Volume 13 · Number 1 · March 2021
- Hypercalcemia in patients with rheumatoid arthritis: a retrospective study [5-9]
- Association of biochemical parameters of bone metabolism with progression and/or development of new aortic calcifications [10-16]
- Search for variants of the LRP4 gene in women with high bone mass and in patients with Chiari type I malformation [17-20]
- The cut-out phenomenon in intertrochanteric femur fracture: analysis using a finite element model [28-31]
Hypercalcemia is a very common water-electrolyte imbalance found in daily clinical practice. It is defined as the presence of a serum calcium concentration greater than 2 standard deviations from the mean laboratory value, which is usually 10.6 mg/dL .
From the pathophysiological point of view, high levels of calcium in the blood increase the difference in electrical potential between cell membranes, which increases the depolarization threshold. Clinically, hypercalcemia may present a very wide spectrum that can range from a certain muscle weakness to depression and even coma and death, and this depends on several factors such as the severity of hypercalcemia, the speed of its onset and other circumstances specific to the patient, such as age, comorbidity and medication received . Therefore, it is not surprising that two patients with the same high serum calcium values present completely different symptoms.
Hypercalcemia is a relatively common clinical problem and a frequent laboratory finding, both in hospital and out-of-hospital practice. Calcium ions play a critical role in many cellular functions. Parathyroid hormone (PTH) and vitamin D are the most important hormones for regulating calcium. The main sources of serum calcium are intestinal absorption, stimulated by active vitamin D metabolites, and bone resorption, usually stimulated by PTH. Therefore, hypercalcemia can be classified as PTH-dependent (due to increased secretion of PTH by the parathyroid glands) and independent of PTH. The latter cases are attributable to increased bone resorption and/or increased intestinal absorption of calcium, induced by factors other than PTH. Among them, PTH-related protein (PTHrP) and locally produced cytokines are factors that often cause hypercalcemia in cancer patients . Unregulated extrarenal synthesis of 1,25-dihydroxyvitamin D can also cause hypercalcemia, particularly in patients with chronic granulomatous disorders and in some patients with lymphoma .
Association of biochemical parameters of bone metabolism with progression and/or development of new aortic calcifications
Atherosclerosis, arteriosclerosis, vascular calcification and osteoporosis are common age-related disorders associated with high morbidity and mortality [1,2]. Due to the increased life expectancy in the Spanish population, these disorders are expected to become more and more frequent in the coming decades. Although recent work has been carried out on the development of non-invasive techniques for the early detection of vascular calcifications, such as pulse wave velocity and non-contrast carotid ultrasound, serum biochemical parameters continue to be the most widely used option for monitoring patients with bone metabolic disorders [3-5].
Search for variants of the LRP4 gene in women with high bone mass and in patients with Chiari type I malformation
The Wnt signalling pathway is involved in a wide range of processes, including bone development and homeostasis . In accordance with this, mutations have been identified in various components of the Wnt pathway that cause different musculoskeletal diseases . The canonical Wnt pathway begins with the formation of a heterotrimeric complex between a co-receptor, LRP5/6, a ligand, WNT, and a receptor, FZD, which produces an accumulation of β-catenin that, once in the nucleus will activate the transcription of numerous important target genes for bone . This activation is finely regulated by a series of extracellular inhibitors such as DKK1 and sclerostin that bind to LRP5/6, preventing the formation of the heterotrimeric complex. For DKK1 and sclerostin to exert their inhibitory activity, they must form another heterotrimeric complex with LRP5 and KREMEN1/2 or LRP4, respectively. Although in the case of DKK1 the presence of KREMEN does not seem to be necessary to carry out a correct inhibition, the presence of LRP4 is essential for the inhibitory function of sclerostin [3,4].
Proximal extremity fractures of the femur are a very common problem in today’s society and of great importance as there has been an increased incidence in the population. This increase is explained by the longer life expectancy in recent years, thus increasing the elderly population and, therefore, related diseases. This is particularly relevant in Spain which has, of late, seen a severe aging of the population .
Several epidemiological studies describe the incidence of hip fracture in Spain. In most cases these are local studies and carried out over short periods of time. National studies have been carried out, although to a lesser extent . According to the Ministry of Health and Social Policy’s 2010 report “Hip fracture care in the hospitals of the National Health System” , a total of 487,973 cases of fracture were recorded between 1997 and 2008. In these figures and in those carried out in various local studies2, a predominance of cases in the female sex and an increase in the incidence in age over the years has been found.
Chronic inflammation is a nonspecific response against aggressor agents mediated by the body’s immune system. In such a scenario, an infiltrate of predominantly mononuclear cells, such as lymphocytes, macrophages and plasma cells, is produced. Under certain conditions or when the aggressor agent persists, a sustainable accumulation and activation of immune cells occurs. Then, the secretion of cytokines, agents that prolong the life of lymphocytes and macrophages, is increased, what leads to chronic inflammation.
Inflammation is the main mechanism involved in bone destruction in chronic inflammatory diseases (CIDs) , such as rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), systemic lupus erythematosus (SLE), multiple sclerosis and/or inflammatory bowel disease (IBD). These diseases show a chronic systemic inflammation that can affect different organs, caused by an alteration of the immune system .
We present the case of a 43-year-old man who presents pain and functional impotence in the left wrist of one year of evolution. Upon examination, an indurated tumor adhered to deep planes is found in this location. Following findings on computerized axial tomography (CT) of images consistent with osteochondroma versus peripheral chondrosarcoma (Figure 1), a bone scan was requested. This bone scintigraphic study in three phases of the upper limbs and a subsequent full-body image (Figure 2), showed the early arrival of the tracer with an increase in the vascular pool of slight-moderate intensity in the distal portion of the left radius (arrow), which persisted with greater intensity in late images. No other diseased findings were observed in the rest of the skeleton. These findings revealed increased vascularity and osteoblastic activity at the distal end of the left radius.
A biopsy was carry out, with a pathological result of osteochondromatous proliferation compatible with Nora’s lesion, confirming this diagnosis after surgical resection.
Care profile of susceptible patients with osteoporosis by telemedicine visits in the post-COVID-19 era
Osteoporotic fractures represent a growing public health problem worldwide. At present, we lack adequate procedures for prevention, diagnosis, assessment, intervention and patient follow-up.
New technologies have provided new communication tools and have changed our mentality, with the possibility of carrying out, virtually, actions or procedures in our daily lives that until now required our physical presence, either for technical, cultural or social reasons .
The COVID-19 pandemic, caused by the SARS-COV-2 virus, has triggered a global public health emergency with rapid evolution and tragic consequences. The fight against this disease is forcing to modify the forms of care, which includes transforming some face-to-face consultations into remote ones .
Prior to the COVID-19 pandemic, telemedicine, in its different forms, was used in exceptional situations. One of the first uses was the tele-nursing practice that emerged in the UK and Canada at a primary care level.