OBJECTIVETo evaluate whether concomitant treatment with low-dose aspirin or other antiplatelet agents have an impact on the risk of severe ischemic complications and in the outcome of patients with giant cell arteritis (GCA).METHODSA retrospective follow-up study of an unselected population of 121 patients with GCA.RESULTSThirty-seven patients (30.5%) received antiplatelet therapy before the onset of GCA symptoms and continued taking it during the corticosteroid treatment (30 received aspirin and 7 other antiplatelet agents). No statistically significant reduction in the incidence of ischemic manifestations (including jaw claudication, visual manifestations, cerebrovascular accidents, ischemic heart disease, and limb claudication due to large artery stenosis) was observed in this group compared with the remaining patients. When we analyzed follow-up data, we found no significant differences between groups in terms of frequency of relapses and percentage of patients recovered from GCA. Corticosteroid requirements among patients in long-lasting remission were lower in those under antiplatelet therapy, but this reduction was fairly modest, statistically non significant and thus of uncertain clinical significance. Similar results were found when only aspirin exposed patients (n=30) were compared to non-exposed patients. Logistic regression analysis showed that antiplatelet therapy (p=0.54, OR 1.31; 95% CI: 0.54-3.19) had not an independent protective effect against ischemic events when adjusted for age, sex, and the presence of atherosclerotic risk factors.CONCLUSIONWe did not observe a significant benefit derived from the use of antiplatelet therapy in either the incidence of severe ischemic events or the disease outcome. Although our results do not discard a potential therapeutic effect of high-dose aspirin, they do not confirm its suggested protective effect in preventing ischemic complications when used at antiplatelet doses.

BACKGROUND:Dyslipidaemia has been described in non-treated rheumatoid arthritis (RA), and improves after therapy with disease modifying anti-rheumatic drugs or glucocorticoids; however, it has generally been perceived that glucocorticoids adversely affect lipid metabolism. The association of low dose glucocorticoid therapy with plasma lipid levels was evaluated in female RA patients.MATERIALS AND METHODS:A cross-sectional study was conducted in 78 female RA patients [mean age: 60 (12) years; mean disease duration: 13 (9) years]. Sixty-five (83%) were on glucocorticoid therapy [total equivalent mean prednisone dose: 5.1 (1.7) mg d(-1)]. Each patient was assessed through a self-reported questionnaire, structured interview and physical examination. Blood samples were obtained for routine biochemistry, lipid profile and haematological tests. Lipid profiles of RA patients who were and were not on glucocorticoid therapy were compared.RESULTS:Clinical and laboratory features of the two groups of patients were similar, except for the Health Assessment Questionnaire and body mass index, which were significantly higher in the patients on glucocorticoid therapy. These patients had 14.7% higher serum high-density lipoprotein cholesterol (HDL-c) levels than untreated patients (P = 0.043), mainly at the expense of HDL2 subfraction, which was 24.4% higher (P < 0.039), whereas HDL3-c was only 7.4% higher (P = 0.219). Serum levels of glucose and total cholesterol, triglyceride, low-density lipoprotein cholesterol (LDL -c), very low-density lipoprotein cholesterol, apolipoproteins A-I and B were not increased in patients on glucocorticoid therapy.CONCLUSIONS:Low dose glucocorticoid therapy in RA patients is associated with an increase in HDL-c, without increasing LDL-c or triglyceride. These lipid changes may overall be considered favourable.

Objective. To evaluate the correlation between neurological deficits indicative of compressive myelopathy and MRI findings in a series of patients with RA and symptomatic involvement of the cervical spine.Methods. Forty-one consecutive patients with RA were studied using cervical spine MRI. Unconditional logistic regression analysis was used to identify MRI parameters of cervical spine involvement associated with the development of neurological dysfunction.Results. The mean age of the 41 patients (33 women and 8 men) was 59 yrs (range 2382 yrs), while the median disease duration was 18 9 yrs (range 440 yrs). According to Ranawats classification, 17 (42) patients were in Class I, 21 (51) in Class II and 3 (7) in Class III. Thus, patients with clinical manifestations of compressive myelopathy (Ranawats Class II III) represented 58 (24/41) of all cases.Among the different MRI parameters of cervical spine involvement analysed, only the presence of atlantoaxial spinal canal stenosis [odds ratio (OR) 4.55; 95 CI 1.1418.15], atlantoaxial cervical cord compression (OR 9.6; 95 CI 1.0885.16) and subaxial myelopathy changes (OR 11.43; 95 CI 1.3100.81) were associated with a significantly increased risk for neurological dysfunction (Ranawats Class II or III).Conclusion. In RA patients with symptomatic cervical spine involvement, there is a strong correlation between the development of neurological dysfunction and MRI identification of atlantoaxial spinal canal stenosis, especially in those cases with evidence of upper cervical cord or brainstem compression and subaxial myelopathy changes.

Many organisms have proposed criteria to identify individuals with low bone mass or increased risk for osteoporotic fracture in order to provide them with the available diagnostic and therapeutic resources. Among these organisms are the WHO, the Catalan Agency for Health Technology Assessment (CAHTA) and the International Committee for Osteoporosis Clinical Guidelines (ICOCG).We designed a prospective multicenter study to determine the prevalence of indications for bone densitometry in rheumatology outpatient clinics by applying the criteria of these three organisms. Two hundred sixty-two women and 98 men aged 18 years or older who attended five rheumatology outpatient clinics were interviewed and their medical records were reviewed. The mean age was 58.3 +/- 13.4 years. Bone densitometry was indicated in 45% of the patients interviewed according to the CAHTA criteria, in 77% according to the WHO criteria and in 62% according to the ICOCG criteria (applicable only to women). The proportion of patients with indications for bone densitometry increased with age, and was higher in women. The concordance among criteria was low.

OBJECTIVESOne of the unresolved challenges posed in giant cell (temporal) arteritis (GCA) is the detection and monitoring of large-artery complications, particularly aortitis. Recent investigations support vascular magnetic resonance imaging (MRI) studies in this issue. We report our preliminary experience with this imaging technique in the study of the aorta and its proximal branches in patients with GCA and/or polymyalgia rheumatica (PMR).METHODSBetween 2000 and 2003, six patients with GCA and/or PMR seen in our department were diagnosed with aortitis using vascular MRI studies. In all cases, the study was performed according to a specifically designed protocol that included MRI and MR angiography (MRA).RESULTSMRI was a hepful non-invasive method for diagnosis of aortitis in all cases, providing accurate information about its extent. In particular, MRI had a higher ability to detect earlier stages of vasculitis disclosing subclinical aortitis in five of the six patients. The main signs of early vascular inflammation observed were vessel wall thickness and oedema (six cases) and increased mural enhancement on postcontrast T1-weighted images (four cases). MRA disclosed lumen changes (stenosis) in two patients. On follow-up studies, whereas vascular stenosis and vessel wall thickness remained invariable, vascular wall oedema and contrast enhancement improved significantly when disease activity decreased.CONCLUSIONMRI may be a useful technique for diagnosing patients with occult major artery involvement in GCA, whether presenting with classic symptoms of temporal arteritis or PMR. Its utility for monitoring the course of the disease and response to treatment requires further confirmation.

Hypophosphatemic osteomalacia is a rare but important complication of multiple myeloma. In these cases, the pathophysiology of the phosphate renal wasting notably differs from oncogenic osteomalacia and is due to light-chain nephropathy, resulting in proximal tubular dysfunction which is not restricted to phosphate handling. These patients seems to have a distinct type of plasma cell disorder characterized by a slow progression of the tumor and by an early phase dominated by the metabolic complications of the renal proximal tubular dysfunction. For this reason hypophosphatemic osteomalacia is the presenting feature that leads to the diagnosis of multiple myeloma in most of these patients. Recognition of this complication is important, since supportive treatment with phosphate supplements and calcitriol may substantially alleviate pain and weakness associated with hypophosphatemia.

Many organisms have proposed criteria to identify individuals with low bone mass or increased risk for osteoporotic fracture in order to provide them with the available diagnostic and therapeutic resources. Among these organisms are the WHO, the Catalan Agency for Health Technology Assessment (CAHTA) and the International Committee for Osteoporosis Clinical Guidelines (ICOCG). We designed a prospective multicenter study to determine the prevalence of indications for bone densitometry in rheumatology outpatient clinics by applying the criteria of these three organisms. Two hundred sixty-two women and 98 men aged 18 years or older who attended five rheumatology outpatient clinics were interviewed and their medical records were reviewed. The mean age was 58.3±13.4 years. Bone densitometry was indicated in 45% of the patients interviewed according to the CAHTA criteria, in 77% according to the WHO criteria and in 62% according to the ICOCG criteria (applicable only to women). The proportion of patients with indications for bone densitometry increased with age, and was higher in women. The concordance among criteria was low.

We analyzed the cases of pyogenic arthritis from group B streptococcus (GBS), or Streptococcus agalactiae, in nonpregnant adults diagnosed in the Hospital Universitari de Bellvitge, a 1,000-bed tertiary care teaching hospital in Barcelona, Spain, during a 10-year period, and we reviewed the available literature to summarize the experience with this infectious entity. From the database of our institution, which does not attend pediatric, obstetric, or burn patients, we collected all microbiologically proven cases of infectious arthritis seen from January 1992 to December 2001. We excluded patients with infection limited to spine; patients with prosthetic joint infection; patients undergoing articular surgery during the year before diagnosis; and those with tuberculous, brucellar, or fungal arthritis. Of a total of 112 patients identified, GBS was the causative organism in 11 (10%) cases. We reviewed the literature using a MEDLINE search (1972–2001), and found 64 additional cases. Of the 75 patients, 34 (45%) were men and 41 (55%) women, with ages ranging from 20 to 87 years (mean age, 57.9 ± 14.9 yr); 37 patients (49%) were over 60 years. Sixty-eight percent (51/75) of the patients presented with monoarthritis, while in 32% (24/75) more than 1 joint was involved. The most common location was the knee (36%), followed by the shoulder (25%). In 66% (43/65) of cases, bacteremia was documented. In 64% (47/74) of patients, a systemic predisposing factor for infection was noted; the most common conditions were diabetes mellitus, malignancies, and chronic liver diseases. In 31% (23/75) of patients, a concomitant infectious process due to the same microorganism was found, mainly vertebral osteomyelitis and urinary tract infection. Penicillin was the main antibiotic used after bacterial identification; surgical drainage was performed in 36% (27/75) of cases. The overall mortality rate was 9% (7/75). GBS is now a significant causative agent of pyogenic arthritis in nonpregnant adults. In this population, joint infection by GBS is a disease that mainly affects aged patients with underlying medical illnesses; polyarticular involvement, bacteremia, and the presence of a concomitant infectious process are frequent conditions. The case-fatality rate is substantial.

OBJECTIVE:To analyse whether bone mineral density (BMD) assessment is required in postmenopausal women presenting with low trauma vertebral fracture. METHODS:Women with vertebral fracture diagnosed over a 10 year period were recruited from our database. The following were excluded: (a) patients with high energy trauma; (b) patients with malignancies; (c) patients with a metabolic bone disease other than osteoporosis. All postmenopausal women were included in whom BMD had been evaluated at both the lumbar spine and femoral neck by dual energy x ray absorptiometry during the six months after the diagnosis. Patients with a potential cause of osteoporosis other than age and menopause were not considered. A total of 215 patients were identified. RESULTS:The mean (SD) age of the patients was 65.9 (6.9) years. BMD at the lumbar spine was 0.725 (0.128) g/cm(2) and the T score was -2.94 (1.22); BMD at the femoral neck was 0.598 (0.095) g/cm(2) and the T score was -2.22 (0.89). The BMD of the patients was significantly lower than that of the general population at both the lumbar spine and femoral neck. When the lowest value of the two analysed zones was considered, six patients (3%) showed a normal BMD, 51 (23.5%) osteopenia, and 158 (73.5%) osteoporosis. The prevalence of osteoporosis at the femoral neck increased with age; it was 25% in patients under 60, 35% in patients aged 60-70, and 60% in patients over 70. CONCLUSION:These results indicate that bone densitometry is not required in postmenopausal women with clinically diagnosed vertebral fractures if it is performed only to confirm the existence of a low BMD.

OBJECTIVE:We study liver damage in forty-two patients with rheumatoid arthritis (RA) using light (LM) and electron microscopy (EM) and assess histological changes after four years of treatment with methotrexate (MTX).PATIENTS AND METHODS:liver biopsies (LB) were taken before and after four years of treatment. Patients received weekly doses of between 7.5-15 mg of MTX.RESULTS:Fourteen per cent of the baseline LB presented mild perisinusoidal fibrosis (Roenigk IIIA) and the rest a lower Roenigk grade; EM identified an increase in collagen fibers in the Disse spaces in 50% of baseline LB. Neither microscopy technique revealed histological progression in any of the sequential LB. Variables that correlated with histological abnormalities were patient's age, length of evolution of the disease, alcohol consumption and biochemical data (gammaglutamate transferase and albumin); the cumulative dose of MTX was not correlated with worse histological findings. Correlation between the two microscopy techniques was good, though EM was more sensitive than LM for the detection of fibrosis.CONCLUSIONS:RA patients present with liver damage before treatment with MTX. The alterations are mild. At low doses MTX treatment is safe. In addition to the recommendations of the American College of Rheumatology, other factors associated with liver impairment are patient's age and length of evolution of the RA.

Objective: To analyze the clinical, microbiological, and radiologic features of patients without drug addiction suffering from spontaneous pyogenic vertebral osteomyelitis. Methods: We collected all microbiologically proved cases of pyogenic vertebral osteomyelitis seen between January 1980 and December 1999 in a teaching hospital. Patients with prior spinal instrumentation or surgery and injection drug users were excluded. Results: Sixty-four patients, with a mean age of 59 ± 17 years, were identified. In 29 (45%) patients, 1 or more underlying medical illnesses were found. The mean duration of symptoms before hospital admission was 48 ± 40 days. Neurologic impairment was present in 18 (28%) patients. Staphylococcus aureus and gram-negative bacilli, mainly Escherichia coli, were the predominant etiologic agents. Blood cultures were positive in 72% (46/64) of cases. The cultures of spinal specimens obtained by x-ray–guided biopsy were positive in 52% (11/21) of cases, and those obtained by open biopsy in 75% (15/20) of cases. Plain radiography showed abnormalities in all but 7 patients. Fifty-one of 53 (96%) technetium Tc 99m diphosphonate bone scans and 40 of 44 (91%) gallium citrate Ga 67 bone scans showed increased uptake of tracers in the involved area. Paraspinal and epidural extension was found on computed tomography and/or magnetic resonance imaging in 74% (39/53) of cases; the presence of an extra-vertebral extension was not associated with the development of neurologic findings in many patients. Two patients died in relation to the infectious process and 3 relapsed; functional sequelae often were found. Conclusions: Spontaneous pyogenic vertebral osteomyelitis in nondrug users is a disease that affects mainly older patients suffering underlying medical illnesses. S aureus and E coli are the main causative microorganisms. Positive blood cultures frequently aided the diagnosis. Extra-vertebral extension is frequent but does not indicate a worse prognosis. Although life outcome is good, functional sequelae are common. Diagnostic delay before admission is a concern, and the physician should be alert to the possibility of this condition in patients with back or neck pain. Semin Arthritis Rheum 31:271-278. Copyright 2002, Elsevier Science (USA). All rights reserved.

Objective-Criteria to decide which patients with rheumatoid arthritis (RA) should be examined by dual energy x ray absorptiometry (DXA) are currently not available. The rheumatologists from Amsterdam have proposed preliminary criteria based on clinical risk factors (age, disease activity, and functional status). These criteria are preliminary and not widely accepted but might be helpful in practice. The value of the proposal in a group of Spanish postmenopausal women with RA is analysed.Methods-DXA (lumbar spine and femoral neck) was performed in 128 patients recruited from a clinical setting, and the proposed criteria were applied. T and Z scores were established for a Spanish reference population.Results-The mean (SD) age of the patients was 61.3 (10.7) and mean duration of the postmenopausal period 14.5 (10.1) years. Mean duration of RA was 13.7 (7.7) years. Mean C reactive protein was 22 (21) mg/l; mean erythrocyte sedimentation rate 26 (18) mm/1st h; and mean Health Assessment Questionnaire score 1.25 (0.79). Ninety (70%) patients fulfilled the proposed criteria. Their sensitivity for the diagnosis of osteoporosis (T score less than or equal to -2.5 SD) was 86% and their specificity, 43%. Positive predictive value was 54% and negative predictive value, 79%.Conclusions-The proposed criteria seem a good screening method for the selection of those patients with RA whose bone mineral density should be assessed as the sensitivity and negative predictive value are acceptable.

The aim of the study was to evaluate whether computed digital absorptiometry (CDA) of the hand might be a useful screening technique for identifying patients with postmenopausal osteoporosis and to compare the results of CDA with those of dual-energy X-ray absorptiometry (DXA) of the lumbar spine and femoral neck. We studied 230 postmenopausal women (mean age 58.4 +/- 7.9 years). For CDA, bone mineral density (BMD) was measured with an AccuDEXA Schick densitometer in the third middle phalanx of the nondominant hand. For DXA, BMD of the lumbar spine and upper femur was assessed using a DXA Hologic QDR-1000 densitometer. We did a comparative analysis (ANOVA) and linear correlation tests. Sensitivity and specificity of CDA and receiver operating characteristic (ROC) curves for the diagnosis of osteoporosis were calculated. The mean BMD with CDA was 0.445 +/- 0.084 (T-score: - 1.27 +/- 1.29). The mean BMD (g/cm(2)) with DXA at the lumbar spine was 0.877 +/- 0. 166 (T-score: - 1.52 +/- 1.59) and 0.708 +/- 0.127 at the femoral neck (T-score: -1.12 +/- 1.25). BMD at the lumbar spine and femoral neck correlated positively with CDA of the hand (r = 0.66 and r = 0.65 respectively, p <0.001). When using as cut-off a T-score of -2.5, according to WHO criteria, 76 women (33%) had osteoporosis of the lumbar spine and/or femoral neck with DXA and 42 (18%) with CDA (p <0.001). The kappa score for osteoporosis was 0.33 for CDA versus spinal DXA and 0.35 for CDA versus femoral DXA. With the cut-off level used, sensitivity and specificity of CDA in detecting osteoporosis at the lumbar spine were 0.39 and 0.90, respectively; sensitivity and specificity of CDA in identifying osteoporosis at the femoral neck were 0.58 and 0.87, respectively. The positive predictive value of CDA for osteoporosis. was 69% and the negative predictive value was 75%. The area under the ROC curve for osteoporosis was 0.822 +/- 0.028. We conclude that: (a) CDA assessment has a moderate correlation with BMD measured by DXA at the lumbar spine and femoral neck; (b) CDA has a low sensitivity for the diagnosis of osteoporosis compared with spinal and femoral DXA; and (c) predictive values for osteoporosis at both the lumbar spine and femoral neck are acceptable.

OBJECTIVE:Few data are available on clinically diagnosed vertebral fracture. Information about osteoporotic vertebral fracture has mainly been obtained via inferences from epidemiological studies of vertebral deformity. We evaluated the characteristics of patients with osteoporotic vertebral fracture diagnosed in a rheumatology department over a 10 year period.METHODS:Patients with back pain and vertebral fracture diagnosed between January 1990 and December 1999 were recruited from our data base. Patients with high energy trauma, malignancies, and metabolic bone diseases other than osteoporosis were excluded. These variables were analyzed: sex, age at diagnosis, type of osteoporosis (primary vs secondary), number of fractures at diagnosis (single vs multiple), and percentage of admissions and length of stay.RESULTS:Of the 669 patients, 534 (80%) were women and 135 (20%) were men. Age at diagnosis ranged from 30 to 91 yrs, mean 67.1 +/- 9.1. Secondary osteoporosis was diagnosed in 177 (26%) patients and the frequency was significantly higher in men than women (55% vs 19%; p < 0.001); the most common associations for secondary osteoporosis were oral corticosteroids, chronic obstructive airway disease, and rheumatoid arthritis. At diagnosis, half of the patients presented with multiple fractures. One hundred twenty (18%) patients were admitted; length of stay ranged from 5 to 56 days, mean 15.9 +/- 7.7. The frequency of admissions was higher in men than women (27% vs 16%; p < 0.001), higher in patients with secondary osteoporosis than in those with primary osteoporosis (33% vs 12%; p < 0.001), and higher in patients with multiple fractures than in those with single fractures (27% vs 8%; p < 0.001).CONCLUSION:Characteristics of patients recruited from a clinical setting differ significantly from those of subjects included in the epidemiological studies. In a rheumatology practice, frequency of secondary osteoporosis, mainly associated with corticosteroid treatment, is notably high. Admission is by no means a rare event.

Background. Some chronic diseases have been associated to an impairment of nutritional status. Objective. To analyze nutritional status and its relation to dietary intake, disease activity and treatment in rheumatoid arthritis. Patients and methods. We have included 93 patients (43 men and 50 women) and 93 age- and sex-matched healthy controls. The assessment of nutritional status included anthropometric (body mass index, tricipital skin fold and midarm muscular circumference) and biochemical (serum albumin, prealbumin and retinol binding protein) parameters. Dietary intake was calculated from a food frequency questionnaire. As a measure of disease activity, we used the Health Assessment Questionnaire, Ritchie index, tender and swollen joint count and C-reactive protein. Statistical analysis was performed in the whole series and in every functional class. Results. In the whole series, midarm muscular circumference and serum albumin were significantly lower in patients than in controls. All anthropometric parameters and serum albumin were significantly lower in patients in functional class IV than in their respective controls. The dietary intake of energy, carbohydrates, vegetal proteins and lipids was higher in patients than in controls. Midarm muscular circumference and serum albumin had a significant inverse relation with disease activity parameters; body mass index, midarm muscular circumference and serum albumin correlated inversely with the cumulative dose of glucocorticoids. Conclusions. Patients with rheumatoid arthritis in functional class IV have an impairment of nutritional status without a deficient dietary intake. The differences found in other functional classes are explained by rheumatoid arthritis itself. Nutritional parameters are related to disease activity and glucocorticoid treatment.

Objectives: 1) To analyze the clinical features and outcome of patients with rheumatoid arthritis and pyarthrosis seen in a rheumatology department during a 9-year period; 2) To review the available literature about this association in the last decade.Methods: From the database of our department, we collected all hospitalized cases of infectious arthritis in native joints between January 1990 and December 1998. In 10 cases (27%), pyarthrosis occurred in patients with rheumatoid arthritis. A detailed analysis of each patient was performed. The literature was reviewed by using MEDLINE from 1990 to 1999.Results: The mean age of patients was 63.2 years; six were female. Most patients had long-standing disease and poor functional class, and all received glucocorticoid treatment. Mean diagnostic delay was 7.3 days. Causative organisms were Staphylococcus aureus (4 cases), gram-negative bacilli (3 cases), anaerobic bacteria (2 cases), and Streptococcus pneumoniae (n = 1). Two patients died. In all but two patients who survived, joint function worsened.Conclusions: Rheumatoid arthritis is a relevant host-related risk factor for septic arthritis. Pyarthrosis in these patients is associated with considerable morbidity and mortality. Copyright (C) 2000 by W.B. Saunders Company.