Giant cell arteritis associated with intravenous zoledronic acid administration

Bisphosphonates frequently provoke a cytokine-driven acute clinical response (ACR) characterized by fever, chills, arthralgias, and myalgias. More rarely, an association between aminobisphosphonates, such as alendronate and zoledronic acid, and rheumatologic and/or immune-mediated syndromes (RIMS) has been described. Herein we report 2 patients, one with a prior history of rheumatic disease and one without, who developed giant cell arteritis meeting the American College of Rheumatology 2022 criteria following zoledronic acid infusion. We subsequently review existing mechanistic and clinical literature supporting this link. The duration of symptoms and elevation of inflammatory markers may serve as indicators for differentiating between the more common ACR and less frequent but potentially morbid RIMS. Although the benefit of bisphosphonates will outweigh the risk of RIMS for most patients with high fracture risk, clinicians should be aware of this phenomenon to assist earlier diagnosis and treatment in affected individuals.

Association of prior treatment with nitrogen-containing bisphosphonates on outcomes of COVID-19 positive patients

COVID-19 infection has resulted in significant morbidity and mortality globally, especially among older adults. Repurposed drugs have demonstrated activity in respiratory illnesses, including nitrogen-containing bisphosphonates. In this retrospective longitudinal study at 4 academic medical centers, we show no benefit of nitrogen-containing bisphosphonates regarding ICU admission, ventilator use, and mortality among older adults with COVID-19 infection. We specifically evaluated the intravenous bisphosphonate zoledronic acid and found no difference compared to oral bisphosphonates.

BACKGROUND

Widely used in osteoporosis treatment, nitrogen-containing bisphosphonates (N-BP) have been associated with reduced mortality and morbidity among older adults. Based on prior studies, we hypothesized that prior treatment with N-BP might reduce intensive care unit (ICU) admission, ventilator use, and death among older adults diagnosed with COVID-19.

METHODS

This retrospective analysis of the PCORnet Common Data Model across 4 academic medical centers through 1 September 2021 identified individuals age >50 years with a diagnosis of COVID-19. The composite outcome included ICU admission, ventilator use, or death within 15, 30, and 180 days of COVID-19 diagnosis. Use of N-BP was defined as a prescription within 3 years prior. ICU admission and ventilator use were determined using administrative codes. Death included both in-hospital and out-of-hospital events. Patients treated with N-BP were matched 1:1 by propensity score to patients without prior N-BP use. Secondary analysis compared outcomes among those prescribed zoledronic acid (ZOL) to those prescribed oral N-BPs.

RESULTS

Of 76,223 COVID-19 patients identified, 1,853 were previously prescribed N-BP, among whom 559 were prescribed ZOL. After propensity score matching, there were no significant differences in the composite outcome at 15 days (HR 1.22, 95% CI: 0.89-1.67), 30 days (HR 1.24, 95% CI: 0.93-1.66), or 180 days (HR 1.17, 95% CI: 0.93-1.48), comparing those prescribed and not prescribed N-BP. Compared to those prescribed oral N-BP, there were no significant differences in outcomes among those prescribed ZOL.

CONCLUSION

Among older COVID-19 patients, prior exposure to N-BP including ZOL was not associated with a reduction in ICU admission, ventilator use, or death.

Reporting of Full-Length Femur Imaging to Detect Incomplete Atypical Femur Fractures: 2023 Official Positions of the International Society for Clinical Densitometry

Incomplete atypical femur fractures (iAFFs) are associated with the long-term use of anti-resorptive therapies. Although X-rays are typically used to screen for iAFFs, images from dual-energy X-ray absorptiometry (DXA) offer an alternate method for detecting iAFFs. Although a previous 2019 ISCD Official Position on this subject exists, our task force aimed to update the literature review and to propose recommendations on reporting findings related to iAFFs that may be observed on DXA images. The task force recommended that full-length femur imaging (FFI) from DXA can be used as a screening tool for iAFFs. The presence of focal lateral cortical thickening and transverse lucencies should be reported, if identified on the FFI. This task force proposed a classification system to determine the likelihood of an iAFF, based on radiographic features seen on the FFI. Lastly, the task force recommended that the clinical assessment of prodromal symptoms (pain) is not required for the assessment of FFI.

DXA Reporting Updates: 2023 Official Positions of the International Society for Clinical Densitometry

INTRODUCTION

Professional guidance and standards assist radiologic interpreters in generating high quality reports. Initially DXA reporting Official Positions were provided by the ISCD in 2003; however, as the field has progressed, some of the current recommendations require revision and updating. This manuscript details the research approach and provides updated DXA reporting guidance.

METHODS

Key Questions were proposed by ISCD established protocols and approved by the Position Development Conference Steering Committee. Literature related to each question was accumulated by searching PubMed, and existing guidelines from other organizations were extracted from websites. Modifications and additions to the ISCD Official Positions were determined by an expert panel after reviewing the Task Force proposals and position papers.

RESULTS

Since most DXA is now performed in radiology departments, an approach was endorsed that better aligns with standard radiologic reports. To achieve this, reporting elements were divided into required minimum or optional. Collectively, required components comprise a standard diagnostic report and are considered the minimum necessary to generate an acceptable report. Additional elements were retained and categorized as optional. These optional components were considered relevant but tailored to a consultative, clinically oriented report. Although this information is beneficial, not all interpreters have access to sufficient clinical information, or may not have the clinical expertise to expand beyond a diagnostic report. Consequently, these are not required for an acceptable report.

CONCLUSION

These updated ISCD positions conform with the DXA field's evolution over the past 20 years. Specifically, a basic diagnostic report better aligns with radiology standards, and additional elements (which are valued by treating clinicians) remain acceptable but are optional and not required. Additionally, reporting guidance for newer elements such as fracture risk assessment are incorporated. It is our expectation that these updated Official Positions will improve compliance with required standards and generate high quality DXA reports that are valuable to the recipient clinician and contribute to best patient care.

Reporting Fewer Than Four Vertebrae: 2023 Official Positions of the International Society for Clinical Densitometry

The precision for spine bone mineral density (BMD) worsens as vertebrae are excluded, so recommendations are needed for least significant change (LSC) for spine BMDs based on fewer than 4 vertebrae. The task force recommends re-analysis of each facility's L1-L4 in-house precision study to determine the precision in order to calculate the LSC for each combination of 2 or 3 reported vertebrae. The task force recommended not reporting spine BMDs based on single vertebral bodies for either the diagnosis or monitoring of osteoporosis. Specific data for studies assessing the precision of two non-contiguous vertebrae are mixed, but ultimately the task force recommended that spine BMD based on 2 non-contiguous vertebrae can be used for the diagnosis and monitoring of osteoporosis.

Bilateral hip DXA Reporting: 2023 Official Positions of the International Society for Clinical Densitometry

INTRODUCTION

This position development conference (PDC) Task Force examined the use and reporting of bilateral hip bone mineral density (BMD) measurements. This was deemed appropriate as increased availability of Dual-energy X-ray Absorptiometry (DXA) technology offering bilateral hip measurement resulted in more routine clinical use. The International Society for Clinical Densitometry Official Positions accept bilateral hip BMD measurement for clinical use but currently do not include recommendations for reporting those studies.

METHODS

Four key questions regarding bilateral hip reporting were proposed by the PDC Steering Committee. Relevant literature was identified using PubMed. Questions included whether bilateral hip measurements are appropriate for diagnostic classification or monitoring, as well as which bilateral hip regions of interest should be reported for diagnosis and monitoring. Additionally, the appropriate nomenclature for bilateral hip acquisition was defined.

RESULTS

The literature review demonstrated that bilateral hip measurement is appropriate and diagnostic classification should be based on the lowest T-score at the right or left side femoral neck or total hip; the mean T-score should not be used for diagnostic purposes. Mean bilateral total hip is preferred for BMD monitoring. The terms hip, or total hip were deemed appropriate nomenclature instead of femur or total proximal femur.

CONCLUSION

Bilateral hip acquisition is clinically appropriate and reporting and nomenclature standards are offered herein when a bilateral hip study is acquired. In terms of future research, the impact of discordant hips on diagnosis and monitoring was identified as a significant knowledge gap.

Utility of iliac crest tetracycline-labelled bone biopsy in osteoporosis and metabolic bone disease: An evaluation of 95 cases over a period of 25 years

Background

Metabolic bone diseases (MBD) are typically diagnosed by non-invasive imaging and clinical biomarkers. However, imaging does not provide structural information, and biomarkers can be transiently affected by many systemic factors. Bone biopsy and pathologic evaluation is the gold standard for diagnosis of MBD, however, it is rarely utilized. We describe our technique for iliac crest tetracycline-labelled bone using a cannulated drill and assess the utility of bone biopsies to provide diagnostic and therapeutic guidance.

Methods

In the 25-year period between March 1998 and January 2023, a total of 95 bone biopsies were performed on 94 patients for an osteological indication at Vanderbilt University Medical Center (VUMC). Patient demographics, bone biopsy indications, complications, diagnostic utility, and subsequent therapeutic guidance were retrospectively reviewed and analyzed.

Results

The procedure had minimal complications and was well tolerated by patients. This technique provided good quality specimens for pathology, which helped establish a diagnosis and treatment change in most patients. Patients that had biopsy-guided treatment alterations showed significant increases in Dual-Energy X-ray Absorptiometry (DEXA) bone mineral density (BMD) scores post-biopsy and subsequent treatment.

Conclusion

Despite scientific and technological progress in non-invasive diagnostic imaging, clinical biomarkers, and procedures for MBD, there remains a small but significant subset of patients who may benefit from inclusion of tetracycline-labelled bone biopsy into the diagnostic and therapeutic picture. Future prospective comparison studies are warranted.

Mini abstract

Tetracycline-labelled bone biopsies are under-utilized. Biopsy led to a histological diagnosis and ensuing treatment alteration in most patients with significant increases in bone mineral density. The biopsy procedure used herein provided good specimens with low pain/adverse events. Bone biopsy remains a valuable tool in a small, though significant, subset of patients.

Denosumab treatment lapses, discontinuation, and off-treatment fracture risk: A retrospective study of patients with osteoporosis in a real-world clinical setting

INTRODUCTION

The purpose of this study was to retrospectively examine predictors of fracture risk when adult patients experienced a denosumab treatment lapse or discontinuation in a real-world clinic setting.

MATERIALS AND METHODS

Eligible patients were adults who had received ≥2 doses of denosumab at an academic health center in the United States. Demographics, treatment doses, reasons for missed doses, and fractures, were collected retrospectively from electronic health records, from an 8-year period (2010-2018). The number of times each patient incurred a treatment lapse, defined as ≥240 days between two doses (excluding lapse due to discontinuation, death, or transfer of care) was computed. The occurrence of denosumab discontinuation (excluding discontinuation due to death or transfer of care), whether the patient initiated alternative therapy, and the reason for each lapse and discontinuation were collected. Cox proportional hazards models assessed characteristics associated with risk of fracture and treatment discontinuation. A logistic regression model was used to determine if cumulative amount of time off medication (i.e., cumulative lapse time) was associated with a higher likelihood of incurring a fracture.

RESULTS

We included 534 patients: 95 % White, 86 % women, 33 % tobacco users, 13 % diagnosed with diabetes, median age 69 years (Interquartile Range (IQR): 62-77), and median Body Mass Index (BMI) 25 kg/m2 (IQR: 22-28). Thirty-six percent of patients incurred 250 lapses; 10 % discontinued therapy. Dental problems/procedures and logistical barriers were the most common reasons for lapses and discontinuations. Nineteen percent (n = 103) incurred a total of 190 fractures; of these, 121 were osteoporotic, 50 were vertebral. Risk of any, osteoporotic, and vertebral fractures were associated with off-treatment status (hazard ratio [HR] = 1.7, p = 0.043; HR = 2.0, p = 0.026; and HR = 4.2, p = 0.001, respectively) and older age (HR = 1.3, p = 0.015; HR = 1.5, p = 0.001; and HR = 1.8, p = 0.005, respectively). Older age was associated with higher risk of discontinuation (HR = 1.4, p = 0.022). There was a non-significant trend of a nonlinear association between incurring a fracture and cumulative lapse time (p = 0.087).

CONCLUSION

Denosumab treatment lapses are common, and off-treatment status may be associated with a higher risk of fractures. Clinical teams should proactively identify and address adverse effects and potential logistical barriers to reduce the risk of treatment lapses.

Toward the use of MRI measurements of bound and pore water in fracture risk assessment

The current clinical assessment of fracture risk lacks information about the inherent quality of a person's bone tissue. Working toward an imaging-based approach to quantify both a bone tissue quality marker (tissue hydration as water bound to the matrix) and a bone microstructure marker (porosity as water in pores), we hypothesized that the concentrations of bound water (Cbw) are lower and concentrations of pore water (Cpw) are higher in patients with osteoporosis (OP) than in age- and sex-matched adults without the disease. Using recent developments in ultrashort echo time (UTE) magnetic resonance imaging (MRI), maps of Cbw and Cpw were acquired from the uninjured distal third radius (Study 1) of 20 patients who experienced a fragility fracture of the distal radius (Fx) and 20 healthy controls (Non-Fx) and from the tibia mid-diaphysis (Study 2) of 30 women with clinical OP (low T-scores) and 15 women without OP (normal T-scores). In Study 1, Cbw was significantly lower (p = 0.0018) and Cpw was higher (p = 0.0022) in the Fx than in the Non-Fx group. In forward stepwise, logistic regression models using Bayesian Information Criterion for selecting the best set of predictors (from imaging parameters, age, BMI, and DXA scanner type), the area-under-the-receiver operator characteristics-curve (AUC with 95 % confidence intervals) was 0.73 (0.56, 0.86) for hip aBMD (best predictors without MRI) and 0.86 (0.70, 0.95) for the combination of Cbw and Cpw (best predictors overall). In Study 2, Cbw was significantly lower (p = 0.0005) in women with OP (23.8 ± 4.3 1H mol/L) than in women without OP (29.9 ± 6.4 1H mol/L); Cpw was significantly higher by estimate of 2.9 1H mol/L (p = 0.0298) with clinical OP, but only when accounting for the type of UTE-MRI scan with 3D providing higher values than 2D (p < 0.0001). Lastly, Cbw, but not Cpw, was sensitive to bone forming osteoporosis medications over 12-months. UTE-MRI-derived measurements of bound and pore water concentrations are potential, aBMD-independent predictors of fracture risk.

Determining the pharmacologic window of bisphosphonates that mitigates severe injury-induced osteoporosis and muscle calcification, while preserving fracture repair

Following severe injury, biomineralization is disrupted and limited therapeutic options exist to correct these pathologic changes. This study utilized a clinically relevant murine model of polytrauma including a severe injury with concomitant musculoskeletal injuries to identify when bisphosphonate administration can prevent the paradoxical decrease of biomineralization in bone and increased biomineralization in soft tissues, yet not interfere with musculoskeletal repair.

INTRODUCTION

Systemic and intrinsic mechanisms in bone and soft tissues help promote biomineralization to the skeleton, while preventing it in soft tissues. However, severe injury can disrupt this homeostatic biomineralization tropism, leading to adverse patient outcomes due to a paradoxical decrease of biomineralization in bone and increased biomineralization in soft tissues. There remains a need for therapeutics that restore the natural tropism of biomineralization in severely injured patients. Bisphosphonates can elicit potent effects on biomineralization, though with variable impact on musculoskeletal repair. Thus, a critical clinical question remains as to the optimal time to initiate bisphosphonate therapy in patients following a polytrauma, in which bone and muscle are injured in combination with a severe injury, such as a burn.

METHODS

To test the hypothesis that the dichotomous effects of bisphosphonates are dependent upon the time of administration relative to the ongoing biomineralization in reparative bone and soft tissues, this study utilized murine models of isolated injury or polytrauma with a severe injury, in conjunction with sensitive, longitudinal measure of musculoskeletal repair.

RESULTS

This study demonstrated that if administered at the time of injury, bisphosphonates prevented severe injury-induced bone loss and soft tissue calcification, but did not interfere with bone repair or remodeling. However, if administered between 7 and 21 days post-injury, bisphosphonates temporally and spatially localized to sites of active biomineralization, leading to impaired fracture callus remodeling and permanence of soft tissue calcification.

CONCLUSION

There is a specific pharmacologic window following polytrauma that bisphosphonates can prevent the consequences of dysregulated biomineralization, yet not impair musculoskeletal regeneration.

Evaluation of a Vitamin D Screening and Treatment Protocol Using a Seasonal Calculator in Athletes

ABSTRACT

Vitamin D is important in musculoskeletal health, and low serum vitamin D concentration is common in athletes. This study implemented a vitamin D screening and supplementation protocol in a cohort of National Collegiate Athletic Association Division I athletes using summer 25-hydroxyvitamin D concentration and a seasonal variation calculator to achieve sufficient vitamin D concentration year-round. After implementation of the Vitamin D Protocol, there was a nonsignificant difference in athletes with sufficient winter vitamin D concentrations (72.6%) compared with summer vitamin D concentrations (66.1%) (P = 0.40). The Seasonal Variation Calculator predicted winter vitamin D concentrations (8 ± 18 ng·mL-1) higher than actual winter vitamin D concentrations (P < 0.01). While most athletes (78%) believed vitamin D was important for athletic performance, athlete compliance to the Vitamin D Protocol was inconsistent. In the future, adjustment of vitamin D screening and supplementation protocols may help athletes achieve sufficient vitamin D status year-round.

Adherence and persistence in patients with rheumatoid arthritis at an integrated health system specialty pharmacy

BACKGROUND: Disease-modifying anti-rheumatic drugs (DMARDs) improve symptoms and delay progression of rheumatoid arthritis (RA), but adherence is often sub-optimal and many patients change medication (either "switching" to a medication with a different mechanism of action or "cycling" to a medication with the same mechanism of action) during the first year of therapy. Some integrated health-system specialty pharmacies embed pharmacists in clinics to help patients access and adhere to specialty medication. OBJECTIVE: This study assessed DMARD switching, cycling, adherence, and persistence at an outpatient rheumatology clinic with an integrated health-system specialty pharmacy. METHODS: We conducted a retrospective cohort study of adults with RA, naïve to biologic or targeted synthetic DMARDs, who filled ≥ 2 biologic or targeted synthetic DMARD prescriptions within 12 months. Adherence was measured using proportion of days covered (PDC); persistence was computed at 12 months. Univariate analyses compared adherence and persistence between patients with and without a medication change. Ordinal logistic regression examined whether PDC was associated with patient age, gender, race, insurance type, and medication change. RESULTS: We included 772 patients: 79% female/21% male, 89% White/11% non-White, median age 56 years (interquartile range = 48-63). Most patients (84%) did not change medication during the study period, 5% cycled medication one or more times (but did not switch), 9% switched medication one or more times (but did not cycle), and 2% of patients both switched and cycled during the study period. Median PDC of the sample was 0.94 and 73% of patients were persistent. Patients with a medication change had lower PDC than those without (0.89 vs 0.95, P = 0.004), but rate of persistence did not significantly differ between groups (77 vs 72%, P = 0.300). Odds of higher PDC was more likely for men (Odds ratio [OR] = 1.82, 95% confidence interval [CI]: 1.34-2.48, P < 0.001) and less likely for patients who changed medication (OR = 0.65, CI: 0.47-0.91, P = 0.011); age, race, and insurance type were not significant. CONCLUSIONS: Patients with RA demonstrated high medication adherence and persistence, and low rates of switching and cycling. Findings support evidence that integrated health-system specialty pharmacies with clinical pharmacists embedded in outpatient clinics help patients overcome barriers to medication adherence to persist on therapy. DISCLOSURES: This study was funded by Sanofi, Inc. James and J. Choi were employed by Sanofi, Inc., at the time of this study. Peter, Zuckerman, DeClercq, L. Choi, and Tanner, received research funding from Sanofi, Inc., for work on this study. Tanner has also received advisory board/speaker bureau fees from Pfizer, Regeneron, and Sanofi-Aventis. This study was presented as a poster at AMCP Nexus in October 2019 at National Harbor, MD.

Low prevalence of bone mineral density testing in patients with systemic lupus erythematosus and glucocorticoid exposure

SummaryPatients with systemic lupus erythematosus (SLE) have an increased risk of developing osteoporosis and fractures due to systemic inflammation and glucocorticoids (GCs). Professional organizations recommend bone mineral density (BMD) testing in SLE patients on GCs, especially within 6 months of initiation. Using a validated algorithm, we identified SLE patients in an electronic health record cohort with long-term GC exposure (≥90 days). Our primary outcome was ever BMD testing. We assessed the impact of patient and provider factors on testing. We identified 693 SLE cases with long-term GC exposure, 41% of whom had BMD testing performed. Only 18% of patients had BMD testing within 6 months of GC initiation. In a logistic regression model for BMD testing, male sex (OR = 0.49, 95% CI 0.27 - 0.87, p = 0.01) was associated with being less likely to have BMD testing after adjusting for race and ethnicity. In contrast, older age (OR = 1.04, p < 0.001) and nephritis (OR = 1.83, p = 0.003) were associated with being more likely to have BMD testing after adjusting for race and ethnicity. Bone health in SLE patients remains an area in need of improvement with attention to patients who are younger and male.

Differential effect of omalizumab on pulmonary function in patients with allergic asthma with and without chronic rhinosinusitis

BACKGROUND

Omalizumab, an anti-immunoglobulin E monoclonal antibody, is approved by the U.S. Food and Drug Administration for the management of patients with allergic asthma and with refractory disease, and has also proven beneficial in the management of selected patients with chronic rhinosinusitis (CRS). The common airway model indicates that patients with both allergic asthma and CRS may be more challenging to manage clinically. This is the first study to evaluate the response of omalizumab in patients with asthma and CRS versus those with asthma alone.

OBJECTIVE

To compare pulmonary function test (PFT) responses in omalizumab-treated patients with asthma with CRS with omalizumab-treated patients with asthma without CRS.

METHODS

This was a retrospective case-control study at a tertiary university clinic. Between 2007 and 2014, a total of 259 patients with allergic asthma had been prescribed omalizumab for asthma. Outcome measures were absolute, and the percentage changes in PFT results were compared with the baseline.

RESULTS

Overall, 81 patients had serial PFT results available for evaluation, among whom 59 (73%) had CRS. Average treatment duration was 27.2, 27.7, and 25.8 months for the entire sample, for patients with asthma and CRS, and for patients with asthma and without CRS, respectively. Overall, PFT metrics improved across all parameters (forced expiratory volume in 1 second, forced vital capacity, forced expiratory volume in 1 second to forced vital capacity ratio, and forced expiratory flow 25-75%). Significant improvement (p < 0.05, paired t-test) was observed for three of four metrics in patients with comorbid CRS but in none of these parameters in patients without CRS.

CONCLUSION

Patients with allergic asthma who were treated with omalizumab manifested some improvement in PFT scores. CRS may add to the overall symptom burden experienced by patients with asthma, especially in those with increasing severity, but comorbid CRS did not adversely impact the therapeutic potential of omalizumab. In fact, the benefit of omalizumab was more likely to be observed in patients with asthma and with CRS than in patients with asthma and without CRS.

Impact of omalizumab therapy on medication requirements for chronic rhinosinusitis

BACKGROUND

Omalizumab is indicated for treatment of patients with moderate to severe allergic asthma. Previous studies have shown 70% of these patients also have chronic rhinosinusitis (CRS). The present series examines the impact of omalizumab on medication use for CRS in a cohort of asthmatic CRS patients who received this therapy.

METHODS

The sample included 25 patients with adequate prescription data preinitiation and postinitiation of therapy. Data was available for a full 12 months both preinitiation and postinitiation of therapy in 20 of 25 patients and for 4 to 8 months in the remaining 5 of 25. Average antibiotic use (# of unique prescriptions per month) and systemic steroid dose (mg/month) were tabulated for each patient and compared before and after initiation of therapy.

RESULTS

Mean antibiotic prescriptions/month decreased by 37%, and this was statistically significant (p = 0.013). Antibiotic use decreased in 15 of 25 (60%), was the same in 7 of 25 (28%), and increased in 3 of 25 (12%) patients. Chronic steroid administration was required in 19 of 25 patients, and dosing was highly variable. Mean monthly steroid dose decreased substantially in 8 of 19 (42%) patients, with reduction ranging from 40% to 100% from pretreatment levels. A modest decrease of 17% to 30% was observed in 4 of 19 (21%) patients. Steroid use was essentially unchanged in 4 of 19 (21%), but dramatically increased (71% to 366% above pretreatment dose) in 3 of 19 (15%) patients.

CONCLUSION

Omalizumab therapy is associated with a decrease in overall antibiotic use for CRS. A subset of patients also experience significant reduction in steroid dependence. Further study is necessary to determine factors predictive of response.

More than healthy bones: a review of vitamin D in muscle health

Vitamin D has known importance to bone health including calcium and phosphate homeostasis and appears to have a role in skeletal muscle health as well. Cases of vitamin D deficiency and insufficiency have been associated with poor muscle health. While the exact effects and mechanism of action remains controversial, current data lean towards insufficient vitamin D playing a role in musculoskeletal pain, sarcopenia, myopathy, falls and indirectly via cerebellar and cognitive dysfunction. Sophisticated experimental techniques have allowed detection of the vitamin D receptor (VDR) on skeletal muscle and cerebellar tissue, which if validated in further large studies, could confirm the mechanism of vitamin D in these associations. While further study is required, vitamin D repletion can have a substantial impact on muscle as well as bone health.

Reversing vascular dysfunction in rheumatoid arthritis: improved augmentation index but not endothelial function with peroxisome proliferator-activated receptor γ agonist therapy

OBJECTIVE

To examine the hypothesis that improving insulin sensitivity improves vascular function in rheumatoid arthritis (RA).

METHODS

We performed a 20-week, single center, randomized, double-blind, placebo-controlled crossover study. Patients with RA (n = 34) with moderate disease activity who were receiving stable disease-modifying antirheumatic drug therapy were randomized to drug sequence, receiving either pioglitazone 45 mg/day or matching placebo for 8 weeks, followed by a 4-week washout period and the alternative treatment for 8 weeks. We measured changes in vascular stiffness (augmentation index and aortic pulse wave velocity [PWV]), endothelial function (reactive hyperemia index), and blood pressure. High-sensitivity C-reactive protein levels and the homeostatic model assessment of insulin resistance were also measured. The treatment effect of pioglitazone on outcomes was analyzed using linear mixed-effects models.

RESULTS

Pioglitazone treatment resulted in a change in augmentation index of -4.7% units (95% confidence interval [95% CI] -7.9, -1.5) (P = 0.004) and in diastolic blood pressure of -3.0 mm Hg (95% CI -5.7, -0.2) (P = 0.03), but did not significantly change aortic PWV (P = 0.33) or reactive hyperemia index (P = 0.46). The improvements in augmentation index and diastolic blood pressure were not mediated by the effect of pioglitazone on insulin resistance or inflammation.

CONCLUSION

Our findings indicate that pioglitazone improves some indices of vascular function, including augmentation index and diastolic blood pressure, in patients with RA. This is not mediated by improved insulin sensitivity.

Definition of osteoporosis by bone density criteria in men: effect of using female instead of male young reference data depends on skeletal site and densitometer manufacturer

Whether to use young male or young female reference data to calculate bone mineral density (BMD) T-scores in men remains controversial. The third National Health and Nutrition Examination and Survey (NHANES III) data show that the mean and standard deviation of femoral neck and total hip BMD is greater in young men than young women, and therefore differences in T-scores at these sites using NHANES III female vs male norms becomes less as BMD decreases. In contrast, manufacturer-specific reference databases generally assume similar standard deviations of BMD in men and women. Using NHANES III reference data for the femoral neck and total hip, respectively we found that men with T-scores of -2.5 when young male norms are used have T-scores of -2.4 and -2.3 when young female norms are used. Using manufacturer-specific reference data, we found that men with T-scores of -2.5 when young male norms are used at the femoral neck, total hip, lumbar spine, or one-third of the forearm would have T-scores ranging from -2.4 to -0.4 when young female norms are used, depending on skeletal site and densitometer manufacturer. The change of proportions of men diagnosed with osteoporosis when young female norms are used instead of young male reference data differs substantially according to skeletal site and densitometer manufacturer.

Consensus of official position of IOF/ISCD FRAX initiatives in Asia-Pacific region

The fracture risk assessment tool (FRAX(®)) has been developed for the identification of individuals with high risk of fracture in whom treatment to prevent fractures would be appropriate. FRAX models are not yet available for all countries or ethnicities, but surrogate models can be used within regions with similar fracture risk. The International Society for Clinical Densitometry (ISCD) and International Osteoporosis Foundation (IOF) are nonprofit multidisciplinary international professional organizations. Their visions are to advance the awareness, education, prevention, and treatment of osteoporosis. In November 2010, the IOF/ISCD FRAX initiative was held in Bucharest, bringing together international experts to review and create evidence-based official positions guiding clinicians for the practical use of FRAX. A consensus meeting of the Asia-Pacific (AP) Panel of the ISCD recently reviewed the most current Official Positions of the Joint Official Positions of ISCD and IOF on FRAX in view of the different population characteristics and health standards in the AP regions. The reviewed position statements included not only the key spectrum of positions but also unique concerns in AP regions.

Osteoporosis update from the 2012 Santa Fe Bone Symposium

The core of the 2012 Santa Fe Bone Symposium consisted of plenary presentations on new developments in the fields of osteoporosis and metabolic bone disease, with a focus on current and future implications for patient care. These were complemented by oral abstracts, interactive discussions of challenging cases, a debate on benefits and risks of long-term bisphosphonate therapy, and a panel discussion of controversial issues in the management of osteoporosis. Other topics included a review of the most important scientific publications in the past year, new and emerging therapy for osteoporosis, the benefits and limitations of clinical practice guidelines in the care of individual patients, the effects of metallic elements on skeletal health, clinical applications of bone turnover markers, an engineering perspective of skeletal health and disease, and an update on the role of the International Society for Clinical Densitometry in education, certification, accreditation, and advocacy for high-quality bone density testing. The symposium was highlighted by an inaugural presentation of "2 Million 2 Many," a national campaign of the National Bone Health Alliance to increase awareness of osteoporosis.

A review of the use of dual-energy X-ray absorptiometry (DXA) in rheumatology

The principal use of dual-energy X-ray absorptiometry (DXA) is to diagnose and monitor osteoporosis and therefore reduce fracture risk, associated morbidity, and mortality. In the field of rheumatology, DXA is an essential component of patient care because of both rheumatologists’ prescription of glucocorticoid treatment as well as the effects of rheumatological diseases on bone health. This review will summarize the use of DXA in the field of rheumatology, including the concern for glucocorticoid-induced osteoporosis, as well as the association of osteoporosis with a sampling of such rheumatologic conditions as rheumatoid arthritis (RA), systemic lupus erythematosus, ankylosing spondylitis, juvenile idiopathic arthritis, and scleroderma or systemic sclerosis. Medicare guidelines recognize the need to perform DXA studies in patients treated with glucocorticoids, and the World Health Organization FRAX tool uses data from DXA as well as the independent risk factors of RA and glucocorticoid use to predict fracture risk. However, patient access to DXA measurement in the US is in jeopardy as a result of reimbursement restrictions. DXA technology can simultaneously be used to discover vertebral fractures with vertebral fracture assessment and provide patients with a rapid, convenient, and low-radiation opportunity to clarify future fracture and comorbidity risks. An emerging use of DXA technology is the analysis of body composition of RA patients and thus the recognition of “rheumatoid cachexia,” in which patients are noted to have a worse prognosis even when the RA appears well controlled. Therefore, the use of DXA in rheumatology is an important tool for detecting osteoporosis, reducing fracture risk and unfavorable outcomes in rheumatological conditions. The widespread use of glucocorticoids and the underlying inflammatory conditions create a need for assessment with DXA. There are complications of conditions found in rheumatology that could be prevented with more widespread patient access to DXA.

Duration of treatment in postmenopausal osteoporosis: how long to treat and what are the consequences of cessation of treatment?

Although a variety of medications are effective for the treatment of postmenopausal osteoporosis, there is concern that long-term use may incur side effects. Consequently, some have proposed discontinuing or temporarily suspending treatment after a defined period of time. As the benefits of fracture risk reduction may recede during this "drug holiday", the clinician may be faced with deciding when to resume therapy (and with which agent) while avoiding the possible cumulative risk of side effects. This article summarizes data regarding length of treatment and the effects of cessation of treatment on bone density, bone turnover markers, and fracture risk.

Choosing a treatment for patients at the time a fracture is presented

The occurrence of a fragility fracture is an opportunity to recognize osteoporosis and begin treatment to reduce the risk of another fracture. However, selecting the treatment may have an impact on the incident fracture and this requires careful consideration of the patient and the treatment choices. There is no consensus regarding the management of osteoporosis at the time of an incident fracture. This review will consider the treatment options after a fragility fracture.

Official Positions for FRAX® clinical regarding rheumatoid arthritis from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®

Rheumatoid arthritis is the only secondary cause of osteoporosis that is considered independent of bone density in the FRAX(®) algorithm. Although input for rheumatoid arthritis in FRAX(®) is a dichotomous variable, intuitively, one would expect that more severe or active disease would be associated with a greater risk for fracture. We reviewed the literature to determine if specific disease parameters or medication use could be used to better characterize fracture risk in individuals with rheumatoid arthritis. Although many studies document a correlation between various parameters of disease activity or severity and decreased bone density, fewer have associated these variables with fracture risk. We reviewed these studies in detail and concluded that disability measures such as HAQ (Health Assessment Questionnaire) and functional class do correlate with clinical fractures but not morphometric vertebral fractures. One large study found a strong correlation with duration of disease and fracture risk but additional studies are needed to confirm this. There was little evidence to correlate other measures of disease such as DAS (disease activity score), VAS (visual analogue scale), acute phase reactants, use of non-glucocorticoid medications and increased fracture risk. We concluded that FRAX(®) calculations may underestimate fracture probability in patients with impaired functional status from rheumatoid arthritis but that this could not be quantified at this time. At this time, other disease measures cannot be used for fracture prediction. However only a few, mostly small studies addressed other disease parameters and further research is needed. Additional questions for future research are suggested.

Proton pump inhibitor therapy improves symptoms in postnasal drainage

BACKGROUND & AIMS

Gastroesophageal reflux is common among patients with postnasal drainage. We investigated whether proton pump inhibitor therapy improved symptoms in patients with postnasal drainage without sinusitis or allergies.

METHODS

In a parallel-group, double-blind, multi-specialty trial, we randomly assigned 75 participants with continued symptoms of chronic postnasal drainage to groups that were given 30 mg of lansoprazole twice daily or placebo. Participants were followed up for 16 weeks. Symptoms were assessed at baseline and after 8 and 16 weeks. Ambulatory pH and impedance monitoring assessed presence of baseline reflux. The primary objective of the study was to determine if acid suppressive therapy improved postnasal drainage symptoms. The secondary objective was to assess if pH and impedance monitoring at baseline predicted response to treatment.

RESULTS

Postnasal drainage symptoms improved significantly among patients given lansoprazole compared with placebo. After 8 and 16 weeks, participants given lansoprazole were 3.12-fold (1.28-7.59) and 3.50-fold (1.41-8.67) more likely to respond, respectively, than participants given placebo. After 16 weeks, median (interquartile) percent symptom improvements were 50.0% (10.0%-72.0%) for participants given lansoprazole and 5.0% (0.0%-40.0%) for participants given placebo (P = .006). Neither baseline presence of typical reflux symptoms nor esophageal physiologic parameters predicted response to therapy.

CONCLUSIONS

Among participants with chronic postnasal drainage without evidence of sinusitis and allergies, twice-daily therapy with proton pump inhibitors significantly improved symptoms after 8 and 16 weeks. The presence of heartburn, regurgitation, abnormal levels of esophageal acid, or nonacid reflux did not predict response to therapy.

Osteoporosis care in the United States after declines in reimbursements for DXA

In January 2007, in the United States (US), Medicare initiated a series of cuts to reimbursement for dual-energy X-ray absorptiometry (DXA) services performed in the nonfacility setting that by January 2010 reduced payments for these services by more than 60% compared with 2006 levels. The objectives of this study were to determine if a temporal association exists between Medicare Physician Fee Schedule changes in office-based DXA reimbursement and attendance at educational conferences for osteoporosis, physicians' perceptions of changes in their medical practices, or national trends in retail prescription medications for osteoporosis in those aged 65 and older. Compared with the 2 yr before the decline in Medicare reimbursement for DXA (2005-2006), attendance at educational meetings for osteoporosis in the US declined in the 2 yr after these cuts (2007-2008) by 6%; declines in attendance were only present in meetings selective for bone densitometry. Survey participants reported changes in DXA services with approximately one-third indicating that they had either decreased the number of DXAs they performed or declined service contracts or hardware/software updates compared with 2005-2006. The number of retail prescriptions for Food and Drug Administration-approved osteoporosis drugs (excluding estrogen compounds and raloxifene) in the age 65 and older population increased by 5.5% in the time period 2007-2008 compared with 2005-2006. However, in the last year of the study (2008), total retail prescriptions for these drugs experienced for the first time over the interval of the study, a decline (1.4%) compared with the previous year. This occurred despite a 2.6% increase in the US population age 65 and older. In conclusion, there were temporal associations noted between Medicare cuts in DXA payments in attendance at educational conferences for bone densitometry, self-report of office-based provision of DXA services in the US, and retail prescriptions for osteoporosis therapies.

Teriparatide is safe and effectively increases bone biomarkers in institutionalized individuals with osteoporosis

Institutionalized adults with severe developmental disabilities have a high rate of minimal trauma and appendicular fracture. There is little information about osteoporosis treatment in this population. In this efficacy and safety study, men and women with severe developmental disabilities and osteoporosis received 20 mcg teriparatide subcutaneously daily for 18-24 months. Markers of bone formation [procollagen type 1 intact N-terminal propeptide (P1NP)] and resorption [C-telopeptide (CTx)] were measured at three-month intervals. Serum calcium was measured at two-week intervals for 12 weeks and thereafter at three-month intervals. Twenty-seven individuals received at least one injection. The incidence of hypercalcemia was 11.1% but was persistent and led to medication discontinuation in only one participant. Biomarkers of bone formation increased rapidly, doubling by three months. At 12 months, P1NP and CTx remained elevated from baseline; P1NP had risen from 66.95 +/- 83.71 microg/l (mean +/- SD) to 142.42 +/- 113.85 microg/l (P = 0.05), and CTx had increased from 0.377 +/- 0.253 to 1.016 +/- 1.048 ng/ml (P = 0.01). The majority of participants had an increase in P1NP of over 10 microg/l. In conclusion, teriparatide is safe and effective in developmentally disabled institutionalized adults. Serial calcium measurements are warranted, particularly during the first three months of therapy.

The geographic availability and associated utilization of dual-energy X-ray absorptiometry (DXA) testing among older persons in the United States

Using national Medicare data from 1999-2006, we evaluated the relationship between travel distance and receipt of dual-energy X-ray absorptiometry (DXA). After adjusting for potentially confounding factors, travel distance was strongly associated with DXA testing. Rural residents were most strongly dependent on the availability of DXAs performed in physician offices.

INTRODUCTION

Medicare reimbursement for DXAs performed in non-facility settings (e.g., physician offices) decreased in 2007. With declining reimbursement, some DXA providers may cease providing this service, which would increase travel distance for some people. The impact of travel distance on access to DXA is unclear.

METHODS

Using national Medicare data, we identified claims for DXA to evaluate trends in the number and locations of DXAs performed. Travel distance was the distance from beneficiaries' residence and the nearest DXA provider. Binomial regression evaluated the relationship between travel distance and receipt of DXA.

RESULTS

In 2006, 2.9 million DXAs were performed, a 103% increase since 1999. In 2005-2006, 8.0% of persons were tested at non-facility sites versus 4.2% at facility sites. The remainder (88%) had no DXA. Persons traveling 5-9, 10-24, 25-39, and 40-54, and > or = 55 miles were less likely to receive DXA (adjusted risk ratios = 0.92, 0.79, 0.43, 0.32, and 0.26, respectively, < 5 miles referent). Rural residents were more dependent than urban residents on the availability of DXA from non-facility providers.

CONCLUSION

Approximately two-thirds of DXAs in 2005-2006 were performed in non-facility settings (e.g., physician offices). Rural residents would have preferentially reduced access to DXA if there were fewer non-facility sites.

Regional variation in the denial of reimbursement for bone mineral density testing among US Medicare beneficiaries

Although the Bone Mass Measurement Act outlines the indications for central dual-energy X-ray absorptiometry (DXA) testing for US Medicare beneficiaries, the specifics regarding the appropriate ICD-9 codes to use for covered indications have not been specified by Medicare and are sometimes ambiguous. We describe the extent to which DXA reimbursement was denied by gender and age of beneficiary, ICD-9 code submitted, time since previous DXA, whether the scan was performed in the physician's office and local Medicare carrier. Using Medicare administrative claims data from 1999 to 2005, we studied a 5% national sample of beneficiaries age > or =65 yr with part A+B coverage who were not health maintenance organization enrollees. We identified central DXA claims and evaluated the relationship between the factors listed above and reimbursement for central DXA (CPT code 76075). Multivariable logistic regression was used to evaluate the independent relationship between DXA reimbursement, ICD-9 diagnosis code, and Medicare carrier. For persons who had no DXA in 1999 or 2000 and who had 1 in 2001 or 2002, the proportion of DXA claims denied was 5.3% for women and 9.1% for men. For repeat DXAs performed within 23 mo, the proportion denied was approximately 19% and did not differ by sex. Reimbursement varied by more than 6-fold according to the ICD-9 diagnosis code submitted. For repeat DXAs performed at <23 mo, the proportion of claims denied ranged from 2% to 43%, depending on Medicare carrier. Denial of Medicare reimbursement for DXA varies significantly by sex, time since previous DXA, ICD-9 diagnosis code submitted, place of service (office vs facility), and local Medicare carrier. Greater guidance and transparency in coding policies are needed to ensure that DXA as a covered service is reimbursed for Medicare beneficiaries with the appropriate indications.

Highly conserved gene expression profiles in humans with allergic rhinitis altered by immunotherapy

BACKGROUND

Atopic diseases, resulting from hypersensitivity to a wide variety of allergens, affect 10-20% of the population. Immunotherapy is an effective treatment for atopic diseases, but its mechanisms are not fully understood.

OBJECTIVE

We studied gene expression profiles in the peripheral blood mononuclear cells (PBMC) and examined whether the individuals with allergic rhinitis (AR) have a unique gene expression profile and how the immunotherapy affect the gene expression profiles.

METHODS

We used cDNA microarray and 'expression analysis systemic explorer' to examine the gene expression profiles in the PBMC of atopic subjects and other groups.

RESULTS

We identified a highly conserved gene expression profile in atopic subjects that permitted their accurate segregation from control or autoimmune subjects. A major feature of this profile was the under-expression of a variety of genes that encode proteins required for apoptosis and over-expression of genes that encode proteins critical for stress responses and signal transduction. We also identified 563 genes that can segregate individuals with AR based upon receipt of immunotherapy.

CONCLUSION

There is a highly conserved gene expression profile in the PBMC of individuals with AR. This profile can be used to identify individuals with AR and to evaluate responses to immunotherapy. Quantitative endpoints, such as gene expression, may assist clinicians faced with clinical decisions in the diagnosis of patients and the evaluation of response to therapy. The knowledge of the possible genetic basis for immunotherapy efficacy may also lead to novel therapeutic approaches for atopic diseases.

Intravenous antibiotics for chronic rhinosinusitis: are they effective?

PURPOSE OF REVIEW

Antibiotics have been used commonly in chronic rhinosinusitis, often because chronic rhinosinusitis has features of a prolonged bacterial sinusitis, including abnormal CT findings and positive bacterial cultures. The advent of peripherally inserted central catheters has enabled outpatient parenteral antibiotic therapy to become a convenient means of delivering potent antibiotics for various conditions when oral antibiotics may not be effective or appropriate. Chronic rhinosinusitis has been included as a condition that may benefit from outpatient parenteral antibiotic therapy; however, there are few studies that document its success and, furthermore, chronic rhinosinusitis may not always be an infectious process.

RECENT FINDINGS

Three recent uncontrolled retrospective studies examined outpatient parenteral antibiotic therapy in chronic rhinosinusitis. In one series outpatient parenteral antibiotic therapy was used as an adjunct to sinus surgery, in another it was used as an alternative to sinus surgery in the pediatric population, and in the third it was used as temporary resolution for adult patients who had failed other therapies including sinus surgery. Short-term success rates were reported in the range of 29 to 89%, but relapse rates were as high as 89%. Complication rates in theses studies ranged from 14 to 26%, including medication reactions and intravenous line problems.

SUMMARY

The role of outpatient parenteral antibiotic therapy in the treatment of chronic rhinosinusitis has not been universally established. Although outpatient parenteral antibiotic therapy may have a role in avoiding sinus surgery in select pediatric populations, the contribution to a lasting resolution in adult patients is less clear and there are possible complications. Recognizing subsets of chronic rhinosinusitis patients for whom outpatient parenteral antibiotic therapy is appropriate will be the challenge for the future.

Prospective analysis of sinus symptoms and correlation with paranasal computed tomography scan

OBJECTIVES

We designed a prospective study to determine whether there is a correlation between the severity of sinus symptoms and the severity of computed tomography (CT) scan evidence of rhinosinusitis.

METHODS

Acute and chronic rhinosinusitis patients rated their symptoms and had a CT scan of the sinuses taken the same day. A Likert severity scale and standardized CT scoring system were used. Data were analyzed by nonparametric methods with Kendall's rank correlation coefficient.

RESULTS

The severity of 5 symptoms correlated with severity of disease on CT scan. Headache and facial pain or pressure had no correlation.

CONCLUSION

The certainty of a clinical diagnosis of rhinosinusitis requiring treatment is enhanced in patients with high symptom severity scores for fatigue, sleep disturbance, nasal discharge, nasal blockage, or decreased sense of smell. Isolated headache and facial pain or pressure are less reliable predictors of CT scan findings supporting the diagnosis rhinosinusitis.

Evidence of free radical-mediated injury (isoprostane overproduction) in scleroderma

OBJECTIVE

Free radical-induced oxidative stress with consequent lipid peroxidation and resultant tissue damage has been suggested as a potential mechanism of the pathogenesis of scleroderma. However, because reliable measurement of lipid peroxidation in vivo is difficult, it has not been possible to adequately examine this hypothesis. We have previously described a series of bioactive prostaglandin F2-like compounds, termed F2-isoprostanes, produced in vivo in humans by the non-cyclooxygenase, free radical-catalyzed, peroxidation of arachidonic acid and have shown them to be a reliable measure of lipid peroxidation in vivo. In the present study, we determined whether scleroderma is associated with enhanced oxidative stress.

METHODS

As a measure of oxidative stress, we determined urinary concentrations of a tetranor-dicarboxylic acid metabolite of F2-isoprostanes (F2IP-M) by mass spectrometry in 8 patients with scleroderma (representing a wide spectrum of disease, including limited disease with refractory digital ulceration or pulmonary hypertension, and diffuse disease) and in 10 healthy control subjects.

RESULTS

F2IP-M concentrations were significantly higher in patients with scleroderma (mean +/- SEM 3.41 +/- 0.64 ng/mg of creatinine) than in healthy controls (1.22 +/- 0.14 ng/mg of creatinine) (P = 0.002). These elevations occurred in patients with limited disease and in those with diffuse disease.

CONCLUSION

The increased level of urinary F2IP-M supports the hypothesis that free radical-induced oxidative injury occurs in scleroderma and provides a biologic marker whose relationship to disease activity and disease therapy may be important. These findings may also provide a rationale for exploring whether antioxidant therapy may influence the natural course of the disease.

The evolution of a case of overlap syndrome with systemic sclerosis, rheumatoid arthritis and systemic lupus erythematosus

An unusual case of overlap syndrome which evolved over a 12-year period is described. The patient initially presented with limited cutaneous systemic sclerosis. She then developed seropositive erosive rheumatoid arthritis and subsequently vasculitis with positive lupus serology. There was no evidence that she had mixed or undifferentiated connective tissue disease, and antibody to ribonuclearprotein was negative. This unusual combination of connective tissue disorders in one patient is reported and the literature is reviewed.

Metabolism of diethylstilbestrol: identification of a catechol derived from dienestrol

The enzymatic oxidation of E-3,4-bis-(p-hydroxyphenyl)-hex-3-ene (diethylstilbestrol) by either mushroom tyrosinase or rat liver microsomes in the presence of NADPH and air yields a catechol. Upon further oxidation of both compounds with periodate and condensation of the resulting o-quinones with o-phenylenediamine, phenazines are produced. The phenazines derived from the products of both the plant and animal enzyme systems are identical to the product obtained by oxidation of diethylstilbestrol with potassium nitrosodisulfonate and condensation of the o-quinone produced with o-phenylenediamine. High and low resolution mass spectra of the phenazine are consistent with its derivation from a catechol having two fewer hydrogens than diethylstilbestrol.