Is there a potential dual effect of denosumab for treatment of osteoporosis and sarcopenia?

BACKGROUND

The prevalence of sarcopenia with osteoporosis results in a higher risk of falling and fractures. It was noted that patients who had completed their planned 5-year denosumab therapy course as treatment for these conditions started to sustain falls.

PURPOSE

To assess (a) whether denosumab has a unique dual effect on both bone and muscle in comparison to other anti-resorptive agents and (b) its effectiveness in the follow-up period post-treatment completion compared to other anti-resorptive agents.

METHOD

One hundred thirty-five patients diagnosed to have postmenopausal/senile osteoporosis and who were prescribed denosumab were compared to a control group of 272 patients stratified into 2 subgroups - 136 prescribed alendronate and 136 prescribed zoledronate. All patients were assessed for: BMD (DXA), falls risk (FRAS), fracture risk (FRAX), and sarcopenia measures. All were re-assessed after 5 years of denosumab/alendronate therapy and 3 years of zoledronate and 1 year after stopping the osteoporosis therapy.

RESULTS

No significant baseline demographic differences between the 3 groups. On completion of the 5-year denosumab therapy, there was significant decrease in falls risk (P = 0.001) and significant improvements in all sarcopenia measures (P = 0.01). One-year post-discontinuation of denosumab, a significant worsening of both falls risk and sarcopenia measures (P = 0.01) noticed.

CONCLUSION

Denosumab displayed positive impact and significant improvements in BMD and sarcopenia measures. It also enhanced multidirectional agility as depicted by Timed Up and Go (TUG). Collectively, this would explain the reduction of falls risk which got worse on stopping the medication. Key points • The coexistence of osteoporosis and sarcopenia has been recently considered in some groups as a syndrome termed 'osteosarcopenia'. • Bone and muscle closely interact with each other not only anatomically, but also at the chemical and metabolic levels. • Denosumab displayed positive impact and significant improvements in all sarcopenia measures, and enhanced multidirectional agility with consequent reduction in falls risk. • Denosumab can be considered as a first osteoporosis therapeutic option in this group of patients presenting with osteosarcopenia manifestations.

Synovitis with pitting edema as the presenting manifestation of systemic lupus erythematosus

Rheumatologists are increasingly aware of the entity synovitis with pitting edema. The remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome has been reported with an array of conditions that include polymyalgia rheumatica, rheumatoid arthritis, Sjögren’s syndrome and psoriatic arthropathy. Synovitis with pitting edema is now being increasingly recognized with systemic lupus erythematosus (SLE). We report a patient who presented with edema of hands and feet and was diagnosed eventually with definite SLE. With magnetic resonance imaging, joint effusions and tenosynovitis were confirmed to be associated with the otherwise-unexplained extremity edema.

Central pontine myelinolysis in the hyperosmolar hyperglycaemic state

OBJECTIVE

To report a rare association of central pontine myelinolysis (CPM) with hyperosmolar hyperglycaemic state (HHS).

CLINICAL PRESENTATION AND INTERVENTION

A diabetic female presented with HHS and prolonged severe hypernatraemia. The metabolic derangement was adequately treated with proper correction of both hyperglycaemia and hypernatraemia. Lack of improvement in the presenting confusional state and the development of a fresh neurological deterioration led to the suspicion of CPM that was confirmed with magnetic resonance imaging. She fully recovered after 4 weeks with no specific medical treatment.

CONCLUSION

This case report showed that osmotic demyelination was linked to hypernatraemia and that CPM could result from severe hypernatraemia of HHS.

Junctional bradycardia with verapamil in renal failure--care required even with mild hyperkalaemia

WHAT IS KNOWN AND OBJECTIVE

Treatment for hypertension with verapamil has a favourable renoprotective effect and is generally considered safe in patients with mild to moderate renal failure. In this report, we highlight the vulnerability of patients with mild to moderate renal failure to verapamil side effects especially in the presence of hyperkalaemia.

CASE SUMMARY AND WHAT IS NEW

We report two cases of junctional bradycardia with slow release (SR) verapamil therapy in the presence of mild hyperkalaemia in patients with mild to moderate chronic renal failure. Verapamil and hyperkalaemia may synergistically increase the vulnerability to atrioventricular conduction delay.

CONCLUSION

Renal failure patients with baseline mild hyperkalaemia are particularly liable to bradyarrhythmias with SR verapamil. In such cases, we would recommend verapamil dose reduction and avoidance of SR formulation. In cases of verapamil toxicity, actively treating any level of hyperkalaemia is recommended.

Mycophenolate mofetil as a maintenance therapy for lupus-related diffuse alveolar hemorrhage: a case report

Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of systemic lupus erythematosus (SLE). Cases complicated with DAH often have active SLE with multi-organ involvement, especially lupus nephritis. We describe a rare case of DAH as the first presenting manifestation of SLE in the absence of lupus nephritis. Remission was induced by IV methylprednisolone, IV cyclophosphamide, and plasmapheresis. Further cycles of cyclophosphamide were prevented by recurrent infections. Maintenance of remission was successfully achieved with oral mycophenolate mofetil 1 g twice daily, with a good control of SLE and without further DAH episodes.

Hypothermia with pneumonia: a rare presentation of brucellosis

OBJECTIVE

To report a very rare form of brucellosis presenting with hypothermia and pneumonia.

CLINICAL PRESENTATION AND INTERVENTION

A 41-year-old male shepherd presented with a depressed level of consciousness. Clinically, his rectal temperature was 29.5°C, and he was cold, apathetic, hyporeflexic, and hypotensive, with atrial fibrillation. He had clinical and radiological evidence of bilateral bronchopneumonia. Blood culture and serologic testing were positive for Brucella melitensis. The patient recovered completely after proper management of the hypothermia and treatment of the brucellosis with antibiotics (doxycycline 100 mg orally twice daily for 6 weeks and streptomycin 1 g i.m. daily for 21 days).

CONCLUSION

This case shows that brucellosis should be considered in the differential diagnosis of septicemic patients presenting with hypothermia.

Anticoagulation for cerebral venous thrombosis with subarachnoid hemorrhage: a case report

OBJECTIVES

To report the success of anticoagulation (AC) treatment in a case of cerebral venous thrombosis (CVT) with subarachnoid hemorrhage (SAH) in view of the limited evidence seen in the literature supporting such a treatment option.

CLINICAL PRESENTATION AND INTERVENTION

A 38-year-old lady with CVT and SAH presented 12 h after the onset of symptoms. AC with low-molecular-weight heparin was started 4 days later, when the repeated brain CT showed regression of the SAH. Heparin was changed to warfarin, and she was asymptomatic over a 12-month follow-up period.

DISCUSSION

In a limited number of small studies, AC has been found to be beneficial for cases of CVT with hemorrhagic complications. The proper time to start AC in such cases was not clearly defined, and a delay of 4-33 days was observed after the onset of symptoms. In cases of spontaneous intracranial hemorrhage (ICH) in general, active bleeding is usually confined to the first 6 h, and chances of hematoma enlargement are higher in the first 24 h. On the other hand, it has been advised to rule out a coincidental vascular malformation and to radiologically confirm regression (or at least non-progression) of the ICH before starting AC.

CONCLUSION

AC for cases of CVT may remain beneficial in the presence of SAH. The time to start AC for CVT with hemorrhagic complications is unclear; however, AC was successful when given 4 days after the onset of symptoms in our case. It may be wise to repeat CT after at least 24 h from the onset of symptoms (to confirm regression or at least non-progression of the ICH) before starting AC. It may also be prudent to perform magnetic resonance angiography, or digital subtraction angiography to rule out a coincidental intracranial aneurysm before AC.

Pulmonary hypertension responding to hyperthyroidism treatment

Pulmonary hypertension in adults with hyperthyroidism is increasingly being reported. Although the mechanism is uncertain, the reversal of pulmonary hypertension following restoration to an euthyroid state supports a causal relationship. This case report is of a 43-year-old woman who presented with Graves disease and right ventricular failure. Echocardiography showed severe pulmonary hypertension, moderate to severe tricuspid regurgitation, normal left heart function and a negative bubble contrast study. Carbimazole therapy was instituted along with diuretics and captopril. The patient was followed for a period of 14 months. Clinical and biochemical euthyroidism was attained after 4 months of treatment. Resolution of right ventricular failure and normalization of pulmonary artery pressure occurred 11 and 14 months after initiation of therapy, respectively. Investigating thyroid status in patients with pulmonary hypertension is recommended. In patients with hyperthyroidism and (otherwise unexplained) pulmonary hypertension, restoration of euthyroidism may cure right ventricular failure and restore normal pulmonary artery pressure.

Can a change in policy reduce emergency hospital admissions? Effect of admission avoidance team, guideline implementation and maximising the observation unit

BACKGROUND

Reduction in admissions is an important aim of emergency department working policy to overcome the problems of a shortage of inpatient beds, overcrowding, rising costs and exhausted resources. A new policy was instituted in the emergency department of a hospital in Kuwait with the following components: (1) an admission avoidance team of emergency department doctors; (2) implementation of disease management guidelines; and (3) maximising the use of an emergency department observation unit.

METHODS

The effects of this policy on reduction in admission rates for total medical admissions and for chest pain, bronchial asthma, heart failure, pneumonia and pyelonephritis as selected samples of common medical conditions were prospectively studied over a period of 3 years from institution of the policy and compared with the 3-year period before the policy was instituted.

RESULTS

There was a significant reduction in admission rates after institution of the new policy, with a relative reduction of 35.9% for total medical admissions, 52.7% for chest pain, 49.2% for bronchial asthma, 34.7% for heart failure, 59.1% for pneumonia and 43.3% for pyelonephritis compared with the period before the policy was instituted.

CONCLUSION

A multidisciplinary emergency department policy, using as much available evidence as possible, was successful in significantly reducing medical hospital admissions in spite of the rising numbers of patients visiting the emergency department and observation unit.