean [SD] 17.9 [12.9]% vs. 9.9 [9.6]%; p < 0.001) and hip fractures (11.0 [11.7]% vs. 4.6 [8.1]%; p < 0.001). CONCLUSIONS: Morphometric vertebral fractures were detected in 18.9 % of patients, i.e. 3-times more frequently than verbally reported by patients. Patients with vs. without fractures had worse quality-of-life and increased fracture risk. Accordingly, it is of utmost importance that women chronically using GCs are assessed for fractures, including morphometric vertebral fractures.

Espondilodiscitis tuberculosa en Cádiz (España) durante diez años / Tuberculous spondylodiscitis. Report of six patients

Background: Tuberculous spondylodiscitis is relatively uncommon but represents the most common location of osseous tuberculosis. Aim: To describe clinical features, imaging studies and laboratory tests to establish the diagnosis in a group of patients living in Cádiz (Spain). Material and Methods: Retrospective analysis of medical records of patients with tuberculous spondylodiscitis diagnosed between 2000 and 2009. The diagnosis was based on microorganism recovery from vertebral samples obtained by imaging guided biopsies. Results: Six patients with positive Mycobac-terium tuberculosis cultures from vertebral samples, were identified (10 percent of extra-pulmonary tuberculosis). In only 2 patients the Ziehl-Nielsen stain was positive, and histology was compatible in 4 cases. Four patients were females, their mean age was 54.3 years and the mean duration of symptoms was 7.3 months. Three patients had lumbar location and a positive Mantoux test. A soft tissue abscess was present in 4 cases. None of these patients had neurological complications. The treatment with four tuberculostatic agents (isoniazid, rifampicin, pyrazinamide and ethambutol) was effective in 5 patients. Conclusions: Tuberculous spondylodiscitis may become a serious disease due to diagnostic and treatment delays. The main examinations to establish diagnosis are magnetic resonance imaging and biopsy with microbiological culture. Generally, antituberculous therapy is effective in this clinical situation.

[Tuberculous spondylodiscitis. Report of six patients]. / Espondilodiscitis tuberculosa en Cádiz (España) durante diez años.

BACKGROUND: Tuberculous spondylodiscitis is relatively uncommon but represents the most common location of osseous tuberculosis. AIM: To describe clinical features, imaging studies and laboratory tests to establish the diagnosis in a group of patients living in Cádiz (Spain). MATERIAL AND METHODS: Retrospective analysis of medical records of patients with tuberculous spondylodiscitis diagnosed between 2000 and 2009. The diagnosis was based on microorganism recovery from vertebral samples obtained by imaging guided biopsies. RESULTS: Six patients with positive Mycobac-terium tuberculosis cultures from vertebral samples, were identified (10% of extra-pulmonary tuberculosis). In only 2 patients the Ziehl-Nielsen stain was positive, and histology was compatible in 4 cases. Four patients were females, their mean age was 54.3 years and the mean duration of symptoms was 7.3 months. Three patients had lumbar location and a positive Mantoux test. A soft tissue abscess was present in 4 cases. None of these patients had neurological complications. The treatment with four tuberculostatic agents (isoniazid, rifampicin, pyrazinamide and ethambutol) was effective in 5 patients. CONCLUSIONS: Tuberculous spondylodiscitis may become a serious disease due to diagnostic and treatment delays. The main examinations to establish diagnosis are magnetic resonance imaging and biopsy with microbiological culture. Generally, antituberculous therapy is effective in this clinical situation.

Modification of pro- and antiinflammatory cytokines and vascular-related molecules by tumor necrosis factor-a blockade in patients with rheumatoid arthritis.

OBJECTIVE: Analysis of serum concentrations and modifications of tumor necrosis factor-a (TNF-a), its soluble receptors (TNFR), interleukin 10 (IL-10), and vascular related molecules [soluble vascular cell adhesion molecule 1 (sVCAM-1), vascular endothelial growth factor (VEGF)] after therapy with methotrexate (MTX) and anti-TNF (infliximab) in patients with rheumatoid arthritis (RA). METHODS: Thirty-six patients with RA and 20 healthy controls were included. Patients had been orally taking a stable dose of MTX of at least 12.5 mg/week for a minimum of 6 months before inclusion in the study. Twenty-five patients had shown a clinical response to MTX (MTX Group). The other 11 had shown an unsatisfactory response and presented with active RA; they were selected for additional treatment with infliximab (MTX + IFM Group). Disease activity score (DAS28), hemoglobin concentration, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum levels of TNF-a, soluble TNFR, IL-10, sVCAM-1 and VEGF were determined at baseline and prior to every infusion of infliximab (3 mg/kg) at 2, 6, 14, 22, and 30 weeks. RESULTS: Although serum levels of TNF-a were similar in patients and controls, patients showed significantly higher concentrations of both soluble TNFR (sTNFR55 and sTNFR75), IL-10, sVCAM-1, and VEGF than healthy individuals. Significantly higher levels of sVCAM-1 and VEGF, but not of the other tested molecules, were detected in those with active disease. After infliximab treatment (MTX + IFM Group) there was a significant decrease in DAS28 and modified Health Assessment Questionnaire scores and ESR and CRP levels. Serum concentration of VEGF showed a significant decrease after infliximab, with levels comparable to those of patients with inactive RA, although VEGF continued to present higher values than in healthy controls. CONCLUSION: Increased levels of vascular related molecules sVCAM-1 and VEGF are serum markers of active RA. The absence of normalization of levels of these molecules in patients with inactive RA could be one of the reasons response to therapy is only temporary.