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Lucioni E, Pellegrino F, Remor D, Cossu A, Niero D, Longo F, Zatelli MC, Giganti M, Carnevale A, Ambrosio MR. Bone densitometry in Thalassemia major: a closer look at pitfalls and operator-related errors in a 10-year follow-up population. LA RADIOLOGIA MEDICA 2024; 129:488-496. [PMID: 38353863 DOI: 10.1007/s11547-024-01759-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/03/2024] [Indexed: 03/16/2024]
Abstract
PURPOSE Dual-energy X-ray absorptiometry (DXA) is the gold standard for measuring bone mineral density (BMD) with tolerable error rate, high precision, and excellent consistency. Our objective was to investigate the frequency and distribution of errors in a cohort of patients with Thalassemia major (TM). METHODS We reviewed the DXA examinations of 340 patients with β-TM followed by our institution, acquired in different imaging centers between 2009 and 2019. We collected sex and age at the time of the first examination and at the last visit, as well as BMD, T-score, and Z-score values. Errors were analyzed by anatomical site (lumbar spine, total hip, femoral neck). RESULTS Out of 5099 total DXA scans, 11.85% presented one or more errors. Specifically, the incorrect examinations were 315 out of 1707 (18.45%) at the lumbar spine level, 113 out of 1697 (6.66%) at the total hip, 176 out of 1695 (10.38%) at the femoral neck. Errors in vertebral inclusion were the most frequently registered (45.86%). A significant difference resulted from the comparison of the T-score and Z-score median values of all the lumbar spine DXA examinations and the correct ones (p value 0.037 and 0.0003, respectively). CONCLUSION Although not directly involved in the performance and interpretation of DXA, physicians interested in osteoporosis management should be familiar with the protocols to minimize errors and allow the proper use of bone densitometry. DXA obtained at the spine level is more frequently affected by errors in patients with TM, potentially influencing the diagnostic assessment of bone health status.
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Affiliation(s)
- Elisa Lucioni
- Department of Translational Medicine, Section of Radiology, University of Ferrara, Via Ludovico Ariosto, 35, 44121, Ferrara, Italy
| | | | - Damiano Remor
- Department of Translational Medicine, Section of Radiology, University of Ferrara, Via Ludovico Ariosto, 35, 44121, Ferrara, Italy.
| | - Alberto Cossu
- Department of Translational Medicine, Section of Radiology, University of Ferrara, Via Ludovico Ariosto, 35, 44121, Ferrara, Italy
| | - Desy Niero
- Department of Radiology, University of Padova, Via VIII Febbraio, 2, 35122, Padua, Italy
| | - Filomena Longo
- Unit of Thalassaemia and Haemoglobinopathies Day Hospital, Regional HUB Centre, Department of Medicine, Sant'Anna University Hospital, 44123, Ferrara, Italy
| | - Maria Chiara Zatelli
- Department of Medical Sciences, Section of Endocrinology and Internal Medicine, University of Ferrara, 44121, Ferrara, Italy
| | - Melchiore Giganti
- Department of Translational Medicine, Section of Radiology, University of Ferrara, Via Ludovico Ariosto, 35, 44121, Ferrara, Italy
| | - Aldo Carnevale
- Department of Translational Medicine, Section of Radiology, University of Ferrara, Via Ludovico Ariosto, 35, 44121, Ferrara, Italy
| | - Maria Rosaria Ambrosio
- Department of Medical Sciences, Section of Endocrinology and Internal Medicine, University of Ferrara, 44121, Ferrara, Italy
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Carsote M, Vasiliu C, Trandafir AI, Albu SE, Dumitrascu MC, Popa A, Mehedintu C, Petca RC, Petca A, Sandru F. New Entity-Thalassemic Endocrine Disease: Major Beta-Thalassemia and Endocrine Involvement. Diagnostics (Basel) 2022; 12:diagnostics12081921. [PMID: 36010271 PMCID: PMC9406368 DOI: 10.3390/diagnostics12081921] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/30/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022] Open
Abstract
Beta-thalassemia (BTH), a recessively inherited haemoglobin (Hb) disorder, causes iron overload (IO), extra-medullary haematopoiesis and bone marrow expansion with major clinical impact. The main objective of this review is to address endocrine components (including aspects of reproductive health as fertility potential and pregnancy outcome) in major beta-thalassemia patients, a complex panel known as thalassemic endocrine disease (TED). We included English, full-text articles based on PubMed research (January 2017–June 2022). TED includes hypogonadism (hypoGn), anomalies of GH/IGF1 axes with growth retardation, hypothyroidism (hypoT), hypoparathyroidism (hypoPT), glucose profile anomalies, adrenal insufficiency, reduced bone mineral density (BMD), and deterioration of microarchitecture with increased fracture risk (FR). The prevalence of each ED varies with population, criteria of definition, etc. At least one out of every three to four children below the age of 12 y have one ED. ED correlates with ferritin and poor compliance to therapy, but not all studies agree. Up to 86% of the adult population is affected by an ED. Age is a positive linear predictor for ED. Low IGF1 is found in 95% of the population with GH deficiency (GHD), but also in 93.6% of persons without GHD. HypoT is mostly pituitary-related; it is not clinically manifested in the majority of cases, hence the importance of TSH/FT4 screening. HypoT is found at any age, with the prevalence varying between 8.3% and 30%. Non-compliance to chelation increases the risk of hypoT, yet not all studies confirmed the correlation with chelation history (reversible hypoT under chelation is reported). The pitfalls of TSH interpretation due to hypophyseal IO should be taken into consideration. HypoPT prevalence varies from 6.66% (below the age of 12) to a maximum of 40% (depending on the study). Serum ferritin might act as a stimulator of FGF23. Associated hypocalcaemia transitions from asymptomatic to severe manifestations. HypoPT is mostly found in association with growth retardation and hypoGn. TED-associated adrenal dysfunction is typically mild; an index of suspicion should be considered due to potential life-threatening complications. Periodic check-up by ACTH stimulation test is advised. Adrenal insufficiency/hypocortisolism status is the rarest ED (but some reported a prevalence of up to one third of patients). Significantly, many studies did not routinely perform a dynamic test. Atypical EM sites might be found in adrenals, mimicking an incidentaloma. Between 7.5–10% of children with major BTH have DM; screening starts by the age of 10, and ferritin correlated with glycaemia. Larger studies found DM in up to 34%of cases. Many studies do not take into consideration IGF, IGT, or do not routinely include OGTT. Glucose anomalies are time dependent. Emerging new markers represent promising alternatives, such as insulin secretion-sensitivity index-2. The pitfalls of glucose profile interpretation include the levels of HbA1c and the particular risk of gestational DM. Thalassemia bone disease (TBD) is related to hypoGn-related osteoporosis, renal function anomalies, DM, GHD, malnutrition, chronic hypoxia-induced calcium malabsorption, and transplant-associated protocols. Low BMD was identified in both paediatric and adult population; the prevalence of osteoporosis/TBD in major BTH patients varies; the highest rate is 40–72% depending on age, studied parameters, DXA evaluation and corrections, and screening thoracic–lumbar spine X-ray. Lower TBS and abnormal dynamics of bone turnover markers are reported. The largest cohorts on transfusion-dependent BTH identified the prevalence of hypoGn to be between 44.5% and 82%. Ferritin positively correlates with pubertal delay, and negatively with pituitary volume. Some authors appreciate hypoGn as the most frequent ED below the age of 15. Long-term untreated hypoGn induces a high cardiovascular risk and increased FR. Hormonal replacement therapy is necessary in addition to specific BTH therapy. Infertility underlines TED-related hormonal elements (primary and secondary hypoGn) and IO-induced gonadal toxicity. Males with BTH are at risk of infertility due to germ cell loss. IO induces an excessive amount of free radicals which impair the quality of sperm, iron being a local catalyser of ROS. Adequate chelation might improve fertility issues. Due to the advances in current therapies, the reproductive health of females with major BTH is improving; a low level of statistical significance reflects the pregnancy status in major BTH (limited data on spontaneous pregnancies and growing evidence of the induction of ovulation/assisted reproductive techniques). Pregnancy outcome also depends on TED approach, including factors such as DM control, adequate replacement of hypoT and hypoPT, and vitamin D supplementation for bone health. Asymptomatic TED elements such as subclinical hypothyroidism or IFG/IGT might become overt during pregnancy. Endocrine glands are particularly sensitive to iron deposits, hence TED includes a complicated puzzle of EDs which massively impacts on the overall picture, including the quality of life in major BTH. The BTH prognostic has registered progress in the last decades due to modern therapy, but the medical and social burden remains elevated. Genetic counselling represents a major step in approaching TH individuals, including as part of the pre-conception assessment. A multidisciplinary surveillance team is mandatory.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, C. Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, 011684 Bucharest, Romania
- Correspondence: (M.C.); (M.-C.D.)
| | - Cristina Vasiliu
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & University Emergency Hospital, 011684 Bucharest, Romania
| | - Alexandra Ioana Trandafir
- Department of Endocrinology, C.I. Parhon National Institute of Endocrinology, 011684 Bucharest, Romania
| | - Simona Elena Albu
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & University Emergency Hospital, 011684 Bucharest, Romania
| | - Mihai-Cristian Dumitrascu
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & University Emergency Hospital, 011684 Bucharest, Romania
- Correspondence: (M.C.); (M.-C.D.)
| | - Adelina Popa
- Department of Dermatovenerology, C. Davila University of Medicine and Pharmacy & “Elias” University Emergency Hospital, 011684 Bucharest, Romania
| | - Claudia Mehedintu
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & “Filantropia” Clinical Hospital, 011684 Bucharest, Romania
| | - Razvan-Cosmin Petca
- Department of Urology, C. Davila University of Medicine and Pharmacy & “Prof. Dr. Theodor Burghele” Clinical Hospital, 011684 Bucharest, Romania
| | - Aida Petca
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & University Emergency Hospital, 011684 Bucharest, Romania
| | - Florica Sandru
- Department of Dermatovenerology, C. Davila University of Medicine and Pharmacy & “Elias” University Emergency Hospital, 011684 Bucharest, Romania
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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Tsartsalis AN, Lambrou GI, Vlachou E, Samartzi A, Chrousos GP, Kanaka-Gantenbein C, Kattamis A. The Effect of Treatment and Bone Metabolic Factors on Fracture Incidence in Patients with Thalassemia-Induced Osteoporosis: An Observational Study. CURRENT DRUG THERAPY 2020. [DOI: 10.2174/1574885515666200106110602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Thalassemia Major (TM) is a hereditary disease caused by defective globin synthesis. Because of the significant increase in life expectancy, these patients suffer from various health conditions, including endocrinopathies and low bone mineral density.
Aim:
The aim of the present study was to evaluate the fracture incidence regarding the markers of bone metabolism, bone mineral density and treatment of osteoporosis as well as treatment of comorbidities.
Methods:
Sixty-four patients with TM (32 men and 32 women) participated in a cross-sectional study design. The patients were recruited from “Aghia Sofia” Children’s Hospital and evaluated using dual-energy X-ray absorptiometry (DXA) of the lumbar spine and femoral neck and with markers of bone remodeling including receptor activator of nuclear factor kappa-Β ligand (RANKL), osteoprotegerin (OPG), C-terminal telopeptide (CTX), and sclerostin.
Results:
The statistical analysis of markers of bone metabolism in relation to fractures revealed no statistical significance. However, statistical analysis of bone mineral density and markers of bone metabolism in relation to fractures was also not significant.
Conclusions:
In TM patients, fractures are not related to bone mineral density. Maybe some other conditions are the cause, haemosidirosis, drugs, comorbid conditions.
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Affiliation(s)
- Athanasios N. Tsartsalis
- Naval Hospital of Athens, Department of Endocrinology Diabetes and Metabolism, Dinokratous 70, 11521, Athens, Greece
| | - George I. Lambrou
- First Department of Pediatrics, National and Kapodistrian University of Athens, Choremeio Research Laboratory, Thivon & Levadeias 8, 11527, Goudi, Athens, Greece
| | - Eugenia Vlachou
- Department of Nursing, School of Health Sciences and Care Professions, University of West Attica, Ag. Spydironos 28, 12243, Aigaleo, Athens, Greece
| | - Athanasia Samartzi
- Naval Hospital of Athens, Department of Endocrinology Diabetes and Metabolism, Dinokratous 70, 11521, Athens, Greece
| | - George P. Chrousos
- First Department of Pediatrics, National and Kapodistrian University of Athens, Choremeio Research Laboratory, Thivon & Levadeias 8, 11527, Goudi, Athens, Greece
| | - Christina Kanaka-Gantenbein
- First Department of Pediatrics, National and Kapodistrian University of Athens, Choremeio Research Laboratory, Thivon & Levadeias 8, 11527, Goudi, Athens, Greece
| | - Antonis Kattamis
- Hematology/Oncology Unit, First Department of Pediatrics, National and Kapodistrian University of Athens, Thivon & Levadeias 8, 11527, Goudi, Athens, Greece
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Pepe J, Body JJ, Hadji P, McCloskey E, Meier C, Obermayer-Pietsch B, Palermo A, Tsourdi E, Zillikens MC, Langdahl B, Ferrari S. Osteoporosis in Premenopausal Women: A Clinical Narrative Review by the ECTS and the IOF. J Clin Endocrinol Metab 2020; 105:5846185. [PMID: 32453819 DOI: 10.1210/clinem/dgaa306] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Consensus regarding diagnosis and management of osteoporosis in premenopausal women (PW) is still lacking due to few studies carried out in this population. DESIGN The European Calcified Tissue Society and the International Osteoporosis Foundation convened a working group to produce an updated review of literature published after 2017 on this topic. RESULTS Fragility fractures in PW are rare and mostly due to secondary osteoporosis (ie, in presence of an underlying disease such as hormonal, inflammatory, or digestive disorders). In absence of another disorder, low bone mineral density (BMD) together with fragility fractures qualifies as idiopathic osteoporosis. In contrast, low BMD alone does not necessarily represent osteoporosis in absence of bone microarchitectural abnormalities. BMD increases in PW with osteoporosis when the underlying disease is treated. For example, in celiac disease, an increase of 9% in radius trabecular volumetric density was achieved after 1 year of gluten-free diet, while anti-tumor necrosis factor alpha improved BMD in PW with inflammatory bowel diseases. In amenorrhea, including anorexia nervosa, appropriately delivered estrogen replacement therapy can also improve BMD. Alternatively, antiresorptive or anabolic therapy has been shown to improve BMD in a variety of conditions, the range of improvement (3%-16%) depending on skeletal site and the nature of the secondary cause. No studies were powered to demonstrate fracture reduction. The effects of bisphosphonates in childbearing women have been scantly studied and caution is needed. CONCLUSION The majority of PW with osteoporosis have an underlying disease. Specific therapy of these diseases, as well as antiresorptive and anabolic drugs, improve BMD, but without evidence of fracture reduction.
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Affiliation(s)
- Jessica Pepe
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, "Sapienza" University of Rome, Italy
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Peyman Hadji
- Frankfurt Center of Bone Health, Frankfurt, Germany and Philipps-University of Marburg, Marburg, Germany
| | - Eugene McCloskey
- Centre for Integrated Research in Musculoskleetal Ageing, Mellanby Centre for Bone Research, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Christian Meier
- Division of Endocrinology, Diabetology and Metabolism, University Hospital and University of Basel, Basel, Switzerland
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Elena Tsourdi
- Department of Medicine III, Technische Universität Dresden Medical Center, Dresden, Germany
- Center for Healthy Aging, Technische Universität Dresden Medical Center, Dresden, Germany
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Serge Ferrari
- Service of Bone Diseases, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
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