Diagnostic performance of vertebral fracture assessment by the lunar iDXA scanner compared to conventional radiography

The purpose of this study was to evaluate the diagnostic performance of vertebral fracture assessment (VFA) using the Lunar iDXA scanner. Conventional spinal radiographs and images acquired by dual-energy X-ray absorptiometry (DXA) of 350 subjects (269 females, 81 males) were evaluated by two different readers. We visualized 4,476/4,550 (98.4 %) vertebrae from T4 to L4 on VFA images compared to 4,535/4,550 (99.7 %) on radiographs. Among the visualized vertebrae, 205/4,535 (4.5 %) and 190/4,476 (4.2 %) were identified as nonfracture deformities by reading of radiographs and VFA, respectively. Vertebral fractures (VFs) were 231 in 126 patients and 228 in 125 patients by semiquantitative assessment of radiographs (SQ-Rx) and by VFA, respectively. There was excellent agreement between the two techniques and high diagnostic performance of VFA both on a per-vertebra basis (k score = 0.984, 95 % CI 0.972-0.996, sensitivity 98.68 %, specificity 99.91 %, PPV 98.25 %, NPV 99.93 %) and on a per-patient basis (k score = 0.957, 95 % CI 0.925-0.988, sensitivity 96.83 %, specificity 98.66 %, PPV 97.60 %, NPV 98.22 %). In older patients (≥65 years) affected by moderate or severe osteoarthritis, SQ-Rx and VFA identified 96 VFs and 95 versus 90 vertebral deformities, respectively. This study demonstrates that most vertebrae are evaluable using the iDXA scanner, with improved VFA diagnostic performance even in discriminating mild VFs from vertebral deformities. Therefore, VFA may be appropriate as an alternative to conventional radiography in patients at high risk of VF who are undergoing DXA bone densitometry and in the follow-up of osteoporotic patients on treatment.

Serum sclerostin levels decline in post-menopausal women with osteoporosis following treatment with intermittent parathyroid hormone

OBJECTIVE

This study was carried out in order to evaluate the effect of 18-month treatment with PTH (1-34) or PTH (1-84) on serum sclerostin levels in humans.

SUBJECTS AND METHODS

We investigated 10 women with severe osteoporosis, previously treated with alendronate and 20 untreated osteoporotic women. Subjects with severe osteoporosis were randomly divided into 2 groups of 5 patients each; the first group was treated with 20 μg of PTH (1-34) and the second one with 100 μg of PTH (1-84) according to an open-label design. Fasting blood samples were collected at baseline and at 2, 4, and 24 h after hormone administration. The same protocol was followed at month 1, 6, 12, 18. Serum sclerostin levels were measured at each time point by a sandwich-type enzyme-linked immunosorbent assay.

RESULTS

Basal serum sclerostin levels were not significantly different between patients previously treated with alendronate and those never treated. No significant acute change of serum sclerostin levels was observed after PTH administration. Fitting a mixed effect regression model, we found a significant time effect (p=0.0012) using the sclerostin level as the response variable and the month of drug administration as a single covariate. Treatment with both PTH molecules induced a monthly mean reduction of sclerostin levels of 0.1956 pmol/l.

CONCLUSIONS

Our results indicate that long-term therapy with PTH (1-34) or PTH (1-84) in women with osteoporosis previously treated with alendronate is associated with a reduction in circulating sclerostin levels. This is a putative mechanism through which PTH performs its anabolic action.

CDC73 mutations and parafibromin immunohistochemistry in parathyroid tumors: clinical correlations in a single-centre patient cohort

OBJECTIVE

To determine if molecular and immunohistochemical (IHC) features of the HRPT2/CDC73 gene and its product, parafibromin, predict the natural history of parathyroid malignancy, particularly atypical adenoma, as seen in a single-centre patient cohort.

METHODS

Matched tumor and non-tumor tissues were obtained from 46 patients with parathyroid carcinoma (CA) (n = 15), atypical adenoma (AA) (n = 14) and typical adenoma (TA) (n = 17), as defined by standardized histopathological criteria. Exons and exon-intron boundaries of the CDC73 gene were sequenced to identify germline or somatic mutations. IHC staining for parafibromin was performed and scored as positive if nuclear staining was at least partially IHC-positive.

RESULTS

Mutations of CDC73 were observed in 9/15 (60 %) CA, 2/14 (14 %) AA, and 1/17 (6 %) TA tumors. A recurrent two basepair mutation in exon 7 -- c.679_680delAG -- accounted for half of all identified mutations. Absence of parafibromin nuclear staining was noted in 8/12 (67 %) CA, 2/13 (15 %) AA, and 3/17 (18 %) TA tumors. Median follow up times were 88 months for CA, 76 months for AA, and 104 months for TA patients. One patient, a member of a previously reported multiplex family with a germline CDC73 mutation was found to have a second adenoma after removal of an atypical adenoma.

CONCLUSIONS

Molecular screening and IHC are both useful tools in the differential diagnosis of parathyroid tumors, but both have limited sensitivity and specificity. CDC73 mutations and negative immunostaining were common in atypical adenomas, but no local recurrence was observed in any case with successful surgical removal after follow-up periods of 27 to 210 months.

Muscle strength and bone in healthy women: effect of age and gonadal status

OBJECTIVE

The aim of this work was to examine the effects of age and menopause on muscle strength and on the muscle-bone interaction.

DESIGN

One hundred ninety-four healthy women (mean age 49.8 ± 12.6 SD years) were assessed. Maximal Voluntary Contraction (MVC, Newton, N) by Hand Grip Dynamometer, bone mineral density at one third of the radius (R-BMD) by dual-energy X-ray absorptiometry (DXA) and phalangeal ultrasound by the DBM Sonic 1200 device were evaluated at the upper dominant limb. Ultrasonometric parameters considered were Amplitude-Dependent Speed of Sound (ADSoS) and Ultrasound Bone Profile Index (UBPI).

RESULTS

MVC significantly decreased with age (r²=-0.12, p<0.005). For each level of age, fertile women had a greater MVC compared to postmenopausal women (r²=0.015, p<0.005).In the whole sample, a statistically significant correlation between MVC and R-BMD (r=0.354, p<0.001) and between MVC and ADSoS (r=0.294) and UBPI (r=0.311)(p<0.001 for both) were observed.

CONCLUSIONS

We conclude that age and menopausal status significantly contributed to the reduction of muscle strength. The decline of muscular strength significantly correlated with quantitative and qualitative bone features.

Chronic constipation in hypercalcemic patients with primary hyperparathyroidism

BACKGROUND

Chronic constipation (C), among gastrointestinal symptoms, is commonly associated with primary hyperparathyroidism (PHPT) and probably attributable to hypercalcemia.

OBJECTIVE OF THE STUDY

To evaluate in patients affected with PHPT the prevalence of C utilizing a validated questionnaire and the current prevalence of C compared to that observed in the past and to evaluate the relationship between C and the severity of PHPT.

METHODS

55 outpatients affected with PHPT, admitted to our Department of Internal Medicine and Medical Specialities in the years (2006-2009) were studied (group 1: 50 postmenopausal women and 5 men, mean age 61.9 +/- 9.4 years), together with 55 sex and age matched controls (group 2). Also considered were a group of PHPT patients observed, in the same ambulatory, during the years '70-'80 (group 3). A questionnaire, Rome II criteria, was administered and used to define C, whereas only anamneses were used to define C in group 3.

RESULTS

The prevalence of C in patients with PHPT was 21.8% in group 1 vs 12.7% in group 2 (n.s.) and 32.7% in group 3. There is a decreasing trend in the prevalence of C in patients with PHPT as observed from 1970-89 to 2006-2009 (p < 0.05). The reduction of C was associated together with a significant reduction in the serum calcium level (p < 0.001). The presence of C vs its absence in patients with PHPT is characterized by higher values of calcemia (p < 0.001), ionized calcium (p < 0.001), and parathyroid hormone (p = 0.019).

CONCLUSION

The actual prevalence of C in patients with PHPT is not significantly different from that found in the control group and is decreasing with respect to the past years. Moreover, C seems to be associated with the severity of the disease rather than with the diagnosis of PHPT per se.

Vertebral morphometry by dual-energy X-ray absorptiometry (DXA) for osteoporotic vertebral fractures assessment (VFA)

PURPOSE

This study was done to evaluate the diagnostic accuracy of dual-energy X-ray absorptiometry (DXA) compared with conventional radiography for identifying vertebral fractures.

MATERIALS AND METHODS

A total of 930 postmenopausal women underwent conventional radiography and DXA imaging of the spine. The images were evaluated by two expert skeletal radiologists using the semiquantitative (SQ) method for conventional radiography and the morphometric vertebral fracture assessment (VFA) for DXA.

RESULTS

The SQ method for radiography (SQ-Rx) analysed 99.1% of vertebrae, identifying 442 vertebral fractures; VFA analysed 97.5% vertebrae, detecting 420 vertebral fractures. Agreement between SQ-Rx and VFA reached 98.76%, and the κ-score was 0.96 [95% confidence interval (CI), 0.95-0.98]. Assessing the grading of vertebral fractures, agreement reached 97.5% and the κ-score was 0.841 (95% CI, 0.821-0.891). Considering SQ-Rx method as "gold standard", VFA had a sensitivity of 97.85 % and a specificity of 99.81%. The negative (NPV) and positive (PPV) predictive value for VFA were 99.83 % and 98.15%, respectively. Fractures were identified in 251 (27 %) and 242 (26 %) of patients on SQ-Rx and VFA, respectively. On a per-patient basis, the agreement between the two methods was 97% and the κ-score was 0.95 (95% CI, 0.920-0.968). The diagnostic parameters for VFA were 97.23% sensitivity, 98.86% specificity, 97.60% PPV and 98.84% NPV.

CONCLUSIONS

This study demonstrated that VFA with DXA may reach a high level of accuracy for diagnosing vertebral fractures, suggesting that VFA should be introduced in the screening of individuals with a risk of osteoporosis and in the follow-up of osteoporotic patients receiving treatment.

[Guidelines on prevention and treatment of vitamin D deficiency. Italian Society for Osteoporosis, Mineral Metabolism and Bone Diseases (SIOMMMS)]

The Italian Society for Osteoporosis, Mineral Metabolism and Bone Diseases (SIOMMMS) has elaborated the following guidelines about the definition, prevention and treatment of inadequate vitamin D status. The highlights are presented here. Daily vitamin D allowance ranges from 1,500 IU (healthy adults) to 2,300 IU (elderly with low calcium intake). Since the average Italian diet includes around 300 IU/day, subjects with no effective sun exposure should be supplemented with 1,200-2,000 IU vitamin D per day. The serum 25-hydroxy-vitamin D [25(OH)D] levels represents the most accurate way to assess vitamin D repletion, even though there are still no standardized assay methods. Conditions of “deficiency” and “insufficiency” are defined by the following ranges of 25(OH)D levels: less than 20 ng/ml and 20-30 ng/ml, respectively. In Italy, approximately 50% of young healthy subjects have vitamin D insufficiency during the winter months. The prevalence of deficiency increases with ageing, affecting almost all elderly subjects not on vitamin D supplements. When a condition of deficiency has been identified, a cumulative dose of 300,000-1,000,000 IU, over 1-4 weeks is recommended. In subjects recently treated for deficiency-insufficiency, a maintenance dose of 800-2,000 IU/day (or weekly equivalent) is recommended. In patients on daily doses over 1,000 IU, 25(OH)D levels should be checked regularly (e.g. once every two years). The highest tolerated daily dose has been identified as 4,000 IU/day. Vitamin D supplementation should be carefully monitored in patients at higher risk of vitamin D intoxication (granulomatosis) or with primary hyperparathyroidism. In pregnant women, vitamin D supplements should be given as in non-pregnant women, but bolus administration (i.e.: single dose >25,000 IU) should be avoided.

Metabolic changes following 500 μg monthly administration of calcidiol: a study in normal females

This study was performed to investigate the effect of monthly oral administration of 500 μg of calcidiol (25-hydroxyvitamin D(3)) for 4 months on both serum vitamin D levels and sequential changes of parameters of calcium metabolism; 18 normal women aged 24-72 years were investigated. There was a significant increase of serum 25(OH)D after the first administration; thereafter all values persisted significantly higher compared to the basal value (P < 0.001). Mean 1,25(OH)(2)D serum levels peaked at day 3 and then tended to stabilize following day 30. During the first month, all mean values observed following the initial administration were significantly higher than basal values. The first calcidiol dose produced a significant reduction of serum PTH levels (P < 0.001), which then remained constant over time. Concerning serum calcium and phosphorus, we were not able to demonstrate any significant change during the entire observation period. Considering the single values for both serum ionized and total calcium, the values of Ca(2+) exceeded upper limits of normal on only two occasions. Regarding biochemical markers of bone remodeling, mean changes of serum bone isoenzyme of alkaline phosphatase activity showed a significant trend to decrease, starting at day 30. No significant changes of serum CTX values were noted. Overall, 24-h urinary excretion of calcium did not change, seven values exceeding the threshold of 4 mg/kg body weight. Monthly administration of 500 μg of 25-hydroxyvitamin D(3) may be considered an alternative for vitamin D repletion, without any detrimental effect.

Vertebral morphometry by X-ray absorptiometry: which reference data for vertebral heights?

INTRODUCTION

The recent improvement in the resolution of dual-energy X-ray absorptiometry (DXA) images enables most vertebral levels to be seen adequately and thus DXA may be a worthwhile alternative to radiologic morphometry for the identification of vertebral fractures (VF). In this multicenter study, we have derived reference data for vertebral heights and their ratios in Italian women using morphometric X-ray absorptiometry (MXA).

METHODS

DXA scans were acquired in 1254 consecutive pre- and postmenopausal women, (mean age 63.7 ± 11.3, range 26-88 yrs), referred to six osteoporosis centers. MXA analysis of these images was performed by the same operator measuring vertebral heights and height ratios from L4 to T4. We calculated measures of central tendency and dispersion of vertebral heights and vertebral ratios using different approaches (mean and standard deviation as well as median and interquartile range of raw data, mean and standard deviation of trimmed data using an iterative algorithm, and mean and standard deviation of not fractured vertebrae).

RESULTS

Independently of the approach that we used, all the measures of central tendency were similar, while significant differences were found when compared with reference ranges in other populations. The vertebral heights of our sample at every vertebral level were significantly smaller than both Rea population and the Lunar reference values, even after normalization. Splitting data according to age groups, there was a decrease in the vertebral heights and ratios between the younger and older women.

CONCLUSIONS

This study demonstrates that reference data for MXA should be population specific and age matched.

Sporadic and hereditary primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine disorder, particularly frequent in post-menopausal women. It is characterized by hypercalcemia with inappropriately high spontaneous plasma PTH. Singlegland adenoma is the most common cause (75- 85%). PHPT is usually a sporadic disease but in approximately <5% of cases, a familial hyperparathyroid syndrome is diagnosed. Familial hyperparathyroidism is a clinically and genetically heterogeneous group of disorders including: multiple endocrine neoplasia (MEN) type 1, MEN type 2A, MEN4, benign familial hypocalciuric hypercalcemia, neonatal severe hyperparathyroidism, hyperparathyroidism-jaw tumor syndrome, and familial isolated hyperparathyroidism. These syndromes show mendelian inheritance patterns and the main genes for most of them have been defined. The classic form of PHPT, which presents with hypercalcemia, kidney stones, and bone disease, is no longer common. Currently, there is an increasing interest in the subtle manifestations of PHPT, particularly the cardiovascular and neuropsychiatric manifestations. Parathyroidectomy is the definitive cure for PHPT even though patients with the asymptomatic form of the disease can be followed conservatively.

Secondary osteoporosis in men and women: clinical challenge of an unresolved issue

OBJECTIVE

To evaluate the clinical and etiological factors of osteoporosis. We also tested the FRAX algorithm to compare the assessment of fracture risk in patients with primary or secondary osteoporosis.

METHODS

A prospective study carried out in a large sample of 123 men and 246 women. All subjects had a biochemical, densitometric, and radiological examination of thoracic and lumbar spine.

RESULTS

The prevalence of primary (men 52.9% vs women 50%; p = nonsignificant) and secondary (men 21.1% vs women 17.5%; p = nonsignificant) osteoporosis did not differ between the sexes. In contrast, the prevalence of primary osteoporosis was significantly higher than secondary causes (p < 0.0001) in both men and women. While women came to our attention for prevention of osteoporosis, men sought help because of clinical symptoms or disease-related complications, such as fractures. As evaluated by the FRAX tool, patients with osteopenia do not need treatment, in agreement with Italian guidelines. The estimated risk of major osteoporotic and hip fractures was significantly higher in women with secondary osteoporosis compared to men and also compared to women with primary osteoporosis.

CONCLUSION

The prevalence of secondary osteoporosis in men is similar to that in women and it is less frequent than commonly reported. In patients with secondary osteoporosis, FRAX calculation may provide an estimate of a particularly high fracture risk in patients whose bone fragility is usually attributed to another disease.

Acute and chronic effects of hypercalcaemia on cortical excitability as studied by 5 Hz repetitive transcranial magnetic stimulation

We designed the present study to disclose changes in cortical excitability in humans with hypercalcaemia, by delivering repetitive transcranial magnetic stimulation (rTMS) over the primary motor area (M1). In 22 patients with chronic hypercalcaemia related to primary hyperparathyroidism and 22 age-matched healthy subjects 5 Hz-rTMS was delivered at rest and during a sustained voluntary contraction of the target muscle. Changes in the resting motor threshold (RMT), motor evoked potential (MEP) amplitudes and cortical silent period (CSP) duration were measured and compared in patients and healthy controls. Two of the 22 patients were re-tested after parathyroidectomy when serum calcium had normalized. In a subgroup of healthy subjects, changes in the rTMS parameters were tested before and after acute hypercalcaemia. No significant difference between healthy normocalcaemic subjects and chronic hypercalcaemic patients was found in the RMT values and MEP amplitude and CSP duration evoked by the first stimulus of the trains. During the course of 5 Hz-rTMS trains, MEP size increased significantly less in patients with chronic hypercalcaemia than in healthy subjects, whereas the CSP duration lengthened to a similar extent in both groups. In the two patients studied after parathyroidectomy, rTMS elicited a normal MEP amplitude facilitation. Our findings indicate that acute hypercalcaemia significantly decreased the MEP amplitude facilitation. Given that 5 Hz-rTMS modulates cortical excitability through mechanisms resembling short-term synaptic enhancement, the reduction of MEP amplitude facilitation by hypercalcaemia may be related to Ca2+-dependent changes in synaptic plasticity.

Effect of a single oral dose of 600,000 IU of cholecalciferol on serum calciotropic hormones in young subjects with vitamin D deficiency: a prospective intervention study

CONTEXT

Effects of vitamin D repletion in young people with low vitamin D status have not been investigated so far.

OBJECTIVE

We evaluated the effect of a single massive dose of cholecalciferol on calcium metabolism at 3, 15, and 30 d, compared to baseline.

DESIGN AND SETTING

We conducted a prospective intervention study in an ambulatory care setting.

PARTICIPANTS

Forty-eight young subjects with vitamin D deficiency participated in the study.

INTERVENTION

A single oral dose of 600,000 IU of cholecalciferol was administered to each subject.

MAIN OUTCOME MEASURES

We evaluated serum changes of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D, calcium, and PTH induced by a single load of cholecalciferol.

RESULTS

The 25(OH)D level was 15.8 ± 6.5 ng/ml at baseline and became 77.2 ± 30.5 ng/ml at 3 d (P < 0.001) and 62.4 ± 26.1 ng/ml at 30 d (P < 0.001). PTH levels concomitantly decreased from 53.0 ± 20.1 to 38.6 ± 17.2 pg/ml at 3 d and to 43.4 ± 14.0 pg/ml at 30 d (P < 0.001 for both). The trends were maintained in a subgroup followed up to 90 d (P < 0.001). Mean serum Ca and P significantly increased compared to baseline, whereas serum Mg decreased at 3 d. 1,25-Dihydroxyvitamin D significantly increased from 46.8 ± 18.9 to 97.8 ± 38.3 pg/ml at 3 d (P < 0.001) and to 59.5 ± 27.3 pg/ml at 60 d (P < 0.05).

CONCLUSIONS

A single oral dose of 600,000 IU of cholecalciferol rapidly enhances 25(OH)D and reduces PTH in young people with vitamin D deficiency.

Regulation of PTH secretion by 25-hydroxyvitamin D and ionized calcium depends on vitamin D status: a study in a large cohort of healthy subjects

INTRODUCTION

Previous papers investigating vitamin D status have often outlined the significant relationships between serum parathyroid hormone (PTH) and 25-hydroxyvitamin D (25OHD), but the influence of ionized calcium levels has not been concomitantly considered.

DESIGN

Cross-sectional.

MATERIALS AND METHODS

In 1050 healthy men (547) and women (503), serum ionized calcium (iCa), creatinine (Cr), albumin, 25OHD, and PTH were measured. After conventional analysis, a regression tree was fitted on the data set.

RESULTS

25OHD and PTH values showed significant opposite seasonal changes. 25OHD levels negatively correlated with PTH, which in turn negatively correlated with iCa. A regression tree was fitted to the whole data set using PTH as the response variable and 25OHD and iCa as covariates. PTH concentration depended on that of iCa only in subjects with 25OHD levels>16.35 ng/mL, while for 25OHD<16.35 ng/mL it depended on 25OHD values.

CONCLUSIONS

Our results indicated that PTH levels were highly conditioned by those of 25OHD in subjects with 25OHD values lower than 16.35 ng/mL and by those of iCa only for higher 25OHD concentration.

Relationship between bone metabolism and adipogenesis

Several findings indicate that adipose tissue and bone have a complex reciprocal relationship. The two cells lineages share a common progenitor, and adipocyte endocrine activity may influence bone metabolism. Recent evidence from animal models suggests that bone cells may contribute regulating energy metabolism.

Phalangeal quantitative ultrasound and bone mineral density in evaluating cortical bone loss: a study in postmenopausal women with primary hyperparathyroidism and subclinical iatrogenic hyperthyroidism

Twenty-five postmenopausal women with primary hyperparathyroidism (PHPT) and 30 age-matched women with subclinical hyperthyroidism (sHTH) were studied to assess cortical bone loss. One hundred two healthy women were also recruited. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at lumbar spine (LS), femoral neck (FN) and femoral total (FT), and at one-third of the radius (R). Amplitude-dependent speed of sound (ADSoS) and Ultrasound Bone Profile Index (UBPI) were also evaluated using phalangeal quantitative ultrasound (QUS). A significant correlation was found between QUS and BMD at LS (ADSoS, p < 0.05) and R (ADSoS and UBPI, p < 0.001) in controls. QUS significantly correlated with BMD at LS, FN (p < 0.01), and FT (p < 0.001) in sHTH. No correlations were found in the PHPT group. Mean T-score values of all parameters were significantly lower in patients compared with controls (p < 0.001); however, they did not differ between PHPT and sHTH patients. T-score of R, ADSoS, and UBPI was reduced compared with other sites (p < 0.001) in both diseases. In postmenopausal women with PHPT and sHTH, bone loss is mainly detectable at cortical level. However, qualitative and/or structural changes of bone could account for the lack of correlations between these 2 techniques at cortical sites.

The effect of recombinant PTH(1-34) and PTH(1-84) on serum ionized calcium, 1,25-dihydroxyvitamin D, and urinary calcium excretion: a pilot study

We investigated the frequency of hypercalcemia and/or hypercalciuria following parathyroid hormone (PTH) 1-34 and 1-84 administration in a crossover trial. Ten postmenopausal osteoporotic women previously treated with bisphosphonates were subdivided into two groups of five patients each. A 24-h urine collection to determine baseline calcium (Ca) and creatinine (Cr) the day before administration of PTH was followed by determination of serum ionized Ca (Ca(2+)), Cr, 25(OH)D, and 1,25(OH)(2)D at baseline. Thereafter, 100 mcg of PTH(1-84) or 20 mcg of PTH(1-34) was administered. A 24-h urinary collection and blood samples 2, 4, and 24-h after each PTH administration were again taken. One week after the first PTH administration patients were rechallenged with the second PTH. The PTH peptides did not differ with respect to changes in Ca(2+) at 2, 4, and 24 h postinjection; at the last time point the values were virtually identical to the initial values. There was no difference in urinary Ca on the day following PTH injection compared to baseline, in terms both of Ca/Cr and of Ca excretion. The two PTH peptides did not differ with respect to changes in 1,25(OH)(2)D at 2, 4, and 24 h considering both the absolute values and the percent changes with respect to baseline (24-h 1-84 = 125.6 + or - 58.6 pg/ml, 153% increase; 1-34 = 124.1 + or - 64.7, 130%). Our results indicate no difference in postinjection serum Ca(2+), 1,25(OH)(2)D, or urinary Ca excretion after a single dose of either PTH(1-84) or PTH(1-34) in patients previously treated with bisphosphonates.

Short and long-term variations in serum calciotropic hormones after a single very large dose of ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3) in the elderly

CONTEXT

In humans, few studies have compared the potencies of ergocalciferol and cholecalciferol in improving and maintaining vitamin D status.

OBJECTIVE

Our objective was to evaluate the effects of a single very large dose of both calciferols on serum changes of 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)(2)D], ionized calcium, and parathyroid hormone (PTH) at baseline, and at 3, 7, 30, and 60 d.

DESIGN

This was a prospective randomized intervention study.

SETTING

The study was performed in a nursing home residence.

PARTICIPANTS

A total of 32 elderly female patients (age range 66-97 yr), with vitamin D deficiency was included in the study.

INTERVENTION

Participants were randomized into four groups of eight to receive a single dose of 300,000 IU ergocalciferol or cholecalciferol by oral (os) or im route.

RESULTS

25(OH)D levels sharply increased at d 3 only when vitamins were given os. The 30-d basal difference in serum 25(OH)D was significantly greater after cholecalciferol os administration (47.8 +/- 7.3 ng/ml) compared with other forms (D(3) im: 15.9 +/- 11.3; D(2) os: 17.3 +/- 4.7; D(2) im: 5 +/- 4.4; all P < 0.001). The area under the curve (AUC) of the serum 25(OH)D against time (AUC(60)) was: D(3) os, 3193 +/- 759 ng x d/ml vs. D(2) os, 1820 +/- 512, P < 0.001; and D(3) im, 1361 +/- 492 vs. D(2) im, 728 +/- 195, P < 0.01. 25(OH)D significantly influences PTH levels at 3 (P < 0.03), 7 (P < 0.01), 30 (P < 0.01), and 60 d (P < 0.05). At 60 d, the form of vitamin (cholecalciferol) significantly lowers PTH levels (P = 0.037).

CONCLUSIONS

Cholecalciferol is almost twice as potent as ergocalciferol in increasing serum 25(OH)D, when administered either by mouth or im. 25(OH)D plays a role in modulating serum PTH.

Biochemical markers in glucocorticoid-induced osteoporosis

Following the introduction of corticosteroids as therapeutic agents in the 1950s, their use has been expanded so that today glucocorticoids are widely used. There are few studies in the literature directly aimed at describing the changes of bone markers following glucocorticoid administration. The interpretation of some of these investigations may be hampered by a number of confounding factors, whose influence is not always taken into consideration. In general, the effects of glucocorticoid administration are represented by a reduction in bone formation markers (particularly considering serum osteocalcin levels) and a trend to an increase or no change in bone resorption markers. The inconsistency of this last finding may be related to the time at which the observation is carried out and to the marker employed.

The effects of alendronate treatment in osteoporotic patients affected by monoclonal gammopathy of undetermined significance

In patients with monoclonal gammopathy of undetermined significance (MGUS) the increase of bone turnover rate can increase the risk of fracture. Thus, a treatment normalizing this negative balance could be of benefit in these patients. We studied 100 patients affected by MGUS, grouped according to the presence (group A, 50 patients) or absence (group B) of vertebral fractures and/or osteoporosis. Group A was treated with alendronate (70 mg/weekly) plus calcium and cholecalciferol for 18 months, and group B was treated with calcium and cholecalciferol. After 18 months, the mean bone mineral density (BMD) of the lumbar spine and total femur had increased by 6.1% and 1.5%, respectively, in group A. In the nine patients of this group not taking alendronate, BMD values of the lumbar spine and total femur decreased by 1.6% (P < or = 0.001 ) and 1.3% (P < or = 0.01), respectively. In patients of group B, BMD increased by 1.2% at the lumbar spine and decreased by 1.2% at the total femur. Corresponding figures of those patients in the same group not taking calcium and vitamin D supplementation were -0.1% and -1.2%, respectively. At 18 months we observed significant decreases of serum bone markers: the difference between the groups was -23.2 (P < or = 0.01) for bone alkaline phosphatase, -23.6 for osteocalcin (P < or = 0.01), -35.1 for C-terminal telopeptides of collagen type I (P < or = 0.001), and -0.47 for bone sialoprotein (P = nonsignificant). Treatment with alendronate could lead to a significant reduction in fracture risk in MGUS patients with skeletal fragility.

Skeletal turnover, bone mineral density, and fractures in male chronic abusers of alcohol

BACKGROUND

Chronic alcohol abuse is a risk factor for osteoporosis and fractures, whose pathogenesis is still unclear. We investigated the influence of alcoholism and other risk factors on calcium and skeletal metabolism, bone mineral density (BMD), and fractures.

MATERIALS AND METHODS

In 51 chronic male alcoholics without liver failure and 31 healthy controls, serum total and ionised calcium, phosphate, creatinine, 25-hydroxy vitamin D (25OHD), PTH, total (ALP) and bone-specific (BALP) alkaline phosphatase, osteocalcin (BGP), carboxy-terminal telopeptide of type I collagen (beta-CTx), osteoprotegerin (OPG) and receptor activator of nuclear factor kappa B ligand (RANKL) were assessed. In patients only, we also measured serum testosterone, 17-beta estradiol, LH, and IGF-I. BMD was measured by dual energy x-ray absorptiometry at lumbar spine (LS-) and femur [neck (FN-) and total hip (TF-)]. Vertebral fractures were identified by a semiquantitative method on thoraco-lumbar spine x-ray, non-vertebral fractures (as life-style factors) by history.

RESULTS

Alcoholics were leaner, had significantly higher ALP and BALP, and lower BGP and 25OHD levels than controls. No significant difference in other calcium and bone metabolism parameters was found. OPG/RANKL ratio was significantly higher in alcoholics. Beta-CTx negatively correlated with abuse duration. OPG positively correlated with daily alcohol assumption and with indexes of liver cytolysis. Though LS-, FN- and TF-BMD of alcoholics and controls did not significantly differ, patients had a much higher prevalence of vertebral fractures. The same was found considering both vertebral and non-vertebral fractures.

CONCLUSIONS

Ethanol-induced skeletal damage seems mainly dependent on negative effects on bone formation. Lifestyle factors and traumas likely contribute to the high fracture incidence of alcohol abusers, independently of BMD.

Tumour markers in internal medicine: a low-cost test or an unnecessary expense? A retrospective study based on appropriateness

OBJECTIVE AND BACKGROUND

In the last 35 years tumour markers (TM) have gained currency in clinical practice. However, in the light of indications by international guidelines, their use is often unjustified. Our aim was to quantify the use of some of the most common TM, assessing their appropriateness and their efficacy in an Internal Medicine Unit.

METHODS

In the three Internal Medicine Units of the Department of Internal Medicine of Policlinico of Modena we have carried out a retrospective analysis of the assessment of the main TM (CEA, CA19.9, CA 125, CA 15.3, NSE). The analysis was divided into two distinct phases: (I) quantitative phase, in order to assess the scale of the problem in economical terms; (II) qualitative phase, in order to assess the efficacy of the tests and the appropriateness of their use.

RESULTS

(I) At last one of the considered TM was requested in 5102 out of the 8253 admitted patients (62%) (period 2001-2003). The trend was similar in all three units examined. (II) The qualitative analyses revealed: (1) the most common motivation for their use (79%) was diagnostic, mostly prior to any other test; (2) a mere 5% of the requests were appropriate according to the international literature; and (3) TM showed a low positive predictive value when used for diagnosis in an unselected population such as that of an Internal Medicine unit.

CONCLUSIONS

The results of our study showed that TM determination represents an overall cost for Internal Medicine units and that there is a high inappropriateness in their use compared to what it is suggested by international guidelines. Though the TM is a low-cost test when used correctly, it seems an unnecessary expense if not adequately incorporated into the decision making process.

Lumbar bone mineral density as the major factor determining increased prevalence of vertebral fractures in monoclonal gammopathy of undetermined significance

The possible relationships between biochemical measurements and both densitometric and radiographic indexes of skeletal fragility were evaluated in 65 postmenopausal women with monoclonal gammopathy of undetermined significance (MGUS). There was a significantly higher prevalence of vertebral fractures in the MGUS group compared with a control population (P < or = 0.001). The MGUS patients were then grouped according to the presence or absence of at least one mild vertebral fracture. Patients with fractures (Fx, n=34) were older (62.8 +/- 6.1 years), with long-standing disease (8.8 +/- 7.1 years) when compared with those without fractures (NFx, n=31; 59.7 +/- 5.0 years, P < or = 0.05 and 5.8 +/- 4.1 years, P < or = 0.05). The receptor activator of nuclear factor kappa-B ligand/osteoprotegerin ratio was higher in Fx compared with NFx (0.092 +/- 0.018 vs. 0.082 +/- 0.020; P < or = 0.05). Lumbar spine (0.811 +/- 0.14 vs. 0.956 +/- 0.12 g/cm2), femoral neck (0.660 +/- 0.09 vs. 0.747 +/- 0.10 g/cm2) and total bone mineral density (BMD) (0.788 +/- 0.11 vs. 0.884 +/- 0.11 g/cm2) were lower (all P < or = 0.001) in FxMGUS compared with Nfx patients. Receiver operating characteristic curves identified lumbar BMD as the variable that best predicted vertebral fractures (area under the curve 0.817; 95% confidence interval, 0.713-0.921). This study provides an indication for the measurement of BMD in MGUS patients, as a means of predicting vertebral fractures, especially in those that are asymptomatic. Patients with prevalent fractures should undergo pharmacological treatment to prevent further fractures.

The risk of fractures in postmenopausal women with primary hyperparathyroidism

OBJECTIVE

To evaluate the prevalence of vertebral (vFr) and non-vertebral (nvFr) fractures in postmenopausal women with primary hyperparathyroidism (PHPT).

MATERIALS AND METHODS

We studied 98 patients with PHPT, divided into 'mild' (M, n = 25) and 'non-mild' (NM, n = 73) sub-groups, according to recently published guidelines (2002), and 89 healthy women (C) matched for age, years since menopause and body mass index. vFr was evaluated according to a visual semiquantitative method; bone mineral density (BMD) at the lumbar spine (LS), and femoral sites (femoral neck, FN and total femur, FT) was measured by dual energy X-ray absorptiometry. Volumetric BMD of the third lumbar vertebra (vBMDL3) was also calculated.

RESULTS

The prevalence of vFr was significantly higher (P < 0.001) in both M and NM PHPT patients compared with C; this prevalence did not differ between M and NM patients. BMD was significantly lower (P < 0.05) in NM patients compared with both C and M patients. BMD at LS in M patients was also significantly higher with respect to C. Similar results were also obtained for vBMDL3; in M patients, vBMDL3 was also significantly higher compared to C. When M and NM patients were subdivided according to the presence or lack of vFr, no difference was found between fractured and unfractured patients for either BMD or vBMDL3 values.

CONCLUSIONS

The risk of vFr is higher in postmenopausal patients with mild PHPT even if BMD appears well preserved. This finding suggests that other factors, such as bone quality, seem to be relevant in determining fracture risk, especially when gonadal function is lacking.

Osteoporosis intervention in ambulatory patients with previous hip fracture: a multicentric, nationwide Italian survey

Our study investigated the patterns of treatment and adherence to prescribed therapies in 2,191 ambulatory patients with previous hip osteoporotic fractures at 207 participating orthopedic centers throughout Italy. All patients who came to the attention of the involved orthopedic surgeons were administered a questionnaire investigating: age, sex, height, weight, date of admission and length of stay in the hospital, other previous clinical fractures, bone density or biochemical testing concerning mineral metabolism, treatment with bone-active drugs in the six months before the fracture, treatment after discharge from the hospital, continuous use of prescribed drugs, pain at the site of hip surgery, and comorbidity. A multivariate logistic regression model was applied, considering a subset of the variables in the questionnaire, in order to determine the factors that significantly influenced discontinuation of treatment after hip fracture. Among the patients, 88.1% were female and 86.2% of the subjects were older than 65. The mean length of hospital stay for hip fracture was 19.0+/-25.3 days. At the time of interview, the mean time elapsed since hospitalization was 542.9+/-1,197.3 days. A previous clinical fracture was referred by 20.2% of patients. Before hip fracture occurrence, 52.8% of patients had never received any kind of treatment, and this figure reached 80% if we also included those who had taken only calcium and/or vitamin D. Corresponding proportions after fracture were 22% and 31.3%, respectively. Finally, 52% of patients had stopped treatment given for osteoporosis after a mean period of 1.4 years. According to the results of the logistic regression, increasing age, pain [odds ratio (OR): 1.36; 95% confidence interval (CI): 1.21-1.65] and no use of diagnostic tests (OR: 2.46; CI: 1.79-3.37) showed a positive effect on the probability of quitting the medication. On the other hand, being female reduces by half (OR: 0.49; CI: 0.37-0.45) the probability of quitting medication. Our data showed a low rate of primary prevention, a still insufficient post-fracture therapy, along with a high rate of early discontinuation of osteoporosis medication in patients with previous hip fracture.

[Paraneoplastic syndromes: a review]

Modern oncology often obtains good results against earlier neoplasms, whilst it's still in difficulties against the advanced ones. The knowledge of paraneoplastic syndromes is crucial both to cure patients and to do an earlier diagnosis. When we recognize a paraneoplastic syndrome that comes before the clinic beginning of a neoplasm, perhaps we save a life. This review discusses all the main paraneoplastic syndromes, focusing mainly on their clinical aspect and reminding the most commonly associated cancers.

[Primary hyperparathyroidism]

Primary hyperparathyroidism (PHPT) is characterized by excessive PTH secretion in respect to calcium homeostasis needs, due to parathyroid adenoma (80% of cases), hyperplasia (15-20%), or carcinoma (1-2%). In familial forms of PHPT, several mutations have an established role: menin gene for MEN type 1, RET for MEN type 2a, calcium-sensing receptor gene for familial hypocalciuric hypercalcemia, parafibromin gene for PHPT-jaw tumour and carcinoma. Etiology of sporadic adenomas (80% of PHPT cases) is less defined, being most commonly found a mutation of menin gene or activation of PRAD1 oncogene. In recent years, the classical features of the disease became less common. Typically, bone involvement is now represented by a reduced bone mass at skeletal sites more rich in cortical tissue. Prominently trabecular skeletal sites are relatively spared, because of the anabolic effects of a slight PTH excess on trabecular tissue. PHPT patients may have increased fracture risk, though it is not clear why bone damage is more severe in a subgroup of patients. Clinical features of hypercalcemia may be fatigue, anorexia, thirst, and polyuria. Vague neurological and psychiatric symptoms, such as weakness, anxiety, depression, paresthesias, and muscular cramps may ameliorate after parathyroidectomy. Recent reports indicate increased cardiovascular mortality in PHPT patients. Diagnosis is based on the detection of hypercalcemia, together with inappropriately high serum PTH levels. Preoperative localization of the diseased glands is mandatory in persistent or recurrent PHPT, as like as when minimally invasive surgery is planned. High resolution ultrasonography and SPECT double-phase 99m Tc-sestamibi scintigraphy are the most commonly employed techniques. Intraoperatory PTH assay may confirm successful surgery when serum concentrations decrease more than 50%. Surgical therapy is indicated in patients with renal or skeletal complications, such as in those with previous parathyrotoxic crisis. Many surgeons in recent years adopted minimally invasive parathyroidectomy. Medical treatment is an option for patients unwilling or unfitted for surgery because of severe concomitant diseases. Employed therapy includes estrogens, SERMs, bisphosphonates and calcimimetics.

Vitamin D status as the major factor determining the circulating levels of parathyroid hormone: a study in normal subjects

We investigated the relative contribution of the major factors regulating calcium homeostasis in determining the circulating levels of PTH. We studied 137 males and 125 females who were healthy volunteers. Circulating PTH levels were determined by three different immunoradiometric assays (IRMA). The first one (PTH Sorin, PTH S) utilizes two affinity-purified polyclonal antibodies directed against the 1-34 and 39-84 sequence of the hormone. The two other IRMA share polyclonal anti-PTH (39-84) antibodies. The first assay (PTH Whole, PTH W) utilizes a second polyclonal antibody, directed against the 1-4 amino acid sequence. The second assay (PTH Total, PTH T) utilizes a second antibody specific for the 7-34 region. Concentrations of PTH fragments lacking the initial amino acid sequence (PTH N-truncated, PTH N-t) were determined by the difference of values between PTH T and PTH W. Vitamin D was the main explicative variable almost in every multiple linear regression model, both considering the group as a whole (PTH S: R2 = 0.238, P < 0.0001; PTH W: R2 = 0.08, P < 0.001; PTH T: R2 = 0.145, P < 0.0001; PTH N-t: R2 = 0.081, P < 0.009) and when considering men and women separately. In subjects with vitamin D insufficiency (n = 53) [25(OH)D < 30 nmol/l], mean serum levels of parathyroid hormone were significantly higher (P < 0.001) than those in subjects of similar age with normal vitamin status (n = 209) with all the assays employed. This study demonstrates the central role of 25(OH)D in regulating PTH secretion in physiological conditions.

Dehydroepiandrosterone sulfate and bone resorption rates as reflected by serum levels of C-terminal telopeptide of type I collagen: a study in healthy men

Sex steroid hormones contribute to the physiological regulation of bone turnover in males. To address this issue, we investigated serum estradiol (E2), total testosterone (T), and DHEAS concentrations, along with serum levels of carboxy-terminal telopeptide of type I collagen (sCTx), in a sample of 76 healthy men aged 23 to 87. The concentration of sCTx declined with age. Both T and DHEAS, at variance with E2, showed a significant age-related decline. T, DHEAS and sCTx significantly (p<0.01) correlated with each other. DHEAS and T were significantly associated after correcting for age (r=0.35, p=0.002) or body mass index (r=0.65, p<0.0001). DHEAS, but not T, significantly correlated with sCTx after correcting for age (r=0.26, p=0.026, and r=0.20, p=0.08, respectively). Stepwise multiple regression analysis showed that only DHEAS (but not T or E2) was a significant independent predictor of sCTx (p=0.0001). Our results show that adrenal androgens play a crucial role in regulating bone resorption in aging men.

Quality of life in ambulatory postmenopausal women: the impact of reduced bone mineral density and subclinical vertebral fractures

Health-related quality of life (HRQOL) in postmenopausal women with osteoporosis has hitherto been mainly assessed in patients with clinically recognized vertebral fractures. Our study aimed to investigate the QOL perception in 361 asymptomatic ambulant postmenopausal women who came to our center for an osteoporosis screening program planned with their general practitioners. The Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) was administered to all subjects. The participants underwent bone mineral density (BMD) measurements by DXA of either the lumbar spine and/or the femoral neck, as well as X-ray examination of the thoracolumbar spine to identify subclinical vertebral fractures. According to the WHO definition, where subjects are subdivided by BMD values into three groups (women with normal BMD, osteopenia, and osteoporosis), a significant difference was found only for the domains which explore general health perception (p<0.01 by ANOVA) and mental function (p<0.001 by ANOVA). When we segregated both osteopenic and osteoporotic women according to whether or not they had vertebral fractures, a significant difference was found only in osteoporotic patients for domains which explore physical function (p<0.001), social function (p<0.001), general health perception (p<0.02), and total QUALEFFO score (p<0.01). Stepwise multiple logistic regression analysis of the whole sample showed that both vertebral fractures and a low femoral BMD impairs QOL perception, while age did not exert a significant influence. ROC curves analysis demonstrated a low discriminating capacity of individual domains and total QUALEFFO score for both vertebral deformities and BMD categorization. Our results showed that QUALEFFO is not able to discriminate between patients with or without subclinical vertebral fractures. However, some aspects of QOL appear to be impaired in patients with subclinical vertebral fractures or reduced BMD.

Skeletal involvement in patients with diabetes mellitus

Studies on skeletal involvement in patients with diabetes mellitus have generated conflicting results, largely because of the pathogenetic complexity of the condition. Several mechanisms may contribute to skeletal damage, including the increased urinary excretion coupled with the lower intestinal absorption of calcium, the inappropriate homeostatic response in terms of parathyroid hormone secretion, and also the complex alteration of vitamin D regulation. Decreased or increased insulin and IGF-1 concentrations and the effects of the accumulation of glycation endproducts on the bone tissue could also play a role. A possible genetic predisposition is also currently under investigation. Finally, the role of fat tissue in type 1 and type 2 diabetes and that of diabetic complications also deserve note. As far as bone mass is concerned, in adult patients with type 1 diabetes a moderately reduced bone mineral density has been shown in both axial and appendicular skeleton. On the contrary, patients with type 2 diabetes seem to have higher bone mineral density in respect to healthy control subjects, especially when overweight women are considered. No clear relationship between bone mass measurements and biochemical parameters of mineral metabolism has been shown in the different types of diabetes. Cohort studies recently carried out on large samples indicate that diabetic patients (with both type 1 and type 2 disease) have a higher risk for fracture, in particular for hip fracture, the most dangerous osteoporotic complication. This seems to be dependent both on qualitative and quantitative alterations of the bone, as well as on extra-skeletal factors due to the neuropathic and microangiopathic complications of the disease.

Potential Clinical Utility of a New IRMA for Parathyroid Hormone in Postmenopausal Patients with Primary Hyperparathyroidism

Background: A new commercially available (so-called second-generation) IRMA for parathyroid hormone (PTH) separately detects intact PTH and its N-truncated fragments; however, no studies have compared the first- and second-generation IRMAs for PTH in patients with primary hyperparathyroidism (PHPT) to assess their respective diagnostic accuracies.

Methods: We concomitantly investigated 39 postmenopausal patients with PHPT and a control group of 70 healthy postmenopausal women matched for age, renal function, and vitamin D status. In all individuals, PTH was measured with a classic IRMA (PTH-S; DiaSorin Inc.), which uses antibodies directed against epitopes 1–34 and 39–84, and a new method (Scantibodies Laboratory. Inc.), which uses antibodies against epitopes 1–4 and 39–84 (PTH-W) and epitopes 7–34 and 39–84 (PTH-T). We also assayed serum PTH in 10 PHPT patients every 24 h for 5 days after successful surgery.

Results: The different assays gave serum PTH values that were &gt;2 SD higher than values for the control population in 59% (PTH-S), 77% (PTH-W), and 82% (PTH-T) of patients with PHPT. However, ROC curve analysis showed no significant differences among the three PTH assays, demonstrating overlapping diagnostic sensitivities. In PHPT patients, the correlation among the assays was highly significant (r = 0.91–0.92; P &lt;0.001). The ratio PTH-W:PTH-T × 100 showed a gaussian distribution in both PHPT patients and controls, whose mean (SD) values [63.4 (13.3)% vs 64.5 (9.5)%, respectively] did not differ significantly. After parathyroidectomy, the mean percentages of variation in PTH detected with all of the assays were quite similar.

Conclusions: The distribution of the PTH-W:PTH-T ratio in patients and controls suggests that PHPT does not markedly influence the rate at which biologically inactive fragments are generated by central or peripheral cleavage of PTH. The similar postoperative curves seem to contradict the hypothesized effect of acute hypocalcemia in modulating the central secretion of hormonal fragments. Our results indicate that the three investigated assays have similar diagnostic sensitivities in PHPT.

Vitamin D status in female patients with primary hyperparathyroidism: does it play a role in skeletal damage?

OBJECTIVE

Vitamin D deficiency, even subclinical, has been considered to worsen the skeletal damage in primary hyperparathyroidism (PHPT). Our study aimed to investigate the impact of vitamin D status on skeletal involvement in PHPT.

DESIGN AND MEASUREMENTS

A cross-sectional study was designed involving 62 female patients with PHPT. Serum total calcium (tCa), phosphate (P), creatinine (Cr) and total alkaline phosphatase activity (AP), together with 24-h (uCa 24 h) and spot fasting (uCa/Cr) urinary calcium, were measured by autoanalyser; ionized calcium (iCa) was assessed by an ion-specific electrode; intact parathyroid hormone (PTH) was measured by immunoradiometric assay (IRMA) and 25-hydroxyvitamin D (25-OHD) by radioimmunoassay (RIA). Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (DXA) at lumbar spine in 58 patients, and at femoral neck, Ward's triangle, greater trochanter, intertrochanteric line and total hip in 56 patients. The associations of all variables with age, 25-OHD, body mass index (BMI) and PTH were studied by linear multiple regression analysis, using progressively restricted models.

RESULTS

The model including age, 25-OHD, PTH and BMI showed significant regression with BMD values. PTH, age and BMI exerted a leading role in determining such a significance, while no significant regression was found between the parameters studied and 25-OHD; this was confirmed by Pearson's linear correlation analysis. The progressively restricted models showed significant regression of BMD at femoral neck, femoral intertrochanteric line and total hip with age, BMI and PTH. BMD measured at the Ward's triangle and greater trochanter showed significant regression with age and BMI, and that measured at lumbar spine with age.

CONCLUSIONS

Our data indicate that in primary hyperparathyroidism patients the influence of 25-hydroxyvitamin D levels on bone mineral density, if any, was overwhelmed by the effects of parathyroid hormone excess, age and body mass index. The latter unequally affected bone mineral density of various measured sites with different composition.

Impact of fractures on health care in a major university hospital in Rome

BACKGROUND AND AIMS

The aim of the study was to investigate the impact of fractures (i.e., hip, Colles, humeral and vertebral fractures), compared with that of other common diseases requiring hospitalization, on health care in the main hospital in Rome (Italy).

METHODS

Hospital discharge forms, filled in according to the 9th International Classification of Diseases, were examined from 1996 to 1999. Data on fractures were compared with those related to other diseases which occupy a considerable proportion of hospital operating time in Italy: coronary heart disease (CHD), cerebrovascular disorders (CVD), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD) and breast cancer (BC).

RESULTS

In all groups of patients, the mean age of females was significantly higher (p<0.0001) than that of males. Male patients with hip fractures had hospital stays significantly longer than females (p<0.0001), whereas women with Colles fractures had significantly (p<0.02) longer stays. When patients were divided according to age (i.e., over or under 60 years), mean hospital stays did not differ between younger and older patients in all groups except Colles fractures (p<0.001). Hip fractures in older patients showed striking in-hospital mortality. Throughout the study period, hip fractures accounted for the highest overall and per-patient costs. The number of female patients with fractures (and, obviously, breast cancer) was higher, while the opposite applied to the other disorders. Male patients with fractures, CHD and CVD were significantly younger than females (p<0.0001). When the percentage of deaths was added to that of patients discharged to other institutions, fractures showed the poorest outcome of any hospitalization event. Per-patient costs were remarkably higher for CHD, followed by fractures.

CONCLUSIONS

Fractures represent a growing but often underestimated burden for hospital care in Italy; further studies are needed on this issue.

Bone metabolism in ochronotic patients

We investigated skeletal involvement in five male and two female patients with ochronosis, aged 26-82 years. The main parameters of mineral metabolism, together with biochemical markers of bone resorption (urinary N-telopeptides of type I collagen) and formation (serum bone isoenzyme of alkaline phosphatase and serum osteocalcin) were evaluated. In the same subjects lumbar spine and femoral bone mineral density (BMD) were also measured by dual energy X-ray absorptiometry. All patients but the younger 26-year-old patient had lower than normal bone mass at femoral neck and total hip, showing marked osteopenia in three cases and osteoporosis in the remaining three cases. However, at lumbar spine BMD measurement provided spuriously overestimated results, because of intervertebral disc calcification and osteophyte formation. As far as biochemical markers of bone turnover are concerned, the most relevant finding was the increased N-telopeptides of type I collagen urinary excretion. Our results suggest that ochronosis may be associated with increased bone resorption rate leading to an accelerated bone loss. A role of the homogentisic acid polymer deposit in bone matrix and cells, possibly with osteocyte damage and interference in collagen metabolism, might be hypothesized.

[Male osteoporosis: current treatments and future options]

PURPOSE

To provide indications for currently approved treatments and future options for male osteoporosis, based on the pathogenetic mechanisms of bone loss in the male sex.

DESIGN

Review of the most significant data reported in the literature.

RESULTS

Unhealthy lifestyle habits should be modified. Testosterone replacement is indicated only in patients with diagnosis of hypogonadism. Based on the demonstrated pathogenetic role of estrogen lack in bone loss in men, either low doses of this hormone or selective androgen receptor modulators have been proposed for the treatment of male osteoporosis. Bisphosphonates are the only medications approved by Food and Drug Administration for idiopathic and glucocorticoid-induced osteoporosis in men. As far as anabolic treatments are concerned, there is not agreement on clinical utility of sodium fluoride. Short-term treatment with parathyroid hormone (PTH) seems to be safe and effective in patients with idiopathic osteoporosis, due to its anabolic action. Therapeutic use of growth hormone (GH) and insulin-like growth factor type I (IGF-I), both considered as potential anabolic agents, is still limited because of the high incidence of side effects and relatively transient efficacy, particularly of IGF-I.

CONCLUSIONS

Treatments should be selected on the basis of anti-fracture efficacy of various medications, which has been demonstrated so far only for alendronate and risedronate. Although anabolic agents produce noticeable increase of bone mineral density, is still debated if they also reduce fracture incidence in males with osteoporosis.

[Clinical aspects of osteoporosis]

The main clinical presentation of osteoporosis is fracture and its consequences. However a number of diseases and factors can induce bone loss and increase the risk of fracture. Therefore the clinical approach should be initially directed to exclude secondary osteoporosis. Vertebral fractures are the most common osteoporotic fractures; they are characterized by back pain, typical physical changes such as kyphosis and height loss, functional impairment and social decline. On the other hand, hip fracture is the most severe consequence of osteoporosis, because of its higher morbility and mortality. The main pathogenetic determinants of hip fracture are represented by both bone loss and several factors contributing to fall in the elderly. Moreover, a number of conditions are responsible for the high mortality rate following hip fracture. Colles' fracture is rarely hospitalized; however, most patients complain a complex algodystrophic syndrome which impairs the quality of life.

Uneven deficits in vertebral bone density in postmenopausal patients with primary hyperparathyroidism as evaluated by posterior-anterior and lateral dual-energy absorptiometry

This investigation was undertaken to determine whether the preservation of bone mass in patients with mild primary hyperparathyroidism (PHPT) could be detected when measuring spine density in the lateral projection. We compared the bone mineral density (BMD) of L2-L4 utilizing the posterior-anterior (PA) and lateral projections in postmenopausal patients with PHPT and in a group of 27 postmenopausal normal women. Thirty-three consecutive postmenopausal patients with PHPT were studied; 25 were asymptomatic whereas the remaining 8 suffered complications related to the disease. Based upon the criteria established by the Consensus Conference on the Management of Asymptomatic PHPT, only 10 of the 25 asymptomatic patients could be considered affected by mild disease; the remaining patients were classified as having moderate disease. Patients with mild disease had mean lateral total BMD values (0.682 +/- 0.113 g/cm(2)) significantly higher than normal women (0.588 +/- 0.076, p<0.02) and patients with moderate disease (0.599 +/- 0.077, p<0.05). There were significant differences among the three groups in both PA L2-L4 and L1-L4 levels: patients with mild disease had significantly higher mean BMD values than patients with moderate disease and normal women, when either three or four vertebrae were considered. Interestingly, at this latter site, patients with moderate disease had significantly ( p<0.05) lower values than normal women. Our results indicate that patients with mild PHPT have a preservation of vertebral mass when compared with the other hyperparathyroid patients and normal women, when taking into account both the mainly trabecular portion and the whole vertebra. The finding that when the PA projection was assessed, BMD values of patients with moderate disease were significantly lower than those of normal women, might be attributed to the detrimental effect of raised parathyroid hormone levels on the cortical component of the vertebral body.

Gender differences in serum markers of bone resorption in healthy subjects and patients with disorders affecting bone

To assess how two different serum markers of bone resorption may reflect changes in bone turnover, we compared age- and sex-related changes in serum C-terminal telopeptide of type I collagen (betaCTx) and tartrate-resistant acid phosphatase activity (TRAP) in 136 healthy men and 184 normal women. Serum levels of the two markers were also assessed in several groups of patients of both sexes presenting with the most common metabolic and endocrine bone diseases: established osteoporosis (n = 77), primary hyperparathyroidism (n = 44), glucocorticoid excess (n = 17), chronic renal failure (n = 39), active Paget's disease of bone (n = 5), humoral hypercalcemia of malignancy (n = 3), osteomalacia (n = 3), hyperthyroidism (n = 10), post-surgical hypoparathyroidism (n = 10), acromegaly (active disease, n = 8) and Cushing's syndrome (n = 10). In men the regression of betaCTx with age showed an initial decrease in bone resorption followed by an increase thereafter, starting from the sixth decade of life. No age-related change in serum TRAP activity was observed. In women, by contrast, a slight but significant linear correlation of both serum betaCTx and TRAP with age (r = 0.223, p<0.003 and r = 0.333, p<0.0001, respectively) was found, the two markers being positively correlated (r = 0.238, p<0.002). In each class of patients the mean Z-scores of betaCTx were significantly higher than those of TRAP activity. Moreover, compared with normal subjects, serum betaCTx seems to be characterized by a superior sensitivity relative to TRAP measurement, at least in the disorders studied.

Short-term effects of surgery in post-menopausal patients with primary hyperparathyroidism and normal bone turnover

The most common clinical presentation of primary hyperparathyroidism (PHPT) is nowadays characterized by a slight skeletal involvement. We studied 5 consecutive female patients with PHPT presenting with bone turnover marker levels within the reference range of our Center and whose bone mineral density values were above the usual fracture risk threshold. In each patient we measured, both in basal conditions and daily, for the first 5 days after surgery, the following indexes: serum total (T-ALP) and bone-specific (B-ALP) alkaline phosphatase activity, osteocalcin (BGP, by two different assays), together with the 24-hour urinary excretions of total pyridinoline (Pyr/Cr) and deoxypyridinoline (DPyr/Cr), free deoxypyridinoline (FD-Pyr/Cr), cross-linked N-telopeptide of type I collagen (NTx/Cr), and type I C-telopeptide (CTx/Cr). The markers of both bone formation and resorption significantly decreased after surgery (p<0.001 by multiple ANOVA). Individual post-surgical markers changes were all significant but T-ALP and FD-Pyr, the most pronounced percent reductions being shown by NTx and CTx. The time-course of such variations substantially differed among the various indexes. These results show that bone formation and resorption markers are up-regulated also in PHPT patients with mild skeletal involvement; acute removal of parathyroid hormone excess differently affected the markers of bone turnover in terms of both entity and time-course.