The surgical management of patients with primary hyperparathyroidism (HP) has resulted in several advances in recent decades which have improved the surgical management of this pathology, notable among which are the techniques of preoperative localisation, the use of minimally invasive techniques and the intraoperative determination of PTH. In spite of these advances, a number of controversies persist in terms of the surgical indications for patients with HP 1.Read More
The arrival of H2 inhibitors and later the proton-pump inhibitor (PPI) changed the clinical course of gastroesophageal disease, greatly reducing the rate of peptic ulcers and their complications. At present they are used in a high proportion of patients with diverse clinical situations 1. They are recommended to treat gastro-esophageal reflux, Helicobacter pylori, Zollinger-Ellison syndrome, duodenal ulcer, gastric ulcer and NSAID-induced peptic ulcer. Their proven benefits in preventing ulcers and encouraging good tolerance have led them to be considered as a popular, safe “gastric protector“, with little adverse effects and used in many situations without indication.
But do not forget that the blockade of acid secretion by PPIs is the cause of some undesirable effects 2. Increased intestinal and systemic infections have been attributed to decreased gastric acid secretion and their bactericidal capacity. Other infections, such as pneumonia, are also more common among patients treated with PPIs. B12 production capacity and intestinal absorption may be reduced by malabsorption. A reduced of antiplatelet effect of clopidogrel therapy has also been described. Some cancers, especially colon cancer, could be more frequent. Finally, it is worth noting the increased risk of fracture in patients treated with long-term PPI. In this issue, a study by Vera Rodríguez et al. 3 on its possible association with increased fractures in the population of the Canary Islands is presented, confirming the increase in non-traumatic fractures in patients over 50 years undergoing long-term PPI treatment compared to those who have never taken these medications.
Fracture of the hip is the most serious complication of osteoporosis, not only due to the morbimortality it entails but due to the social-health costs which it generates . However, in spite of this enormous impact, in practice the identification and treatment of osteoporosis and the adequate monitoring of those who have suffered a hip fracture is highly irregular .
In Spain, the use of antiosteoporotic medication is, in general and in the primary care setting in particular, higher in the group of women with an average age of 65 years. However, it is much lower in those at ages with a greater propensity to hip fracture [3,4]. Furthermore, in spite of the fact that the therapeutic arsenal for osteoporosis has increased notably in the last decade, the use of antiresorptive or osteoforming drugs after a hip fracture occurs is low, and has even reduced in countries such as the US .Read More
Introduction: The relationship between osteoporosis and arterial hypertension has not been clearly established, with alterations in calcium metabolism having been reported in the latter which may explain their association. Our objective was to establish the relationship between the A986S polymorphism of the calcium-sensing receptor (CaSR) and the presence of osteoporotic clinical fractures in a group of patients with hypertension.
Material: Prospective observational cohort study in 71 patients with hypertension, from 2001 to June 2014. We obtained socio-demographic and clinical data, including osteoporotic clinical fractures. The CaSR polymorphism was analysed using molecular techniques. The data was analysed using SPSS 15.0 (p<0.5) Results: 43.77% of the patients were men and 56.3% women. Genotype AA was found in 67.6% of patients, genotype SS in 2.8% and genotype AS in 29.6%. Those with genotype AA did not have higher comorbidity (27% vs 26%, p=0.9) or more pathological fractures (14.6% vs 21.7%, p=0.4) than the others. In the subgroup of women, 11 osteoporotic clinical fractures were recorded, without there being any differences between those with the AA genotype and the others (28% vs 27%, p=0.9). Conclusions: We found no association between the A986S polymorphism and the presence of osteoporotic clinical fractures in our cohort.Read More
Factors related to bone forming inadequate response to treatment (teriparatide/PTH 1-84) in patients with severe osteoporosis. Preliminary results
The aim of this study was to evaluate the long-term bone mineral density (BMD) response rate to osteoanabolic treatment in patients with severe osteoporosis and the factors related to “inadequate“ response (IR).
Methods: 49 patients (46F:3M) with a mean age of 69.5±11.1 years treated with teriparatide (41) or PTH1-84 (8) during 18/24months were included (84% had vertebral fractures and 84% had previously received bisphosphonates). Previous skeletal fractures and antiosteoporotic treatment, risk factors and cause of osteoporosis were recorded in all patients. Bone turnover markers (BTM) and 25-OH vitamin D (25OHD) levels were assessed before and at 3, 6, 12 and 18/24 months. Lumbar and femoral BMD and spinal X-ray were assessed at baseline and at 12 and 18/24 months. IR was defined by a lumbar BMD change <3% at 18/24 months. Results: 29% of patients showed IR to therapy. No significant differences were observed in age, baseline BMD and BTM and 25OHD levels between patients with or without IR. 92% of IR patients had been previously treated with bisphosphonates (vs 79%, p=0.34) during 7±4.8 years (vs 4.9±4.2 years, p=0.19). No significant differences were observed between groups in the magnitude of changes in BTM throughout the study. Conclusions: 29% of patients with severe osteoporosis presented IR to osteoanabolic therapy. Although no predictive factors related to this finding were identified, previous prolonged therapy with bisphosphonates may play a role.
Use of bisphosphonates in postmenopausal women with rheumatoid arthritis; results of a multicentre study
Objective: The objective of this study was to analyse the use of bisphosphonates in women with rheumatoid arthritis (RA) in the Canary Islands.
Material and methods: This multicentre observational study included women aged 50 years or over. At a single visit, demographic variables and those relating to the RA, history of fragility fractures, use of corticoids, performance of bone densitometry (DXA) and current treatment with bisphosphonates were recorded. The simplified FRAX ® tool was used and the recommendations of the American College of Rheumatology (ACR) for the prophylaxis of osteoporosis with corticoids were applied.
Results: 192 women were included, with an average age of 62 years. A total of 91 (48%) patients were receiving corticoids; 17 of these (9%) had suffered a fracture; 123 (66%) had had a DXA; and 52 (28%) were taking bisphosphonates (70% of the patients with osteoporosis or fracture and 45% of those with criteria for prophylactic use of corticoids for osteoporosis). Those factors having a significant association with the use of bisphosphonates were age, duration of the disease, the HAQ functional capacity questionnaire, the risk of fracture determined by FRAX®, treatment with corticoids, history of fracture and the previous performance of DXA. In the multivariate study only the DXA (p=0.03) and history of fracture (p=0.02) were significantly associated.
Conclusions: In postmenopausal women from the Canary Islands with RA the prescription of bisphosphonates could conform better to the guidelines, especially in patients receiving treatment with corticoids.Read More
Melorheostosis is a form of hyperostosis which affects both bone and the adjacent soft tissues. Its incidence is variable, although it is higher in the second and third decades of life due to the slowly progressive nature of the disease. It generally presents with pain which may cause significant functional limitation. We may be assisted in its diagnosis by its characteristic radiological image which resembles “wax melting down the side of a candle”. A case of melorheostosis is presented with clinical findings and radiological characteristics. The patient had previously been diagnosed with Paget’s disease of bone, so we proposed a differential diagnosis of this pathology.Read More
The VEGF (VEGFR2) 2 receptor and PTH (PTH1R) 1 receptor act as mediators in the anti-apoptotic response to mechanical stimulus in MLO-Y4 osteocyte-like cell
Mechanical stimulation plays a crucial role in bone mineral maintenance. This stimulation prevents osteocyte apoptosis by a mechanism that involves ß-catenin accumulation and nuclear translocation of extracellular-signal-regulated kinases (ERKs). The vascular endothelial growth factor (VEGF) and parathyroid hormone-related protein (PTHrP) modulate bone formation, although their interaction with osteocytes is unknown. In this paper we have considered the possible role of VEGF (VEGFR2) 2 receptor and PTH (PTH1R) type 1 receptor in the anti-apoptotic response to mechanical stimulation of MLO-Y4 osteocyte-like cells. The cells were subjected to mechanical stress by laminar fluid flow (10 min, 10 dinas/cm2) or hypotonic shock (240 mOsm, 1h), or stimulated with VEGF165 or PTHrP (1-36). We also compared the effects of overexpressed VEGFR2 and mechanical stimulation of these cells. Mechanical stimulation, VEGF165 or PTHrP (1-36) stimulated cellular viability and β-catenin stabilization in a similar manner, associated with its localization in the membrane. Mechanical stimulation increased PTH1R presence in the membrane. VEGFR2 inhibition as well as the PTHrP (7-34) antagonist reduced these effects. On the other hand, VEGFR2 overexpression in MLO-Y4 cells mimicked the mechanical stimulation effect on β-catenin and cellular viability. Our findings support a functional role for both systems, VEGF/VEGFR2 and PTHrP/PTH1R, in the early response to mechanical stimulation in promoting osteocyte-like viability.Read More
Introduction: Treatment of osteoporosis is focussed on the prevention fragility fractures, fractures of the hip being those which produce the highest rates of morbidity and mortality. The existence of a previous fracture is an important predictor of a new fracture.
Objective: we intend to analyse how treatment for osteoporosis varies before and after a hip fracture.
Material and methods: Using the 4,126,030 clinical records in the database for pharmaco-epidemiological research in primary care (Base de Datos para la Investigación Farmacoepidemiológica en Atención Primaria [BIFAP] ) 2011 for the whole of Spain, information was obtained regarding patients who had a first hip fracture recorded between 2005-2011, having been monitored for at least a year before and after. We analyse the previous and subsequent treatment for osteoporosis (including calcium and vitamin D supplements).
Results: 2,763 patients over 60 years of age (average 81 years) had suffered a hip fracture, of whom 81.6% were women. Before the fracture 26.5% (95% confidence interval [CI]: 24.8-28.1%) had received some antiosteoporotic treatment, of which 12% (95% CI: 11.0-13.5%), were bisphosphonates. 38.6% (95%CI: 36.8-40.4%) received treatment after the fracture, 20.4% (95%: 18.9-22%) treated with bisphosphonates. The factors associated with the initiation of treatment after the fracture were being a woman, being younger and having a previous diagnosis of osteoporosis.
Conclusions: Most of the patients studied were not receiving preventative treatment before their hip fracture. After the fracture the prescription of treatment increased a little. The drugs most commonly added were calcium, vitamin D and bisphosphonates.Read More
BMD evolution during treatment with aromatase inhibitors and its relation to the CYP11A1 gene: prospective study in the B-ABLE cohort
Objectives: The aim of this study was to analyze bone mineral density (BMD) changes throughout aromatase inhibitor (AI) treatment in clinical cases and also consider its association with the CYP11A1 gene and the BMD variation after treatment.
Material and methods: The B-ABLE cohort is a prospective study of postmenopausal women with breast cancer, in AI treatment. BMD variation was analyzed during AI treatment, as well as the differences those patients who were treated and not treated previously with tamoxifen (TMX). Three polymorphisms (rs4077581, rs11632698 and rs900798) of the CYP11A1 gene were genotyped for their association with BMD variation.
Results: TMX-treated patients presented more rapid BMD loss than those who did not undergo prior TMX treatment (60% less in spine and 46% in femur at 2 years and 70% less in the spine and 63% in the femur at 3 years). However, no significant BMD loss was detected after treatment in either group. The 3 CYP11A1 gene polymorphisms were significantly associated with BMD variation in the femur at the end of the treatment.
Conclusions: BMD was reduced more rapidly in patients with prior TMX treatment than in those who only received AI, although no significant differences were detected after treatment. The 3 CYP11A1 gene polymorphisms were associated with BMD variation in response to AI treatment.
Gitelman syndrome is a tubulopathy of autosomal recessive inheritance which presents with, among other manifestations, hypomagnesemia and hypocalciuria. We present the case of a woman of 68 years of age who came for a consultation due to arthritis in the large joints, in the absence of other symptomology. The X-ray study showed deposits of calcium pyrophosphate in the knees, pubic symphysis and other joints. Blood tests revealed hypomagnesemia and hypocalciuria compatible with Gitelman syndrome, which was confirmed following a genetic study.Read More
HPTP is a very frequent pathology which often develops asymptomatically. Surgical intervention being the only curative treatment for this disease there are some criteria for the indication of surgery, but these do not always fit the reality of the patient since they are based on clinical complications (osteoporosis, renal insufficiency, urolithiasis, fragility fractures).
We present the clinical case of a patient who did not meet any of the requirements for having surgical intervention according to the position documents, and who was operated on after the existence was shown of a deterioration of the trabecular bone structure, determined by the TBS (trabecular bone score) technique, and located in the adenoma using gammagraphy. The possible use of these techniques, not seen in the position documents, to complement the decision regarding surgery, is discussed.Read More
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