MON-356 Atypical Femur Fracture with Denosumab

Abstract Background: Osteoporosis (OP) is a systemic disease that is associated with increased risk for fractures. Anti-resorptive medications (ARM) are an effective modality for treatment and prevention of fractures in OP. Long-term use of ARM like bisphosphonates (BP) is associated with increased risk of atypical femoral fractures (AFF). Denosumab (DM) is monoclonal antibody that targets receptor activator of nuclear factor KB ligand (RANKL). A few cases of AFF with DM have been reported in patients who have previously been on long term BP therapy. We present a case where the patient had only received two zoledronic acid (ZA) infusions, last one three years prior to being initiated on DM and experienced AFF. Case: 73-year-old postmenopausal woman presented to the emergency room with sudden onset pain in the right thigh. Patient was standing and reaching into her closet when she felt a snap in right thigh followed by inability to move the right leg or bear weight on it. X-ray of the right femur showed a displaced femoral shaft fracture with a short transverse fracture line and a spike, without comminution. History was significant for OP for which she received raloxifene for a couple of years followed by ZA in 2013 and 2015 by her primary care. Fracture history was significant for a wrist fracture in 2015, and T12 and L1 fractures in 2017 from coughing while on Medrol dospak for an acute episode of bronchitis. In 2017, bone density showed L1-L4 T score of -2.0, the left total hip T score was -1.8 and left femoral neck T score was -2.5 consistent with OP. Work up for secondary causes of OP was unremarkable. Due to recent T12 and L1 compression fractures, she was recommended DM. She received DM in June 2018 as she was undergoing a dental implant followed by December 2018 and June 2019 and presented with the right femoral fracture in November 2019. Past history was significant for idiopathic pulmonary fibrosis which had been relatively stable without need for long-term steroid therapy. History was negative for diabetes or kidney disease. Menarche was at age 14, menopause at 52 and she did not take any hormone replacement therapy. She underwent surgical fixation with intramedullary rod. Due to concern about ARM associated sub-trochanteric fracture in the right femur, left femur was imaged. She had cortical beaking in the distal third of the left femur, and underwent prophylactic medullary nailing of the left femur as well. Conclusion: AFF are an uncommon complication of ARM used for OP. Not many cases of AFF have been reported with the use of DM and most of the reported cases are associated with prolonged BP therapy. Our case is unusual in that AFF occurred in the absence of prolonged BP therapy and raises concern that a couple of ZA infusions in the past can also increase the risk of AFF. Clinicians need to have a high index of suspicion and may consider doing femur x-rays in patients who have previously been on BP prior to starting DM.

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Bilateral Psoas Haematomata Complicating Renal Transplantation

Surgery Research and Practice ◽

10.1155/2014/678979 ◽

2014 ◽

Vol 2014 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Jacob A. Akoh ◽

Tahawar A. Rana ◽

Daniel Higgs

Keyword(s):

Renal Transplantation ◽

Past History ◽

Postoperative Bleeding ◽

Cerebrovascular Event ◽

Heparin Infusion ◽

Prolonged Hospitalisation ◽

Increased Risk ◽

Living Donor Transplantation ◽

History Of

Background. The challenge in managing patients undergoing renal transplantation is how to achieve optimum levels of anticoagulation to avoid both clotting and postoperative bleeding. We report a rare case of severe postoperative retroperitoneal bleeding including psoas haematomata complicating renal transplantation.Case Report. SM, a 55-year-old female, had a past history of aortic valve replacement, cerebrovascular event, and thoracic aortic aneurysm and was on long-term warfarin that was switched to enoxaparin 60 mg daily a week prior to her living donor transplantation. Postoperatively, she was started on a heparin infusion, but this was complicated by a large retroperitoneal bleed requiring surgical evacuation on the first postoperative day. Four weeks later, she developed features compatible with acute femoral neuropathy and a CT scan revealed bilateral psoas haematomata. Following conservative management, she made steady progress and was discharged home via a community hospital 94 days after transplantation. At her last visit 18 months after transplantation, she had returned to full fitness with excellent transplant function.Conclusion. Patients in established renal failure who require significant anticoagulation are at increased risk of bleeding that may involve prolonged hospitalisation and more protracted recovery and patients should be carefully counselled about this.

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Radiofrequency Multi Echographic Spectrometry (REMS) Technology in Patients With Bone Artifacts

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.507 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A249-A249

Author(s):

Maria Dea Tomai Pitinca ◽

Carla Caffarelli ◽

Stefano Gonnelli

Keyword(s):

Lumbar Spine ◽

Femoral Neck ◽

Bone Fracture ◽

Gamma Nail ◽

Mineral Density ◽

Left Femur ◽

Diagnosis Of Osteoporosis ◽

T Score ◽

Femoral Site ◽

The Right

Abstract Introduction: Dual-energy X-ray Absorptiometry (DXA) is considered the gold standard examination for the evaluation of bone mineral density (BMD). However, it is known that some conditions, such as arthrosis, vertebral collapse, or vertebroplasty, result in an overestimation of the BMD measured by DXA. Conversely, Radiofrequency Echographic Multi-Spectrometry (REMS) technology is able to automatically discard signals related to bone artifacts, such as calcifications or osteophytes, thanks to the identification of unexpected spectral features (Diez-Perez et al. 2019). The aim of this work is to assess the performance of REMS technology in patients with bone alterations that could alter the densitometric examination. Materials: The bone densitometry exams, both REMS and DXA, of patients with evidences of bone alterations at lumbar vertebrae or femoral neck were analysed. Written patient informed consent was obtained before the scans. Results: Eighty-seven patients with spinal artifacts, including 22 patients with vertebroplasty, 26 patients with bone fracture and 38 patients with osteo-arthrosis were considered. At lumbar spine, the mean BMD and T-score values assessed by REMS was lower than the ones measured by DXA. Moreover, the results obtained by the two technologies were not correlated. On the contrary, the BMD and T-score values measured by REMS and DXA at the femoral site were highly correlated (p<0.01), as well as BMD and the T-score values measured by DXA at the femoral neck and by REMS at the lumbar spine (p<0.01). As concerning artifacts involving femoral site, a patient with an intramedullary gamma nail positioned following a displaced pertrochanteric fracture of the left femur underwent a DXA scan of the right femur and a REMS scan of both femurs. A diagnosis of osteoporosis at the right femur was posed by both technologies. At the left femur with intramedullary gamma nail, REMS only made a diagnosis of osteoporosis highly corresponding with the one performed at right femur. Conclusions: The results from the patient series with spinal artifacts and the clinical case with femoral intramedullary gamma nail show the ability of REMS to evaluate anatomical sites that would not be assessable by DXA, such as in case of implanted nails, or that would give unreliable higher BMD values, such as in case of vertebroplasty, osteo-arthrosis and bone fracture. References: Diez-Perez et al. Aging Clin Exp Res 2019;31(10):1375–89

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Acute blue finger syndrome: a rare benign cause of acute digit discolouration

BMJ Case Reports ◽

10.1136/bcr-2017-223365 ◽

2019 ◽

Vol 12 (1) ◽

pp. e223365

Author(s):

Kiran Dhaliwal ◽

Colin Thomas Brewster ◽

Sivarajasingham Pakeerathan

Keyword(s):

Rapid Assessment ◽

Middle Finger ◽

X Rays ◽

Benign Condition ◽

Volar Aspect ◽

History Of ◽

The Right ◽

Digital Ischaemia ◽

First Time

Acute blue finger syndrome is a rare benign condition that mimics digital ischaemia. We discuss the case of a 32-year-old woman who presented with a 6hour history of blue discolouration of the middle finger of the right hand, associated with pain and swelling. There was no history of trauma and this was the first time that the patient had experienced these symptoms. Examination found blue discolouration of the digit primarily on the volar aspect with associated swelling. All investigations, including blood tests, X-rays and Doppler scanning, were normal. The symptoms resolved spontaneously within 48 hours. There were no recurrent episodes or long-term sequelae. Patients presenting with an acutely blue finger need rapid assessment to exclude digit ischaemia. Knowledge of this rare benign condition may prevent unnecessary distress, invasive investigations and potentially harmful treatment of a healthy patient.

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Bisphosphonate-Induced Periprosthetic Fracture: A Cause of Painful Total Hip Arthroplasty

Case Reports in Surgery ◽

10.1155/2014/631709 ◽

2014 ◽

Vol 2014 ◽

pp. 1-3 ◽

Cited By ~ 3

Author(s):

Rahul Bhattacharyya ◽

Stephanie Spence ◽

Gavin O’Neill ◽

Kumar Periasamy

Keyword(s):

Periprosthetic Fracture ◽

Weight Bearing ◽

Femoral Shaft ◽

Interesting Case ◽

X Rays ◽

Mri Scan ◽

Total Hip ◽

Important Addition ◽

The Right

Background. Cases have been reported in the literature of periprosthetic fractures associated with the use of bisphosphonates occurring in the long term following a Total Hip Replacement (THR). We report an interesting case of periprosthetic fracture secondary to bisphosphonate use only a few months after a THR.Case Report. A 72-year-old lady (on bisphosphonates for 10 years) underwent a THR for osteoarthritis. She was pain-free in the first four months postoperatively. Thereafter, she developed spontaneous onset of pain in the lateral aspect of her thigh and groin and found it difficult to weight-bear. X-rays and blood tests were unremarkable. An ultrasound and MRI scan showed no evidence of effusion/collection or periprosthetic fracture. A radionuclide bone scan showed an abnormal appearance of the right femoral shaft. A subsequent CT scan showed an oblique vertical split on the anterior surface of the upper right femoral shaft. This stress fracture was managed nonoperatively with protected weight bearing. She has progressed well with good clinical and radiological signs of fracture healing.Conclusion. This case is an important addition to our knowledge that bisphosphonate-induced periprosthetic stress fractures can be a cause of hip pain only a few months following a THR.

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Comorbidities in patients with non-functioning pituitary adenoma: influence of long-term growth hormone replacement

Acta Endocrinologica ◽

10.1530/eje-18-0370 ◽

2018 ◽

Vol 179 (4) ◽

pp. 229-237 ◽

Cited By ~ 1

Author(s):

Casper Hammarstrand ◽

Oskar Ragnarsson ◽

Olivia Bengtsson ◽

Ing-Liss Bryngelsson ◽

Gudmundur Johannsson ◽

...

Keyword(s):

Growth Hormone ◽

Cerebral Infarction ◽

Malignant Tumors ◽

Hormone Replacement ◽

Normal Incidence ◽

Growth Hormone Replacement ◽

Growth Hormone Replacement Therapy ◽

Increased Risk ◽

National Patient

Background Patients with hypopituitarism have an increased mortality. The aim of this study was to investigate comorbidities including cerebral infarction, type 2 diabetes mellitus (T2DM) and malignant tumors in patients with non-functioning pituitary adenomas (NFPA) with and without growth hormone replacement therapy (GHRT). Methods Observational cohort study in patients with NFPA within the western region of Sweden. Subjects were identified through the National Patient Registry and followed between 1987 and 2014. Patient records were reviewed and standardized incidence ratios (SIRs) with 95% CIs for comorbidities were calculated. Results In total, 426 patients were included, 206 with GHRT and 219 without. Median (range) follow-up time for patients with and without GHRT was 12.2 (0–24) and 8.2 (0–27) years, respectively. Mean ± s.d. BMI was 28.5 ± 4.5 and 26.5 ± 4.4 for patients with and without GHRT, respectively (P < 0.001). Incidence of cerebral infarction was increased (SIR: 1.39; 95% CI: 1.03–1.84; P = 0.032), with no difference between patients with and without GHRT. SIR for T2DM in patients not receiving GHRT was increased (1.65; 1.06–2.46; P = 0.018), whereas the incidence in patients receiving GHRT was not (0.99; 0.55–1.63; P = 0.99). The incidence of malignant tumors was not increased, either in patients with or without GHRT. Conclusion The incidence of cerebral infarction is increased in patients with NFPA irrespective of GHRT. Patients without GHRT had an increased risk of T2DM, whereas patients with GHRT had a normal incidence of T2DM, despite having higher BMI. Incidence of malignant tumors was not increased. Thus, long-term GHRT seems to be safe regarding risk of comorbidities.

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A Rare Presentation of Coeliac Disease; Intractable Itching with Recurrent Heart Attack and Dermatitis Herpetiformis

Asthma Allergy Immunology ◽

10.21911/aai.616 ◽

2021 ◽

Vol 19 (3) ◽

pp. 186-190

Author(s):

Sumeyra ALAN YALIM ◽

Betül DUMANOĞLU ◽

Merve POYRAZ ◽

Gulistan ALPAGAT ◽

Ayse BAÇÇIOĞLU ◽

...

Keyword(s):

Myocardial Infarction ◽

Coeliac Disease ◽

Dermatitis Herpetiformis ◽

Normal Population ◽

Systemic Disease ◽

Rare Presentation ◽

St Segment Elevation ◽

Increased Risk ◽

Important Symptom ◽

The Right

Coeliac disease (CD) is a systemic disease of the unwarranted immune reaction to gluten and is associated with a 10% increased risk of cardiovascular disease. Here we present a patient with recurrent myocardial ischemia and intractable itching who was eventually diagnosed with CD. A 53-year-old man presented to the allergy department due to intractable itching that was resistant to antihistamine therapy. In addition, despite successful percutaneous intervention with stent implantation to the right coronary artery, there was an ST segment elevation with myocardial infarction (MI) in the lower wall that had occurred three times. After dermatitis herpetiformis was reported as a result of the biopsy performed from the lesions, duodenal biopsy confirmed the diagnosis of CD. Diagnosis of CD with atypical presentation can be difficult. Cardiovascular risk is increased in patients with celiac disease compared to the normal population. Itching is an important symptom that needs to be evaluated in detail, even without the typical gastrointestinal manifestations of CD. Keywords: Allergy, coeliac disease, dermatitis herpetiformis, myocardial infarction, omalizumab, recurrent stenosis

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Efficacy and Safety of Biologics for Psoriasis and Psoriatic Arthritis and Their Impact on Comorbidities: A Literature Review

International Journal of Molecular Sciences ◽

10.3390/ijms21051690 ◽

2020 ◽

Vol 21 (5) ◽

pp. 1690 ◽

Cited By ~ 8

Author(s):

Masahiro Kamata ◽

Yayoi Tada

Keyword(s):

Psoriatic Arthritis ◽

Safety Profile ◽

Skin Disease ◽

Systemic Disease ◽

Efficacy And Safety ◽

Disease Impact ◽

The Right ◽

The Impact

Psoriasis is a chronic inflammatory skin disease characterized by scaly indurated erythema. It impairs patients’ quality of life enormously. It has been recognized not only as a skin disease but as a systemic disease, since it also causes arthritis (psoriatic arthritis) and mental disorders. Furthermore, an association with cardiovascular events is indicated. With the advent of biologics, treatment of psoriasis dramatically changed due to its high efficacy and tolerable safety. A variety of biologic agents are available for the treatment of psoriasis nowadays. However, characteristics such as rapidity of onset, long-term efficacy, safety profile, and effects on comorbidities are different. Better understanding of those characteristic leads to the right choice for individual patients, resulting in higher persistence, longer drug survival, higher patient satisfaction, and minimizing the disease impact of psoriasis. In this paper, we focus on the efficacy and safety profile of biologics in psoriasis patients, including plaque psoriasis and psoriatic arthritis. In addition, we discuss the impact of biologics on comorbidities caused by psoriasis.

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Bone Breaking Triglycerides

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.626 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A307-A307

Author(s):

Ellen Dauterive ◽

Virginia Wright

Keyword(s):

Bone Biopsy ◽

Bone Lesion ◽

Fragility Fractures ◽

Bone Lesions ◽

Insulin Regimen ◽

African American Female ◽

X Rays ◽

Left Femur ◽

Arm Pain ◽

The Right

Abstract A 40 yo African American female with pmhx of T2DM, DLD was admitted for worsening leg and arm pain that started a year prior but had worsened in the last 6 months. Pain started in the right arm and progressed to include the right leg and left leg. She had presented to the ER 3 times in the last 3 weeks with no diagnosis and prescribed anti-inflammatories. On ROS she had unintended weight loss of 50 lbs. Pain was not relieved with anti-inflammatories or narcotics. She was diagnosed with diabetes in the previous 5 years and had not been compliant with her medications. Plain x-rays showed OA of the hip. An osseus survey showed multiple expansile, bubbly, and lucent intramedullary lesions consistent with polyostotic fibrous dysplasia versus multiple myeloma. CT showed a radiolucent lesion of the left femur with absence of normal bone trabeculae. Her labs showed normal calcium, phosphorous, renal function, PTH and no evidence of monoclonal gammopathy. Vitamin D was low at 8.2 ng/ml (6.6–49 ng/ml). CT CAP showed no concern for malignancy in other organs. A lipid profile was done and showed elevated fasting triglycerides of 2617 mg/dL (<150 mg/dl) and LDL direct 54 mg/dl (<100 mg/dl). A1c was 11.2% on admission. She denied any use of alcohol, estrogens, SSRI’s. No history of pancreatitis. On physical exam she did not have tendinous xanthomas, eruptive xanthomas, palmar xanthomas, or lipemia retinalis. Family history not significant for lipid disorders. Patient was fasted for 24 hours and then started on intensive insulin regimen as well as fenofibrate for hypertriglyceridemia. Triglycerides came down to less than 500 over 7 days. She was evaluated by ortho for her bone lesions and underwent bone lesion biopsy as well as prophylactic IMN of her bilateral femurs for prevention of impending fragility fractures. Bone biopsy was significant for xanthoma of the bone. Following discharge, she remained on fenofibrate and fish oil as well as a basal/bolus insulin regimen. Triglycerides remained controlled. She has not followed up outpatient for further workup. This case highlights an atypical presentation of triglyceride deposition in the setting of hypertriglyceridemia. It shows that hypertriglyceridemia should be included in the differential for lytic lesions when preliminary workup is negative. It also highlights that complications other than pancreatitis and cardiovascular disease can significantly alter a patient’s life if triglycerides go untreated.

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Impact of prediabetes on long-term cardiovascular outcomes in patients with myocardial infarction with nonobstructive coronary arteries

Diabetology & Metabolic Syndrome ◽

10.1186/s13098-021-00721-9 ◽

2021 ◽

Vol 13 (1) ◽

Author(s):

Side Gao ◽

Wenjian Ma ◽

Sizhuang Huang ◽

Xuze Lin ◽

Mengyue Yu

Keyword(s):

Myocardial Infarction ◽

Coronary Arteries ◽

Cox Regression ◽

Early Recognition ◽

Past History ◽

Major Adverse Cardiovascular Events ◽

Abnormal Glucose Metabolism ◽

Kaplan Meier ◽

Increased Risk

Abstract Background Abnormal glucose metabolism including diabetes (DM) and prediabetes (pre-DM) have been reported as predictors of poorer outcomes after acute myocardial infarction (AMI). However, the prognostic value of pre-DM in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) remains unclear. Methods A total of 1179 MINOCA patients were prospectively recruited and divided into normoglycemia (NG), pre-DM, and DM groups according to glycated hemoglobin (HbA1c) levels or past history. The primary endpoint was a composite of major adverse cardiovascular events (MACE), including all-cause death, nonfatal MI, nonfatal stroke, revascularization and hospitalization for unstable angina or heart failure. Kaplan–Meier and Cox regression analyses were performed. Results Patients with pre-DM and DM had a significantly higher incidence of MACE compared with NG group (10.8%, 16.1%, 19.4%; p = 0.003) over the median follow-up of 41.7 months. After multivariate adjustment, both pre-DM and DM were significantly associated with an increased risk of MACE (NG as reference; pre-DM: 1.45, 95% CI 1.03–2.09, p = 0.042; DM: HR 1.79, 95% CI 1.20–2.66, p = 0.005). At subgroup analysis, pre-DM remained a robust risk factor of MACE compared to NG. In addition, pre-DM had a similar impact as DM on long-term prognosis in patients with MINOCA. Conclusions Pre-DM defined as raised HbA1c was associated with a poor prognosis in patients with MINOCA. Routine assessment of HbA1c enables an early recognition of pre-DM and thus may facilitate risk stratification in this specific population.

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Symptomatic menopausal transition and risk of subsequent stroke

PeerJ ◽

10.7717/peerj.7964 ◽

2019 ◽

Vol 7 ◽

pp. e7964

Author(s):

Chao-Hung Yu ◽

Chew-Teng Kor ◽

Shuo-Chun Weng ◽

Chia-Chu Chang ◽

Ching-Pei Chen ◽

...

Keyword(s):

Cohort Study ◽

Comparison Group ◽

Hormone Replacement ◽

Clinic Visit ◽

Menopausal Transition ◽

Prior History ◽

Chronic Obstructive ◽

Visit Frequency ◽

Increased Risk

Objective To examine the long-term risk of stroke in women who have experienced symptomatic menopausal transition. Methods In this nationwide, population-based cohort study conducted from January 1, 2000 to December 31, 2013, we identified 22,058 women with no prior history of stroke, who experienced symptomatic menopausal transition at ≥45 years of age. Moreover, 22,058 women without symptomatic menopause were matched by propensity scores and enrolled as a comparison group. The propensity score was calculated by using all characteristic variables of each subject, including demographics (age and monthly income), comorbidities (hypertension, hyperlipidemia, diabetes mellitus, obesity, chronic kidney disease, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, dysrhythmia, peripheral artery occlusive disease), Charlson’s comorbidity index score, clinic visit frequency, and long-term medications (antihypertensives, antidiabetic agents, statins, antiplatelets, aspirin, warfarin, and hormone replacement therapy). The primary endpoint was the development of stroke after the onset of symptomatic menopausal transition. The Fine and Gray’s proportional subhazards model was performed to assess the association between symptomatic menopausal transition and subsequent stroke. All subjects were followed up until December 31, 2013. Results During a mean follow-up of 8.5 years (standard deviation 4.7 years, maximum 14 years), 2,274 (10.31%) women with symptomatic menopausal transition, and 1,184 (5.37%) matched comparison participants developed stroke. The incidence rates were 11.17 per 1,000 person-years in the symptomatic menopausal transition group compared with 8.57 per 1,000 person-years in the comparison group. The risk of developing stroke was significantly higher in women with symptomatic menopausal transition (crude subhazard ratio, 1.31; 95% confidence interval (CI) [1.22–1.41]; P < 0.001). After adjusting for demographics, comorbidities, clinic visit frequency, and long-term medications, the risk of stroke remained statistically significant (adjusted subhazard ratio, 1.30; 95% CI [1.21–1.40]; P < 0.001). Moreover, subgroup analyses revealed no evidence for inconsistent effects for symptomatic menopausal transition on subsequent risk of stroke across all subgroups except age, comorbidities, hypertension, and use of antihypertensives. Women with early menopausal transition (before age 50), without comorbid condition, without hypertension, or without use of antihypertensives are at a higher risk of stroke. The longer duration of symptomatic menopausal transition was associated with higher risk of stroke (P for trend < 0.001). Conclusion In this large-scale retrospective cohort study, symptomatic menopausal transition was statistically significantly associated with a 30% increased risk of stroke. Further prospective studies are required to confirm our findings.

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