The effects of treatment and the individual responsiveness to growth hormone (GH) replacement therapy in 665 GH-deficient adults. KIMS Study Group and the KIMS International Board

Data from 665 adults with GH deficiency (GHD; 332 women; 169 childhood-onset GHD; mean age, 44 yr) were analyzed to determine the efficacy of and individual responsiveness to GH replacement therapy. GH replacement was started at enrolment into KIMS (Pharmacia & Upjohn, Inc. International Metabolic Database). Mean maintenance doses of GH after 6 and 12 months were 0.43 and 0.53 mg/day (1.3 and 1.6 IU/day) for men and women, respectively. Serum insulin-like growth factor I (IGF-I) SD score increased from -2.2 and -4.2 in men and women, respectively, to 1.8 and -0.9 at 6 months and 0.8 and -0.7 at 12 months. The waist/hip ratio decreased after 6 and 12 months, with the changes more pronounced in men. The waist/hip ratio was not influenced by age of onset of GHD, severity of hypopituitarism, or gonadal status. Total cholesterol decreased significantly in men, and high density lipoprotein cholesterol increased in women. Systolic blood pressure was unchanged during GH therapy, but diastolic blood pressure decreased in women. Quality of life, determined by a specific questionnaire for assessment of GHD in adults, improved after 6 and 12 months of GH therapy; this was more pronounced in adult-onset than in childhood-onset GHD, but was not influenced by gender, severity of hypopituitarism, or gonadal status. In 80% of patients, the starting dose of GH was 0.27 mg/day or less. This and the absence of a correlation between body weight and change in IGF-I were consistent with a dose-titration approach, which would tend to obscure individual variations in responses (determined by IGF-I levels). Nonetheless, the increase in IGF-I was significantly higher in men than in women on similar mean GH doses. Weak correlations were observed between the maintenance dose of GH and the change in IGF-I in men and women receiving sex steroid replacement, but not in patients with untreated hypogonadism or an intact gonadotropin reserve. Similarly, the increment in IGF-I was not related to the severity of GHD, as determined by the number of additional pituitary hormone deficiencies. Differences in IGF-I generation may partly explain the gender differences in reduction of central adiposity. These data highlight the value of large longitudinal surveillance databases in defining the optimum dose regimen for GH replacement and indicate that women may need a higher replacement dose of GH than men.

GH replacement in 1034 growth hormone deficient hypopituitary adults: demographic and clinical characteristics, dosing and safety

OBJECTIVE

Long-term experience of growth hormone (GH) replacement therapy in a large population of hypopituitary adults with GH deficiency (GHD) is limited, and safety surveillance is clearly essential. KIMS, the Pharmacia & Upjohn International Metabolic Database, is a long-term, open, outcomes research programme of hypopituitary adult patients with GHD who are treated in a conventional clinical setting.

PATIENTS

The present analysis encompasses data from 1034 hypopituitary adult GHD patients treated with GH for a total of 818 patient years.

RESULTS

Prior to GH therapy, the KIMS patient population exhibited an increased prevalence of obesity, diabetes mellitus (in females) and hyperlipidaemia, compared with normal populations described in published studies. Quality of life, assessed using a disease-specific questionnaire (QoL-AGHDA), was also reduced in KIMS patients. The maintenance dose of GH was significantly higher in patients who were receiving GH prior to enrolment into KIMS (non-naive patients) compared with patients who commenced GH at the time of enrolment (naive patients). In addition, dose of GH correlated significantly with body weight in the former group of patients. Analysis of serum levels of IGF-I indicated that overtreatment with GH was markedly more common in non-naive than in naive patients. The frequency of adverse events in KIMS patients was no higher than that reported in patients receiving placebo in previous clinical trials. Recurrence of pituitary or CNS tumours was reported in six patients, a rate consistent with data from control series. Three deaths were reported, none of which was obviously associated with GH treatment.

CONCLUSIONS

Our data, drawn from a large population of hypopituitary adults treated with GH for a total of more than 800 patient years, confirm previous reports that untreated GHD in hypopituitary adults is associated with a number of important clinical problems. In addition, the results suggest that there has been a shift in recent years from determination of GH dose on the basis of body weight to dose titration of individual patients, and indicate that the latter technique has important advantages. The data provide further evidence that GH replacement therapy is well-tolerated in adults. However, it is possible that some adverse events may not become evident over the time scale covered by the present analysis, and continued surveillance therefore remains mandatory.

[Quantitative bone ultrasound (QUS) of the heel bone for diagnosis of osteoporosis in the general community]

OBJECTIVE

The aim of the present study was to investigate how quantitative bone ultrasonometry (QUS) can detect patients at risk for osteoporosis in a general community.

MATERIAL AND METHODS

260 women aged 63 +/- 10 were examined using questionnaire, osteological history and QUS (Achilles+).

RESULTS

The most frequent osteoporosis risk factors were: no estrogens, no sports and osteoporosis within the family. Risk-patients had lower QUS values compared to persons without risk-factors. There was a negative correlation of ultrasound parameters with age, but not with height or weight. Patients showed a mean loss of body height of -1.2 +/- 1.8 cm versus height in passports, which was positively correlated with QUS. 30% of patients with osteoporosis (T = -2.3 +/- 1.4 SD) had lower QUS than those without (T = -1.4 +/- 1.4 SD). 22% have had a atraumatic fracture (T = -2.5 +/- 1.4 SD), 12 patients had suffered a hip fracture (T = -2.8 +/- 1.8 SD) and 15 patients had a vertebral fracture (T = -2.6 +/- 1.6 SD). Patients on estrogens had T = -1.5 +/- 1.4 SD, which was higher than in those without HRT (T = -2.0 +/- 1.3 SD, p < 0.05).

CONCLUSIONS

We conclude from this study that risk patients for osteoporosis can be detected within the community using QUS. QUS is able to detect differences between treated and untreated and can be used in clinical practice to manage patients with osteoporosis risk.

Stiffness index identifies patients with osteoporotic fractures better than ultrasound velocity or attenuation alone

OBJECTIVES

To compare a composite ultrasonometry variable, the stiffness index (SI), with its two component variables of speed of sound (SOS) and broadband ultrasound attenuation (BUA), in identifying post-menopausal women with low bone mineral density (BMD) and/or osteoporotic fracture.

METHODS

A cross sectional sample of 1217 women (mean (S.D.) age 53.9 (9.7) years) was studied. Risk factors for osteoporosis were assessed by detailed questionnaire and women with diseases, or those taking treatments known to affect bone metabolism were excluded. Women were allocated to one of four groups: pre-menopausal women (n = 476), healthy post-menopausal women (n = 583), post-menopausal women with low BMD (n = 101), and post-menopausal women with osteoporotic fracture (n = 57). An Achilles ultrasonometer was used to perform quantitative ultrasonometry (QUS) at the os calcis. The SI. calculated mathematically from SOS and BUA, was computed.

RESULTS

Analysis of receiver operating curves (ROC) between healthy post-menopausal women and post-menopausal women with low BMD but no fracture, showed that the area under the curve (AUC) for SI was significantly greater than that for BUA (P < 0.001) or SOS (P < 0.05). For healthy post-menopausal women compared to women with fracture, the area AUC for SI was significantly greater than that for BUA (P < 0.05) or SOS (P < 0.001). No significant difference was found for AUC between BUA and SOS.

CONCLUSION

QUS variables discriminated women with low density or fracture from healthy postmenopausal controls. The SI was a significantly better indicator than BUA or SOS in this retrospective study.

Quantitative ultrasonometry (QUS) for the evaluation of osteoporosis risk: reference data for various measurement sites, limitations and application possibilities

Osteoporosis is a wide-spread disease characterized by low bone mass, deterioration of bone structure and typical fractures, which lead to pain, disability and high costs for health systems. Quantitative Ultrasonometry (QUS) is a new, non-invasive method to study bone density and structure in vivo. This technique has the following advantages: it is safe; it is easy to use, there is no radiation load on the patient, and instruments can be transported and are relatively cheap, as compared with the substantially more expensive methods of traditional osteodensitometry (dual X-ray absorptiometry = DXA, quantitative computed tomography = QCT). For measuring the osteoporosis risk, QUS has the same value as the conventional radiological osteodensitometry methods (QCT, DXA) The combination ofQUS, DXA and QCT improves the message. At present, there are three measurement sites for QUS measurement at the skeleton: the calcaneus, the tibia and the phalanges. The oldest method is the calcaneus measurement, and instruments with and without a water bath are available for this purpose. QUS might be a screening method for osteoporosis. Currently QUS can already be used in clinical practice. It can, for example, be an aid in decision-making for female patients who do not wish to have a postmenopausal hormone replacement therapy (HRT) or who can only barely tolerate doses with a bone-protective effect. In addition, patients can be examined before and after a glucocorticoid therapy with regard to a possible loss in bone mass. As a third possibility, QUS provides a further opportunity for subdividing into development stages patients with an established osteoporosis resulting in fractures, since there is an indication that by means of QUS it may be possible to account for more structural bone changes than with the traditional DXA or QCT methods. Treatment can also be monitored by means of QUS. As prospective studies have shown, increases in SOS by HRT and alendronate and precision error of QUS are lower than expected changes. Due to the greater practicability of QUS (no radiation load, portable instruments), this method ought to be further used in research and clinical settings, and more experience ought to be collected with this method so that wide-ranging experience can help the management of our patients.

[Reduced incidence of side-effects of growth hormone substitution in 404 patients with hypophyseal insufficiency. Results of a multicenter indications study]

BACKGROUND

Substitution of pituitary insufficient patients with recombinant human growth hormone (rhGH) in addition to the conventional substitution with glucocorticoids, L-thyroxine and sex hormones has been approved by the regulatory authorities in 1995 with the imposition to conduct surveillance studies to monitor drug safety.

RESULTS

24% of all patients were within their 2nd treatment year, 15% within their 4th year, maximum treatment period was 6 years. There were 2 peaks within the patients age distribution: 30 to 39 years (24%) and 50 to 59 years (24%). The causes for pituitary disease were as follows: pituitary adenomas (47%), idiopathic (16%), craniopharyngeomas (16%) and others (21%). Mean GH dose was 1.5 IU/d s.c. (range 0.4 to 4 IU/d). Serum-IGF-1 increased by 159 and 192% in females and males. Waist circumference decreased by 2% and serum cholesterol was lowered by 5.5% in males. There were 2 cases with new carcinomas, 1 diabetes mellitus II and 1 death. Adverse events (AEs) within KIMS were compared to those of the treatment (GH) and placebo (PI) groups of the previous admission trials (in percent): edema: KIMS 10, GH 37, Pl 3; arthralgia: KIMS 8, GH 19, Pl 2; muscle pain: KIMS 3, GH 16, Pl 3; dizziness: KIMS 2, GH 1, Pl 3; headache: KIMS 2, GH 3, Pl 2; others: KIMS 2, GH 22, Pl 13. The reported incidence of AEs in KIMS was lower than in previous clinical trials. There might be 3 reasons for this: 1. under-reporting, particularly those AEs not likely to be related to GH treatment; 2. doses used in trials were 2-fold higher than in KIMS; 3. dose titration for individual patients.

CONCLUSION

Surveillance programs are important for monitoring of drug long-term efficacy and safety.

[Multiple endocrine neoplasia associated with multiple lipomas]

BACKGROUND

Multiple endocrine neoplasia type 1 (MEN-1) is characterized by tumors of the parathyroids, the neuroendocrine pancreas-duodenum and the anterior pituitary, but shows also a wide clinical variety of other symptoms.

CASE REPORT

We present a case of a 68-year-old woman with a 18 year history of MEN-1 consisting of gastrinoma and primary hyperparathyroidism. Beside these typical symptoms, the patient suffered from thyroid adenoma, malignant kidney tumor and multiple subcutaneous lipomas.

RESULT

While the number of autopsies declined from 113 in 1977 to 66 in 1984, the number of diagnostic techniques used increased continuously (94, 107, 118 and 140, amounting to 0.83, 1.34, 1.76 and 2.12 per patient). The premortal detection of abdominal abnormalities increased globally from 16.8 to 32.5%. This increase was largely due to better diagnosis of liver and gallbladder abnormalities which were in most cases of little relevance.

CONCLUSION

Whether these non-endocrine tumors are associated to MEN-1 is unclear and has to be tested by examining the chromosomal regions 11q13 and 11q24/25 of the tumors sample, in which the possible MEN-1 involved tumor suppressor genes are located.

Ultrasound transmission speed and ultrasound bone profile score (UBPS) of the phalanges in normal women and women with osteoporosis

The distal metaphysis of the first phalanx of the fingers II-V is, like the vertebral body, a useful site for the measurement of mineralisation and structure of the bone because of the simultaneous presence of compact and trabecular bone. With an ultrasound device (DBM sonic 1200, IGEA, Italy), we measured the adSOS (the amplitude dependent speed of sound) and the UBPS (ultrasound bone profile score), a score which is calculated from the graphic traces of the receiving probe with an expert system which uses fuzzy-logic at phalanges II-IV, as well as bone mineral density (BMD) at lumbar spine using dual X-ray absorptiometry (DXA). Precision of the measurements was as follows: adSOS: short-time-CV% = 0.576, long-time-CV% = 1.1, SCV% = 5.9, RMSSD% = 1.825. UBPS: short-time CV% = 5.95. There was no correlation between adSOS or UBPS and lumbar BMD (DXA). There was a significant positive correlation between adSOS and UBPS, r = 0.804 (p<0.00001). The validity of adSOS and UBPS was examined in 25 young and healthy women (mean age: 33.4 year), 15 postmenopausal healthy women (mean age: 58.5 years), 17 women with osteopenia, (mean age: 52.4 years), as defined by a t-score between -1 to -2.5 SD as lumbar BMD (DXA), and 20 women with osteoporosis and vertebral fractures (mean age: 61.4 years). We compared the healthy postmenopausal women and the women with osteoporotic vertebral fractures, the z-score of the adSOS was below minus 1.5 SD and UBPS was below 40, sensitivity was 0.7 for adSOS, and 0.85 for UBPS, with a specificity 0.97 for adSOS, and of 0.93 for UBPS; positive predictive value: adSOS: 0.93, UBPS: 0.85. AdSOS declined with age (r= 0.694, p=0.021); the UBPS was not age dependent (r=-0.15, p = n.s.). The ROC-curve shows a value of 0.96 for adSOS and 0.94 for UBPS. AdSOS and UBPS could discriminate well between the healthy controls and the women with osteopenia or vertebral fractures (p<0.00001). These results show that adSOS and UBPS are precise parameters to be measured at the phalanges. The detection level of pathological changes in osteoporosis are similar between adSOS and lumbar BMD (DXA) and improved by using the UBPS. This might be explained by the influence of structural changes in bone on UBPS, rather than change in bone mineral alone. Prospective studies have to clarify the role of adSOS and UBPS in fracture prediction.

[Measuring bone density with ultrasound--ready for general practice?]

Osteoporosis is characterized by low bone mass, loss of bone structure and/or typical fractures (vertebrae, radius, hip). The costs for the treatment of hip fractures in Germany are about 1 billion DM per year, the mortality rate after hip fractures is between 10 and 30% within the first year. Low bone mass is an important risk factor for the development of fractures; so far however, no procedure for the measurement of bone density has been able to 100 percent differentiate between patients with established osteoporosis and healthy people of the same age. This is due to the fact that the defect in bone structure causing the disease could not be measured so far. Quantitative ultrasonometry (QUS) is a new, non-invasive, radiation-free method for the in vivo measurement of bone density and bone structure. Measurements at the calcaneus and at the phalanxes have shown the equivalence of QUS compared to radiological methods in prospective studies with regard to the prediction of hip fractures. Furthermore it was shown that the beneficial osseous effects of postmenopausal estrogen/gestagen replacement therapy can be detected by QUS. Since QUS is considerably cheaper and the devices are easily transportable, this method is a valuable supplement in the range of diagnostic tools in osteology. Its clinical value however depends on the experience of the user and it should be applied in patients only together with medical history, physical examination and perhaps additional imaging procedures. It was not the inadequate methodology that has brought osteodensitometric methods into discredit but the undifferentiated handling by inexperienced users.

Weight-/height-related bone mineral density is not reduced after renal transplantation

Growth retardation is a frequent finding in patients after renal transplantation (Tx). Areal bone mineral density (BMD) in these patients has usually been reported to be low for age. We investigated the possible influence of height and weight retardation on the measurement of BMD in lumbar spine (BMD(L2-4)) and total body (BMDbody) using dual-energy X-ray absorptiometry in 44 (13 female) pediatric Tx patients with a median age of 13.1 (range 3.3-23.1) years. Patients were studied at 2.9 (range 1-10) years after Tx. Median body height in female and male patients was -2.10 (-3.6 to -0.3) and -2.35 (-5.3 to +1.0) standard deviation score (SDS), respectively. BMD expressed as grams per square centimeter bone area according to age was below the 5th percentile in 10 of 44 patients, but only 1 patient had low values for BMD(L2-4), and none for BMDbody, when the data were corrected for height or weight. BMDbody was closely correlated with height, weight, and body surface area (r=0.88), whereas the correlation for BMD(L2-4) was less (r=0.76). In 6 patients who achieved final height, height SDS was -2.27 (-4.3-0.4). Z-scores for BMDbody related to age, height, and weight were -1.0 (-2.6 to -2.3), 1.25 (0.1-3.4), and 0.81 (0.0-2.4), respectively. There was no age-dependent change when areal BMD values (g/cm2) were corrected for vertebral size to obtain bone volumetric density (BMDvol, g/cm3). Independent of height, cumulative methylprednisolone dose correlated negatively with BMD(L2-4) only in patients who had received a total dose of more than 6 g/m2 of the drug (r = -0.54, P= 0.045). In conclusion, BMD in pediatric patients after Tx is no longer diminished when the data are corrected for height or weight rather than age, or when the data are expressed as bone volumetric density.

Measurement of forearm bone mineral density: comparison of precision of five different instruments

Measurement of bone mineral density (BMD) is used for clinical estimation of fracture risk in osteoporosis. The precision of the method is important for the evaluation of true and clinical relevant changes in BMD in patients with osteoporosis. We measured BMD of the forearm in 14 young, healthy probands (10 males, 4 females), aged 24. 6 +/- 1.5 years with five different instruments using dual-energy X-ray absorptiometry (DXA), single-photon absorptiometry (SPA), and peripheral quantitative computed tomography (pQCT). Precision was expressed as the percentage coefficient of variation (CV%). In addition, the standardized CV% (sCV%) and the root mean square standard deviation (rmsSD%) was calculated for long-term precision. CV% ranged from 1.04 (SPA, distal BMD) to 2.75% (pQCT, trabecular BMD) for short-term precision and from 1.49 (DXA, QDR 1000, 1/3-distal BMD) to 4.33% (SPA, ultradistal) for long-term precision, respectively. The results for the rmsSD% were higher but correlated well with the CV%. A change that exceeds 2 radical2 CV% has been considered as being significant. On this basis, 24.0 +/- 5.1% (mean +/- SEM) of the participants in our study would be expected to have a significant change in BMD without any correlation to the time-delay between the two measurements. Measurements of BMD were done at two locations with all five instruments: ultradistal and middistal BMD using DXA and SPA and total and trabecular BMD using pQCT, respectively. Coefficients of correlation for "between-instrumental" correlation were greater than 0.5 for almost all instruments. Distal and ultradistal BMD measured by SPA and trabecular and total BMD measured by pQCT correlated better with ultradistal BMD measured by DXA. Correspondingly, "within-instrumental" correlation was better for pQCT and SPA than for DXA. The coefficients of correlation between the different DXA methods were greater than 0.95 when corresponding locations were compared. We conclude that the clinical value of monitoring bone loss by measurement of forearm BMD is compromised by the low precision which was seen for DXA methods as well as for SPA and even pQCT in young healthy controls.

[Vertebral deformity as an index of osteoporosis-induced spinal fracture--an external validity construct based on bone density data]

BACKGROUND

In order to test the validity of vertebral morphometry for the assessment of prevalent vertebral osteoporotic fractures, we examined the association between vertebral deformities and bone mineral density (BMD).

METHOD

The study population consisted of 595 postmenopausal women and 581 men aged 50 to 82 years who participated in the baseline survey of the European Vertebral Osteoporosis Study (EVOS) in Germany and received BMD measurements by dual-X-ray-absorptiometry (DXA) at the femur and the lumbar spine.

RESULTS

In both sexes only vertebral deformities defined by more stringent morphometric criteria (McCloskey; Eastell 4 SD criterion) were significantly and inversely related to BMD (odds ratios 1.42 to 3.21 for a 1 SD [standard deviation] reduction in BMD; p < 0.05). The strength of the association depended on the stringency of the morphometric algorithm applied, and on the site of BMD measurement. The strongest associations were observed with femoral neck BMD in women and with BMD at the lumbar spine in men. In contingency analyses between vertebral deformities and osteoporosis (WHO criteria; European young female BMD reference values), vertebral deformities proved to be highly specific by all methods, even slightly more so in men (87.8 to 97.5%) than in women (86.3 to 96.7%). The predictive value of a positive test with respect to vertebral osteoporosis reached a maximum value of about 50% in both sexes. It further increased up to 72%, when the definition of osteoporosis was based on low BMD values at either the spine or the femoral neck, but only in women.

CONCLUSIONS

In conclusion, for both men and women the likelihood of vertebral deformities to be related to osteoporosis increases with the stringency of the morphometric method, with a similar probability of major deformities to represent vertebral osteoporotic fractures in men as in women. Nevertheless, even the most stringent morphometric criteria are not sufficiently valid instruments for the assessment of the prevalence of vertebral osteoporotic fractures in epidemiological studies.

[Osteosonography of the phalanges of men]

BACKGROUND

The distal metaphysis of the first phalanx of the fingers II to V is, like the vertebral body, a useful site for the measurement of mineralisation and structure of the bone, because of the simultaneous presence of compact and trabecular bone.

METHOD

With an osteosonographic device (DBM sonic 1200, IGEA, Italy) we measured in 38 young and healthy men, 14 elderly and healthy men, 18 men with osteopenia, 8 men with osteoporosis and vertebral fractures and 10 men with long-standing cortisone medication, the adSOS (amplitude-dependent speed of sound) and the UBPS (ultrasound bone profile score) at the phalanges, as well as bone mineral density (BMD) at lumbar spine using dual-X-ray absorptiometry (DXA).

RESULTS

There was no correlation between adSOS or UBPS and lumbar BMD (DXA). There was a significant positive correlation between adSOS and UBPS, r = 0.826 (p < 0.00001). AdSOS declined with age (r = 0.694, p = 0.021); the UBPS was not age-dependent (r = -0.15, p = n.s.), as expected. AdSOS and UBPS could discriminate significantly between the young and healthy controls and the men with osteopenia/vertebral fractures or oral steroids (p < 0.00001). The DXA could be significantly discriminate all healthy controls from the patients with osteopenia or vertebral fractures. It could not significantly discriminate the healthy controls from the patients taking oral glucoconticoids. Only the UBPS could significantly discriminate this group from the healthy controls.

CONCLUSION

These results show, that adSOS and UBPS are precise parameters to be measured at the phalanges. The detection level of pathological changes in osteoporosis are similar between adSOS and lumbar BMD (DXA) and improved by using UBPS. This might be explained by the influence of structural changes in bone on UBPS, rather than changes in bone mineral alone. Prospective studies have to clarify the role of adSOS and UBPS in fracture prediction.

Benefits of growth hormone treatment on bone metabolism, bone density and bone strength in growth hormone deficiency and osteoporosis

Bone mass is reduced in patients with GH deficiency (GHD) leading to an increased vertebral fracture rate and clinically significant osteoporosis. Patients with GHD of juvenile onset have reduced skeletal mineralization. When substituting GH in patients with GHD, bone turnover is increased and bone mineral density initially decreases during the first year due to the increase in remodelling space. From the experience in patients with acromegaly, cortical bone mass is increased and trabecular bone mass is normal in eugonadal or decreased in the hypogonadal patients. However, bone mineral content and bone area are increased leading to a higher biomechanical competence of bone as shown in rats. In patients with GHD of juvenile onset, mineralization and bone maturation are achieved during treatment with GH in adult life after having reached final body height leading to an increase in bone mass. The GH/ IGF-I system is dysregulated in patients with post-menopausal osteoporosis. This is shown by reduced systemic IGF and IGFBP-3-levels in osteoporosis suggesting a decrease of endogenous GH-secretion or a dysregulation of the GH receptor system which is beyond the normal ageing process of the GH/IGF system, the "somatopause". A premature somatopause may be responsible for the dysregulation in some patients with osteoporosis. However, 24-h GH profiles do not differ between patients suffering from osteoporosis or osteoarthritis. Treatment of osteoporosis with GH might be beneficial due to the increased bone metabolism and improved bone geometry which occurs with GH. The substantial increase of bone remodelling achieved with GH may be helpful during late post-menopause with decreased bone turnover and impaired osteoblastic function. Using GH to prevent physiological bone loss that occurs with age seems possible, but has to be discussed on an ethical and economic basis.

Ultrasound measurements at the proximal phalanges in healthy women and patients with hip fractures

Measurements of bone mineral density (BMD) are useful for the assessment of fracture risk in osteoporosis. First prospective studies showed that quantitative ultrasound as measured at the calcaneus also predicts future hip fracture risk, independently of BMD and as accurately as BMD. The aim of this study was to compile a reference population for a new ultrasound device that determines amplitude-dependent speed of sound (AD-SOS) through the proximal phalanges of the hand and to prove its ability to distinguish between health volunteers and osteoporotic patients. In a case-control study we examined 139 healthy women aged 21-94 years and a group of 24 female patients aged 69-94 years with recent hip fractures. In the healthy reference population additional BMD measurements were performed with dual-energy X-ray absorptiometry (DXA) and quantitative ultrasound measurements at the calcaneus were carried out. In vivo precision of AD-SOS measurements through the phalanges was 0.52% CV. Simple regression analyses showed a negative correlation with age (r = -0.73, p < 0.001); modest significant correlations with BMD of the lumbar spine (r = 0.36, p < 0.001) and BMD of the femoral neck (r = 0.37, p = 0.002) as measured with DXA were shown. The comparison with another ultrasound device measuring SOS and broadband ultrasound attenuation (BUA) through the calcaneus showed correlation with SOS (r = 0.50, p < 0.001); no significant correlation was found with BUA measurements. Furthermore a dependency of AD-SOS values in anthropometric factors such as body mass index (r = 0.37, p < 0.001), height (r = 0.40, p < 0.001) and weight (r = 0.23, p < 0.05) was shown. First study results on 24 clinically diagnosed osteoporotic patients, defined as patients with recent (< 1 week) pertrochanteric or femoral neck fractures, showed a good separation between age- and sex-matched controls and osteoporotic patients (Z = -2.0 SD). Receiver operating characteristic (ROC) curves showed an area under the fitted curve of 0.83 +/- 0.06. These results are powerful for a device measuring AD-SOS through the proximal phalanges of the hand, and further prospective studies have proven the capability of phalangeal ultrasound in fracture risk assessment.

[Bisphosphonate therapy in osteoporosis. Inhibition of trabecular perforation by aminobisphosphonate]

After many years of experience with bisophosphonates in the treatment of "tumor osteopathy" and Paget's disease, these substances have now also been approved for use in the treatment of osteoporosis. Owing to their high affinity for calcium hydroxyapatite, the bisphosphonates are deposited in the bony surface, and the aminobisphosphonates exert their effect at the site of active resorption via direct inhibition of active osteoclasts. As a result of this inhibition of the osteoclastic bone resorption, trabecular perforation is reduced and during the course of bone remodelling by the activity of the osteoblasts, boneformation occurs. In addition to an increase in bone density, both etidronate and alendronate have been shown to inhibit vertebral fractures in patients with osteoporosis. In addition, in patients with preexisting fractures, alendronate is able, at the same time, to lower the incidence of fractures of the femoral neck. With proper administration, the associated occasional gastrointestinal side effects can be avoided. The introduction of bisphosphonates into the treatment of osteoporosis is definitely an enrichment of the therapeutic spectrum in conjunction with the basic treatment comprising calcium, vitamin D, diet and physical measures.

Endocrine function and bone metabolism 5 years after autologous bone marrow/blood-derived progenitor cell transplantation

BACKGROUND

High dose chemotherapy with or without total body irradiation supported by autologous transplantation of hematopoietic progenitor cells is increasingly being used for hematologic and solid tumors. However, there is only limited information available on late toxicity.

METHODS

The authors investigated endocrine function and bone metabolism in 29 patients with a median interval of 5 years after autografting.

RESULTS

In accordance with an earlier report on this patient cohort, ovarian failure was observed to be unchanged, except for one woman with recovered ovarian function who gave birth to two healthy children. In two-thirds of the men, follicle-stimulating hormone levels were elevated, suggesting germinal aplasia. Determination of bone mineral density did not reveal osteopenia, despite several risk factors: prolonged immobilization, high dose corticosteroid treatment, and, in women, transient estrogen insufficiency. Frequent impairment of thyroid function has been reported in patients receiving single dose total body irradiation. Overt or subclinical hypothyroidism was not detected, most likely because the total body irradiation was hyperfractionated.

CONCLUSIONS

With the exception of gonadal failure, no significant late effects on endocrine function or bone metabolism were observed in this patient cohort.

Relationship between circulating insulin-like growth factor components and sex hormones in a population-based sample of 50- to 80-year-old men and women

There is a large body of evidence that points to a systemic link between the somatotropic axis and sex hormones, but epidemiologic data on the interactions between the two hormonal systems are still missing. We examined here the associations between the plasma levels of insulin-like growth factor (IGF) I, IGF-II, IGF-binding protein 3 (IGFBP-3), and sex hormones in a population-based sample of 486 men and women, aged 50-80 yr. The strongest association was an age-independent inverse correlation between all three circulating IGF components and sex hormone-binding globulin (SHBG), the major testosterone-binding protein in plasma. Consistent with this, bio-available (non-SHBG-bound) but not total testosterone levels were positively associated with the IGF system in men, and 3 alpha-androstanediol glucuronide was positively correlated with circulating IGFs in women. Moreover, part of the correlation between the circulating IGF system and bone mineral density at the femur and the calcaneus could be accounted for by SHBG. Our data suggest that sex hormones and the GH/IGF system are significantly interrelated in the elderly population. These hormonal interactions may play an important role in human aging and the pathogenesis of age-related diseases.

Ultrasound velocity of the tibia in normal German women and hip fracture patients

One of the latest developments in quantitative ultrasound (QUS) is the measurement of the speed of sound (SOS) of cortical bone of the midtibia. To determine the diagnostic validity of this method we measured 150 healthy women aged 22-94 years. Additionally, we report on first results of patients with hip fracture. Precision in vivo of the tibial QUS expressed as the percentage coefficient of variation (CV) was 0.39% for the first day and 0.45% after repositioning the second day (mean CV = 0.42%). No significant dependency of tibial SOS was found with weight, height, and body mass index in pre- and postmenopausal women. There was a significant decline of SOS with age in postmenopausal women (SOS = 4225 - 5.3 age, r = -0.46, P < 0. 001), whereas premenopausal women showed no decline (SOS = 3906 + 1. 3 age, r = 0.13, ns) Mean SOS values of premenopausal women were significantly higher than those of postmenopausal women (3960 +/- 78.7 m/second and 3898 +/- 120 m/second, respectively, P < 0.001). Postmenopausal women on estrogen substitution had significantly higher mean tibial SOS values than age-comparable postmenopausal women without estrogen substitution (3980 +/- 99 m/second and 3869 +/- 100 m/second, respectively, P < 0.001). Significant difference between age-matched healthy women, n = 11, and hip fracture patients, n = 13, expressed as z-score of -1.4 SD was found. In conclusion, tibial QUS declines with age and detects higher values in premenopausal women and postmenopausal women on estrogen substitution and lower values in hip fracture patients. Further prospective studies are needed to clarify its role in fracture risk assessment.

Multicenter German reference data base for peripheral quantitative computer tomography

The wide spread use of bone densitometers in Germany and other European countries has required the establishment of a validated reference population data base. A semianthropomorphic forearm cross-calibration phantom (EFP), developed during a concerted research action of the European Union's programme in Biomedical Engineering (COMAC-BME), was used to cross-calibrate the peripheral quantitative computer tomography (pQCT) devices at four German centers participating in the multicenter study. In total, 723 women and 208 men were included in the normal data base. No significant regional differences were found between the data of the different centers. In addition to the manufacturers calibration standard, proper calibration of the pQCT devices could be monitored during collection of the normal female and male data base. As a merit of the COMAC-BME study the measurements obtained with all pQCT devices thus ensured an uniform reference data base for distal radius measurements in Germany.

Forearm BMD as measured by peripheral quantitative computed tomography (pQCT) in a German reference population

Low bone mass as estimated by decreased bone mineral density (BMD) is an established predictor of osteoporotic fractures. One of the latest developments in bone densitometry is peripheral quantitative computed tomography (pQCT) of the forearm. In Germany, the CT bone scanner XCT 900 has already been widely used; however, interpretation of measurements with respect to osteoporosis risk assessment can be improved by better defined and validated reference data. In the present study, this device was used to measure BMD at the distal radius in a well-defined healthy population of 179 German adults (91 men, 88 women) aged 20-79 years. In vivo precision was 1.67% for trabecular and 0.81% for total BMD measurements. Peak values of trabecular and total BMD were observed at the ages 40-50 years in women and 30-40 years in men. Beyond these ages, both trabecular and total BMD showed a linear decline with age, decreasing by 0.85% and 1.08% per year in women and by 0.59% and 0.54% in men, respectively. Measures of BMD were not influenced by weight, height or body mass index (BMI). In both sexes, trabecular and total radial BMD showed a positive and significant correlation with femoral BMD measures obtained by dual X-ray absorptiometry (DXA). Weaker correlations were observed with DXA measures of the lumbar spine. Compared with the 95% reference range provided by the manufacturer, the distribution of age- and sex-specific values of trabecular BMD of the distal radius was shifted to lower values by up to 1 standard deviation.(ABSTRACT TRUNCATED AT 250 WORDS)

Decreased serum levels of insulin-like growth factors and IGF binding protein 3 in osteoporosis

OBJECTIVES

The aim of the study was to investigate endogenous growth hormone (GH) secretion in patients with osteoporosis and in patients with degenerative bone diseases or no spinal disease by measuring serum insulin-like growth factors 1 and 2 (IGFs) and their major binding protein 3 (BP-3) as an indirect parameter of GH secretion.

DESIGN

A cross-sectional study.

SETTING

All patients were seen as out-patients of the Endocrinology Department of the University of Heidelberg where all bone parameters were measured. IGFs and BP-3 serum levels were measured at the Children's Hospital of the University of Tübingen.

SUBJECTS

A total number of 310 patients were studied. The group with primary osteoporosis and vertebral fractures (OPO) consisted of 141 patients (98 females, 43 males). Spinal degenerative bone disease or osteoarthritis (DEG) was present in 108 patients (91 females, 17 males). Sixty-one control patients (56 females, 5 males) had no spinal disease on X-ray, but presented with lower back pain.

MAIN OUTCOME MEASURES

Serum levels of IGFs, BP-3, PTH and 25-vitamin D3 were measured by radioimmunoassay. Bone mineral density (BMD) was determined using absorptiometry; anthropometric parameters and menopausal status were recorded.

RESULTS

There was no difference in age and years after menopause between OPO and DEG, but control individuals were younger. Mean IGFs and BP-3 serum levels in patients with OPO were lower (P < 0.001) than those in patients with DEG or in controls. Patients with DEG had significantly higher BP-3 levels than controls (P < 0.001). There was a significant (P < 0.05) negative correlation of BP-3 with age in females with OPO, but not in controls or in DEG patients. The IGFs did not decrease with age in any of the three groups. Binding protein 3 was positively correlated (P < 0.05) with BMD in postmenopausal women with OPO but not in controls or DEG patients.

CONCLUSION

We conclude that systemic IGFs and IGF binding protein 3 are decreased in patients with osteoporosis. Further studies are needed to investigate whether this is as a result of diminished secretion of endogenous GH and whether this reflects the local circumstances of IGFs and IGF binding proteins in bone.