[Laparoscopic radical cystectomy with intracorporeal creation of a continent urinary diversion. Future or present?]

Once laparoscopic radical prostatectomy has been mastered, the step to performing a radical cystectomy is not that far. The challenge is to create the urinary diversion by laparoscopy. In this report we describe our experience with 11 laparoscopic radical cystectomies and intracorporeal construction of a continent urinary diversion (Mainz pouch II) as a treatment option in patients with muscle-invading bladder cancer. All 11 procedures could be performed successfully. A conversion to open surgery was not required in any case. The mean surgery time was 6.7 h. Except for two pouch fistulas we did not observe any intra- or postoperative complications. The functional as well as the oncological results are convincing. Less morbidity and faster recovery are the main advantages of this minimally invasive procedure. In addition, the low levels of blood loss, fluid shifts, and electrolyte loss considerably reduce cardiovascular stress. Radical cystectomy and construction of a continent urinary diversion represent the limit of technically feasible laparoscopy and should be done exclusively in specialized centers.

Influenza vaccination, hospitalizations, and costs among members of a Medicare managed care plan

OBJECTIVE

To evaluate the effectiveness and possible cost savings of influenza vaccination.

SUBJECTS

Members age 65 and older in a Medicare managed care plan during the 1994-1995, 1995-1996, and 1996-1997 influenza seasons.

RESEARCH DESIGN

The study examined administrative data on influenza vaccination and subsequent hospitalizations. Outcomes included hospitalization with pneumonia or influenza, with any respiratory condition, and with congestive heart failure (CHF).

RESULTS

Vaccinated subjects experienced fewer hospitalizations with respiratory conditions or CHF than had unvaccinated subjects (OR=0.8 (95% CI, 0.7, 0.9) in analyses adjusted for age, sex, pneumococcal vaccination, health utilization, and morbidity). Analyses adjusted in addition for ethnicity obtained similar results among the subgroup of members whose ethnicity was known. Subjects without major disease in the previous 12 months had lower odds ratios for vaccination than subjects with major disease (OR values of 0.5 [95% CI, 0.4, 0.7] and 0.9 [95% CI, 0.8, 1.1], respectively). Subjects ages 65 to 79 had lower odds ratios for vaccination than subjects ages 80 and older (OR values of 0.7 [95% CI, 0.6, 0.9] and 0.9 [95% CI, 0.8, 1.1], respectively). Estimated cost savings averaged about $80 per vaccinated subject.

CONCLUSIONS

Subjects ages 65 to 79 who had received influenza vaccination experienced fewer hospitalizations and had lower costs than had unvaccinated subjects. Associations were weaker for subjects age 80 and older. The results, consistent with recommendations for the use of influenza vaccine, suggest that people ages 65 to 79 should be heavily targeted for vaccination.

Quality of life after treatment for localized prostate cancer: differences based on treatment modality

PURPOSE

Brachytherapy with 103palladium (103Pd) is an increasingly administered treatment modality for localized prostate cancer. We compared general and disease specific health related quality of life after 103Pd treatment, radical prostatectomy and external beam radiation therapy given during the same time frame.

MATERIALS AND METHODS

We performed a retrospective cross-sectional survey study of patients treated at a single community medical center between 1995 and 1999. We mailed 5 validated health related quality of life survey instruments to 269, 142 and 222 men who underwent radical prostatectomy, 103Pd treatment and external beam radiation therapy, respectively, with a response rate of greater than 80% in all groups.

RESULTS

General health related quality of life assessed by the SF-36 showed the same scores in patients who underwent prostatectomy and 103Pd treatment. The University of California-Los Angeles Prostate Cancer Index was used to assess bowel, urinary and sexual function/bothersomeness. External beam radiation therapy reported was associated with worse bowel function and greater bowel bothersomeness. Prostatectomy was associated with worse urinary function compared to 103Pd and external beam radiation therapy. Prostatectomy was associated with worse sexual function than 103Pd or external beam radiation therapy, although nerve sparing surgery and erectile aids minimized the difference. American Urological Association symptom scores were initially higher for 103Pd but became equal to those in the other groups in patients treated greater than 12 months from survey time. Disease-free men who underwent prostatectomy and 103Pd brachytherapy were equally confident that cancer would not recur in the future. Satisfaction rates were equivalent and biochemical failure significantly decreased satisfaction in all groups.

CONCLUSIONS

While general health related quality of life was mostly unaffected by the 3 most common treatments for prostate cancer, there were differences in bowel, urinary and sexual function. This information may aid patients in the decision making process.

Quantitation of serum prostate-specific membrane antigen by a novel protein biochip immunoassay discriminates benign from malignant prostate disease

The lack of a sensitive immunoassay for quantitating serum prostate-specific membrane antigen (PSMA) hinders its clinical utility as a diagnostic/prognostic biomarker. An innovative protein biochip immunoassay was used to quantitate and compare serum PSMA levels in healthy men and patients with either benign or malignant prostate disease. PSMA was captured from serum by anti-PSMA antibody bound to ProteinChip arrays, the captured PSMA detected by surface-enhanced laser desorption/ionization mass spectrometry, and quantitated by comparing the mass signal integrals to a standard curve established using purified recombinant PSMA. The average serum PSMA value for prostate cancer (623.1 ng/ml) was significantly different (P < 0.001) from that for benign prostate hyperplasia (117.1 ng/ml) and the normal groups (age <50, 272.9 ng/ml; age >50, 359.4 ng/ml). These initial results suggest that serum PSMA may be a more effective biomarker than prostate-specific antigen for differentiating benign from malignant prostate disease and warrants additional evaluation of the surface-enhanced laser desorption/ionization PSMA immunoassay to determine its diagnostic utility.

Low bone density is not associated with aortic calcification

The aging process is associated with an increasing prevalence of osteoporosis and aortic calcification, but it is uncertain if these two conditions are interrelated. We examined the relationship between bone mineral density (BMD) and evidence of aortic calcification on spinal radiographs among 524 Japanese-American women living in Hawaii. The prevalence of aortic calcification increased with age from less than 10% below age 55 to essentially all women over age 75. Unadjusted BMD was significantly lower among women with aortic calcification at all measured sites (distal and proximal radius and calcaneus). However, the differences in BMD between women with and without calcification were diminished and no longer significant after adjustment for age. Aortic calcification was positively associated with body mass index (BMI), systolic blood pressure, diabetes, current smoking, and thiazide use, but negatively associated with physical activity index. Multivariate logistic regression analysis showed that age, systolic blood pressure, physical activity index (protective), and current smoking (common etiological factors for aortic calcification) were independently associated with aortic calcification, whereas BMD (mean Z-score) was not. We conclude that there is little evidence to support a direct relationship between osteoporosis (low BMD) and aortic calcification. Osteoporosis and aortic calcification appear to be independent processes that occur as women age. However, potential confounding factors may be involved, and prospective studies are needed to investigate this issue further.

Delayed pulmonary hemorrhage 17 years after gunshot wound to the chest

A 45-year-old male returned 17 years after a gunshot wound to the chest with intermittent hemoptysis that progressed to frank pulmonary hemorrhage. The complications of retained intrathoracic foreign bodies are briefly reviewed.

Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal

BACKGROUND

The mechanism for clearing the cervical spine in patients with altered mental status remains controversial. Recommendations have ranged from removal of the cervical collar after 24 hours in patients with normal radiographs, to indefinite immobilization in a cervical collar, and recently cervical flexion-extension examinations using dynamic fluoroscopy. The purpose of this study was to evaluate the efficacy and safety of dynamic fluoroscopy flexion-extension examinations in identifying ligamentous cervical spine injury and clearing the cervical spine in patients with altered mental status after trauma.

METHODS

Patients with a Glasgow Coma Scale score < 13 for greater than 48 hours after admission and normal cervical spine radiographs were candidates for fluoroscopic evaluation. The protocol required visualization of the entire cervical spine, through T1, through full extension and flexion under the direct supervision of a radiologist. Oblique fluoroscopic views were obtained, as necessary, to visualize the cervicothoracic junction. Demographic data, fluoroscopy time, total time per study, true and false positives and negatives, and complications were recorded.

RESULTS

From July 1992 through December 1999, fluoroscopic examinations were performed on 301 patients. There were 297 true-negative examinations, 2 true-positive examinations (stable injuries), 1 false-negative examination, and 1 false-positive examination. The incidence of ligamentous injury identified by fluoroscopy in this study was 2 of 301 (0.7%). Unstable cervical spine ligamentous injuries were identified in only 0.02% of all trauma patients. One patient developed quadriplegia when fluoroscopic evaluation was performed after two protocol violations.

CONCLUSION

Unstable cervical spine ligamentous injury without fracture is a rare occurrence. The cervical spine may be cleared after a normal cervical spine series (plain radiograph and computed tomographic scan) as recommended in the 1998 Eastern Association for the Surgery of Trauma guidelines. If dynamic fluoroscopy is to be used, adherence to the protocol, including review of the cervical spine radiographs before fluoroscopy and visualization of the entire cervical spine, C1-T1, is mandatory to ensure patient safety.

The relation between lifestyle factors and biochemical markers of bone turnover among early postmenopausal women

We examined the associations of two biochemical markers of bone turnover with lifestyle factors in 340 postmenopausal women in Hawaii, ages 45-59 years, from the Early Postmenopausal Intervention Cohort. Physical activity, calcium supplement use, smoking and alcohol use in the prior 2 weeks were measured and examined as independent variables in multiple regression analyses with bone turnover markers as dependent variables, adjusted for weight, height, whole body bone mass, serum estradiol, years since menopause, and ethnicity. Calcium supplement and alcohol use were significantly associated with reduced levels of urinary type I collagen cross-linked N-telopeptides (NTX). The mean NTX level was 12% lower among women using > or = 250 mg of calcium supplements per day as compared with other women, and 20% lower among alcohol users compared with nonusers. Both calcium supplement use and alcohol intake were associated with lower mean serum osteocalcin (a marker of bone formation) and NTX z-scores. By contrast, smoking was associated with lower osteocalcin levels, without any effect on NTX. The osteocalcin level was 12% lower among smokers compared with nonsmokers. In addition, the z-score difference between NTX and osteocalcin was significantly associated with smoking, with a shift towards more NTX than osteocalcin. Physical activity was not significantly associated with either of the markers. These findings suggest that biochemical markers may help to identify lifestyle factors that affect bone, and provide estimates of the relative magnitude of these effects on bone formation and resorption, independent of each other.

Prevention of apoptosis by 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in the MCF-10A cell line: correlation with increased transforming growth factor alpha production

We have recently reported that 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) inhibits epidermal growth factor (EGF) withdrawal-induced apoptosis in the human mammary epithelial cell line MCF-10A. We hypothesized that TCDD-mediated inhibition of apoptosis was due to its ability to stimulate the EGF receptor (EGFR) pathway. Indeed, in the present studies, the EGFR inhibitor AG1478 was able to prevent TCDD-, EGF-, and transforming growth factor alpha (TGF-alpha)-dependent cell recovery and inhibition of apoptosis. These effects were specific for an EGFR-mediated pathway because cotreatment with AG825, an erbB2 inhibitor, had little effect on apoptosis. In addition, TCDD was able to mimic the EGF and TGF-alpha signaling as demonstrated by increasing Akt and extracellular signal-regulated kinase 1,2 phosphorylation. These effects were dependent on EGFR activity because AG1478, but not AG825, was able to prevent EGF-, TGF-alpha, or TCDD-mediated Akt and extracellular signal-regulated kinase 1,2 phosphorylation. The ability of TCDD to stimulate the EGFR pathway and inhibit apoptosis may be due to the ability of TCDD to increase expression of TGF-alpha, a ligand for EGFR. Treatment with 10 nM TCDD increased TGF-alpha mRNA at 2 h and TGF-alpha protein at 6 h. These data suggest a mechanism whereby TCDD is able to inhibit apoptosis in human mammary epithelial cells by stimulating TGF-alpha production, resulting in an autocrine effect.

Bilateral testicular lymphoma treated with chemotherapy and radiation without orchiectomy: complete response relapsed at 52 months in the vitreous humor

We report the first detailed case of testicular lymphoma managed with chemotherapy and radiation without orchiectomy. A 60-year-old man with Stage II extralymphatic bilateral testicular lymphoma refused orchiectomy, but underwent cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy and radiation. He remained disease free for 52 months, when a solitary central nervous system relapse to the vitreous humor was diagnosed. The optimal therapy for testicular lymphoma is unclear but often includes orchiectomy with adjuvant chemotherapy and radiation. Stage I testicular lymphoma can be cured by surgery alone; however, the relapse rates for all stages of testicular lymphoma are high despite systemic therapy. For Stage II disease and higher, chemotherapy/radiation is recommended; orchiectomy may not be mandatory.

Alcohol use inventory: screening and assessment of first-time driving-while-impaired offenders. II. Typology and predictive validity

This study evaluated the use of Alcohol Use Inventory (AUI) for driving-while-impaired (DWI) screening, by determining whether DWI offenders (n = 1644), grouped according to their reported alcohol involvement on the AUI, would have different rates of recidivism in a 5-year follow-up. Cluster analysis using the six second-order scales produced six groups (clusters 1-6) described as the Low-Profile (50%), Alcohol-Preoccupation (14%), Enhanced (22%), Enhanced-Disrupt (9%), Anxious-Disrupt (3%), and High-Profile (1%) types. They were characterized by different sociodemographic profiles. Members of cluster 4 were associated with the highest DWI recidivism rate (40%), committing one or more further DWI, and clusters 5 and 6 were associated with the highest rate of committing two or more DWIs. Rates of subsequent traffic convictions and crashes were, however, not statistically different among the clusters. Predictors of DWI recidivism included male gender, young age, less-educated, high blood-alcohol concentration at arrest, and clusters of 3 and 4. Different typologies indicated that the needs for treatment might be different. Evaluators should keep in mind the strength of AUI, use risk factors identified in the study, and take measures of test-taking defensiveness to enhance overall predictive validity.

Analysis of genetic and epigenetic mechanisms of toxicity: potential roles of toxicogenomics and proteomics in toxicology

The article highlighted in this issue is "An Aryl Hydrocarbon Receptor Independent Mechanism of JP-8 Jet Fuel Immunotoxicity in Ah-Responsive and Ah-Nonresponsive Mice" by Andrew C. Dudley, Margie M. Peden-Adams, Jackie EuDaly, Richard S. Pollenz, and Deborah E. Keil (pp. 251-259).

Domestic violence and the trauma surgeon: results of a study on knowledge and education

BACKGROUND

Despite the frequency of domestic violence in trauma patients, little emphasis has been placed on this subject in the education of surgeons and emergency medicine physicians. The 1997 Advanced Trauma Life Support (ATLS) course included, for the first time, education about domestic violence. This study was done to test the hypothesis that baseline knowledge about domestic violence in trauma care providers is poor and is not improved by the 1997 ATLS course.

STUDY DESIGN

A study on domestic violence was designed using attending general surgeons, general surgery and emergency medicine residents, and medical students as test subjects. An educational lecture and pre- and post-tests were developed using the Eastern Association for the Surgery of Trauma position paper on domestic violence and other peer-reviewed literature as information sources. Data collected included level of training, date ATLS course was taken, and pre- and post-test scores. Statistical analysis was performed with ANOVA, with significance attributed to p < 0.05.

RESULTS

Ninety-two subjects attended the lecture and completed the pre- and post-tests. The overall mean pre-test score was 54 +/- 1. There was no difference in scores for the 1997 ATLS cohort (with domestic violence material) versus the group with earlier ATLS courses (52 +/- 2 versus 51 +/- 1). The group that had never taken ATLS scored significantly better on the pre-test than the other groups (58 +/- 2, p < 0.05). All groups had significantly increased scores on the post-test (mean 77 < 1, p < 0.001 versus pre-test).

CONCLUSIONS

Baseline knowledge about domestic violence among surgeons and emergency medicine physicians was poor and was not improved by participation in the 1997 ATLS course. This study strongly supports the need for expanded domestic violence education for trauma care providers.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) inhibits growth factor withdrawal-induced apoptosis in the human mammary epithelial cell line, MCF-10A

Previous studies have demonstrated that 2,3,7, 8-tetrachlorodibenzo-p-dioxin (TCDD) increases cell recovery in the human mammary epithelial cell line MCF-10A grown under growth factor-restricted conditions. TCDD was also found to mimic growth factor signaling pathways by stimulating the tyrosine phosphorylation of numerous effector molecules, and increased phosphatidylinositol 3-kinase (PI3K) activity in the absence of exogenously added growth factors. In the present studies, we have expanded on these initial results to show that TCDD (3-30 nM) increases cell recovery on days 2-6 by as much as 80% when insulin or epidermal growth factor (EGF) was removed from the media. The mechanism for this effect appears to be complex as TCDD inhibited apoptosis stimulated by EGF, or EGF and insulin, withdrawal by almost 80% as determined by Annexin V binding. However, withdrawal of insulin alone did not induce apoptosis even though TCDD did increase cell number in its absence. These results were corroborated by immunoblot analysis of poly(ADP-ribose) polymerase cleavage. Since TCDD stimulates PI3K activity, the phosphorylation status of Akt, a serine/threonine kinase that mediates PI3K-dependent inhibition of apoptosis, was examined. Immunoblot analysis revealed that TCDD causes a transient increase in the phosphorylated form of Akt that peaks at 6 h and disappears by 12 h. It appears that EGF stimulates an anti-apoptotic pathway, while insulin signals a pro-mitogenic pathway. By stimulating or mimicking one or both of these pathways TCDD may alter tightly regulated growth pathways in the MCF-10A cell line.

Relation between body composition and biochemical markers of bone turnover among early postmenopausal women

We studied the associations between body composition and biochemical markers of bone formation and resorption among 1600 postmenopausal women, ages 45-59. Multiple regression analyses were performed to examine the independent associations of fat mass, muscle strength (quadriceps strength), height, and whole body bone mineral content (BMC) with biochemical markers of bone formation (serum osteocalcin) and resorption (urinary type I collagen crosslinked N-telopeptides [NTX]). Per interquartile range (IQR) (the difference between 75th and 25th percentiles) increase in fat mass and whole body BMC, the mean levels of osteocalcin decreased by 3% and 13%, respectively; NTX decreased by 5 and 21%. Fat mass and whole-body BMC were also significantly associated with decreases in the average of osteocalcin and NTX Z-scores. By contrast, the mean levels of serum osteocalcin increased by 2 and 11%, respectively, per IQR increase in muscle strength and height; NTX increased by 4 (not significant) and 14%, respectively. Both muscle strength and height were significantly associated with increases in the average Z-scores. These exploratory analyses suggest that fat mass and whole-body BMC were associated with decreased bone turnover, while muscle strength and height were associated with increased bone turnover.

Alendronate and estrogen-progestin in the long-term prevention of bone loss: four-year results from the early postmenopausal intervention cohort study. A randomized, controlled trial

BACKGROUND

Up to 3 years of treatment with alendronate, 5 mg/d, prevents postmenopausal bone loss.

OBJECTIVE

To determine whether the effect of alendronate is sustained at 4 years of treatment and persists after treatment is discontinued.

DESIGN

Randomized, controlled trial.

SETTING

United States and Europe.

PARTICIPANTS

1609 postmenopausal women 45 to 59 years of age.

INTERVENTION

Participants were randomly assigned to receive oral alendronate, 5 mg/d or 2.5 mg/d; placebo; or open-label estrogen-progestin. Women in the alendronate groups received alendronate for the first 2 years of the study. Treatment was then continued without change or replaced with placebo for the last 2 years of the study.

MEASUREMENTS

Annual measurement of bone mineral density.

RESULTS

By year 4, the bone mineral density of participants in the placebo group had decreased by 1% to 6% (P < 0.001). Four years of treatment with 5 mg of alendronate per day increased bone mineral density at the spine (mean change [+/-SE], 3.8%+/-0.3%), hip (mean, 2.9%+/-0.2%), and total body (mean, 0.9%+/-0.2%) (P < 0.001 overall). By year 4, bone mineral density at most skeletal sites was greater in participants who switched from alendronate to placebo than in those who continuously received placebo. In years 3 and 4, bone loss in participants who switched from alendronate to placebo was similar to that seen during years 1 and 2 in those who continuously received placebo. Compared with 5 mg of alendronate per day, estrogen-medroxyprogesterone acetate produced similar increases in bone mineral density and estradiol-norethisterone acetate produced increases that were substantially greater.

CONCLUSIONS

Four years of treatment with alendronate or estrogen-progestin prevented postmenopausal bone loss. A residual effect was seen 2 years after alendronate therapy was stopped; however, continuous alendronate treatment was more effective in preventing postmenopausal bone loss than 2 years of alendronate followed by 2 years of placebo.

Means for load variation during echocardiographic assessment of the Frank-Starling relationship

Because minimally invasive methods of preload variation are not validated for load-insensitive indexes of cardiac performance, intravenous nitroglycerin (NTG), phenylephrine, and saline solution (VOL) boluses were used in blocked and intact autonomic states to alter load and were compared with vena caval occlusion in the assessment of preload recruitable stroke work relationships between stroke work and left ventricular end-diastolic volume in dogs. In both autonomic states NTG and VOL produced comparable linear relationships. NTG and saline solution were combined with noninvasive measurements of left ventricular pressure and volume to construct echocardiographic relationships between stroke work and left ventricular end-diastolic cross-sectional area; NTG produced linear relationships similar to vena caval occlusion. Therefore NTG and VOL reliably alter load in constructing preload recruitable stroke work relationships, and NTG may be used with noninvasive measurements to provide load-insensitive estimates of cardiac function in a minimally invasive manner.

The durability of external beam radiation therapy for prostate cancer: can it be identified?

PURPOSE

We establish criteria to identify a durable response to external beam radiation therapy by calculation of biochemical progression-free probability for patients who attained and maintained defined nadir prostate specific antigen (PSA) levels more than 5 years after treatment.

MATERIALS AND METHODS

A total of 460 patients were treated with external beam radiation monotherapy from 1976 to 1995. Patients with PSA less than 0.5 (group 1) or 0.5 to 1.0 (group 2) ng./ml. more than 5 years after treatment were identified. Treatment failure was defined as 3 consecutive increases in PSA after nadir. Progression-free probability after 60 months was calculated for each group. A comparison was also made to patients achieving the same nadir levels anytime after treatment.

RESULTS

Failure occurred at 133 months in 1 of 26 group 1 patients (4%) and at a median of 76 months in 5 of 26 group 2 patients (19%). At 10 years progression-free probability was 91% for group 1 compared to 72% for group 2 (p = 0.0575). These same nadir levels anytime after treatment were associated with higher failure rates of 55% for group 1 and 72% for group 2.

CONCLUSIONS

If a PSA nadir of less than 0.5 ng./ml. was maintained 5 years after therapy, subsequent failure was rare. Although statistical significance was not reached (p = 0.0575), a higher failure rate was noted if the nadir PSA was 0.5 to 1.0 ng./ml. at 5 years. Thus, patients with PSA 0.5 to 1.0 ng./ml. require careful continued surveillance. Nadir levels less than 1.0 ng./ml. anytime before 5 years were associated with a substantial risk of subsequent progression.

Ethnic, anthropometric, and lifestyle associations with regional variations in peak bone mass

The study investigated the ability of ethnicity and anthropometric and lifestyle factors to account for differences within subjects in bone mass at different skeletal sites. The subjects were young, adult, Japanese, Filipino, Hawaiian, and white women ages 25-34. In the preliminary analyses, they were divided into thirds based on their BMD z-scores. Thirty-five percent exhibited high variability in bone mass: they were in the upper third at one or more bone sites and in the lower third at one or more sites. Other women had more generalized low bone mass: 25% were in the lowest third for two or more sites, and there were no sites with low bone mass in the upper third. In subsequent analyses, ethnicity, anthropometry, and lifestyle influences were examined as possible predictors of differences in bone mineral content (BMC) between bone sites in bone-size adjusted models. White women had greater BMC at the proximal radius and calcaneus than at the distal radius compared with other ethnic groups. This may be explained by the fact that they had exceptionally wide bone widths at the distal radius. Of the anthropometric variables, fat mass was associated with higher bone mass at sites with higher proportions of cancellous tissue (calcaneus > spine > radius sites). Muscle mass was associated with greater bone mass at the calcaneus and proximal radius than at the spine. For the lifestyle variables, women with greater milk consumption between the ages of 10-24 years had higher spine bone mass than expected from their measurements at the proximal radius. Women 12-17 years of age who had been more active in sports had higher calcaneous bone mass than expected from their spine measurements. As the study participants were still young women, the results suggest that regional differences in bone mass may partly derive from anthropometric and lifestyle influences during skeletal maturation.