Precision in assessment of osteoporosis from spine radiographs

Inter- and intra-observer variation in spine radiographs of 100 osteoporotic women and longitudinal change in roentgenologic status after 1 year of antiosteoporotic treatment were assessed. The method applied was naked eye inspection, and a score system estimating severity of fractures - vertebral deformation score (VDS). Agreement was assessed by the Kappa coefficient corrected for agreement by change. The results showed a satisfactory inter- and intraobserver agreement for wedge (Kappa = 0.72 and 0.90) and compression fractures (Kappa = 0.60 and 0.92). The method proved less reliable for endplate fractures (Kappa = 0.39 and 0.73). We think that the method of investigation is well suited for monitoring treatment effects in longitudinal studies.

The carboxy-terminal propeptide of type I procollagen in serum as a marker of bone formation: the effect of nandrolone decanoate and female sex hormones

Seventy-nine osteoporotic (prior forearm or vertebral fracture), but otherwise healthy, postmenopausal women (aged 55 to 75 years) were allocated to two double-blind trials: (1) 39 women received either nandrolone decanoate (anabolic steroid) 50 mg as an intramuscular depot injection or a placebo injection every 3 weeks for 1 year; and (2) 40 women received either 2 mg 17 beta-estradiol plus 1 mg norethisterone acetate or placebo tablets daily for 1 year. Sixty-seven (85%) completed the 1 year of treatment. Serum concentration of type I procollagen carboxy-terminal propeptide (PICP) was measured before and at 3, 6, 9, and 12 months of therapy. In addition, 32 of the women had an iliac bone biopsy taken after double tetracycline labeling. Initial serum PICP correlated significantly with histomorphometrically measured rate of bone formation (r = .4; P less than .05) and plasma bone Gla protein (r = .6; P less than .001), but not with histomorphometrically measured bone resorption or biochemical estimates of bone resorption (fasting urinary hydroxyproline and calcium). Estrogen-progestogen therapy significantly decreased (P less than .001) serum PICP by about 30%, whereas anabolic steroid therapy hardly affected it. We conclude that serum PICP may be used as a noninvasive measurement of bone formation on a group basis. Whereas bone formation is clearly decreased during estrogen-progestogen therapy, it is not affected by long-term therapy with anabolic steroids.

Collagen synthesis in postmenopausal women during therapy with anabolic steroid or female sex hormones

The effect of anabolic steroid therapy and estrogen-progestogen substitution therapy on serum concentration of procollagen type III aminoterminal peptide (PIIINP), a measure of collagen synthesis, in postmenopausal women was studied in two double-blind studies: (1) 39 women allocated to treatment with either 50 mg nandrolone decanoate as an intramuscular depot or placebo injections every third week for 1 year, and (2) 40 women allocated to receive either 2 mg 17 beta-estradiol plus 1 mg norethisterone acetate daily or placebo tablets for 1 year. Serum PIIINP was measured every 3 months during the study. Anabolic steroid therapy resulted in a more than 50% increase (P less than .001) in serum PIIINP at 3 months, which thereafter decayed but remained significantly increased throughout the study period. Serum PIIINP showed the same pattern during estrogen-progestogen therapy, but to a lesser degree. We conclude that anabolic steroids stimulate type III collagen synthesis in postmenopausal women, while estrogen-progestogen therapy may have such an effect, but only to a lesser degree.

Nandrolone decanoate treatment of post-menopausal osteoporosis for 2 years and effects of withdrawal

This study investigated the effects of nandrolone decanoate (ND) therapy (50 mg i.m. every 3 or 4 wk) on bone mass and soft tissue body composition in post-menopausal women. Twenty-two (22) women were followed up over a period of 30 mth, during which they received ND therapy for 12-24 mth and were treatment-free for the other 6-18 mth. While they were receiving treatment forearm bone mineral content (BMC) and lean body mass (LBM) increased, whereas fat mass (FM) decreased. After withdrawal of ND therapy the BMC, LBM and FM values all tended to return to pretreatment levels. Serum high-density-lipoprotein cholesterol showed a non-significant decrease, while serum low-density-lipoprotein cholesterol and serum total cholesterol remained unchanged during therapy. It was concluded that ND therapy can achieve an increase in BMC in post-menopausal women, but this is maintained only for as long as therapy is continued.

Regional bone mineral in healthy and osteoporotic women: a cross-sectional study

Regional bone mineral content and density (BMC and BMD) was measured in six regions (head, arms, chest, spine, pelvis, and legs) using dual photon 153Gd absorptiometry (DPA) in 128 healthy women aged 21-77 years, and in 45 women presenting with Colles' fracture (mean age 65 years), 46 women with vertebral crush or wedge fracture (mean age 68 years), and 27 women with femoral neck-fracture (mean age 74 years). The age-related normal bone loss was generalized, uniformly distributed, and best described by a combination of a premenopausal linear and a postmenopausal exponential regression in all six regions. Looking at BMD, the overall expected bone loss from age 20 to age 80 was approximately 20% in all the regions. When the fracture patients were examined, we found also generalized bone deficit as the prominent feature, amounting to about 20% of the premenopausal level for Colles' and spinal fractures, and about 25% for femoral neck-fracture. However, there was a regional bias in the fracture patients, as the Colles' and spinal fracture patients had a preferential reduction in spinal and pelvic BMD, whereas the patients with femoral neck-fracture had a preferential reduction in pelvic and leg BMD. We conclude that age-related and osteoporotic bone loss is generalized. Furthermore, we propose that regional differences in osteoporotic bone loss are brought about by a simple biological variability of the range of (i) relative amount of trabecular and cortical bone, (ii) rate of loss in the two types of bone tissue, and (iii) time of onset of trabecular relative to cortical bone loss.

Nasal calcitonin for treatment of established osteoporosis

Thirty-seven women with established osteoporosis completed a one-year double-blind, placebo-controlled study with the primary aim of examining the effect of nasal salmon calcitonin (200 IU daily) on bone and calcium metabolism. All the women received a daily calcium supplement of 500 mg. For comparison we also report data from an age-matched group of healthy women who did not receive calcium supplementation. The bone mineral measured in the forearm (single photon absorptiometry) and spine (dual photon absorptiometry) showed a similar pattern during treatment. The calcitonin group (n = 17) did not lose bone mineral in comparison with the placebo (n = 20) and the control groups (n = 19) (P less than 0.01). The biochemical estimates of both bone resorption and bone formation decreased highly significantly in the calcitonin group (P less than 0.001) and were unchanged in the control group, whereas the placebo (calcium) group showed intermediate values. Neither subjective nor objective side-effects occurred in any of the groups. We conclude that nasal calcitonin is a realistic treatment of established osteoporosis.

Treatment of postmenopausal osteoporosis: is the anabolic steroid nandrolone decanoate a candidate?

Thirty-nine postmenopausal women (aged 55-75 years) with at least one osteoporotic fracture were allocated to one year of treatment with the anabolic steroid nandrolone decanoate (50 mg i.m. every 3 weeks) or placebo injection. Both groups also received a daily intake of 500 mg calcium. Thirty-six women (92%) completed the study. In the nandrolone decanoate-treated group the fat corrected bone mineral content in the proximal part of the distal forearm (measured by single photon absorptiometry) showed a significant increase of 3% compared with placebo (P less than 0.01), and the same tendency was seen in the bone mineral content of the distal part of the distal forearm and density of the lumbar spine (measured by dual photon absorptiometry). However, this did not reach significance. In the placebo group all bone mineral measurements remained unchanged. The biochemical estimates of bone formation (plasma bone Gla protein (BGP), serum alkaline phosphatase) and whole body retention (WBR) of 99mTc-diphosphonates were not statistically significantly changed by the nandrolone decanoate therapy. We conclude that treatment with nandrolone decanoate does increase the bone mineral content; however, this may not be due to a direct increase in bone formation. The mechanism may theoretically be a combination of decreased bone resorption and increased muscle mass, which both play a beneficial role in conserving bone.

Discriminative ability of total body bone-mineral measured by dual photon absorptiometry

We investigated the discriminative ability of total body bone-mineral expressed as the total body bone-density (TBBD) measured by dual photon absorptiometry (DPA) in 79 healthy premenopausal women, 27 healthy postmenopausal women, and 120 female osteoporotic fracture patients presenting with either Colles' fracture, vertebral fracture or femoral neck-fracture. TBBD was compared to the bone-mineral density of the lumbar spine (BMDspine) also measured by DPA, and to the bone-mineral content of the forearms (BMCforearm) measured by single photon absorptiometry (SPA). TBBD, BMDspine and BMCforearm showed that all the fracture patient groups had significantly reduced bone-mass. Using receiver operating characteristic (ROC) analysis, we found that TBBD had a tendency towards better discriminative ability than BMDspine or BMCforearm with regard to the discrimination between healthy premenopausal women and the three types of osteoporotic fractures (not significant in spinal fracture patients). BMCforearm had an intermediate position, whereas BMDspine had the smallest discriminative ability. TBBD also discriminated better between healthy postmenopausal women and hip-fracture patients than BMDspine or BMCforearm, whereas there was no significant difference between the three methods regarding the discrimination between the healthy postmenopausal women and the Colles' and spinal fracture patients. We conclude that the TBBD measurement by DPA has a discriminative potential which is better than the local spine or forearm measurements.

Changes in soft tissue body composition and plasma lipid metabolism during nandrolone decanoate therapy in postmenopausal osteoporotic women

Thirty-nine osteoporotic (prior spine or Colles' fracture) but otherwise healthy postmenopausal women were allocated to receive blindly either 50 mg nandrolone decanoate (ND) intramuscularly or placebo injections every 3 weeks for 1 year. Thirty-six women (92%) completed the study. ND treatment resulted in an increase in non-osseous lean weight and a corresponding decrease in fat mass (measured by dual photon absorptiometry). A 20% increase in the 24-hour urinary creatinine excretion indicated that the increase in non-osseous lean weight was caused mainly by an increase in muscle mass. With regard to serum lipids and lipoproteins, ND treatment slightly decreased high density lipoprotein (HDL) cholesterol without significantly affecting total cholesterol, low density lipoprotein (LDL) cholesterol or triglycerides. In conclusion, treatment with ND changes the soft tissue composition in osteoporotic postmenopausal women towards a leaner and more muscular body.

Iliac crest biopsy in longitudinal therapeutic trials of osteoporosis

Changes in tetracycline-labelled iliac crest biopsies taken before and after 1 year of treatment with nandrolone decanoate + calcium, 17 beta-estradiol + norethisterone acetate + calcium or placebo were compared with changes in plasma bone Gla protein (pBGP), serum alkaline phosphatase (sAP), whole body retention (WBR) of Technetium-99m-diphosphonate [( 99mTc]DP) and bone mineral content (BMC) of the forearm. Based on a comparison between biopsy and noninvasive results, as well as on evaluation of the variation in the groups, certain guidelines for the use of bone histomorphometry in longitudinal therapeutic trials are suggested. It is proposed that bone biopsy is not used to monitor changes in amount of bone and that evaluation of changes in biopsy evaluated bone turnover is only attempted when the groups are large.

Accuracy of lumbar spine bone mineral content by dual photon absorptiometry

The accuracy of measurement of the bone mineral content (BMC, g) and bone mineral density (BMD, g/cm2) of the lumbar spine by dual photon absorptiometry (DPA) was estimated by means of two different spine scanners (a Nuclear Data 2100 and a Lunar Radiation DP3). The lumbar spines of 13 cadavers were used. BMC and BMD were measured in situ and on the excised vertebrae in a solution of water/ethanol; and covered with ox muscle/porcine muscle/lard. The actual mineral weight and areal density were determined after chemical maceration, fat extraction, drying to a constant weight, ashing for 24 hr at 600 degrees C, and correction for the transverse processes. The true are was measured by parallax free X rays and planimetry. All measurements of BMC or BMD were highly interrelated (r = 0.94-0.99). The standard error of estimate (s.e.e.) of BMC in situ versus BMC in water/ethanol was 5.2%. The agreement between the BMD values of the two scanners was very good (s.e.e. = 2.9%). BMC in situ predicted the actual vertebral mineral mass with an s.e.e. of 8.1%. BMD in situ and BMD in water/ethanol predicted the actual area density with s.e.e.s of 10.3% and 5.0%, respectively. This study discloses the correlation and accuracy error of spinal DPA measurements in situ in whole cadavers versus the actual BMC and BMD. The error, which is underestimated in in vitro studies, amounts to 10%.

Bone turnover in spinal osteoporosis

We have investigated biochemical indices of bone formation and bone resorption: serum alkaline phosphatase (sAP) plasma bone Gla protein (pBGP), fasting urinary hydroxyproline corrected for creatinine (FuHP/Cr), and fasting urinary calcium corrected for creatinine (FuCa/Cr) in 43 postmenopausal women with spinal fractures. Furthermore, histomorphometric indices of bone resorption and bone formation, as well as whole body retention (WBR) of 99m-technetium-diphosphonate (99mTc-DP), were determined. The results are compared to pre- and postmenopausal normal subjects. The results showed that indices of bone formation were mutually correlated except for sAP vs. WBR. sAP, WBR, and pBGP increased with age. sAP and WBR were not different between osteoporotics and age-matched controls, while pBGP and probably histological indices of bone formation were lower in osteoporotics than in age-matched controls. pBGP--and to a lesser extent sAP--were significantly correlated with all histological parameters reflecting bone formation. Finally, biochemical indices of bone resorption were high in osteoporotic patients and poorly correlated with histological bone resorption. The discrepancy between biochemical markers of bone formation may be related to the low sensitivity of sAP and WBR. Conversely, pBGP, sAP, and WBR may reflect different aspects of osteoblastic activity and bone mineralization. Finally, our data suggest that bone turnover increases with aging and that osteoporotic patients have higher bone resorption and probably lower bone formation than age-matched controls.

Elements in normal and cirrhotic human liver tissue. II. Potassium, sulphur, chlorine and bromine measured by X-ray fluorescence spectrometry

Elements (K, S, Cl, Br) were measured by X-ray fluorescence spectrometry in normal liver tissue obtained at autopsy from 74 subjects (44 male, 30 female), median age 62 years (range 20-87), and in cirrhotic liver tissue from 27 subjects (14 alcoholic, 13 non-alcoholic cirrhosis). The element content (median and 5-95 percentile interval) in normal livers in mmol/kg dry tissue was: K, 198.75 (150.95-256.42); S, 147.60 (73.86-233.97); Cl, 98.73 (69.51-163.55); Br, 0.1101 (0.0701-0.4205). None of the elements displayed any sex difference. There were correlations between the content of Br and Cl (r = 0.26, P less than 0.05) and Br and K (r = 0.24, p less than 0.05). In both groups of cirrhotic livers, K, S and Cl content was within the normal range. Median Br content was above normal both in alcoholic (0.2265 mmol/kg, P less than 0.01) and non-alcoholic cirrhotic livers (0.2228 mmol/kg, P less than 0.01).

Usefulness of regional bone measurements in patients with osteoporotic fractures of the spine and distal forearm

Bone mineral mass was measured in normal subjects and osteoporotic patients at two forearm sites (proximal and distal of the 8 mm site between the two forearm bones) by single photon absorptiometry and in the spine and whole body by dual photon absorptiometry. There were no signs of preferential low spinal bone mass in 28 patients with vertebral fractures. Their bone mass was at all sites 26% to 37% lower than the premenopausal mean value and 7% to 13% lower than in age-matched normal women. In 45 patients with forearm fractures bone reduction was also universal but only 3% to 6% lower than in healthy women of comparable age. The spinal bone mass in all the patients was significantly related to both forearm measurements with coefficients of correlation of 0.58-0.61 and s.e.e. of 18%. Compared to the premenopausal normal range the distal forearm site had a greater sensitivity in identifying patients with vertebral fractures than had the spinal measurement (chi-square test, p less than 0.01). We thus conclude that patients with vertebral fractures have universal osteoporosis and that measurement of spinal BMC had no predictive advantages over that of the forearm bone mass for population studies.

Regional variations in histomorphometric bone dynamics from the skeleton of an osteoporotic woman

Histomorphometric evaluation of bone formation in an intravital tetracycline-labeled skeleton of a suddenly deceased osteoporotic woman is presented. The 24 skeletal sites investigated displayed substantial regional variations which, for two out of four cortical bone dynamics and all trabecular bone dynamics, were significantly higher than the intraspecimen variation. Poor agreement was found between bone formation in left- and right-sided iliac crest specimens. Furthermore, no agreement was found between trabecular bone formation and amount of hematopoietic bone marrow. With all the limitations that the study of a single patient involves it is suggested that bone biopsy in individual patients should not be the only basis for therapeutic decisions in postmenopausal osteoporosis; amount of hematopoietic marrow does not seem to influence bone formation; and bone formation in the skeleton displays large regional variations, which are larger for the fraction of labeled surfaces than for appositional rate.

Bone composition in the distal forearm

Recent data have indicated that measurements of bone mass in the very distal part of the forearm is superior to more proximal measurements in identifying osteoporosis. Bone slices from the distal part of the forearm were obtained from 16 necropsies and the trabecular fraction of the total dry bone weight was measured in adjacent bone slices, 8 mm thick. Prior to autopsy bone mass at the corresponding sites was measured using a multipath single photon absorptiometric method by which scans are obtained proximal (proximal BMC) and distal (distal BMC) to the site, where the ulna and radius are 8 mm apart. The accuracy of bone measurements at the two sites was virtually similar (r = 0.98 and r = 0.94, respectively). In both areas the amount of trabecular bone increased towards the metaphysis with a trabecular/cortical ratio ranging from 10 to 60% (wt/wt). If bone composition is known it is possible to estimate rates of bone loss from the two compartments.

Noninvasive diagnosis of uremic osteodystrophy: uses and limitations

45 bone biopsies from patients with chronic uremia were reviewed to define which noninvasive investigations were of value in predicting the histological diagnosis and to quantify the spectrum of uremic bone disease at a center that has consistently used an aluminum-free dialysis bath. 17 biopsies were taken postmortem. 15 patients received conservative treatment, the rest were on maintenance dialysis. 13 patients had symptomatic bone disease. Virtually all patients with a uremia duration greater than 3 years had uremic osteodystrophy. All patients with clinical bone disease, hypercalcemia or raised alkaline phosphatase activity had osteodystrophy, but the specific histology was not indicated. Greatly raised parathyroid levels suggested secondary hyperparathyroidism, but the test was only 100% specific when 20 times normal. Total aluminum consumption was highly indicative of bone aluminum concentration (p less than 0.0001) and aluminum-related osteomalacia (5 cases), suggesting that a considerable proportion of uremic bone disease is iatrogenic. Serum aluminum was of some use in the diagnosis of aluminum-related osteomalacia, but was not wholly reliable. Bone mineral content (BMC) using both forearm measurements and total body bone mineral levels (TBBM) were assessed in 32 patients and were found to be reduced in 12, with a preponderance of secondary hyperparathyroidism. BMC and TBBM were negatively correlated to resorbing surfaces and bone formation rate, suggesting that secondary hyperparathyroidism is the uremic bone disease that represents the greatest threat to bone mass. It is concluded that while noninvasive investigations give considerable information, reliable diagnosis requires the use of histological methods.

The effect of oral aluminium salts on the bone of non-dialysed uremic patients

12 patients with conservatively treated uremia were investigated using bone histomorphometry, bone aluminium concentration determination and total body bone mineral content (TBBM). The bone aluminum was raised in 10 patients and was significantly related to oral aluminium salt consumption (p less than 0.01). Two of four patients who had not received aluminium also had raised levels but the difference was not significant from nonuremic patients. The two patients with the highest levels had a mineralisation defect despite normal levels of 1,25-dihydroxyvitamin D. Three patients had significant bone loss of whom one had osteomalacia (OM) while two had secondary hyperparathyroidism (2HP). It is concluded that 1) aluminium salt consumption results in bone aluminium accumulation, and may contribute to the mineralisation defect; 2) uremic patients not treated ith aluminium salts may have slightly raised levels, but this seems not to be clinically important; 3) secondary hyperparathyroidism causes greater destruction of bone mass than other uremic bone diseases; 4) atomic absorption spectrometry is a more sensitive method for detecting aluminium bone deposition than histochemical methods.

Hydroxyproline/creatinine ratios as estimates of bone resorption in early postmenopausal women. Fasting and 24-h urine samples compared

Ratio of urinary hydroxyproline/creatinine excretion is often used as an index of bone resorption. To establish the difference between the fasting urinary content (FU-HPR/CR) and the 24-h urinary excretion (24 h-U-HPR/CR) we determined hydroxyproline and creatinine in specimens from a group of early postmenopausal women. One hundred and eighty-six early postmenopausal women were randomized into 10 groups receiving various doses of sequential female sex hormones and/or 1,25(OH)2D3, 0.25 microgram per day, or placebo. In all groups there were parallel changes of FU-HPR/CR and 24 h-U-HPR/CR, and in all groups treated with oestrogens the values decreased significantly. The changes in FU-HPR/CR were more pronounced than in the 24-h-U-HPR/CR, which indicates that FU-HPR/CR is a more sensitive marker of changes in bone resorption. The strong correlation between the mean values of 24-h-U-HPR/CR and those of FU-HPR/CR suggests that both methods are convenient for evaluating changes during long-term studies in groups of patients. The correlation on an individual basis is weak. The substantial intraindividual variation in 24-h-U-HPR/CR, (34.6%) indicates that FU-HPR/CR (CV = 17.0%) is the more valid variable for individual patients.

Iliac crest biopsy: an investigation on certain aspects of precision and accuracy

We investigated the intraobserver and section to section variation in static and dynamic histomorphometric variables in ten iliac crest biopsies. We also did a comparative study of iliac crest and lumbar spine specimens from 14 cadavers. The ten patients had osteoporosis (spinal crush fractures) and the 14 specimens taken at the necropsies were either normal or osteopenic, without malignant bone disease, bone metastases or metabolic bone disease. The majority of the coefficients of variation (CV%) were between 5 and 15% in the intraobserver analysis and 10 and 30% in the section to section analysis. These results suggest that more sections from each biopsy should be investigated to increase the precision. The correlation of variables from the iliac crest and spine showed poor agreement between resorption and osteoid variables. This fact, combined with a rather low precision of bone dynamic variables in the section to section investigation, raises the question of whether iliac crest biopsy is representative for trabecular bone turnover in the skeleton.

Trace elements in normal and cirrhotic human liver tissue. I. Iron, copper, zinc, selenium, manganese, titanium and lead measured by X-ray fluorescence spectrometry

Trace elements (Fe, Cu, Zn, Se, Mn, Ti, Pb) were measured by X-ray fluorescence spectrometry in normal liver tissue obtained at autopsy from 74 subjects (44 male, 30 female), median age 62 years (range 20-87), and in tissue from 27 cirrhotic livers (14 alcoholic, 13 non-alcoholic cirrhosis). The element content (median and 5-95 percentile interval) in normal livers in mmol/kg dry tissue was: Fe, 16.51 (7.82-39.03); Cu, 0.378 (0.189-0.629); Zn, 4.01 (2.59-9.33); Se, 0.018 (less than 0.004-0.035); Mn, less than 0.055 (less than 0.055-0.237); Ti, less than 0.146 (less than 0.146-0.919); Pb, less than 0.0005 (less than 0.0005-0.0154). Only copper content showed a sex difference, being higher in males than in females (P less than 0.04). In both groups of cirrhotic liver, Fe content was within normal, Cu content above normal (P less than 0.05, P less than 0.02), and Se content below normal (P less than 0.0001, P less than 0.04). Alcoholic cirrhotic livers had lower Zn levels (P less than 0.02), higher Mn levels (P less than 0.06), and higher Pb levels (P less than 0.03) than normal livers.

Iliac crest biopsy: representativity for the amount of mineralized bone

The aim of the study was to evaluate the representativity of iliac crest biopsy for the amount of mineralized trabecular and cortical bone in the skeleton. The following data were obtained on bone from 14 necropsies: right sided iliac crest biopsy, lumbar spine biopsy, dry fat free weight of lumbar spine, bone mineral density (BMD) in the lumbar spine and dry fat free weight of cortical and trabecular bone from the left distal forearm. The amount of mineralized cortical and trabecular bone from various sites was compared by linear regression analysis. The results confirm iliac crest biopsy as a good predictor of the amount of trabecular bone, but not of cortical bone. Furthermore, iliac crest biopsy is a better estimate of the amount of trabecular bone in the lumbar spine than spinal BMD.

Bone aluminum deposition in maintenance dialysis patients treated with aluminium-free dialysate: role of aluminium hydroxide consumption

Postmortem iliac crest biopsies were performed on 16 uremic patients. 3 had been treated conservatively while 13 had been entered into a maintenance dialysis program. The dialysate was treated by reverse osmosis for more than 10 years, and the aluminium concentration was consistently below the detection limit of 0.15 mol/l. 14 patients had been treated with aluminium hydroxide. Bone histomorphometry, aluminium labelling intensity, osteoid surface aluminium labelling extent (Al/OBI) and bone aluminium concentration were measured. 14 patients had significant bone aluminium deposition, including 2 who were not on dialysis of whom 1 had not received aluminium hydroxide. Bone aluminium concentration and labelling intensity were correlated to total aluminium hydroxide consumption (p less than 0.001, p less than 0.05) and present dose (p less than 0.01, p less than 0.01), while Al/OBI was not. The two patients with the highest aluminium concentrations had symptomatic osteomalacia, but 4 patients with significantly raised concentrations and mineralisation front labelling had secondary hyperparathyroidism. It is concluded that bone aluminium deposition occurs despite the use of aluminium-free dialysate and is associated with total and present aluminium hydroxide consumption; heavy aluminium deposition is associated with severe and symptomatic osteomalacia, but can also be observed in the presence of predominant hyperparathyroidism; aluminium deposition can occur in the absence of treatment with dialysis or aluminium hydroxide; bone aluminium concentration and labelling intensity are a better measure of bone deposition than Al/OBI.

Metabolic bone disease and aluminium contamination in 38 uremic patients. A bone histomorphometric study

Iliac crest biopsies from 38 uremic patients, 26 hemodialysis, and 12 chronic uremics from a nephrology department with verified aluminium free dialysis water were investigated with histomorphometric method and aluminium-specific staining. For both the uremic and the dialysed group the results showed a high incidence of both metabolic bone disease (75%, 69% respectively) and aluminium contamination (25%, 62%).

Metabolic bone disease with and without osteomalacia after intestinal bypass surgery: a bone histomorphometric study

We performed iliac bone histomorphometry after in vivo double tetracycline labeling 3-14 years after intestinal bypass surgery for obesity in 21 patients, selected because of clinical suspicion of metabolic bone disease, and compared the results with those of 40 age-matched normal control subjects. Osteomalacia defined by rigorous kinetic criteria was found in six cases, histologic features of secondary hyperparathyroidism without significantly impaired mineralization in one case, and possible osteomalacia masked by impaired matrix synthesis in one case. In the patients with definite osteomalacia, nonfracture bone pain was more frequent, corrected plasma calcium lower, plasma alkaline phosphatase and magnesium higher, and secondary hyperparathyroidism more severe than in the other patients. In the patients without osteomalacia there was a 24.5% reduction in trabecular bone volume compared to the controls; in contrast to age-related bone loss and post-menopausal osteoporosis, this was due mainly to reduction in the thickness rather than the density of trabecular plates. About two-thirds of the reduction in trabecular thickness was due to reduction in interstitial bone thickness, representing the cumulative effect of increased depth of osteoclastic resorption cavities, probably due in part to secondary hyperparathyroidism. About one-third of the reduction in trabecular thickness was the result of reduced mean wall thickness, representing insufficient osteoblastic matrix synthesis, probably due in part to malabsorption of an unidentified nutrient necessary for normal bone health. Resorption indices were not increased at the time of the biopsy, but there were persistent defects in the recruitment and activity of osteoblasts. Clinically significant bone loss after intestinal shunt surgery, as in several other clinical situations, results from the combined effects of an unsustained increase in bone resorption and a sustained decrease in bone formation.

Serum bone Gla protein variations during estrogen and calcium prophylaxis of postmenopausal women

We have evaluated serum bone Gla protein (BGP) changes in a double-blind study of early postmenopausal women during treatment with estrogen and calcium. To substantiate the changes in bone turnover, serum alkaline phosphatase, 24-hour urinary calcium, and bone mineral content (BMC) have also been measured. Our results indicate that serum BGP is a valuable measurement of bone metabolism.

Iron, copper, zinc and selenium in human liver tissue measured by X-ray fluorescence spectrometry

The content of iron, copper, zinc and selenium was measured by energy-dispersive X-ray fluorescence (XRF) spectrometry in normal liver tissue obtained at autopsy from 16 females and 12 males 46-87 years old. The precision of the XRF analysis, expressed by the coefficient of variation was: iron, 1.8%; copper, 3.2%; zinc, 1.0%; and selenium, 26.7%. In large liver samples, mean amount-of-substance contents of elements in dry liver tissue were: iron, 16.95 mmol/kg (range 7.90-27.31 mmol/kg); copper, 0.33 mmol/kg (0.08-0.76 mmol/kg); zinc, 5.12 mmol/kg (2.92-9.47 mmol/kg); selenium 0.02 mmol/kg (less than 0.004-0.04 mmol/kg). Furthermore the amounts of iron, copper and zinc were measured in wet-ashed Menghini needle biopsy specimens taken from the centre of 20 large liver samples. There was good agreement between results obtained in biopsy specimens and large samples concerning iron (r = 0.96, P less than 0.001) and zinc (r = 0.97, P less than 0.001), but not concerning copper (r = 0.66, P less than 0.01). XRF analysis appears to be a convenient method for element analysis in liver tissue and for measurement of iron and zinc in needle biopsy specimens.

Tumor heterogeneity in lung cancer based on light microscopic features. A retrospective study of a consecutive series of 200 patients, treated surgically

In order to study the problem of morphological tumor heterogeneity in lung cancer, 200 consecutive patients who had undergone surgery for a malignant lung tumor, were evaluated retrospectively with regard to morphological type. The tumor was classified morphologically in 187 patients, and 163 (87%) had a morphologically homogeneous tumor, based on light microscopic features and using the criteria recommended by the World Health Organization. The remaining 24 patients (13%) had a tumor with morphologic features of more than one cell type. It is concluded that morphological heterogeneity is a considerable problem in the classification of malignant lung tumors. This heterogeneity had been regarded as evidence of an endodermal origin of all major types of lung cancer. Future prospective studies will have to determine whether it has any therapeutic significance.