[Localization diagnosis of enlarged parathyroid glands: 201Tl-99mTc-subtraction scintigraphy compared with 5-MHz-sonography]

Fifty patients clinically suspected of having primary hyperparathyroidism were examined by scintigraphy (201Tl-99mTc subtraction) and sonography (5 MHz). In 28 cases, the results of subtraction scintigraphy, and in 26 cases, the results of sonography were checked by operation. In 25 patients there was a solitary parathyroid adenoma and in two, primary hyperplasia. In one patient all four parathyroid glands were normal. Subtraction scintigraphy had a sensitivity of 90% and a specificity of 98%, while sonography had a sensitivity of 82% and a specificity of 95%. The combination of 201Tl-99mTc subtraction scintigraphy as a functional investigation and sonography as a structural imaging method produced a sensitivity of 96% and is therefore superior to all other methods of localisation for normally situated glands. Diagnostic certainty is reduced by the presence of a nodular thyroid.

[Preoperative localization diagnosis of parathyroid adenomas in 72 cases of primary hyperparathyroidism by selective catheterization of neck veins and parathyroid hormone determination]

In 72 cases of primary hyperparathyroidism, selective venous catheterization was performed preoperatively to localize parathyroid adenomas. Diagnosis of primary hyperparathyroidism was proved by operation in all but 5 cases, in which no adenomas could be found intraoperatively. By venous catheterization of the neck and upper region of the thorax, an average of 10 blood samples per patient were taken. Parathyroid hormone was estimated by radioimmunoassay with high sensitivity against the intact PTH-molecule and carboxy-terminal fragments. Only in 24 out of 72 cases was localization of parathyroid adenomas prognosticated correctly with respect to side and height, while in a total of 38 cases localization on the right or left side only could be determined preoperatively. These unsatisfactory results can be improved only by a much more extensive catheterization technic which would be justified only in patients already operated on before without success. The final evaluation of non-invasive methods, e.g. ultrasonics and computerized tomography, is still under discussion.

Delaying effect of cyclophosphamide on bone fracture healing chemical analyses of rat femora

Hydroxyproline, calcium and inorganic phosphate contents of osteotomised rat femora were compared with those from rats treated with cyclophosphamide. The treatment consisted of 10 mg/kg/body weight injected intraperitoneally daily for 14 days after (group II) and before (group III) operation. The obtained results indicated a reduction in the hydroxyproline content of the callus and a diminution of the calcium and phosphate deposition upon it, thus inhibiting collagen formation and delaying mineralisation, retarding the healing process of the fraction. The degree of inhibition was decreased when the cyclophosphamide treatment discontinued before osteotomy was performed (group III). We would like to draw attention to these results, and suggest that cyclophosphamide treatment should not coincide with the healing of bone fracture.

[Clinical relevance of 25-hydroxyvitamin D estimation in plasma (author's transl)]

Plasma concentrations of 25-hydroxyvitamin D (25-OH-D) were determined in 40 healthy persons and in patients with primary osteoporosis (n = 43), primary hyperparathyroidism (n = 19), intestinal osteopathy (n = 13), and after small intestine bypass operations (n = 8). The control group showed physiologic seasonal variations which must be taken into account in the individual case. Whereas there were no deviations from the normal in patients with osteoporosis, significantly lower values were obtained in the other disease groups. Estimation of 25-OH-D in plasma represents a valuable contribution for the diagnosis of generalized osteopathies and for the differential diagnosis of hypercalcaemia. In addition, the effects of vitamin D treatment may be objectively assessed. Overdosage and intoxication may be recognized in time.

[Treatment of Paget's disease of bone with salmon calcitonin (author's transl)]

Subcutaneous injections for two days of 100 MRC units each of synthetic salmon calcitonin were administered to 40 out of 77 patients with Paget's disease of bone. Chemical pathology (alkaline serum phosphatase, hydroxyprolinuria) showed an initially satisfactory response of all patients to this treatment. Resistance developed in 6 out of 8 patients on long term treatment with recurrence of increased serum alkaline phosphatase, occurring after 4 months at the earliest and 24 months at the latest. Human calcitonin may be an alternative of treatment in these cases of secondary resistance. Treatment with calcitonin is nearly risk-free and represents a definite progress in comparison with earlier forms of treatment.

[Calcium and bone metabolism after jejunal bypass operation for alimentary obesity: model for a intestinally-conditioned disorder (author's transl)]

Jejuno-ileostomy was performed in eight women because of severe alimentary obesity. Their calcium phosphate and bone metabolism was studied an average of 31 months post-operatively. This revealed secondary intestinal hyperparathyroidism due to an artificial malabsorption syndrome. While most of the significant metabolic factors were within normal limits, examination of calcium balance and kinetics indicated a marked disorder of calcium and bone metabolism. Calcium balance averaged-138 mg daily, corresponding to a yearly loss of skeletal mass of 4-5%.

[Diaphyseal dysplasia (Camurati-Engelmann syndrome) with progressive loss of vision: 30-year observations and the effect of prednisolone treatment (author's transl)]

Radiological changes in the skeleton had been present for 30 years in a now 42-year-old man with diaphyseal dysplasia (Camurati-Engelmann syndrome). Because of threatened blindness by bony narrowing of the optic canal prednisolone was administered over several years. Biochemical, calcium-kinetic and ophthalmological studies demonstrated a favourable effect of this treatment.

[The diagnostic value of the alveolar lamina dura in generalised bone disease (author's transl)]

Changes in the alveolar lamina dura in 134 patients have been analysed. They included 32 cases with urolithiasis in whom generalised bone disease had been excluded, 37 cases of primary hyperparathyroidism, 31 cases of secondary hyperparathyroidism and 34 with primary osteoporosis. The state of the lamina dura was related to biochemical, radiological and histological findings in the various groups. The value of the lamina dura in the diagnosis of generalised skeletal abnormalities has been defined.

Deconvolution analysis of 99mTc-methylene diphosphonate kinetics in metabolic bone disease

The kinetics of 99mTc-methylene diphosphonate (MDP) and 47Ca were studied in three patients with osteoporosis, three patients with hyperparathyroidism, and two patients with osteomalacia. The activities of 99mTc-MDP were recorded in the lumbar spine, paravertebral soft tissues, and in venous blood samples for 1 h after injection. The results were submitted to deconvolution analysis to determine regional bone accumulation rates. 47Ca kinetics were analysed by a linear two-compartment model quantitating short-term mineral exchange, exchangeable bone calcium, and calcium accretion. The 99mTc-MDP accumulation rates were small in osteoporosis, greater in hyperparathyroidism, and greatest in osteomalacia. No correlations were obtained between 99mTc-MDP bone accumulation rates and the results of 47Ca kinetics. However, there was a significant relationship between the level of serum alkaline phosphatase and bone accumulation rates (R = 0.71, P less than 0.025). As a result deconvolution analysis of regional 99mTc-MDP kinetics in dynamic bone scans might be useful to quantitate osseous tracer accumulation in metabolic bone disease. The lack of correlation between the results of 99mTc-MDP kinetics and 47Ca kinetics might suggest a preferential binding of 99mTc-MDP to the organic matrix of the bone, as has been suggested by other authors on the basis of experimental and clinical investigations.

Bone calcium exchange in primary hyperparathyroidism as measured by 47calcium kinetics

A 2-compartmental analysis of 47Ca kinetics was carried out in 21 patients with primary hyperparathyroidism (pHPT) and 7 healthy control subjects. The results were compared with serum concentrations of calcium, inorganic phosphorus, alkaline phosphatase, and immunoreactive parathyroid hormone (iPTH). The well known increase in exchangeable calcium was found to be not uniform in its subcompartments and with a marked predominance of the osseous fraction. The most important result was the increase of calcium efflux from osseous into extraosseous exchangeable calcium in agreement with the results of Talmage et al. studying PTH actions on calcium flux rates between blood and bone in rats. The increased calcium efflux in pHPT was the only kinetic parameter correlated with serum iPTH. Neither increased calcium accretion indicating high bone turnover, nor serum calcium concentrations and exchangeable calcium fractions correlated with serum iPTH. These results lead to the following conclusions: radiocalcium kinetics provides valuable parameters of bone calcium turnover (osseous exchangeable calcium, bone-calcium efflux, and calcium accretion). Calcium efflux from exchangeable bone calcium, determined kinetically, might be related to PTH induced calcium transport from bone fluid compartment to extracellular fluids according to the concept of Talmage 1977.

Pathogenesis and natural course of primary osteoporosis

A new concept of the pathogenesis and natural course of osteoporosis is described, based on histomorphometric evaluation of iliac crest bone biopsies of 108 patients with untreated primary osteoporosis. It is suggested that primary osteoporosis spontaneously runs a three-phase course: during the initial period of negative bone balance, bone mass falls below the normal range; during the second phase bone mass remains consistently below age-related normal values; in the third phase restitution of osteoporosis is introduced by a positive bone balance. It is suggested that only about a quarter of patients with a skeletal mass below the age-related normal range have true primary osteoporosis; the remaining three-quarters may have secondary forms of osteoporosis where the underlying disease responsible for the bone loss had been missed before the osteoporosis was diagnosed.

[Results of long-term treatment of primary osteoporosis with sodium fluoride (author's transl)]

Twenty-three patients with primary osteoporosis were treated with sodium fluoride over 25 months. Mean total dose was 21 g fluoride. Symptoms, body size, biochemical results, radiological changes and skeletal mineral content as well as bone histomorphometry were evaluated in assessing results of treatment. Accordingly, no advance in the disease process was demonstrable in 13 patients, while there was definite improvement in six, but in four there was further progression.

[Resections of the pancreas: their effects on bone and calcium metabolism (author's transl)]

Four to ten years after partial or total resections of the pancreas calcium and bone metabolism was investigated. A high-turnover osteoporosis is proved by bone histomorphometry. There were no signs of osteomalacia or secondary hyperparathyroidism. Radiocalciumkinetics in all cases showed an increase endogenous fecal loss of calcium. Both, intestinal absorption and renal excretion of calcium were normal. Pathophysiologic relationship between resections of the pancreas and their influence on calcium and bone metabolism has not been sufficiently explained until now. Further investigation will be necessary.

On an attempt to treat primary and secondary osteoporosis with human growth hormone

Three male patients with severe osteoporosis were treated with human growth hormone. One of them had a primary osteoporosis, the two others osteogenesis imperfecta. The duration of therapy was 8 to 15 months and average doses per day were 1.45 to 2.3 mg. While clinical and 47calcium kinetic data failed to prove marked influences of the treatment, histomorphometry of bone biopsies showed indisputable changes. There was an increase of periosteal new bone formation as well as of intracortical bone resorption, while at the same time the relative activity of osteoblasts on endosteal surfaces showed a significant increase.