Журнал «Боль. Суставы. Позвоночник» Том 7, №4, 2017

N. Grygorieva, V. Povoroznyuk

State Institution “D.F. Chebotarev Institute of Gerontology of the NAMS Ukraine”, Kyiv, Ukraine

Introduction. Bone mineral density (BMD) and Trabecular bone score (TBS) are independent parameters of bone which are measured by DXA and effective para–meters that predict osteoporotic fractures risk. Fracture Risk Assessment Tool (FRAX^®) and adjusted FRAX by TBS are simple calculators which integrate clinical information regardless of BMD and assess the 10-years probability of osteoporotic fractures for major osteoporotic fractures (MOFs) and hip fracture (HF). Significance of these parameters confirmed in various studies, however, data in patients without osteoporosis with previous fractures are limited. The purpose was to study indices of FRAX^®, BMD, TBS and adjusted FRAX by TBS in postmenopausal women without osteoporosis with different types of fractures. Materials and methods. We examined 239 postmenopausal women aged 50 years and older without osteoporosis confirmed by DXA. Patients were divided into two groups depending on previous fractures. In addition, women with fractures were divided according fracture localization: vertebral fractures (VF; n = 64), Humerus fractures (HF; n = 18), Wrist fractures (WF; n = 35), Combined vertebral and peripheral fractures (CVPF; n = 34) and Combined peripheral fractures (CPF; n = 18). BMD and TBS were measured by X-ray absorptio–metry (DXA, Lunar, Prodigy), assessment of risk factors was performed by FRAX^® and adjusted FRAX by TBS. FRAX scores with BMD (FRAX/BMD) and body mass index (BMI) (FRAX/BMI) were calculated. Results. We found out that indices of FRAX/BMI-MOF were significantly higher for women independently from type of fractures, however, FRAX/BMI-HF were reliable higher only at women with VF and CVPF compare to parameters of group without previous fractures (WPF). Similar differences were observed in parameters of adjusted FRAX by TBS. In addition these indices at women with CVPF were significantly higher in comparison with same parameters in women with HF and WF, though they did not differ in comparison with indices at women with VF. Indices of FRAX/BMD-MOF were significantly higher at women independently from type of fractures, except for patients with HF, which did not differ from patients WPF. In addition, parameters of FRAX/BMD-HF were higher than same in patient WPF only for women with VF and CVPF. Conclusions. FRAX^® and adjusted FRAX by TBS are important indices for fractures risk assessment in postmenopausal women without osteoporosis with previous fractures which propose additional information without BMD measurement.

 

L.A. Holzer^{1, 2}, N. Huyer¹, J. Friesenbichler¹, A. Leithner¹

¹Department of Orthopaedic and Trauma, Medical University of Graz, Graz, Austria 

²AUVA Trauma Center Klagenfurt, Klagenfurt, Austria

Introduction. Patients with primary malignant bone tumors are facing different challenges in their everyday lives due to improved treatment and prolonged survival. This raises the question whether and to what extent their quality of life, body image and self-esteem is affected by their disease. The purpose of this retrospective study was to analyze the quality of life, body image and self-esteem of patients with primary malignant bone tumors compared to a healthy control group. Materials and methods. A total of 56 patients (39 male, 17 female; average age 33.80 ± 14.29 years) who were treated with either osteosarcoma or Ewing-Sarcoma at the authors’ institution between Jan 1989 and May 2015 were included into the study (mean follow up: 9.1 ± 6.6 years). The control group consisted of 58 (average age 24.4 ± 3.1 years, 31 male, 27 female) healthy medical students. Standardized questionnaires were used to assess quality of life (SF-36), body image (MBSRQ) and self-esteem (RSE-scale). Student t-tests were used for statistical analysis. Results. Quality of life (SF-36) (in physical categories) and body image (MBSRQ) was significantly lower in patients with primary malignant bone tumors compared to healthy cohort (p < 0.001). Self-esteem was not affected in patients and did not show any difference compared to control group (23.96 vs 24.00). Conclusions. Physical categories of qua–lity of life and body imagesensation of patients with primary malignant bone tumors are worse compared healthy controls. However, self-esteem does not seem to be affected by the condition and its management. 

 

Z. Killinger, L. Gajdarova, M. Kužma, A. Krajcovicova, K. Brazdilova, P. Jackuliak, J. Payer

Comenius University Faculty of Medicine, 5th Department of Internal Medicine, University Hospital Bratislava, Bratislava, Slovakia

Introduction. Patients with rheumatoid arthritis (RA) are at greater risk of osteoporosis (OP) and fracture than the general population. The most important factor involved in the pathogenesis is the inflammation. Thus, inhibition of TNF may influence activity of RA as well as bone mineral density (BMD). Decreased BMD not entirely explains the fracture risk in RA patients. Past few years, trabecular bone score (TBS) is promising method for assessment of bone quality and risk of fracture. Purpose. To compare the effects of biological disease-modifying antirheumatic drugs (bDMARDs) to conventional synthetic DMARDs (methotrexate) on BMD and TBS in patients suffering from active RA. Materials and methods. A 12-month prospective trial was performed in 105 patients with active RA. The cohort was divided into two groups: group 1 (n = 84, mean age 54 yrs) treated with bDMARDs (anti TNF and IL 6 blockers) and group 2 (n = 21, mean age 53 yrs) treated with non-biological DMARDs (Methotrexate). There was no significant difference in baseline characteristics between both groups observed. The mean daily dose of glucocorticoids (GC) was 6.2 mg vs 6.6 mg between group 1 vs 2 (NS), respectively. Patients with bisphosphonates or other antiporotic treatment were not included. All patients were admi–nistered with calcium (600 mg) and vitamin D (800 IU). The BMD at lumbar spine (LS), femoral neck (FN) were measured at baseline and after 1 year of treatment by dual energy X-ray absorptiometry (DXA, Hologic). TBS was performed by TBS Insight software (Medimaps,France) from LS DXA scans. Results. Treatment with bDMARDS led to increase of 1.7 % (p < 0.05) in TBS and levels of osteocalcin of 26 % (p < 0.001) but not on BMD and CTx after one year of treatment. The greatest TBS increase was observed in premenopausal females within group 1. No effect of ccsDMARDS (Methotrexate ) treatment on TBS and BTM but slight decrease of BMD was observed. Conclusions. The main finding of this study was increase of TBS but not BMD in patients on bDMARDS, whereas in the group on ccsDMARDS no effect on TBS and slight decrease BMD was observed. Treatment with DMARDs seems to be effective in decreasing the risk of future osteoporotic fracture among patients with RA, especially in premenopausal females.

 

M. Kužma¹, P. Vaňuga², N.Binkley³, I. Ságová⁴, D. Pávai², P. Blažíček⁵, Z. Kužmová¹, P. Jackuliak¹, A. Vaňuga², Z. Killinger¹, J. Payer¹

¹Comenius University Faculty of Medicine, 5th Department of Internal Medicine, University Hospital Bratislava, Slovakia

²National institute of Endocrinology and Diabetology, Lubochna, Slovakia 

³Department of Medicine, University of Wisconsin, Madison, Wisconsin, United States of America

⁴Comenius University Jessenius Faculty of Medicine, 1th department of Internal Medicine, University Hospital Martin, Slovakia

⁵Private laboratory 4vive, Bratislava, Slovakia

Introduction. Multiple chemokines are important in osteoclastogenesis. Thus, chemokine called fractalkine may be an important factor linking thyroid status and bone remodeling as fractalkine gene expression is affected by tetrac, a derivative of thyroxine. Purpose. To assess the relationship between serum fractalkine levels, thyroid hormones and bone parameters in premenopausal females with active and cured Graves’ disease (GD) in comparison to healthy controls. Materials and methods. A case-control study pre-menopausal women with GD was conducted. The study sample consisted of three patients groups: active-treatment naive GD; cured GD and healthy age, gender and BMI-matched controls. In all study subjects, fractalkine serum levels (Quantikine ELISA), total amino-terminal peptide of procollagen type 1 (P1NP), CTx (β-crosslaps), thyroid hormones, calcium and intact parathyroid hormone (iPTH) were measured. Each subject had BMD and TBS measurement performed. Results. Totally, 60 subjects (21; 16 and 23 subjects in active GD, cured GD and healthy control groups, respectively) were included. Fractalkine levels were higher within active and cured GD subjects in comparison to healthy controls (mean 0.70 ± 0.14; 0.93 ± 0.15; 0.48 ± 0.13 ng/mL; p < 0.05, respectively). There was no difference in FN BMD among study groups. LS BMD was lowest in the cured GD group in comparison to active GD and control group subjects (0.926 ± 0.030; 1.016 ± 0.030; 1.051 ± 0.030 g/cm2; p < 0,05, respectively ). The TBS in active GD patients were lower than in cured GD patients, with the highest values observed among healthy controls (1.395 ± 0.020; 1.402 ± 0.020, 1.469 ± 0.020; p < 0.05, respectively). There was a postitive relationship between fT4, fractalkine, P1NP and CTx and negative between fractalkine, a-TSH and TBS values observed. Conclusions. Active GD in pre-menopausal females is associated with increased levels of fractalkine and decreased TBS, but not BMD, proving that osteoblast-induced osteoclastogenesis, as measured by fractalkine levels, leads to detoriation of trabecular microarchitecture.

 

V. Povoroznyuk 

State Institution “D.F. Chebotarev Institute of Gerontology of the NAMS Ukraine”, Kyiv, Ukraine

Introduction. Vitamin D deficiency is prevalent in all the world countries. Recent studies show the correlation between Vitamin D deficiency and musculoskeletal disorders. The purpose of this study is to examine 25(ОН)D level, Vitamin D deficiency and insufficiency prevalence in patients of various ages who have musculoskeletal disorders, and to reveal the influence of seasonal factors on these conditions. Materials and methods. 3460 patients of the Ukrainian Scientific-Medical Center of Osteoporosis Problems, aged 1 to 92 years, who were referred by other specialists to the Center for bone state evaluation, were examined. Their predominant group was made by patients with systemic osteoporosis and its complications, spinal osteochondrosis, knee and hip osteoarthritis (mean age — 52.9 ± 21.1 years). Among them, women took over (83.5 %), their mean age being 55.6 ± 19.4 years, while men’s mean age was 38.6 ± 17.3 years (р < 0.001). 25(ОН)D and PTH analyses were performed by means of electrochemiluminescent method (Elecsys 2010 analyzer, Roche Diagnostics, Germany) and cobas test-systems. “Statistica 6.0” software package (Copyright StatSoft, Inc. 1984–2001) was also applied. Results. Among the patients with bone-muscular pathology, the highest 25(ОН)D level was noted in the age group of 1–9 years (30.6 ± 15.1 ng/ml) and the lowest — in the age group of 80 and over (20.4 ± 11.4 ng/ml). Age negatively influenced 25(ОН)D concentration values. Prevalence of vitamin D deficiency among the patients with bone-muscular pathology was 37.3 %, vitamin D insufficiency — 30.6 %, normal vitamin D status — in 32.1 %. Normal 25(OH)D concentration was found in 38.0 % of children, 33.2 % of adults and in 29.6 % of elderly patients. Month of blood-sampling had a significant influence on 25(ОН)D concentration values (F = 7.49, p < 0.0000001). The highest 25(ОН)D concentrations were observed in August (28.6 ± 11.4 ng/ml) and September (28.6 ± 11.6 ng/ml), the lowest — in February (23.1 ± 11.6 ng/ml) and March (23.4 ± 11.3 ng/ml). Children had the lowest 25(ОН)D concentration in February (20.8 ± 10.9 ng/ml), and the highest in August (35.7 ± 11.1 ng/ml); adults had the lowest in February (23.5 ± 12.0 ng/ml) and in March (23.1 ± 10.4 ng/ml), and the highest in August (30.4 ± 10.8 ng/ml) and September (29.9 ± 11.1 ng/ml); elderly people had the lowest 25(ОН)D concentrations in February (23.1 ± 11.3 ng/ml) and in March (23.3 ± 11.0 ng/ml), and the highest in September (26.7 ± 11.1 ng/ml). The highest significant differences in 25(ОН)D concentrations during the summer vs. winter months were observed in the age groups of 10–19 years (18.2 %), 40–49 years (17.3 %), 30–39 years (16.2 %) and 1–9 years (16.1 %). There were no significant seasonal differences observed in the elderly patients (60 years and older) with musculoskeletal pathology. Conclusions. Despite the combined calcium and vitamin D supplementation utilized by most patients with a bone-muscular pathology, only 37.9 % of children, 33.2 % of adults and 29.6 % of the elderly people had normal 25(ОН)D concentration values and thus required screening examination of vitamin D level in patients with musculoskeletal disorders and additional vitamin D prescriptions (Guidelines for the Central and Eastern Europe).

 

V. Povoroznyuk, N. Dzerovych, R. Povoroznyuk

State Institution “D.F. Chebotarev Institute of Gerontology of the NAMS Ukraine”, Kyiv, Ukraine

Introduction. Sarcopenia is a geriatric syndrome characterized by an age-related reduction in muscle mass, strength and performance. The frequency of sarcopenia affecting the Ukrainian women aged 65 yrs and older is 21.3 % (Povoroznyuk V., 2017); however, there are many underlying causes of age-related skeletal muscle mass loss. Recent studies attest to a strong connection of dietary peculiarities and body composition of elderly people (Evans W.J., 2004; Campbell W.W., 2007; Lord C. et al., 2007; Bopp M.J. et al., 2007; Cruz-Jentoft A.J. et al., 2010; Morley J.E. et al., 2010; Budul S.L., 2015). In this context, protein with its prominent dietary status gains an especial standing as far as the older population’s health is concerned. There has also been a number of studies exa–mining associations among skeletal muscles and vitamin D, as well as androgens and growth hormone (Di Monaco M., 2011; Cruz-Jentoft A.J., 2010; Buehring B., Binkley N., 2013; Yuki A. et al., 2015; Cangussu L.M., 2015). The purpose of the study was to study the risk factors (dietary protein intake, vitamin D, growth hormone (GH), total and free testosterone level (TT, FT)) of sarcopenia in Ukrainian postmenopausal women. Materials and methods. To evaluate the connection between appendicular lean mass (ALM) and dietary protein intake we have examined 63 women aged 52–89 yrs (mean age — 68.46 ± 9.26 yrs). For the purpose of studying the correlation between skeletal muscles and vitamin D level 87 healthy women aged 45–83 yrs were examined (mean age — 66.29 ± 8.35 yrs). To study the correlation between skeletal muscles and GH, TT, FT level, 42 healthy women aged 60–86 yrs (mean age — 70.62 ± 6.97 yrs) were examined. To assess the dietary habits of women, we used a three-day sampling method. Lean mass was evaluated using Dual X-ray absorptiometry (Prodigy, USA). Strength of skeletal muscle was evaluated using springy carpal dynamometer, the functional capacity of skeletal muscle — by «four-meter» test. To determine the level of 25(OH)D, GH, TT and FT electrochemiluminescent method was used. Results. Women of 80–89 yrs consuming less than 1.0 grams of protein per 1 kg of body weight accounted for more than a half of their group (57.1 %). Significant correlations among dietary protein, aminoacids and ALM index values (p < 0.01) were determined. We determined a significant correlation between parameters of lean mass (p = 0.05) and vitamin D level; skeletal muscle functionality (p = 0.04) and vitamin D level. Significant correlation between ALM and level of GH (60–74 yrs: r = 0.36; 60–89 yrs: r = 0.31), between strength of skeletal muscle and level of TT (75–89 yrs: r = 0.55; 60–89 yrs: r = 0.32), FT (75–89 yrs: r = 0.31), GH (75–89 yrs: r = 0.35; 60–89 yrs: r = 0.32); between function of skeletal muscle and level of TT (75–89 yrs: r = 0.46), FT (75–89 yrs: r = 0.48) was found. Conclusions. Significant correlation between parameters of lean mass, skeletal muscle strength, functionality and dietary protein intake, vitamin D, GH, TT and FT level was determined in the Ukrainian postmenopausal women.

 

V. Povoroznyuk¹, O. Puzanova²

¹State Institution “D.F. Chebotarev Institute of Gerontology of the NAMS Ukraine”, Kyiv, Ukraine

²Bogomolets National Medical University, Kyiv, Ukraine

Introduction. Evidence-based medicine (EBM) movement in Ukraine began in the early 2000s. Then, taking into account priority of both disease prevention and primary health care (PHC) development as national strategy, the concept of evidence-based prevention in health care and the system of its implementation were substantiated. The purpose of the research was to identify problems of the implementation of evidence-based management of patients with musculoskeletal disorders (MSDs), especially in PHC. Materials and methods. The study involved electronic and printed sources of EBM, incl. systematic reviews (SRs) from the Cochrane Collaboration website (n = 300, as 6 samples of the top-50); totalities of the recommendations of the USPSTF (n = 187) and CTFPHC (n = 62); contents of the TRIP Database and its categories; adapted clinical recommendations (n = 50) from the Register of medical standardi–zation in the system of the Ministry of health of Ukraine; questionnaires for Kyiv PHC doctors (n = 252, the sample population) and for the officials (n = 30) that were responsible for conducting trainings on EBM. We used systemic approach, content-analysis, methods of medical statistics, expert assessments, sociological method as well. Results. 1. Conducted analysis of structure, content and dynamics of referrals to the most popular SRs revealed a 3,9-fold increase of the number of their downloads during 2011–2013. High interest to EBM-managing of MSDs (incl. surgical aspects) has been proved: the share of such SRs in the structures of top-50 was up to 18 %. 2. Having analyzed the TRIP Database content, we confirm expediency of use it for evidence support of managing patients with MSDs: from 2012 to 2014 the number of documents in category «Orthopedics» increased 10,5 times, in «Rheumatology» — 8.1 times, on these issues in category «Primary care» — 3.1 and 5.1 times respectively. 3. The share of papers on MSDs in the structures of the USPSTF and CTFPHC recommendations turned out to be small — 3.9 and 5.8 % respectively. The category MSDs of the USPSTF recommendations includes 4 papers of 2004–2012. Most of them (75 %) are devoted to screening: «Idiopathic scoliosis in adolescents»,«Developmental hip dysplasia», «Osteoporosis», and 25 % — to counseling and medication «Falls prevention in older adults» (topics of the CTFPHC recommendations are similar). There are no statements of grade A in these papers, and only 2 statements of grade B which recommend screening on osteoporosis in women older than 65 years as well as offering exercise or physiotherapy and vitamin D supplementation for falls prevention in older adults. 4. Only 1 adapted clinical recommendation developed in Ukraine since 2012 was devoted to MRDs (namely to rheumatoid arthritis, based on the EULAR and NICE recommendations). Neither the Cochrane Collaboration website, nor the USPSTF and TRIP data have been used as a source of national medical standards development. 5. Based on the results of our sociological studies, we revealed some needs as to quality of staffing and technical support of EBM-management in PHC. Much attention should be paid to problem of routine use of diagnostic tests in populations with low pre-test probability of MSDs. The respondents have shown a predominantly low level of knowledge and of self-assessment of it on EBM-methodology (64.7 ± 3.0 % of them). Most doctors (77.8 ± 2.6 %) noted the high need for trainings on information support and methodology of EBM. Conclusions. Common and specific for Ukraine problems of implementation of EBM-managing of the patients with MSDs especially in PHC, as well as the needs to improve its information and staffing support are identified in the study.

 

U. Renner, M. Kužma, C. Muschitz, J. Haschka, D. Kirchdörfer, J. Payer, H. Resch, R. Kocijan

St. Vincent Hospital — Medical Department II, The VINFORCE Study Group, Academic Teaching Hospital of Medical University of Vienna, Austria 

Comenius University Faculty of Medicine, 5th Department of Internal Medicine, University Hospital Bratislava, Slovakia 

Introduction. Hypophosphatasia (HPP) is a rare genetic bone disease caused by low levels of tissue non-specific alkaline phosphatase (TNSALP) leading to defects in bone mineralization. Consequently HPP is characterized by stress fractures with poor healing, bone deformities and extra-skeletal manifestations. To date, no data regarding bone microstructure, one of the main components of bone strength, are available in HPP. Materials and methods. Twenty-one adult patients with clinical HPP were examined (9 genetically tested, 6 male, 15 female, mean age 50.7 ± 12.8 yrs). Children were excluded from the analysis. Microstructure and volumetric bone mineral density (vBMD) were assessed by HR-pQCT (SCANCO Medical) at the ultra-distal radius and tibia. Total, trabecular and cortical vBMD (mgHA/cm3) were evaluated. Microstructure analysis included the trabecular bone volume fraction (BV/TV), trabecular number (Tb.N, 1/mm), trabecular thickness (Tb.Th, mm), cortical thickness (Ct.Th, mm) and cortical porosity (Ct.Po, %). Areal BMD (aBMD) by DXA and TBS as well as bone turnover markers (BTM) were measured. Data were compared to a healthy, age and gender-matched control group (CTRL, 15 female, 6 male, mean age 52.8 ± 14.1 years). In addition, correlations between demographic data, TNSALP, BMD and microstructure were carried out. Results. TNSALP was decreased in all HPP patients (mean 26.0 ±12.7 U/L), Pyridoxal phosphate was elevated (mean 478.9 ± 836.7 μ/l). A positive family history for HPP was found in 50 % of HPP patients. Bone turnover markers, Calcium and Phosphate were in normal range in all HPP patients. Vitamin D deficiency (< 30 ng/ml) was found in 19 % of HPP patients. Tb.Th was significantly lower in HPP than in CTRL. All other trabecular and cortical bone microstructure parameters as well as vBMD were comparable between HPP and CTRL at both measuring sites. High aBMD at the lumbar spine (T-score +5.6) was found in 1 patient with HPP. aBMD at the lumbar spine was similar in HPP and controls whereas aBMD values at the hip were lower in HPP by trend. TBS was above the reference range (> 1.250) in all HPP patients and comparable to CTRL. TNSALP was not correlated to parameters of bone microstructure or bone mineral density. Conclusions. Trabecular thinning is the most conspicuous finding in bone microstructure in HPP. Established bone turnover markers besides TNSALP P do not reflect the increased fracture risk in adult patients with HPP. A wide range of aBMD values was found in HPP, but it was seen that aBMD is lower at the hip — but not the spine — in HPP.

 

L. Yankovskaya, V. Snezhitskiy, T. Stepuro

Grodno State Medical University, Grodno, Belarus

The purpose of the study was to perform a comparative analysis of the frequencies of the genotypes by the alleles BsmI (B/b) (rs1544410) and FokI (F/f) (rs2228570) of the VDR gene in patients with cardiovascular pathology of Grodno region in comparison with the genotypes of ethnic Belarusians living in six regions of Belarus. Materials and methods. 182 patients aged from 30 to 79 years were examined, 100 of them with arterial hypertension (AH) II degree and 82 with ischemic heart disease (IHD) in combination with AH II degree. The determination of BsmI and FokI of the VDR gene was performed by polymerase chain reaction. For comparison, the results of analysis of the genotypes of 719 ethnic Belarusians, including the Western region, were used. Statistical analysis was carried out by Statistica 10.0 software. Results. The heterozygous genotype at both polymorphic loci of BsmI and FokI of VDR gene was found with the greatest frequency. Genotypes BB and ff were encountered with the lowest frequency (p < 0.0001) both among patients and in the population, including Western population. Genotype bb and allele b were more frequent (p < 0.05) among patients (41.2 and 63.2 %, respectively) and in the Western region (42.9 and 65.3 %, respectively) than in the general population (31.4 and 56.7 %, respectively). Homozygous genotype BBff associated with the expression of the less active form of VDR was found with the lowest frequency, both among patients and in the population, including Western populations. Genotype bbFF associated with the expression of a more active form of VDR was more common in patients with IHD 17.1% than in the entire population of Belarus — 8.8 % (p = 0.02) and more often than in the Western population 6.7 % (p = 0.04). The most common among Western region Belarusians bbFf genotype — 28.1 %, was less common among patients with AH — 16.0% (p = 0.047) and IHD — 13.4 % (p = 0.017). Genotype bbff was more common among the whole group of patients — 12.1% (p = 0.005) and among patients with AH — 15.0 % (p = 0.001) than in the entire population of Belarusians — 5.7 %. Residents of Grodno region with genotype bbff of VDR gene have an increased risk of cardiovascular pathology (OR = 2.3 (95% CI 1.32–3.93) and AH developing (OR = 2.92 (95% CI 1.55–5.496), and those with genotype bbFF of VDR gene also have an increased risk of cardiovascular pathology (OR = 1.74 (95% CI 1.06–2.83) and IHD developing (OR = 2.14 (95% CI 1.14–4.03). Conclusions. Significant diffe–rences in frequency distribution of genotypes BsmI and FokI of the VDR gene in patients with cardiovascular pathology of Grodno region from general population data and an increased risk of development of AH/IHD in genotypes bbff and bbFF of VDR gene have been established.