Chronic arthritides and bone structure: focus on rheumatoid arthritis-an update.

Normal bone remodeling depends of a balance between bone forming cells, osteoblasts and bone resorbing cells, the osteoclasts. In chronic arthritides and some inflammatory and autoimmune diseases such as rheumatoid arthritis, there is a great constellation of cytokines produced by pannus that impair bone formation and stimulate bone resorption by inducing osteoclast differentiation and inhibiting osteoblast maturation. Patients with chronic inflammation have multiple causes that lead to low bone mineral density, osteoporosis and a high risk of fracture including circulating cytokines, impaired mobility, chronic administration of glucocorticoids, low vitamin D levels and post-menopausal status in women, among others. Biologic agents and other therapeutic measures to reach prompt remission might ameliorate these deleterious effects. In many cases, bone acting agents need to be added to conventional treatment to reduce the risk of fractures and to preserve articular integrity and independency for daily living activities. A limited number of studies related to fractures in chronic arthritides were published, and future investigation is needed to determine the risk of fractures and the protective effects of different treatments to reduce this risk.

Evidence based Latin American Guidelines of clinical practice on prevention, diagnosis, management and treatment of glucocorticoid induced osteoporosis. A 2022 update : This manuscript has been produced under the auspices of the Committee of National Societies (CNS) and the Committee of Scientific Advisors (CSA) of the International Osteoporosis Foundation (IOF).

Guidelines and recommendations developed and endorsed by the International Osteoporosis Foundation (IOF) are intended to provide guidance for particular pattern of practice for physicians who usually prescribe glucocorticoid (GC) therapy, and not to dictate the care of a particular patient. Adherence to the recommendations within this guideline is voluntary and the ultimate determination regarding their application should be made by the physician in light of each patient's circumstances. Guidelines and recommendations are intended to promote a desirable outcome but cannot guarantee any specific outcome. This guideline and its recommendations are not intended to dictate payment, reimbursement or insurance decisions. Guidelines and recommendations are subjected to periodic revisions as a consequence of the evolution of medicine, technology and clinical practice. A panel of Latin American (LATAM) experts specialized in osteoporosis with recognized clinical experience in managing patients with glucocorticoid-induced osteoporosis (GIO) met to produce evidence-based LATAM recommendations for the diagnosis and management of GIO. These guidelines are particularly intended to general practitioners and primary care physicians who prescribe GC treatments in LATAM to guide their daily clinical practice in terms of evaluation, prevention and treatment of GIO. These recommendations were based on systematic literature review using MEDLINE, EMBASE, SCOPUS and COCHRANE Library database during the period from 2012 to 2021. Randomized clinical trials (RCT), systematic reviews of RCT, controlled observational studies, guidelines and consensus were considered. Based on the review and expert opinion the panel members voted recommendations during two successive rounds of voting by panel members. Agreements for each statement were considered if a concordance of at least 70% was achieved following Delphi methodology. Grading of recommendations was made according to the Oxford Centre for the Evidence-based Medicine (EBM) criteria. Among five GIO guidelines and consensus initially identified, two of them (American College of Rheumatology 2017 and the Brazilian Guidelines 2021) were selected for comparison considering the latter as the most current guides in the LATAM region. Based on this methodology fifty statements were issued. All of them but four (1.20, 1.21, 1.23 and 4.2) attained agreement.

Refractory fibromyalgia.

In the medical literature, there are only a few references on refractory fibromyalgia and there is no consensus definition available on this concept. Some definitions of refractory fibromyalgia have been proposed based on the lack of response to a number of medications, and perhaps the most appropriate term is treatment-refractory fibromyalgia. To achieve the definition of treatment-refractory fibromyalgia, it is necessary to consider several previous steps, such as making sure the diagnosis has been made properly and a differential diagnosis with entities that can mimic fibromyalgia symptoms (including complete physical examination and laboratory test) has been made. The possibility that another factor that alters the response to treatment should be investigated, and in particular review all prescribed medication and search for some non-medical reasons that could mask the response to treatment (e.g., legal compensation). The definition of refractory fibromyalgia is complex and probably should include a lack of response to a specified number of drugs or to combination therapy with at least two non-pharmacological measures. In this article, it is not our purpose to present a formal definition, but to raise the possible bases for this purpose. We believe that it is a subject that must be discussed extensively before reaching a consensus definition. Key Points • There is no appropriate definition to classify fibromyalgia patients who do not respond to the usual pharmacological and non-pharmacological measures according to the national or international guidelines. • A consensus definition is required to classify these patients, which could help standardize future management strategies. In this article, we propose the bases on which refractory fibromyalgia could be defined.

Severe Bone Microarchitecture Impairment in Women With Pregnancy and Lactation-Associated Osteoporosis.

CONTEXT: Pregnancy- and lactation-associated osteoporosis (PLO) is a rare condition characterized by fragility fractures, mostly vertebral, during the third trimester of pregnancy or the early postpartum period. OBJECTIVE: The aim of this study was to evaluate bone microarchitecture in women with PLO to better understand the pathophysiology of this disease. METHODS: In this retrospective study, we included women with PLO referred to our bone center between November 2007 and July 2012. We assessed bone mineral density (BMD) by dual-energy x-ray absorptiometry, bone turnover markers, and bone microarchitecture by high-resolution peripheral quantitative computed tomography. Results were compared with a control group of healthy lactating women. RESULTS: Of the 7 primiparous patients with PLO, 6 suffered vertebral fractures and 1 developed a hip fracture during the seventh month of gestation. Fractures occurred within the eighth month of pregnancy and the fourth month post partum; vertebral fractures were multiple in 85.7%. Major or minor risk factors for osteoporosis were present in 86% of our patients. Trabecular density, number, and thickness were 34%, 20% and 22% lower than controls (P < .01, P = .01, and P = .01, respectively). Cortical parameters were also deteriorated but to a lesser extent. CONCLUSION: In comparison with healthy lactating women, patients with PLO presented severe deterioration of bone trabecular and cortical microarchitecture. This significant compromise may explain the occurrence of multiple fractures in these otherwise healthy young women. Further prospective studies are needed to determine whether bone microarchitecture might be able to be restored in the future.

Osteoporosis: a clinical and pharmacological update.

Osteoporosis is characterized by the loss of bone mass, deterioration of the bone microarchitecture, and an increased risk of fractures; these later complications are associated with significant morbidity and mortality. The asymptomatic and progressive nature of osteoporosis underscores the importance of identifying this entity in early stages. Despite the various treatments available, the prevention of the disease represents the most important aspect of management. An adequate intake of calcium and vitamin D as well as a healthy lifestyle is the basis for maintaining bone health. When osteoporosis is diagnosed, the choice of medications must be individualized considering characteristics of the patient and the risk of fractures. In this article, we review the main causes of osteoporosis, when and how to start treatment, and appropriate therapy and monitoring.

Heart failure complicating myocardial infarction. A report of the Peruvian Registry of ST-elevation myocardial infarction (PERSTEMI).

OBJECTIVES: The aim of this study is to determine the incidence, associated factors, and 30-day mortality of patients with heart failure (HF) after ST elevation myocardial infarction (STEMI) in Peru. METHODS: Observational, cohort, multicentre study was conducted at the national level on patients enrolled in the Peruvian registry of STEMI, excluding patients with a history of HF. A comparison was made with the epidemiological characteristics, treatment, and 30 day-outcome of patients with (Group 1) and without (Group 2) heart failure after infarction. RESULTS: Of the 388 patients studied, 48.7% had symptoms of HF, or a left ventricular ejection fraction <40% after infarction (Group 1). Age>75 years, anterior wall infarction, and the absence of electrocardiographic signs of reperfusion were the factors related to a higher incidence of HF. The hospital mortality in Group 1 was 20.6%, and the independent factors related to higher mortality were age>75 years, and the absence of electrocardiographic signs of reperfusion. CONCLUSIONS: Heart failure complicates almost 50% of patients with STEMI, and is associated with higher hospital and 30-day mortality. Age greater than 75 years and the absence of negative T waves in the post-reperfusion ECG are independent factors for a higher incidence of HF and 30-day mortality.

Heart failure complicating myocardial infarction. A report of the Peruvian Registry of ST-elevation myocardial infarction (PERSTEMI) / Insuficiencia cardiaca complicando el infarto de miocardio. Un reporte de Peruvian Registry of ST-elevation Myocardial Infarction (PERSTEMI)

Abstract Objectives: The aim of this study is to determine the incidence, associated factors, and 30-day mortality of patients with heart failure (HF) after ST elevation myocardial infarction (STEMI) in Peru. Methods: Observational, cohort, multicentre study was conducted at the national level on patients enrolled in the Peruvian registry of STEMI, excluding patients with a history of HF. A comparison was made with the epidemiological characteristics, treatment, and 30 day-outcome of patients with (Group 1) and without (Group 2) heart failure after infarction. Results: Of the 388 patients studied, 48.7% had symptoms of HF, or a left ventricular ejection fraction <40% after infarction (Group 1). Age > 75 years, anterior wall infarction, and the absence of electrocardiographic signs of reperfusion were the factors related to a higher incidence of HF. The hospital mortality in Group 1 was 20.6%, and the independent factors related to higher mortality were age > 75 years, and the absence of electrocardiographic signs of reperfusion. Conclusions: Heart failure complicates almost 50% of patients with STEMI, and is associated with higher hospital and 30-day mortality. Age greater than 75 years and the absence of negative T waves in the post-reperfusion ECG are independent factors for a higher incidence of HF and 30-day mortality.

Resumen Objetivos: Se desea saber la incidencia, los factores asociados y la mortalidad a 30 días de los pacientes con insuficiencia cardiaca (IC) postinfarto de miocardio con elevación del segmento ST (IMCEST) en Perú. Métodos: Estudio observacional, de cohortes, multicéntrico a nivel nacional, de pacientes enrolados en el registro peruano de IMCEST, excluyendo los pacientes con antecedente de IC. Se compararon las características epidemiológicas, tratamiento y evolución a 30 días de los pacientes con (grupo 1) y sin (grupo 2) IC postinfarto. Resultados: De 388 pacientes se encontró un 48.7% con síntomas de IC o fracción de eyección de ventrículo izquierdo < 40% postinfarto (grupo 1). La edad > 75 años, el infarto de pared anterior y la ausencia de signos electrocardiográficos de reperfusión fueron los factores relacionados a mayor incidencia de IC. La mortalidad intrahospitalaria en el grupo 1 fue del 20.6% y los factores independientes relacionados a mayor mortalidad fueron la edad > 75 años y la ausencia de signos electrocardiográficos de reperfusión. Conclusiones: La IC complica casi al 50% de pacientes con IMCEST y está asociada a mayor mortalidad intrahospitalaria y a 30 días. La edad > 75 años y la ausencia de ondas T negativas en el electrocardiograma posreperfusión son factores independientes de mayor incidencia de IC y de mortalidad a 30 días.

Sintomatología depresiva en pacientes con fibromialgia / Depressive symptoms in fibromyalgia

Introducción: La fibromialgia es una entidad frecuente en la práctica clínica y se ha considerado que está asociada con desórdenes psiquiátricos, en particular con depresión, lo cual podría tener un impacto en el tratamiento de esta entidad. Objetivo: Evaluar la prevalencia de síntomas depresivos en pacientes con fibromialgia. Diseño: Estudio observacional y de tipo transversal. Lugar: Servicio de Reumatología, Hospital Departamental María Auxiliadora. Participantes: Pacientes de ambos sexos con diagnóstico de fibromialgia. Intervenciones: Se utilizó la escala de Hamilton para la depresión (HDRS) y el recuento de puntos dolorosos para fibromialgia. Principales medidas de resultados: Porcentaje de pacientes con síntomas depresivos. Puntaje total de la HDRS en relación al recuento de puntos dolorosos. Resultados: La edad promedio fue 54,9 ± 14 años, 80 por ciento fue del sexo femenino y el número promedio de puntos dolorosos, 14,4 ± 1,5. El 32,7 por ciento de pacientes no tenía síntomas de ánimo depresivo, en 27,7 por ciento los síntomas fueron leves, en 30,9 por ciento moderados y solo en 9 por ciento severos. Ningún paciente presentó síntomas compatibles con ánimo depresivo muy severo. Encontramos una correlación significativa entre el número de puntos dolorosos y el puntaje de la escala HDRS (r= 0,740), p< 0,001. Conclusiones: Los síntomas depresivos severos se encuentran en una proporción baja en pacientes con fibromialgia y parecen estar directamente asociados con el número de puntos dolorosos.

Introduction: Fibromyalgia is a common musculoskeletal problem in clinical practice and is associated with psychiatric disorders. The association with major depression potentially has therapeutic implications. Objective: To determine the prevalence of depressive symptoms in a sample of patient with fibromyalgia. Design: Observational and transversal study. Setting: Rheumatology Department, Maria Auxiliadora Hospital, Lima, Peru. Participants: Fifty-five patients of both sexes with fibromyalgia. Interventions: Fibromyalgia tender points count and use of Hamilton Rating Scale for Depression (HDRS). Main outcome measures: Percentage of depressive symptoms. Total HDRS score in relation to tender point count. Results: Average age was 54,9 ± 14 years, 80 per cent were females, and the average tender point score was 14,4 ± 1,5. The HDRS score did not show depression mood symptoms in 32,7 per cent, 27,7 per cent had mild symptoms, 30,9 per cent moderate and 9 per cent severe symptoms. In no patient depression mood symptoms were considered very severe. There was significant correlation between the number of tender points and HDRS score (r= 0,740), p< 0,001. Conclusions: Severe or very depressive symptoms are infrequent in fibromyalgia and depression mood symptoms seem to correlate positively with the number of tender points.

Metabolismo mineral óseo durante la gestación y efectos sobre la masa ósea de la madre / Bone mineral metabolism during gestation and its effects on maternal bone mass

La gestación y lactancia son periodos de alta demanda de calcio, para el crecimiento fetal y para la producción de leche materna. Durante la gestación, la madre transfiere al feto 25 a 30 g de calcio y durante la lactancia se secretan 200 a 240 mg de calcio diario en la leche materna. Durante la gestación, los mecanismos adaptativos más importantes son el incremento en la absorción de calcio y el incremento del recambio óseo materno; durante la lactancia, hay tendencia a conservar más calcio a nivel renal, pero la desmineralización temporal del esqueleto materno parece ser el mecanismo más importante. Los estudios que emplean absorciometría dual de rayos X (DXA) son escasos, por el riesgo de radiación materna y fetal; pero, con otras técnicas, como el ultrasonido cuantitativo, se ha descrito una pérdida de masa ósea durante la gestación predominantemente dependiente del hueso trabecular. Mediante marcadores bioquímicos del remodelamiento óseo se ha demostrado que los suplementos de calcio reducen la tasa de remodelamiento durante el embarazo y parecen tener efecto benéfico sobre la pérdida ósea materna. Estudios longitudinales que emplean ultrasonido cuantitativo también han encontrado una disminución de la pérdida ósea, entre las mujeres que recibieron aporte o suplemento adecuado de calcio durante la gestación.

Pregnancy and lactation are periods of high calcium demand for skeletal growth and maternal milk production. Approximately 25-30 g of calcium are transferred to the fetus during pregnancy, and breast-feeding mothers secrete 200-240 mg/day of calcium in breast milk every day. During pregnancy, major physiologic adaptations include increased both calcium intestinal absorption and rate of maternal bone turnover; during lactation, there is a contribution of renal calcium conservation, but temporary maternal bone demineralization is the main mechanism to meet calcium requirements. Data on bone mineral density assessed by dual energy x-ray absortiometry (DXA) are sparse mainly due to concern about potential risk of radiation exposure to the fetus. Other radiation-free techniques like quantitative ultrasound have been used to assess maternal bone mass changes during pregnancy. Maternal bone loss mainly depending on trabecular areas during pregnancy has been described. Calcium supplements reduce maternal skeletal-bone turnover as evaluated by bone resorption markers during pregnancy and seem to have beneficial effects on maternal bone loss. Longitudinal studies with repeated measurements of quantitative ultrasound during pregnancy have found decrease in bone loss in pregnant women with adequate calciumin take or supplementation.