Are Differences in Living Kidney Donation Rates a Sex or a Gender Disparity?

Sex-disaggregated data reveal significant disparities in living kidney donation, with more female than male living kidney donors in most countries and proportions over 60% in some countries. We summarize the present state of knowledge with respect to the potential drivers of this disparity and argue that it is primarily driven by gender-related factors. First, we present the differences between sex and gender and then proceed to summarize the potential medical reasons that have been proposed to explain why males are less likely to be living kidney donors than females, such as the higher prevalence of kidney failure in males. We then present counterarguments as to why biological sex differences are not enough to explain lower living kidney donation among males, such as a higher prevalence of chronic kidney disease among females, which could affect donation rates. We argue that gender differences likely provide a better explanation as to why there are more women than men living kidney donors and explore the role of economic and social factors, as well as gender roles and expectations, in affecting living kidney donation among both men and women. We conclude with the need for a gender analysis to explain this complex psychosocial phenomenon in living kidney donation.

The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement

;Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril-Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril-Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril-Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril-Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40-50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk.

Anti-T-Lymphocyte Immunoglobulin (Grafalon) as an Induction Agent for Renal Transplantation: A Real-World, Retrospective, Single-Center Experience

OBJECTIVES

Polyclonal antithymocyte globulins are widely used in the induction regimens of solid-organ transplant recipients; however, their doses and outcomes remain to be standardized in Indian patients. We report our clinical experience from the real-world use of Grafalon (an anti-T-lymphocyte globulin; ATG-Fresenius) as an induction agentin renal transplant recipients from India.

MATERIALS AND METHODS

In this retrospective, single- center, observational study, we analyzed the medical records of 177 consecutive, kidney-only transplant recipients who received induction therapy with Grafalon from September 2016 to March 2018 at our center. Incidences of biopsy-proven acute rejection and graft dysfunction, immunosuppression protocol, Grafalon dosage, 18-month post-transplant graft and patient survival, treatment-related adverse events, and infective complications were reported.

RESULTS

Mean age of patients was 41.46 years (range, 14-68 years), (85% were males). The average dose of Grafalon was 5.81 ± 1.95 mg/kg (range, 2.41 to 10.07 mg/kg). Graft dysfunction (ie, at least 20% increase in serum creatinine from baseline) was observed in 26 patients (14%): 11 patients (6.2%) had biopsy-proven acute rejections, 11 patients (6.2%) had acute tubular necrosis, and 4 patients (2.2%) had calcineurin inhibitor toxicity. Seven deaths were recorded: 2 each from fungal pneumonia, bacterial pneumonia, and acute coronary syndrome and 1 with urinary tract infection with septicemia. Death-censored graft survival was 100% at 12 months and 98% at 18-month follow-up; overall patient survival was 96%. Infective complications occurred in 40 patients (22.5%), with the most common being urinary tract infection in 32 patients (18%). No malignancies were reported.

CONCLUSIONS

Use of a potent induction therapy like anti-T-lymphocyte globulin (Grafalon) is often restricted by the risk of side effects and lack of local clinical evidence supporting its role in long-term graft survival. Real-world evidence support the safe and effective use of anti-T-lymphocyte globulin as an induction agent in renal transplant recipients with an individualized dosing approach.

Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020

Continuous ambulatory peritoneal dialysis (CAPD) related peritonitis is a major cause of technique failure, morbidity, and mortality in patients on CAPD. Its prevention and management is key to success of CAPD program. Due to variability in practice, microbiological trends and sensitivity towards antibiotics, there is a need for customized guidelines for management of CAPD related peritonitis (CAPDRP) in India. With this need, Peritoneal Dialysis Society of India (PDSI) organized a structured meeting to discuss various aspects of management of CAPDRP and formulated a consensus agreement which will help in management of patients with CAPDRP.

Comparison of short-term outcomes with and without induction therapy in low-risk renal transplant recipients

With low rates of rejection with current immunosuppression consisting of steroids, mycophenolic acid and tacrolimus, the question arises whether induction offers any additional benefit in low-risk renal transplant recipients. This study evaluated outcomes with and without induction in low-risk renal transplant recipients. A prospective observational study in which 100 low-risk renal transplant recipients were included and divided into two groups - one that received induction (IND) and another that did not (NO IND). They were followed for 1.5 years. Three endpoints were compared - efficacy of induction, patient and graft survival, and adverse effects. Incidence of rejection in early posttransplant period did not differ (4% NO IND vs. 6% IND; P = 0.171). Rejection as cause of late graft dysfunction was seen in 16% in IND vs. 20% NO IND; (P = 0.603). No difference in serum creatinine at end of 1.5 years was seen. Graft survival was also similar. Relapsing and recurrent urinary tract infections (46% IND vs. 16% NO IND; P = 0.09), hospitalization requiring infections (76%IND vs. 64% NO IND; P = 0.119 NS) were more common in IND. Cytomegalovirus infection affected only IND (6% vs. none; P = 0.07). Patient survival at 1.5 years was comparable (94% IND vs. 96% NO IND; P = 0.646). The study showed comparable results between IND and NO IND with however an increased incidence of infections and hospitalizations in the IND group. The use of induction may be avoided in low-risk renal transplant recipients.

MO190NORMATIVE DATA FOR GLOMERULAR FILTRATION RATE IN HEALTHY KIDNEY DONOR POPULATION

Background and Aims

Glomerular filtration rate (GFR) is estimated traditionally from 24-hour urinary creatinine clearance. Creatinine is mainly filtered by glomerulus. The collection of 24-hour urinary sample is a difficult task with many patients fail to collect all the urine samples. As measuring GFR is cumbersome, expensive, and not easily available in all centers, various equations are developed for estimating GFR from creatinine like MDRD, CKD EPI creatinine. GFR obtained from serum creatinine shows wide variation as muscle mass and dietary protein intake are important determinants of serum creatinine concentration. Literature shows very few studies with GFR estimation with reference to age in Indian population. Hence, this study is planned to develop age specific nomogram for GFR in healthy kidney donor population as well as to study agreement between GFR obtained by 99m Tc DTPA three sample method and GFR estimated by 24-hour urinary creatinine. The aim of this stidy was to develop age-specific nomogram GFR in healthy kidney donor population and to study the agreement between the GFR measured by Technetium-99m diethylene triamine pentaacetic acid (99m Tc DTPA) and 24-hour urinary creatinine method.

Method

This study was conducted at Sir Ganga Ram hospital, New Delhi. All healthy individuals aged more than 20 years and less than 65 years, undergoing evaluation as prospective kidney donor at our hospital were the part of this study. GFR was measured by 99m Tc DTPA clearance using 3 sample method. GFR measured by DTPA method was used to develop nomogram. Creatinine Clearance was calculated from 24-hour urinary creatinine by formula U x V/P where, U is urinary creatinine level, P is plasma creatinine level and V is total volume of urine. Nomogram was developed with respect to these 3 Age groups; namely, 20 to 40 years, 40 to 50 years and 50 to 65 years

Results

Total 100 kidney donors were included in this study. Enrolled subjects were divided into 3 age groups; 20 to 40 years (n=28), 40 to 50 years (n=46) and 50 to 65 years (n=26). Majority of the donors were females (n=80). The agreement between GFR obtained by 99m Tc DTPA and 24-hour urinary creatinine clearance methods was 92.6 vs. 94 ml/min, 80.4 vs. 76 ml/min and 76.3 vs. 70 ml/min in respective age groups.

Conclusion

In the younger age group (20 to 40 years), there is better agreement in GFR measured by 99m Tc DTPA method and 24-hour urinary creatinine clearance methods.

P1339ARTERIOVENOUS FISTULA AND BASILIC VEIN TRANSPOSITION IN ELDERLY PATIENTS ON HEMODIALYSIS: AN OBSERVATIONAL STUDY

Background and Aims

With the increase in the line expectancy of chronic kidney disease in the older population (>60 years), the numbers requiring haemodialysis is progressively rising. The elderly population may be different from the younger in terms of non-suitable vessels for access creation, non-maturation, and vascular calcifications, and this may alter the outcomes of use of arteriovenous fistula (AVF). This study was conducted to analyse the outcomes of AVF in elderly patients (>60 years).

Method

Retrospective study was conducted in the Department of Nephrology at Sir Ganga Ram Hospital, New Delhi. Patients of more than 60 years of age in whom AVF was created from 1st January 2012 to 31st December 2016 were included in the study. Follow-up data of 3.5 years was analysed. The primary endpoint was to assess primary and secondary patency rates.

Results

A total of 300 patients were included in the study. The mean age was 63.8 years. Radiocephalic AVF (RCAVF) was the most common site of [69.8% (n = 210)], followed by brachiocephalic (BCAVF) in 25.2% (n = 75) and basilic vein transposition (BVT) in 5% (n = 15). At 12 months, overall survival of the AVF was 66.8%. At 42 months, the primary patency rate of RCAVF, BCAVF, and BVT was 50.6%, 52.6%, and 50.4% respectively. The commonest cause of access failure was thrombosis (20.4%) followed by non-maturation (9%). Vascular access abandonment was found least in BCAVF.

Conclusion

AVF remains the preferred vascular access for haemodialysis in the elderly population. Brachiocephalic AVF has higher primary and secondary patency rates. Thrombosis and failure of maturation are major concerns in the elderly AVF.

P1737MICROBIOLOGICAL DIAGNOSIS OF DIARRHEA IN RENAL TRANSPLANT PATIENT BY MULTIPLEX PCR

Background and Aims

Acute gastroenteritis is an unwelcome and harmful yet unavoidable complication in the renal transplant patient. Infections, especially atypical organisms like Norovirus, Cryptosporidium, along with typical microorganisms like E. coli and Giardia, form the significant players in the pathogenesis of diarrhea. Standard methods of staining and culture have reduced sensitivity as well as require considerable time for the reports. Stool Polymerase Chain Reaction (PCR)is a quick, sensitive, and hassle-free method that diagnoses more than 20 organisms within 1 hour. This study aims to determine the infective etiology of acute gastroenteritis in the transplant population as well to compare the yield of stool PCR with conservative methods.

Method

We retrospectively analyzed all renal transplant patients admitted between 2015 to 2018 with complaints of diarrhea (>3 stools/day with loose consistency). The sample was tested for conventional microbiological methods, including a stool routine for microscopy and culture. A stool sample was also sent for Multiplex PCR, which was analyzed by Bio Fire FilmArray GI Panel, which identifies 22 enteropathogens. Endoscopic procedures were also undertaken in suspected cases for CMV colitis and pseudomembranous colitis.

Results

110 diarrheal events (admission for diarrhea) were recorded in 82 patients, with 181 organisms isolated in all samples. 16 events did not reveal any organisms in stool PCR. 85% sample yielded a positive result. The conventional method yielded a positive result in only 32.3% as compared to stool PCR. Co-infections were common, as 71.2% of events were associated with 2 or more organisms. Conventional methods failed to diagnose any co-infections. Norovirus G1/G2(20%) was the most common organism isolated from the stool, followed by Giardia (17%) and Enteropathogenic E. coli (16%). Giardia Lamblia with Norovirus G1/G2 was the most common co-infection in 19% of patients.

Conclusion

Stool PCR significantly improves the diagnostic yield in diagnosing enteric pathogens. Stool PCR is especially sensitive in detecting multiple organisms where conventional microbiological methods were completely unsuccessful. Norovirus is the most common enteropathogen, which is not picked by the conventional method. Giardia with Norovirus was the most common co-infection among post-transplant patients.

P1778PROFILE OF NON-BACTERIAL INFECTIONS SPECIFIC TO RENAL TRANSPLANT RECIPIENTS

Background and Aims

Infections in renal transplant recipients are a major cause of morbidity and mortality. It is the one of the major cause of patient death with functioning graft. Hence this project was done to study the profile of non-bacterial infections specific to renal transplant recipients and to determine the risk factors associated with such infections.

Method

Renal-transplant recipients admitted to the department of nephrology with suspected infection were included in the study.

Results

: A total of 342 patients were included in the study. The mean age of the patients was 45.2 ± 13.3 years. 17.5% had ABO incompatible renal transplant. 91% (87% received leukocyte depleting and 4% received non-leukocyte depleting agents) had received induction as majority had three or more HLA mismatch (70%) and the most common donor was wife. 12.8% had history of graft rejection. A total of 147 infectious episodes were encountered in 121 patients. The incidence of non-bacterial infections was 35% (121/342). Viral infections (68/147 = 46%) and invasive fungal infections (44/147 = 30%) were the most common. Cytomegalovirus infection was the most common 35%. Other viral infections encountered were BK virus associated nephropathy (2.3%) and reactivation of Hepatitis B or C virus (2.6%). The most common site of invasive fungal infection were lower respiratory tract, urinary tract, CNS cryptococcosis, soft tissue infection or cellulitis and oesophageal candidiasis in 41%, 32%, 9%, 9% and 9% respectively. Aspergillus (61%) and Rhizopus (33%) was the most common organism causing fungal pneumonia. Four patients were diagnosed with Pneumocystis jirovecii pneumonia. Majority (60%) of the infections were detected after one year post-transplant. Risk factors found to have statistically significance were ABO incompatibility, diabetes mellitus (pre or post-transplant) and history of graft rejection. Nine patients (7%) died of non-bacterial infections specific to renal transplant recipients.

Conclusion

Non-bacterial infections are not uncommon in Indian scenario and the timeline of such infections has changed.

P1267EFFECT OF SODIUM AND ULTRAFILTRATION MODELING VERSUS LOW TEMPERATURE DIALYSATE IN PREVENTION OF INTRADIALYSIS HYPOTENSION: A SINGLE CENTRE STUDY FROM INDIA

Background and Aims

Symptomatic intradialytic hypotension is the most frequent complication in patients receiving hemodialysis. It complicates 5 to 30 percent of all dialysis treatments. In our study, we aimed to compare the effect of sodium and ultrafiltration modeling versus low-temperature dialysate on the occurrence of intradialytic hypotensive episodes.

Method

Single center, prospective, randomized trial. Patients with chronic kidney disease (CKD) stage V on maintenance hemodialysis (HD) for at least twice weekly for a minimum of 3 months were observed for the occurrence of ≥1 intradialytic hypotensive episode per month. After full filling the inclusion and exclusion criteria, patients were randomized 1:1 ratio into two groups based on computer-generated randomization numbers allotted to them by the dialysis coordinator.

Group 1: Underwent dialysis with sodium and Ultrafiltration modeling (Linearly decreasing dialysate sodium from 141 mmol/L to 128 mmol/L and linearly decreasing ultrafiltration rate).

Group 2: Underwent dialysis with low-temperature dialysate (36 degrees Celsius).

Primary outcome was number of hypotensive episodes per month. Secondary outcomes were interdialytic weight gain and ultrafiltration volume per session.

Results

A total of 320 patients were observed for 3 months in our centre. Intradialytic hypotension was found in 18.75 % of patients. Diabetic nephropathy (61.66%) was the leading cause of end-stage renal disease in these patients. There was no significant difference between the two groups in mean arterial blood pressure, hemoglobin, cardiac status, and serum albumin before dialysis. Both groups had a similar incidence of intradialytic hypotensive episodes (P >0.05). Interdialytic weight gain and ultrafiltration volume removed per session were also similar in both groups.

Conclusion

Sodium and ultrafiltration modeling and low-temperature dialysate were both equally effective in the prevention of intradialytic hypotensive episodes.

P1181URGENT START OF PERITONEAL DIALYSIS: OUTCOMES AND EXPERIENCE FROM NORTHERN INDIA

Background and Aims

Peritoneal dialysis (PD) widely practiced as the first-line modality for renal replacement therapy in end-stage renal disease (ESRD) patients. Urgent-start PD (use of the PD catheter within 14 days of insertion) is an effective approach to prompt initiation of PD after catheter insertion. However, there is a paucity of data regarding complications of urgent-start PD. We investigated the outcomes of urgent-start PD in our subset (Indian population).

Method

All patients in whom PD was initiated between 01 January 2015 and 31 July 2019 (54 months) were included. Patients were grouped according to the initiation of PD (break-in period) as <8 days (PD1), 8 to 14 days (PD2), and >14 days (PD3).

Results

In 100 patients included in the study, 57.5% were males. Among them, 75%, 10%, and 15% patients were in the PD1, PD2, PD3 break-in groups respectively. The most common cause of ESRD was diabetes mellitus. Functional catheter malfunction was the most frequent complication in PD1. The incidence of mechanical complications during the first six months was similar in all three groups (p = 0.06). No significant differences with respect to the catheter dysfunction requiring surgical intervention (p > 0.05) were observed. In PD1 group, catheter patency rate at the end of the 1-month and 1-year was 98.6% and 95.4% respectively. No significant differences were found in the rate of peritonitis among the three groups. Female sex, low haemoglobin, and low albumin levels were independent risk factors for peritonitis.

Conclusion

Early break-in period of less than seven days is a feasible option for patients requiring urgent dialysis with no increased risk of mechanical or infectious complications. It offers a safe and efficacious option for unplanned ESRD patients.

P1771NOCARDIOSIS IN RENAL TRANSPLANT RECIPIENTS- TEN YEARS OF SINGLE CENTER EXPERIENCE

Background and Aims

Nocardiosis is a localized or disseminated bacterial infection caused by aerobic Actinomyces that commonly affects immunocompromised hosts. This study aimed to retrospectively review the clinical course and outcome of nocardiosis in renal transplant recipients at our center

Method

Data was obtained from hospital records retrospectively. Sixteen cases of nocardiosis were identified in a series of more than 1800 consecutive renal transplants performed at Sir Ganga Ram Hospital in the last decade from the year 2010 to 2019.

Results

Thirteen out of Sixteen patients(81.25%) had developed nocardiosis within a 1-year post-renal transplant. The diabetic population constituted 31.3%. CMV disease was present in 25% of patients six months prior to the diagnosis of Nocardiosis.56.3% of patients were on Trimethoprim-sulfamethoxazole prophylaxis while they were diagnosed with nocardiosis. Pleuropulmonary nocardiosis was the most common form of infection(68.75%). Primary cutaneous nocardiosis was identified in one patient(6.25%). cerebral nocardiosis and disseminated nocardiosis was diagnosed in two patients each(12.5%).In the last 3 years with the introduction of MALDI-TOF led to the identification of the subspecies of Nocardia which was not possible earlier. In the last 3 years, 6 patients were diagnosed with nocardiosis, in which 4 were infected with Nocardia farcinica, one patient with Nocardia Asiatica and one with Nocardia cyrigeorgica. Nocardia farcinica was resistant to cotrimoxazole, which used to be first-line therapy against Nocardiosis before subspecies identification and sensitivity testing. With the help of proper identification of subspecies by MALDI-TOF and antibiotic susceptibility by E-testing, 5 out of 6 patients could be treated while earlier 6 out of 10 patients could be treated.

Conclusion

Nocardiosis is a rare, difficult-to-diagnose-and-treat infection following kidney transplantation. Trimethoprim-sulfamethoxazole prophylaxis was not effective in the prevention of disease. The Subspecies identification and modification of the plan of management according to antibiotic sensitivity results in improved outcomes.

P0386OUTCOMES OF PAUCI-IMMUNE CRESCENTIC GLOMERULONEPHRITIS BASED ON THE INTERNATIONAL HISTOPATHOLOGICAL CLASSIFICATION AND RECENTLY PROPOSED RENAL RISK SCORE IN ADULTS: A SINGLE CENTER STUDY

Background and Aims

Pauci-immune crescentic glomerulonephritis is rare form of glomerulonephritis that frequently presents as rapidly progressive renal failure. The histopathological classification proposed by Berden a decade earlier described difference in the outcomes of patients in the focal, crescentic, mixed and sclerotic category with best prognosis for focal and worst for sclerotic group. The newly proposed renal risk score (Brix SR at al.) takes into account both the histopathological parameters (% of normal glomeruli, tubular atrophy and interstitial fibrosis) and clinical parameter (eGFR) which influence outcome in these patients. Present study was undertaken to determine outcomes of pauci-immune crescentic glomerulonephritis based on both of these prognostic systems and also to determine effect of individual risk factors on renal outcome.

Method

64 patients diagnosed as pauci-immune crescentic glomerulonephritis from January 2013 to December 2018 were retrospectively analyzed. There histopathological slides were reviewed for percentage normal glomeruli, extent of interstitial fibrosis and tubular atrophy and biopsies were also grouped according to histopathological classification into focal, crescentic, mixed and sclerotic categories. The clinical parameters including serum creatinine, eGFR at time of biopsy and follow-up, and status of ANCA positivity were obtained from electronic records. Renal biopsies were scored based on renal risk score depending on the % of normal glomeruli (>25%,10-25% and <10%), percentage of tubular atrophy and interstitial fibrosis(≤25%,>25%) and eGFR(>15ml/min,≤15ml/min) into 3 risk categories.

Results

There were 61 adult patients and 3 pediatric patients. Two patient with insufficient glomeruli (<7) on biopsy and 8 patients without follow-up were excluded. A total of 51 adult patients were included of which 28 were male and 23 females. The mean age was 51.2±15.7 years. The mean serum creatinine at the time of biopsy was 7.05±4.57 mg/dl and the mean eGFR was 13.6±12.16 ml/min/1.73m2. There were 33 ANCA positive and 18 ANCA negative(35%) cases. Distribution of patients according to Berden’s histopathological classification was focal(4), crescentic(29), mixed(12) and sclerotic(6). The distribution of patients into risk categories based on renal risk score was low(8),medium(23) and high(20). Univariate Cox regression analysis showed that eGFR at biopsy (p 0.024), % IFTA (p 0.001) and % normal glomeruli in biopsy (p 0.023) are predictors of ESRD. Multivariate Cox regression analysis including age, eGFR, % IFTA and % normal glomeruli in biopsy also confirmed IFTA (p<0.001) and % normal glomeruli in biopsy (p 0.018) as significant predictors of ESRD. When % normal glomeruli was replaced by Berden’s histopathological classed it didn’t reach statistical significance to predict ESRD. Kaplan-Meier survival analysis for histological categories showed best renal survival in focal group and worst in sclerotic group (Log-Rank p=0.046). Kaplan-Meier analysis for the renal risk categories showed best survival in low risk group followed by medium and high risk groups respectively (Log-Rank p=0.002). Kaplan-Meier survival analysis was also done for percentage of normal glomeruli, IFTA and renal function.

Conclusion

In our study of Pauci-immune crescentic glomerulonpehritis ANCA was negative in 35% cases. Percentage of normal glomeruli, IFTA and eGFR at time of biopsy were important histopathological and clinical risk factors influencing renal survival in these patients. Results of our study validate that recently proposed renal risk score is a better predictor of survival (p=0.002) as compared to histological classification proposed by Berden (p=0.046).

Pregnancy-associated osteoporosis: a UK case series and literature review

Mini Abstract: Pregnancy-associated osteoporosis (PAO) is a rare syndrome affecting women during late pregnancy and the early postpartum period. We set out to review the clinical features of ten cases of PAO from a single UK centre. Patients had attended the Royal National Hospital for Rheumatic Diseases, Bath (RNHRD) between January 2000 and June 2016. The principal criterion for inclusion was the occurrence of low trauma fractures either during pregnancy or the immediate post-partum period. Data were obtained from retrospective review of medical notes. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (Hologic ®Discovery system) at the lumbar spine and hip. Data pertaining to the pregnancy, as well as type and duration of treatment received, were reviewed. All ten cases presented with vertebral fractures. In four patients, no risk factors for fracture other than pregnancy or breastfeeding could be identified. Four patients were found to have vitamin D insufficiency at the time of diagnosis, and a further two patients had received treatment with low molecular weight heparin (LMWH). In one case, further investigation led to a diagnosis of osteogenesis imperfecta (OI) confirmed on genetic testing. In terms of treatment, eight out of the ten patients in this series received a bisphosphonate, most commonly risedronate due to its relatively short skeletal retention time. Clinicians should be aware of PAO, a rare but recognised complication of pregnancy. The condition should be especially considered in women presenting with new onset back pain in pregnancy or the postpartum period.

BK Virus nephropathy in living donor renal allograft recipients: An observational study from a large transplant center in India

BK virus is a polyoma virus which remains in latent phase in the urinary tract, particularly in the renal tubular epithelial cells. In immunosuppressed patients, it is activated and manifests as tubule-interstitial nephritis causing renal allograft dysfunction. A total of 402 patients who underwent renal allograft biopsy from 2013 to 2016 were included in this study; six patients were diagnosed to have BK virus nephropathy. Histopathology showed ground glass intra-nuclear inclusions accompanied by acute tubular injury, interstitial inflammation, and varying degree of interstitial fibrosis and tubular atrophy. Patients were managed with reduction in the overall immunosuppression. Only one patient progressed to graft failure on follow-up. The overall prevalence of polyoma virus at our center is 1.49%.

Hypoferremic State in Overweight and Obese Children

Children with high body mass index (BMI) are at risk of iron deficiency. In present study, 71 children with overweight or obesity were screened for iron deficiency. Mean BMI, ferritin and plasma soluble transferrin receptor (sTrfR) levels were 26.1 kg/m2, 41.9 µg/L and 0.375 mg/L, respectively. Twenty (28%) children had anemia, and 44 (62%) had an underlying hypoferraemic state.

Degenerative inter-vertebral disc disease osteochondrosis intervertebralis in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over

Objectives

To assess the prevalences across Europe of radiological indices of degenerative inter-vertebral disc disease (DDD); and to quantify their associations with, age, sex, physical anthropometry, areal BMD (aBMD) and change in aBMD with time.

Methods

In the population-based European Prospective Osteoporosis Study, 27 age-stratified samples of men and women from across the continent aged 50+ years had standardized lateral radiographs of the lumbar and thoracic spine to evaluate the severity of DDD, using the Kellgren-Lawrence (KL) scale. Measurements of anterior, mid-body and posterior vertebral heights on all assessed vertebrae from T4 to L4 were used to generate indices of end-plate curvature.

Results

Images from 10 132 participants (56% female, mean age 63.9 years) passed quality checks. Overall, 47% of men and women had DDD grade 3 or more in the lumbar spine and 36% in both thoracic and lumbar spine. Risk ratios for DDD grades 3 and 4, adjusted for age and anthropometric determinants, varied across a three-fold range between centres, yet prevalences were highly correlated in men and women. DDD was associated with flattened, non-ovoid inter-vertebral disc spaces. KL grade 4 and loss of inter-vertebral disc space were associated with higher spine aBMD.

Conclusion

KL grades 3 and 4 are often used clinically to categorize radiological DDD. Highly variable European prevalences of radiologically defined DDD grades 3+ along with the large effects of age may have growing and geographically unequal health and economic impacts as the population ages. These data encourage further studies of potential genetic and environmental causes.

Clinical efficacy of oral alendronate in ankylosing spondylitis: a randomised placebo-controlled trial

OBJECTIVES

A prospective, double blind, randomised, placebo controlled trial over 2 years was performed to test the efficacy of alendronate, an oral aminobisphosphonate, in improving symptoms and arrest disease progression in patients with mild to severe ankylosing spondylitis (AS).

METHODS

180 patients with AS were randomised to receive weekly alendronate 70 mg or placebo (1:1 randomisation). BAS-G was the primary outcome measure with Bath indices as secondary outcomes. Vertebral x-rays were performed at 0 and 24 months. Biomarkers (including CRP, IL-1beta, IL6, VEGF, MMP-1, and MMP-3) were collected during the first 12 months.

RESULTS

There was no significant difference between the placebo and treatment groups in any of the recorded outcomes over the 2 years including clinical indices, biomarkers, and radiology. The change in BAS-G, the primary outcome measure, was -0.21 for the treatment group and -0.42 for the placebo group p=0.57. Change in all other clinical outcome measures were also non-significant; BASDAI p=0.86, BASFI p=0.37, BASMI p=0.021. Sub-group analysis of those subjects with a baseline BASDAI >4 were also non-significant.

CONCLUSIONS

This prospective study demonstrates that alendronate 70mg weekly for 2 years was no more efficacious than placebo in improving clinical or laboratory measures of disease activity or measures of physical impact in subjects with mild to severe active AS.

TRIAL REGISTRATION

ID SRCTN12308164, registered on 15.12.2015.

Is there an increased risk of metabolic syndrome among childhood acute lymphoblastic leukemia survivors? A developing country experience

Data on metabolic syndrome (MS) in survivors of childhood acute lymphoblastic leukemia (ALL) from developing countries are lacking. The purpose of this single-center, uncontrolled, observational study was to assess the frequency of MS in our survivors. The survivors of ALL ≤15 years at diagnosis, who had completed therapy ≥2 years earlier, were enrolled. Anthropometric measurements (weight, height, waist circumference), biochemistry (glucose, insulin, triglycerides, high-density lipoprotein [HDL], thyroid function tests, C-reactive protein [CRP], magnesium), measurement of blood pressure, and Tanner staging were performed. MS was defined by International Diabetes Federation (IDF) and the National Cholesterol Education Program Third Adult Treatment Panel guidelines (NCEP ATP III) criteria, modified by Cook et al. (Arch Pediatr Adolesc Med. 2003;157:821-827) and Ford et al. (Diabetes Care. 2005;28:878-881). The median age of 76 survivors was 11.9 years (interquartile range [IQR]: 9.6-13.5). Twenty-four (32%) survivors were obese or overweight. The prevalence of insulin resistance (17%), hypertension (7%), hypertriglyceridemia (20%), and low HDL (37%) was comparable to the prevalence in children/adolescents in historical population-based studies from India. The prevalence of MS ranged from 1.3% to 5.2%, as per different defining criteria. Cranial radiotherapy, age at diagnosis, sex, or socioeconomic status were not risk factors for MS. The prevalence of MS in survivors of childhood ALL, at a median duration of 3 years from completion of chemotherapy, was comparable to the reference population. The prevalence of being obese or overweight was, however, greater than historical controls.

Vertebral Scheuermann's disease in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over

In 27 centres across Europe, the prevalence of deforming spinal Scheuermann's disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8% in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann's, helping the differential diagnosis from osteoporosis.

INTRODUCTION

This study aims to assess the prevalence of Scheuermann's disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture.

METHODS

In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann's disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl's node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2-L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann's by alternative published algorithms when these used the radiographic signs we assessed.

RESULTS

Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann's varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8% with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann's was not associated with BMD of the spine or hip.

CONCLUSIONS

Since most of the variation in population impact of Scheuermann's was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.

Renal failure due to granulomatous interstitial nephritis in native and allograft renal biopsies: experience from a tertiary care hospital

Granulomatous interstitial nephritis is a rare cause of renal failure in both native and allograft renal biopsies. Drugs and sarcoidosis are the commonest causes of granulomatous interstitial nephritis as reported in Western countries. Unlike the west, tuberculosis is the commonest cause of granulomatous interstitial nephritis in Indian subcontinent. The etiological factors, clinical course, glomerular and tubulointerstitial changes associated with granulomatous interstitial nephritis have been analyzed in the present study along with the outcome in patients with granulomatous interstitial nephritis.

Vitamin D levels during and after resolution of ketoacidosis in children with new onset Type 1 diabetes

AIM

To study the effect of ketoacidosis on measured 25-hydroxyvitamin D3 in children with new onset Type 1 diabetes.

METHODS

Measurement of pH and bicarbonate levels was carried out in children with newly diagnosed Type 1 diabetes at presentation with ketoacidosis. 25-hydroxyvitamin D3 estimation was carried out at presentation (timepoint 1) and 1 month later (timepoint 2). There was no significant difference in the mean (±sd) 25-hydroxyvitamin D3 levels [35.39 (±25.79) vs 39.63 (±48.03) nmol/L; P = 0.661) at the two timepoints in the study.

RESULTS

Correlation analysis revealed a positive correlation between bicarbonate levels and timepoint 1, i.e. the lower the bicarbonate levels, the lower were the timepoint 1 levels and vice versa (correlation coefficient 0.538, P = 0.001). Timepoint 2 levels also showed a positive correlation with serum bicarbonate levels with a correlation coefficient of 0.379 (P = 0.032). None of the variables other than bicarbonate,.(age, gender, BMI, pH or time), was found to have the predictive ability for timepoint1 levels. Similarly for predicting timepoint 2 levels, BMI was found to have independent predictive ability in addition to bicarbonate.

CONCLUSIONS

Severe ketoacidosis, as judged by bicarbonate but not pH, may transiently lower 25-hydroxyvitamin D3 levels in children with new onset Type 1 diabetes. Persistence of low 25-hydroxyvitamin D3 levels after resolution of ketoacidosis suggests a state of permanent vitamin D deficiency in our patient population.

Longitudinal growth of head circumference in term symmetric and asymmetric small for gestational age infants

AIMS

To study longitudinal growth pattern of head circumference of full-term symmetric and asymmetric small for gestational age (SGA) infants of the two sexes during first year of life.

STUDY DESIGN

Mixed-longitudinal growth research design.

SUBJECTS

Head circumference amongst full-term 100 symmetric, 100 asymmetric as well as 100 appropriate for gestational age (AGA) infants was measured at birth, 1, 3, 6, 9 and 12 months of age using standardized technique and instrument.

RESULTS

The mean head circumference of male symmetric SGA infants measured significantly (p≤0.001) smaller than asymmetric SGA infants while, in female symmetric SGA infants it measured shorter beyond 6 months. As compared to AGA infants, head circumference in symmetric and asymmetric SGA infants measured significantly smaller in size. Growth velocity for head circumference amongst symmetric and asymmetric SGA male infants did not show statistically significant differences. Rate of head circumference growth remained significantly higher amongst female asymmetric SGA infants than the symmetric ones between 3 and 6 months while, a reversal of trend was observed between 9 and 12 months.

CONCLUSION

The better growth attainments for head circumference of male and female asymmetric SGA infants than their symmetric SGA counterparts during first postnatal year of life may be attributed to the continuation of influence of "head sparing" experienced by asymmetric SGA babies during prenatal life.

Association of cytokine and matrix metalloproteinase profiles with disease activity and function in ankylosing spondylitis

Introduction

The pathology of ankylosing spondylitis (AS) suggests that certain cytokines and matrix metalloproteinases (MMPs) might provide useful markers of disease activity. Serum levels of some cytokines and MMPs have been found to be elevated in active disease, but there is a general lack of information about biomarker profiles in AS and how these are related to disease activity and function. The purpose of this study was to investigate whether clinical measures of disease activity and function in AS are associated with particular profiles of circulating cytokines and MMPs.

Methods

Measurement of 30 cytokines, five MMPs and four tissue inhibitors of metalloproteinases was carried out using Luminex^® technology on a well-characterised population of AS patients (n = 157). The relationship between biomarker levels and measures of disease activity (Bath ankylosing spondylitis disease activity index (BASDAI)), function (Bath ankylosing spondylitis functional index) and global health (Bath ankylosing spondylitis global health) was investigated. Principal component analysis was used to reduce the large number of biomarkers to a smaller set of independent components, which were investigated for their association with clinical measures. Further analyses were carried out using hierarchical clustering, multiple regression or multivariate logistic regression.

Results

Principal component analysis identified eight clusters consisting of various combinations of cytokines and MMPs. The strongest association with the BASDAI was found with a component consisting of MMP-8, MMP-9, hepatocyte growth factor and CXCL8, and was independent of C-reactive protein levels. This component was also associated with current smoking. Hierarchical clustering revealed two distinct patient clusters that could be separated on the basis of MMP levels. The high MMP cluster was associated with increased C-reactive protein, the BASDAI and the Bath ankylosing spondylitis functional index.

Conclusions

A profile consisting of high levels of MMP-8, MMP-9, hepatocyte growth factor and CXCL8 is associated with increased disease activity in AS. High MMP levels are also associated with smoking and worse function in AS.

Intake of antioxidants and their status in chronic kidney disease patients

OBJECTIVE

To evaluate the intake and status of antioxidants in chronic kidney disease (CKD) patients.

DESIGN

Randomized control trial.

SETTING

Hospital outpatient department.

SUBJECTS

One hundred eighty-five subjects (145 predialysis CKD patients and 40 apparently healthy controls) were enrolled for this study. The patients were divided into moderate and severe renal failure groups based on their creatinine and glomerular filtration rates.

INTERVENTION

All patients completed a food frequency questionnaire, 24-hour dietary recall form, and anthropometric measurements and underwent biochemical and antioxidant lab tests.

MAIN OUTCOME MEASURES

Dietary intake, anthropometry, biochemical measures of blood and antioxidant enzymes as well as oxidative stress.

RESULTS

Overall, the diet was significantly lower in antioxidant-rich food intake in all the CKD patients as compared with controls. The oxidative stress measured in blood was found to be in consonance with the intake from diet.

CONCLUSION

Micronutrients play a major role in the antioxidant status of the patients and must be monitored, as deficiency of these might elevate the oxidative stress of the body, especially in the chronic diseases.

Low levels of vitamin D in North Indian children with newly diagnosed type 1 diabetes

BACKGROUND

To find out whether vitamin D levels are lower in children with newly diagnosed type 1 diabetes (T1D) as compared to non-diabetic subjects.

METHODS

Plasma levels of vitamin D (25-OHD) were measured by high performance liquid chromatography (HPLC) in 50 children aged between 6 and 12 yr within a week of diagnosis of T1D, and in 50 healthy children.

RESULTS

The mean levels of vitamin D were significantly lower in patients as compared to their controls [20.02 +/- 10.63 ng/mL (50.05 +/- 26.57 mmol/L) vs. 26.16 +/- 12.28 ng/mL (65.4 +/- 30.7 mmol/L), p-value 0.009]. Twenty-nine (58%) children in the study group were vitamin D deficient (25-OHD level < 20 ng/mL or < 50 mmol/L) as compared to only 16 (32%) in the control group. Overall, 43 (86%) diabetic and 38 (76%) healthy children were either vitamin D deficient or insufficient.

CONCLUSION

These results suggest that vitamin D levels are low at the onset of T1D, and they strongly support the need for further clinical studies to prospectively evaluate the effect of vitamin D supplementation on T1D rates in this patient population.

Lateral back pain identifies prevalent vertebral fractures in post-menopausal women: cross-sectional analysis of a primary care-based cohort

OBJECTIVE

Vertebral fractures (VFs) are frequently under-recognized, reflecting their lack of diagnostic clinical features. For example, although VFs are associated with back pain, this is also common in the general population. To establish whether back pain can be used to recognize patients with VF, we investigated the site of pain in people with and without VFs using a simple tool.

METHODS

A cohort of 504 post-menopausal women was recruited from primary care in South West UK. Back pain was assessed by self-completion of the Margolis pain diagram, and analysis was modified to assess whether pain was mid-line or lateral. VFs were diagnosed by the algorithm-based qualitative method on radiographs. A cross-sectional analysis was carried out to assess the association between back pain and VFs.

RESULTS

Three hundred and twenty-two women (64.1%) reported back pain over the last 12 months. Thirty seven (7.3%) had one or more VFs. In women with back pain, the presence of lateral waist area pain was associated with a 4.5-fold increased risk of VFs [odds ratio (OR) 4.48; 95% CI 2.02, 9.94; P < 0.001].

CONCLUSIONS

In post-menopausal women with back pain, the presence of lateral waist pain, as shown on the Margolis pain diagram, may identify women at higher risk of prevalent VF.

Use of clinical risk factors to identify postmenopausal women with vertebral fractures

INTRODUCTION AND HYPOTHESIS

Previous studies have been unable to identify risk factors for prevalent vertebral fractures (VF), which are suitable for use in selection strategies intended to target high-risk sub-groups for diagnostic assessment. However, these studies generally consisted of large epidemiology surveys based on questionnaires and were only able to evaluate a limited number of risk factors. Here, we investigated whether a stronger relationship exists with prevalent VF when conventional risk factors are combined with additional information obtained from detailed one-to-one assessment.

METHODS

Women aged 65-75 registered at four geographically distinct GP practices were invited to participate (n=1,518), of whom 540 attended for assessment as follows: a questionnaire asking about risk factors for osteoporosis such as height loss compared to age 25 and history of non-vertebral fracture (NVF), the get-up-and-go test, Margolis back pain score, measurement of wall-tragus and rib-pelvis distances, and BMD as measured by the distal forearm BMD. A lateral thoraco-lumbar spine X-ray was obtained, which was subsequently scored for the presence of significant vertebral deformities.

RESULTS

Of the 509 subjects who underwent spinal radiographs, 37 (7.3%) were found to have one or more VF. Following logistic regression analysis, the four most predictive clinical risk factors for prevalent VF were: height loss (P=0.006), past NVF (P=0.004), history of back pain (P=0.075) and age (P=0.05). BMD was also significantly associated with prevalent VF (P=0.002), but its inclusion did not affect associations with other variables. Factors elicited from detailed one-to-one assessment were not related to the risk of one or more prevalent VFs. The area under ROC curves derived from these regressions, which suggested that models for prevalent VF had modest predictive accuracy, were as follows: 0.68 (BMD), 0.74 (four clinical risk factors above) and 0.78 (clinical risk factors + BMD). Analyses were repeated in relation to the subgroup of 13 patients with two or more VFs, which revealed that in this instance, the Margolis back pain score and rib-pelvis distance were associated with the presence of multiple VFs (P=0.022 and 0.026, respectively). Moreover, the predictive value as reflected by the ROC curve area was improved: 0.80 (BMD), 0.88 (the four most predictive clinical risk factors consisting of the height loss, past NVF, Margolis back pain score and rib-pelvis distance) and 0.91 (clinical risk factors + BMD).

CONCLUSIONS

Evaluation of additional risk factors from detailed one-to-one assessment does not improve the predictive value of risk factors for one or more prevalent vertebral deformities in postmenopausal women. However, the use of factors such as the Margolis back pain score and rib-pelvis distance may be helpful in identifying postmenopausal women at high risk of multiple prevalent VFs.

Low BMD is less predictive than reported falls for future limb fractures in women across Europe: results from the European Prospective Osteoporosis Study

We have previously shown that center- and sex-specific fall rates explained one-third of between-center variation in upper limb fractures across Europe. In this current analysis, our aim was to determine how much of the between-center variation in fractures could be attributed to repeated falling, bone mineral density (BMD), and other risk factors in individuals, and to compare the relative contributions of center-specific BMD vs. center-specific fall rates. A clinical history of fracture was assessed prospectively in 2451 men and 2919 women aged 50-80 from 20 centers participating in the European Prospective Osteoporosis Study (EPOS) using standardized questionnaires (mean follow-up = 3 years). Bone mineral density (BMD, femoral neck, trochanter, and/or spine) was measured in 2103 men and 2565 women at these centers. Cox regression was used to model the risk of incident fracture as a function of the person-specific covariates: age, BMD, personal fracture history (PFH), family hip fracture history (FAMHIP), time spent walking/cycling, number of 'all falls' and falls not causing fracture ('fracture-free') during follow-up, alcohol consumption, and body mass index. Center effects were modeled by inclusion of multiplicative gamma-distributed random effects, termed center-shared frailty (CSF), with mean 1 and finite variance theta (theta) acting on the hazard rate. The relative contributions of center-specific fall risk and center-specific BMD on the incidence of limb fractures were evaluated as components of CSF. In women, the risk of any incident nonspine fracture (n = 190) increased with age, PFH, FAMHIP, > or =1 h/day walking/cycling, and number of 'all falls' during follow-up (all P < 0.074). 'Fracture-free' falls (P = 0.726) and femoral neck BMD did not have a significant effect at the individual level, but there was a significant center-shared frailty effect (theta = 0.271, P = 0.001) that was reduced by 4% after adjusting for mean center BMD and reduced by 19% when adjusted for mean center fall rate. Femoral trochanter BMD was a significant determinant of lower limb fractures (n = 53, P = 0.014) and the center-shared frailty effect was significant for upper limb fractures (theta = 0.271, P = 0.011). This upper limb fracture center effect was unchanged after adjusting for mean center BMD but was reduced by 36% after adjusting for center mean fall rates. In men, risk of any nonspine fracture (n = 75) increased with PFH, fall during follow-up (P < 0.026), and with a decrease in trochanteric BMD [RR 1.38 (1.08, 1.79) per 1 SD decrease]. There was no center effect evident (theta = 0.081, P = 0.096). We conclude that BMD alone cannot be validly used to discriminate between the risk of upper limb fractures across populations without taking account of population-specific variations in fall risk and other factors. These variations might reflect shared environmental or possibly genetic factors that contribute quite substantially to the risk of upper limb fractures in women.

A comparison of bone loss in early and late rheumatoid arthritis using quantitative phalangeal ultrasound

This study compares amplitude-dependent speed of sound (AD-SoS) measured by phalangeal ultrasonography in a group of 60 patients with early rheumatoid arthritis (RA) with those who had had the disease for more than 4 years. The mean duration of the early disease group was 1.4 years, and the mean of the established RA group was 14.6 years. Plasma viscosity (PV), C-reactive protein (CRP) and HAQ scores were obtained. Forty-nine patients with early RA had hand radiographs assessed by the Larsen score method. The DBM Sonic system was assessed on normal volunteers and a coefficient of variation of 0.88% obtained. A significant correlation was found between the left and right hands of the patients groups studied ( r=0.84). The mean Z score of both hands was therefore used in comparing the two clinical groups. Results showed no correlation between CRP, PV and Z scores of AD-SoS. The HAQ scores showed a weak negative correlation, and there was no correlation between the Larsen score and Z score, or the number of swollen joints and Z score. However, the early and established groups with RA were significantly different (#E5/E5#=0.004). Within the early RA group the Z score for AD-SoS was lower in those with disease duration of less than 2 years (-1.71) than in those with disease duration of 2-4 years (-1.01). This suggests that bone loss in the fingers is greater in the first 2 years of disease than in the following 2 years, which might reflect an effect of treatment.

Health-related quality of life and radiographic vertebral fracture

BACKGROUND

Vertebral fractures are associated with back pain and disability; however, relatively little is known about the impact of radiographic vertebral fractures on quality of life in population samples. The aim of this study was to determine the impact of a recent radiographic vertebral fracture on health-related quality of life (HRQoL).

METHODS

Men and women aged 50 years and over were recruited from population registers in 12 European centers. Subjects completed an interviewer-administered questionnaire and had lateral spine radiographs performed. Subjects in these centers were followed prospectively and had repeat spinal radiographs performed a mean of 3.8 years later. Prevalent deformities were defined using established morphometric criteria, and incident vertebral fractures by both morphometric criteria and qualitative assessment. For each incident fracture case, three controls matched for age, gender, and center were selected: one with a prevalent deformity (at baseline) and two without prevalent deformities. All subjects were interviewed or completed a postal questionnaire instrument which included Short Form 12 (SF-12), the EQ-5D (former EuroQol), and the quality of life questionnaire of the International Osteoporosis Foundation (QUALEFFO). The median time from the second spinal radiograph until the quality of life survey was 1.9 years. Comparison between cases and their matched controls was undertaken using the signed rank test.

RESULTS

73 subjects with incident vertebral fracture (cases), mean age 64.8 years (of whom 23 had a baseline deformity), and 196 controls, mean age 63.9 years (of whom 60 had a baseline deformity), were studied. There were strong correlations between the domain scores for each of the three instruments. There was no statistically significant difference in any of the domain scores between cases and those controls with a prevalent deformity. However, compared with the controls without a prevalent deformity the cases had significantly impaired quality of life as determined using the total QUALEFFO score (38.2 vs 33.7), the physical component score of the SF-12 (39.9 vs 43.7) and the health status score of the EQ-5D (62.3 vs 69.9). When the analysis was repeated after stratification of the cases by baseline deformity status (i.e., cases with and without a prevalent deformity at baseline), cases with a prevalent deformity had impaired quality of life compared with their matched controls, both with and without a prevalent deformity. In contrast there was no significant difference in quality of life among the cases without a prevalent deformity and either control group.

CONCLUSIONS

In this population-based study a recent vertebral fracture was associated with impairment in quality of life, though this was mainly among those who had sustained a previous vertebral deformity.

Cerebral gigantism with West syndrome

A case of cerebral gigantism (Sotos syndrome) with West syndrome in a one-year-old male child is reported. The case had a large stature, typical facies and neurodevelopmental delay along with infantile spasms, which were refractory to treatment with valproate and clonazepam.

Counting respiratory rate in infants under 2 months: comparison between observation and auscultation

The World Health Organization's global programme for the control of acute respiratory infections relies on counting respiratory rate (RR) by observing abdominal and chest movements in order to diagnose pneumonia. However, few studies on the reliability of the observation method have been published. We counted RR simultaneously by observation and auscultation in 100 healthy infants at 1, 2, 4, 6 and 8 weeks of age for 15, 30 and 60 sec, and compared RRs obtained by the two methods. In all the age groups studied, the co-efficients of variation for the RRs recorded by observation or auscultation were similar. The mean RR by observation was higher by 1-3 breaths/min than mean RR by auscultation (p < 0.001). The 95% confidence interval (+/-2 SD) for the difference between RR by the two methods ranged from +5 to -8 breaths/min for RR counted for 1 full minute. Our data support the assumption that observation is as reliable as auscultation for counting RR.

Falls explain between-center differences in the incidence of limb fracture across Europe

There is important geographic variation in the occurrence of the major osteoporotic fractures across Europe. The aim of this study was to determine whether between-center variation in limb fracture rates across Europe could be explained by variation in the incidence of falls. Men and women, aged 50-79 years, were recruited from population-based registers in 30 European centers. Subjects were followed by postal questionnaire to ascertain the occurrence of incident fractures, and were also asked about the occurrence and number of recent falls. Self-reported fractures were confirmed, where possible, by review of the radiographs, medical record, or subject interview. The age- and gender-adjusted incidence of falls was calculated by center using Poisson regression. Poisson regression was also used to assess the extent to which between-center differences in the incidence of limb fractures could be explained by differences in the age- and gender-adjusted incidence of falls at those centers. In all, 6302 men (mean age 63.9 years) and 6761 women (mean age 63.1 years) completed at least one questionnaire concerning fractures and falls. During a median follow-up time of 3 years, 3647 falls were reported by men and 4783 by women. After adjusting for age and gender, there was evidence of significant between-center differences in the occurrence of falls. There was also between-center variation in the occurrence of upper limb, lower limb, and distal forearm fractures. Variation in the age- and gender-adjusted center-specific fall rates explained 24%, 14%, and 6% of the between-center variation in incidence of distal forearm and upper and lower limb fractures, respectively. Given the constraints inherent in such an analysis, in men and women aged 50-79 years, variation in fall rates could explain a significant proportion of the between-center variation in the incidence of limb fracture across Europe.

Methotrexate in the treatment of rheumatoid arthritis. I. In vitro effects on cells of the osteoblast lineage

OBJECTIVE

Low-dose methotrexate (MTX) is often used in the treatment of rheumatoid arthritis (RA). To be effective, treatment must be long-term, and there are concerns that MTX may impair bone formation in a population already predisposed to osteoporosis. The purpose of this investigation was to determine the direct effects of MTX at clinically relevant doses on the growth and differentiation of human cells of the osteoblast (bone-forming) lineage.

METHODS

Cells derived from the marrow stroma (BMSC) and trabecular surfaces [human bone-derived cells (HBDC)] of adult ribs were cultured in the absence or presence of MTX (1-1000 nM). To promote the differentiation and further maturation of cells of the osteoblast lineage, one half of the cultures were treated additionally with 10 nM dexamethasone (Dx).

RESULTS

In cultures of BMSC, treatment with MTX (+/-Dx) did not affect the total number of colonies that formed or the expression of the developmental markers STRO-1 and alkaline phosphatase (AP). At concentrations > or =10 nM, however, there was a statistically significant reduction in the number of cells harvested at the end of primary culture. In cultures of HBDC, treatment with MTX (in the presence of Dx) did not affect cell number or the expression of AP.

CONCLUSIONS

At concentrations > or =10 nM, treatment with MTX inhibits the proliferation of primitive marrow stromal cells, but not their ability to undergo osteogenic differentiation. The proliferation and further maturation of cells of the osteoblast lineage is not affected by treatment with MTX. These findings are reassuring for clinicians using MTX in the treatment of RA.

Methotrexate in the treatment of rheumatoid arthritis. II. In vivo effects on bone mineral density

OBJECTIVE

To determine the effect of methotrexate (MTX) on bone mineral density (BMD) in rheumatoid arthritis (RA).

METHODS

One hundred and sixteen non-steroid-treated RA subjects (90 women) were studied in a prospective, longitudinal, non-randomized study. Subjects started MTX (n=36) or sulphasalazine (n=23) or continued long-term (>5 yr) treatment with MTX (n=28) or other disease-modifying anti-rheumatic drugs (n=29). BMD was estimated at entry and after 1 yr. Markers of bone turnover were measured at entry and at 1 yr, and additionally at 3 and 6 months in those starting treatment. Bone biopsies were taken before and after MTX treatment in four subjects. The primary outcome was change in BMD Z score and secondary outcomes were changes in bone turnover markers and bone formation by histomorphometry.

RESULTS

Univariate analysis of covariance found that MTX at baseline was associated with reduced BMD at the femoral neck. However, femoral neck BMD was also associated with radiological damage score for the hand. Multivariate analysis and discriminant analysis of the subset of post-menopausal women showed that reduced bone density associated with MTX was due to confounders such as disease activity. There was no adverse effect of MTX on bone turnover markers or on measures of bone formation in biopsies.

CONCLUSIONS

No adverse effect of low-dose MTX (mean 10 mg/week) on bone formation in RA was found.

Bone mineral density, calcaneal ultrasound, and bone turnover markers in women with ankylosing spondylitis

OBJECTIVE

To assess bone mineral density (BMD) by dual energy x-ray absorptiometry (DEXA) and calcaneal quantitative ultrasound (QUS) in a cohort of pre- and postmenopausal women with ankylosing spondylitis (AS), and to determine any relationships with markers of bone turnover and disease activity or severity.

METHODS

Fifty premenopausal and 16 postmenopausal women with AS were studied. Clinical and radiological status was assessed by the Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), Bath AS Metrology Index (BASMI), and Bath AS Radiology Index (BASRI). BMD of the hip and spine was measured by DEXA, and QUS measured at the heel. Serum osteocalcin (OC), bone-specific alkaline phosphatase (BALP), urinary D-pyridinoline crosslinks (D-PYR), and C-reactive protein (CRP) were assayed.

RESULTS

Women with AS (n = 66) had reduced BMD at the hip compared to age and sex matched controls (n = 132). The mean t scores were -1.1 and -2.0, and z scores -0.4 and -0.37, for pre- and postmenopausal women, respectively. Four (6%) had osteoporosis and 34 (52%) had osteopenia according to the WHO definitions. Using a multiple regression model, femoral neck BMD was found to be significantly affected by age, body mass index, and the sacroiliac radiographic score. There were no significant correlations of BMD with disease duration or disease activity. QUS measures did not correlate with DEXA measures of BMD. Women with AS had significantly lower markers of bone formation, OC and BALP, and a trend to higher D-PYR than controls. Serum OC levels correlated negatively with femoral neck BMD, whereas D-PYR correlated with CRP levels.

CONCLUSION

Women with AS have reduced hip BMD, 0.39 SD below age and sex matched controls. Bone turnover in women with AS is characterized by low OC and BALP.

Prevalent vertebral deformity predicts incident hip though not distal forearm fracture: results from the European Prospective Osteoporosis Study

The presence of a vertebral deformity increases the risk of subsequent spinal deformities. The aim of this analysis was to determine whether the presence of vertebral deformity predicts incident hip and other limb fractures. Six thousand three hundred and forty-four men and 6788 women aged 50 years and over were recruited from population registers in 31 European centers and followed prospectively for a median of 3 years. All subjects had radiographs performed at baseline and the presence of vertebral deformity was assessed using established morphometric methods. Incident limb fractures which occurred during the follow- up period were ascertained by annual postal questionnaire and confirmed by radiographs, review of medical records and personal interview. During a total of 40348 person-years of follow-up, 138 men and 391 women sustained a limb fracture. Amongst the women, after adjustment for age, prevalent vertebral deformity was a strong predictor of incident hip fracture, (rate ratio (RR) = 4.5; 95% CI 2.1-9.4) and a weak predictor of 'other' limb fractures (RR = 1.6; 95% CI 1.1-2.4), though not distal forearm fracture (RR = 1.0; 95% CI 0.6-1.6). The predictive risk increased with increasing number of prevalent deformities, particularly for subsequent hip fracture: for two or more deformities, RR = 7.2 (95% CI 3.0-17.3). Amongst men, vertebral deformity was not associated with an increased risk of incident limb fracture though there was a nonsignificant trend toward an increased risk of hip fracture with increasing number of deformities. In summary, prevalent radiographic vertebral deformities in women are a strong predictor of hip fracture, and to a lesser extent humerus and 'other' limb fractures; however, they do not predict distal forearm fractures.

The clinical impact of metabolic bone disease in coeliac disease

Bone mineral density was measured by dual energy x ray absorptiometry (DEXA) at the lumbar spine and femoral neck in 15 adults who had metabolic bone disease in association with coeliac disease (mean age at diagnosis 53.5 years, range 37 to 66). Results were expressed as a T score (the number of standard deviations by which patient's bone density differed from the sex matched young adult mean). Three patients had no skeletal symptoms and normal routine calcium biochemistry but severely reduced axial bone mineral density on DEXA. Eleven patients had symptomatic skeletal fractures, including fractures of proximal femur (3), vertebrae (4), and radius (6). Three patients had osteomalacia confirmed on bone biopsy, two of whom had characteristic biochemistry. Secondary and tertiary hyperparathyroidism were seen. Seventy five further patients (60 female) with coeliac disease (mean age 52.0 years, median duration of gluten-free diet 3.4 years) and 75 paired healthy age and sex matched controls were questioned on past fracture history. Patients with coeliac disease underwent detailed studies of calcium biochemistry, dietary intake, and bone mineral density. Sixteen had a past history of fractures (chi(2) = 10.7, p = 0.0004, v controls), which were of typical osteoporotic type. Ten patients had fracture before diagnosis of coeliac disease and six after diagnosis. Patients who had a fracture were older (56.3 v 50.3 years, p < 0.02, Wilcoxon rank sum test) than those with no fracture. There was no significant difference in bone mineral density (z score -0.31 v -0. 77), serum calcium (2.30 v 2.26 mmol/l), 25-hydroxyvitamin D (19.7 v 23.7 nmol/l), parathyroid hormone (2.6 v 3.1 pmol/l), or dietary calcium intake (1021.0 v 1033.0 mg/day) in patients with fracture compared with those without fracture. Metabolic bone disease is common in coeliac disease and is associated with premature osteoporotic fractures.