Current rheumatology reports
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Review
Osteoporosis and orthopedic surgery: effect of bone health on total joint arthroplasty outcome.
Osteoporosis is a common condition. As the population ages, more patients with osteoporosis will require orthopedic procedures, including arthroplasty. Adverse outcomes are more likely for patients with osteoporosis requiring orthopedic procedures, for example those with intraoperative fractures, periprosthetic osteolysis with implant migration, and postoperative periprosthetic fractures. ⋯ Vitamin D deficiency is common among patients undergoing joint arthroplasty and the ideal vitamin D level for joint arthroplasty has yet to be determined. Both bisphosphonates and teriparatide may aide successful osteointegration among patients undergoing noncemented joint arthroplasty. Focusing on bone health perioperatively should result in better outcomes for orthopedic procedures.
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Belimumab has recently been approved, and several other types of biological therapy with different mechanisms of action are currently in phase II and III studies. This review puts these approaches in context, emphasizing mechanistic categories and clinical trial designs. Most of the promising approaches involve B cell depletion or modulation. Post-approval experience with belimumab is critically reviewed.
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Systemic sclerosis (SSc) is a heterogeneous condition characterized by the deposition of excess collagen in skin and internal organs due to vasculopathy, immune activation, low grade inflammation, and fibrosis. Progressive diffuse cutaneous SSc with organ involvement has a poor prognosis. ⋯ The ASTIS and SCOT trials will determine whether the benefits of HSCT outweigh the risks of serious adverse events including treatment-related mortality of around 6-10% and potential long-term complications. Better patient selection and safer transplant regimens may improve the outcome of HSCT for SSc.
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The recent increase in the number of patients taking opioids chronically for pain has not yielded the expected benefits in reduction of symptoms and improved function. Chronic pain patients typically respond well initially to opioid medications, but regular use is associated with adverse psychological and physical effects. ⋯ In the common rheumatological conditions of fibromyalgia and osteoarthritis, opioid treatment is of limited benefit because of lack of efficacy and prominent side effects. Chronic opioid therapy may be more usefully regarded as a form of comfort care, reserved for those patients who have exhausted other treatments and prospects of recovery.
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Glucocorticoids (GC) are a standard treatment for pediatric rheumatic disease. Recent literature highlights skeletal vulnerability in children with rheumatic illness, including vertebral and peripheral fractures and reductions in bone mineral density in longitudinal follow-up. Annual vertebral fracture incidence of 4-6 % in those recently diagnosed and prevalence of 7-28 % in those several years post diagnosis have been reported. ⋯ Bone mass accrual is typically suboptimum across time, although the use of potent steroid-sparing anti-inflammatory agents may counteract the effects of GC and active disease. Vitamin D insufficiency warrants ongoing monitoring. Additional targeted studies are justified to increase understanding of bone health risks in this population.