[Bone complications in diabetic subjects with good metabolic control and without any long-term complications--certain problems. Part III: The influence of hypertension and type 2 diabetes mellitus co-incidence of calcium, phosphorus and magnesium metabolism]

Both high morbidity and potentiation of systemic complications emphasise significance of diabetes mellitus and hypertension co-incidence. The aim of the study was to analyse the influence of hypertension accompanied with type 2 diabetes mellitus on calcium phosphorus and magnesium metabolism. The study was performed in standard low-calcium diet conditions on the group of 49 patients with type 2 diabetes mellitus (among them 27 had hypertension), 14 patients with essential hypertension and 20 healthy persons. Both serum and urine concentration of creatinine, calcium, phosphorus, hydroxyproline, hydroxylysine and uric acid were analysed. Oral calcium load test was done. Serum alkaline phosphatase activity and oxalic acid urine excretion were also estimated. There were no significant differences between diabetic patients with and without hypertension as far as calcium, phosphorus or magnesium metabolism were concerned.

[Bone complication in diabetic subjects with good metabolic control and without any late complications: selected problems. Part I: calcium, phosphorus and magnesium metabolism]

The aim of the study was to evaluate whether in diabetics with good metabolic control and without any diabetic complications, disturbances of calcium, phosphorus and magnesium metabolism or hormonal regulation (parathormone/calcitonin) were present, and if they depended on type of diabetes, duration time of diabetes, kind of hypoglycaemic treatment, sex or age of patients. 83 subjects were examined, including: 14 with type 1 diabetes mellitus, 49 with type 2 diabetes mellitus and 20 healthy persons. All tests were performed in standarized low-calcium diet conditions. In basal conditions both serum concentrations and daily urine excretion of calcium, phosphorus, magnesium were estimated. Oral and intravenous calcium load tests with simultaneous parathormone, calcitonin, calcium, magnesium and phosphorus concentrations estimation were done. The final conclusions were as follow: Both in type 1 diabetes mellitus and type 2 diabetes mellitus subjects with good metabolic compensation and without advanced diabetic complications a tendency to early disturbances of calcium-phosphorus metabolism is observed. Physiological hormonal control (parathormone/calcitonin) is preserved. Correlations between mineral metabolism and type of diabetes, duration time of diabetes, daily insulin dose, body mass index and sex are observed. Kind of hypoglycaemic treatment has only slight influence on the mineral metabolism.

Bone mineral content and bone mineral density in adolescent girls with anorexia nervosa--a longitudinal study

OBJECTIVE

Total body and lumbar spine bone mineral density (BMD-TB, BMD-L) and total body bone mineral content (BMC-TB) were measured to establish the course of bone demineralization in anorexia nervosa and the clinical factors influencing BMC-TB and BMD changes during treatment.

METHOD

Forty-two girls with DSM III-R anorexia nervosa, age 14.7+/-2.4 years. BMC-TB, BMD-TB and BMD-L were measured in approximately 7-month intervals for 27.8+/-4.1 months using DXA.

RESULTS

Despite nutritional improvement, there was an initial decrease of BMD-L, and no change in BMC-TB and BMD-TB. an increase in BMC-TB and BMD was observed after approx. 21 months from the beginning of the study.

CONCLUSION

The improvement in BMC-TB and BMD was related to changes in nutritional status and was significantly marked in younger patients, with earlier anorexia onset and before menarche.

Bone density reduction in patients with Crohn disease and associations with demographic and disease variables: cross-sectional data from a population-based study

BACKGROUND

The extent of bone density reduction in patients with Crohn disease is still being debated. The aim of this study was to examine bone mineral density (BMD) and factors associated with reduced BMD in a representative population of patients with Crohn disease aged between 20 and 70 years.

METHODS

BMD (using dual energy X-ray absorptiometry) was measured in spine and hip in 55 patients with Crohn disease recruited from the entire Crohn population (n = 96) in a defined area of southern Norway. Demographic and clinical data were also collected. The patients were compared with 52 age- and gender-matched healthy controls. Potential demographic and disease-related factors associated with BMD reduction were statistically tested with bi- and multivariate analyses.

RESULTS

The BMD reduction in patients with Crohn disease was 7.1% (P = 0.02) in spine L1-4, 6.1% (P = 0.08) in femoral neck and 8.4% (P = 0.02) in total hip as compared with the controls. In total hip and femoral neck, age, body weight and gender were independently associated with reduced BMD, but in the spine only body weight. Among the disease-related variables, only ever use of prednisolone was independently associated with reduction in BMD but this only in the femoral neck.

CONCLUSIONS

The spine and hip BMD reduction of 6%-8% is similar to that found in a comparable population-based study performed in another area in Norway. Among the disease-related variables tested for, only the use of prednisolone was independently associated with BMD reduction. However, the BMD reduction measured in this study indicates that disease-related mechanisms are involved.

Disuse osteoporosis as evidence of brachial plexus palsy due to intrauterine fetal maladaptation

We report what may be overlooked evidence of the effects of intrauterine maladaptation as a cause of brachial plexus palsy. A case of total brachial plexus palsy in the posterior arm associated with Horner's syndrome and severe demineralization of the bones of the affected arm is analyzed. In this litigated case, a report of marked demineralization of the bones of the affected arm was analyzed by the plaintiff's radiology expert as diagnostic of disuse osteoporosis. The presence of clear-cut evidence of disuse osteoporosis during the early neonatal period is compelling evidence of an intrauterine onset of brachial plexus palsy.

[Anemia and limping in a vegetarian adolescent]

A vegan diet in the child and adolescent can induce severe bone sequelae by rickets and osteomalacia and megaloblastic anemia by cobalamin deficiency.

CASE REPORT

A 15-year-old adolescent was hospitalized because of lameness and pallor. The lameness was explained by femoral epiphysiolysis caused by rickets with severe hypocalcemia. The pallor, jaundice and splenomegalia were due to cobalamin-deficiency megaloblastic anemia. A prolonged supplemental diet with calcium, vitamins D and B12 as well as orthopedic treatment stabilized the bone lesions. The megaloblastic anemia was cured by parenteral cobalamin. The adolescent and his brother were victims of a diet imposed by a cult and a lack of care due to their parents refusing that a vegan diet was the cause of the deficient pathology. Penal proceedings led to the incarceration of the parents and to the placement of the children.

COMMENTS

Deficiencies in calcium and vitamins D and B12 may be severe in a child's development with a vegan diet. This case report reveals the social and legal problems of an inappropriate diet in infancy imposed by parents who are followers of a fundamentalist church. Beyond the management of children in cults, health professionals have to prevent, screen and supplement the deficient diet.

Human water, sodium, and calcium regulation during space flight and exercise

When one is exposed to microgravity, fluid which is normally pooled in the lower extremities is redistributed headward and weight bearing bones begin to demineralize due to reduced mechanical stresses. The kidney, which is the primary regulator of body fluid volume and composition, responds to the fluid shift and bone demineralization by increasing the urinary output of water, sodium, and calcium. This research involves developing a mathematical description of how water and electrolytes are internally redistributed and exchanged with the environment during space flight. This model consequently involves kidney function and the associated endocrine system. The model agrees well with actual data, including that a low sodium diet can prevent bone demineralization. Therefore, assumptions made to develop the model are most likely valid. Additionally, various levels of activity are also considered in the model since exercise may help to eliminate some of the undesired effects of space flight such as muscle atrophy and bone demineralization.

Changes in calcium metabolism and bone demineralization after orthotopic intestinal neobladder creation

PURPOSE

We evaluated calcium metabolism and bone demineralization by measuring specific markers for bone reabsorption and bone mineral density in patients with an intestinal neobladder.

MATERIALS AND METHODS

We studied 33 men 55 to 72 years old who underwent creation of an orthotopic sigmoid (23), ileocolic (8) or ascending colon (2) neobladder after cystectomy. Mean followup plus or minus standard deviation (SD) was 28.4+/-30.1 months (range 4 to 114). Serum electrolytes and arterial blood gases were measured. As markers of bone absorption we assayed urinary pyridinoline, deoxypyridinoline and N-terminal pyridinoline cross-linked telopeptides, and serum pyridinoline cross-linked C-terminal telopeptide of type I collagen. Bone mineral density of the spine and femur was determined by dual x-ray absorptiometry.

RESULTS

Mean blood pH plus or minus SD was 7.38+/-0.04 (range 7.29 to 7.43). Mean plasma bicarbonate was 22.9+/-3.4 mmol./l. and mean base excess was -1.63+/-3.61 mmol./l. Serum sodium, potassium, calcium, alkaline phosphatase and phosphate were normal in most patients. Mean serum chloride was 108.0+/-3.5 mEq./l., and was elevated in 9 of the 33 patients (27.3%). Serum intact parathyroid hormone was normal in all patients, osteocalcin was increased in 2 and 1alpha, 25-dihydroxyvitamin D3 was decreased in 2. Pyridinoline cross-linked C-terminal telopeptide of type I collagen was higher in 19 of 33 cases (57.6%) and N-terminal pyridinoline cross-linked telopeptides were elevated in 6 (18.2%). Pyridinoline and deoxypyridinoline were higher than normal in 19 (57.6%) and 7 (21.2%) patients, respectively. C-terminal telopeptide of type I collagen and deoxypyridinoline significantly correlated with serum pH (p = 0.017 and 0.0418, respectively). Z score for the bone mineral density of L2 to L4, the femoral neck and Ward's triangle was -0.350+/-1.031, -0.82+/-0.99 and -0.94+/-1.01, respectively.

CONCLUSIONS

In patients with a neobladder of intestinal segments metabolic acidosis results in increased bone absorption and decreased bone mass. Thus, attention should be given to bone metabolism in patients with even mild acidosis after orthotopic neobladder creation.

[The effect of smoking tobacco and drinking of alcohol and coffee on bone mineral density of healthy men 40 years of age]

The aim of the study was to evaluate the effects of smoking, alcohol and coffee drinking on bone mineral content (BMC) in a group of 258 healthy men, aged 40-63, occupationally active inhabitants of Wroclaw. Trabecular, cortical and total BMC at the distal radius of the non-dominant hand were measured by pQCT method using the Stratec apparatus. The data concerning smoking, alcohol and coffee intake were obtained through a questionnaire. The significance of BMC differences between groups were tested using a one-way analysis of variance ANOVA. The extent of alcohol intake did not differentiate BMC values at the distal radius, whereas the significant detrimental effects of both smoking and coffee drinking on trabecular (but not cortical and total) BMC were revealed. Among healthy Polish males coffee drinking was associated with a significant reduction of trabecular BMC. Simultaneously, smokers and ex-smokers (when compared to never-smokers) had lower trabecular BMC.

[Effect of gravitation loading and retabolil on development of atrophy in muscles and bones of rats due to suspension]

In a 3-wk experiment with tail-suspended rats histological and histomorphometric methods were used to determine the effects of graded gravitational loading (GGL) and anabolic steroid retabolil (nortestosterone decanoate) on the course of atrophy in soleus m. (SM), gastrocnemius m. (GM), tibia and humerus, and functioning of somatotrophic hormones (STH) of the pituitary and thyrocytes of the thyroid. Suspension was found to produce atrophy in SM and, to a less degree, in GM, partial transformation of SM slow fibers into the fast ones, suppression of the tibial longitudinal growth, demineralization of the tibial and humeral spongious metaphyses; besides, functional activities of STH-cells and thyrocytes were inhibited. Graded gravitational loading of rats by intermittence of suspension for 2 hrs slowed down atrophy in both muscles and osteopenia in tibia, stimulated the synthetic and secretory functions of STH-cells without any marked effect on thyrocytes or humeral osteopenia. GGL failed to influence the slow-to-fast transformation of SM fibers. Two injections of retabolil at the total dose of 3 mg/kg of the body mass somewhat interfered with the SM atrophy and humoral osteopenia, and were favorable to the synthetic but not secretory activity of STH-cells. Neither SM and tibial atrophies nor thyroid activity of the gland were improved. The prophylactic action of GGL upon the SM and humeral atrophies was significantly higher when combined with retabolil, whereas GM and tibia were not noticeably cured by retabolil. Inhibition of the SM atrophy and humeral osteopenia in rats treated with GGL and retabolil concurred with elevated activities of STH-cells and thyrocytes indirectly suggesting their more intensive production of the growth hormone and thyroid hormones, respectively.

Determinants of bone loss in patients with Kock ileal urinary reservoir

The purpose of the present study was to determine the change in bone mineral density (BMD) measured with dual energy X-ray absorptiometry (DXA) in patients with Kock reservoirs for urinary diversion who were examined with the same technique 3 years earlier, and relate the changes to kidney function and variables reflecting bone metabolism. A total of 28 patients with Kock ileal reservoirs to the skin (23) or urethra (5) were reinvestigated 3 years after the first measurement. BMD was measured in the lumbar spine, femur and whole body with DXA. Bone specific alkaline phosphatase, osteocalcin, parathyroid hormone (PTH), calcitonin and chloride were also determined in serum. GFR was determined from the plasma clearance of 51Cr-EDTA. The mean values for BMD expressed in percentage of corresponding mean values for age-matched controls (BMD%) were almost identical after 3 years. Only osteocalcin levels correlated with the BMD% values. However, significant positive correlations were found between GFR and the observed individual changes in BMD% over the 3 years in spite of the fact that most GFR values were fairly normal. Enhanced bone loss was associated with high concentrations of osteocalcin and bone specific alkaline phosphatase. Comparisons with blood gas analyses and determination of 1,25 dihydroxyvitamin D performed in the previous study indicate to us that the relation between reduced GFR and low mineral content might, in part, be related to a low-grade metabolic acidosis and reduced availability of the biologically active vitamin D hormone. The conclusion to be drawn is that urinary diversion with a Kock reservoir does not regularly cause bone demineralization. However, patients with even moderately reduced GFR appear to be at risk for developing osteoporosis in the long-time run.

Acromioclavicular joint subluxation is rare in rheumatoid arthritis. A radiographic 15-year study

AIM

To conduct a radiographic assessment of the occurrence of the acromioclavicular joint subluxation in patients with long-standing rheumatoid arthritis.

METHODS

A cohort of 74 patients with seropositive rheumatoid arthritis was followed prospectively for 15 years. At the 15-year visit, plain radiographs of both shoulders (n = 148) were obtained using a standard method. Acromioclavicular joint destruction was evaluated using Larsen's method, and radiographic subluxation was measured on the radiographs using two different methods. In one of these methods (method A), the distance between the upper edge of the coracoid process and the upper surface of the clavicle was measured. The other method (method B) involved measurement of the alignment of the upper joint margins of the acromion and clavicle.

RESULTS AND CONCLUSION

Two of the 148 acromioclavicular joints fulfilled criteria for subluxation with method B. Neither measurement A nor measurement B differed significantly between unaffected joints (Larsen's grade 0 or 1) and affected joints (Larsen's grade > or = 2). In addition, neither measurement was correlated with the stage of acromioclavicular joint destruction (r < 0.10 for both measurements). Measurements A and B were significantly correlated to each other (r = 0.23; 95% CI, 0.07 to 0.38). The two subluxations (one upward and one downward) occurred among the nine joints with the most severe destructive lesions (Larsen's grade 5). In conclusion, acromioclavicular joint subluxation is rare in rheumatoid arthritis, occurring only when destruction of the joint is severe. The method B used in this study may prove useful for both population studies and routine clinical work.

[Bone demineralization in Crohn's disease, its diagnosis, therapy and prevention]

In 20-60% of patients with Crohn's disease bone demineralization is found, usually osteoporosis, but also osteoporosis with malatic features. The cause is the reduced calcium intake (loss of appetite, lactose intolerance and malabsorption), reduced vitamin D intake and corticoid therapy. Nowadays the diagnosis is facilitated by the use of densitometers (ultrasonic and DEXA) and markers of osteoresorption and new bone formation. In treatment in addition to calcium and vitamin D used for a long time, fluorides are administered (only as monofluorophosphate), nasal thyrocalcitonin and bisphosphonates of the third series (alendronate). In postmenopausal women also hormonal treatment can be used unless contraindicated. However, burdening of the bones with regular exercise is a necessity. For prevention adequate calcium and vitamin D intake is important, non-smoking, and exercise.

Bone mineral density in children and young adults with Crohn's disease

Reduced bone mineral density (BMD) has been reported in adults with Crohn's disease (CD). Less is known about abnormal BMD in children and young adults with CD. The aims of this study are to determine the prevalence of low BMD and to evaluate the effect of growth and pubertal development on BMD in children and young adults with CD. One hundred-nineteen patients with CD underwent dual-energy X-ray absorptiometry (DXA) to determine BMD. Anthropometry and pubertal development were measured. Bone age was measured only in patients older than 8 years of age and who had not grown in height during the last year. One hundred-nineteen patients (72 male, 47 female) were evaluated. Seventy percent of patients had BMD z-scores < or = -1.0 and 32% had z-scores < or = -2.0. Weight and height z-scores were significantly associated with BMD z-scores. BMD z-scores based on bone age and on chronological age were highly correlated, except when the chronological age BMD z-score was < or = -2.0. BMD z-score was significantly different between males and females for the group (-1.75 +/- 1.06 vs. -1.08 +/- 1.00), respectively. Children and young adults with CD have a high prevalence of low BMD and routine evaluation by DXA is indicated. In patients with a chronological age-based BMD z-score < or = -2.0, a bone age-based BMD should be considered.

The G-factor as a tool to learn more about bone structure and function

In normal life on earth, the locomotor system is exposed to two types of stimulation: gravity (passive stimulation) and motion (active stimulation). Both permanently combine, and the interactions between locomotion and gravity induce an overall recruitment which is repeated daily and maintains the bone tissue structure within the range of constraints to which it is adapted. This range is one of the basic hypotheses underlying the mechanical concepts of bone structure control, and it has been considered as logical to assume that weightlessness of spaceflight should produce bone loss since astronauts are outside of the terrestrial gravitational field of forces, no longer relying on muscular work to change positions or move. But, thirty years after the first changes in phospho-calcium metabolism were observed in astronauts after spaceflight, current knowledge does not provide a full understanding of this pathogeny, and prove the G-factor is now considered as an essential component of the experimental tools available to study bone physiology. The study of the physiology of bone tissue usually consists in the investigation of its two fundamental roles, i.e. reservoir of inorganic elements (calcium, phosphorus, magnesium) and mechanical support for soft tissues. Together with the combined action of muscles, tendons, and ligaments, this support permits motion and locomotion. These two functions rely on a sophisticated bone tissue architecture, and on the adaptability of this structure, with modeling and remodeling processes, themselves associated with the coupled activity of specialized bone cell populations.

Osteopenia in anorexia nervosa: specific mechanisms of bone loss

Osteopenia is a well recognized medical complication of anorexia nervosa (AN). The mechanism of bone loss is not fully understood and there is uncertainty about its management. New markers of bone turnover have been developed. C-terminal type 1 propeptide (PICP) is a measure of bone formation and urinary pyridinolines such as deoxypyridinoline (DPYRX) and serum carboxyterminal crosslinked telopeptide (ICTP) are markers of bone resorption. The aim of this study was to examine these bone markers in patients with AN. Twenty female patients with AN and 12 healthy controls were included in the study. Bone mineral density (BMD) of AN patients was measured by dual energy X-ray absorptiometry (DEXA). Lumbar bone density was significantly reduced in the AN group compared to standardised values of thirty year old adults (t-score 83.2%, S.D. 12.1). Femoral neck bone density showed an even greater reduction (t-score 79.4%, S.D. 13.5). We found a significant negative correlation between femoral BMD and the duration of the illness. Femoral BMD correlated significantly with minimal body weight (r(16) = 0.504, p = 0.033). The markers of bone resorption were significantly higher in the patients with AN compared to the values of the control group (ICTP t(30) = -2.15, p = 0.04, DPYRX t(25) = -2.26, p = 0.033), whereas the markers of bone formation did not differ significantly between the groups. AN appears to be a low turn over state associated with increased bone resorption without concomitant bone formation. This pattern differs from osteopenia in menopausal women and should, therefore, lead to the development of specific therapeutic strategies in AN associated osteopenia. Hormone replacement therapy as well as calcium and vitamine D-supplementation are so far discussed controversially. Long-term treatment studies are warranted.

Bone mineral density of the proximal femur after unilateral cementless total hip replacement

It was the aim of this study to examine bone mineral density changes in the non-operated contralateral femur of patients undergoing total hip replacement. Bone density in the contralateral femur of 45 patients with an average age of 54 years was measured with the aid of the DEXA technique at one week, 3 and 6 months after total hip replacement. Within the first 3 months there was an average reduction of bone density of 3.9% (3.0%-5.9%). After a further 3 months the average difference was 2.5%.

[A 63-year-old patient with worsening general condition, bone demineralization, hypocalcemia and excess parathyroid hormone: late manifestations of pseudohypohyperparathyroidism]

HISTORY AND CLINICAL FINDINGS

A 63-year-old man was hospitalized because of his worsening general condition and weight loss. Physical examination revealed marked thoracic kyphosis with impaired mobility of his back and restricted walking because of pain in the right hip. He also had other bone pains.

INVESTIGATIONS

Serum calcium was reduced (1.60 mmol/l) and there was generalized bone demineralization. Subsequently an increased parathormone (PTH) level was noted (499.0 ng/l) as well as markedly increased activity of enzymes involved in bone metabolism, decreased renal excretion of phosphates (4.76 mmol/24 h) and multiple pathological fractures.

TREATMENT AND COURSE

The listed abnormalities indicated the diagnosis of pseudohypoparathyroidism (PHP), type 1 b. After treatment had been started with vitamin D (calcitriol 2 x 0.25 micrograms/d) and calcium (calcium gluconate, 3 x 500 mg/d), the levels of calcium, PTH and enzymes in bone metabolism gradually became normal. A cataract operation had to be performed because of calcification of the lens.

CONCLUSION

The level of PTH should be determined in patients with extensive bone demineralization and hypocalcaemia. If PTH is raised, PHP should be included in the differential diagnosis. Normalization of serum calcium by calcium substitution and vitamin D administration will normalize PTH and improve mineralization of the skeleton. In this way the debilitating effects of osteodystrophia cystica generalisata (OCG) (Engel von Recklinghausen syndrome) can be prevented. Also, the consequences of extraosseous calcification, such as extrapyramidal symptoms of calcification of the brain-stem ganglia can be avoided if treated in time.

Long-term consequences of fracture of the lower leg: cross-sectional study and long-term longitudinal follow-up of bone mineral density in the hip after fracture of lower leg

The purpose of this study was to investigate whether bone loss in the hip, occurring after a fracture of the lower leg, persists many years after the fracture. In a long-term follow-up we measured bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) of both hips and the lumbar spine in a group of 11 patients, 5 years after a fracture of the lower leg. These patients were part of an earlier study, evaluating bone loss in the hip, up to 1 year after fracture of the lower leg. In this follow-up study, 5 years after fracture, loss from baseline BMD in the trochanteric region of the ipsilateral hip was 4.7% (p=0.04), whereas after a year in this group there was a decrease of 12.5% from baseline. On the contralateral side, hardly any change occurred. In the ipsilateral femoral neck, 5 years after fracture, BMD decreased by 2.9% (p=0.10), after 1 year loss from baseline was 5.1%. In a cross-sectional study we examined the differences in BMD of both hips, measured by DXA, in a group of 19 elderly patients reporting a fracture of the lower leg, with a mean time of 9.3 years after fracture. In this study, we found a 4.7% lower BMD in the trochanteric region of the hip on the fractured side compared with the nonfractured side (p=0.006), and a 2.9% lower BMD in the femoral neck (p=0.25). We conclude that, after fracture of the lower leg, BMD in the ipsilateral hip decreases significantly, with maximal bone loss after 1 year. After 5 years recovery has occurred, but not to baseline. Thereafter, significant excess bone loss is still observed in the trochanteric region. This persisting lower BMD may lead to an increased risk of another fracture in later years.