Lumbar spine bone mineral density and trabecular bone score-adjusted FRAX, but not FRAX without bone mineral density, identify subclinical carotid atherosclerosis

PURPOSE

Osteoporosis and atherosclerosis share common risk factors. Aim of this study was to test if FRAX (which is an algorithm that can identify subjects at risk of fracture), without or with BMD values, also adjusted for trabecular bone score (TBS) was able to identify subclinical atherosclerosis, evaluated by measurement of carotid intima media thickness (cIMT ≥ 0.9 mm) as compared to DXA values.

METHODS

Ninety postmenopausal women underwent DXA measurement and cIMT evaluation. For each patient, the FRAX algorithm for major osteoporotic fracture (M) and for hip fracture (H) without BMD was computed, together with FRAX with BMD and TBS-adjusted FRAX. Serum levels of osteoprotegerin, sRANKL, and interleukin-6 were also measured.

RESULTS

There were no differences in anthropometric parameters and cardiovascular risk factors between subjects with cIMT ≥ 0.9 mm (35% of subjects, group A) compared to those with cIMT < 0.9 mm (group B). The prevalence of osteoporosis and FRAX BMD, TBS-adjusted FRAX both for M and H were higher in group A compared to group B. The best ROC curves to identify subjects with a cIMT ≥ 0.9 mm were: lumbar spine T-score, with a threshold of - 2.5 SD (area under the curve, AUC 0.64; p = 0.02) with a sensibility of 50% and a specificity of 76%; TBS-adjusted FRAX H with a sensibility of 50% and a specificity of 72% (AUC 0.64; p = 0.01 with a threshold of 3%). Interleukin-6 positively correlated with FRAX BMD H and M.

CONCLUSIONS

FRAX without BMD does not identify subclinical carotid atherosclerosis, while lumbar spine T-score and TBS-adjusted FRAX H similarly detected it with higher specificity for T-score.

Patients' reasons for adhering to long-term alendronate therapy

We aimed to determine patients' reasons for continuing alendronate therapy over 5 years by administering a questionnaire. Bone mineral density, fractures, drugs, Charlson comorbidity index, and lifestyle factors were also considered. Education and awareness of the disease appeared highly associated with good alendronate adherence while worsening health status with discontinuation.

INTRODUCTION

Aim of this study was to investigate patients' reasons for adhering to long-term alendronate therapy (more than 5 years), as data is not available in the current literature regarding the reasons behind long-term adherence.

METHODS

We studied 204 long-term adherent alendronate users: 65 postmenopausal outpatients still adherent (group C, years on treatment = 8.70 ± 1.31) were compared to 139 age-matched patients who discontinued therapy (group S, years on treatment = 8.64 ± 1.43). We evaluated main biochemical parameters, BMD values, fractures, and Charlson comorbidity index (CCI). A questionnaire was administered to analyze the reasons for long-term adherence.

RESULTS

There were no significant differences between groups concerning baseline DXA values, number of fractures, and CCI. A higher education level was observed in group C (C 54% vs S 35% of patients, p = 0.001). At the time of interview, there was a significantly higher number of patients with a CCI of two in group S compared to the beginning of treatment (56% vs 43%, p = 0.04), together with a higher number of patients taking more than 3 drugs (22% vs 11%, p = 0.01) compared to basal evaluation. Forty-seven percent of patients reported new diseases during the treatment as the main reason for stopping alendronate. A multivariate, stepwise logistic regression analysis showed that awareness of the disease was highly associated with adherence (OR = 0.20; 95% CI 0.045-0.93, p = 0.04) followed by higher education (OR = 0.526, 95% CI 0.345-0.801, p = 0.003). Worsening of CCI was associated with discontinuation (OR = 2.75, 95% CI 1.033-7.324, p = 0.04).

CONCLUSIONS

Education and disease awareness are associated with long-term alendronate adherence while competing health problems negatively impact adherence.

Henoch-Schönlein purpura in a patient with bowel bypass syndrome

Henoch-Schönlein purpura (HSP) is a common vasculitis being characterized by the classic tetrad of nonthrombocytopenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. Antigen-antibody (IgA) complexes activate the alternative complement pathway, resulting in inflammation and small vessels vasculitis. We present the case of a 53 years old Italian woman with HSP who was previously hospitalized for purpura skin lesions of the lower legs and diarrhea; a skin biopsy showed a leukocytoclastic vasculitis with perivascular accumulation of neutrophils and mononuclear cells. She was treated with immunosuppressive therapy. After 8 months she was hospitalized again for a recurrent episode of purpura skin lesions of the lower legs. At age 49 she was affected by obesity (BMI = 41.6 Kg/m2), treated via a bilio-pancreatic diversion that led, within a year, to a BMI reduction (25 Kg/m2). We suppose that bariatric surgery played a role on the development of autoimmune phenomena and that the formation of immunecomplexes is secondary to the excess of intestinal bacterial antigens. A cyclic therapy with Paromomicine 500 mg twice daily and Metronidazole 250 mg twice daily was performed with a clear up of the clinical picture. In medical literature are described numerous complications which include arthritis, erythema nodosum-like lesions, eruptions and other skin manifestations in patients who have undergone jejunocolic bypass. This case report describes for the first time the presence of HSP in a patient with bowel bypass syndrome and it is also able to demonstrate the relationship between the intestinal bacterial overgrowth and the systemic autoimmune system.