Volume 1 · Number 1 · December 2009
- Our Journal [5-5]
- Epidemiology of Paget’s disease of bone in an area of Barcelona [7-12]
- Study of bone mass in the alcoholic patient [15-19]
- Patient of 92 years with gouty Arthropathy [31-33]
- Hip fracture as the first manifestation of Cushing’s Disease with genotype of Fabry’s Disease [35-39]
It is an honour for the Management Board of SEIOMM to present to you the new journal of our Society –Revista de Osteoporosis y Metabolismo Mineral– which is going to take forward the difficult mission of replacing the Spanish Journal of Metabolic Bone Diseases, which, for reasons known to you all, is no longer our official journal.
From the start the new journal will be six-monthly and will contain the classic contents of a scientific publication. Revista de Osteoporosis y Metabolismo Mineral is born to last, and will provide a quality channel through which work by the specialists who make up SEIOMM can be published. Original articles, reviews, clinical notes… will all have a place in the new publication, in which you will also be able to find news of the activities of our Society and its working groups. The annual calendar of publication will be completed by a third issue per year dedicated to bringing together the material presented at our annual Conference, and there is also the possibility of our producing extraordinary editions on current themes of interest to our scientific community.
Paget’s disease of bone (PD) is a focussed disorder, asymptomatic in the majority of cases and of an unknown etiology. The epidemiology of this disease is little characterised; its global prevalence or incidence in Spain is not known. The objective of this study is to determine the prevalence and incidence of PD in an area of the city of Barcelona (Barceloneta) which has a health care system in which primary, hospital and specialised care are integrated, and in which digitised archives of complementary investigations, diagnoses and treatments are available.
Patients and Methods: The population of the area of Barceloneta is 18,509 inhabitants (1996 Census) with 6,989 people older than 55 years. The process fro the identification of patients affected by PD in the area of Barceloneta was carried out through a review of the digitized archives of diagnoses, treatments, analyses, pathological anatomy, and bone radiography and gammagraphy from the primary care centre (CAP), the Rheumatology service and other services of the Hospital del Mar. In cases detected the diagnosis was confirmed through a review of the clinical history by the researchers.
Results: 16 patients were found to have the disease (10 women and 6 men). The average age was 79.2 years (range 65-92). Monostotic/Polyostotic: 8/8. Symptomatic/Asymptomatic: 9/7. The apparent prevalence in the population over 55 years of age was 0.23%. In the period 1996-2000, five new cases were diagnosed, the incidence being 1.78/10,000 person/years. Assuming that only 20% of cases are symptomatic is it is possible to infer that the total number of patients is 45, real P being calculated at 0.64%.
Conclusions: In the area of Barceloneta (Barcelona, Spain), the real prevalence calculated is 0.64% and the estimated incidence is 1.78/10,000 person/years, all figures referring to the population over 55 years of age.
A prospective descriptive study was conducted to assess the alteration in bone mineral density (BMD) in alcoholic patients, under the age of 65 and free of non-modifiable risk factors for osteoporosis, who were admitted to the Clinical Toxicology Unit for detoxification and subsequent supervision, between January 2007 and May 2008. Nutritional profile and liver function were also analysed in order to establish a relationship with the BMD observed in subsequent studies. 36 male patients were studied with an average age of 51 years. Pathological levels of bone mass (in the spinal column and hip) were detected in 53% of patients (42% with osteopenia and 11% with osteoporosis), a much higher percentage than that expected in a male population of such an age. Vertebral fractures were observed in six patients (16%) and hip fractures in four (11%).
The care of alcoholic patients must be comprehensive and depends on the state of the addictive disorder, with the active treatment of the alcoholism being essential and a priority. However, given the risk of fractures associated with falls, once a metabolic abnormality is diagnosed, the appropriate treatment should be initiated as soon as possible.
Ulcerous colitis and Crohn’s disease constitute the principal components of inflammatory bowel disease (IBD). Osteoporosis is a well-known complication of IBD presenting a multifactorial etiology, although the importance of the inflammatory process in itself seems to be ever greater. The end of this article reviews the existing data on bone mineral metabolism in these patients, both in relation to the prevalence of the loss of bone mass, as in the situation of the markers for bone turnover, the factors involved, as well as the risk factors. In this way, it is intended to shine a light on the importance of osteoporosis in IBD.read more
Gout is a metabolic disease characterised by the deposition of monosodium urate crystals in the interior structures of the joints. Its prevalence is approximately 8.4 cases per 1000 individuals and is more frequent in middle-aged and older males1.
Although hyperuricemia is a necessary predispositional factor, its presence does not always imply the development of gout. In fact, the majority of hyperuricemic patients never develop gout2,3,4. Individual differences in the formation of the crystals or in the inflammatory response, or in both, could play a role in determining if a patient with hyperuricemia will develop gout. Unfortunately, there is not yet a satisfactory explanation for some of the clinical aspects of acute gout, including5,6,7,8 the precipitation of acute attacks by trauma or surgery, its predilection for the first metatarsal-phalangeal joint, and the spontaneous resolution of the attacks.
The clinical manifestations of gout include recurrent attacks of acute inflammatory arthritis, accumulation of monosodium urate crystals in the form of tophaceous deposits, nephrolithiasis caused by the uric acid and chronic nephropathy. Three classic stages are described in the natural history of the progressive deposition of monosodium urate, which includes acute gouty arthritis, an interval, or intercritical gout, and then chronic tophaceous gout.
Acute gouty arthritis generally occurs some years after a period of asymptomatic hyperuricemia. A typical attack, which is markedly inflammatory, consists of severe pain, reddening, swelling and functional impairment which reach their maximum intensity after a few hours. In general (80%), the initial attacks only affect a single joint, typically in the lower extremities, often at the base of the big toe (podagra), or the knee. The associated signs of inflammation frequently extend beyond the affected joint and at times, can affect a number of joints, with tenosinovitis, dactilitis and even celulitis also apparent.
Overall, it has been observed that 12-43% of patients with episodes of gout show normal or even reduced values of uric acid in the blood9,10,11.
Presentation of case
SLV is a woman of 35, who attended for a consultation for the first time in April 2008, having suffered a hip fracture.
Personal medical history: Arterial hypertension, with pre-eclampsia during her sole pregnancy which resulted in a cesarian section at 34 weeks, and at present controlled by medication.
Family medical history: Grandmother, father and sister with hypertension.
Start of the disease: The patient was found to be asymptomatic with adequate control of her arterial tension, until 17th November 2007, when, whilst going down the stairs carrying a load, the made a brisk movement of her right foot and noted a sensation of a “snap” in her right hip, without trauma and without falling over. She was seen the same day by a traumatologist who ordered an X-ray of her hip (Figure 1) on which no pathology was detected and from which the diagnosis of “torn muscle” was made, and for which he prescribed analgesics and rehabilitation, which the patient started to receive at a centre in this city.
The patient did not observe any improvement and attended the clinic again some days later. The rehabilitative doctor observed the existences of pain on the rotation, and limitations in the flexing, of the right hip, pain in when in the standing position, and the absence of contraction or haematomas. He requested a new X-ray of the pelvis (Figure 2) in which there were still no pathological signs, and he advised treatment with magnetotherapy, analgesics, pulsating ultrasound and by taking weight off the leg.
The patient continued to worsen, so an RMN of the hip was requested (Figure 3) in which was observed “bone oedema in the right femoral neck, with an oblique fracture without significant displacement of fragments (transcervical fracture, Pauwels type II), without changes in the morphology of either femoral heads”. Treatment by resting the leg and with analgesics was prescribed. One month later the X-ray of the hip showed a radiological consolidation of the fracture with leg deformity, (Figure 4) for which was indicated a prgramme of rehabilitation, which included progressively increasing weight on the leg and hydrotherapy. For several months the patient followed the rehabilitative treatment, not observing any improvement in the pain. On the contrary, she noticed it worsening as soon she started putting weight on it.
In April 2008, the patient attended our Bone Metabolism Unit where a detailed clinical history was taken, which did not show any new details from those outlined earlier, the physical examination being normal (height: 157.5 cm. weight: 61 Kg. BMI: 24.7 Kg/m2, arm span: 158 cm). We did not see the existence of the “buffalo hump”, truncular obesity, wine-coloured stretchmarks, or any other characteristic signs of Cushing’s Disease.
Consensus document of the Spanish Society for Bone and Mineral Metabolism Research (SEIOMM) in conjunction with: Spanish Association for the Study of the Menopause (AEEM), Hispanic Foundation for Osteoporosis and Metabolic Diseases (FHOEMO), Spanish Society of Mouth Surgery (SECIB), Spanish Society of Oral and Maxillofacial Surgery (SECOM), Spanish Society of Orthopedic Surgery and Traumatology (SECOT), Spanish Society of Endochrinology and Nutrition /SEEN), Spanish Society of Osteoporotic Fractures (SEFRAOS), Spanish Society of Geriatrics and Gerontology (SEGG), Spanish Society for Family and Community Medicine (SEMFyC), Spanish Society of Internal Medicine (SEMI), Spanish Society of Oral Medicine (SEMO), Spanish Society of Doctors in Primary Medicine (SEMERGEN), Spanish Society for Rehabilitation and Physical Medicine (SERMEF), Spanish Society of Rheumatology (SER), Ibero-American Society for Bone and Mineral Metabolism Research (SIBOMM).
Our objective has been to write a position statement on the risk of developing maxillary osteonecrosis (ONJ) in patients receiving bisphosphonates for the treatment of osteoporosis, and identifying and evaluating the extent of the evidence which supports the recommendations. In order to do this we have reviewed the published studies on the definition, epidemiology, physiopathology, clinical manifestation, diagnosis and treatment of ONJ, producing, after their analysis, the current recommendations. These have been developed after a pre-agreed and reproducible process, which included an accepted model for the evaluation and citing of the evidence which supports them. The document, once produced by the co-ordinators, was reviewed and discussed by all the members of the panel, who produced draft recommendations which were finally studied and approved by the experts of the medical societies concerned with bone mineral metabolism, listed in Annex 2.read more
When the last version of the “Clinical Practice Guidelines for Posmenopausal, Esteroid and Male Osteoporosis”, Society of Bone and Mineral Metabolism Research1 was produced it was agreed that it should be revised at least every 5-6 years, by editing a new version of the same document. At an intermediate point –at around 2-3 years– an update should have been produced, to include issues which could not wait for the editing of the new version, especially taking into account the fact that even as the second version was written the introduction to market of the new drugs was already being foreseen. The following document includes this update. It should be stressed that this should not be treated as an entire revision of the guides, rather only of some aspects –fundamentally therapeutic issues– considered most urgent.
Given that this should not be treated as a complete revision of the guides, rather only its update, we have considered it proper to take into account solely information relevant from the practical point of view; specifically, information related to the efficacy of the drugs in reducing the incidence of fractures. We have not assessed data related to substituted variables, such as Bone Mineral Density (BMD) or markers for bone turnover. However, we have included comparative studies or non-inferiority studies regularly carried out with BMD as a variable of efficacy, given that they definitely constitute an indirect way of establishing the usefulness of a particular drug –or in a particular way of administering them– for fractures.
A systematic search of the bibliography in PubMed was carried out, with two different approaches: a) a search under “Theraputics”, of the “Clinical Enquiries” section, using the names of the various drugs; b) a search starting with the MeSH terms, using the names of the various drugs, plus the terms “fracture” or “osteoporosis”. The names of the drugs used in the searches were the following: etidronate, alendronate, risedronate, ibandronate, zoledronate, strontium ranelate, oestrogens, hormone replacement therapy, raloxifene, tibolone, calcitonin, PTH, parathormone, PTH 1-34, teriparatide, PTH 1-84, fluoride. The period of the bibliographic search started in January 2006, the point at which the systematic search for the second version of the guides ceased, and ended in December 2008. In addition to the works found in the systematic search over the aforementioned period, we also considered for this update information based on personal knowledge gained through regular handling of the bibliography related to this subject, and data presented at conferences; this information was included even though it was collected after the systematic search had been completed.
In order to assess efficacy in relation to fractures we analysed only works designed as clinical trials or meta-analyses, rejecting observational studies.
A first draft was written by the co-ordinator of guides (JGM), which was distributed among all the members of the Committee of Experts of the SEIOMM charged with producing the second version. They proposed changes to the document, according to which a second draft was produced, which again was sent to the members of the Committee. Finally, with the comments on this second draft the final, definitive version was produced, which was approved by the Committee. The document was submitted for the consideration of the scientific societies interested in osteoporosis.