Secondary Causes of Osteoporosis

Serum Levels of Parathyroid Hormone and Parathyroid‐related Peptide in Psoriasis

Psoriasis is a common skin disorder that may be triggered by hormonal disturbances, among other factors. Some studies have demonstrated an elevation of serum parathyroid hormone (PTH) levels in psoriasis and several other diseases of keratinization of unknown aetiology. PTH-related peptide (PTH-rp), on the other hand, is a potent inhibitor of epidermal cell growth factor and is not expressed in psoriatic skin. Serum levels of this peptide have not been reported in psoriasis. Immunoassay was used to measure serum PTH and PTH-rp in 22 patients with plaque-type psoriasis before and after treatment with mometasone furoate. Results were compared with a group of 20 healthy, non-psoriatic volunteers. Serum PTH levels were significantly elevated in the psoriatic group compared with the control group (p=0.001) and were significantly reduced after treatment (p=0.01). A correlation was found between pretreatment serum PTH levels and psoriasis area and severity scores (PASI) (r=0.42; p=0.01). In contrast, serum PTH-rp levels were not different between psoriatics and controls and were not affected by treatment. These findings indicate that serum PTH concentrations reflect disease activity in patients with psoriasis.

[Primary and secondary osteoporosis. The important role of internal medicine in its differential diagnosis]

Bone metabolism as an important part of internal medicine is covered by endocrinologists, rheumatologists and nephrologists. Primary osteoporosis is an inheritable metabolic bone disease, which can be strongly modified by lifestyle, ageing and underlying diseases. Chronic inflammatory diseases, disorders of metabolism and nutritional deficits enhance the risk. Secondary osteoporosis is caused by endocrinological disorders and drugs such as glucocorticoids. It is the task of internists to clinically recognise and diagnose prominent individual risk factors for primary osteoporosis and underlying diseases for secondary osteoporosis. The key competence of internal medicine in metabolism, hormone-related disorders, malignant diseases and in handling complex medical treatment modalities represents an indispensable segment of an interdisciplinary network approach in patient care, research and teaching. This network includes orthopaedic surgery, paediatrics and gynaecology in addition to other specialties.

Clinical utility of laboratory testing in women with osteoporosis

Clinicians regularly order laboratory tests in women with osteoporosis to assess if an underlying medical condition is contributing to bone loss. To determine which laboratory tests are associated with osteoporosis we conducted a secondary analyses of data collected as part of the Fracture Intervention Trial (FIT), which included 15,316 postmenopausal women. Women had tests of liver and kidney function, mineral metabolism, electrolytes and complete blood count, femoral neck and total body BMD and spinal radiographs. The prevalence of abnormal tests in women with osteoporosis compared to women without was not different, except for low TSH (<0.5 IU/ml). Among women with and without osteoporosis at the femoral neck the prevalence of low TSH was 4.9% (95% CI: 4.4-5.5) and 3.7% (95% CI: 3.3-4.1), respectively, yielding a positive likelihood ratio of 1.2 (95% CI: 1.1-1.3). We observed similar results for women with vertebral fractures compared to women without vertebral fractures; positive likelihood ratio of 1.4 (95% CI: 1.3-1.6). Our data suggests that when assessing healthy women with osteoporosis ordering a routine panel of laboratory tests is not useful but measuring TSH may be informative.

Rehabilitation of orthopedic and rheumatologic disorders. 1. Osteoporosis assessment, treatment, and rehabilitation

This self-directed learning module highlights a clinical vignette of a female patient with osteoporosis and addresses the clinical presentation, assessment, medical management, and rehabilitation approaches to a patient with an acute vertebral fracture. It is part of the study guide on osteoporosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This chapter emphasizes the differential diagnosis, clinical diagnostic considerations, current pharmacotherapy, invasive procedure options, and orthotic and exercise interventions for a patient with postmenopausal osteoporosis.

OVERALL ARTICLE OBJECTIVE

To summarize the clinical evaluation, medical management, and rehabilitation strategies in women with postmenopausal osteoporosis and acute vertebral fracture presentation.

Osteomalacia after Roux-en-Y gastric bypass

OBJECTIVE

To emphasize the potential for Roux-en-Y gastric bypass treatment of morbid obesity to result in late development of metabolic bone disease and to illustrate the error of treating a low bone mineral density with bisphosphonates in the presence of unrecognized osteomalacia.

METHODS

We conducted a retrospective case review of clinical, laboratory, and radiologic details in a patient who underwent Roux-en-Y gastric bypass as well as a review of the literature relative to metabolic bone disease associated with bariatric surgical procedures.

RESULTS

A 42-year-old woman was diagnosed with high bone turnover osteoporosis and failed to respond to bisphosphonate (alendronate) therapy. Her past medical history included corticosteroid-dependent asthma and a Roux-en-Y gastric bypass surgical procedure for obesity approximately 6 1/2 years before the current assessment. Evaluation revealed vitamin D deficiency in conjunction with pronounced secondary hyperparathyroidism and biochemical evidence of osteomalacia. Aggressive calcium and vitamin D supplementation corrected the vitamin D-deficient state and was accompanied by rapid improvement in clinical symptoms, biochemical variables, and bone mineral density.

CONCLUSION

This case exemplifies two principles: (1) the potential for a Roux-en-Y gastric bypass surgical procedure to lead to the development of metabolic bone disease and (2) the importance of recognizing mineralization defects as a cause for low bone mineral density, before initiation of therapy with bisphosphonates.

Bone Mineral Density in Menopausal Women with Primary Hyperparathyroidism before and after Parathyroidectomy

The relationship between osteoporosis and primary hyperparathyroidism (pHPT) has not been definitely established because both diseases occur predominantly in postmenopausal women, and because PTH has a paradoxical effect on bone. We have investigated the prevalence of reduced bone mineral density (BMD) in women with pHPT, its relationship with metabolic parameters, and its course after parathyroidectomy. A prospective observational study was carried out on perimenopausal and postmenopausal women consecutively diagnosed and operated on for pHPT. Demographic data were recorded, as well as, PTH, Ca, calciuria/24h, P, vitamin D, adenoma weight. The BMD was measured at three sites: femoral neck (FN), proximal femur (PF), and lumbar spine (LS). Fifty-two patients were included with a mean age of 61+/-12 years. The prevalence of reduced BMD (< or = 1SD, T-score) was 80%-100% depending on site. Parathyroid hormone was higher in patients with osteoporosis (319+/-181 pg/ml) than in those with osteopenia (230+/-83 pg/ml) or normal BMD (148+/-81 pg/ml;p < 0,04). Twenty-eight patients were investigated 1 year after parathyroidectomy. The BMD improved significantly at all sites, particularly in patients with osteoporosis. Age correlated inversely with BMD increases at the femoral sites (r= -0,47;p = 0,02) but not at the LS. 25-OHD3 plasma levels correlated inversely with BMD increases at PF (r= -0,76; p < 0,0001). In pHPT, there is a high prevalence of BMD abnormalities. No metabolic variables had a definite influence on BMD values but a tendency was observed for lower BMD in severe pHPT. One year after parathyroidectomy, there were significant BMD increases that were more marked at femoral sites, in younger patients, in patients with preoperative osteoporosis, and in those with lower plasma levels of 25-OHD3.

Metabolic bone disease and parenteral nutrition

Metabolic bone disease (MBD) is abnormal bone metabolism and includes the common disorders of osteoporosis and osteomalacia, which can develop in patients receiving long-term parenteral nutrition (PN). Patients who require long-term PN have significant gastrointestinal failure and malabsorption, which is generally caused by severe inflammatory bowel disease, intestinal ischemia, or malignancy. The exact cause of MBD in long-term PN patients is unknown, but its origin is thought to be multifactorial, with factors including underlying disease, effect of medications used to treat this disease (eg, corticosteroids), and various components of the PN solution. Caring for patients on long-term PN requires routine assessment and monitoring for MBD. Appropriate adjustments of the PN solution can help reduce the risk for developing PN-associated MBD and in some instances improve bone mineral density. Recent developments in pharmacologic treatment for osteoporosis show promise for patients with MBD receiving PN.

The use of biochemical markers in osteoporosis

Osteoporosis is a skeletal disease in which there is a loss of, or de-crease in, bone mass with a deterioration of the microarchitecture of bone tissue. The disease is progressive, taking place over a period of years, and involves derangements in the processes of bone turnover. These derangements can be classified as those in which osteoclast activity (resorption) is stimulated so that more bone is re-moved than formed or in which osteoblast activity (formation) is hindered such that refilling of the resorption cavity is incomplete. Regardless of the process, a key pathologic development is the net loss of bone mass. This article reviews the use of biochemical markers in osteoporosis.

Comprehensive evaluation of the older woman

Nearly 50% of American women will be older than 45 years by the year 2015. Because the life expectancy of women is anticipated to extend to an average age of 81 years by 2050, the aging woman will become the predominant patient seeking health care. These statistics reveal the importance for health care providers to become familiar with the health care needs of this segment of the population. Over their life span, women are more likely to experience disease and disability and subsequently require intervention and treatment. This review is an evaluation of the older woman in the primary care setting. In the first section, which is an overall assessment of the older woman, we introduce common geriatric syndromes that should be recognized by health care professionals. We include an approach to the older woman and specific clinical tools that may be useful for comprehensive evaluation in the outpatient setting. In the second section, we discuss sex-specific illnesses as they relate to the older woman. In the third section, we provide insights on end-of-life issues, cultural competence, and socioeconomic concerns. In the last section, we summarize the key components in the evaluation and management of the older woman. The goal of this article is to provide the health care provider with a clear understanding of factors that must be considered to provide optimal care to these patients.

Lower bone mass detected at femoral neck and lumbar spine in lower-weight vs normal-weight small-boned women

Sixty-one nonsmoking, healthy, young, menstruating women aged 18 to 30 years generally considered at peak skeletal bone mass were screened for diseases and drugs known to adversely affect bone mineral density (BMD). Anthropometric measures, BMD of the lumbar spine (LS) and femoral neck (FN), exercise time, selected nutrient, and energy intake were compared. The women were categorized by frame size and body mass index (BMI), with the upper range for normal weight (NW) being BMI 23.0 to 25.9 (n=30) and lower weight (LW) being BMI 16.0-19.9 (n=31). Multivariate t tests, Pearson correlations, and independent sample t tests were used for statistical analysis. Ten of 21 in the LW group, all with small frames, had varying degrees of low BMD of the LS and/or FN. The amount of exercise time was greater in the NW group. Energy and nutrient intakes did not differ significantly between groups.

Percutaneous vertebroplasty: A to Z

Percutaneous vertebroplasty has been performed in the United States since 1995, and widespread application of the procedure for osteoporotic and neoplastic compression fractures or vertebral infiltration has demonstrated remarkable efficacy with rare complications. Appropriate patient selection criteria and a thorough understanding of safe technique is essential for clinical success; imaging studies must be combined with careful physical examination to direct treatment to the appropriate level in patients with multiple compression deformities. Preoperative consultation with the patient and their family provides an opportunity to clarify the patient's treatment expectations and helps to anticipate and obviate potential obstacles to treatment.