Hip fractures (HF) following low-impact trauma are the most visible and dramatic consequences of osteoporosis (OP). It is estimated that within one year after HF, 20 to 30% of the patients die, 50-60% become disabled and only 30-40% fully recover their previous functional levels. Therefore, its medical, societal and economic impact is huge and it is not fully delivered by the event itself, but rather by its consequences. This paper aims to update data published by Branco et al. 2009 about epidemiology and burden of HF, specifically to revise the national data. In Portugal there have been 77,083 HF reported between 2000 and 2008 with increasing numbers with ageing along with due associated refracture and mortality rates. Recent results suggest a slight change at clinical level concerning the pharmacological approach for the treatment of HF, however it is still important to stay alert to the patients' needs and to their bone mineral density losses in order to avoid repeating the occurrence of these events, aiming to generate significant benefits in terms of health outcomes and due public expenditure.

Breast cancer is the most commonly diagnosed cancer among women, but despite survival rates improvement, it is still the second major cause of cancer related death. In postmenopausal women with estrogen receptor (ER) dependent breast cancer, hormone therapy is an option, either by direct inhibition of ER using tamoxifen or by aromatase inhibition, resulting in decreased estrogen production. In this paper these two endocrine therapy approaches are compared in terms of their impact on bone health. Guidance for the prevention of bone loss and occurrence of fractures in postmenopausal women receiving AIs is also proposed. Despite intervention strategies to maintain bone health in AI-treated patients are not well established, recommendations by international societies to identify women with high risk of fracture and advice on the preventive anti-fracture therapy are exposed. Finally, available therapeutic options for management of bone loss in patients receiving AIs are presented. The search strategy for this literature review was conducted by using the key words "aromatase inhibitor*" and "bone loss" OR "aromatase inhibitor*" and "osteoporosis" in the MEDLINE/PubMed database. Nowadays, hormone-responsive breast cancer in postmenopausal women is preferably being treated with AIs instead of tamoxifen, due to clear benefits in disease-free survival and reduced recurrence. AIs have an advantageous side effect profile compared to tamoxifen, however all AIs have detrimental long-term effects on bone, due to nearly complete depletion of estrogens, resulting in increased bone loss and increased risk of fracture. Current recommendations state that all women treated with AIs should be evaluated for their fracture risk prior to initiation of AI-treatment, taking in consideration individual bone mineral density and several risk factors. The thresholds to introduce preventive therapy and drugs proposed differ among the available recommendations. Lifestyle modifications and adequate calcium and vitamin D supplementation have been documented to have good impact in long-term bone health. Additionally, bisphosphonates are the first therapeutic option for AI induced bone loss and should be continued as long as AI-treatment is maintained, being iv zoledronic acid 4 mg every 6 months the best tolerated option.

Glucocorticoids have potent anti-inflammatory and immunomodulatory effects and are widely use in the management of rheumatoid arthritis in combination with other synthetic and with biological disease-modifying anti-rheumatic drugs. Concerns about the risk of adverse effects of glucocorticoids, especially if they are given at higher dosages and for a longer time, hamper their use despite the clear symptomatic and disease modifying benefits. However, the evidence base for these concerns for low dose glucocorticoid therapy is quite limited due to the scarcity of quality literature on its safety in rheumatoid arthritis. This review discusses the current understanding about their disease-modifying effects, toxicity data from recent trials and observational studies, recommendations for their management and the current efforts to improve the therapeutic ratio of glucocorticoid through the development of new formulations, such as modified-release prednisone.

ting continuous confusion. After successful licensing in several countries around the world, the European licensing authority EMA has recently received the first application for an infliximab biosimilar, which resulted in a positive opinion for appli cation in several inflammatory joint diseases that most likely will be followed by start of marketing in the upcoming year. Facing these developments, the Portuguese Society of Rheumatology has taken the chance (and challenge) to analyze all available data on biosimi lars in rheumatic disease, and has formulated several sta tements that can be regarded pivotal for the European and rheumatologists worldwide with respect to the impact and further use of biosimilars in the daily clinical practice. When analyzing the decisions and statements of the Portuguese colleagues, especially from a country that still has the luxury of a more or less unrestricted access to biologics, several aspects need to be mentioned and commented. To position the patient and his or her medical needs on an individual risk-benefit profile and not solely on an economic basis underlines the value of the human being and the general task of the caring physician. To request clear decision processes and guidelines when applying biologics and biosimilars supports the idea of a clear distinction and positioning of the drug used, even if the biosimilar shows equivalent effects (and side effects such as immunogenicity) in all relevant aspects. Here, it needs to be mentioned that in terms of interchangeability and extrapolation, non-TNF bio simi lars might be a completely different story than TNF biosimilars, as could be seen in the varying outcomes of anti-CD20 and Anti-IL-6 originator antibodies in the past years. The request for monitoring the use and effects of biosimilars in a long-term registry will improve not only the overall knowledge in the field of therapeutic an Although based on very well known cellular and molecu lar targets in chronic inflammatory rheumatic diseases and the proven beneficial effects of the res pective monoclonal therapeutic antibodies since more than a decade, antibody-based biosimilars targeting the same proinflammatory effector molecules and cells appear to become the most intensively discussed drugs amongst rheumatologists, basic scientists, health economists, patients, industry and politicians – to some extent their development even divides the discussants in heavily opposing parties. The background of these turbulences is multifactorial, ranging from i) the interesting scientific question, how “similar“ or “identical“ a therapeutically used human(ized) therapeutic antibody can be if compared to an originator antibody, given the fact that even the batches of the originator drug vary significantly over the years due to variations in the (mostly improved) production processes, to ii) the “natural“ expiration of the patents for the originator biologics, which –owing to their therapeutic successmust stimulate pharmaceutical companies to initiate the development of “bio logic generics“ as performed for chemical drugs on a routine basis, and iii) the painful financial restrictions of the health system of several (European) countries, which demand cheaper drugs to be able to treat more patients according to the state-of-the-art, and iv) the subsequently arising question for the licensing application, whether a successful clinical trial of a biosimilar for a given disease can be extrapolated to other di sease entities without performing further clinical trials, to v) the yet unsolved problem of naming the biosi milar with a unique (international nonproprietary) name vs. “established–mab biosimilar“ without crea -

The aim of this study was to use a multifactorial approach to characterize episodic and recurrent fallers risk profiles in Portuguese older adults. To accomplish the mentioned purpose, 1416 Portuguese older adults above 65 years were tested with three different field measurements: 1) health and falls questionnaire; 2) Physical Activity questionnaire and 3) a set of functional fitness tests. The subjects were divided in three different groups according to fall prevalence: non-fallers, subjects who did not report any falls during the previous year, episodic fallers, those who reported to have fallen only once during the previous year, and recurrent fallers, the ones that fell twice or more times during the previous year. Episodic and Recurrent fallers risk profiles were established using multifactorial logistic regression models in order to avoid confounding effects between the variables. The results showed that age was not a risk factor for either episodic or recurrent falling. In addition, health parameters were shown to be the factors distinguishing recurrent from episodic fallers. This may imply that, comparing with episodic falls, recurrent falls are more associated with higher presence of chronic conditions and are less likely to occur due to external factors. Furthermore, being a woman, having fear of falling and lower functional fitness levels were determinant factors for both episodic and recurrent falls. It is also important to note that, although total physical activity was only related with episodic falling, promoting physical activity and exercise may be the easiest and cheapest way to improve functional fitness and health levels and therefore, its role in fall prevention should not be underestimated. The results of this study reinforce the importance of using a multifactorial approach, not only focusing on cognitive-behavioral factors, but also on promoting physical activity and healthy lifestyles, when assessing fall risk or planning an intervention aiming at fall prevention within the older population.

Osteoarthritis (OA) is the most common form of chronic arthritis worldwide. The etiology of pain in osteoarthritis is multifactoral, and includes mechanical and inflammatory processes. The use of intra-articular viscosupplementation in the nonoperative management of patients with osteoarthritis has become quite popular. Recent clinical data have demonstrated that the anti-inflammatory and chondroprotective actions of hyaluronic acid viscosupplementation reduce pain, from 4 to 14 weeks after injection, while improving patient function. Viscosupplements are comparable in efficacy to systemic forms of active intervention, with more local reactions but fewer systemic adverse events, and hyaluronic acid has more prolonged effects than IA corticosteroids. Although several randomized controlled trials have established the efficacy of this treatment modality, additional high quality randomized control studies with appropriate comparison are still required to clearly define the role of intra-articular hyaluronic acid injections in the treatment of osteoarthritis. We review the basic science and development of viscosupplementation and discuss the mounting evidence in support of its efficacy and safety profile.

To perform an observational retrospective cross-sectional case-control study to evaluate prevalence, clinical patterns and outcomes of neurological involvement in a cohort of Primary Sjögren Syndrome (pSS) patients followed up in a single center. From a total of 93 pSS patients, diagnosed according to the 2002 criteria proposed by the American-European Consensus Group, we reviewed the clinical data of those with neurological complaints that were referred to observation by Neuroimmunology doctors. Demographic, clinical, seroimmunological data were compared between patients with and without neurological involvement. Neurological involvement was detected in 26 (28%) of the 93 patients. Neurological symptoms preceded the diagnosis of pSS in 12 (46%) patients. They were all females. The mean age at disease onset and neurological onset were 41,2 and 47,9 years, respectively. Twelve patients (46%) had peripheral system involvement (PNS), 13 (50%) patients had central nervous involvement (CNS) disorders and one (4%) patient had both PNS and CNS involvement. In patients with PNS, pure sensory neuropathy (small fiber neuropathy confirmed by quantitative sensory testing and sural neuropathy) occurred most frequently (n =5), followed by cranial nerve involvement affecting trigeminal, facial, or trochlear nerves (n = 4). Multiple mononeuropathy (n = 1), sensorimotor polyneuropathy (n=1), autonomic neuropathy (n=1) and myasthenia gravis (n = 1), were also observed. In patients with CNS disorders, headache (n=3) occurred most frequently, in two patients with MRI abnormalities compatible with inflammatory disease. Spinal cord involvement (n=2), seizures (n = 2), motor and sensory deficit (n=2), movement disorders (n=2), neuromyelitis optica (n=2), aseptic meningitis (n=1) were others manifestations observed. Cognitive dysfunction was observed in 3 of these patients. The frequency of constitutional symptoms (such as fever and fatigue) and lung involvement was significantly higher (p< 0,05) and the articular symptoms were significantly less frequent (p< 0,05) in pSS with neurological involvement. The neurologic outcome was good in 77% of the patients. The current study underlines the diversity of neurologic complications of pSS. The frequency of neurologic manifestations as first manifestation of pSS, especially in the event of CNS involvement, could explain why SS is frequently under diagnosed or late diagnosed. Screening for SS should be systematically performed in cases of acute or chronic myelopathy, axonal sensorimotor neuropathy, or cranial nerve involvement.