Turkish Journal of Rheumatology - 2006; 21(2)

Osteoporosis in Cirrhotic Patients

Selda Sar�kaya, �zg�r Ortanc�l, Y�cel �st�nda�, �lk� Ko�, Aynur Ba�aran — 2006-06-01

Objective: The aim of this study was to determine the osteoporosis at different sites in cirrhotic patients and relation of osteoporosis with duration and severity of disease. Patients and Methods: Twenty-eight patients (13 women, 15 men) with cirrhosis were included in this study. Dual-energy X-ray absorptiometry ( DEXA) was used to measure the bone mineral densities (BMD) of the lumbar spine (L1-L4), left femur (total) and forearm. The severity of cirrhosis was graded using the Child-Pugh score. Results: Osteoporosis at lumbar spine was found in 23.1% of female and 46.7% of male patients while 23.1% of females and 20% of males had osteoporosis at femur. According to forearm BMD measurements, 33% of women and 50% of men had osteoporosis. There were no significant differences between Child-Pugh class A, B and C in BMD and Z scores (p>0.05). We found no statistically significant correlation between disease duration and spine (r=-0.053, p=0.790), femur(r=0.302, p=0.119) and forearm (r=-0.236, p=0.303) Z scores. There were no statistically significant correlation between disease duration and spine (r=-0.071, p=0.721)and femur (r=0.090, p=0.650 T scores while there was a statistically significant negative correlation between disease duration and forearm T score (r=-0.486; p=0.025). Conclusion: One of two cirrhotic patients has osteoporosis in our study. Cirrhotic patients have sedantery lives due to their diseases. Osteoporotic fractures increase the duration and grade of immobilisation and diminish quality of patients lives. For this reason cirrhotic patients should be evaluated for osteoporosis thus the number of subsequent fractures may be decreased by early diagnose and intervention. (Rheumatism 2006; 21: 37-40)

Corelations of Clinical Features and Findings in Fibromyalgia Patients

G�lcan G�rer, �mer Faruk �endur — 2006-06-01

Objective: Fibromyalgia (FM) is a common disorder with unknown etiology which is characterized by chronic musculoskeletal pain and increased tenderness at standardized tender points. Additional symptoms are fatigue, sleep disturbances, deconditioning and reduced quality of life. In this study, we investigated the clinical features of fibromyalgia and correlations between the symptoms. Patients and Methods: A total of 171 patients with FM (170 female, one male) were included this study . The severity of the pain was recorded with a visual analog scale and verbal pain scale. Fibromyalgia Impact Questionnaire (FIQ) was used to determine the current health status of patients with FM. Pearson correlation test was used as a statistical test. Results: The most common complaints among patients were fatigue in 163 (%95.3), widespread pain in 156 of cases (%91.2), headache in 143 (%83.6), paresthesia in 135 (%78.9), sleep disturbances in 130 (%76), swollen impression in 111 (%64.9), dry mouth in 96 (%56.1), loss in libido in 65 (%38), symptoms referred to irritable bowel syndrome in 63 (%36.8), dysmenorrhea in 55 (%35), Raynaud's phenomenon in 47 (%27.5). Significant correlations were determined between clinical features similiar to the literature on this subject. (Rheumatism 2006; 21: 41-4)

The Performance of the Clinical Disease Activity Index in Patients with Rheumatoid Arthritis

Rezzan G�nayd�n, Alt�nay G�ksel Karatepe, Taciser Kaya — 2006-06-01

Objective: This study was performed in order to investigate the agreement between the Clinical Disease Activity Index (CDAI) which has been developed recently to observe the disease activity in patients with rheumatoid arthritis (RA) and the other indices which are the Simplified Disease Activity Index (SDAI) and DAS28, and to study the relation among the CDAI, acute phase reactants and functional status. Patients and Methods: 73 cases followed with the diagnosis of RA were enrolled in the study. The scores of the CDAI, the SDAI and DAS28 were calculated. The functional status was assessed with the Health Assessment Questionnaire (HAQ). The cases were assigned to the 20% of segments based on their scores of all three indices. The cases were also classified according to their levels of disease activity (remission, low, moderate, or high disease activity). The agreement among the CDAI, DAS28 and the SDAI were assessed with weighted kappa statistics, and the relation among the CDAI, ESR, CRP and functional status were examined using the Spearman's correlation analysis. Results: In the groups which were composed according to both the 20% of segments and the levels of disease activity, the agreement between the CDAI and DAS28 was assessed as “good” (κ = 0.765 and 0.705, respectively). The agreement between the CDAI and the SDAI were obtained as “excellent” in both groups (κ = 0.876 and 0.891, respectively). It is observed that a positive correlations among the CDAI, ESR, CRP and HAQ scores (r = 0.284 p = 0.015, r = 0.275 p = 0.018, r = 0.459 p = 0.000, respectively). Conclusion: It is concluded that the CDAI could be employed for determining the disease activity in patients with RA, especially in routine practice, in terms of acceleration for therapeutic decision making or changing for any time and anywhere, without requiring any calculator or laboratory assessment. (Rheumatism 2006; 21: 45-8)

The Role of Cytokines in Postmenopausal Osteoporosis; Relationship with Estrogen, Bone Density and Turnover Biomarkers

G�l Soykan, Peyman Yal��n — 2006-06-01

Objective: Estrogen deficiency probably induces increase of some cytokines (IL-1β, IL-2, IL-6, IL-8, TNF-α) that play role in bone resorption. The aim of our study was to determine the role of the cytokines in the etiopathogenesis of postmenopausal OP and its relationship with estrogen level, bone mineral density and bone turnover markers. Patients and Methods: The study group consisted of 108 subjects, 72 postmenopausal and 36 premenopausal women aged 30-85 years. The postmenopausal women were divided into 2 groups according to the presence of osteoporosis. Serum levels of cytokines (IL-1β, IL-2, IL-6, IL-8, TNF-α), estrogen, osteocalcin and urinary levels of deoxypyridinoline (DOP) were measured. Bone mineral density (BMD) of the lumbar spine and femur neck were measured by dual-energy X-ray absorbtiometry (DEXA). Results: Generally a decrease in estrogen level and an increase in cytokine production were observed in postmenopausal women. There was no significant differences between the groups with respect to levels of IL-1β, IL-2 ve IL-8 (p>0.05). The level of IL-6 was significantly higher in the osteoporotic group compared to the other groups (p<0.001). Postmenopausal women had higher values of TNF-α compared to the premenopausal women. There was no significant difference between the osteoporotic group and non-osteoporotic group (p>0.05). The groups didn't significantly differ with respect to serum estrogen and cytokine levels (p>0.05). In premenopausal women, a negative correlation was observed between IL-1β and lomber BMD values (r=-0.445, p=0.031). In postmenopausal osteoporotic group, a negative correlation was found between IL-1β and DOP levels (r=-0.423 p=0.016). Significant positive correlations were found between IL-2 (r=0.437, p=0.018), IL-6 (r=0.413, p=0.026) and osteocalcin in premenopausal women. Conclusion: It is concluded that levels of IL-6 abd TNF-α show an increase together with a decrease in estrogen levels in postmenopausal women. Cytokines however, don't seem to have relationship with the levels of estrogen, BMD and bone turnover markers. (Rheumatism 2006; 21: 49-55)

Comparison of Effectiveness of Methotrexate Monotherapy with Combination Therapy in The Patients with Rheumatoid Arthritis

�mit D�ndar, Deniz Evcik, Aycan T�rel, Vural Kavuncu — 2006-06-01

Objective: Substantial changes occurred in the treatment of rheumatoid arthritis (RA) after the mid 1990s. Disease modifying antirheumatic drugs (DMARD) were started earlier in the course of the disease with higher doses and combination as well as anti-cytokine therapies were preferred in the treatment of RA. The aim of this study was to compare effectiveness of methotrexate with combination therapy (methotrexate + other DMARD) in the patients with RA. Patients and Methods: Retrospectively 40 patients with a diagnosis of RA (according to American College of Rheumatology criteria) and at least one year of follow up, enrolled in this study. A total of 17 patients in the first group took methotrexate monotherapy for a year. There were 23 patients in the combination therapy group and they took combination therapy with two drugs (methotrexate + other DMARD) for a year. Patients were evaluated for clinical, and laboratory parameters at the beginning and after one year. Clinical parameters included number of swollen joints, number of tender joints and disease activity score (DAS) 28). Laboratory evaluation included erythrocyte sedimentation rate and C-reactive protein measurements. Results: DAS 28 score was 3.1 � 1.3 at the beginning and 2.85 � 1.1 after one year in the methotrexate group. DAS 28 score in combination therapy group was; 4.4 � 1.4 at the beginning and 2.88 � 1.1 after one year. DAS 28 score was significantly higher in combination therapy group than in methotrexate group at the beginning. But, after one year of therapy, DAS 28 scores were similar in both group. The change in DAS 28 scores after one year of therapy was significantly higher in combination therapy group. Conclusion: This study shows that combination therapy controls disease activity more successfully in the patients with RA when compared with methotrexate monotherapy. (Rheumatism 2006; 21: 56-9)

Methotrexate and Leflunomide in the Treatment of Rheumatoid Arthritis

Hatice Bodur — 2006-06-01

The treatment of rheumatoid arthritis has changed in the last ten years. Methotrexate is an antimetabolite drug and commonly used as the first disease modifying antirheumatic drug (DMARD). Its clinical efficacy and safety profile has been documented and it slows the development of radiological erosions. Leflunomide is also an antimetabolite drug and relatively new. In this review the efficacy, safety, mono and combination therapy of these drugs have been discussed. (Rheumatism 2006; 21: 60-6)

Principles of Treatment in Osteoarthritis

P�nar �zg�rsoy — 2006-06-01

Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability. The effective treatment of osteoarthritis is complex and subject to many treatment- and patient-related variables. The treatment includes nonpharmacologic modes of therapy as well as pharmacologic agents. In this review the treatment approaches will be discussed. (Rheumatism 2006; 21: 67-72)

Bilateral Femoral Neuropathy Due to Bilateral Iliopsoas Hematoma During Anticoagulation Therapy: A Case Report

Emel Ek�io�lu, Asl�han Sever, Ece �nl�, Ajda Bal, Ayt�l �akc� — 2006-06-01

Anticoagulation therapy is used for both therapeutic and prophylactic purposes that decreases the mortality and morbidity, but may lead to serious bleeding complications in some cases. One of these complications is femoral neuropathy that is an important clinical problem due to bleeding in iliopsoas muscle. Here we present a case that was diagnosed bilateral femoral neuropathy due to hematoma in iliopsoas muscles after anticoagulation therapy for deep vein trombosis. (Rheumatism 2006; 21: 73-5)

A Case with Seronegative Spondyloarthropathy: Ankylosing Spondylitis or Familial Mediterranean Fever?

Deniz D�lgero�lu, Canan Aybay, Eylem D.G. K�rb�y�k, Ay�eg�l Barlak, Sumru �zel — 2006-06-01

Familial Mediterranean Fever (FMF) is an inherited genetic disease characterized with recurrent episodes of fever, and attacks of peritonitis, pleuritis, and synovitis. It is mostly seen in Sephardic Jews, Armenians, Turks, and Arabic races. In this case report, we present a Turkish male patient who had been followed for long years with the diagnosis of ankylosing spondylitis (AS), and then it was found that he had episodes of fever and abdominal pain and investigated for FMF in our clinic. This patient, who had spondylitis and bilateral sacroiliitis, was investigated both for AS and FMF. He was HLA B27 negative, and his findings were not fully consistent with AS except for sacroiliitis. There was no formation of syndesmophytosis, which is characteristic for AS. In the genetic analysis performed, M694V mutation was found in Mediterranean Fever gene that is frequently seen in FMF. As a result, it was concluded that the patient was a FMF case with SNSA. It was observed that fever and abdominal pain attacks were less frequent, and complaints of joints were better with Colchicine and nonsteroidal antiinflammatory drug regime. In patients with spondylitiis, sacroiliitis and involvoment of great peripheral joints fever and abdominal pain attacks must be inquired. If these are present and if the patient is from an ethnic origin consistent with FMF, then FMF must be considered, and the patient must be investigated also for FMF along with AS. (Rheumatism 2006; 21: 76-9)

A Case of Pseudogout with Acute Polyarthritis

�mer Faruk �endur, G�lcan G�rer, Cavidan Ay — 2006-06-01

In this study, we report a case of pseudogout with acute polyarthritis. A 59 years old woman was admitted with multiple joint pain. Her plain radiographs of shoulder, hip, symphysis pubis and knee showed chondrocalcinosis. She was diagnosed as pseudogout and treated with colchicine upon the finding of high levels of erythrocyte sedimentation rate and C-reactive protein in laboratory assessment and calcium pyrophosphate dehydrate crystals (CPPD) in analysis of synovial fluid under polarized light microscopy. Her complaints regressed with treatment. Pseudogout disease has been revised in the context of this case and current literature. (Rheumatism 2006; 21: 80-3)