AB1219 ADHERENCE TO THE MEDITERRANEAN DIET IN PATIENTS WITH RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS, MULTICENTER STUDY

Background:

The Mediterranean diet (MD) has proven beneficial in a large number of chronic diseases. The relationship between the MD and rheumatic diseases is complex and there are few studies that have studied this relationship. These show that there could be a positive association between adherence to the Mediterranean diet (MD-A) and a lower prevalence of OA. In the case of RA, it has been proposed that the MD could reduce pain and improve functionality.

Objectives:

To determine the MD-A diet of patients with RA and OA, and compare it with that of healthy subjects.

Methods:

Multicenter, cross-sectional, observational study. Patients who attend the rheumatology outpatient and meet the ACR / EULAR 2010 criteria for RA and ACR for OA of hands, knees or hips are included in the study. The healthy are recruited among health personnel and companions of patients who do not live in the same address as the patient. The study is being carried out in the rheumatology consultations of two Hospitals and an outpatient center with specialized care. All participants have answered a survey of 14 questions (MEDAS-14), based on the Predimed study, which assesses MD-A. Fisher’s exact test and the Mann-Whitney U test have been used to assess statistical significance. The study was approved by the Clinical Ethics and Research Committee of the centers.

Results:

There have been 279 surveys (132 RA, 82 OA and 65 healthy). The MD-A in patients with RA is lower than in healthy (6.26 vs. 7.15, p <0.05). Patients with OA also have less adherence to the MD than healthy ones but this difference is not statistically significant (6.85 vs. 7.15, p> 0.05). The proportion of patients with RA and OA who consume 2 or more servings of vegetables daily is lower than that of healthy subjects (RA 20%; OA 13% and healthy 34%, p <0.05). The proportion of RA and OA that eats more than 3 weekly servings of nuts compared to healthy is also lower (RA 21%, OA 17%, healthy 35% p <0.05). The proportion of RA and OA that consume less than 1 serving of butter is lower than that of healthy (RA 86%; OA 82% and 98%, p <0.05). The proportion of RA that consumes 3 or more servings of legumes per week is lower than healthy (23% vs 40%, p <0.05). These differences between the OA group and healthy are not appreciated. The consumption of more than three pieces of fruit daily is more frequent in OA than in healthy ones (45% vs 26%, p <0.05).

Conclusion:

The MD-A diet quantified by MEDAS-14 in subjects with RA and OA is lower than in healthy subjects, being significant in RA. Patients with RA and OA eat less vegetables and nuts but the intake of butter is higher. The RA group consumes less legumes than healthy ones. Patients with OA eat more fruit than healthy ones, this is the only food in the MD valued by MEDAS-14 that is consumed in a lower proportion in healthy ones. Longitudinal intervention studies are necessary to assess whether the differences observed in this study have any causal relationship.

References:

[1]Estruch R, Ros E, Salas-Salvadó J, Covas M-I, Corella D, Arós F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013;368(14):1279-90.

[2]Trichopoulou A, Martínez-González MA, Tong TY, Forouhi NG, Khandelwal S, Prabhakaran D, et al. Definitions and potential health benefits of the Mediterranean diet: views from experts around the world. BMC Med. 2014;12:112.

[3]Morales-Ivorra I, Romera-Baures M, Roman-Viñas B, Serra-Majem L. Osteoarthritis and the Mediterranean Diet: A Systematic Review. Nutrients. 2018;10(8) pii: E1030. doi: 10.3390/nu10081030.

[4]Forsyth C, Kouvari M, D’Cunha NM, Georgousopoulou EN, Panagiotakos DB, Mellor DD, et al. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatol Int. 2018 May;38(5):737–47.

Disclosure of Interests:

None declared

Limited Joint Mobility Progression in Type 1 Diabetes: A 15-Year Follow-Up Study

OBJECTIVE

To assess the evolution of joint mobility over a period of 15 years in type 1 diabetic patients and healthy controls and to determine whether microalbuminuria is associated with a different evolution of joint mobility.

METHODS

Joint mobility of hand and wrist was determined in 63 patients with type 1 diabetes and 63 healthy subjects. Fifteen years later, 37 (58.7%) diabetic patients and 16 (25.4%) healthy subjects were studied again. Joint mobility was assessed with the Prayer sign and by measuring the angle of maximal flexion of the fifth and third metacarpophalangeal (MCP) joints and wrist. Patients with diabetes were visited 2-4 times every year with regular assessment of glycated hemoglobin (HbA1_c), urinary albumin excretion (UAE), and ophthalmoscopy.

RESULTS

Fifteen years after the initial exam, diabetic patients showed reduced flexion of the fifth MCP joint (82.6 ± 5.8 versus 76.0 ± 6.4 degrees, p < 0.001) and wrist (75.9 ± 8.1 versus 73.2 ± 7.4 degrees, p = 0.015) compared to baseline examination. Joint mobility did not change significantly in healthy subjects. Patients with microalbuminuria showed greater reduction in hand joint mobility than diabetic patients with normal UAE or than healthy subjects (p < 0.001).

CONCLUSIONS

In type 1 diabetic patients, the severity of LJM progresses with time, and the progression is enhanced in patients with microalbuminuria.

Improved prediction of knee osteoarthritis progression by genetic polymorphisms: the Arthrotest Study

OBJECTIVE

The aim of this study was to develop a genetic prognostic tool to predict radiographic progression towards severe disease in primary knee OA (KOA) patients.

METHODS

This investigation was a cross-sectional, retrospective, multicentric association study in 595 Spanish KOA patients. Caucasian patients aged ≥40 years at the time of diagnosis of primary KOA of Kellgren-Lawrence grade 2 or 3 were included. Patients who progressed to Kellgren-Lawrence score 4 or who were referred for total knee replacement within 8 years after diagnosis were classified as progressors to severe disease. Clinical variables of the initial stages of the disease (gender, BMI, age at diagnosis, OA in the contralateral knee, and OA in other joints) were registered as potential predictors. Single nucleotide polymorphisms and clinical variables with an association of P < 0.05 were included in the multivariate analysis using forward logistic regression.

RESULTS

A total of 23 single nucleotide polymorphisms and the time of primary KOA diagnosis were significantly associated with KOA severe progression in the exploratory cohort (n = 220; P < 0.05). The predictive accuracy of the clinical variables was limited: area under the curve (AUC) = 0.66. When genetic variables were added to the clinical model (full model), the prediction of KOA progression was significantly improved (AUC = 0.82). Combining only genetic variables (rs2073508, rs10845493, rs2206593, rs10519263, rs874692, rs7342880, rs780094 and rs12009), a predictive model with good accuracy was also obtained (AUC = 0.78). The predictive ability for KOA progression of the full model was confirmed on the replication cohort (two-sample Z-test; n = 62; P = 0.190).

CONCLUSION

An accurate prognostic tool to predict primary KOA progression has been developed based on genetic and clinical information from OA patients.

[Differences in the frequency of osteoporosis according to the skeletal site evaluated. Analysis in 987 Spanish postmenopausal women referred to a bone densitometry unit]

OBJECTIVE

To analyze the differences in the frequency of osteoporosis according to the skeletal site evaluated in a group of Spanish postmenopausal women.

METHODS

We reviewed the data of 987 postmenopausal women (mean age, 53.8±5.5 years). BMD status was evaluated by DXA. We used the WHO thresholds to classify the patients. T-score was obtained from the single evaluation of each lumbar vertebra (L2, L3 and L4), the mean value of lumbar spine (L2-L4), femoral neck and total hip.

RESULTS

In 144 (14.7%) women, discrepancies were observed when we considered the single vertebral analysis versus the L2-L4 analysis; 62 (6%) women who presented osteoporosis in at least one vertebra would have been due to the osteopenia category when L2-L4 value was selected. In 271 (27.8%) women, discrepancies were observed when we considered the total hip analysis versus the femoral neck analysis. The frequency of osteoporosis ranged from 3% when only the analysis of the total hip was considered to 16% when the results of L2-L4 and proximal femur (total hip or femoral neck) measurements were selected.

CONCLUSIONS

Frequency of osteoporosis varies notably according to the skeletal zone considered.

Decision rules for selecting women for bone mineral density testing: application in postmenopausal women referred to a bone densitometry unit

OBJECTIVE

Although several decision rules have been developed to identify postmenopausal women who may be selected for dual-energy x-ray absorptiometry measurements, information on their utility in a clinical setting is scarce. We evaluated the utility of 4 previously validated decision rules in a large group of Spanish postmenopausal women referred to a bone densitometry unit.

METHODS

We reviewed the data on 665 postmenopausal women (mean age 54.2 +/- 5.4 yrs). We selected the 4 decision rules that could be applied with the information that was available: the Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST), Osteoporosis Index of Risk (OSIRIS), and Body Weight Criterion (BWC). The sensitivity, specificity, and predictive values of each decision rule were determined.

RESULTS

The ORAI would recommend 45% of women for bone mineral density (BMD) testing, OST 46%, OSIRIS 37%, and BWC 70%. Sensitivity values obtained in the overall series were 64.1% for the ORAI, 69.2% for OST, 58.1% for OSIRIS, and 83.8% for BWC. The sensitivity increased progressively with age. The negative predictive value in the overall series was 88.5% for ORAI, 89.9% for OST, 88.4% for OSIRIS, and 90.6% for BWC.

CONCLUSION

In a complementary way with previous studies in older women, where decision rules were valuable to identify the majority of women likely to have osteoporosis, our data indicate that in younger postmenopausal women, decision rules are useful as a screening method to rule out the presence of osteoporosis and the need for BMD scanning.

[Evaluation of two proposals based on clinical factors for selecting what male patients with rheumatoid arthritis should undergo a bone densitometry]

Criteria based on age, inflammation, and immobility have been proposed to identify which patients with rheumatoid arthritis (RA) should be examined by dual energy X-ray absorptiometry (DXA) to diagnose osteoporosis. Recently, a modified version of the criteria by including weight and the use of corticosteroids has been proposed. These two set of criteria have not been tested in male patients in a clinical setting.

OBJECTIVE

To analyse, in a group of patients followed in a teaching hospital, the value of two proposals to select men with RA for bone densitometry.

PATIENTS AND METHOD

Clinical and demographic data were collected from the charts of a total of 65 men with RA, submitted to the bone densitometry unit during a fouryear period. Bone mineral density (BMD) was measured in spine and femoral neck by DXA. Two set of criteria were tested: a) three item criteria (age, inflammation and immobility), and b) five item criteria (age, inflammation, immobility, weight, and ever use of corticosteroids). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

RESULTS

Thirty five (54%) patients fulfilled the three item criteria and 38 (59%) the five item criteria. For the diagnosis of osteoporosis using the three item criteria, the sensitivity was 62%, specificity 48%, PPV 23% and NPV 83%; using the 5 item criteria the sensitivity was 90%, specificity 47%, PPV 23%, and NPV 96%.

CONCLUSIONS

The five item criteria are a more accurate tool to identify, in clinical practice, male patients with RA and osteoporosis than the three item criteria. It seems a good screening method for the selection of those patients with RA whose BMD should be assessed, as the sensitivity and NPV seem acceptable.

Usefulness of bone densitometry in postmenopausal women with clinically diagnosed vertebral fractures

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.

Osteoporotic vertebral fracture in clinical practice. 669 Patients diagnosed over a 10 year period

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.

Bone mineral density in patients with type 1 diabetes mellitus

Although osteopenia is often reported as a complication of type 1 diabetes mellitus, its frequency and severity remain unclear, and studies of bone mineral density in type 1 diabetics have yielded conflicting results. We measured bone mineral density at the lumbar spine and femoral neck in 88 Spanish adults with type 1 diabetes mellitus responsible for moderately severe complications. Mean age (+/- SD) was 28.9 +/- 8.8 years, and mean disease duration was 11.2 +/- 6.4 years. As compared to normal Spanish adults, bone mineral density was decreased in the patients at the lumbar spine (Z-score, -0.32 +/- 1.08; P < 0.001) but not at the femoral neck (Z-score, -0.21 +/- 1.03; P non-significant). The magnitude of bone loss in the diabetics was small (T-score, -0.38 +/- 1.13 at the lumbar spine and -0.37 +/- 1.08 at the femoral neck). Only three patients met WHO criteria for osteoporosis at one or both measurement sites. Patients with retinopathy (n = 37) had lower lumbar spine bone mineral density values than patients without retinopathy; however, this difference was no longer present after adjustment for age and disease duration. Bone mineral density values were similar in patients with (n = 13) and without microalbuminuria. Our findings suggest that bone loss is not a major problem in younger type 1 diabetics with short disease durations and no severe diabetic complications.

Bone mineral density in patients with peripheral psoriatic arthritis

BACKGROUND

Little information is available on the occurrence of generalized osteopenia in psoriatic arthritis. The only two published studies of bone mass in psoriatic arthritis produced conflicting results.

METHODS

We compared bone mineral density measured at the lumbar spine and femoral neck using dual-energy X-ray absorptiometry in 52 patients with active peripheral psoriatic arthritis and in 52 controls. The psoriatic arthritis group included 19 males, 14 premenopausal women, and 19 post-menopausal women. Controls were matched to the patients on sex, age, and menopausal status.

RESULTS

In the overall study population no significant differences were found between psoriatic arthritis patients and controls. Postmenopausal psoriatic arthritis patients had a lower femoral neck bone mineral density than the relevant subgroup of controls. No significant differences in lumbar spine bone mineral density were found in the analyses of the male, premenopausal female, and postmenopausal female subgroups. Neither was femoral neck density significantly different between male or premenopausal female psoriatic arthritis patients and controls.

CONCLUSION

These results suggest that peripheral psoriatic arthritis is not associated with significant generalized bone loss.

Microalbuminuria is associated with limited joint mobility in type I diabetes mellitus

OBJECTIVE

To determine whether limited joint mobility (LJM) is associated with microalbuminuria in type I diabetes mellitus.

METHODS

Joint mobility was measured in a control group of 63 healthy subjects and in 63 type I diabetic patients, older than 18 years (mean 31.7 years, range 18-57), recruited from the outpatient clinic of the Endocrine Unit. Patients with established diabetic nephropathy (proteinuria or increased creatinine) were excluded. Joint mobility was assessed qualitatively with the prayer manoeuvre and quantitatively by measuring the angles of maximal flexion and extension of the fifth and third metacarpophalangeal (MCP) joints and wrist. Diabetic retinopathy was assessed by direct ophthalmoscopy. Urinary albumin excretion (UAE) was determined in at least two 24 hour urine samples.

RESULTS

Joint mobility was limited in diabetic patients compared with control subjects. Diabetic patients with LJM had longer duration of diabetes (12.1 (SD 6.4) years compared with 6.9 (5.7) years; p < 0.001). Joint mobility was limited in patients with retinopathy: prayer manoeuvre was positive in 96.4% of patients with retinopathy, but in only 40.0% of patients with no retinopathy (p < 0.001); mobility of MCP joints and wrist was limited in diabetic patients with retinopathy even when the longer duration of their diabetes was taken into consideration. Microalbuminuria, present in 11 patients (17.5%), was associated with LJM: prayer manoeuvre was positive in 90.9% of patients with microalbuminuria, but in only 57.4% of patients with normal UAE (p < 0.05). Maximal flexion of MCP joints was reduced in patients with microalbuminuria. Microalbuminuria, but not LJM, was associated with risk factors of cardiovascular disease.

CONCLUSION

LJM is associated with microalbuminuria and retinopathy in type I diabetes. The association is independent of age and duration of diabetes.

Bone mineral density in patients with temporal arteritis and polymyalgia rheumatica

OBJECTIVE

To assess the influence of corticosteroids in the mineral content of patients with giant cell arteritis (GCA), 56 patients, 28 with polymyalgia rheumatica (PMR) and 28 with temporal arteritis (TA) were studied.

METHODS

The bone mineral density (BMD) in the lumbar spine and the femoral neck was measured by dual photon X-ray absorptiometry. A control group (48 people) comparable in age and sex was also evaluated.

RESULTS

Compared with the controls, the patients with GCA had lower values of BMD in the femoral neck (men: p < 0.03; women: p < 0.001). In the lumbar spine differences were significant in women (p < 0.05) but not in men (p < 0.1). Multiple regression analysis showed that the BMD at L2-L4 in men correlated with height and weight and was inversely related to the cumulative dose of corticosteroids and the duration of treatment. The BMD at L2-L4 in women correlated with height and weight, but not with corticosteroids. Multiple regression analysis in men showed that age and the total dose of corticosteroids were significant independent predictors of femoral BMD. In women BMD in the femoral neck was correlated with age and weight, but not with corticosteroid treatment.

CONCLUSION

The total dose and duration of corticosteroid treatment have been shown to be determinant factors of bone mass in patients with GCA who received corticosteroids.

[Pseudopodagra caused by hydroxyapatite. Report of 3 cases]

Calcium hydroxyapatite crystals deposit in periarticular soft tissues usually translates itself clinically through pain and mobility limitation of affected joint. Compromise of small joints in feet is infrequent, less than 1% of all cases. Recently pseudopodagra crises have been described due to the deposit of this material in soft tissues adjacent to metatarsal or phalangeal first joint. Its clinical expression is practically undistinguishable from gout crises. Three new cases of pseudopodagra due to hidroxyamatite are presented and some considerations are made concerning this clinical entity and its differential diagnosis in relation to gout.

[Septic arthritis induced by pyogenic germs in patients without parenteral drug addiction. Analysis of 44 cases]

BACKGROUND

The aim of this study was to evaluate the clinical-microbiological characteristics presented in the area of influence of the Hospital de Bellvitge-Prínceps d'Espanya, of articular infection induced by pyogenic germs in patients without intravenous drug addiction.

METHODS

All the cases of microbiologically confirmed articular infection in patients without intravenous drug addiction diagnosed during the period of 1981-1990 were evaluated by protocol.

RESULTS

Five cases (11%) with gonococcal arthritis and 39 cases (89%) of non gonococcal arthritis were observed with Staphylococcus aureus being the causal germ in 27 cases. Sixty percent of the patients presented one or more predisposing factors for the appearance of infectious arthritis. Monoarticular involvement was seen in 84% of the cases. At the time of diagnosis fourteen patients presented radiological signs compatible with septic involvement, with the isotopic study with 99mTc being positive in the 27 cases in which it was carried out. Delay in diagnosis was of 20 +/- 25 days. Functional results were considered as satisfactory in 57% of the cases.

CONCLUSION

In the area of influence of the Hospital de Bellvitge-Prínceps d'Espanya, the prevalence of gonococcal arthritis is low. Gram positive germ are the most frequent causal agents in all the age groups studied. Gammagraphy with 99mTc presented high profitability in the diagnosis of articular infections. The functional results observed were not optimal and improvement of the same probably requires a shortening in the time of delay in diagnosis.

[Limitations of joint mobility in patients with type 1 diabetes mellitus]

BACKGROUND

To assess limitation of joint mobility in patients with type I diabetes mellitus and to evaluate its relation with retinopathy, joint mobility was prospectively assessed in 96 diabetic patients and 68 healthy controls.

METHODS

Joint mobility was explored with the praying maneuver and the measurement in mobility degrees of the third and fifth metacarpophalangeal joints, wrists and elbows. The degree of metabolic control was assessed with the mean glycosylated hemoglobin in the last two years. Retinopathy was investigated with direct funduscopy. The results were statistically evaluated with chi-square and Student's t tests and the linear coefficient.

RESULTS

A reduced joint mobility was found in 41 diabetics and 5 controls (p less than 0.0001). The reduction in joint mobility was related with the patients' age but not with the degree of metabolic control. 85% of diabetics with joint involvement had retinopathy of some degree.

CONCLUSIONS

A limited joint mobility is a common complication of type I diabetes mellitus. The demonstration of this abnormality in diabetic patients might represent a first and simple marker of microangiopathy.

Munchausen's syndrome simulating reflex sympathetic dystrophy

A 15 year old girl who had pain, oedema of her left hand, and fever of four months' duration is described. Marked demineralisation of her hand was shown by radiography, and increased articular uptake by technetium-99m bone scan. All these changes were indistinguishable from reflex sympathetic dystrophy. After two admissions to hospital and multiple explorations we discovered that she had induced her symptoms herself and a diagnosis of Munchausen's syndrome was made. As far as we know this presentation has not been previously reported and might help to explain the physiopathology of some signs of reflex sympathetic dystrophy.

The time of blood sampling for osteocalcin determinations

Images