Generalized low areal and volumetric bone mineral density in adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) may be associated with generalized low bone mineral status. The bone mineral density (BMD) of 75 girls of 12-14 years of age and diagnosed as having AIS were compared with 94 age-matched female control subjects. Areal BMD (aBMD) of the lumbar spine (L2-L4) and the bilateral proximal femur were measured using-energy X-ray absorptiometry (DEXA), and volumetric BMD (vBMD) of the nondominant distal radius and bilateral distal tibias was measured with peripheral quantitative computer tomography (pQCT). Relevant anthropometric parameters and the severity of the spinal deformity (Cobb's angle) also were evaluated and correlated with the BMD measurements. Results revealed the presence of a generalized lower bone mineral status in AIS patients. Detailed analysis showed that the aBMD and vBMD measured at the bilateral lower extremities were significantly lower in AIS patients when compared with the same in the normal controls. The most significant effect was seen in the trabecular BMD (tBMD) of the distal tibias. Of all the AIS girls, 38% of the aBMD and 36% of the vBMD were below -1 SD of the normal. BMD was found to correlate better with "years since menarche" (YSM) than with chronological age. When the BMD was evaluated for the 3 YSM groups, aBMD of the proximal femur and tBMD of distal tibias were found to be significantly lower in the AIS patients. Neither the aBMD nor the vBMD of AIS patients was found to be associated with the severity of spinal deformity. In addition, anthropometric measurements showed significantly longer arm span and lower extremities in the AIS girls. We concluded that the AIS girls had generalized lower aBMDs and vBMDs.

Increased risk of hip fracture among patients with end-stage renal disease

BACKGROUND

Although patients with end-stage renal disease (ESRD) are at increased risk for bone loss, the risk of hip fracture in this population is not known. We compared the risk of hip fracture among dialysis patients with the general population.

METHODS

We used data from the United States Renal Data System (USRDS) to identify all new Caucasian dialysis patients who began dialysis between January 1, 1989, and December 31, 1996. All hip fractures occurring during this time period were ascertained. The observed number of hip fractures was compared with the expected number based on the experience of residents of Olmstead County (MN, USA). Standardized incidence ratios were calculated as the ratio between observed and expected. The risk attributable to ESRD was calculated as the difference between the observed and expected rate of hip fracture per 1000 person-years.

RESULTS

The number of dialysis patients was 326,464 (55.9% male and 44.1% female). There were 6542 hip fractures observed during the follow-up period of 643, 831 patient years. The overall incidence of hip fracture was 7.45 per 1000 person years for males and 13.63 per 1000 person years for females. The overall relative risk for hip fracture was 4.44 (95% CI, 4.16 to 4.75) for male dialysis patients and 4.40 (95% CI, 4.17 to 4.64) for female dialysis patients compared with people of the same sex in the general population. While the age-specific relative risk of hip fracture was highest in the youngest age groups, the added risks of fracture associated with dialysis rose steadily with increasing age. The relative risk of hip fracture increased as time since first dialysis increased.

CONCLUSIONS

The overall risk of hip fracture among Caucasian patients with ESRD is considerably higher than in the general population, independent of age and gender.

[Bone mineral density of adults living in the city of Wrocław compared with the reference ranges]

Certain elements of lifestyles (distinctive for the particular population) are presumed to influence on bone metabolism. This fact results in considerable differences between various populations, concerning both the occurrence of the normal variability of BMD (bone mineral content) among adult and elderly men and women, and also the prevalence of osteopenia or osteoporosis. The purpose of the study was to evaluate the variability of BMD in a group of healthy and occupationally active inhabitants of the city of Wroclaw, Poland (426 men aged 20-59 and 1218 women aged 20-62) and to compare our results with the reference ranges provided by the producer of the Stratec 960 apparatus. Trabecular and total BMD at the distal radius of the nondominant hand were assessed by peripheral Quantitative Computed Tomography (pQCT) using the Stratec 960 apparatus. BMD of Polish men and women significantly differ from the reference ranges of Stratec 960. The unfavourable phenomenon of the greater BMD decline with age, as compared to the standard values provided by the producer of the device, occurred. It should also be stressed that this reduction is more intense with age and it is marked among men older than 36. Taking into consideration the fact, that our material comprises only occupationally active subjects, the revealed differences would be probably greater, if they were evaluated in Polish population as a whole (our sample does not include persons, who are retired from the healthy conditions). Considering those significant discrepancies between our data and the Stratec reference population, one should be careful when using the normative database provided by Stratec for the densitometric diagnosis of osteoporosis among Polish women and men. Additionally the present study reveals that BMD (and its age-related changes during normal aging) is one of the features characteristic for the particular regional population, which is due to inter-populational differences of those elements of lifestyle, which can influence both general health condition and bone mineral density.

Determinants of bone density and prevalence of osteopenia among female runners in their second to seventh decades of age

This is a cross-sectional study of spine and hip bone density (BMD) in 124 female athletes, aged 16-68 years, who trained for at least 3 hs/week. The aim was to document the effects of competitive running on BMD in women over a broad age range. Thirty-three subjects, aged <35 years, were currently oligo- or amenorrheic and, of the 50 who were >40 years, and who were now menstruating normally, 13 had previously been oligo- or amenorrheic. Fifty-two women <50 years of age had never had disturbed menses. Twenty-four older women were postmenopausal. Women who had never had menstrual disturbance had significantly increased bone density at the lumbar spine, femoral neck, and femoral trochanter, as compared with young normal European reference data (range from +0.4 population SD or T-score units to +1. 2 units according to measurement site and age group). In contrast, young amenorrheic or oligomenorrheic runners had reduced bone density, particularly at the spine (mean T score < -1.1), whereas older runners who previously had disturbed menses, but were now menstruating normally, had bone densities that were similar to sedentary young controls. Postmenopausal runners had bone density values that differed little from sedentary postmenopausal controls matched for time since menopause, after adjusting for the runners' lower body weight. Bone density outcomes were related to candidate explanatory variables. After taking into account the other variables, age, per se, influenced only the femoral neck and Ward's area. Years since last exposure to estrogen (at premenopausal levels) was an important determinant of bone loss at both hip and spine. Body weight had a beneficial influence on the femoral neck region, whereas (in contrast) height had a positive influence on the lumbar spine. Months of breastfeeding (totaled for all children) had a modest, positive influence, which was larger in the femoral measurement sites. There was no evidence of an effect of calcium intake or percent body fat on BMD at any site independent of these other effects. It is concluded that, with the consistent presence of normal premenopausal estrogen levels, running at least 3 hs/week substantially improves bone density, particularly at the proximal femur. This beneficial effect is reversed in the absence of the consistent past and current presence of normal menstrual function. There was no clear benefit of running seen on BMD in postmenopausal women, but premenopausal veteran athletes who started running after the age of 30 years were not disadvantaged compared with early starters.

Osteopenia in insulin-dependent diabetes mellitus; prevalence and aspects of pathophysiology

The objective was to evaluate the prevalence and severity of osteopenia in patients with uncomplicated insulin-dependent diabetes mellitus (IDDM) and to obtain more information on the pathophysiology of diabetic osteopenia. In 35 patients with uncomplicated IDDM (21 men and 14 women; age 37.6+/-9.9 yr; duration of disease 8.5+/-3.5 years) bone mineral density was measured by dual energy X-ray absorptiometry (DEXA). In addition, markers of bone formation [plasma insulin-like growth factor I (IGF-I), serum alkaline phosphatase (ALP), serum bone alkaline phosphatase (BAP) and serum osteocalcin] and bone resorption [urinary excretion of calcium and of the cross-linked N-telopeptide of type 1 collagen, both corrected for the excretion of creatinine] were measured in the diabetic patients and in 33 healthy controls, matched for sex, age, height, weight and body mass index (BMI). In 67% of the diabetic men and 57% of the diabetic women osteopenia of the femoral neck and/or the lumbar spine (T-value < or = -1 SD) was present. Fourteen percent of the male patients, but none of the female patients, met the criteria for osteoporosis (T-value < or = -2.5 SD). In the whole group of diabetic patients the mean plasma IGF-I level tended to be lower (p<0.10) as compared to that in the controls. In the diabetic patients with femoral neck osteopenia, the mean plasma IGF-I level was significantly lower (p<0.05) than in those without osteopenia at this site. There were no differences in the mean serum ALP, BAP and osteocalcin levels between the diabetic patients and the controls, nor between the diabetic patients with and without femoral neck osteopenia. Considering only the male diabetic patients, significantly lower mean plasma IGF-I (-26%), serum ALP (-24%) and serum osteocalcin (-38%) levels were present in the patients with femoral neck osteopenia than in those without osteopenia at this site, suggesting lowered bone formation. The bone resorption markers were similar in all (sub)groups of diabetic patients and not different between diabetic patients and controls. Bone mineral density (BMD) did not correlate with plasma levels of glycosylated hemoglobin (HbA1c). BMD values were not related to any of the bone resorption or formation markers, except for plasma IGF-I both in the femoral neck (r=+0.38, p=0.026) and the lumbar spine (r=+0.34, p=0.043). Our data demonstrate that at least in male patients with IDDM, osteopenia is the consequence of a lowered bone formation with a predominance of bone resorption over formation.

Bone and joint complications related to Gaucher disease

There is a broad spectrum of Gaucher disease-related skeletal complications, ranging from asymptomatic osteopenia to osteonecrosis (of the shoulders and hips) with secondary degenerative joint disease. Characterization of the pattern and severity of bone involvement in the individual patient requires the application of conventional and advanced radiographic techniques. The introduction of enzyme replacement therapy (ERT) for this inborn error of glycosphingolipid metabolism has focused great interest in determining the nature and extent of the bone responses with this mode of treatment. The multifactorial etiology of the bone complications necessitates a multifaceted approach, combining pharmacologic strategies with physical therapy and orthopedic intervention. As bone disease can lead to chronic pain and debility with a resultant adverse impact on quality of life, it is important that patients be monitored closely and that early intervention with ERT prior to established bone disease (infarction and fibrosis) be considered.

Total-body bone mineral content in non-corticosteroid-treated postpubertal females with juvenile rheumatoid arthritis: frequency of osteopenia and contributing factors

OBJECTIVE

To determine the extent of low total-body bone mineral content (BMC) in non-corticosteroid-treated white postpubertal females with juvenile rheumatoid arthritis (JRA) compared with healthy age- and race-matched female controls, and to identify variables that significantly contribute to total-body BMC.

METHODS

Thirty-six females with definite JRA who had never received corticosteroids and 51 healthy female controls were evaluated. All subjects had had their first menstrual period at least 2 years prior to enrollment. Total-body BMC, lumbar spine bone mineral density, and body composition were determined by dual x-ray absorptiometry. Total-body BMC Z-scores were calculated for JRA patients using data from controls. JRA patients were dichotomized into those with "normal" bone mass (total-body BMC at or above the mean or no more than 1 SD below the mean) and those with "low" bone mass (total-body BMC more than 1 SD below the mean). Comparisons of anthropometric measurements, laboratory measurements of bone metabolism, disease activity, dietary intake, and physical activity were performed. Stepwise logistic regression was utilized to determine the presence or absence of low total-body BMC and to identify associated contributing factors.

RESULTS

Total-body BMC was 4.5% lower in JRA patients than in controls (mean +/- SD 2,050 +/- 379 gm versus 2,143 +/- 308 gm; P = 0.21). Twenty-five of 36 patients (69.4%) had "normal" and 11 of 36 (30.6%) had "low" total-body BMC. Comparison of JRA patients with "normal" versus those with "low" total-body BMC revealed significant differences in disease characteristics, anthropometric and physical development characteristics, laboratory measures of bone mineralization, and dietary intake. The final regression model contained only lean mass (P = 0.01), which accounted for 76.3% of the variance in total-body BMC. The odds ratio for lean mass was 0.4451 (95% confidence interval 0.2374-0.8348).

CONCLUSION

In this study, approximately 30% of the subjects in a sample of postpubertal female patients with mild-to-moderate, non-corticosteroid-treated JRA had low bone mass. The predictor variable that significantly contributed to total-body BMC was lean mass, which demonstrated a protective effect of 0.56 risk reduction for low total-body BMC.

[Osteopenia and osteoporosis in postmenopausal women in Panama]

We present the results of densitometry studies performed on 1031 females, from September 1996 to September 1997. The studies were subsidized by the Foundation for Metabolic and Bone Diseases and the pharmaceutical institutions. The results were classified according to the WHO recommendations, taking in consideration the age of the patients, in normal, with osteopenia and with osteoporosis. 821 (79.63%) of the patients suffered from osteopenia or osteoporosis and 807 (78.2%) were postmenopause: only 14% of them were normal and 86% with osteoporosis or osteopenia.

Screening for osteoporosis using easily obtainable biometrical data: diagnostic accuracy of measured, self-reported and recalled BMI, and related costs of bone mineral density measurements

The aims of the present study were: to determine the diagnostic accuracy of objectively measured, self-reported and recalled body mass index (BMI) for osteoporosis and osteopenia; to determine the diagnostic costs, in terms of bone mineral density (BMD) measurements, per osteoporotic or osteopenic patient detected, using different BMI tests; and to determine the extent to which the results can be used within the framework of the current screening program for breast cancer in The Netherlands. Within the framework of a cross-sectional study on the prevalence of osteoporosis in the south of The Netherlands, 1155 postmenopausal women aged 50-80 years were asked for their present height and their weight at age 20-30 years. Subsequently their actual weight, height and BMD of the lumbar spine (DXA) were measured. The BMD cutoff was 0.800 g/cm2 for osteoporosis and 0.970 g/cm2 for low BMD (osteoporosis + osteopenia). After receiver operating characteristic analysis, age was cut off at 60 years and BMI at 27 kg/m2. Diagnostic accuracies of objectively measured, self-reported and recalled BMI were evaluated using predictive values (PV) and odds ratios. The resulting 'true positive' and 'false positive' rates were used to calculate diagnostic costs (i.e., DXA) for each osteoporotic patient or low-BMD patient detected. The prevalence of osteoporosis in the study population was 25%, that of low BMD 65%. Only the age-BMI tests 'age > or = 60, BMI < or = 27' showed PVs for osteoporosis (31-41%) and for low BMD (71-81%) that were higher than the prior probabilities for these conditions. Related odds ratios were 2.14-3.18 (osteoporosis) and 1.87-3.04 (low BMD). The objective BMI test detected 50% of the osteoporotic patients. Using the self-reported BMI test and the recalled BMI test, detection rates increased to 55% and 69%, respectively. Concomitant costs per osteoporotic patient detected rose by 24%. Detection of patients with a low BMD increased from 38% for objective BMI and 42% for self-reported BMI to 60% for recalled BMI. Related costs increased by 11%. If all women over 50 years of age (irrespective of their BMI) were to be referred for BMD measurement, costs per osteoporotic patient or low-BMD patient detected would be 304 and 116 Euros, respectively. Only in women over 60 years does a BMI below 27 kg/m2 provide a better prediction of the presence of osteoporosis or low BMD than could be expected solely on the basis of the relevant prevalences in postmenopausal women aged 50-80 years. If the use of BMI for the detection of osteoporotic or low-BMD patients is still considered, measuring weight and just asking for a person's height will do. Although age and BMI are the strongest risk factors for osteoporosis, they are of less significance when used for screening the population for osteoporosis. More research is needed before age and BMI can be included in any screening program. As regards practical considerations alone, measurements of BMD could be implemented within the screening program for breast cancer.

Fracture threshold in the Thai elderly and bone mineral density evaluation

Fractures in the elderly as the result of minor trauma or normal physiological stress in daily activities usually occur in load-bearing body areas such as the lumbar spine and the neck or trochanter of the femur, causing high morbidity and mortality. Surveillance of high-risk Thai elderly with low bone mineral density by determining the cutoff point as the fracture threshold may guide us in the proper management for preventing these unpleasant events. Of 329 elderly with age range of 50-110 years, 63 with lumbar spine fracture and 55 with hip fracture were descriptively and studied prospectively during May 1997 to December 1998 at Pramongkutklao Hospital. Bone mineral density (BMD) was analyzed to determine the fracture threshold using a receiver-operating characteristic (ROC) curve and compared with the total BMD at the lumbar spine and proximal femur. The cutoff point of the lumbar BMD at 0.799 g/cm2 (78.30% sensitivity, 73.60% specificity, and 74.5% accuracy) yields the likelihood of lumbar spine or hip fracture. For the femoral BMD, the cutoff point at 0.649 g/cm2 (92.5% sensitivity, 73.2% specificity, and 73.05% accuracy) is also used to predict the likelihood of lumbar spine or hip fracture. Of the nonfracture group, 27.33% had a total BMD value below the fracture threshold. In conclusion, early prevention among the elderly to decrease the risks of fracture is very important. Also, the detection and fracture prevention for normal population who had BMD below the fracture threshold are interesting. The BMD measurements and the loss of bone mass in Thai elderly people and the other risks of fracture need further studies.

Fibromyalgia: a risk factor for osteoporosis

OBJECTIVE

To investigate associations of bone mineral density (BMD) and osteoporosis in patients with fibromyalgia (FM) and healthy controls.

METHODS

Twenty-four women meeting the American College of Rheumatology criteria for FM (23 Caucasians, one Asian) were each compared to 2 age (+/-3 years) and ethnically matched controls by bone densitometry of the femoral neck and lumbar spine. The patients' ages were 33 to 60 years. No patient or control used steroids or other bone demineralizing agents. Simple T tests were used to compare hip and lumbar spine BMD of FM cases to controls by 3 decades (31-40, 41-50, 51-60 years).

RESULTS

The patients with FM in all 3 decades had a lower mean BMD of the spine (p<0.05). The femoral neck BMD were also lower, but reached significance (p<0.05) only in the 51-60 age group.

CONCLUSION

FM in this pilot study was frequently associated with osteoporosis. Early detection and implementation of appropriate nutritional supplementation (calcium/vitamin D), resistive and weight bearing exercise, and specific bone mineral enhancing pharmacological therapy may be indicated in pre, peri, and postmenopausal subjects.

Comparison of accuracy and cost effectiveness of clinical criteria and BUA for referral for BMD assessment by DXA in osteoporotic and osteopenic perimenopausal subjects

A pilot study of 107 women aged 60-69 years recently suggested that the measurement of broadband ultrasound attenuation (BUA) provides a superior cost effective pre-screen referral method for bone mineral density (BMD) measurement by DXA (dual-energy X-ray absorptiometry) than can be achieved by clinical criteria (CC). The aim of this study was to compare the accuracy and cost effectiveness of BUA and clinical criteria in a younger cohort. 599 women aged 50-54 years (52.18 +/- 1.35) had previously been measured by DXA at lumbar spine and right femoral neck, along with BUA measurement of the right calcaneus. Each subject had also completed an extensive clinical and social questionnaire to ascertain those who would have met one or more of the six general clinical criteria adopted by our Centre. Each subject was classified by DXA using the WHO criteria as normal, osteopenic or osteoporotic, defined at lumbar spine or femoral neck. Sensitivity, specificity and accuracy were calculated for BUA and the clinical criteria, noting that analysis was undertaken with and without the oestrogen deficiency clinical criterion (CC1): "Any oestrogen deficient woman who would want to be treated or would want to continue treatment if found to be osteopenic or osteoporotic". The accuracy for identifying osteoporotic subjects was 72.8% for BUA (at the point of matched sensitivity and specificity, 75 dB MHz(-1)), 30.7% for CC(1-6) and 64.3% for CC(2-6). When osteopenic subjects were incorporated, the accuracies were 63.8% for BUA (at the point of matched sensitivity and specificity, 82 dB MHz(-1)), 60.3% for CC(1-6) and 55.7% for CC(2-6). The minimum cost per osteoporotic subject correctly identified was pound sterling 573.50 by DXA alone, pound sterling 325 by BUA, pound sterling 458 by CC(1-6) and pound sterling 416 by CC(2-6). When osteopenic subjects were incorporated, the costs were pound sterling 87, pound sterling 83.50, pound sterling 78 and pound sterling 74, respectively. The overall cost, dependent upon the prevalence of osteoporosis (or osteopenia) within the population, more accurately indicates the feasibility of a population-based screening programme. For the identification of either osteoporotic or osteopenic subjects from the general population by DXA, the prevalence-compensated cost (cost per subject correctly identified multiplied by prevalence) is pound sterling 45, irrespective of age cohort. If CC(2-6) were adopted for the identification of osteoporotic subjects alone, the prevalence-compensated cost would be pound sterling 32 and pound sterling 42 for the 50-54 and 60-69 aged cohorts, respectively. For BUA, the prevalence-compensated cost falls to pound sterling 25 and pound sterling 43 for the 50-54 and 60-69 aged cohorts, respectively. If osteoporotic or osteopenic subjects were to be identified in the 50-54 aged cohort, both CC(2-6) (pound sterling 38) and BUA (pound sterling 43) perform similarly to DXA alone. BUA appears to provide a valuable population pre-screen for the identification of osteoporotic subjects, less so for osteopenic. It is suggested that if both osteopenic and osteoporotic women are to be identified for clinical management incorporating DXA, then neither BUA nor clinical criteria are satisfactory referral methods. An unanswered question from this study, however, is whether ultrasound has an independent role in the assessment of fracture risk for perimenopausal women who do not have the benefit of referral for DXA.

Osteoporosis, body composition, and bone turnover in ankylosing spondylitis

OBJECTIVE

To study the prevalence of osteoporosis (OP) and osteopenia in ankylosing spondylitis (AS) and to investigate the relationship between symptomatic and structural severity, the indices of bone turnover, and body composition.

METHODS

Eighty patients with AS were enrolled prospectively: 52 men (65%) and 28 women, mean age 36.7 years +/- 11.5 (range 18-67); they were studied clinically, radiologically, and by dual energy x-ray absorptiometry. Sixty-three underwent biological assessment of bone turnover markers.

RESULTS

OP and osteopenia as defined by the World Health Organization (T score < -2.5 SD and between -1 and -2.5 SD, respectively) were observed in 15 (18.7%) and 25 patients (31.2%) at the lumbar spine and in 11 (13.7%) and 33 patients (41.2%) at the femoral neck, respectively. Patients with OP had a lower body mass index (BMI) and fat mass percentage. There was a trend to a lower disease duration in patients with OP at the spine than in healthy subjects. Bone resorption markers (urinary D-pyridinoline or C-telopeptide concentrations) were increased in 34 patients (53.9%). Bone turnover markers were positively correlated with C-reactive protein concentration and Larsen radiological hip score; they were negatively correlated with Schober index and fat mass percentage.

CONCLUSION

(1) OP is frequent in AS and can be observed in early stages of the disease. (2) Patients with AS are more susceptible to develop OP when they have low BMI, low fat mass percentage, and active and severe disease. OP was observed in parallel with increased bone resorption.

Discrepancies in pediatric bone mineral density reference data: potential for misdiagnosis of osteopenia

OBJECTIVE

To evaluate published pediatric dual-energy x-ray absorptiometry bone mineral density (BMD) reference data by comparing the diagnostic classification of measured BMD in children at risk for osteopenia as healthy or osteopenic according to reference source.

STUDY DESIGN

Spine BMD was measured in 95 children, ages 9 to 15 years, at risk for osteopenia because of childhood disease. The BMD results were converted to age-specific z scores for each of the 5 reference data sets, and the z -score distributions were compared.

RESULTS

Between 11% and 30% of children were classified as osteopenic (z score < -2.0) depending on the reference data set. The 2 sex-specific reference data sets yielded similar diagnostic classification of boys and girls: 10% of boys and 11% to 16% of girls were osteopenic (P =.4). The 3 sex-nonspecific reference data sets classified 9% to 13% of girls and 24% to 44% of boys as osteopenic; the diagnosis of osteopenia was significantly greater in boys (P <.01).

CONCLUSIONS

The use of different published reference data for the assessment of children at risk for osteopenia results in inconsistent diagnostic classification of BMD results. These inconsistencies can be partially attributed to sex-nonspecific reference data that result in misclassification of boys as osteopenic.

Association of edentulousness with systemic factors in elderly people living at home

OBJECTIVE

To examine the association of edentulousness with systemic factors: age, gender, tobacco-smoking, alcohol intake, body mass index, functioning in daily living, cortical thickness at the mandibular angle, and systemic diseases: bone-fracture (an indicator for osteoporosis), diabetes, thyroid disease, hyperparathyroidism, asthma, heart failure, hypertension.

METHODS

The study population comprised 293 elderly subjects, 124 (42%) edentulous and 169 (58%) dentate. The data from clinical and radiographic examinations and structured interviews were analyzed by multiple logistic regression.

RESULTS

When edentulousness in both the mandible and the maxilla was considered, history of bone fracture and tobacco-smoking were significantly related to complete edentulousness with odds ratios (OR) of 2.51 (95% CI: 1.47-4.28) and 2.42 (95% CI: 1.32-4.43) respectively, associations independent of age and gender. A similar association was found for the edentulous mandible. In the elderly subjects with an edentulous maxilla, besides the significant factors of history of bone fracture and tobacco-smoking, asthma was also associated with edentulousness at an odds ratio of 10.81 (95% CI: 1.38-84.66), oldest subjects most often being edentulous (OR: 2.23, 95% CI: 1.13-4.39). Diabetes was not related to edentulousness either in the mandible or in the maxilla.

CONCLUSIONS

The finding of associations of history of bone fracture, tobacco-smoking, and asthma with edentulousness emphasizes the association of systemic conditions with edentulousness. Advanced age was related to an edentulous maxilla. The relationship between asthma and total tooth loss in the maxilla might suggest a local oral effect of medications used by asthmatic patients.

Relative osteopenia after treatment for acute lymphoblastic leukemia

Osteoporosis in adult life is associated with a significant morbidity and may be predisposed to by osteopenia and failure to reach peak bone mass in childhood. Children treated for acute lymphoblastic leukemia (ALL) may be at risk of osteopenia as a result of previous therapy or as a consequence of the disease process itself. Dual energy x-ray absorptiometry measurements of bone mineral content (BMC) for the whole body and at the lumbar spine and hip were taken in 35 (14 male) long-term survivors of ALL and compared with results in 20 (10 male) survivors of other malignancies and 31 (17 male) healthy sibling controls. The measured BMC was expressed as a percentage of a predicted value derived from the control group and based on the variables that had influence upon it. BMC (%) was reduced at the spine in the ALL group compared with controls [92.4 (8.0)% versus 100.4 (9.7)%, respectively; p < 0.005] and at the hip compared with both other malignancies and controls [89.0 (11.5)% versus 96.1 (11.7)% and 100.4 (9.2)%, respectively; p < 0.0005]. Increasing length of time off therapy was associated with a significant increase in %BMC at both the spine and the hip. For the spine, this association was significantly different between the ALL group and other malignancies, suggesting that any gain in %BMC after therapy was slower in children treated for ALL. Both exercise capacity and levels of physical activity were correlated with %BMC at the hip (r = 0.44, p < 0.001 and r = 0.29, p < 0.01, respectively). Previous exposure to methotrexate, ifosfamide, and bleomycin was associated with a reduction in %BMC at the spine. Exposure to 6-mercaptopurine and cisplatin was associated with a reduction at the hip. In conclusion, children treated for ALL are osteopenic. The mechanism is probably multifactorial but is partially related to previous chemotherapy, limited exercise capacity, and relative physical inactivity.

[Prevalence of osteoporosis in postmenopausal women in family practice]

OBJECTIVE

To assess the prevalence of osteopenia, osteoporosis and severe vertebral deformities in general practice.

DESIGN

Cross-sectional study.

METHODS

Of a randomly selected group of 712 women aged 55 to 84 years in a general practice in Noordwijk, the Netherlands, 449 (63%) participated in a study in 1996, in which Dual Energy X-ray Absorptiometry (DXA) of the femoral neck was performed: in 428 women vertebral morphometry of lateral radiographs of the spine was also done. The World Health Organization definitions of osteopenia and osteoporosis were used.

RESULTS

The mean bone mineral density (BMD) was 0.866 g/cm2 (SD: 0.135). With increasing age the BMD decreased statistically significantly by 0.0073 g/cm2/year. There were 189 women with osteopenia (42%). 33 (7%) with osteoporosis and 44 (10%) with one or more severe vertebral deformities. A significantly lower mean BMD was found in those with severe vertebral deformities than in those without.

Measurement of radial bone mineral density in patients after heart transplantation

Limited physical activity, steroidotherapy and immunosuppression are known risk factors for the development of osteoporosis. The purpose of our current work was to investigate whether patients after heart transplantation (Htx) have an increased incidence of osteoporosis. We compared bone mineral density (BMD) in 32 post-transplant patients with a reference group of 1548 healthy age-matched males. Measurement of BMD was carried out with a Dtx 100 Osteometer on the distal and ultradistal segment of the non-dominant radius. Our results revealed a decreased BMD in HTx patients ranging from 6.9 to 10% in the ultradistal (p = 0.0446) and from 0.4 to 3.5% in the distal segment (p = 0.0593).

Is there any association between the presence of bone disease and cumulative exposure to lead?

There is evidence from cell culture experiments, animal studies, and from measurements in humans that lead may exert detrimental effects on bone mineral metabolism. In order to explore a possible association between lead and bone disease, both cortical and trabecular bone lead content as well as serum lead concentration was measured in 117 patients who attended a metabolic bone disease clinic (n = 92) or were undergoing dialysis for renal failure (n = 25). Cortical bone lead content was higher in patients suffering from Paget's disease than it was in controls, patients with osteoporosis, and patients on dialysis. Trabecular bone lead content was lowest in patients with Paget's disease or osteitis fibrosa. There was no association between bone lead content and serum alkaline phosphatase concentration in patients suffering from osteoporosis. No statistically significant differences in serum lead concentrations were found between groups. Our results do not distinguish between the two possibilities that increased bone turnover due to Paget's disease releases lead from trabecular bone which is then available for deposition into cortical bone or the alternative possibility that an increased lead content in cortical bone may cause increased turnover with release of lead from trabecular bone.

Bone mineral density, collagen type 1 alpha 1 genotypes and bone turnover in premenopausal women with diabetes mellitus

Osteopenia is a recognised complication of diabetes mellitus which could be due to abnormal bone turnover or disturbances in the calcium/parathyroid hormone/vitamin D axis or both. Genetic factors also play an important part in determining bone mass although this has not been studied in diabetes. Recently a polymorphism of the collagen type 1 alpha 1 (COL1A1) gene has been shown to be associated with low bone mass in British women. To identify subjects with diabetes who may be at risk of developing osteoporosis and fractures, we analysed bone mineral density in relation to the biochemical markers of bone turnover, calcium homeostasis and the COL1A1 genotype in a group of premenopausal women with Type I (insulin-dependent) diabetes mellitus (n = 31), Type II (non-insulin dependent) diabetes mellitus (n = 21) and control subjects (n = 20). Bone mineral density was lower at the femoral neck in the subjects with Type I diabetes (p = 0.08) as were serum 25-hydroxyvitamin D compared with control subjects (p = 0.023) and this was negatively correlated with serum collagen type 1 C-terminal propeptide (r = -0.56, p < 0.001). Bone mineral density in Type II diabetes was not different from control subjects, after correction for body mass index. Bone resorption was, however, raised in the Type II diabetic subjects as reflected by the higher urinary deoxypyridinoline values (p = 0.016) and lower collagen type 1 C-terminal propeptide:deoxypyridinoline ratio (p = 0.04). In the whole group studied, subjects with the COL1A1 's' genotype had lower bone mineral density at the femoral neck (p = 0.01) which was partly attributable to a lower body mass index. Following multiple regression analysis body mass index and collagen type 1 C-terminal propeptide concentrations remained determinants of bone mass at all three sites, whereas genotype appeared to be a predictor of bone mass at the femoral neck only. We conclude that measurement of these variables could prove useful in firstly identifying those diabetic women at risk of osteoporosis and secondly guiding therapeutic intervention.

Interpretation of bone mineral density values in pediatric Crohn's disease

Patients with Crohn's disease (CD) often have low bone mineral density (BMD) for their chronological age (CA). However, pediatric cases frequently have growth failure and delayed bone age (BA) and height age (HA). Do they really have the amount of osteoporosis as measured by BMD and calculated for their CA? The aim was to compare z-scores for BMD in relation to CA and z-scores corrected for BA or height age in pediatric patients. A group of 43 pediatric patients (mean age, 12 years; 14 girls, 29 boys) with CD in remission, prospectively had BMD (measured by dual energy x-ray absorptiometry) and BA. Abnormally low z-score for BMD (below 2 standard deviation [SD] for CA was found in 19 patients (44%). Among these, 9 patients (21% overall) had a BA of more than 2 SD lower than their CA and 12 had height age at least 2 years below CA. When the BMD z-score in these patients was corrected for their BA and height age, 6 of 9 and 8 of 12 patients had a normal BMD. In conclusion, when corrected for BA or CA delay, BMD was abnormal in 26 to 30% rather than 44% of cases. Correct assessment of BMD in Crohn's disease patients with bone age delay requires interpretation in terms of BA or HA, rather than CA.

Satoyoshi's syndrome in an adult: a review of the literature of adult onset cases

Satoyoshi syndrome consists of painful intermittent muscle spasms, alopecia and diarrhea. The age of onset is commonly less than 20 years of age. Adult onset of this syndrome is rare. We report a 65-year-old Japanese woman with Satoyoshi's syndrome of adult onset. Satoyoshi's syndrome of adult onset shows no skeletal abnormalities, in comparison with the classical pediatric cases. The clinical features in our patient revealed the benign and long-term course of muscle spasm and alopecia. This progression differed markedly from the other patients of adult onset. Thus, the severity of Satoyoshi's syndrome is variable in adult onset cases, and this diagnosis should be considered in adults with various and unexplained muscle spasms.

Prospective bone mineral density evaluation in patients with insulin-dependent diabetes mellitus

The bone mineral density (BMD) in patients with insulin-dependent diabetes mellitus (IDDM) was evaluated prospectively to assess the course of osteopenia in IDDM. We measured BMD in the lumbar spine, femoral region, and total body calcium in 23 patients aged 21-53 years with IDDM for 2.3 to 20 years using a dual energy X-ray absorptiometry. A second BMD measurement was done after 26.5+/-4.1 months in all patients. The blood glucose control, insulin dosage, and disease duration were also assessed. Eleven patients had osteopenia (1 Z-score below the mean values of normal gender- and age-matched individuals). These patients had a longer IDDM duration (8.6+/-5.1 years in osteopenics versus 4.6+/-3.75 years in non-osteopenics; p=0.03). The blood glucose control and insulin dosage were not significantly different throughout the study. The mean spinal BMD was higher in the second evaluation in both osteopenics (0.91+/-0.12 g/cm2 and 0.96+/-0.09 g/cm2, p=0.035) and non-osteopenics (1.24+/-0.15 g/cm2 and 1.29+/-0.16 g/cm2; p=0.02). In the end of the study, however, the osteopenic group persisted with lower subnormal BMD values than the non-osteopenic group (p < 0.001). The small BMD increment observed in the spine did not correlate with changes in the metabolic control or with IDDM duration, but occurred mainly in patients younger than 30 years old. There was no significant change in the femoral BMD or total body calcium. None of the patients developed or significantly worsened the osteopenia. We conclude that diabetic osteopenia, despite being a complication of high prevalence in IDDM, seems to be non-progressive in the majority of patients. In some patients, the spinal BMD increased during observation and may have been due to achievement of peak bone mass.

Endemic chronic fluoride toxicity and dietary calcium deficiency interaction syndromes of metabolic bone disease and deformities in India: year 2000

Epidemiological studies during 1963-1997 were conducted in 45,725 children exposed to high intake of endemic fluoride in the drinking water since their birth. Children with adequate (dietary calcium > 800 mg/d) and inadequate (dietary calcium < 300 mg/d) calcium nutrition and with comparable intakes of fluoride (mean 9.5 +/- 1.9 mg/d) were compared. The toxic-effects of fluoride were severe and more complex and the incidence of metabolic bone disease (rickets, osteoporosis. PTH bone disease) and bony leg deformities (genu valgum, genu varum, bowing, rotational and wind-swept) was greater (> 90%) in children with calcium deficiency as compared to < 25% in children with adequate calcium who largely had osteosclerotic form of skeletal fluorosis with minimal secondary hyperparathyroidism. The syndrome of skeletal fluorosis and associated metabolic bone disease and deformity is a unique clinical entity classified as a variant of osteosclerotic form of skeletal fluorosis. This syndrome chiefly results from the biological impact of excess fluoride, low calcium, high PTH and 1,25 (OH)2D3 separately and through their interactions on bone structure and metabolism as studied by radiology, bone scanning, bone histomorphometry and relevant metabolic and endocrine laboratory investigations. Metabolically active and vascular bones of children accumulate fluoride at faster and greater rate than adults (at the sites of active growth). In calcium deficient children the toxic effects of fluoride manifest even at marginally high (> 2.5 mg/d) exposures to fluoride. Fluoride toxicity also exaggerates the metabolic effects of calcium deficiency on bone. The findings strongly suggest that children with calcium deficiency rickets reported in the literature should be re-investigated for possible fluoride interactions. Deep bore drinking water supply with fluoride < 0.5 ppm and improvement of calcium nutrition provide 100% protection against the toxic effects of fluoride and are recommended as the cost effective and practical public health measures for the prevention and control of endemic fluorosis.

[Prevalence of osteoporosis in the Czech Republic]

BACKGROUND

The objective of this study was to evaluate the prevalence of osteoporosis and osteopenia in Czech women and men aged 50 to 75 years.

METHODS AND RESULTS

Bone mineral density was assessed in an age-stratified random sample of 713 women and 429 men from two cities (Prague and Litomĕrice) in the lumbar spine, proximal femur and total body by dual X-ray absorptiometry and in the distal forearm by single X-ray absorptiometry. The proportion of women and men in each age group with bone density below specified levels at any of these skeletal sites was projected to the population structure of the Czech Republic. With advancing age, in women at 55 years and in men at 65 years of age the population with normal bone mineral density becomes smaller, and a greater proportion has osteopenia or osteoporosis. Overall, an estimated 428,000 women and 195,000 men over age 50 have osteoporosis and another 680,000 women and 435,000 men have osteopenia.

CONCLUSIONS

The results of this first population-based cross sectional study in the Czech Republic document a high prevalence of osteoporosis and osteopenia which is comparable with that published for the Netherlands and the United States. The results offer a basis for economical considerations in diagnosis, treatment and consequences of osteoporosis.

The prevalence of low bone mineral density in Dutch perimenopausal women: the Eindhoven perimenopausal osteoporosis study

The aim of this study was to estimate the prevalence of osteopenia and osteoporosis in perimenopausal women, and to assess determinants of low bone mineral density (BMD). All women born between 1941 and 1947 (aged between 46 and 54 years) living in the city of Eindhoven were invited to participate in the study: 5896 white Dutch women, representing 73% of the total number of Dutch women in this age group, were studied. Of these, 24% were using estrogen preparations and 19% had undergone hysterectomy, with or without oophorectomy. All women were interviewed and bone mineral density (BMD) of the lumbar spine was measured by dual-energy X-ray absorptiometry (DXA). Osteopenia and osteoporosis were defined according to the criteria proposed by a WHO working group. In the population studied the prevalence of osteopenia and osteoporosis was 27.3% and 4.1%, respectively. With progression from premenopause to menopause, the prevalence of osteoporosis increased from 0.4% to 12.7%, and that of osteopenia from 14.5% to 42.8%. An increased risk for low BMD (osteopenia and osteoporosis) was associated with age, menopausal status and smoking, while alcohol consumption, high body mass index (BMI) and use of estrogens had a protective effect. This study of a large population-based cohort of perimenopausal women revealed a high prevalence of low bone mass and, therefore, a higher risk for osteoporotic fractures. The data further suggest that, when issues on the long-term efficacy and safety of preventive treatments are resolved, it may be possible to identify women at higher risk who are most likely to benefit from screening strategies.

High prevalence of vitamin D deficiency and reduced bone mass in Parkinson's disease

Despite excessive hip fractures in patients with Parkinson's disease (PD), little is known about bone changes in these patients. We measured bone mineral density (BMD; Z scores) in PD patients and analyzed its relation to serum biochemical indices and sunlight exposure. We measured BMD in 71 patients in the second metacarpals and divided the patients into two groups according to functional independence; group 1, Hoehn and Yahr stages 1 and 2; and group 2, stages 3 to 5. In four of 20 patients in group 1 (20%), the Z score was less than -1.0, indicating osteopenia. In 51 patients in group 2, 31 (61%) had a Z score less than -1.0. The group 1 patients showed a normal mean serum level of 25-hydroxyvitamin D (25-OHD; 21.7 ng/ml), while most group 2 patients were in a deficiency range (group mean 8.9 ng/ml). Many group 2 patients were sunlight deprived. Both groups had elevated serum ionized calcium levels correlating positively with Hoehn and Yahr stage and markedly depressed serum 1,25-dihydroxyvitamin D (1,25-[OH]2D) concentrations, indicating that immobilization-induced hypercalcemia had inhibited 1,25-[OH]2D production. Z scores correlated positively with 25-OHD levels and negatively with parathyroid hormone concentration and Hoehn and Yahr stage. Vitamin D deficiency due to sunlight deprivation and hypercalcemia induces compensatory hyperparathyroidism, which contributes to reduced BMD in PD patients, particularly those who are functionally dependent. Low BMD increases risk of hip fractures in patients with PD but may be improved by vitamin D supplementation.

Prevalence of low femoral bone density in older U.S. adults from NHANES III

Most estimates of osteoporosis in older U.S. adults have been based on its occurrence in white women, even though it is known to affect men and minority women. In the present study, we used dual-energy X-ray absorptiometry measurements of femoral bone mineral density (BMD) from the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) to estimate the overall scope of the disease in the older U.S. population. Specifically, we estimate prevalences of low femoral BMD in women 50 years and older and explore different approaches for defining low BMD in older men in that age range. Low BMD levels were defined in accordance with an approach proposed by an expert panel of the World Health Organization and used BMD data from 382 non-Hispanic white (NHW) men or 409 NHW women ages 20-29 years from the NHANES III dataset. For women, estimates indicate 13-18%, or 4-6 million, have osteoporosis (i.e., BMD > 2.5 standard deviations [SD] below the mean of young NHW women) and 37-50%, or 13-17 million, have osteopenia (BMD between 1 and 2.5 SD below the mean of young NHW women). For men, these numbers depend on the gender of the reference group used to define cutoff values. When based on male cutoffs, 3-6% (1-2-million) of men have osteoporosis and 28-47% (8-13 million) have osteopenia; when based on female cutoffs, 1-4% (280,000-1 million) have osteoporosis and 15-33% (4-9 million) have osteopenia. Most of the older U.S. adults with low femur BMD are women, but, regardless of which cutoffs are used, the number of men is substantial.

[Lower bone density (osteopenia) in adolescent girls with oligomenorrhea and secondary amenorrhea]

Occurrence of reduced BMD among adolescent girls and young women due to certain specific oligomenorrhea or amenorrhea (anorexia nervosa, excessive sport or ballet, etc.) is well known. However the prevalence of osteopenia among 16-18 years old girls with the cycle disorders mentioned above--caused by "pure" hypothalamo-pituitary-ovarian insufficiency--is not yet sufficiently examined. The hormonal (FSH, LH, prolactin, LH/FSH, estradiol. testosterone, progesterone) and ion (Ca++,PO4(3-),Na+,K+,Cl-) parameters and the bone mineral density (BMD) of the lumbar spine of 19 girls age 16-18 with oligomenorrhea or secondary amenorrhea, due to hypothalamo-pituitary-ovarian axis insufficiency were investigated, and correlation were searched for among them. In 3 of the case significant BMD reduction was found with a value lower than the -2 SD. compared to the age, sex and race matched control values, showing definite osteoporosis. The BMD of 10 girls was between the -2.SD. and -1 SD.: they had osteopenia. Only 6 of them had normal BMD ranging from the -1 SD. to the +1 SD. Neither the ion or hormonal values, nor the clinical parameters (height, weight age, age at menarche, duration of amenorrheic period) showed correlation with the BMD values, except of the body mass index (BMI), which showed a loose positive linear correlation. The measured low BMD values have a significance, referring to a possible reduction in the peak BMD. Patients having low peak BMD have an inclination for earlier, and more sever osteoporosis and fractures in the climacteric decades. These results emphasize the need of effective and early treatment of adolescent bleeding disorders from the point of view of prevention of osteoporosis as well.

High prevalence of bone disorders after gastrectomy

BACKGROUND

Studies indicate that gastrectomy might alter calcium and bone metabolism, resulting in bone disorders. No data are currently available on the prevalence of bone disorders after gastrectomy.

METHODS

Sixty gastrectomy patients were investigated for serum parameters of calcium and bone metabolism 5 to 20 years postoperatively and compared to an age- and sex-matched healthy control population. Forty patients agreed to a radiological investigation of the spine by anterior-posterior and lateral radiographs of the thoracic and lumbar spine and by computed tomography (CT) osteodensitometry.

RESULTS

Serum calcium and 25-(OH)-vitamin D were decreased in gastrectomized patients, while parathyroid hormone and 1,25-(OH)2-vitamin D were increased. Serum parameters of calcium metabolism were altered in as many as 68% of patients. We found 31 vertebral fractures in 13 patients, 30 grade 2 vertebral deformities in 18 patients, and osteopenia in 15 patients, corresponding to a prevalence of 33%, 45%, and 37% in gastrectomized patients, respectively. The overall rate of gastrectomy patients having vertebral fractures and/or osteopenia was 55%. The risk of having a vertebral deformity was increased by more than sixfold after gastrectomy. Our study is the first report evaluating vertebral deformities in gastrectomized patients, and the largest series of gastrectomized patients investigated by CT osteodensitometry.

CONCLUSION

We found a high prevalence of bone disorders in gastrectomized patients, possibly resulting from disorders in calcium metabolism. Postgastrectomy bone disease might derive from a calcium deficit, which increases calcium release from bone and impairs calcification of newly build bone matrix.

Osteopenia in alcoholics after tibia shaft fractures

A marked reduction of 40-70% in regional bone mineral density (BMD) has been reported after fractures of long bones, and this post-traumatic osteopenia may to some extent persist for several years, perhaps lifelong. In this cross-sectional study, we investigated whether prolonged alcohol abuse had any effect on the degree of post-traumatic osteopenia after isolated tibia shaft fractures, the rationale for such a suspicion being the deranged bone metabolism found in alcoholics. We also wanted to investigate whether dual energy X-ray absorptiometry (DEXA) or quantitative ultrasound technique could detect differences between abusers and non-abusers in post-traumatic bone loss. We measured the BMD in 61 male patients with isolated tibia shaft fractures (1984-94) with the Lunar DPX-L and the Lunar Achilles. Twenty-four of the patients were verified to be high consumers of alcohol. After correction for differences in age and the time elapsed since the fracture event, we found significantly lower (11%; P = 0.017) BMD in the femoral neck of the fractured leg in abusers when utilizing the DEXA technique. No differences between abusers and non-abusers in BMD were detectable when using the ultrasound technique. We found a fair correlation (r = 0.63-0.81) between the DEXA and the ultrasound techniques in regions with spongious bone. Our findings suggest that alcohol abuse has some, albeit a limited, effect on the degree of post-traumatic osteopenia and that ultrasound measurements in the calcaneus are of little use in detecting an increased post-traumatic osteopenia in this patient group.

Site of osteodensitometry in perimenopausal women: correlation and limits of agreement between anatomic regions

Because the bone mineral density (BMD) in different anatomic regions is heterogenous the number of women who fulfill the World Health Organization definition of osteopenia or osteoporosis increases with the number of regions examined. The purpose of this study was to investigate the agreement between measurements of the spine, femur, forearm, and whole body following menopause. Two thousand and five healthy, perimenopausal women, mean age 50.6 years, were studied using Hologic QDR-1000/W and QDR-2000 densitometers. Though the BMD of different anatomic regions were correlated (r = 0.40-0.77, p < 0.01), the variability in each patient regarding T and Z scores between regions was considerable. For example, despite a high correlation (r = 0.67, p < 0.01) and no systematic difference between the T scores for total femoral and lumbar BMD, the limits of agreement (mean difference +/- 2 SD) for the comparison were -1.89 to 1.87. Femoral neck T scores were 0.5 SD lower than those of the other regions, confirming reports that the young adult reference for this measurement is disproportionally high. The prevalence of osteoporosis was 1.2% when femur total BMD was considered alone and 5.9% when lumbar and ultradistal forearm results were included. However, as many as 7.9% showed osteoporosis of the femoral neck when the Hologic T score was used, compared with 0.7% using National Health and Nutrition Examination Survey (NHANES) values. The choice of anatomic region and availability of appropriate young adult reference data has considerable impact on the apparent prevalence of osteoporosis. Given the heterogeneity between regions, a combination of spinal and femoral densitometry should be used in diagnosing osteoporosis, though this increases the prevalence of osteoporosis by 50% or more in perimenopausal women.

Prevalence of osteopenia and osteoporosis in a normal female Puerto Rican population

The World Health Organization criteria for the diagnosis of Osteopenia and Osteopoposis was applied to a control group of 33 females ages 50 to 59 years and 24 females ages 60 to 69 years. The general exclusion criteria for the selection of subjects included early menopause and diseases, use of drugs and toxic habits such as smoking and alcoholism, known to affect bone and mineral metabolism. Bone mineral densities were measured with a DEXA Hologic, model 1000. In the reference population mean peak bone mineral density expressed in g/cm2 was 1.051 (SD = 0.119) for the lumbar spine at age 30 to 39 years and for the femoral neck 0.861 (SD = 0.098) at age 20 to 29 years. Bone densities below 1 to 2.5 SD from mean peak bone mass ranged from 0.932 to 0.754 g/cm2 in the lumbar spine and 0.763 to 0.616 g/cm2 for the femoral neck. The mean age of the pooled group was 58.4 years. The prevalence of osteopenia in the pooled group was 42 % for the lumbar spine and 56% for the femoral neck and of osteoporosis, 12% for the lumbar spine and 8.7% for the femoral neck. A similar prevalence has been found by other investigators in hispanic populations. Such a high percentage of females with osteopenia implicates that bone densitometry must be done in the perimenopausal years and in young individuals at risk so as to proceed with early medical intervention to prevent osteoporosis.

Osteopenia and stable isotope ratios in bone collagen of Nubian female mummies

Stable carbon and nitrogen isotopes were analysed on bone collagen of 43 Sudanese Nubians from the X-Group period to test dietary hypotheses for the high frequency of osteopenia in this population. Stable carbon isotope ratios indicate that both normal and osteopenic individuals consumed the same mixed diet of C3 and C4 sources, which are assumed to have been constituted by the grain staples wheat/barley and sorghum/millet respectively. Females with osteopenia, however, have significantly elevated delta 15N values. The enrichment effect is greatest in the third and fifth decades of life, and is consistently patterned with microstructural and frequency differences previously reported by other researchers. It is suggested that delta 15N is reflecting differences in urea excretion and the renal processing and clearance of calcium and phosphorus. The study not only alerts us to the susceptibility of stable nitrogen isotopes to non-dietary (i.e. physiological) factors, but also identifies nitrogen isotope ratios as a possible new marker for osteopenia.

Vitamin D, calcium, and bone status in children with developmental delay in relation to anticonvulsant use and ambulatory status

Reports of abnormalities in vitamin D, calcium, and bone status associated with anticonvulsant use are inconsistent and difficult to interpret because of widely varying study designs, particularly for ambulatory status. We examined the relative effects of anticonvulsant use and ambulatory status on vitamin D, calcium, and bone status in a large group (n = 338) of children who had either normal motor function (ambulatory) or were nonambulatory and either receiving anticonvulsants or not; all had developmental delays. Data included diet records, serum analyses (calcium and calcidiol), and hand-wrist radiographs evaluated for bone maturation and quality. Data were analyzed by using a general linear models (GLM) procedure. Dietary and biochemical data were compared with those of a group of 34 normal children. There were no differences in calcium or vitamin D intakes among the four study groups; however, a high percentage of intakes was below the recommended dietary allowances for calcium (56%) and vitamin D (70%). Vitamin D intakes were positively associated with serum calcium (P < 0.005) and calcidiol (P < 0.01) concentrations. Analysis of covariance indicated that ambulatory status but neither anticonvulsant use nor their interaction contributed significantly to the prediction of serum calcium (P < 0.009) and calcidiol (P < 0.0001), the Z scores for number of ossified centers (P < 0.008), bone age (P < 0.0001), and bone area (P < 0.003). A strong interaction between anticonvulsant use and ambulatory status was seen for percentage cortical area (P < 0.0008), which was entirely due to anticonvulsant use in nonambulatory children (effect size = 0.98). Results suggest that ambulatory status is more important than was recognized previously in relation to abnormalities in vitamin D, calcium, and bone statuses; that all nonambulatory children may be at risk for low serum calcidiol and osteopenia; and that routine monitoring of risk and consideration of prophylactic vitamin D supplementation are warranted.

Reduction of bone mass in women after bone marrow transplantation

Osteoporosis is a common disease among patients undergoing transplantation. Its prevalence and complications have been well described in solid organ recipients, especially kidney, liver, and heart. However, studies in bone marrow transplantation (BMT) are scarce. Among the mechanisms invoked in the pathogenesis of BMT osteoporosis are the baseline disease, the use of immunosuppressive drugs and, more remarkably, secondary hypogonadism. We present a study of 27 women who underwent BMT, all of them suffering ovarian failure. We studied different biochemical markers of bone formation/resorption and also evaluated the presence of osteopenia/osteoporosis by dual energy X-ray absorptiometry (DXA) of the lumbar spine. Osteopenia was observed in nine patients (33%) and osteoporosis in another five (18%), according to the World Health Organization criteria. We also detected a subgroup showing elevation of several bone turnover biochemical markers, indicating high osseous remodeling. A remarkable increase in urine hydroxyproline/creatinine was detected in 95% of cases, although an explanation is lacking. We outline a reasonable therapeutic approach for osteoporosis in BMT emphasizing the need to monitor these patients after transplantation.

[The incidence of hip fractures in pre- and postmenopausal women in Panama]

During the year 1994, 318 women suffered from hip fractures in the Republic of Panama. Of these, 310 fractures occurred in post-menopausal women (97.5%). The rate of hip fractures in post-menopausal women is 191.76 by 100,000 women of fifty or more years of age. Both public health and other civic entities should organize a nationwide campaign to prevent osteoporosis and fractures in general.

The relationship of fluorosis and brick tea drinking in Chinese Tibetans

Brick tea-drinking fluorosis is an unusual environmental problem. As a result of an investigation of tea-drinking habits, total fluoride intakes, dental fluorosis, and skeletal fluorosis, this disease has been found in the Sichuan Province of China in Tibetans with a long history of drinking brick tea. The dental fluorosis investigation of 375 Tibetan children (213 males, 162 females) and 161 Han children (86 males, 75 females), 8-15 years of age, was carried out in Daofu County, Sichuan Province. According to the standard of the Chinese Health Ministry, a skeletal fluorosis survey of 658 Tibetans (264 males, 394 females) and 41 Hans (20 males, 11 females), all over 16 years old, was performed. The total fluoride intake and fluorosis were determined from a question--calculation method in all participants. The morbidities of dental fluorosis in Tibetan and Han children are 51.2% and 11.05%, respectively, and the indexes of dental fluorosis are 1.33 and 0.17 (chi 2 = 75.7, p < 0.01) respectively. The morbidity of skeletal fluorosis is 32.83% for Tibetan children and zero for the Han children. The fluoride intakes of Tibetan children and adults were 5.49 mg/person/day and 10.43 mg/person/day, respectively, in this area. Of total everyday fluoride intake, 94.2% by children and 94.4% by adults was from brick tea and zanba (r = 0.99).

Retired elite female ballet dancers and nonathletic controls have similar bone mineral density at weightbearing sites

Elite female ballet dancers exhibit several risk factors for osteoporosis during their performing years. To study the long-term effect of this lifestyle, we compared the bone mineral density (BMD) of 101 retired elite female ballet dancers (mean age 51 years, SD = 14 years) and 101 normal controls, derived from a twin study, matched hierarchically for age, height, weight, and menopausal status. The dancers, who had been retired for a mean of 25.6 years (range 1-53 years) reported a greater prevalence of previous menstrual disturbance, greater lifetime alcohol intake and smoking, and a lower dietary milk intake in adolescence than controls (all p < 0.05). However, current exercise in the dancers was twice that of the controls (p < 0.01). The BMD of retired dancers did not differ from that of the controls at weightbearing sites. The mean +/- SE difference in BMD (dancers minus controls) was 0.009 +/- 0.013 at the total body, -0.009 +/- 0.018 at the total hip, 0.005 +/- 0.017 at the femoral neck, 0.014 +/- 0.018 at the femoral trochanter, 0.036 +/- 0.022 at the femoral intertrochanter and -0.017 +/- 0.021 at the lumbar spine. Retired dancers had lower mean (+/- SE) BMD at the nonweightbearing sites: ultradistal radius (-0.029 +/- 0.008) (p < 0.01) and at the midthird radius (-0.019 +/- 0.011) (p < 0.05). There was no difference in the proportion in each of the World Health Organization (WHO) categories of osteopenia (t score -1.0 to -2.5) and osteoporosis (t score < -2.5) at any of the measured sites. Regression analysis revealed that menstrual disturbance was negatively associated with BMD at the lumbar spine and the ultradistal radial sites, but not at the weightbearing femoral sites. This sample of retired elite ballet dancers who had multiple historical risk factors does not appear to have an increased risk for future hip or vertebral fracture based on WHO standards.

Factors associated with bone mineral density in middle-aged men

This cross-sectional population-based study examined the association of anthropometric and lifestyle risk factors with bone mineral density (BMD) in 218 white ambulatory men aged 50-64 from the Rancho Bernardo, California cohort. BMD was measured at the lumbar spine and hip using dual-energy X-ray absorptiometry and at the ultradistal wrist and midshaft radius of the forearm using single-photon absorptiometry. Body mass index (BMI) was significantly correlated with BMD at all four skeletal sites. Overall, 17.0% of men aged 55-64 were osteopenic (BMD > or = 2 SD below the distribution for ages 50-54) at one skeletal site, 16.5% were osteopenic at two sites, and 13.6% were osteopenic at three or more sites. Men who reported regular exercise had significantly higher BMD levels at the spine and hip. Men meeting the recommended daily allowance (RDA) for calcium intake (> or = 800 g/day) had significantly higher BMD levels at the spine and wrist. Alcohol intake and smoking were associated with differences of borderline significance in BMD at the spine. In analyses adjusted for BMI, weight change, exercise, smoking, drinking, and calcium intake, there was a significant independent age-related decline in BMD at the hip (0.008 g/cm2/year; p = 0.001), at the wrist (0.004 g/cm2; p < 0.01), at the forearm (0.006 g/cm2; p < 0.01), but not at the spine (0.005 g/cm2). These data, although cross-sectional, strongly suggest that age-related bone loss occurs in middle-aged men and that both physical activity and an adequate calcium intake are associated with better bone density.

Long-term bone loss in kidney transplant recipients: a cross-sectional and longitudinal study

Organ transplantation is associated with an early bone loss that subsequently increases the risk of osteopenia and bone fractures. It is not known whether bone loss continues in long-term survivors, but persistent bone demineralization could further jeopardize an already diminished bone mass. To better define long-term bone status of kidney transplant recipients (KTR), we conducted cross-sectional and longitudinal evaluations of bone mineral density (BMD) in 70 KTR with a mean posttransplantation time of 8.1 years. BMD was determined by dual-energy X-ray absorptiometry and was repeated in 55 of the patients after a mean follow-up period of 22 +/- 5 months. Lumbar and femoral osteopenia, defined as a BMD lower than 2 standard deviations from mean value of sex- and age-matched controls, was present in 28.6% and 10.5% of patients, respectively. There was a significant negative correlation between cumulative prednisone dose and adjusted lumbar as well as femoral BMD (R = 0.45, P < 0.001 and R = 0.29, P < 0.05, respectively). Five patients had a vertebral BMD below a fracture threshold of 0.777 g/cm2. Vertebral fractures (VF) were found in four men and were associated with higher prednisone dosage (P < 0.05), larger cumulative prednisone dose (P < 0.05), and significantly lower BMD values. According to World Health Organization recent criteria for women, prevalences of lumbar and femoral osteopenia and lumbar and femoral osteoporosis in female patients reach 75%, 65%, 33%, and 10%, respectively. The longitudinal part of the study showed a persistent pathological lumbar demineralization process. Over the study period, BMD, expressed as a percentage of that of controls, decreased from 89 +/- 14% to 86 +/- 14% (P < 0.001). Annual change of bone mass was -1.7 +/- 2.8% per year. Accelerated vertebral bone loss (defined as a decrease of BMD, expressed as a percentage of that of controls, of more than 1% per year) was present in 56% of patients and was associated with higher prednisone dosage (P < 0.01). In conclusion, although VF are relatively infrequent in long-term survivors of renal transplantation, osteopenia is a frequent finding, and a substantial proportion of women present lumbar osteoporosis. An ongoing demineralization process of the spine is also demonstrated and probably contributes to long-term spinal osteoporosis incidence. Prednisone dosage remains the most constantly isolated risk factor.

Frequency of metabolic bone disease in haemodialysis patients

The frequency of metabolic bone disease related to secondary hyperparathyroidism was studied in 47 haemodialysis patients, using biochemical, radiological parameters and bone biopsy (30 males, 17 females; mean age 48 years). The duration on dialysis ranged from 1-5 years. Hypocalcemia was found in 47% while 62% had raised phosphorus levels and 49% raised alkaline phosphatase. Serum parathyroid hormone was elevated in 86%, while in 13% it was markedly raised. On radiological examination there was generalized osteopenia in 49% and decreased bone density in 21%. In 30% no radiological abnormality was detected. In 40% bone biopsy revealed osteomalacia, mixed osteodystrophy 21%, osteoporosis 8.5% and in 25% no histological abnormality was observed.

Vertebral fracture epidemiology

Vertebral fractures are the most common but least understood of all osteoporotic fractures. Their study has been hampered by the lack of a common morphometric definition, and the fact that many vertebral fractures are asymptomatic and not clinically evident. Population-based radiographic surveys are therefore required for comparative studies. Risk factors fall into five major categories: (1) age, or age-related, (2) genetic, (3) environmental, (40 endogenous hormones or chronic diseases, and (5) physical characteristics of bone. Bone density is the most clinically useful risk factor, particularly for purposes of prevention. Because vertebral fracture prevalence parallels levels of bone density, bone density is also useful for epidemiological surveys. Based on WHO diagnostic criteria, 54% of postmenopausal white women in the United States have osteopenia, and another 30% have osteoporosis. Existing fractures are also strong, independent predictors of future vertebral fracture risk, but also represent a later, and less treatable, stage of the disease.

No evidence of osteopenia 5 to 8 years after ileal orthotopic bladder substitution

PURPOSE

The use of bowel segments as bladder substitutes may result in chronic, impaired vitamin D and calcium metabolism, and ultimately in bone demineralization.

MATERIALS AND METHODS

Bone metabolism was examined in 14 patients who lived for 5 to 8 years with an ileal low pressure bladder substitute after radical cystectomy for bladder cancer. Bone mineral density was measured using dual energy x-ray absorptiometry of the total skeleton, lumbar spine, femoral neck, and tibial epiphysis and diaphysis. Laboratory studies included serum levels of 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D, intact parathyroid hormone, plasma alkaline phosphatase, electrolytes, creatinine and blood gas analysis.

RESULTS

Bone mineral density was normal in all patients. There was no evidence of deficient vitamin D stores. There was a tendency toward slightly elevated serum creatinine values in patients with preexisting impaired renal function, including 1 who also had slight acidosis. No patient had hyperchloremia.

CONCLUSIONS

We found no evidence of osteomalacia, osteoporosis or significant metabolic acidosis in 14 patients with an ileal bladder substitute for 5 to 8 years. However, it is not known whether the absence of osteopenia would also apply to patients with poor renal function, to those not followed meticulously and, thus, at risk for major long-term functional or metabolic disturbances from the ileal bladder substitute or to patients with orthotopic bladder substitutes made from longer or other bowel segments than we used.

Prevalence of metacarpal osteopenia in young rheumatoid arthritis patients

The aim of this study was to assess the prevalence of and diagnostic role of metacarpal osteopenia in rheumatoid arthritis (RA) and to evaluate its detectability using receiver operating characteristic (ROC) analysis. Metacarpal bone mineral density was measured in 98 patients with classical RA using a computer-assisted measure of 6 metacarpal diameters (radiogrammetry) in patients aged less than 50 years. Sensitivity and specificity of the technique in discriminating the RA patients from 85 normal controls and osteopenic RA subjects from their normopenic counterparts, was determined by standard statistical techniques. Clinical, laboratory and radiological variables were compared in their ability to explain the variance of metacarpal bone density. The prevalence of metacarpal osteopenia in RA was 55%. Prolonged disease and reduced function significantly differentiated osteopenic from non-osteopenic RA patients. Discriminant analysis of RA and control groups showed that measurement of 6 metacarpals was more accurate than the 2nd metacarpal measurement alone in predicting the RA patients. The sum of 6 metacarpal combined cortical width (CCW) had a sensitivity of 61% and specificity of 68% in discriminating the RA patients from the controls. Receiver operating characteristics curves showed, not surprisingly, that objective measurement of bone diameters was superior to clinical or laboratory measures of disease activity in correctly classifying a randomly chosen RA patient as osteopenic or not. Metacarpal osteopenia is common in RA and it may be a useful measure of the disease in young patients.

Bone fractures in children undergoing orthotopic liver transplantation

This retrospective study documents the incidence and distribution of fractures in 117 children with end-stage liver disease who underwent orthotopic liver transplantation (OLT) over a 6-year period (1987-1993). Both the pre- and post-OLT phases were included. Nineteen children (16.2 %) sustained a total of 69 fractures. Age at time of fracture ranged from 3 months to 9 years 8 months (median 13.5 months). There was no documented trauma in 14/19 cases. Metabolic bone disease, assessed qualitatively on plain radiographs, was present in 17/19 children at the time of fracture. This took the form of rickets (n = 3), osteopenia (n = 12) and osteosclerosis (n = 2). Potential risk factors including pre-existing metabolic bone disease, drugs and immobilization were assessed. The findings emphasise the need for clinical and radiological awareness of the fracture risk, particularly during the peri-transplant period when this risk may be greatest.

An investigation into the health and welfare of red squirrels, Sciurus vulgaris, involved in reintroduction studies

The threats posed by parapoxvirus infection, metabolic bone disease and coccidiosis to the reintroduction of red squirrels into Thetford Chase were investigated by making blood biochemical, radiological and parasitological examinations on the squirrels before they were released and on resident squirrels. Red squirrels found dead in Thetford Chase were examined post mortem by parasitological, electron microscopical and radiological techniques. Parapoxvirus infection was the probable cause of death of two red squirrels. Parapoxvirus infection may be a significant threat to remnant populations of red squirrels in England, and to the success of conservation measures.